Antibiotics – a tragedy of the commons

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This article was written by Susanna Sternberg Lewerin, Professor in Epizootiology & Disease Control at the Department do Biomedical Sciences & Veterinary public Health, SLU.

Antibiotics kill susceptible bacteria while those who have acquired traits to destroy the drug or protect themselves from it survive and multiply. Resistant bacteria can share their resistance genes with others. Illustration: SLU

Today is the Antibiotic Awareness Day. It is a day to be grateful for these important medicines, and to consider how to best preserve them for the future.

Antibiotics, drugs to combat bacteria, are useful tools in both veterinary and human medicine. They allow us to treat bacterial infections in animals and people, common diseases as well as those that occur due to immunosuppressive treatments such as cancer therapy or following transplant surgery. The problem is that all use of antibiotics kills the susceptible bacteria and leave the field open for those who have  become resistant to the antibiotic. In a successful treatment course, the few remaining (resistant) bacteria can be killed by the host’s immune system and the host, animal or person, is cured. On the other hand, if the majority of the disease-causing bacteria are resistant, the treatment will be ineffective.

To preserve antibiotics as medical tools, we must use them as little as possible, only when needed, in the correct dose so that enough of the drug reaches the body site where the bacteria are causing the disease, and only for the time needed, until the immune system has eliminated the disease-causing bacteria. This is not as easy as it sounds, it takes insight into what diseases cause problems in animals and people in different settings, how to prevent them and how to treat them effectively, with or without antibiotics.

In Sweden, disease prevention is a key feature of veterinary medicine. Good animal husbandry, good biosecurity, vaccination and other strategies to control and prevent disease has been and continues to be a major research focus. We also collaborate in EU projects where different practices, attitudes and societal systems present new challenges that can be addressed by learning from the Swedish experiences (successes as well as failures) and by new ideas and innovations.

In low-income countries, antibiotics are not restricted to prescription from a veterinarian or a doctor but can be bought over-the-counter in drug stores where the products can be of poor quality and the information about how to use them may be lacking or misleading.

Poor farmers sometimes use the volume intended for treatment of one animal to treat several animals (i.e. with a lower dose), rendering the treatment ineffective and paving the way for resistant bacteria without curing the disease. If no veterinarian is involved in determining the cause of the disease, antibiotics may be used to treat diseases that are not caused by bacteria, so that the treatment is a waste of money and, again, promotes the resistant bacteria.

We collaborate with researchers in low-income countries on how to prevent and control animal diseases. We also work on developing systems for monitoring of diseases and antibiotic use, to provide information about what diseases are common and which antibiotics are used effectively. This project also addresses ways to increase the interaction between veterinarians and farmers by video consultations, to facilitate farmers’ access to veterinary advice on disease treatments while improving profitability for both groups. 

It is important to recognise the need for different strategies in different settings, disease prevention and control rely on knowledge of the local situation and its context-specific challenges and opportunities. Still, the worries and hopes of farmers are similar in countries all over the world and serve as incentives for improvement of animal health and production. The long-term goals of our research focus on animal health and welfare, for a sustainable animal production with a sustainable use of antibiotics. We must all contribute to preserving antibiotics for the future. Don’t let it be nobody’s responsibility, it lies with everyone.

Pushing back against disease with participatory epidemiology

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By: Dr. Alin Kadfak, Department of Urban and Rural Development, SLU

A herd of animals can be the only source of income for many families in areas like northern Uganda or southern Africa. Farmers with poor access to infrastructure and capital struggle to address and manage disease outbreaks, which can wipe out a household’s economy. Worldwide 750 million low-income livestock farmers depend on healthy animals for their productivity and livelihood. So, yes! Animal health matters.

