Is there a connect between
gender and antimicrobial resistance (AMR)? If you think that infection-causing
microbes (virus, bacteria, fungi, parasites) impact all genders the same, be
welcome to read on...
Gender is a social
construct which defines the roles, behaviors, expressions, and identities of
girls, women, boys, men, and gender-diverse peoples.
Drug resistance or
Antimicrobial Resistance (AMR) is caused by misuse and overuse of medicines in
human health, livestock health, food and agriculture and it is also polluting
our environment. We cannot afford any misuse and overuse of medicines in any
sector if we are to deliver on SDGs. However, AMR is already among top 10
global health threats and is also threatening food security and our environment
along with a significant economic cost.
Women and girls
(including those sick with infectious diseases) are the primary careers in most
settings - especially in the Global South. But the infection prevention and
control measures in the healthcare facilities, communities and homes are far
from optimal to protect them and undermine the roles and responsibilities they
shoulder.
Many studies looking
at male: female ratio of child vaccination, unsurprisingly reveal that the male
child is more likely to have received essential immunization as compared to a
girl child.
When it comes to
screening and diagnostics for a range of infections, no prizes for guessing
people of which gender are less likely to seek health services in a
rights-based, person-centered and gender transformative manner?
“A complex mix of
biological, social, cultural and economic factors arising from gender-based
inequalities and injustices impact infection prevention and control. Gender
inequalities, harmful gender norms, stereotypes, and tropes have normalized the
neglect of well-being of girls and women, making them more vulnerable to AMR,”
said Shobha Shukla, Chairperson of Global AMR Media Alliance (GAMA) and Host of
SHE & Rights to advance gender equality and human right to health.
AMR and gender-based
violence
“The lived
experience of girls and women and gender diverse communities show how violence
puts them at increased risk of getting infected with sexually transmitted
infections,” said Shobha Shukla, who was also the Lead Discussant for SDG-3 at
United Nations High Level Political Forum (HLPF) in New York last year.
According to Dr Soumya
Swaminathan (former Deputy Director General for Programs and former Chief
Scientist of the World Health Organization - WHO), we cannot be successful
in reducing or preventing AMR, without tackling gender-based violence, as violence,
impacts the access of women to healthcare.
“Women are at a very
high risk of intimate partner violence or domestic violence - physical or
sexual. This could lead to more infections. And because of their position
within the household and the community, they are less likely to seek timely and
adequate care for these injuries or infections, which could lead to
drug-resistant infections. Whether it is sexually transmitted infections or
urinary tract infections, or reproductive tract infections, or pelvic
inflammatory disease, all of these are linked with sexual violence and an
increased risk of antibiotic use. Also, even if the woman seeks care, quite
often follow-up is poor. She may have taken a partial course of antibiotics or
the wrong doses. Women facing an unplanned pregnancy, or those who go for an
unsafe abortion are also at higher risk of AMR.”
Dr Swaminathan is
Chairperson, MS Swaminathan Research Foundation; and former Secretary, Dept of
Health Research, Ministry of Health and Family Welfare, Government of India and
former Director General, Indian Council of Medical Research (ICMR).
Stigma fuels AMR
“Diseases like TB or
HIV/AIDS carry a huge stigma in our society especially for the women. In many
communities a woman diagnosed with TB or HIV is judged not only as a patient
but as someone who has brought shame to the family. Her character, her marriage
prospects and even her abilities to being a good wife, daughter, mother are
questioned. I have seen many women hide their illness because of this stigma.
They delay testing, they avoid going to the clinics, some take the medicine
secretly and others stop treatment early to prevent family members or neighbors
from finding out about it”, says Bhakti Chavan, a survivor of extensively
drug-resistant TB (XDR-TB) - one of the most serious forms of drug-resistant
TB. Bhakti is also a member of WHO Task Force of AMR Survivors.
Impact of AMR is not
gender blind. If we want to fight AMR effectively, we must listen to the women,
diagnose them early on, ensure proper treatment, support adherence and design
policies that consider women's realities.
Power dynamics at
work
“The burden of
disease predominantly remains in populations that have the least access to
resources, including antibiotics, to be able to treat infections effectively.
The power differential between the patient, the end user and the healthcare
provider is very strong and that is impacted by gender. It is impacted by
gender norms and roles within society as well as within healthcare services.
Women often have the least power in being able to negotiate and advocate for
themselves within the healthcare settings- whether they are healthcare
professionals or whether there are patients. Women have the unrecognised and
unspoken role of care providers. And they often put their own healthcare needs
behind those of other family members. We saw in the hospitals in India that
women would often come in as carers for their family members and not
necessarily seeking care themselves. Also, when there is out of pocket
expenditure on healthcare, often male family members might be selected over
female family members. We need to recognise this and identify how we can
leverage power for positive outcomes”, opines Dr Esmita Charani, Associate
Professor, University of Cape Town, South Africa.
Agrees Anand
Balachandran, who formerly headed an AMR unit at the World Health Organization
(WHO) headquarters in Geneva, Switzerland. “We need to move beyond the
‘bugs and drugs’ approach and adopt a more social science lens. It is
critical to view inequity in healthcare, including through the AAAQ framework
(Availability, Accessibility, Acceptability and Quality) of healthcare.”
