How dogma trumps evidence in the practice of prescribing antibiotics

by Helen Lambert

Most of the UK population have grown up with the message that patients must complete their course of antibiotics to stop drug resistance developing. A recent paper in the British Medical Journal caused international controversy by pointing out that far from preventing the emergence of antibacterial resistance, greater exposure to antibiotics increases the risk of acquiring resistant pathogens; and where research evidence exists, shorter courses of antibiotics are mostly (though not always) as effective as longer ones.

Yet this is nothing new; almost two decades ago the Lancet highlighted the fact that drug resistance mostly isn’t created by not ‘completing the course’ but by other mechanisms. Both 1999 and 2017 publications attribute the familiar mantra  ‘complete the course’ to fear of undertreating the infection, and both observe that recommended course durations are based on historical convention, and both call for more research (randomised controlled trials) to discover the minimum effective duration of antibiotic treatment for different types of infection. But the extensive media coverage that followed the 2017 paper ignored the problem of missing evidence and focused on the ‘news’ that advice to ‘keep taking the tablets’ is incorrect.

UK medical authorities have continued to oppose the withdrawal of this advice. According to the Royal College of General Practitioners, “The mantra to always take the full course of antibiotics is well-known. Changing this will simply confuse people”, while the British Society for Antimicrobial Chemotherapy states, “Much clearer evidence and advice are needed before changes in policy are considered”. Is it justifiable to give advice which isn’t backed by scientific evidence and may do more harm than good (by exposing individual patients to the acquisition of drug resistance) simply because we don’t know what else to tell people? Explicit acknowledgement that current prescribing conventions are not fit for purpose would strengthen the case that we urgently ‘need to improve our evidence-base on appropriate durations of therapy for particular infections and patient groups.’

Would overturning dogma increase risk to patients?

Doctors worry that if not advised to ‘complete the course’, patients will stop taking antibiotics when they feel better. This assumes people obey instructions on medication use, but decades of social science research show that patients adapt or simply ignore doctors’ advice according to circumstances and personal experience.

In primary care, antibiotics are used to treat illnesses symptomatically – so when patients are (mis)prescribed antibiotics for viral infections, the sooner they stop, the better. For common bacterial infections (except TB), the therapeutic consequences of people stopping antibiotics once they feel better are unknown, but it’s not inconceivable that subjective perceptions reflect effective treatment; after all, subjective wellness is consistently associated with longer survival. Turning the familiar advice on antibiotics ‘on its head’ only relates to people who get antibiotics as outpatients anyway; clinicians decide on type and duration of antibiotic courses for those in hospital.

Are recommendations to seek medical advice helpful?

Advice to ‘complete the course’ has been dropped by some authorities including the WHO, in favour of, ‘always follow a doctor’s advice’ or, ‘Only use antibiotics when prescribed by a certified health professional’. Such messages may be appropriate in high-income settings like the UK, but where care from qualified health professionals is lacking or costly, such exhortations are sadly unachievable for many. Self-medication with antibiotics purchased over-the-counter is all too often the cheapest and most accessible option for the poor; and it may be a less important driver of AMR than overprescribing of broad-spectrum antibiotics in private hospitals. Public education about the global challenge of AMR needs to address the reality of different contexts.

Waiting in vain for more evidence

The 1999 article’s author, my father (who died in April, aged 90), told me the journal’s editors added the question mark in its title against his wishes; he had wanted to make a clear statement about the fallacy behind antibiotic prescribing conventions. Eighteen years have seen scant progress in withdrawing advice to complete the course or answering the call for evidence. Trials to compare antibiotic dosages and durations for different infections lack support and funding. The methodology is complex, ethics clearance difficult and pharmaceutical companies have no incentive to demonstrate that shorter courses work as well as longer ones. A recent commentary on the controversy reiterated the need for evidence, concluding with inadvertent irony, ‘We would rather not read the same headline a decade from now’. Now antimicrobial resistance is recognised as a global threat, funding pours into research on diagnostic technologies and novel antimicrobials, while the decision-making needs of doctors and ordinary people remain unmet.

The real controversy lies not in whether advice to ‘complete the course’ is appropriate, but in what to tell patients instead. Lacking information on how long is long enough, too many health professionals fear admitting medical ignorance to their patients. It looks as though the mantra may be secure for a few more years yet – a testament to the tenacity of medical dogma, and the valorisation of basic science and technology innovation over essential clinical, social and population health research.

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Helen Lambert is grateful to Professor Alison Holmes for insightful comments.

You can follow Helen on Twitter @HelenSLambert

Find out more about what the research councils are doing to tackle antimicrobial resistance and the battle to keep our drugs working.

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Standardisation: Curing or obscuring AMR’s language problem?

In this month’s guest blog post, Marco Haenssgen, Nutcha Charoenboon, and Yuzana Khine Zaw reflect on the problems of language entailed in describing and tackling AMR at a global level, drawing on their experience with a range of communities in northern Thailand. They point out that calls to agree a standardised AMR vocabulary don’t take account of situations where there is no direct equivalent in local language for ‘antibiotics’; and they suggest that attending to the social or economic drivers of medicine use may be more important than focusing on individual ‘awareness raising’.  

