Whenever there is a discussion of superbugs, bacteria that have become resistant to all our antibiotics, they round up the usual suspects.
First, there are the pharmaceutical companies. They are not interested in developing antibiotics, because a patient will take them only occasionally and for a short period. Such drugs are not nearly as profitable as those that a person has to be on for a lifetime. Then, there is the agricultural industry, which accounts for a great deal of antibiotic use. Finally, there are the doctors, who are responsible for overprescribing antibiotics. But no sooner are the doctors mentioned, than the blame is shifted to the real villains of the piece, the patients. An example is provided by the CDC:
Patients shouldn’t pressure doctors to prescribe antibiotics for viral infections (they don’t work on these illnesses) and doctors shouldn’t reach for their prescription pad merely to please patients. Many common ailments can be best treated without antibiotics, so always ask what other options there are if your doctor advises them.
The emphasis here is on the patient. He is the one who is active in the misuse of antibiotics, while the doctor is merely passive, simply responding to the demands of those patients. Furthermore, in the final sentence, there is the suggestion that when you go to see your doctor, and he gives you a prescription, it is your responsibility to make sure your doctor is doing the right thing. So even if you did not pressure the doctor for the antibiotics he prescribes, you need to ask him if there might be a better way of treating your illness that he is not telling you about.
One of my favorite pieces of advice along these lines is the following: “If you have a viral infection and your doctor prescribes antibiotics, it’s a good idea to ask your doctor why he/she has done so.” In other words, it is up to the patient to know the difference between a virus and a bacterium, to know that he has a viral rather than a bacterial infection, to further know that antibiotics are not useful in the case of the former, and then to ask the doctor why he is prescribing something that is useless.
In a recently published article by The Independent, a doctor is quoted placing the blame squarely on the patient:
… a leading GP told The Independent on Sunday that the time had come for the general public to take responsibility. "The change needs to come in patient expectation. We need public education: that not every ill needs a pill," said Dr Peter Swinyard, chairman of the Family Doctor Association.
This is followed by the usual token acceptance of blame on the part of the medical community.
"We try hard not to prescribe, but it's difficult in practice. The patient will be dissatisfied with your consultation, and is likely to vote with their feet, register somewhere else or go to the walk-in centre and get antibiotics from the nurse.
In this case, doctors yield to the demands of their patients not so much from a desire merely to please their patients, as suggested by the CDC, but from the pressure of free-market capitalism. Also, having already blamed the patient, notice the shameless way the doctor now blames the nurse. He continues:
"But if we go into a post-antibiotic phase, we may find that people with pneumonia will not be treatable with an antibiotic, and will die, whereas at the moment they would live.
"People need to realise the link. If you treat little Johnny's ear infection with antibiotics, his mummy may end up dying of pneumonia. It's stark and it's, of course, not direct, but on a population-wide level, that's the kind of link we're talking about."
All right, so the goal is to educate the public on the difference between viruses and bacteria, and make them further aware of the ills of antibiotic overuse, in hopes that patients will quit victimizing their doctors. I suggest that we be realistic. The people who are ill-informed are likely to remain so, and the only kind of education they will respond to is when the doctor says, “You have a viral infection, for which antibiotics are of no use,” or “You have a bacterial infection that will probably clear up on its own, so a prescription of antibiotics is not warranted.” It is that or nothing. And if the patient walks, he walks.
But let us assume for the moment that people can be educated in these matters. In that case, they will not want antibiotics for a virus, of course, but what if they have a bacterial infection? Consider the last quoted paragraph. First, I have to call attention to the fact that the situation is not couched in terms of a mother and her child, but rather in the condescending terms of “Johnny” and “mummy.” That aside, granted that mummy has been properly educated in these matters, she understands the following choice being given to her: Either she can put Johnny on antibiotics, which will speed up his recovery and help avoid complications; or she can forgo the treatment of Johnny’s infection in hopes of reducing her chance of dying of pneumonia some day.
Well, per hypothesis, she is not stupid enough to believe that. In all fairness, the doctor being quoted admits that he is really speaking in the collective rather than the distributive sense. So, the alternative facing mummy is better understood as the following: Either she can put Johnny on antibiotics, which will speed up his recovery and help avoid complications; or she can forgo the treatment of Johnny’s infection for the greater good of mankind.
What we have here is an example of the prisoner’s dilemma. While it is true that everyone would be better off in general if we all cut back on the use of antibiotics, a given individual will always be better off if he defects, and takes the antibiotics that will help him fight the infection he has at some particular moment. From which it follows that mummy is likely to want to treat Johnny’s infection with antibiotics, and worry about mankind on another day.
Ultimately, however, one has to wonder if it really matters whether the responsibility lies with the doctor or the patient, since human use of antibiotics is relatively small. Eighty percent of antibiotic use occurs in the treatment of livestock by farmers, so most of the problem with superbugs undoubtedly lies there. But I doubt that it is the farmers who are at fault. They probably just feel pressured by their animals.