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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