Antimicrobial resistance threatens everyone, but rural Americans face a uniquely dangerous combination of structural barriers, workforce shortages, and limited access to new treatments.
Henry Skinner, Ph.D.
CEO, AMR Action Fund
In rural Maine last winter, a woman undergoing cancer treatment faced a choice no patient should have to make. She had developed a suspected drug-resistant fungal infection and needed prolonged intravenous therapy. Her physician recommended placing a PICC line, a device that would deliver a regulated dose of a powerful antifungal medication.
However, when the doctor explained that the line would prevent her from lifting more than five pounds, the patient refused. She lived alone in a remote cabin. Her only source of heat was a wood-burning stove and, as she told the physician, her ax weighed well more than that.
“So I’m either going to die from this infection,” she told her doctor, “or freeze to death.”
This was not a case of noncompliance or misinformation. It was a rational decision shaped by the barriers to healthcare that burden countless rural Americans. As antimicrobial resistance (AMR) accelerates, these structural challenges will become more acute.
The scale of the problem
AMR — the ability of bacteria, fungi, and other pathogens to evade the drugs we rely on to treat infections — is already undermining U.S. healthcare. The Centers for Disease Control and Prevention estimates that resistant infections kill more than 35,000 Americans every year and add $4.6 billion in annual health costs. But while AMR threatens everyone, rural Americans face distinct challenges.
Nearly 80% of U.S. counties have no infectious disease physician. Two-thirds of federally designated primary care shortage areas are rural. Many hospitals lack laboratory staff and pharmacists, forcing generalist providers to prescribe older, broad-spectrum antibiotics while they wait for test results from distant labs.
The consequences fall heaviest on vulnerable patient populations. Children in rural counties are more likely to be prescribed antibiotics inappropriately. Mothers face higher infection risks during pregnancy and delivery, at a time when more than half of rural counties no longer have obstetric care providers. Farmworkers, slaughterhouse employees, and families living near industrial livestock operations face occupational and environmental exposures that drive resistant infections into the community.
What must change
Strengthening the rural health workforce is essential to sharpening rural America’s defenses against this growing threat. Physicians are part of the puzzle, as are lab technicians and pharmacists, who play an essential role in diagnosing and treating bacterial and fungal infections in a timely fashion, but are in short supply.
Incentives to recruit and retain infectious disease specialists, pediatricians, and laboratory staff in rural areas are critical. Loan repayment programs may help attract medical school graduates who are shouldering more debt than ever, as could enhanced support for rural residency tracks.
Properly treating patients with complex, life-threatening infections in a rural setting also demands that rural hospitals have access to new, innovative antimicrobials and better diagnostics. Currently, the pipelines of antibiotics and antifungals in development are perilously thin, and the field has been starved of private investment. Policymakers need to enact market-based reforms that incentivize investment into these lifesaving drugs to ensure patients across the United States will have access to effective therapies when they need them most.
Strengthening the rural health workforce and modernizing antimicrobial innovation are not partisan issues. They are national imperatives, and policymakers must act accordingly.
