Anthropology of Infectious Disease: U Narayandas - Essay Example

Anthropology of Infectious Disease: U.Narayandas. Anthropology of Infectious Disease: Objective: To discuss and analyze whether "Western" ideologies and cultural practices of overusing antibiotics are leading to an emergence/re-emergence of infectious diseases and if it is so to find out remedial measures to curb the situation. Introduction: The emergence of human immunodeficiency virus (HIV) infection causing the disease acquired immunodeficiency syndrome (AIDS) and its killer sequels have brought into focus the emergence and re-emergence of infectious diseases. While AIDS is only the trigger, its sequels - diarrhea, tuberculosis, and systemic fungal infections are the bullets that actually kill. These sequels need special attention as all three in their non-AIDS context are of a socio cultural nature: tuberculosis is a socio-economic disease caused by malnutrition and diarrhea and systemic fungal infections are caused by poor hygiene and contaminated water. Further, all three were amenable to antibiotics/anti-fungal drugs and easily managed. The emergence of resistant and virulent strains of organisms causing them juxtaposed with the acutely debilitating AIDS is making them virtual killer diseases. Staggering Statistics: According to a press release by the American College of Physicians in July 2000, the annual consumption of antibiotics in the United States was $ 15 billion and the cost of treating antibiotic resistant diseases was at least $ 1.3 billion. Even if the consumption were to grow at a modest 10% every year, the figures would be a staggering $ 24 billion and $ 2.09 billion in 2005. There were, in one year, 51 million visits to physicians for cold, upper respiratory tract infections and bronchitis and in these visits 50%-66% were prescribed antibiotics even though these conditions usually do not need antibiotics. It was possible that the physicians prescribed more powerful antibiotics than needed or prescribed antibiotics for viral infections, for which they were useless. The report opines that behind the doctors stands, "an array of forces that keep the antibiotic consumption high". They include: patients' hunger for magic remedies, only which satisfied them that the doctor was really treating them; a system where novices were in charge of prescribing drugs; direct to consumer advertising by drug companies to induce patients to demand newer, costlier antibiotics where older, generic drugs would have worked as well or no drug was required and most importantly a health system that set targets to its physicians to see patients by the hour, reduce the number of return visits and get the patients out of the hospitals faster. (Misuse of Antibiotics Fueled by Culture and Economics. 2000) This is a damning indictment on the system not by a wayward whistle-blower but introspection by the American College of Physicians on the state of healthcare today. According to a report broadcast by the Australian Broadcasting Corporation the Australians consumed more than 200 tonnes of antibiotics in the year 2000-01, often for common viruses, which do not respond to drugs. According to a report prepared by the National Health and Medical Research Council of Australia, 50 % of the 24 million prescriptions written by the doctors in that year were unnecessary. (Over consumption of antibiotics.2001) Culture 'psyching' consumption: One of the principal reasons behind the indiscrimate use of antibiotics seems to be the role culture plays in the relationship between the patient and the doctor and the methods adopted to treat diseases. While the environment determines nosology or disease pattern of a society, it is the socio cultural milieu that determines its constituents' response to disease. The first component in the social interplay that approaches illness and its response is the patient. From the patient's point of view the prescription of an antibiotic seems to imply three things: one, that the patient has an illness; two that a diagnosis has been made and three that the illness is amenable to treatment. This is the reason why patients want antibiotics to be prescribed and physicians oblige them. "Patients want antibiotics, and physicians continue to prescribe them in situations where antibiotics may be withheld for many reasons. The act of prescribing an antibiotic has social and medical implications. From the patient's point of view, the prescribing of an antibiotic validates that the patient does have an illness, that a diagnosis has been made and that the illness is amenable to treatment. The fact that there is a "cure" for their problem reassures them that the illness is not serious." (Colgan R. et. al. 2001) Further, patients who are accustomed to receiving antibiotics, very strongly believe that antibiotics demonstrate efficacy and are necessary for proper treatment, even in benign cases, which do not require any antibiotics. There is the curious case in which patients refused to participate in a clinical trial because they did not want to be in the placebo arm of a randomized, double blind clinical trial. "Patients are accustomed to receiving antibiotics for benign URIs and have come to believe, sometimes very strongly, that antibiotics demonstrate efficacy and are necessary for proper treatment of these illnesses. So convinced are patients of the efficacy of antibiotics that