Leadership Needed to Fight Superbugs and Health Inequities

Kenneth E. Thorpe, PhD

Most doctors are well aware of the looming crisis posed by "superbugs," the bacteria and fungi that are growing increasingly resistant to even our strongest antimicrobials. But physicians might not realize that antimicrobial resistance (AMR) isn't just a public health issue — it's an equity issue too.

Luckily, there's a bill that is currently before Congress that could fight these superbugs — and help address AMR-related health inequities in the process.

Consider methicillin-resistant Staphylococcus aureus (MRSA), the leading cause of superbug deaths today — accounting for more than 100,000 deaths in 2019. Black individuals in the United States are 1.6 times more likely to become infected by MRSA than are White individuals.

Black individuals are also more likely to contract hospital-acquired infections and twice as likely to die from complications driven by antibiotic resistance. The Centers for Disease Control and Prevention has identified at least a dozen examples of bacteria that notably show disparities in the communities that they affect most.

It's no surprise that there are disparities in health outcomes related to resistant infections because the risks for AMR are also closely tied to social determinants of health. Minority groups are more likely to work in industries like healthcare or agriculture, where they are at greater risk of being exposed to resistant bacteria. They're also more likely to rely on hospitals and clinics with weaker infection controls because of resource challenges. A disproportionate number of the 2.8 million antibiotic-resistant infections that occur annually in the United States affect those who are at higher risk and, arguably, exacerbate health disparities.

The disparate rate of COVID-19 among communities of color is a significant example of the work that is needed to better address similar health threats — and AMR is one of them.

These disparities exist overseas too. According to a study published in The Lancet, AMR was associated with nearly 5 million deaths globally in 2019 and was directly attributable to 1.3 million deaths. That's more than the death toll of HIV or malaria. Experts estimate that by 2050, more people will die from AMR than from cancer. Fatalities are particularly high in developing nations, where sanitation and public health infrastructure are inadequate.

Solving these inequities will require a holistic approach — from outreach and education on infection control and prevention to better stewardship of antibiotics, as well as improved surveillance to provide data that can motivate and support interventions that address root causes. But to truly combat AMR, we will need new treatments to replace those with waning efficacy. More than 70% of the bacteria that cause hospital infections are resistant to at least one antibiotic.

Unfortunately, the development of new antibiotics hasn't kept pace with the spread of drug-resistant diseases. The World Health Organization warns that the current pipeline of antibiotics is "near static," with just 43 in development.

Creating antibiotics that can take aim at superbugs will require a completely new model for drug development, but that's a lot easier said than done. If a drug company released a new novel antibiotic today, it likely wouldn't be able to sell enough of the medicine to justify the enormous development cost. It can take $1.5 billion to develop a new antibiotic, yet the expected annual revenue per drug is less than $50 million per year.

A new bipartisan bill — the PASTEUR Act of 2021 — could solve this market failure with an innovative subscription-style model. Under the bill, the federal government would offer drug developers upfront payments for access to new antibiotics — an approach similar to Operation Warp Speed, the program that brought us COVID-19 vaccines.

The PASTEUR Act would "delink" revenue from sales volume by incentivizing companies to invent new antibiotics even if demand is currently low. Essentially, it'd be like paying yearly premiums to an insurance company. You may never need their services, but they'll be available if you do.

The COVID-19 pandemic caught the entire world by surprise, shaking health systems in the United States and across the globe to their cores.

We shouldn't sit and wait for the next pandemic-type threat because we know the AMR crisis is already looming. Looking at how to address AMR — and doing so with a health equity lens — is an urgent concern for health officials worldwide and a crucial priority for policymakers as we work toward solutions. We must be better able to manage or even prevent the disparate risks for exposure, transmission, and susceptibility to infection. We must work to improve access to quality treatments and care.

The first step is to recognize the urgency of AMR and its status as a health equity issue. The time is now for our leaders to address this crisis.

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