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The author is a science commentator

Antibiotic resistance occurs when pathogens – microorganisms that cause disease, such as viruses, bacteria, fungi and parasites – become unresponsive to drugs. The World Bank estimates that antibiotic resistance could increase healthcare costs by $1 trillion by 2050.

A study by the World Health Organization now suggests that women may be more affected by such superbugs than men due to a complex mix of biological, social, cultural and economic factors. Whether this leads to more disease in women is still unclear, but the WHO is urging countries to share sex and gender information when monitoring drug-resistant infections.

This new perspective—that AMR risk is not the same everywhere and for everyone—is valuable. Without reliable infection control, cornerstones of modern medicine like cesarean sections and hip replacements become pathways to infection, disease, disability, and death. Superbugs directly killed about 1.3 million people in 2019.

Last month, the Food and Drug Administration added four new pathogens to its list of drug-resistant bacteria. The world needs to curb antimicrobial misuse, including in food production, and better support research and development. But understanding who is most vulnerable and why can help us create better policies.

Zlatina Dobreva and WHO colleagues in Geneva teamed up with researchers at York University’s Global Strategy Lab in Toronto to search the scientific literature on AMR for information on sex (defined as biological sex assigned at birth) and gender (which reflects broader social norms, such as caregiving responsibilities). Their findings, based on 130 papers and funded by the Fleming Fund, will be formally published next month, but Dobreva offered a recent preview, reported in Nature.

Dobreva told me that there is evidence that “women are at higher risk of exposure to potentially drug-resistant infections,” not least through giving birth and giving birth in environments that are not always sterile. In many low- and middle-income countries, women and girls are the ones who fetch water, prepare food and care for others, putting them more at risk of exposure to bacteria such as E. coli.

Poor hygiene can make the monthly period a window of risk: inadequately washed clothes, for example, increase the likelihood of infections. Some girls skip school during menstruation, limiting their prospects and jeopardizing the health decisions they make later for themselves and their children (such as childhood vaccinations). Sex work and sexual violence put some women at risk of drug-resistant sexually transmitted diseases such as gonorrhea.

Prompt diagnosis and treatment can take time and money – and sometimes husband’s permission and child care. These difficulties can lead women to self-diagnose, buy medications over the counter or informally, try herbal remedies, or share medications. Women are also more likely to receive antibiotics over the course of their lives than men. All of these are factors that lead to AMR.

In addition, around 70 percent of health workers worldwide are women, making superbugs an occupational hazard; personal protective equipment, when available, is usually designed for men and fits poorly; when food is scarce, women are rarely given priority; malnutrition makes opportunistic infections more likely. One rare advantage: women have more frequent contact with medical personnel and follow prescribed treatment.

While researchers are certain that women are at greater risk worldwide, they do not know whether this is why women are more likely to get sick or whether the same pattern is observed in all countries. A recent European study suggests that men are slightly more likely to get drug-resistant infections than women for unknown reasons and that age plays a role. “We need more data,” says Dobreva.

The WHO wants demographic details to be included by default when countries submit data to the global AMR surveillance system. Professor Shona Hilton, a health policy researcher at the University of Glasgow who is supporting Tanzania with its AMR action plan, agrees that gender is underrepresented in policy deliberations. The WHO analysis, Hilton says, shows that “poor countries need tailored plans to address the particular challenges they face,” including sparse health infrastructure and scarce resources.

It is a stereotype that women, especially in developing countries, have a lot to do. If the WHO report is to be believed, they do have a lot to do.

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