By Marco J Haenssgen, Nutcha Charoenboon, and Yuzana Khine Zaw

A comment in Nature recently highlighted that “antibiotic resistance has a language problem” (Mendelson et al., 2017), alluding to the ambiguity of terms like “stewardship,” lacking popular awareness of “antimicrobial resistance,” and the problematic translation of “antimicrobial resistance” (AMR) into other languages. The authors suggest that unambiguous umbrella terms like “drug-resistant infections” and “antibiotics” could support efforts to address the global health priority issue of antimicrobial resistance, although the local interpretation of these words may vary across and within countries. Drawing on our research on antibiotic-related behaviour in Southeast Asia with the Centre for Tropical Medicine and Global Health (University of Oxford), we agree that language is an important and locally specific facet of antimicrobial resistance, but we caution against championing globally standardised and awareness-centred approaches in light of deeper-rooted local understandings and behaviours involving antibiotic use.

Language does indeed matter, and it is an expression of how people think about medicine and illness. Take for instance our work in Chiang Rai in Northern Thailand (pictured). In interviews with fever patients, we have come across varied expressions of “antibiotics.” For example, antibiotics are often translated into “anti-inflammatory medicine” (“ยาแก้อักเสบ” or “yah kae ak seb”) (So & Woodhouse, 2014:84).i This notion of anti-inflammatory drugs resonates with local descriptions of illnesses as being caused by inflammations of the body (e.g. in the case of a sore throat), for which this “anti-inflammatory” medicine may be deemed appropriate.ii Moreover, some local ethnic groups in Chiang Rai (e.g. Akha) may not have an equivalent of the Thai term in their mother tongue and rather refer to antibiotics as “medicine that relieves the pain,” and yet other people would not actively distinguish between antibiotics and other kinds of medicine.iii The literal translation of “antibiotic” (“ยาปฏิชีวนะ” or “yah pa ti chee wa na”) is a technical term with Pali roots (akin to Latin) that is hardly used or understood in rural Chiang Rai. Even seemingly unambiguous expressions like “drug resistance” (“ดื้อยา” or “due yah”)—literally translated into being “stubborn to [the effects of] medicine”—can be interpreted by non-native speakers or people without active conceptions of antibiotic resistance as meaning “stubborn to take medicine.”

Landscape in Chiang Rai Photo credits: Nutcha Charoenboon.

Landscape in Chiang Rai
Photo credits: Nutcha Charoenboon

What does this teach us? On the one hand, a standard language to tackle antimicrobial resistance may reach its limits in contexts where there is no shared understanding of antibiotics or other antimicrobials, and where there is no clear distinction between antibiotics and other medicine. We thereby share Helen Lambert’s concern that simplistic and standardised messages that do not take account of local notions of illness and medicine could lead to unforeseen behaviours like scaring people off medicine when they in fact need it (Lambert, 2016). This is not a purely theoretical concern, as we have witnessed such cases first-hand in other studies involving non-verbal communication for AMR.

On the other hand, the common policy emphasis on education and “awareness raising” for AMR (Department of Health, 2013; Gelband et al., 2015; The Review on Antimicrobial Resistance, 2016:19-20; WHO, 2015) assumes that irrational choices are the main driver behind problematic antibiotic-related behaviour (e.g. over- or under-use of antibiotics), but not all medicine consumption is the result of active choice. Social, economic, and health system constraints may drive people into behaviours where they may be more likely to access antibiotics—knowingly or unknowingly. These broader determinants of behaviour require us to think out of the box. Consider for example the recent Thai “Antibiotic Smart Use” campaign to reduce antibiotic over-prescription for conditions like sore throats. This campaign has encouraged primary healthcare providers to prescribe traditional herbal medicines capsules to patients who might expect to receive medicine in return for a costly visit to the healthcare provider (So & Woodhouse, 2014:84). Poorer and more remote population groups might benefit from the “Antibiotic Smart Use” approach because their expectations  might be accentuated by higher costs and greater hardship to reach healthcare facilities (yet, not all are actually able to access public healthcare). But activities that influence antibiotic use may not stop at health policies and interventions: Might for instance sick leave, access to financial services like loans and savings accounts, or more efficient public transport alleviate some of the constraints that shape the antibiotic use among marginalised groups?

In summary, while we agree that antimicrobial resistance has a language problem, we do not believe that its solutions lie primarily in standardising terminology but rather in appreciating and responding to local conceptions, and in strategies beyond awareness raising that help to reduce antibiotic over-use without discouraging access to medical treatment and essential medicines for socially, economically, or spatially marginalised groups. Social research (including e.g. anthropology, sociology, economics, or political sciences) can help to learn the extent to which this argument holds. Our own research programme in Southeast Asia thereby studies the relationship between patients and the health system, focusing on the role of primary-care-level biomarker testing, the evolution of explicit and implicit antibiotic demand and supply, and the constraints and social dynamics that entail varied forms of antibiotic access.

Notes

i This mirrors for example reports from China (Fang, 2014; Lv et al., 2014; Yu et al., 2014).

ii Our point is not that this is a wonderful foreign context—antibiotic over-prescription e.g. for sore throat can also be observed in high-income Europe; see e.g. Dekker et al. (2015).

iii These are not the only examples, and our informants also had a wide range of notions and descriptions for other medicines ranging from brand names (e.g. Tiffy) via generic descriptions (fever reliever) to visual descriptions (“the white pill”).

