On World Health Day, the World Health Organization (WHO), celebrating its 75th birthday, has set a theme of ‘health for all’, a goal the world is very, very far from achieving. The anniversary lands in a world that is certainly more aware of the threats to everyone. Just as in Victorian times infectious disease could kill the rich as well as the poor, we’re all again at risk, in ways we seemed to have escaped a few decades ago.
The post-antibiotic era of superbugs
Public awareness of this has been driven of course by the continuing Covid-19 pandemic, but also the Marburg virus (a close relative of Ebola) outbreaks in Africa – and even seeps into the public consciousness in television drama such as The Last of Us.
Yet beyond the far-fetched fiction, there’s also rising alarm among experts about antimicrobial resistance (AMR), the ability of microbes to evolve resistance to therapeutic treatments. This threatens doctors’ ability to treat some of the most common infections, with few new drugs in the pipeline to replace those that are no longer effective.
In 2019, an estimated five million deaths were associated with antibiotic resistant bacterial infections across the globe. The WHO now speaks of the ‘post-antibiotic era’ of ‘superbugs’.
Like Covid-19, AMR does not respect borders and is globally widespread. However, there are socio-demographic risk factors that can increase the likelihood of transmission and colonisation of drug-resistant, infectious microbes. Poverty and inequality increase the risk to individuals affected, but also to all of us.
Displacement and poverty as a driving factor
The WHO estimates that there are more than 80 million forcibly displaced people in the world today. They are frequently exposed to conditions that favour the emergence and transmission of AMR during both the journey to and living in host countries. A study across Europe found reasons for continuing risk include the struggle migrants may face when trying to navigate foreign healthcare systems, legal restrictions on access; fear of deportations and proof of address requirements; lack of information on how to access healthcare; reduced awareness of GPs on refugee health and economic barriers.
There’s also increased incidence of AMR in the countries of origin of migrants, where there may be insufficient health infrastructure, poor antibiotic stewardship, reduced AMR surveillance and low levels of infection prevention, particularly in the context of conflict. Not only this, but there are also AMR threats that may be faced during transit, including the poor living conditions, lack of access to health care and clean water or sanitation and lack of high-quality treatment in detention or refugee facilities. (Another argument for providing orderly, safe routes for refugees, rather than this government’s hostile environment.)
Wherever there is poverty, people are at increased risk of contracting infectious diseases; this increases the exposure to antibiotics, which drives the further emergence and spread of AMR infections. Canadian researchers found a 73% risk reduction in community acquired MRSA infections for every $100,000 income increase.
The dispossessed are the most vulnerable to AMR
Looking closer to home, tuberculosis infections in homeless people is of great concern. In 2007, 44% of all drug resistant tuberculosis infections in London were found in homeless people, prisoners and problem drug users. Key concerns and factors increasing AMR likelihood in these populations include poor adherence to therapeutic treatments and loss of follow-up care.
A neglected story from the Covid pandemic was how hard prisons were hit. This vulnerable, medically under-served community has not been little studied, but the risks of AMR are obvious. In often poorly ventilated buildings, with overcrowding or poor hygiene facilities, there is an increased rate of infectious, AMR disease transmission, particularly through airborne transmission. Some 31% of multidrug resistant cases of tuberculosis in Georgia (USA) were directly or indirectly linked to prisons.
AMR must be treated systemically
This year, I asked the government what steps they are taking to monitor and mitigate the impact of antimicrobial resistance on marginalised communities in the UK. In response, I got appropriate sounding words about tackling health inequalities, developing an engagement strategy and recommendations for public health actions, plus a reference to the identification of vulnerable migrants, people in contact with the justice system and people experiencing homelessness as ‘Core20PLUS’ populations, to which further programmes will be directed.
That’s still a long way from 2014, when then prime minister David Cameron was making the topic a major issue at the top of government. But, as important as tackling medical misuse and the huge issue of the use of antibiotics in factory and industrial farming are, the threat can’t be tackled just through AMR policies.
The arguments for genuinely tackling poverty and deprivation in the UK and around the world (restoring official aid spending would be a good start) are clear. There are moral and even economic arguments (see Britain’s ‘productivity problem’), but poverty is also a major threat to public health, and an AMR risk. As we learnt during Covid, no one is safe until everyone is safe.
This article was written with British Society for Antimicrobial Chemotherapy senior interns Emily Stevenson and Julze Alejandre
