Preventing Antimicrobial Resistance Together
Most Indians’ first memory of healthcare includes an old biscuit tin converted into a medicine chest. Diseases were diagnosed by the vaguest of symptoms: “My stomach hurts”, and amma would dispense medicines with an air of self-assurance that would make anyone feel safe. Much of India, even today, keeps medicines for common illnesses stocked at home and uses them without prescription, stopping the course when symptoms do. This is partly guided by economic logic — many people with precarious livelihoods cannot afford a full course of medicines, or to miss a day’s work for a doctor’s visit. Another contributor is a common (mis)understanding of the immune system, where antimicrobials (antibiotics, antifungals, antivirals and antiparasitics) are seen to cause dependency, disturbing the body’s “natural balance”. The issue of antimicrobial resistance rarely figures into the decision.
The World Health Organization (WHO) recognises Antimicrobial Resistance (AMR) as one of the top 10 global public-health challenges facing humanity today. A study in Lancet estimated that, in 2019 alone, antibiotic-resistant bacteria caused more than 1.2 million deaths globally; South Asia accounted for 389,000 of these deaths. The region also had the second-highest rate of deaths attributable to bacterial AMR, behind only Sub-Saharan Africa. Dr Kamini Walia, who led an Indian Council of Medical Research (ICMR) study on AMR, has said that “the resistance level (in India) is increasing [by] 5 to 10% every year for broad-spectrum antimicrobials which are highly misused.”
Combating AMR requires urgent multi-sectoral action. Unfortunately, it is often perceived solely as a medical problem, with solutions focusing on the behaviour of individual doctors, who prescribe medicines, and patients, who make “irrational demands” for them. This narrow view of AMR is underpinned by the larger medicalisation of health, which places questions of health squarely within the hospital and away from communities that are affected by them. This leads to a low presence of social scientists and civil society in discussions surrounding AMR and prevents us from understanding the deep socio-economic roots of antimicrobial resistance such as poverty, inequality and a lack of access to civic infrastructure.
Social, cultural and economic determinants of antimicrobial resistance, mostly ignored in medical studies, are central to social science research on AMR. For example, a 2016 anthropological report on AMR analyses the appeal of ‘irrational’ or ‘inappropriate’ use of medicines taking into account their symbolic value and their role in rituals of care. Doctors explain that patients who are not prescribed antibiotics are dissatisfied with the quality of care. Some sociologists frame ‘inappropriate’ antibiotic consumption within a “sociology of deviance” where the unprescribed use of antibiotics and shortening of a medicine course are not seen as deviant behaviour, but as economically rational practices. In the post-pandemic world where scepticism of medical authority is rising, sociology of deviance has become a valuable framework to understand the ways in which people seek healthcare. International Relations studies look at how the creation of legal instruments and new norms propels international collective action. They compare the AMR issue to HIV/AIDS and pandemic preparedness where diplomacy has produced considerable success.
In 2015, the WHO released a Global Action Plan (GAP) on AMR with five overarching objectives. One of these objectives is to “strengthen the knowledge and evidence base through surveillance and research.” A comprehensive review of the GAP by the WHO Evaluation Office highlights there has been much more emphasis and progress on surveillance than on research. A bibliographic study from 2019 argues that while AMR is witnessing some rise in academic attention, social science research on AMR still makes up a minuscule share.
Behavioural interventions on AMR, hampered by their inability to draw from diverse social science disciplines, often ignore the socio-economic determinants that drive the overuse of antimicrobials. Individuals in underdeveloped countries, saddled with the responsibility of good hygiene, are forced to find “quick fixes” that are more accessible such as the use of antimicrobials. In regions struggling with chronic dysentery, antimicrobials are used as a quick fix for productivity since they allow patients to return to work early. Many hospitals in the Global South, overcrowded due to a lack of beds and unable to meet sterilisation requirements for patient rooms, pump patients with antimicrobials to stave off infection. In all these settings, public health is reduced to the provision of pharmaceuticals.
In this context, the role of civil society and social workers must go beyond ‘awareness generation.’ Advocacy must focus on plugging infrastructural and knowledge gaps so that behavioural interventions at the individual or community level are sustainable. The interventions themselves should employ images and metaphors that are relatable to the target audience and build a sense of social responsibility, rather than relying on compliance with authority. It is essential that we hear from social scientists, community workers and civil society, along with doctors and medical researchers, to work out implementable solutions to AMR and not just quick fixes.
An edited version of this article was published on Scroll.in and can be found here.