Contributors

Marco J Haenssgen has a background in development studies and is Postdoctoral Scientist – Health Policy and Systems at the Centre for Tropical Medicine and Global Health (CTMGH), University of Oxford, where he leads social research on antibiotic-related behaviour in Southeast Asia (including a Theme-4 grant of the Cross-council Initiative to Tackle Antimicrobial Resistance: http://gtr.rcuk.ac.uk/projects?ref=ES%2FP00511X%2F1). Nutcha Charoenboon is based at the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok. She has a background in biology and works as research officer on these projects in Thailand, Myanmar, and Lao PDR. Yuzana Khine Zaw is an MSc candidate in International Health and Tropical Medicine at the CTMGH, where her thesis research compares local conceptions of illness and medicine in the context of biomarker testing in Myanmar and Thailand.

References

Dekker, A. R. J., Verheij, T. J. M., & van der Velden, A. W. (2015). Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Family Practice, 32(4), 401-407. doi: 10.1093/fampra/cmv019

Department of Health. (2013). UK five year antimicrobial resistance strategy: 2013 to 2018. London: Department of Health.

Fang, Y. (2014). China should curb non-prescription use of antibiotics in the community. BMJ : British Medical Journal, 348. doi: 10.1136/bmj.g4233

Gelband, H., Miller-Petrie, M., Pant, S., Gandra, S., Levinson, J., Barter, D., et al. (2015). State of the world’s antibiotics, 2015. Washington, DC: Center for Disease Dynamics, Economics & Policy.

Lambert, H. (2016). The rhetoric of resistance.  Retrieved from amrchamp.blogs.ilrt.org/2016/09/21/the-rhetoric-of-resistance/

Lv, B., Zhou, Z., Xu, G., Yang, D., Wu, L., Shen, Q., et al. (2014). Knowledge, attitudes and practices concerning self-medication with antibiotics among university students in western China. Tropical Medicine & International Health, 19(7), 769-779. doi: 10.1111/tmi.12322

Mendelson, M., Balasegaram, M., Jinks, T., Pulcini, C., & Sharland, M. (2017). Antibiotic resistance has a language problem. Nature, 545(7652), 23-25. doi: 10.1038/545023a

So, A. D., & Woodhouse, W. (2014). Thailand: Antibiotic Smart Use Initiative. In M. Bidgeli, D. H. Peters & A. K. Wagner (Eds.), Medicines in health systems: advancing access, affordability and appropriate use (pp. 83-86). Geneva: World Health Organization.

The Review on Antimicrobial Resistance. (2016). Tackling drug-resistant infections globally: final report and recommendations. London: The UK Prime Minister.

WHO. (2015). Global action plan on antimicrobial resistance. Geneva: World Health Organization.

Yu, M., Zhao, G., Stålsby Lundborg, C., Zhu, Y., Zhao, Q., & Xu, B. (2014). Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children: a cross-sectional study. BMC Infectious Diseases, 14(1), 112. doi: 10.1186/1471-2334-14-112

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Studying antimicrobial resistance: Interdisciplinary research is critical, but challenging

In this month’s blog post, Carolyn Tarrant reflects on the challenges and rewards of doing cross-disciplinary AMR research, drawing on her experience of participating in the workshop on ‘Interdisciplinary Research and AMR’ convened in Bristol by the ESRC AMR Research Champion in March 2017.

By Carolyn Tarrant

In March 2017 I travelled down to Bristol for a two day meeting on interdisciplinary research into antimicrobial resistance (AMR), organised by Helen Lambert (ESRC AMR Research Champion), University of Bristol. Around 50 researchers had come together for the workshop, and they were a diverse group – over coffee and dinner I spoke to lab-based researchers, economists, psychologists, sociologists, and clinical researchers. All were working on, or were interested in, infection, antibiotic use, and antimicrobial resistance, but all were looking at the problem in different ways. The workshop was part of an ongoing investment in an ambitious cross- research council initiative which has been running since 2015, with the aim of creating an infrastructure for interdisciplinary research into AMR.

Interdisciplinary research is becoming ubiquitous, but why is interdisciplinary research particularly important in the case of AMR? Antibiotic resistance is one of the pressing problems of our age, and a global risk. Through exposure to antibiotics bacteria can develop resistance, meaning that antibiotics that were previously effective in treating infections will no longer work. Some have predicted a catastrophic future scenario where people will be at risk of dying from even minor injuries and infections because we can no longer call on antibiotics to treat them.

There is no simple answer to the problem. Although scientific research into new ways of treating infection and better diagnostic tests will make an important contribution, the proliferation of antibiotic resistance is as much a social as a technical problem – it’s down to the ways we use (and over-use) antibiotics. Because behaviour around antibiotic use is so important for controlling the spread of resistance, social scientists have an important role to play, working alongside scientists, clinicians, and policymakers to better understand the nature of the problem and find ways to intervene. Interdisciplinary approaches to research offer exciting possibilities for novel solutions, but can also pose significant challenges, not least navigating the political, emotional, and practical aspects of working in interdisciplinary teams. The ESRC workshop was a valuable opportunity to reflect on these benefits and challenges in the context of work on infection control and AMR.

