A project chartered by the British government, which has been examining everything that can be done to stem the tide of antibiotic resistance, in its next-to-last report has focused on the basics: municipal sanitation and hospital hygiene.

It’s something of a change in tone for the Review on Antimicrobial Resistance, a two-year effort created by Prime Minister David Cameron, supported by the Wellcome Trust and chaired by Lord Jim O’Neill, the former chief economist of Goldman Sachs (who now also serves in an unpaid post in Cameron’s government). The Review’s previous reports have examined what could be changed or created to solve problems that contribute to the rise of resistance: funding drug development, supporting vaccine research, detecting counterfeit drugs, innovating rapid-diagnosis devices and improving vaccine use.

In its new analysis, the group backs away from technological optimism to address seemingly intractable problems: how hospitals continue to cause antibiotic-resistant infections in their most vulnerable patients, and how the lack of clean water and sanitation both create diseases that demand antibiotic use, and also spread antibiotic-resistant bacteria.

Obviously neither of those concerns are new: Ignaz Semelweis linked unwashed hands to fatal childbed fever in 1847, and John Snow made the connection between contaminated water and a cholera outbreak in 1854. Yet today, just in the United States, more than 1.7 million people contract healthcare-associated infections each year, and worldwide, more than 2 million people die from waterborne diarrheal disease.

So the problems are not solved. “We felt it would be of value to point out that just doing the basics can make a huge amount of difference,” Lord O’Neill said by phone. “It is concerning that not enough has happened, and that’s a reason for a new, independent voice to highlight that.”

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The Review commissioned an analysis from postgraduate students at the London School of Economics which found that, just in four countries with emerging economies (India, Indonesia, Nigeria and Brazil), 494 million cases of diarrhea each year are treated with antibiotics, a number that could rise to 622 million cases by 2030. If infrastructure were improved, 60 percent of those courses of antibiotics could be foregone. The report says that contaminated water also allows bacteria to cycle between humans and the environment, spinning up the dissemination of resistance genes. (In fact, in 2011, the team who discovered the resistance supergene NDM identified municipal water supplies and puddles as a major contributor to the spread of that almost untreatable bug.)

If sanitation seems a simple goal, so does hygiene—yet the Review finds that persistent neglect of simple tasks such as washing hands is fueling the spread of resistance. As few as 30 to 40 percent of hospital staff wash their hands as often as they should, it says, and doctors perform worse than nurses or staff who are lower in the hierarchy. Though it is crucial those rates be improved, there group finds there is nowhere near enough research into what actually motivates healthcare workers to change their behavior, and recommends funding studies that could pick apart what works. (Dismayingly, that does not now happen. A few years ago, infection-prevention specialist Dr. Eli Perencevich and several colleagues analyzed funding awarded by the National Institutes of Health to study AIDS, versus funding for research into hospital infections. For every US death from AIDS, they found, the NIH awarded the equivalent of $69,000; for every US death from MRSA, drug-resistant staph, $570.)

In its final comments, the Review calls for something that, for years, researchers deep in the trenches of antibiotic resistance research have been begging for: the creation of a comprehensive, global, rapid surveillance system that could alert the world when something new emerges. Two examples of where that would have made a difference: NDM was first identified in Sweden in 2008, but was subsequently found to have been diagnosed in India, its place of origin, as early as 2006. And MCR-1, the most recent dismaying superbug—which is resistant to the utterly last-resort drug colistin—was found last fall to have spread to more than a dozen countries, but was first identified in China in 2013.

“Even in some of the world’s most developed health systems, AMR surveillance data is often patchy and retrospective—virtually none is ‘real time’,” the Review says. “Without effective monitoring, we will lack early warning of emerging patterns of drug resistance, and lack the insights needed to guide and evaluate our response.”