Health Equity is Essential to Overcoming Antimicrobial Resistance
The antimicrobial resistance (AMR) crisis stems from natural microbial adaptation and the lack of new antimicrobials in development. Vulnerable populations worldwide, including within the US, are disproportionately affected, exacerbating the spread of resistance.
Jacinda C. Abdul-Mutakabbir PharmD, MPH
Image credit: UCSD
Globally, it is estimated that over 1 million individuals die each year from antimicrobial-resistant (AMR) infections.1 This number is projected to exceed 10 million deaths over the next 25 years. This alarming reality demands our immediate attention, and we must consider several important factors. First, AMR is a naturally occurring phenomenon that occurs overtime through genomic changes in microbes.2 Second, there is a significant lack of novel antimicrobials in the clinical pipeline, leaving treatment options for AMR infections limited and costly.3
Moreover, we must recognize that vulnerable populations, both outside the United States4 and within our own country, will be disproportionately affected by AMR.5 The COVID-19 pandemic has demonstrated how microbes can easily transcend national boundaries and impact individuals across different socioeconomic statuses. If we neglect the needs of the most vulnerable and marginalized communities, we will weaken our ability to combat AMR, leading to unprecedented increases in resistance across every social class. Prioritizing health equity in our efforts against AMR is non-negotiable.
Overview of the AMR Pandemic and Current Outlook
The spread of antimicrobial-resistant (AMR) organisms is often referred to as a “silent” pandemic due to the lack of general awareness regarding the impacts of these infections.2 Although this issue is often under-discussed, AMR microbes cause significant harm and render commonly used antimicrobials ineffective daily. This problem is not limited to human infectious diseases; resistant microbes can circulate among humans, animals, and the environment.6 A notable example of this is the New Delhi metallo-beta-lactamase 1 gene (blaNDM-1), which originated in India and traveled to other regions.7 To date, the blaNDM-1 gene has been identified in numerous individuals globally8 and is associated with high mortality rates,9 particularly among critically ill patients. Soil sampling from areas outside India has revealed the presence of blaNDM-1, suggesting that the gene may have been transmitted through animals (via food or water systems) or other environmental factors.10
These findings highlight the urgent need for a One Health approach that considers the interdependence of human, animal, and environmental dimensions on the continued propagation of AMR pathogens.6 Ideally, this approach should incorporate principles of global health equity and inclusivity.11However, achieving this requires a coordinated and collaborative global effort. Without such action, we may witness a rise in other resistant genes and the continued spread of resistant organisms. Complicating the situation further is the insufficient antimicrobial pipeline for treating resistant pathogens, with only a few novel agents approved in the last decade.12 Additionally, there is a lack of tools available globally to rapidly and accurately detect AMR genes responsible for infections, particularly in low- and middle-income countries.13 The consequences of these issues will ultimately be felt worldwide but will disproportionately affect the most vulnerable populations.
AMR Inequities in the United States
In the US, we have seen firsthand the impacts of AMR across vulnerable communities. Many of the risks associated with acquiring AMR are linked to social determinants of health (SDoH), including education, socioeconomic status, environment, and access to healthcare.14 Inequities in these areas have been connected to poorer health outcomes.15 For example, in a study16 examining data collected from hospitals in Texas, investigators report that the prevalence of AmpC beta-lactamases and methicillin-resistant Staphylococcus aureus was higher in areas of low socioeconomic status. Similarly, a study15 conducted in North Carolina discovered that individuals who resided in areas of low socioeconomic status were more likely to have a multi-drug resistant infection and to exhibit resistance to an antibiotic in the penicillin class in comparison to those who resided in areas of higher socioeconomic status. Additionally, low socioeconomic status regions are more prone to healthcare provider shortages, resulting in reduced access to healthcare and inadequate management of chronic diseases.17Chronic illnesses, such as type 2 diabetes mellitus (T2DM),18 have been shown to contribute to the emergence of AMR, and research indicates that individuals in low socioeconomic status areas have higher rates of T2DM diagnoses.19
Unfortunately, the burden of chronic illnesses and the detection of AMR infections can be amplified at the intersection of socioeconomic status and race and ethnicity. Notably, a study conducted at a Southern California hospital found that patients with AMR Candida spp. infections were more likely to identify as part of a racially and ethnically minoritized group, and they were also more likely to have a pre-existing T2DM diagnosis.20 Consequently, there have been reports of decreasing rates of preventative health screenings, including those necessary to diagnose T2DM, observed across communities of low socioeconomic status.21 This trend suggests that these communities may experience an increase in AMR infections, as well as related morbidity and mortality.
Together, We Can Do It
It is crucial to prioritize the most vulnerable regions and communities to ensure the protection of all citizens. All clinicians, veterinarians, academics, public health professionals, and industry leaders must come together to address the existing disparities and advocate for continued change. Without a focus on health equity in addressing the AMR pandemic, we risk facing the reality of the projected 39 million deaths attributed to AMR. Those deaths will not be selective.