Among those presenting were Henry Buller and Kristen Reyher (Universities of Bristol and Exeter), who are working on interdisciplinary projects on antibiotic use in farming and who emphasised the challenges of developing a shared vocabulary, and the importance of engaging the wider community of farmers in their research. Marco Haenssgen (University of Oxford) drew on his experience as a social scientist of working on interdisciplinary research on AMR in India, China, and Thailand to highlight the challenges arising from people working within different paradigms and with different objectives, assumptions and expectations, but also to emphasise the value of interdisciplinary research in tackling problems more holistically, and not losing sight of the ‘big picture’.

What also became apparent, but is perhaps less often discussed, is the challenge of forming interdisciplinary teams in the first place. How do we meet people we might need to work with? How do we overcome our suspicions of others who may speak a different ‘language?’ We need more opportunities to meet and talk to others outside of our discipline. In my work I rarely come across farmers or vets, but from talking to researchers in these fields during the workshop I now understand much more about the range of stakeholders in this global problem, and appreciate the value of an integrative ‘One Health’ approach. We need to know who the important people for us to talk to and work with are, and have the opportunity to build some level of familiarity and trust, which are critical elements for the start of a good working relationship.

The presentations and discussions resonated with my own experience of working on the interdisciplinary project: ‘Antimicrobial resistance as a social dilemma’. The project involves social scientists from different disciplines and methodological backgrounds, along with clinicians in microbiology/infection control, and this has thrown up both benefits and challenges.

First the positives: the big benefit of interdisciplinary working is the stimulation of new ways of thinking. Clearly, there are potential benefits from using social science theory to help us understand how to tackle the important but seemingly intractable problem of AMR. But as social scientists, working on a new, applied problem also brings opportunities to develop within our disciplines. One of my co-investigators is particularly excited about how working on AMR will help take things forward in his field; he feels he would not have thought about working on AMR if we had not put together this interdisciplinary team. The clinician role in our project is critical, and the social scientists in the group have learned a lot from the clinicians. As social scientists we can theorise but we don’t have that insight into important aspects of day-to-day clinical practice – the decisions that have to be made, the risks that have to be balanced, the challenges that arise, and the way that behaviour is shaped by the context in which they practice. This insight is so critical in ensuring that theorising is anchored in the realities of the clinical world.

But it hasn’t all been plain sailing! I’ve found there are different expectations in the team of the goals of the research and what the outputs might be. Perhaps not unexpectedly, the clinicians are more interested in interventions – they want to know what can be done differently to optimise prescribing. The academic social scientists have a strong slant towards theory development, but different theoretical perspectives can pull the research in different directions. Within this project we’ll need to keep the dialogue going about expectations goals, and end outputs from this particular project. But at the same time, as it’s a pump priming grant, we’re keen to explore how we can develop ideas for future research together.

At our second meeting, one of the team bravely admitted that they didn’t understand anything about agent-based modelling, an approach we plan to use in the project. We all recognised similar gaps in our knowledge and expressed anxieties about this – some team members didn’t really understand qualitative research methods, or how antibiotic resistance comes about. I’ve reassured the team that the value of interdisciplinary research is that everyone brings different and valuable expertise and perspectives to the problem. We don’t all need to be experts in everything, instead we need to recognise where we each are experts, and be aware of the extent and limits of our knowledge. But, if we’re going to be able to bring these different perspectives together we all need some level of shared understanding to orient towards the problem. My ‘crib sheet’ folder of key, accessible resources, which has been shared with the team, is one way of trying to help us develop this shared understanding.

What’s also helpful is having someone who can act as a lynchpin – with a broad level of understanding of the different disciplines or perspectives, and with the interactional expertise to orchestrate cooperation between people from different worlds. I’m cognisant of the need for me to play that role; as project lead, managing relationships and interactions within the team will be as important as project management.

We’ve also faced practical challenges of getting the team together for a meeting – so far our meeting plans have been disrupted by a Tube strike, Storm Doris, and the need to avoid the Sri Lankan monsoon season!

Perhaps the strongest message that I took away from the workshop and from beginning work on our project is that tackling antimicrobial resistance will be impossible without interdisciplinary research, but we also need to recognise that we have to work hard at building strong cooperative relationships and maintaining open communication in order to help make it work.

Contributor

Carolyn Tarrant is a Senior lecturer in SAPPHIRE, Department of Health Sciences, University of Leicester. Social scientist and qualitative researcher. Interested in ethnography, evaluation, patient safety, quality improvement, acure care, healthcare associated infections.