in one clinical trial of acute bronchitis, 60 percent of patients screened for the study refused to participate because they did not wish to be randomized to the placebo arm of the trial." (Colgan R. et. al. 2001). The researchers opine that benign upper respiratory tract infections (URIs) do not require antibiotics but patients are often unnecessarily prescribed antibiotics even for such conditions. The demand for antibiotics can be affected by consumers' knowledge, attitudes and practices. The results of a survey conducted by the Foodborne Diseases Active Surveillance Network (FoodNet) in 1998-99 are indicative: twelve percent of the respondents in the population based, random digit telephone survey (including questions regarding respondents' knowledge, attitudes and practices of antibiotic use) "had recently taken antibiotics; 27% believed that taking antibiotics when they had a cold made them better more quickly, 32% believed that taking antibiotics when they had a cold prevented more serious illness, and 48% expected a prescription for antibiotics when they were ill enough from a cold to seek medical attention." (Jodi V.E., et.al 2003). How wonderful would it be to allow 'mother nature' to take care of a common cold or a sore throat rather than popping a pill at the first sign of a sniffle Steam inhalation was the oldest prescribed remedy for a common cold and gargle with a pinch of salt in warm water for sore throat. The survey had a revealing observation "These misguided beliefs and expectations were associated with a lack of awareness of the dangers of antibiotic use; 58% of patients were not aware of the possible health dangers." (Ibid) The authors had this recommendation: "National educational efforts are needed to address these issues if patient demand for antibiotics is to be reduced." (Ibid) A cultural reflection of the use of antibiotics was observed in a town on the US side of the Mexican border where 75% of the persons interviewed said they purchased antibiotics without prescription, in Mexico, as their sale is not regulated in that country. This was also observed in other cultural groups depending on their place of origin and whether antibiotic supply was regulated there or not. One of the reasons why patients seek antibiotic prescriptions (when they are not indicated) was possible misinformation by physicians and pharmacists. The US Food and Drug administration proposed that all antibiotics dispensed in the US should carry warning labels encouraging physicians to prescribe antibiotics only when absolutely necessary, and counsel patients to use them exactly as directed. (Mainous III) In Latin American countries drug rules are lax and pharmacists and hospital staff dispense or prescribe medicines, even those with a red band and require strict medical supervision. However the situation is changing as these countries too are turning to regulating antibiotic sales in view of the global alert sounded by the World Health Organization. Increased microbial resistance is recognized to be due to "lack of national control policies, poor antiseptic conditions, badly trained or overworked health care workers, and a popular culture of freewheeling antibiotic use.staff treating patients who have already consumed antibiotics in other hospitals and are now serving as hosts to resistant strains." (Spatuzza A. 2002) In Brazil, it was seen "over two thirds of pharmacies dispensed antimicrobials without prescription and the quantity depended on the patient's ability to pay." Anti-diarrheals were dispensed to patients with watery diarrhea without any oral re-hydration salts. All pharmacies dispensed antibiotics enough for one or two days although the recommended regimens ranged from one to five days. (Ibid) Belgian researchers found that educating the public on the appropriate use of antibiotics helped in cutting down their use. For example when a flu-like epidemic broke they launched two public education campaigns in the years 2000-2001 and 2001-2002. In these campaigns public were educated through booklets, handouts, posters, prime time television advertisements and websites. After the first year campaign antibiotic sales decreased by 11.7% and after the second year by 9.6% with an overall reduction of 13% during the two years. (Gordon 2004) Self treatment with left overs: The second most important concern about consumption of antibiotics is self treatment with left over antibiotics from a previous use. According to a survey conducted on 101 randomly selected adults 26% said that they saved antibiotics from a previous prescription that they have not fully used; 14% would take left over antibiotics without consulting a physician or other health care providers and 7% of them would share the antibiotics with others. It was estimated (in 2000) that 128 million doses of oral antibiotics were prescribed annually in the US. The health system does not have any control on - at least the - left over portion of orally administered antibiotics. If 26% of these prescriptions are added to the 'left over' kitty, 14% used without proper medical advice and 7% shared with others again without proper medical advice, then we are in for a dangerous cocktail. (Ceaser S., et. Al. 2000) "Not fully using a prescription" in itself can have serious implications as this can lead to antibiotic resistance. Further there is the possibility that the patients who shared