Poverty and Root Causes of Resistance in Developing Countries

  • Iruka N. OkekeEmail author


Antimicrobial use provides selective pressure for resistant strains but there are other factors that combine with use to promote the emergence and spread of resistant bacteria, mobile elements, and genes. Many of these factors are only superficially understood, if at all, and are complicated to study. Comparative antimicrobial resistance data from populations with different risk factors for resistance are hard to come by and inevitably suffer from bias. Nonetheless, a few studies document regional variations in resistance and some provide clues about factors that might exacerbate resistance. Data from these studies appear to suggest that antimicrobial misuse, prophylactic use, diagnostic imprecision, and interpersonal spread are key factors in the selection and dissemination of resistant strains. All these factors are promoted by poverty at the individual patient, health system, and national levels.


Poor Country Poor People Refugee Camp Secure Supply Chain Resistance Containment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



INO is a Branco Weiss Fellow of the Society-in-Science, ETHZ, Zürich, Switzerland.


  1. Ballereau, F., Prazuck, T., Schrive, I., Lafleuriel, M., Rozec, D., Fisch, A., and Lafaix, C. 1997. Stability of essential drugs in the field: results of a study conducted over a two-year period in Burkina Faso. Am. J. Trop. Med. Hyg. 57:31–36.PubMedGoogle Scholar
  2. Berkley, J. A., Lowe, B. S., Mwangi, I., Williams, T., Bauni, E., Mwarumba, S., Ngetsa, C., Slack, M. P., Njenga, S., Hart, C. A., Maitland, K., English, M., Marsh, K., and Scott, J. A. 2005. Bacteremia among children admitted to a rural hospital in Kenya. N. Engl. J. Med. 352:39–47.CrossRefPubMedGoogle Scholar
  3. Bi, P., Tong, S., and Parton, K. A. 2000. Family self-medication and antibiotics abuse for children and juveniles in a Chinese city. Soc. Sci. Med. 50:1445–1450.CrossRefPubMedGoogle Scholar
  4. D'Alessandro, U. and Buttiens, H. 2001. History and importance of antimalarial drug resistance. Trop. Med. Int. Health 6:845–848.CrossRefPubMedGoogle Scholar
  5. Ehrenberg, J. P. and Ault, S. K. 2005. Neglected diseases of neglected populations: thinking to reshape the determinants of health in Latin America and the Caribbean. BMC Public Health 5:119.CrossRefPubMedGoogle Scholar
  6. Engels, D., Madaras, T., Nyandwi, S., and Murray, J. 1995. Epidemic dysentery caused by Shigella dysenteriae type 1: a sentinel site surveillance of antimicrobial resistance patterns in Burundi. Bull. World Health Organ. 73:787–791.PubMedGoogle Scholar
  7. Goma Epidemiology Group. 1995. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994. Lancet 345:339–344.CrossRefGoogle Scholar
  8. Kariuki, S., Revathi, G., Kariuki, N., Kiiru, J., Mwituria, J., and Hart, C. A. 2006. Characterisation of community acquired non-typhoidal Salmonella from bacteraemia and diarrhoeal infections in children admitted to hospital in Nairobi, Kenya. BMC Microbiol. 6:101.CrossRefPubMedGoogle Scholar
  9. Kindermans, J. M., Vandenbergh, D., Vreeke, E., Olliaro, P., and D'Altilia, J. P. 2007. Estimating antimalarial drugs consumption in Africa before the switch to artemisinin-based combination therapies (ACTs). Malar. J. 6:91.CrossRefPubMedGoogle Scholar
  10. Lamikanra, A. and Okeke, I. N. 1997. A study of the effect of the urban/rural divide on the incidence of antibiotic resistance in Escherichia coli. Biomed. Lett. 55:91–97.Google Scholar
  11. Lee, N. Y., Song, J. H., Kim, S., Peck, K. R., Ahn, K. M., Lee, S. I., Yang, Y., Li, J., Chongthaleong, A., Tiengrim, S., Aswapokee, N., Lin, T. Y., Wu, J. L., Chiu, C. H., Lalitha, M. K., Thomas, K., Cherian, T., Perera, J., Yee, T. T., Jamal, F., Warsa, U. C., Van, P. H., Carlos, C.C., Shibl, A. M., Jacobs, M. R., and Appelbaum, P. C. 2001. Carriage of antibiotic-resistant pneumococci among Asian children: a multinational surveillance by the Asian Network for Surveillance of Resistant Pathogens (ANSORP). Clin. Infect. Dis. 32:1463–1469.CrossRefGoogle Scholar
  12. Lester, S. C., del Pilar Pla, M., Wang, F., Perez Schael, I., Jiang, H., and O'Brien, T. F. 1990. The carriage of Escherichia coli resistant to antimicrobial agents by healthy children in Boston, in Caracas, Venezuela, and in Qin Pu, China. N. Engl. J. Med. 323:285–289.CrossRefPubMedGoogle Scholar
  13. Mthwalo, M., Wasas, A., Huebner, R., Koornhof, H. J., and Klugman, K. P. 1998. Antibiotic resistance of nasopharyngeal isolates of Streptococcus pneumoniae from children in Lesotho. Bull. World Health Organ. 76:641–650.PubMedGoogle Scholar
  14. Murray, C. J. and Lopez, A. D. 1997. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 349:1269–1276.CrossRefPubMedGoogle Scholar