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Tackling AMR through behaviour change: a cross-disciplinary and multi-professional research collaboration

This month’s guest blog reports on the programme of social science and interdisciplinary research that is being carried out within the UK’s three NIHR-funded Health Protection Research Units that focus on Hospital-Acquired Infections and Antimicrobial Resistance. Raheelah Ahmad and Sarah Tonkin-Crine’s report into their annual joint meeting gives a flavour of the wide range of interesting and important work on AMR being undertaken in, or associated with, UK NHS and public health settings. The value of synergies generated by expanding cross-disciplinary collaboration in AMR and HCAI research was evident at the meeting and the report describes a number of interesting issues and opportunities for further research.

by Raheelah Ahmad & Sarah Tonkin-Crine

At the end of last year the NIHR Health Protection Research Units for Antimicrobial Resistance (AMR) and Healthcare Associated Infections (it’s a mouthful), convened for the annual meet, to exchange new investigative approaches, share findings and ensure synergies and collaboration in behavioural research. Professors Alison Holmes (Imperial) and Sarah Walker (Oxford) co-chaired.

Liberally plied with watermelon, sandwiches and hot beverages, researchers from Imperial, Oxford, UCL, Bristol and Public Health England (PHE) grappled and debated what more? what next?  as well as who?  We did our best to refrain from the usual finger pointing (at the different professional groups and different sections of the public); so less of the ‘who dunnit?’ and ‘who should fix it?’ to more ‘how can we fix this together?’ The participant list boasted a healthy smattering of social scientists, behavioural economists, epidemiologists, sociologists and those from cross-disciplinary management sciences. Professionally, GPs, Infectious Disease (ID) consultants, pharmacists, nurses, and microbiologists were around the table.

Following on from the first meeting in November 2015, Sarah Walker kicked off with an update of progress on collaborative projects. Sarah Tonkin-Crine and Annegret Schneider, both Health Psychologists, co-presented findings from a mixed method process evaluation of the latest AMR trial from PHE. Two talks focused on patient/professional communication: Tim Rawson (ID junior doctor and BRC Fellow) reported on his qualitative study to help shape enhanced communication resources and methods in the acute hospital setting; Donna Lecky (PHE) shared learning on the development  of TARGET patient leaflets for urinary tract infections in the GP setting during consultations to change prescribing expectations and behaviour. At the population level, findings on public attitudes to antibiotic use and resistance and implications for national level interventions were the theme of talks from Larry Roope (economist) and Tim Chadborn (Behavioural Insights Lead at PHE). From an international perspective Annegret Schneider gave a whistle stop tour on use of behavioural theories to develop interventions in the context of China. Alastair Hay (GP) provided insights from intervention development targeting GPs and parents to manage children with respiratory tract infections. For capturing the multiple policies implemented in the primary care setting, Raheelah Ahmad (NIHR Knowledge Mobilisation Fellow) used an organisational behaviour and strategic management lens to show the potential of System Dynamics to model knowledge mobilisation activities.

Alison Holmes chaired the afternoon in-depth discussion and Esmita Charani (Research Pharmacist) scribed the action points for the year ahead. The need for capturing evaluation and learning when new national level campaigns are rolled out was reiterated. The group reflected upon the opportunities for interventions aimed at different stakeholders before, during and after consultations within organised healthcare. How to optimise opportunities along the life-course as the public traverse in and out of the ‘patient’ role were also discussed.

The day was eloquently bought to a close with a frank and helpful talk from Helen Lambert. Helen encouraged recognition and use of the full breadth of social science disciplines and also drew on her international experiences. We had certainly exposed ourselves to new ideas, reflected and challenged our own logic models. In addition, as researchers and many as health professionals, we reminded ourselves of the need for reflexivity.

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Anti-microbial resistance and citizen science

This month the AMR Research Champion blog hosts a piece on the role of citizen science in AMR by an Oxford research team who have been exploring microbes in English kitchens. Their work is illustrated in a short film: Good Germs; Bad Germs. What 14 households in Oxford tell us about public understandings of the microbiome has yet to be seen, but check out our guest writers’ reflections on creating a citizen science project below and their valuable tips on what anyone planning participatory research on AMR needs to consider.

by Timothy Hodgetts, Jamie Lorimer, Richard Grenyer and Beth Greenhough

Citizen science projects have grown in number and ambition over recent years. In part that growth has been made possible by online networks that make it easier to contact and communicate with large groups of interested people. But there has also been a notable shift in the politics of science. The shift has happened through two forms of opening.

First, there has been an opening-up of laboratories from the inside. This movement starts from within scientific laboratories and moves towards an outside of concerned publics. The outward shift has been variously motivated: education for its own sake, a desire to ‘get people excited about science’ and to make an ‘impact’, a concern around communicating the uncertainty inherent in (most) scientific outputs, a recognition by funders that public funding requires public support, and an understanding that scientific futures require inspired apprentices. Furthermore, there has been a realisation amongst some practitioners that taking certain (but by no means all) forms of science out of the laboratory can lead to better science. Such research is ‘better’ in the sense that results are more accurate, or more reflective of the ‘real-world’ situations that they seek to inform.

Second, there has been opening-up of laboratories from the outside. This move is slightly different. It rests on the political claim that ‘better science’ involves the inclusion of interested publics from the earliest stages of scientific endeavour. Not only because including non-scientists might make the resulting research more robust, by voicing the contingencies of real-world situations that laboratory scientists might overlook. But also because the early stages of research are inherently political. There is always a politics involved in deciding what questions get asked, and what kinds of answers are deemed admissible. Excluding publics from this process amounts to an elitist exercise of undemocratic power. Including non-scientists in the early stages of research allows participation in setting the agenda, direction, and means of scientific practices. Such democratization is valuable in itself, but is also desirable if it makes the outputs of research (and their assumptions, caveats, and uncertainties) more translatable and palatable to a sceptical public.

