Women have a lot on their Petri dish

The writer is a science commentator

Antimicrobial resistance happens when pathogens — microorganisms that cause disease, like viruses, bacteria, fungi and parasites — stop responding to medicines. The World Bank estimates AMR could add $1tn to healthcare costs by 2050.

Now, a survey by the World Health Organization suggests that women could be more exposed than men to such superbugs, thanks to a complex mix of biological, social, cultural and economic factors. It is unclear yet whether that leads to more disease among women but WHO is urging countries to pass on information on sex and gender in their monitoring of drug-resistant infections.

This new perspective — that AMR risk is not the same everywhere for everyone — is valuable. Without reliable infection control, staples of modern medicine like caesarean births and hip replacements become routes to infection, disease, disability and death. Superbugs directly killed about 1.3mn in 2019. 

Last month, the health agency added four new pathogens to its hit list of drug-resistant bacteria. The world needs to clamp down on antimicrobial misuse, including in food production, and better incentivise R&D. But understanding who is most vulnerable and why, could also shape better policy interventions.  

Zlatina Dobreva and WHO colleagues in Geneva teamed up with researchers from the Global Strategy Lab at Toronto’s York University, to review the scientific literature on AMR for information on sex (defined as biological sex assigned at birth) and gender (reflecting broader social norms, such as caring responsibilities). Their findings, based on 130 papers and bankrolled by the Fleming Fund, come out officially next month but Dobreva offered a recent preview, reported in Nature.

The evidence, Dobreva told me, is that “women are at a higher risk of exposure to potentially drug-resistant infections,” not least through childbirth and abortion in settings that might not always be sterile. In many low- and middle-income countries, women and girls tend to fetch water, prepare food and care for others, bringing them more frequently into contact with bacteria like E. coli.

A lack of sanitation can make periods a monthly window of risk: inadequately washed cloths, for example, make infections more likely. Some girls skip school during menstruation, limiting their prospects and compromising the health decisions they later make for themselves and their children (such as childhood vaccination). Sex work and sexual violence exposes some to drug-resistant sexually transmitted diseases, including gonorrhoea.

Prompt diagnosis and treatment can take time and money — and sometimes male permission and childcare. Those difficulties can mean women instead self-diagnose; buy drugs over the counter or informally; try herbal remedies; or share medicines. Women are also more likely than men to receive antibiotics in their lifetime. All are factors in AMR. 

On top of that, women make up about 70 per cent of healthcare workers globally, making superbugs an occupational hazard; personal protective equipment, if available, is generally designed for men and a poor fit. When food is scarce, women are rarely prioritised; malnutrition makes opportunistic infections more likely. A rare upside: women are more likely to have contact with healthcare professionals and to comply with prescribed treatment.  

While the researchers are confident that, globally, women are more exposed, they do not know whether women suffer more disease as a result, nor whether all countries show the same pattern. A recent European study suggests men have slightly higher rates of drug-resistant infection than women, for unknown reasons, and that age matters. “We need more data,” Dobreva says. 

The WHO wants demographic detail included as standard when nations send data to the global AMR surveillance system. Professor Shona Hilton, a public health policy researcher at Glasgow university who is helping Tanzania with its AMR action plan, agrees that gender is under-represented in policy considerations. The WHO analysis, Hilton says, shows that “poor countries need tailored plans to address the distinct challenges they face”, including sparse healthcare infrastructure and squeezed resources.  

It is a cliché that women, particularly in the global south, have a lot on their plate. If the WHO report is anything to go by, they also have a lot on their Petri dish.