Please Sir, I Want Some More …. Antibiotics: The over-prescription problem and a lesson from history
In the Charles Dickens classic Oliver Twist, we’re familiar with the scene where the trembling waif of a boy famously asks, Please sir, I want some more, referring to a bowl of gruel. The sight of the vulnerable child not only evokes audience sympathy, but also the sympathy, and, ultimately, acquiescence to the request, by the mean-spirited men of the workhouse whose job it was to oversee child labor in Old England.
Modern day physicians are hardly the functional equivalent of the overlords of 19th century child labor; to the contrary, we can assume they only want the best for a sick boy or girl. But that wholesome desire, oddly enough, is where the modern and developing problem of antibiotic resistance often begins.
It goes something like this. The child accompanied by a parent comes to the doctor’s office with some combination of a runny nose, a sore throat, a cough, or chest congestion (not to mention signs of the ubiquitous middle-ear infection). The child may have a cold or the flu or is perhaps developing pneumonia and has been off school for several days. The problem seems to be getting worse and the family wants something – anything – to be done, which typically means they want to leave the doctor’s office with a prescription.
The doctor, feeling the pressure and wanting to do something, prescribes the modern day cure-all, the antibiotic. The doctor feels validated, she did in fact do “something;” if nothing else the placebo effect may actually do some good. And besides, she may think, what’s the harm? If the antibiotic doesn’t work these kinds of symptoms typically run their course in a week anyway. The child is happy because he knows he’ll get better because the doctor gave him medicine. And the father is happy knowing that he was able to do something for his child, confident in the knowledge that the doctor wouldn’t have taken this course of action if it wasn’t going to work.
We are left, however, with one tiny problem – antibiotics don’t cure viral infections and that is what the common cold, the flu, a lot of pneumonia’s and ear infections usually are. Nevertheless, variations of this scene are played out in doctor’s offices across the land at an alarming rate. According to a report this April in the New England Journal of Medicine, 250 million courses of antibiotics were prescribed in the U.S. in 2010 for a population just shy of 309 million. That translates to a whopping 833 antibiotic prescriptions for every 1,000 people. Jim Hutchinson, medical director for the antimicrobial stewardship program of the Vancouver Island Health Authority, commenting on Canadian physician behavior, told the Ottawa Citizen this past June that “doctors weren’t aware of the long-term effects of antibiotics … so they prescribed what they thought was a harmless cure-all rather indiscriminately.”
Hutchinson’s inference is clear: this is not a harmless practice. When antibiotics are prescribed when they shouldn’t be they wipe out healthy bacteria that are susceptible to it. What’s left is the drug resistant mutant strains that flourish because they no longer have to compete with the now defunct healthy bacteria. These strains are then passed between people and are thus able to rip through communities in countries throughout the world. The upshot is the global health problem of antibiotic resistance described earlier this year as an “apocalyptic threat” by Britain’s chief medical officer, Sally Davies, echoing similar concerns expressed by the World Health Organization, and the Centers for Disease Control and Prevention in the U.S.
It’s crucial to understand that this global problem begins very near home, at the local doctor’s office, where a sick child, a caring parent, and a well-meaning doctor all too often unwittingly conspire to do the wrong thing – misuse an antibiotic.
We have a hard time imagining the scene in the doctor’s office as anything but wholesome. But there might be another way to look at it. What if antibiotics were available to the overseers of the 19th century workhouse and they had laced young Oliver’s bowl of food with them? And as a result of this common practice tens of thousands of English people, including children, died each year because they had contracted a bacterial-caused infectious disease no longer susceptible to an antibiotic.
In hindsight, it’s pretty obvious how we would view such a practice. And it raises an important question for us today: how is that practice any different, morally or practically, than what’s being played out on a daily basis in doctor’s offices today?