Of course, none of this is new. These various opening-up movements have been occurring for many years now, albeit to differing extents depending on the context. These forms of participation seem particularly relevant for contemporary research into anti-microbial resistance (AMR), given the intersection of scientific and social uncertainties that characterize current concerns around public health. But the question of how to facilitate these trends – for more accurate and grounded research, and for more democratic and participatory public science – in the context of AMR is pressing and not (as yet) fully answered. Incorporating citizens simply as data gatherers is less complicated. Indeed, some projects have already been designed and enacted on these lines, although there are some real and not inconsequential ethical issues involved in so doing (as we will discuss more below). But incorporating citizens as scientists, who are involved in formulating the aims and objectives of research, in designing research interventions, and in evaluating their outcomes poses greater challenges. After all, microbiology can be complicated. The methods involved can be difficult to understand, the tools require specialist knowledge, and interpreting results can be an exercise in navigating ambiguity.

How then to facilitate a participatory form of research into contemporary anti-microbial resistance? Drawing on our current work in participatory microbiology, we suggest there are three key issues that need to be addressed:

(1) Mapping multiple understandings. Public understandings of microbiology differ. People in the UK have been educated in different eras of scientific knowledge, and to different levels of detail. Popular media have a tendency towards alarmist, and often contradictory, messages. Microbes, bacteria, and germs carry differing meanings for people and shape public practices in various ways. Horizontal Gene Transfer doesn’t get much airtime, or perhaps as much as it deserves. Future participatory research into AMR needs to take account of this heterogeneous context without simply seeking to ‘educate’ participants.

(2) Democratising methods. Democratising scientific practice requires involving public participants ‘upstream’, in question-setting and methodological design, not simply in collecting data. Microbiology tends to rely on specialized methods that assume significant pre-existing knowledge. The onus here thus falls on microbiologists and their academic co-investigators, to reflect critically on their methods and communicate the capabilities of these methods to participants. The co-production of research (assumed in democratized forms of science) relies on both publics and scientists to work together in order to make sense of experimental possibilities.

(3) Engaging with ethical challenges. Researching anti-microbial resistance through participatory methods poses some significant ethical challenges. The most pressing relate to the implications of emphasizing to public participants the extremity of the threat posed by resistant pathogens in particular circumstances; combined with the ambiguous state of knowledge around the social and ecological factors that generate AMR. The message: this is very scary, and we don’t know how to fix it (yet). There is a very real risk that in seeking to develop participatory forms of science, researchers may inculcate significant and health-altering fears and anxieties in participating publics; and not even have the prospect of a ready ‘solution’ to serve as antidote. In part, these concerns can be addressed by strict protocols that exclude at-risk participants with relevant health histories. They also need to be addressed through managing the narrative of scientists and the tools made available to publics. Researchers must therefore tread a line between the lofty goals of democratic science articulated above, and the grounded reality of avoiding harm to participants; and the latter concern must always come first in this form of research.

In our current research, we have had to navigate all three of these issues. Rather than AMR, our project revolves around public understandings of the microbiome – both the ‘good’ and ‘bad’ bacteria found in the human built environment (and inside humans). Working with 14 households in Oxford, we have been piloting a form of ‘participatory metagenomics’ in order to help people explore the microbial communities of their kitchens. We enable our participants to use cutting-edge microbiological tools, and to design their own experiments. We work together to make sense of the methodological possibilities, and to interpret the results. There are, of course, all manner of subtle and hidden power dynamics that structure this co-production. Our scientists retain a position of knowledge with respect to the dark arts of metagenomic sequencing. Our social scientists have a not inconsequential hand in steering the group’s overall direction. We have had to navigate different levels of formal microbiological education amongst the group, whilst making space for diverse forms of practical knowledge, experience and beliefs. We have deliberately avoided using microbiological tools that can identify specific pathogens (despite the call for their inclusion from some of our participants) in order to avoid unnecessary anxieties and to focus the discussion on wider microbial ecologies. We thus continually tread the lines between science-education and multiple knowledges, and between science-democratization and the avoidance of harm.

We think participatory forms of science of the kind outlined here have much to offer the AMR research agenda. Instrumentally, we suggest they might lead to ‘better’ research: more applicable to the challenges faced by people in their everyday lives. Ethically, we suggest they may lead to more inclusive forms of public science that work to dissipate the contemporary distrust of ‘experts’. Economically, we suggest that such methods therefore represent excellent value for money. We hope that the guidelines above might aid researchers embarking on this route.

You can read more about our project, and watch a short introductory film, at www.goodgerms.org. We have drawn on a wide-range of work in the argument above, but key resources include:

Callon M, Lascoumes P & Barthe Y 2009. Acting in an uncertain world: An essay on technical democracy, Cambridge, Mass., MIT Press.

Whatmore, S 2009. Mapping knowledge controversies: science, democracy and the redistribution of expertise. Progress in Human Geography, 33, 587-598.

