Inequality is driving antimicrobial resistance. Here’s how to curb it

This article is brought to you thanks to the collaboration of The European Sting with the World Economic Forum.

Author: Michael Anderson, Health Organisation, Policy, Economics (HOPE), Centre for Primary Care & Health Services Research, The University of Manchester, United Kingdom, Gunnar Ljungqvist, Center for Global Health Science and Security, Georgetown University, Washington, DC, United States of America, Victoria Sain, Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Germany

• Antimicrobial resistance is one of the biggest global challenges of our time. It threatens public health and requires urgent action.
• The driving forces of antimicrobial resistance are unequally distributed across society, with vulnerable populations at the sharp end of associated health and economic risks and burdens.
• International and national antimicrobial resistance policies must consider social and economic factors to maximize their effectiveness and minimize health inequalities.

Antimicrobial resistance (also known as AMR) is estimated to be directly responsible for 1.27 million deaths in 2019 alone, equivalent to approximately 3,500 people each day. This number is estimated to reach 10 million per annum by 2050 without substantial action.

The economic consequences of antimicrobial resistance for individuals, health systems and society are also considerable. Individuals who contract antimicrobial-resistant infections are at risk of mortality, treatment delays, long-term disability, lost income and debt or poverty from high health costs, with suffering and socio-economic impacts for families and communities.

Antimicrobial resistance increases financial pressure on health systems as it leads to more hospitalizations, longer stays, more expensive diagnosis and treatment and reduced ability to provide treatments such as chemotherapy and surgical care safely.

It can also negatively impact national economies, which may have fewer and less productive workers and populations spending more on health care. If infections cannot be prevented and treated, trade and agriculture can also be negatively affected, with increased death and illness among farmed animals.

However, the consequences of antimicrobial resistance are not equally distributed across society.

Who does antimicrobial resistance affect?

Social, cultural and biological factors mean that women are more likely than men to experience occupational exposure to antimicrobial resistance and to be prescribed antimicrobials for several infections.

The risk of its development is heightened in populations living in urban and overcrowded environments with limited access to clean water, sanitation, and hygiene (WASH) infrastructure, as is the case in many low- and middle-income countries. Populations with limited access to formal healthcare can experience increased inappropriate antibiotic use due to poorly regulated access. Many countries also experience persistent shortages of essential antimicrobials, leaving them infected for longer periods and given less targeted antimicrobials.

Conditions in conflict-affected areas make infections easier to spread, with populations who are forcibly displaced also facing fragile healthcare systems, supply of essential antimicrobials and access to WASH infrastructure. Implementing effective policies to combat antimicrobial resistance is also challenging in contexts with political instability, limited rule of law and higher levels of corruption.

How environmental factors impact resistant infections

Climate change is a significant driver of antimicrobial resistance as rising ambient temperatures increase the proliferation of bacteria while also contributing to extreme weather events that can disrupt healthcare services, displace communities and reduce access to sanitation.

The use of antimicrobials on animals, together with poor measures to prevent and control infections, can further drive antimicrobial resistance. Drug-resistant pathogens can be passed between animals and humans in occupational settings and through food contamination.

Pollution is also a major driver of antimicrobial resistance in the environment – for example, through waste from the pharmaceutical and healthcare industries, heavy metals from industrial and agricultural processes, particle pollution in the air and plastic waste in our water systems.

Policies must go beyond ‘drugs and bugs’

Until recently, policymakers and academics have primarily focused on the medical and microbiological factors that drive antimicrobial resistance. There has been insufficient focus on the relationship between the social and economic factors described here and the emergence of antimicrobial-resistant infections.

A new report published by the European Observatory on Health Systems and Policies, distilling findings from research supported by the World Economic Forum and the Novo Nordisk Foundation, sheds light on key socio-economic drivers and impacts of antimicrobial resistance and what this will mean for policy and research.

It helps explain how these factors can impact our health and economies and the effectiveness of measures to tackle antimicrobial resistance at the individual, health system and societal levels.

The policy report argues that four socio-economic elements must be built into the design of antimicrobial resistance policy and policy implementation, monitoring and evaluation (Figure 1):

• Governance and leadership that are mindful of the socio-economic drivers and impacts of antimicrobial resistance are central to co-ordinate action across different sectors.
• Action focused on people and that fosters equity and encourages policies responsive to individuals’ needs.
• Multi-sectorality recognizes antimicrobial resistance policy as a cross-cutting issue with involvement from various government departments and levels.
• Best evidence-informed policies help ensure that they look beyond the biomedical and value research from different disciplines and approaches to tackle the socio-economic drivers and impacts of antimicrobial resistance.

Figure 1 – Policy framework on socioeconomic drivers and impacts of antimicrobial resistance.

The report describes how these overarching principles can be incorporated into four core antimicrobial resistance policy areas.

• Stewardship relates to the responsible use of pre-existing and new antimicrobials, in humans and animals. However, many people, especially in low- and middle-income countries still die from a lack of or delayed access to antimicrobials. A balanced approach is therefore needed to promote rational use of antimicrobials while not inadvertently creating barriers for populations in situations of vulnerability.
• Prevention highlights the need for more investment in programmes that prevent and control infections in community and healthcare settings and biosecurity measures in animal health settings. Policymakers must also not neglect the global need for equitable access to WASH infrastructure.
• Access relates to ensuring equitable access to essential health services, antimicrobials, and diagnostics. This requires reducing barriers to accessing healthcare, changing procurement policy and strengthening the supply of antimicrobials in poorer and richer countries.
• Innovation in antimicrobial resistance health technologies seeks to improve prevention, diagnosis and treatment of infections. Stimulating research and development requires investment and incentivization but in ways that match the needs and operational contexts of lower resource settings, including access and affordability.

Many policymakers are currently revisiting their policy priorities related to antimicrobial resistance. At the international level, the UN General Assembly is holding a high-level meeting, which is expected to result in a political declaration on global antimicrobial resistance priorities and commitments. Simultaneously, many countries are revising their national action plans on antimicrobial resistance.

Policymakers and other stakeholders must leverage this critical window of opportunity to move beyond a “drugs and bugs” approach to antimicrobial resistance towards a more holistic, people-centred, equity-oriented approach that tackles key social and economic drivers and impacts of antimicrobial resistance.

Learn more by registering for the European Observatory webinar series “From evidence to practice in AMR prevention and control” on 21 May and 23 May 2024.