Antimicrobial resistance under gender lens

Bobby Ramakant *

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, behaviours, 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 carers 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 immunisation 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-centred 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 normalised 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 Programmes 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 neighbours 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 feminisation 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, recognising 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.