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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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What can Leonardo Da Vinci teach us about tackling drug resistant infections?

by Christie Cabral and Helen Lambert

Anti-microbial resistance (AMR) is a ‘wicked problem’ leading to drug resistant infections.  The evidence is incomplete or contradictory, there are many different interest groups with different needs and views, and the ‘solution’ depends on how the ‘problem’ is framed and vice versa.  Like other ‘wicked problems’ (e.g. climate change, species conservation, pandemic influenza) that result from the complex interaction of a huge range of influences, there is no single, simple solution and so our response needs to be multifaceted.

LeonardoLeonardo Da Vinci, one of the best known polymaths, excelled in different artistic and scientific fields long before we had separated these activities out into the numerous disciplines we have today.  This boundary-crossing approach is what is called for by the Cross-Council Initiative to tackle antimicrobial resistance.

Inter-disciplinary research is often under-funded and poorly regarded but it is essential “to solve the grand challenges facing society”.  The Cross-Council Initiative is a rare call for everyone from Artists to Veterinary Scientists to work together on the problem of AMR.

 

So far, a lot of attention has focussed on possible technological solutions (such as new antibiotics and rapid diagnostic tests), but key work by the O’Neill Review team has rightly highlighted the importance of understanding economic processes.  These underline the ‘wicked’ nature of this problem, as the needs and views of stakeholders are not aligned.  Pharma companies want to maximise profits, but governments want to restrict the use of new antibiotics to preserve their effectiveness – so the pharmaceutical industry cannot recoup the costs of developing them through sales. The O’Neill Review recommends other financial mechanisms to encourage the pharmaceutical industry to develop new drugs that can be reserved for use when current ‘last resort’ antibiotics become ineffective.

But improving the likelihood of future technological innovations can only ever be part of a solution. When, how and why people use existing antibiotics unnecessarily – for themselves or their animals – are problems that can’t be tackled through drug or diagnostics development.  For many people around the world, especially in lower and middle income countries, the problem is not so much too many antibiotics as insufficient access to them.  The tension between access and excess is another dimension of the ‘wickedness’ of the problem; seemingly obvious solutions, like banning over-the-counter antibiotics sales in low-income countries, risk denying essential life-saving drugs to the poor, who lack easy access to decent medical care where they can be prescribed appropriate antibiotics when needed. Here social science is needed to understand the complexities of human behaviour and the cultural, social, institutional and political forces that shape it, as well as individual psychology. This way we can gain insights into ways to ensure that people get access to these life-saving drugs when they need them, while not using them unnecessarily so that infections become resistant to them.

The ESRC-led Theme 4 of the Cross-Council Initiative is entitled ‘Behaviour within and beyond the health care setting’.  As we saw at our recent Social Science and AMR workshop (#amrchamp), potentially relevant research covers a broad range of topics.  When social scientists get together, some interesting questions get asked: what types of drug resistance are a problem, in which contexts and for whom?  Issues of justice and future security are highlighted by international relations researchers looking at the unequal balance between access to antibiotics and the development of drug resistant infections across the globe.  Geographers, sociologists, environmental and veterinary scientists are looking at how our environments are entangled and the poorly understood microbiological pathways and social networks by which resistance is spread, without which we cannot know which ‘human and animal behaviours’ it might be sensible to target.  Artists and engineers are exploring how to design infection control into our world and how to communicate important messages to the wider community.

We come back to the ‘wicked’ nature of the issue.  The way the ‘problem’ is framed is important to how we tackle it: excessive use, or lack of access; public demand, or market-led health systems that incentivise medical practitioners to overprescribe; international travel, or locally occurring ‘pockets’ of resistance; lack of incentives for commercial pharmaceutical production or lack of non-profit making alternatives for developing new drugs; medical/veterinary overuse, or environmental contamination?

The Theme 4 call is an opportunity for truly interdisciplinary research involving biological, medical and social scientists, engineers and artists.  Thinking and acting collaboratively is perhaps the only way we might truly be able to tackle this wickedly complex problem.

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Social Science Research on Antimicrobial Resistance

Social scientists from all over the British Isles came together to talk about antimicrobial resistance (AMR) at our workshop on Friday 22nd April.

The focus was on research which might be relevant to the forthcoming call for the cross council AMR Theme 4: behaviour within and beyond the health care setting.  To receive updates on this and similar funding opportunities, register an interest here.

Here are some of the highlights recorded by participants on Twitter #amrchamp

Helen Lambert introduces workshop

At Bristol zoo for day on social science research on AMR – looks like it will be an interesting day

Ian Donald: Social Sciences & AMR

  

Ian Donald: five questions we need to answer about behaviour and

Ian Donald says AMR research coming of age – needs a broad view of what social sciences can bring to AMR research

Matthew Avison on microbiology of AMR

Matthew Avison – when we distrupt our normal microflora we go around “sucking up new bugs like a hoover”

 Matthew Avison (@MutantBug) worth checking out if only for cat with hoover picture!