Social norms affect
AMR control
Dr Deepshikha
Bhateja, Principal Research Scientist, Indian School of Business (ISB), and
Visiting Fellow at One Health Trust rues that there are norms around
menstruation, around caregiving responsibilities, around what kind of jobs are
suitable for women, around son preference, around pregnancy and around control
and ownership of financial assets. All of these lead to women’s reduced access
to WASH (Water, sanitation and hygiene). They lead to lower education and
awareness amongst women and prohibit women and girls from seeking healthcare
freely. This impacts the intermediary drivers of AMR which increases their
susceptibility of infection. It reduces their health-seeking behaviour and
ability to seek and afford essential antibiotics and quality healthcare and
leads to inappropriate diagnosis and management by healthcare providers. This
in turn impacts AMR outcomes of inadequate access to essential antibiotics,
lack of appropriate diagnosis and leads to increased antibiotic intake and
increased AMR.
Agrees Esmita that
“we have to understand that the gendered roles within society and culture are
barriers to access - is it the husband or is it the family members who are not
allowing the women to actually make it to the clinic in the first place?”
Intersectional
approach
Dr Esmita Charani
said that we need an intersectional lens because our position within society,
within the community and within the family in which we live is very much
dependent on gender and also on our religion, culture, caste, migration status,
or race and identity in some settings. We have to take an intersectional lens
to understand how access is compromised based on intersectional identities and
also how we can leverage the power that we have within the community to develop
interventions that are more likely to be taken up.
Dr Soumya
Swaminathan cites the example of feminization of agriculture. “From an
intersectional perspective, here is a woman who lives in a rural area, she is
also a small farmer, she has some livestock and she does some agriculture, and
she has a family to look after. And she is alone because she has a migrant
husband. And therefore, she has less access to health centers. She has less
financial autonomy as well. In such a situation, she would be probably more
likely to either neglect infections or take inappropriate treatment”.
In the opinion of Dr
Salman Khan, former member, Quadripartite Working Group on Youth Engagement for
AMR and Youth Engagement consultant at ReAct Asia Pacific, AMR is a deeply
social problem.
“We often frame AMR
as a technical problem where microbes evolve, drugs fail, antimicrobial
pipelines dry up. But AMR is shaped by those who have power, whose health is
prioritised, who control resources, and whose voices are ultimately heard in decision-making,"
said Dr Salman Khan.
One ounce of prevention is
worth a pound of cure
So said Dr Mayssam
Akroush, Founding President of The Pan Arab Women Physicians Association. For
her women can play a lead role in combating irrational antibiotic use, that
fuels AMR.
“Women are the head
of the pyramid and a very important part of the equation. They are mothers,
leaders, teachers, prescribing doctors and they are also in the pharmacy who
sell the product. So they are at a great position to lead the change on irrational
antibiotic use. As a mother she might be in a hurry to recover and might need
to buy the antibiotic for herself. But as a mother she is also the decision
maker for her child's health- whether to give or not to give the antibiotic.
She might be the only one who can change the mindset of the youth on using
antibiotics for their health. She should be the targeted person in our
campaigns where we must educate women and thus get a whole population educated
on how, when, and whether to use antibiotics or not. Women as caregivers, as
educators and decision makers, can be our targeted audience for any AMR
campaign”.
There is a common
consensus on the need to address gender inequalities in our National Action
Plans on AMR.
“We must include
gender-based violence indicators in AMR National Action Plans, recognizing that
sexual health and violence services are hotspots for antibiotic exposure and we
must also include gender-sensitive stewardship indicators”, said Dr Swaminathan.
End
drug-resistant TB if we are to end TB by 2030
“With World TB Day
coming up and also as someone from India – the country with the highest TB (and
drug-resistant TB) burden worldwide, I would like to draw attention to drug
resistant forms of TB. In the year 2000, the upper-end estimates showed that we
had around 400,000 cases of drug-resistant TB. In 2024, we also had a similar
number of people with drug-resistant TB. We have failed down the line to
prevent drug-resistant TB. We could have done better on infection prevention
and control in healthcare settings, communities and homes. We could have done
better on stopping misuse, underuse or overuse of TB medicines. We had the
science, tools, and evidence to do better. But we could not. If we are to end
TB, we have to ensure zero drug-resistant TB that occurs due to
failure of infection prevention and control, or misuse, overuse or underuse of
TB medicines. It is high time for accountability,” said Shobha Shukla,
Chairperson, Global AMR Media Alliance (GAMA); and Founder Executive Director, CNS
and Host of AMR Dialogues, and coordinator of Prevent-Find-Treat All TB
campaign.
Best AMR response is a
feminist response
“Only possible
effective and sustainable way to prevent AMR has to be a feminist way. AMR and
other health responses must be rooted in feminist development justice model,
which is based on care and solidarity for each other, where no one is left behind
in the truest sense of the words. In 2024, the WHO released its guidance on
"Addressing gender inequalities in national action plans on AMR".
This guidance provides practical recommendations for countries to integrate
gender responsive approaches into AMR policies by addressing key gender
disparities in the prevention, diagnosis and treatment of drug-resistant
infections,” shared Shobha.
“We must address
health inequities. We as the AMR community, need to engage with the health
systems teams at local, national and global levels.
Ultimately strengthening primary healthcare to achieve universal
healthcare should address these inequities and the AMR response should be
embedded within these health systems strengthening efforts,” added Anand
Balachandran.
