Antimicrobial Resistance (AMR) has been identified as a global health and developmental challenge. The Global Research on Antimicrobial Resistance (GRAM) project findings for 2019 estimated 4.95 million deaths due to drug-resistant bacterial infection, with a higher burden on low-resource settings (1). 

The 79th United Nations General Assembly (UNGA) High-Level Meeting on AMR was held in September 2024, and global leaders committed to reducing the AMR death rate annually by 10% (2). While new drug development can be challenging, various new drugs show promising antibacterial activity. However, access to these drugs is still predominantly only in high-income countries. While it is important that Low- and middle-income countries (LMIC) also have access to these antibiotics, there is the dilemma of managing access without excess use of antibiotics (3).

Understanding the socio-economic drivers of AMR, such as gender, living conditions, access to healthcare and climate change, can help develop sustainable interventions for mitigating AMR (4). These social determinants of health intersect and interact with one another to shape an individual’s societal experiences. Such interactions can be better understood by adopting an intersectional lens. Understanding the experiences of AMR from individuals differently impacted by AMR due to these social determinants of health contributes to building culture-sensitive and responsible interventions against AMR (5).

LMICs also face challenges around access to clean water, sanitation, and health (WASH), which contributes to their high infectious disease burden. This issue is more prominent in the rural areas and marginalized populations, including women and girls, of these countries (6). Women and girls also have inadequate access to healthcare. They are more exposed to drug-resistant infections due to their role in food production, caregiving, and water collection and a higher rate of sexual violence. Women also constitute 70% of the healthcare workforce, which contributes to their exposure to drug-resistant infections (7).

In LMICs like India, the caste system poses a challenge to ensuring equitable access to healthcare. The caste system represents a hierarchy of social roles that hold inherent characteristics. The status attached to one’s caste has been passed down over the generations, changing it from a social role to a hereditary role (8). People who belong to the lower castes, such as Dalits, are limited to occupations such as domestic laborers, scavengers, and sweepers and have lower access to education and healthcare in addition to facing social discrimination in society (9). In many other parts of the world, race also affects health-seeking and health-providing behaviors. These social constructs can also influence their access to education and income levels.

The use of intersectional research in health care is gaining momentum now. Intersectional research can be conducted by using various qualitative, quantitative, and mixed methods, amongst which qualitative methods like ethnography are the most common. When conducting such studies, researchers must know how their biases, shaped by their social constructs, can influence their research work. Although it may not be possible to eliminate such biases, cultivating this self-awareness enables researchers to consciously avoid letting personal judgments distort their findings. In the Wellcome Trust funded the PROTEA study that we are currently undertaking, which investigates the intersection of socio-economic and cultural drivers on AMR and its health-seeking and health-providing behaviors, potential researcher biases will be addressed through reflexivity, methodological and analytical triangulation, and working closely with research participants and collaborators (10).

It is also important that these cultural drivers are considered in AMR policies. In a review of National Actional Plans, it was found that there is little to no recognition of addressing the cultural drivers of health-seeking and health-providing behaviors (11). It is important that AMR interventions include an intersectional approach and are contextually fit and culturally sensitive. Multisectoral collaboration is also key in tackling AMR. Healthcare professionals, researchers, community members, activists, policymakers, environmentalists, veterinarians, climate change experts should join hands to develop interventions against AMR from a One Health perspective.

By ISID Emerging Leader, Vrinda Nampoothiri

References

1. Global Research on Antimicrobial Resistance. Global burden of bacterial AMR. https://www.tropicalmedicine.ox.ac.uk/gram/research/global-burden-of-bacterial antimicrobial-resistance
2. World leaders commit to decisive action on antimicrobial resistance. https://www.unep.org/news-and-stories/press-release/world-leaders-commit-decisive-action-antimicrobial-resistance
3. Patel TS, Sati H, Lessa FC, Patel PK, Srinivasan A, Hicks LA, et al. Defining access without excess: expanding appropriate use of antibiotics targeting multidrug-resistant organisms. The Lancet Microbe. 2024 Jan 1;5(1):e93–8.
4. Anderson M, Ljungqvist G, van Kessel R, Saint V, Mossialos E. The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024
5. Charani E, Mendelson M, Ashiru-Oredope D, Hutchinson E, Kaur M, McKee M, et al. Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach. JAC Antimicrob Resist. 2021 Oct 1;3(4):dlab123. doi: 10.1093/jacamr/dlab123.
6. Biswas S, Adhikary M, Alam A, Islam N, Roy R. Disparities in access to water, sanitation, and hygiene (WASH) services and the status of SDG-6 implementation across districts and states in India. Heliyon. 2024 Sep 30;10(18):e37646.
7. WHO releases guidance on gender inequalities and antimicrobial resistance. https://www.who.int/news/item/16-09-2024-who-releases-guidance-on-gender-inequalities-and-antimicrobial-resistance
8. Sankaran S, Sekerdej M, von Hecker U. The Role of Indian Caste Identity and Caste Inconsistent Norms on Status Representation. Front Psychol. 2017 Mar 31;8:487. doi: 10.3389/fpsyg.2017.00487. PMID: 28408896; PMCID: PMC5374864.
9. Thapa R, Teijlingen E van, Regmi PR, Heaslip V. Caste Exclusion and Health Discrimination in South Asia: A Systematic Review. Asia-Pacific Journal of Public Health. 2021 May 24;33(8):828.
10. Charani E, Dlamini S, Koch A, Singh S, Hodes R, Laxminarayan R, et al. Power Relations in Optimisation of Therapies and Equity in Access to Antibiotics (PROTEA) Study: investigating the intersection of socio-economic and cultural drivers on antimicrobial resistance (AMR) and its influence on healthcare access and health-providing behaviours in India and South Africa. Wellcome Open Res. 2024 Jul 24;9:400.
11. Charani E, Mendelson M, Pallett SJC, Ahmad R, Mpundu M, Mbamalu O, et al. An analysis of existing national action plans for antimicrobial resistance-gaps and opportunities in strategies optimising antibiotic use in human populations. Lancet Glob Health. 2023 Mar;11(3):e466-e474. doi: 10.1016/S2214-109X(23)00019-0.