Gina Pinchbeck Vetinary Sciences and AMR

Gina Pinchbeck – what’s really happening with guidelines for antibiotic use in animals

Alasdair MacGowan: Infections and public health


Alasdair MacGowan: how can we measure the impact of antibiotic resistance

Alisdair MacGowan – takes a long time for patients with resistant infections to get the right treatment

Clare Chandler: a view from anthropology

Clare Chandler – there’s lot more to than changing behaviour to fix a single problem

Clare Chandler asking classic anthropological questions – AMR what is resisting what, where & why?

Jo Coast: a view from economics

we have really limited evidence on the cost of antibiotic resistance, need to change this

 Jo Coast – should we tax antibiotics?

Hayley Macgregor: a view from development studies

@PatriciaJLucas

Hayley mcgregor on the complex relationships between formal and informal health sectors. Fascinating

Import to rememb that many lack access to antibiotics, and informal unregulated access may be saving lives

 

Steve Hinchcliffe – antimicrobials are part of out (food) production infrastructure.

Stephan Elbe – Need to learn from past examples of health problems being thought of as security issues e.g. bird flu – pros & cons

Sujatha Raman: a view from sociology/science and technology studies

on how science & tech studies can help us to understand discourse of amr

Great meeting emphasising the key role of Soc Sci in the fight against AMR

 AMR is a ‘wicked’ problem – we need to find way to act despite inevitable uncertainty

Naomi Beaumont from ESRC chairs expert panel Q&A

@EmmaJ_Roe

Super expert presentations from these social scientists on AMR. A taster for future conferences.

Afternoon discussion sessions


Fantastic discussion at

Bristol Zoo Gardens – excellent venue!

Getting a break from AMR discussions…

Last session of Bristol AMR workshops. Interesting, engaging, productive & worth the 4.45 alarm-clock

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Reducing antibiotic prescriptions for children with coughs: who to target?

head shot  By Christie Cabral

Do parents want antibiotics when a child has a cough?  I’ve spoken to a lot of parents over the past five years and pretty well all of them say they would really rather not give their child any kind of drug treatment.  Yet the belief that parent demand for antibiotics is an important driver of antibiotic over-prescription is very persistent among clinicians and policy makers.

Over-prescription of antibiotics is a serious issue as it contributes to the problem of rising drug-resistant infections.  Considerable effort is going into trying to reduce over-prescription of antibiotics.  However, figuring out where best to target that effort is not always that straightforward.  The TARGET research programme and related Conker project investigated what influences antibiotic prescribing for children with coughs.

The parents we talked to in our study worry about the impact of any kind of medication on their child.  Many express fears around overdosing with child paracetamol and ibuprofen and believe that antibiotics should only be given if really needed.  All of this supports a general preference for not giving children any pharmaceutical treatment at all.

So that sounds like good news – parents don’t want antibiotics, problem solved; right?  Well of course the reality is messier than that.  Parents do want antibiotic treatment if they think it’s going to make a difference, to help their child to get better or to suffer less.   The key influence on parental expectation of antibiotic treatment is experience of antibiotics being prescribed for something similar in the past.  Often when antibiotics are prescribed, there is little explanation of the reasons, leaving parents to develop their own ideas about what symptoms indicate a need for antibiotic treatment.  These ideas are shared and reproduced within communities.  We have created an animation which shows how this happens.

The animation also illustrates a doctor’s point of view.  The doctor’s main concern is making sure they don’t miss a child with a potentially life threatening infection.  I think we would all agree that this is a good top priority.  However, because there is currently no definitive way of identifying children who may develop a serious illness from those who are poorly but will get better, doctors have to use their judgement to decide which ones to treat.  Most of the time, clinicians are able to judge confidently, but in a minority of cases there remains some uncertainty.   This is where the problem lies.  Faced with clinical uncertainty, many doctors will prescribe antibiotics in the belief that not only is it safer for the child in front of them but it also protects the doctor from the potentially serious medico-legal consequences of ‘missing a sick child’.

Reducing over-prescription of antibiotics for children with a cough is a challenging problem. Our research found that current antibiotic prescribing practices by doctors are a key influence on parental expectations (rather than the other way around).  Enabling doctors to change their practice will be a key part of the solution.  There is a need for basic science to help reduce clinical uncertainty, but we are still a long way from eliminating this.  In the meantime, there is a role for social science research in understanding how clinicians deal with uncertainty and how a different balance might be struck between the immediate risks to the patient and doctor and the wider risks to all of us from drug resistant infections.

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Newton Fund: Opportunity for China-UK research collaboration on AMR

Helen Lambert, ESRC Research Champion, attended image012
the UK-China joint workshop in Shanghai to discuss the recently announced call for collaborative research on AMR.

UK research councils (ESRC, MRC & BBSRC) together with the National Natural Science Foundation of China (NSFC) announced the call for photo1research into antibacterial resistance in China just before Christmas (details below if you missed it).  The funds for this call will be channeled through the Newton Fund which aims to promote the economic development and social welfare of partner countries. Applicant teams will need to include partner institutions from both the UK
and China which are eligible for funding from their respective country funding bodies new iPhone photos Jan 2016 532
(ESRC, MRC or BBSRC in the UK or NSFC in China).

Key Deadlines:

Expression of Interest: 15th January 2015

Full proposals: 1st March 2016new iPhone photos Jan 2016 448

Further information

new iPhone photos Jan 2016 502 new iPhone photos Jan 2016 480

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