The COVID pandemic has exposed longstanding structural flaws in societies, particularly in health systems. These same inequalities are also at the root of another major global health problem: antimicrobial resistance.
The World Health Organization defines antimicrobial resistance as the process by which microbes change over time and no longer respond to drugs. This makes infections more difficult to treat. It also increases the risk of disease spread, serious illness and death. The resistance of bacteria to antibiotics is of particular concern.
Global deaths from antimicrobial resistance are projected increase from 700,000 a year now to 10 million by 2050. These losses disproportionately affect the world’s poorest and most vulnerable people in low- and middle-income countries. For example, throughout sub-Saharan Africa, rates deaths due to antibiotic resistance are 24 per 100,000 people. In high-income countries, the death rate is 13 per 100,000.
Antimicrobial resistance is a complex and difficult problem to solve. It also encompasses a wide range of factors. These include the biomedical, political, economic and socio-cultural domains, and go beyond individual disciplines and sectors. Yet most efforts to combat antimicrobial resistance tend to use a biomedical lens. These efforts do not consider the experiences of those most affected, including those responsible for delivering health care and those who benefit from it.
Our to research in East Africa is moving away from this narrow biomedical focus. Our aim is to shed light on the daily experiences and struggles of diverse stakeholders. We wanted to demonstrate the impact of the challenges of antimicrobial resistance on the lives of healthcare providers and patients as well as farmers who tend their livestock in East Africa.
Understanding the local experiences, motivations, and challenges of healthcare providers and patients is an essential step in designing sustainable health interventions that directly address concerns expressed by intended beneficiaries.
Increasing levels of bacterial resistance to a range of commonly used antibiotics have been reported in hospital settings and communities with livestock in East Africa. Our research examined how antimicrobial resistance fits into broader health challenges in the region. We used qualitative social science to gather the perspectives of health providers from key regional and rural health centers, their patients, and pastoralists.
From the interviews, we identified three main types of challenges people face in providing and receiving health care:
- health infrastructure capacity
- health care access and choice
- health communications.
We see inequalities between contexts and populations, but they are felt most acutely in the most remote rural communities. Likewise, those with less social power (especially women and children) also tend to face considerable challenges. In these compelling circumstances, people have sometimes resorted to self-medication. The combination of these factors could lead to antimicrobial resistance due to the way drugs are prescribed, accessed and used.
Infrastructural challenges have arisen at all levels of the health system. Respondents reported shortages of healthcare personnel, supplies, laboratory equipment to properly diagnose infections, personal protective equipment, infection control resources and people’s time. For example, drugs of appropriate quality were not always available. This presented the risk of patients receiving drug levels that would not eliminate the infection and could promote resistance. Ineffective drugs could also inflict economic hardship by eating into the limited budgets of families and health systems that must treat multiple times or buy additional drugs for a single problem.
Lack of basic infrastructure like roads and telephone networks or diagnostics can limit people’s ability to make good health choices. The state of transportation, roads, telephones, and the internet—all needed to connect and support people in the health system—was limited in our study areas.
Thus, linked to infrastructure is the issue of access to available services. This is essential for patients and providers. Access encompasses not only when and where services are available, but to whom. Access is also related to the presence of care, trust in that care, and feeling empowered to make and act on good health decisions.
When people do not feel empowered or confident about their care options, it can lead to self-treatment without professional advice. Hence concerns about the development and spread of antimicrobial resistance in people and livestock.
Our participants, providers and patients, expressed the importance of communication and identifying trusted sources of information in their healthcare experiences. Yet the responsibility for good health generally rests with individuals. Patients are accused of not following advice or taking self-care measures that create the risk of antimicrobial resistance.
Patients seeking information did not always feel that providers listened to them or gave them adequate advice. Providers felt pressured by patients to prescribe medications even when they were not needed. They said the patients did not understand the constraints they were under. We have seen how unnecessary cycles of blame can be triggered.
These findings resemble a previous review that we have conducted which have shown that these problems are prevalent throughout East Africa.
There is a global consensus that universal access to health care is a basic human right and essential to sustainable development. But large disparities still exist between and within countries.
The cracks and flaws in the healthcare system that we highlight show what individuals, families and communities face when trying to obtain healthcare.
Antimicrobial resistance exists within this broader historical and socio-political context. The fight against antimicrobial resistance must continue in a way that tackles, rather than reproduces, existing health inequalities. To do this, more voices need to be heard.
Preventable suffering and death must be addressed by expanding access to critical health infrastructure, improving health communications, and rethinking the health narrative not just as an individual responsibility, but as a public good.
Alicia DavisAssociate Professor of Global Health, Institute of Health and Wellbeing/School of Social and Political Sciences, University of Glasgow; Blandina MmbagaLecturer, Kilimanjaro Christian Medical University College, Tumaini Makumira University; Stephen Mshanaprofessor of clinical microbiology and consultant clinical microbiologist, Catholic University of Health and Allied Sciencesand Tiziana LemboLecturer (Institute of Biodiversity Animal Health & Comparative Medicine) Associate (School of Veterinary Medicine), University of Glasgow