But so far, we know very little about how perceptive farmers are and what their response to disease outbreaks is. A seminar ‘Exploring the Whys and the Hows of epidemiology: Integrating social sciences with veterinary research for better understanding and action towards improved animal health in the Global South’  held at the Swedish University of Agricultural Sciences, SLU on the 20th of November, 2018 explored a broader picture of how scientists  across disciplines see  the way local farmers understand the diseases and prevention mechanisms.

Why epidemiology is important?

The role of epidemiology in animal health is to identify the risk factors and the causes of disease outbreak. This knowledge provides a base for interventions which can ultimately prevent an outbreak or an epidemic. With that, epidemiology is crucial for poverty reduction and plays a vital role in increasing resilience toward risks of epidemics in low-income countries.

Even though our scientific knowledge about animal diseases has stepped forward, disease control leaves much to be desired. For instance, African swine fever continues to spread from Africa to Europe and Asia, harming many pig farms.

Karl Ståhl, Swedish National Veterinary Institute (SVA), traced an African swine fever outbreak through a trade route in Northern Uganda. He found that local pig farmers knew very well the clinical signs of the disease and how it spreads. They could even identify the potential control mechanisms. But as soon as they noticed sick pigs, they sold them to secure their income.

It became clear for Karl and his team that what they were facing in Northern Uganda is not the lack of knowledge by the farmers, but rather the lack of information on specific needs and circumstances of pig producers and supply chain actors during the outbreak. To solve the problem, Karl suggests it is necessary to bring in societal aspect into the equation. In his opinion this will help to find solutions that fit with local socio-economic and cultural context.

Is interdisciplinarity the way forward?

Social science still remains on the periphery of disease outbreak management – social sciences are rarely integrated into epidemiology. However, it is becoming apparent that quality disease prevention isn’t possible without considering socio-cultural, economic and political dimensions. This engagement can be done through an interdisciplinary approach.

Learning from the Ebola outbreak in West Africa, Paul Richards (Wageningen University) suggests to look beyond the classic idea of epidemiological and biomedical approaches and take into account human emotions.

During the early phase of the Ebola outbreak, epidemiologists built Ebola treatment centres to bring in patients, or suspected patients, hoping to isolate the patients’ from the outside world. But this created anxiety among patients and their families. The disease continued to spread.

By 2013, Paul together with locally trained field assistants used anthropological approach to collect information through real-time action-research. Human emotion appeared to be the missing link to the treatment – families needed to be able to talk to each other and have meals together. As a result, Paul’s team recommended to build more community quarantines so that families could be close the patients. Through watchful care and close communication between patients and their communities, the epidemic was eventually brought under control.

Participatory epidemiology

Participatory epidemiology has been influenced by Participatory Rural Appraisal (PRA), an approach that puts local participation at the heart of the process. However, participatory epidemiology has been adopted largely by natural scientists, who usually focus on m research quantitative methods. Meanwhile, from the experience of social scientists, statistics do not always reflect the reality of local communities. So, well-tailored solutions require real participation form the local people.

Klara Fischer and Erika Chenais’s work in Uganda is an attempt to engage a local participation in an epidemiology study. Instead of using a top-down approach, Klara and Erika let local perspectives guide their study. They used several participatory methods, such as participatory wealth-ranking and focus group discussion to understand how a community can prioritise, understand and deal with cattle diseases.

Susanna Sternberg Lewerin confirmed the value of a participatory approach in disease prevention practices. For her, it was important to create a relaxed atmosphere during participatory discussions and recruit local facilitators who could facilitate in the local language.

So, how can diseases control benefit from cross-pollination between veterinary epidemiology and social sciences? There are at least three ways:

  1. Veterinary epidemiology and social science can cooperate and increase understanding of contextualised knowledge that affects decisions relating to disease control.
  2. Using participatory methods to engage indigenous perspectives can improve disease prevention and control mechanisms.
  3. It is key to remember that there are no ‘fixed-tools’ in epidemiology. Tools need to be adapted and adjusted to the local context, addressing local heterogeneity, power dynamics and conflicts.

This article was originally published at SIANI.