The rhetoric of resistance

by Helen Lambert

In the run up to the UN Global Assembly’s high-level meeting on antimicrobial resistance (21st September 2016), lobbying by European policymakers is stepping up a gear. The meeting is seen as a unique opportunity to make a concrete impact on measures to stem the rise of drug-resistant infections at global level.  The WHO has been ratcheting up efforts to push AMR up the global health agenda  and the UK’s Chief Medical Officer Dame Sally Davies has been a key player in turning what has been a significant concern among infectious disease experts for nearly two decades into a high visibility political issue. The Wellcome Trust has published a report with policy recommendations to tackle ‘drug-resistant infections’ from the ‘high level’ international summit it held earlier this year and has launched a public petition that focuses concern on the use of antibiotics in animals.  And news media have widely circulated the words of commentators including the UK’s former Prime Minister threatening ‘a return to the dark ages’ or an ‘antibiotic apocalypse’.

In Europe a clear consensus is developing, based on northern European experiences of attempting to limit antibiotic use.  Last week a major European public health organisation devoted its annual meeting to the issue of AMR. A favoured tool was a map that highlights in stark red and blue the contrasts between countries where antibiotic use is declining or stable (Scandinavia and several other northern European countries) and those (parts of southern Europe and huge swathes across the low and middle-income countries of Africa, Asia and South America) where antibiotic consumption is ‘still’ increasing.  The audience was told that ‘high’ standards found in the ‘good’ (blue) countries need to ‘set the bar’, or ‘lead the way’, for the ‘bad’ (red) countries. Ministers of Health and heads of influential organisations described the steps their countries and professional associations (of pharmacists, nurses, clinicians and microbiologists) are already taking to combat AMR.  Bar charts and diagrams showing worrying levels of ‘irrational’ antibiotic use in countries outside northern Europe were used to demonstrate the ‘threat’ of AMR that, as we were reminded, does not respect national borders. Some speakers described the ‘excess’ antibiotic use and ‘lack’ of microbiological testing found in many poorly resourced countries in the kind of indignant tones usually reserved for the most deeply irresponsible, even wilfully negligent, behaviour.

What seems to be happening is that the widespread consensus on the need for concerted action is being treated as though we already know what kinds of action will be effective and what will be acceptable to policymakers worldwide. Is the direction in which the proposed interventions take us the right one for our shared future health and wellbeing? And is the language of threat and misdemeanour the best way to get everyone on board? Three issues are worth considering: equity, awareness-raising, and context-appropriateness. And in all of these, language is crucial.

First and most obviously, the use of oppositional language by Europeans – high vs low, good vs bad, even red vs blue – is unhelpful for galvanising collective action when low and middle-income countries are continually placed on the negative side of the divide.  If nothing else, the politics of diplomacy should alert those seeking to create global consensus to the dangers of this kind of language. Portraying resource-poor countries as failing to take seriously the threat of AMR, or as being negligent in, for example, not prohibiting over-the-counter sales of antibiotics, is not only stigmatising; it is inaccurate.

In Europe, a generic focus on the need to reduce antibiotic use makes sense. Jim O’Neill’s comment (accurate or not) that people take antibiotics ‘like sweets’ was a media-friendly soundbite that drew attention to the problem of expectations in many high-income countries where antibiotics have long been prescribed routinely. But the assumption that widespread antibiotic use automatically indicates overuse is unwarranted.  India is the largest consumer of antibiotics for human health in the world; but fewer antibiotics are used per capita than in the UK, despite the fact that levels of morbidity and mortality from common bacterial infections are several magnitudes greater. One estimate puts the number of childhood deaths from pneumonia that would be averted by having prompt access to antibiotics in India alone at almost 170,000 a year.

In such circumstances, rising levels of antibiotic consumption may well be a good thing.  Even in the UK, while more antibiotics overall are prescribed in poorer areas of the country (as we should expect, given the greater burden of disease among the poor), fewer antibiotics are prescribed per consultation than in wealthier areas.  This suggests that GPs are limiting prescribing more in poorer than in wealthier areas. And the most plausible explanation for this is simply that, like all other forms of health care, better educated and more articulate patients are more likely to gain access to limited health care resources than poorer and less articulate ones (aka the ‘inverse care law’) – regardless of what is or isn’t wrong with them.  The pleasant consensus that unthinkingly translates ‘appropriate’ use into ‘restricting availability of antibiotics’ conceals the potential for real harm to the poorest and least powerful sections of every country upon whom generic restrictions will have the greatest impact.

To put it another way, equity is central to decision-making about which policies and measures will really contain AMR effectively – but this issue too is effectively masked by what is fast becoming an empty alliterative slogan, ‘excess versus access’.  In reality, the tension between these two poles will only be resolved by addressing the difficult, mundane, long-term problems of poorly resourced health systems that mean access to high quality clinical care and diagnostics is limited to a wealthy minority (and often, in the competitive private medical markets that characterise much of the developing world and lead to overprescribing, unnecessary testing and overdiagnosis, not even them).  There is, as yet, little evidence on which interventions will really be most effective in limiting AMR prevalence; given the extremely complex ways that environment, human and animal health are interlinked in the development and circulation of AMR, perhaps there never will be. But old-fashioned public health measures – better sanitation, clean water and childhood vaccination to prevent infections – and improved health systems that would bring quality primary health care and efficient referral mechanisms within reach to the bulk of the global population, hold at least as much promise as high-tech solutions of rapid diagnostic testing and new drug discovery mechanisms.  Yet pharmaceutical ‘innovation’ has consistently captured far more attention in both research and media forums than these relatively low-cost mechanisms for prevention.

When it comes to public awareness, too, the repeated claims that too many antibiotics are prescribed because of patients’ ‘irrational demands’ stigmatises the public. Within the AMR research community it goes without saying that ‘irrational’ is a technical term that refers to the use of antibiotics without microbiological or (in some versions) adequate clinical indication.  But in ordinary language, ‘irrational’ is a pejorative word that suggests lack of judgement, understanding or intelligence.  One of the policy components that WHO and various European countries are seeking to have adopted at the UNGA is that of ‘raising public awareness’. The rationale for this rests on two related assumptions. The first is that doctors prescribe antibiotics because of ‘irrational demand’ from patients – a canard that continues to be propagated in policy and media circles despite a wealth of research evidence showing that the problem is mostly to do with poor doctor-patient communication and the need for clinicians to avoid risk by prescribing ‘just in case’.  The second is that consumer pressure will help reduce prescribing by getting patients to refuse antibiotic prescriptions when they are not essential.  There may be some grounds for ‘public awareness’ campaigns in high income countries to generate such pressure, although the success of such campaigns in the past has been mixed. But the ‘public awareness’ component of proposed measures to contain AMR worldwide completely disregards the fundamental requirement for strategies to be context-appropriate if they are to be effective.  Under any circumstances, the notion of antibiotics as a generic class (spanning some types of pharmaceuticals but not others across a multitude of brand names and generics) is a complex one to grasp. The demand for campaigns to ‘raise public awareness’ or ‘educate the public’ about antibiotics skates over the risks of disseminating simplistic messages in low-literacy environments where access to antibiotics is already limited. At best, such messages are likely to cause misunderstandings and at worst, they may lead people who genuinely need antibiotics to avoid or refuse them. 

As it is, a worried mother seeking help for her ailing baby who is recommended to buy two capsules at the medicine shop, after finding the nearest rural health post locked up (again) because the health worker has not turned up, is not acting irrationally when she uses scarce cash to buy that precious medicine. What other choice does she have?

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