  15. Nys, S., Okeke, I. N., Kariuki, S., Dinant, G. J., Driessen, C., and Stobberingh, E. E. 2004. Antibiotic resistance of faecal Escherichia coli from healthy volunteers from eight developing countries. J. Antimicrob. Chemother. 54:952–955.CrossRefPubMedGoogle Scholar
  16. Obadare, E. 2005. A crisis of trust: history, politics, religion and the polio controversy in Northern Nigeria. Patterns Prejudice 39:265–266.CrossRefGoogle Scholar
  17. Okeke, I. 2003. Antibiotic use and resistance in developing countries. In the resistance phenomenon in microbes and infectious disease vectors: implications for human health and strategies for containment – Workshop Summary, ed. S. Knobler, S. Lemon, M. Najafi, and T. Burroughs, pp. 132–139. Washington DC: Institute of Medicine, National Academy of Science.Google Scholar
  18. Okeke, I. N., Fayinka, S. T., and Lamikanra, A. 2000. Antibiotic resistance in Escherichia coli from Nigerian students, 1986 1998. Emerg. Infect. Dis. 6:393–396.Google Scholar
  19. Okeke, I. N., and Lamikanra, A. 2003. Export of antimicrobial drugs by West African travelers. J. Travel. Med. 10:133–135.CrossRefPubMedGoogle Scholar
  20. Okeke, I. N., Klugman, K. P., Bhutta, Z. A., Duse, A. G., Jenkins, P., O'Brien, T. F., Pablos-Mendez, A., and Laxminarayan, R. 2005. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect. Dis. 5:568–580.CrossRefPubMedGoogle Scholar
  21. Okeke, I. N. 2006. Diagnostic insufficiency in Africa. Clin. Infect. Dis. 42:1501–1503.CrossRefPubMedGoogle Scholar
  22. Onwujekwe, O., Ojukwu, J., Shu, E., and Uzochukwu, B. 2007. Inequities in valuation of benefits, choice of drugs, and mode of payment for malaria treatment services provided by Community Health Workers in Nigeria. Am. J. Trop. Med. Hyg. 77:16–21.PubMedGoogle Scholar
  23. Petti, C. A., Polage, C. R., Quinn, T. C., Ronald, A. R., and Sande, M. A. 2006. Laboratory medicine in Africa: a barrier to effective health care. Clin. Infect. Dis. 42:377–382.CrossRefPubMedGoogle Scholar
  24. Quagliarello, A. B., Parry, C. M., Hien, T. T., and Farrar, J. J. 2003. Factors associated with carriage of penicillin-resistant Streptococcus pneumoniae among Vietnamese children: a rural-urban divide. J. Health Popul. Nutr. 21:316–324.PubMedGoogle Scholar
  25. Ringertz, S., Bellete, B., Karlsson, I., Ohman, G., Gedebou, M., and Kronvall, G. 1990. Antibiotic susceptibility of Escherichia coli isolates from inpatients with urinary tract infections in hospitals in Addis Ababa and Stockholm. Bull. World Health Organ. 68:61–68.PubMedGoogle Scholar
  26. Schapira, A. 1994. A standard protocol for assessing the proportion of children presenting with febrile disease who suffer from malarial disease. Geneva: World Health Organization.Google Scholar
  27. Siddique, A. K., Salam, A., Islam, M. S., Akram, K., Majumdar, R. N., Zaman, K., Fronczak, N., and Laston, S. 1995. Why treatment centres failed to prevent cholera deaths among Rwandan refugees in Goma, Zaire. Lancet 345:359–361.CrossRefPubMedGoogle Scholar
  28. Singh, J. A., Upshur, R., and Padayatchi, N. 2007. XDR-TB in South Africa: No time for denial or complacency. PLoS Med. 4:e50.CrossRefPubMedGoogle Scholar
  29. Songsore, J. 2004. Urbanization and health in Africa: exploring the interconnections between poverty, inequality and the burden of disease. Heath Clark Lecture delivered on June 2002 at the London School of Tropical Medicine and Hygiene. Accra: Ghana Universities Press.Google Scholar
  30. Toole, M. J., and Waldman, R. J. 1997. The public health aspects of complex emergencies and refugee situations. Annu. Rev. Public Health 18:283–312.CrossRefPubMedGoogle Scholar
  31. Tsegaye, G. 1998. Assessment of knowledge and practice in urban and rural communities in Jimma zone. J. Health Sci. 8:92–93.Google Scholar
  32. Victora, C. G., Huicho, L., Amaral, J. J., Armstrong-Schellenberg, J., Manzi, F., Mason, E., and Scherpbier, R. 2006. Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania. Bull. World Health Organ. 84:792–801.CrossRefPubMedGoogle Scholar
  33. Whyte, S. R., Geest, S. V. D., and Hardon, A. 2002. Social lives of medicines. Cambridge: Cambridge University PressGoogle Scholar
  34. Worku, S. and Abebe, G. 2003. Practice of self medication in Jimma town. Ethiop J. Health Dev. 17:111–116.Google Scholar
  35. Zaidi, M. B., Zamora, E., Diaz, P., Tollefson, L., Fedorka-Cray, P. J., and Headrick, M. L. 2003. Risk factors for fecal quinolone-resistant Escherichia coli in Mexican children. Antimicrob. Agents Chemother. 47:1999–2001.CrossRefPubMedGoogle Scholar
  36. Zhang, R., Eggleston, K., Rotimi, V., and Zeckhauser, R. J. 2006. Antibiotic resistance as a global threat: evidence from China, Kuwait and the United States. Global Health 2:6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of BiologyHaverford CollegeHaverfordUSA

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