Antimicrobial resistance (AMR) has emerged as one of the most pressing global health threats of the 21st century, undermining decades of medical progress and increasingly compromising the effective treatment of common infectious diseases. Although AMR is frequently framed as a microbiological, clinical, or pharmaceutical challenge, it is also a profound issue of health equity. The risk of acquiring a resistant infection, the probability of receiving timely and effective treatment, and the consequences of treatment failure are not equally distributed across populations. Instead, they are strongly influenced by the social, economic, political, and environmental conditions in which people are born, live, work, and access healthcare.
The burden of AMR can therefore fall disproportionately on marginalized populations, including people experiencing poverty, displacement, structural racism, ethnic or religious discrimination, insecure employment, homelessness, incarceration, migration-related vulnerability, and other forms of social exclusion. These vulnerabilities frequently intersect, creating multiple and reinforcing disadvantages. AMR does not create these inequalities, but it can magnify them by increasing the complexity, duration, and cost of treating infections among populations that already face substantial barriers to healthcare.
Marginalized communities may be disproportionately exposed to conditions that increase both the risk of acquiring infectious diseases and the likelihood of transmission. Overcrowded housing, inadequate water, sanitation and hygiene (WASH) infrastructure, unsafe working environments, food insecurity, environmental contamination, and limited access to vaccination and preventive healthcare can facilitate the spread of infectious diseases and increase reliance on antimicrobial treatment. Refugee camps, informal settlements, detention facilities, overcrowded households, and other environments characterized by inadequate infrastructure may provide particularly challenging conditions for infection prevention and control.
The relationship between marginalization and AMR, however, extends well beyond exposure to infection. Access to timely, affordable, and high-quality healthcare remains profoundly unequal within and between countries. Financial constraints, geographic isolation, lack of transportation, shortages of healthcare professionals, weak health systems, language barriers, legal or migration status, discrimination, and lack of trust in institutions can delay access to diagnosis and treatment. When appropriate care is delayed, initially manageable infections may become more severe, potentially requiring prolonged or repeated courses of antimicrobial therapy, hospitalization, or the use of broader-spectrum and more expensive agents.
Diagnostic inequity is an especially important but sometimes overlooked component of this relationship. Effective antimicrobial stewardship increasingly depends on access to microbiological diagnosis, antimicrobial susceptibility testing, and, where available, rapid diagnostic technologies. Yet these resources remain unevenly distributed. In many low-resource or underserved settings, clinicians may be required to treat infections empirically because microbiological testing is unavailable, unaffordable, or too slow to influence clinical decision-making. The result is a paradox: populations facing some of the greatest infectious disease burdens may have the least access to the diagnostic infrastructure required for targeted antimicrobial treatment.
Access to effective antimicrobials represents another critical dimension of inequity. The global AMR debate often emphasizes excessive or inappropriate antibiotic consumption, yet millions of people simultaneously experience inadequate access to essential antimicrobials. These realities are not contradictory. Both inappropriate use and lack of access can coexist, sometimes within the same country or community. Restrictive policies designed to reduce antimicrobial consumption must therefore be implemented carefully to ensure that stewardship does not become an additional barrier for patients who already struggle to obtain essential treatment. Responsible antimicrobial use should mean providing the right antimicrobial, to the right patient, at the right dose and duration, while ensuring that those who genuinely need treatment can obtain it.
Marginalized populations may also experience patterns of inappropriate antimicrobial use that are driven not primarily by individual behaviour but by structural constraints. Where access to qualified healthcare professionals is limited, individuals may rely on self-medication, informal providers, unregulated markets, or antibiotics obtained without adequate clinical assessment. Financial hardship may result in interrupted treatment courses or the purchase of only part of a prescribed regimen. Conversely, healthcare systems with limited diagnostic capacity may rely excessively on empirical broad-spectrum treatment. Understanding these behaviours requires moving beyond narratives that place responsibility solely on individual patients and recognizing the broader systems that shape the choices available to them.
The consequences of resistant infections can themselves deepen marginalization. Resistant infections may require longer hospital stays, more expensive second- or third-line therapies, additional diagnostic procedures, prolonged recovery, and greater time away from work or education. For individuals without adequate health insurance, social protection, paid sick leave, or employment security, these consequences can be financially devastating. Families may face catastrophic healthcare expenditure, loss of income, or long-term socioeconomic instability. AMR can therefore participate in a vicious cycle in which social disadvantage increases vulnerability to resistant infections, while resistant infections further reinforce poverty and exclusion.
Displacement, conflict, and humanitarian emergencies illustrate particularly clearly how these mechanisms converge. Health infrastructure may be damaged or destroyed, medicine supply chains disrupted, vaccination programmes interrupted, and infection prevention measures weakened. Large populations may be forced into overcrowded settings with inadequate sanitation and limited access to healthcare. Continuity of antimicrobial treatment can become difficult, while laboratory surveillance and diagnostic capacity may collapse precisely when they are most needed. Addressing AMR in these contexts therefore requires integration with humanitarian health, WASH, infection prevention and control, universal access to essential medicines, and health-system resilience rather than treating resistance as an isolated technical problem.
Despite these realities, global responses to AMR have historically emphasized technical interventions, including antimicrobial stewardship, surveillance, infection prevention and control, diagnostic innovation, and the development of new antimicrobials. These interventions remain indispensable, but they cannot fully address AMR if implemented without attention to the social and structural conditions that determine who is exposed, who receives appropriate treatment, and who suffers the greatest consequences. Surveillance systems themselves must become more inclusive, since populations poorly connected to formal healthcare systems may also be underrepresented in AMR data, making important inequalities effectively invisible.
An equitable AMR strategy therefore requires action at multiple levels. Universal access to quality healthcare, essential antimicrobials, vaccines, diagnostics, clean water, sanitation, infection prevention, and reliable health information should be considered integral components of AMR policy. Surveillance should identify not only resistant organisms but also disparities in exposure, access, treatment, and outcomes. Communities affected by marginalization should be meaningfully represented in the development and implementation of policies rather than regarded solely as recipients of interventions. International strategies should similarly recognize the substantial differences in resources and capacities between countries and avoid transferring disproportionate responsibilities to health systems with the fewest resources.
Ultimately, AMR should be understood not only as a threat to antimicrobial effectiveness but also as a reflection of broader inequalities in global health. Resistant microorganisms cross geographic and social boundaries, but the capacity to prevent, diagnose, and treat the infections they cause remains profoundly unequal. A response based exclusively on reducing antimicrobial consumption or developing new technologies will therefore be insufficient.
Embedding equity at the core of AMR governance is both an ethical imperative and a strategic necessity. Reducing the burden of resistant infections requires addressing the structural determinants that shape exposure to disease, strengthening access to prevention and timely diagnosis, ensuring equitable availability of effective treatment, and protecting populations from the social and economic consequences of illness. Equity should not be considered an additional component of the global response to AMR; it should be one of the principles through which every AMR intervention is designed, implemented, and evaluated. Only through such an approach can the global community build an AMR response that is effective, resilient, inclusive, and sustainable.
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