Many Indians may have a familiar memory of healthcare: an old biscuit tin converted into a medicine box, diseases diagnosed by vague symptoms (“my stomach hurts”) and a parent dispensing medicines with a self-assured air.
Even today, many Indians stock medicines at home for common illnesses, using them without prescription and stopping the course when symptoms subside. This is partly guided by economic logic. Many 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 misunderstanding of the immune system: antimicrobials (antibiotics, antifungals, antivirals and antiparasitics) are seen to cause dependency, disturbing the body’s “natural balance”. The problem of antimicrobial resistance rarely figures into the decision.
Antimicrobial Resistance, says the World Health Organization, “occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death”.
A public health challenge
Antimicrobial resistance is recognised by the World Health Organization as one of the top 10 global public-health challenges today. A study in The Lancet medical journal estimated that, in 2019 alone, antibiotic-resistant bacteria caused more than 12 lakh deaths globally. South Asia accounted for 3,89,000 of these deaths.
South Asia also had the second-highest rate of deaths attributable to bacterial antimicrobial resistance, behind only Sub-Saharan Africa. “The resistance level [in India] is increasing [by] 5 to 10% every year for broad-spectrum antimicrobials which are highly misused,” said Dr Kamini Walia, who led a study by Indian Council of Medical Research on antimicrobial resistance, Broad-spectrum antimicrobials are effective against a wide range of bacteria.
Unfortunately, antimicrobial resistance 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 antimicrobial resistance is underpinned by the larger medicalisation of health, which places related questions squarely within the hospital and away from the communities that are affected by them.
It also leads to a low presence of social scientists and the civil society in discussions about antimicrobial resistance and prevents understanding the deep socio-economic roots of this problem such as poverty, inequality and a lack of access to civic infrastructure.
Social aspects of health
Social, cultural and economic determinants, largely ignored in medical studies, are central to social science research on antimicrobial resistance. For example, a 2016 anthropological report on antimicrobial resistance analysed 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 course of medicine are not seen as deviant, but as economically rational practices. According to the research paper published by the Economic and Social Research Council, the sociology of deviance refers to the “violation of norms and socially created standards”.
In the post-pandemic world where scepticism of medical authority is rising, the sociology of deviance has become a valuable framework to understand the ways in which people seek healthcare. International relations studies looks at how the creation of legal instruments and new norms propels international collective action. Scholars in this field compare antimicrobial resistance to HIV/AIDS and pandemic preparedness where diplomacy produced considerable success.
In 2015, the World Health Organization released a Global Action Plan on antimicrobial resistance 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 Global Action Plan by the World Health Organization Evaluation Office highlights there has been much more emphasis and progress on surveillance than on research.
A bibliographic study from 2019, titled “The state of social science research on antimicrobial resistance”, argues that while antimicrobial resistance is witnessing some increase in academic attention, social science research on it still makes up a minuscule share.
Behavioural interventions on antimicrobial resistance, hampered by the inability to draw from diverse social science disciplines, often ignore the socio-economic determinants that drive the overuse of antimicrobials. For instance, in underdeveloped countries that have to ensure good hygiene, antimicrobials are “quick fixes”.
In regions struggling with chronic dysentery, using antimicrobials allows 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 these settings, public health is reduced to the provision of pharmaceuticals.
In such a 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 antimicrobial resistance and not just quick fixes.
November 18-24 is World Antimicrobial Awareness Week.
Akshay Bhagwat is a Programme Officer at Toxics Link, a Delhi-based environmental organisation engaged in disseminating information on toxic pollution and providing cleaner alternatives since 1996.