the left over antibiotics have not seen a physician with the dangerous implication that a patient who was prescribed an antibiotic and who has not fully utilized his prescription has now become a quack. Consumption of contaminated meat: One more environmental reason for antibiotics losing their effectiveness is consumption of beef and poultry contaminated with antibiotics. Antibiotics find their way into meat through animal feeds, which are added to ironically keep the animals healthy and increase yields. A majority of Americans, it was revealed in a survey the results of which were posted on the Keep Antibiotics Working.com website, were blissfully unaware of antibiotic contamination. Animals raised in their natural environments do not require these feeds laced with antibiotics On the other hand animals which received antibiotic containing feeds during their breeding are likely to have residues in their meat leading to bacterial resistance in humans. (Nationwide Survey Reveals Most Americans Are Unaware They Consume Beef And Poultry Raised on Antibiotics. 2003) Iatrogenesis: The second component in the system that contributes to the excessive use of antibiotics is the physician. The Greek phrase - iatrogenic - literally means caused by the physician. Complications arising out of excessive use of antibiotics are iatrogenic in nature. According to the Centers for Disease Control and Prevention, approximately 50 percent of the antibiotic prescriptions written by office-based physicians are unnecessary. "The Centers for Disease Control and Prevention (CDC) estimates that about 100 million courses of antibiotics are prescribed by office-based physicians each year, and that approximately one half of those prescriptions are unnecessary." (Colgan R. et. al. 2001) There may be a plethora of reasons for this; one of them could be that doctors pressed for time may give in to patients' demands as detailed above. Two other reasons listed in the introductory of this pamphlet are: novices being entrusted with writing prescriptions and pharmaceutical industry's high-pressure campaigns. Physicians may be inclined to prescribe antibiotics for a bronchitis patient with purulent nasal discharge or when there is persistent cough for more than three days. The infection could be of viral origin in which case the prescription would be ineffective. (Colgan R. et. al. 2001). The higher consumption of antibiotics in British Columbia (than in northern Europe - Denmark, Sweden and the UK) is attributed to different standards of treatment followed there. For example doctors in the Canadian province treating middle ear infections (known as otitis media in medical parlance), straight away use antibiotics whereas in northern Europe they do so only after decongestants fail. In addition, guidelines for antibiotic usage may be funded by pharmaceutical companies, which have a vested interest in making the physicians prescribe them. Northern Europe has introduced such guidelines without the aid of the pharmaceutical industry with an aim to cut back the use of antibiotics. CDC advocates educating the physicians to convince the patients when antibiotics are not needed for minor ailments like colds and other means to arrest the spread of infections like hand washing. (Antibiotic Consumption Higher in British Columbia than Northern Europe CDC Announcements 2004) Another branch of iatrogenic diseases is 'infections acquired in hospitals' known as nosocomial infections in medical parlance. Virulent microorganisms resistant to antibiotics cause nosocomial infections. The answer is not in seeking more and more powerful antibiotics as the earlier ones become ineffective but improving the quality of care in hospitals. In blunt language this means that hospitals should ensure maintenance of total aseptic conditions in their premises including surgical theatres and wards and in the surgical operating procedures. (Over consumption of antibiotics. 2001) Development of Resistance: Resistance is often developed when the antibiotics are not used in adequate doses or not used for the duration required allowing the bacteria to survive and adapt to the environment by mutating. Prolonged use of antibiotics impairs the body's immune mechanism, resulting in an immuno-compromised state, which in turn makes the body vulnerable to further infections. A few antibiotics particularly the sulfa drugs and penicillins may cause severe allergenic - even life threatening anaphylactic - reactions. Others like tetracyclines, aminoglycosides, chloramphenicol and several anti-fungal drugs, such as amphotericin B, ketoconazole and niridazole have been shown to markedly impair the phagocytic action of neutrophils - a key component in body's natural immune mechanism. (Descotes 1999 64) The indiscriminate and improper use of antibiotics results in a survival-of-the-fittest selection process for microbes, which can both inherit and acquire resistance to drugs, through mutation or by sharing DNA. Just as in normal Darwinian evolution but accelerated umpteen times by the division of millions of microbes, an infection treated with the wrong drug or for too short a time results in most bacteria being killed while the resistant ones survive to multiply. (Spatuzza 2002) What we should do: This is what the general consumers should do to reduce indiscriminate use of antibiotics: Do not demand for antibiotics to be prescribed. Antibiotics