Issue No. 19: Intersection of Health Equity and AMR
Antimicrobial resistance (AMR) is a threat to people around the world. In 2019 alone, antibacterial-resistant infections contributed to nearly 5 million deaths worldwide and directly led to over 1.2 million deaths. Left unchecked, antimicrobial resistance could take10 million lives annually by 2050. And some communities will be hit harder than others.
Like the COVID-19 pandemic, drug-resistant “superbugs” have already deepened health inequities in our society. Superbugs are particularly threatening to the individuals who are already disproportionately impacted by the inequities of healthcare systems, such as people of color, pregnant people, older people, people experiencing homelessness, and immunocompromised individuals.
These AMR-related inequities have long been under-measured, including in the United States. Thankfully, that’s beginning to change. This year the Centers for Disease Control and Prevention released data showing that antibiotic-resistant infections are frequently connected to structural inequities and social determinants of health — conditions that affect one’s quality of life and health outcomes, including income, education, pollution, discrimination, and access to safe housing.
Below, we break down some of that data and put AMR in the context of broader health disparities affecting vulnerable communities across the nation.
Racial and Ethnic Identity
Americans of color bear the disproportionate burden of disease in our healthcare system. Unfortunately, AMR is no exception.
Such disparities are evident in the disproportionately high rates of life-threatening sepsis among people of color. Sepsis occurs when the body’s response to an infection is so extreme that it damages its own tissues. As more infections become resistant to antimicrobials, more people are at risk for developing sepsis. Non-white patients are nearly twice as likely to develop sepsis as white patients.
These disparities also persist in maternal health. According to new data from the National Center for Health Statistics, Black patients were nearly three times more likely to die from pregnancy-related complications in 2020 than their white counterparts — an increase of nearly 18% from the previous year. Infection or sepsis is the second-leading cause of pregnancy-related death, and severe sepsis among pregnant and birthing patients is more than twice as common among Black patients than white patients.
Individuals belonging to under-served racial and ethnic groups are also disproportionately affected by chronic diseases and underlying comorbidities, which increase the risk of hospitalization and the chance of developing a hospital-acquired drug-resistant infection. According to the CDC, rates of common hospital bloodstream infections caused by the fungus Candida — which can be drug-resistant — are twice as high in Black individuals as they are in non-Black individuals. Disparities in drug-resistant infections exacerbate existing health disparities that lead to worse outcomes for patients of color with other diseases.
These inequities affect communities of color outside the hospital, too. Some health conditions that have an outsized impact on minority patients, like diabetes, weaken the immune system. As a result, these individuals can be at increased risk of infection.
The CDC reports that rates of infections that can be drug resistant like tuberculosis were highest in Black, Hispanic, and Asian populations in 2020. Black populations are also at a higher risk of contracting a type of drug-resistant staph infection, known as MRSA.
Research from around the world has revealed that individuals with lower socioeconomic statuses are at higher risk of infections of all sorts, including those related to AMR. According to the CDC, community-associated ESBL-Enterobacterales — a group of bacteria including E. coli — infections disproportionately impact regions with low median incomes, rates of insured individuals, and education levels. The CDC also notes that older adults living in regions with high poverty are also at a disproportionate risk of contracting an infection from Salmonella. Both of these infections can be drug-resistant.
While no individual is immune to superbugs, those who are already underserved by our healthcare institutions face the greatest danger. Unfortunately, most of these health disparities do not exist in a vacuum. They overlap with one another to compound an individual’s risk of infection.
For instance, CDC data indicates that women who are pregnant and undergo childbirth have an increased risk of infection from pathogens like a drug-resistant strain of Group B streptococcus — most commonly found in the intestines and other lower internal organs. But that same strain also disproportionately affects infants, Black individuals, the elderly, and people with other medical conditions such as diabetes. A strain of Group A strep — the group associated with strep throat — that’s resistant to the antibiotic erythromycin has an outsized impact on individuals experiencing homelessness or incarceration, as well as those who reside in long-term healthcare facilities or inject drugs.
