LEISURE, LIFESTYLE & WELLNESS

Life

Antibiotic resistance: Broader implications for humanity

Sakib Burza (IANS) and Kavitha Devadas (IANS)
16 November 2017 0

It is difficult to imagine a world where a minor bacterial infection from a wound is untreatable
and could possibly lead to death. In the short time that antibiotics have been around, their
excessive and occasionally irrational usage by humans for medical purposes as well as in
livestock and agriculture has contributed to the speeding up of a natural process of evolution and
mutation in bacteria -- a phenomenon known as antibiotic resistance (ABR).

As a medical humanitarian organisation, MSF uses antibiotics at various levels of treatment and
care. Drug resistant infections are rising rapidly across the world in our various projects and
should the world run out of effective antibiotics, typically the poorest and most vulnerable will
be the hardest hit.

The doctor-patient relationship forms the crux of any initiative trying to address antibiotic
resistance. In the cultural context of India, where public health infrastructure is overburdened
and there is a widespread shortage of doctors in rural areas, this gap is filled by pharmacists and
non-allopathic practitioners who out of necessity dispense medical advice and medication with
minimal oversight. This is facilitated by the under-regulated procurement and ease of over-the-
counter access to antibiotics.

Even among allopathic doctors, irrational and over-prescription of antibiotics is common, which
is likely to be exacerbated in an opaque doctor-pharmaceutical company nexus. Antibiograms
are often lacking in public health systems and found to be expensive in the private sector. Our
experience of working on antibiotic resistance in India confirmed much of what we already
knew, but also threw light on areas which need further investigation.

Since 2015, MSF has been working on antibiotic resistance in collaboration with the Ministry of
Health in West Bengal. As part of this project, MSF worked in the outpatient clinic of a district
hospital and two primary health care centres, treating acute respiratory illness in children aged 6
months to 12 years. To better understand the context we were operating in, a baseline audit of
prescribing practices of district hospital doctors as well as health promotion activities for the
local community were conducted alongside medical consultations.

Our prescription audit collected and analysed antibiotic prescription practices of doctors at the
district hospital and PHC level. The audit revealed that irrational prescribing of antibiotics was
widespread. In many instances, no diagnosis was documented in the medical record or
prescription, rather only listing the drug to be dispensed.

Both sites included in the audit received over hundreds of patients per day, with only one
medical doctor overseeing the consultation. Without a doubt, this affected the quality of the
consultation, given the limited time allotted to each patient. Patients' understanding of and
expectations for specific types of drugs, such as antibiotics, are hard to manage when pressed for
time, as observed by a doctor from the hospital.
Our health promotion teams interacted with local pharmacists, who felt they were only fulfilling
a void in a system where the patients demand antibiotics, and the medical shops supply it.
Considering the shortage of doctors in public health facilities, medical shops provided a
convenient and quicker shortcut, even if antibiotics were expensive.

Reflecting on the tendency of self-diagnosis, a pharmacist remarked that people consume

antibiotics as if they were not medicines but vegetables. Our doctors would encounter patients
who described antibiotics vaguely as "red capsules" or "white tablets" but with an unshakable
belief in its need and efficacy.

Antibiotic resistance is not a conventionally distinct disease, and has not captured public
imagination the way other critical public health threats or epidemics have. This means
deconstructing and changing popular perceptions and habits about antibiotics can be tricky. How
do you break a habit when you cannot describe what the problem looks like? Discontented
parents who do not receive antibiotics for their child's common cold or cough often became
suspicious and angry. As a parent in our clinic argued, "We've been using these tablets since
childhood without any problems. I came here for the medicine, not your silly advice."

Our experience reaffirms the need within health systems for better surveillance and data
collection of emerging and existing resistance patterns. Once the evidence is collected, we must
ensure proper systems are in place to analyse and share this information. Our efforts at patient
counselling and community outreach have taught us that antibiotic misuse is not just a medical
issue but a complex socio-cultural problem that is influenced by cost, access and knowledge.

Patient education is as vital as sensitisation of medical practitioners and policy makers. We

desperately need the new drugs, but we need to preserve what we already have and how we use
them even more.