are useful only against bacterial infections. Viruses cause the common cold and flu, and antibiotics are ineffective in treating these. Ask your doctor whether the antibiotics prescribed are indeed necessary. Question him about any possible side effects and allergic reactions. Please follow your physician's advice while taking antibiotics and conform to dosage regulations and duration of treatment. If you do not do this you may unwittingly play a part in the development of resistance. Throw away any "leftover" antibiotics and do not try to save a few dollars or a visit to the doctor for a subsequent illness. The "leftover" antibiotic may be the wrong one and the quantity "left over" may be insufficient to treat the illness, which will be a possible ground for development of resistance. Use a regular (non-antibacterial) soap and warm water to wash your hands frequently and especially at meal times. This is the best way to avoid spreading harmful microbes. Avoid putting hands and fingers in your mouth, nose, and eyes, the primary entry points for bacteria to enter your body. (Spatuzza A. 2002). Following these simple rules will ensure primarily, in the reduction of unnecessary use of antibiotics and as a corollary prevention of resistance development. Similarly awareness about the hazards consuming meat contaminated with antibiotics should be created and consumption of organic meat produced without the use of harmful antibiotics should be encouraged. On their part the physicians should assume both the responsibility and the decision to prescribe antibiotics and not coerced into prescribing them if they feel antibiotics are not indicated. If they decide that an antibiotic is not needed they should properly counsel the patient. This implies assuring the patient that the physician is the best judge to decide what is to be done and will do all that is needed to bring the patient back to health. If the physician decides to prescribe an antibiotic he should follow due procedures in selecting antibiotic/s and take the time to explain the proper use of them to the patient so that there is neither excessive/indiscriminate use nor irregular usage. On the part of the government, health authorities and other important stake holders there is a need to frame guidelines for not only prescribing antibiotics but also promoting the sale of antibiotics - similar to good manufacturing practices and good clinical practices. Although it will amount to grappling with the cash rich pharmaceutical lobby, perhaps national drug control authorities might step in to regulate the promotion of antibiotics and totally ban direct to consumer advertising for antibiotics. Educating publics about the need for selective use of antibiotics, their ineffectiveness in viral diseases and hazards of indiscriminate use through various channels mentioned in the Belgian example cited above might yield results in reducing consumption. Educating publics about personal hygiene guidelines like washing hands frequently with regular soap and avoiding putting fingers in the mouth, nose, ears and eyes will also go some way in minimizing the incidence and spread of bacterial diseases and the consequent necessity to use antibiotics. Bibliographic References: Antibiotic Consumption Higher in British Columbia than Northern Europe. Announcements. 2004-06-04. CDC BC Centers for Disease Control and Prevention. URL: http://www.bccdc.org Descotes, Jacques. 1999. An Introduction to Immunotoxicology. London. Taylor & Francis Ltd., Gordon S., Healthday Reporter. Education Campaigns Cut Antibiotic Use: Better public awareness may stem resistance to drugs. 2004-11-23. Health Scout. URL: http://www.healthscout.com/template.asppage=taf&ap=1&id=522516 Jodi Vanden Eng, Ruthanne Marcus, James L. Hadler, Beth Imhoff, Duc J. Vugia, Paul R. Cieslak, Elizabeth Zell, Valerie Deneen, Katherine Gibbs McCombs, Shelley M. Zansky, Marguerite A. Hawkins, and Richard E. Besser. 2003. Consumer Attitudes and Use of Antibiotics. CDC Emerging Infectious Diseases. Vol. 9, No. 9 September 2003. URL: http://www.cdc.gov/ncidod/EID/citation.htm Mainous III, A G., Hueston, W.J. 2001.Controlling Antibiotic Resistance: Will We Someday See Limited Prescribing Autonomy Editorial. American Family Physician. June 2001. Vol. 63 No. 6. URL: http://www.aafp.org/afp/20010315/contents.html Misuse of Antibiotics Fueled by Culture and Economics. 2000. American College of Physicians. ACP-ASIM Press Room. URL: http://www.acponline.org/index.htmlft Nationwide Survey Reveals Most Americans Are Unaware They Consume Beef And Poultry Raised on Antibiotics. 2003.06.12. Keep Antibiotics Working. The Campaign to End Antibiotic Overuse. URL: http://www.keepantibioticsworking.org/pages/ Over consumption of antibiotics. Australian Broadcasting Corporation.2001-07-25 URL: http://www.abc.net.au/7.30/content/2001/s335520.htm Richard Colgan and John H. Powers.2001.Appropriate Antimicrobial Prescribting: Approaches that Limit Antibiotic Resistance. American Family Physician. September 2001. 64:999-1004. Sarah Ceaser, and Rebecca Wurtz. 2000 Letter. "Leftover" Antibiotics in the Medicine Cabinet. Annals of Internal Medicine. Vol. 33 Issue 1. 74. URL: http://www.annals.org/ Spatuzza Alaxandre. 2002. Antibiotic Resistance: Are We Killing the Cures. Perspectives in Health Magazine. The Magazine of the Pan American Health Organization. Vol. 7 No. 1. Read More