Rates of community-associated bacterial C. difficile infections, which often manifest in the colon, are higher in low-income and foreign-born populations, those who live in crowded conditions, and individuals who speak less English at home.
The data speak volumes. Drug-resistant infections affect certain individuals more than others — especially members of historically marginalized and vulnerable communities. As part of our larger commitment to health equity, we urgently need an aggressive response to antimicrobial resistance. It must focus on public health needs while addressing economic barriers that prevent us from treating the most threatening infections. We need a strong pipeline of antimicrobial products that can treat the deadliest infections of today and tomorrow. We need to prepare our healthcare system to use these drugs appropriately to prevent the spread of resistant infections.
AMR Disparities: Finding Solutions
One important step in making progress against health disparities — in the AMR crisis and beyond — is compiling and maintaining data to track equity trends. After all, it’s nearly impossible to address a problem if we don’t have consistent information on it.
Several data-tracking initiatives are underway. The Antimicrobial Resistance Laboratory Network analyzes patient demographic data in conjunction with laboratory test results. The CDC has also partnered with the National Healthcare Safety Network to supply patient demographic data for analysis and to spur advances in healthcare quality.
Other programs are working to address inequities in AMR morbidity and mortality specifically. Project Firstline, for example, helps close gaps in infection control knowledge among healthcare workers from diverse backgrounds. The initiative aims to empower these providers to share their knowledge with their broader communities — and prevent AMR-related infections in the first place.
But there’s still far more work to be done. For example, several Tufts University researchers have called on medical and public health professionals to address AMR-related inequities by raising awareness about superbugs and infection prevention in non-traditional settings, such as convenience stores, bodegas, daycares, and preschools. Holistic approaches like these are key to combating the disparities in the AMR crisis — and the inequities in the broader healthcare system as well.
Recent Progress to Address AMR
There has been some recent progress made in the fight against AMR. In the past few months, stakeholders across the public and private sectors have taken critical steps to combat superbugs.
The U.S. Department of Health and Human Services included $828 million in its fiscal year 2023 budget for the Biomedical Advanced Research and Development Authority to advance biosecurity and medical countermeasures. The funding will support BARDA’s Broad-Spectrum Antimicrobials Program, which oversees the federal government’s efforts to bring more novel antibacterials through clinical development.
The budget also includes a plan to decouple an antimicrobial manufacturer’s revenue from the volume of the drug sold — and instead have the government provide developers of newly approved antimicrobials with a set, annual payment. This proposal aligns with the PASTEUR Act currently under consideration in Congress, which would help fix the broken market for antimicrobials — and encourage the development of new medications to help fight antibiotic resistance.
Meanwhile, the AMR Action Fund — the world’s largest partnership between some leading pharmaceutical companies and non-business entities like the World Health Organization and the global charitable organization Wellcome that is focused on combatting AMR — has committed to investing at least $1 billion in small biotech companies to help bring up to four novel antibiotics to patients by 2030. This spring, the organization announced its first round of investments to Maryland-based Adaptive Phage Therapeutics and Pennsylvania-based Venatorx Pharmaceuticals.
Earlier this year, the HHS and Wellcome also renewed their financial support of CARB-X, a non-profit led by Boston University working to accelerate early-stage antibacterial research and development. BARDA within the HHS and Wellcome committed up to $370 million over the next 10 years.
Looking Ahead to Closing the Gaps
Like so many other healthcare issues, AMR has an outsized impact on the most vulnerable communities in the United States. As the unsettling data from the CDC and other researchers have revealed, these AMR-related disparities are rooted in the systemic inequities in our health system.
Effectively addressing AMR will also require addressing these health equity gaps to eliminate the risk of superbugs for everyone — no matter their race, ethnicity, socioeconomic status, or gender.
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