This reflective essay by Ms Julianne Jessica Talens Leow from Tanjong Katong Girls’ School was awarded one of the two Merit Awards by our judges.

Antibiotic Resistance, Paralysis, and Stewardship: The Walking Ecosphere’s Destiny

I read the headline many times over: “FDA (United States Food and Drug Administration) Fails to Protect Against Antibiotic Resistance, Guarantees More Needless Deaths and Suffering” (Mercola, 2014). It’s getting harder to read. The situation presented by a medical powerhouse was surreal. It was incredibly worrying. It sunk in that the anticipated future of the post-antibiotic world has dawned.

More headlines left me perturbed. “A Drug-Resistant Superbug May Be Stealthily Spreading (in U.S. hospitals)” (Kwon, 2017). Anyone would be likely to feel the same way I did after reading through what seems like a sweeping death sentence looming in on Man – death by an infectious disease. Our minds become ‘paralysed’, unable or not wanting to think beyond what we are presented with. But have the World Health Organisation (WHO), FDA and other health organisations published these ‘frightening’ figures to scare us out of our wits? Shouldn’t we be thinking of how we can change our destiny?

If it is not fear that we are feeling, perhaps we are immobilised. We don’t know what actions to take. So we wait. We expect the governments to continuously fund research efforts. We anticipate the next scientific breakthrough and big production of new and better antibiotics by scientists. There has to be another type in the pharmacies, right? This is how we become mere observers and passive in a situation where that ‘death sentence’ has been issued. Everyone is vulnerable to diseases, yet most of us are merely pensive, hoping that the authorities can protect us all.

Interestingly, most of us are aware of climate change. In fact, we keep discussing the changing weather patterns and make blockbusters about how the world is being twisted into an inhabitable dimension. Climate change is important and deserves the worldwide attention it is getting, with much focus at an international scale, evident in the Paris Agreement having 195 signatories (United Nations Treaty Collection, 2017). With so much emphasis on the big ecosystem, can’t we simply acknowledge that since the beginning of time, the human species are walking ecospheres? Hence, it seems a little ironic that less attention is paid to ourselves. Imagine a powerful superbug wreaking havoc in the walking-feeling-breathing human ecosphere. Like the climate, bacteria see us as a faceless paradise to thrive, reproduce, and then move on. Humanity could just be wiped out by this bacterium at the same rate as climate change can destroy our planet.

There are many around us advocating green movements; yet the movement to advocate actions to stop antibiotic abuse and misuse should be no less than the same. We must free ourselves from immobility. We can’t let ourselves be ‘paralysed’ forever, or be blinded by thinking how microscopic antibiotic resistance is, as a problem.

These series of thought processes led me to search: reasons for antibiotic resistance in humans. There can be tighter regulation by governments and greater emphasis on adherence to guidelines by healthcare providers. In Thailand, where antibiotics are widely accessible and can be easily purchased at a low cost and without a prescription, antibiotic abuse has become a significant problem, accounting for 19122 deaths caused by drug-resistant bacteria in 2010 (Ministry of Public Health, Thailand & Britain’s Wellcome Trust, 2016). There have also been overlooked cases in the United States where individuals purchase antibiotics over the Internet, since authorities pay more attention to tracking counter-bands being transported across their borders (Nahman, 2014).

I added another tab: unnecessary prescription of antibiotics. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey found that from an estimated 154 million prescriptions in 2010 in the US, 30% of them were unnecessary (Centers for Disease Control and Prevention, 2010). So, can we even trust our doctors? Back in 2005 in China, doctors in hospitals could get a 20% rebate for antibiotics from manufacturers (Lin, Zhang, 2009) and this had likely caused them to prescribe unnecessarily. Some doctors vested in their own financial interests, rather than the patients’.

Now, we come to realise that this ‘war’ against antibiotic abuse and misuse is not an easy one. We may be our own enemies in this ‘war’. It is no longer just a microbe, but it could be a loved one, a parent, or even ourselves. The very people who need to change are whom we love, trust and respect.

Therefore, the key is to practice “stewardship” (Kieny, 2017) on a more personal level – having the sense of responsibility and empowerment to act against the situation. “Stewardship” also means that we start to view ourselves as a walking- feeling-breathing ecosphere. Only when “stewardship” is achieved among us, together with the authorities’ efforts, then can we become a powerful weapon in fighting antibiotic resistance.

The easiest way to achieve “stewardship” is through education. Medical students should be the most informed, but just educating them on how and when to prescribe antibiotics isn’t enough. They must be aware of why they need to do so. As a ‘steward’ of antibiotics, the medical student should be able to make responsible judgements – for instance, whether they should prioritise the patient’s health over incentives (Littmann, Viens, 2015). However, it shouldn’t be assumed that medical students understand antibiotic resistance in medical school. They also need to understand the seriousness of communicating the message of responsible dispensing of antibiotics to patients. Medically illiterate patients are prone to self- prescribing antibiotics without seeking professional consultation, which can lead to long term abuse. Because of this, doctors cannot afford to think that their responsibility over their patients ends after prescribing medicines. Medical students should know that they aren’t just becoming doctors, but educators too. Has this crucial point on ethics been sacrificed in their education?

Education also needs to reach out to school students like myself. The study of viruses and bacteria should be a topic included in schools’ curriculum as soon as possible. Take the GCE Ordinary Level Biology syllabus as an example. We are taught an entire chapter about man’s impact on the environment, about how human activities can upset the ecosystem, its implications on us and possible actions we can take. This topic is deserving of being taught to youths as we can and must make a difference to our daily lives. We realize that we have a role to play, sparking the willingness to do whatever we can to resolve these issues. And that’s the main aim of learning, to equip us with the knowledge and core values to be responsible global citizens. So why does antibiotic resistance have so little, or no screen time at all in the curriculum?

Viruses, bacteria, and the concern of antibiotic resistance involves our health and lives directly. Humans as ecospheres. Include it in the syllabus. The textbook would be the most effective way to communicate this message to students because we must study it. We gain the early knowledge of antibiotic resistance and the effect of abuse and misuse on the near future, which leads to conviction – students empowered to act responsibly against antibiotic resistance. Maybe we would see more youth advocates in the battle against antibiotic resistance if we first learn it in our textbooks.

Raising public awareness is the first step in helping to counter the problem. Health organisations can ensure more media coverage and initiate community dialogue sessions on antibiotic abuse and resistance – all to turn our ignorance into awareness and “stewardship”. The National Environment Agency (NEA) organises public sessions to campaign the fight against dengue and deterring mosquito breeding. If health organisations start reaching out to the community in the way NEA has, I’m positive that national awareness can be raised to a higher level. Not to forget, students can also be involved in antibiotic resistance awareness projects to spread the word to others, it can leave a positive impact on the near future!

I looked out of the window. I saw children playing at the playground, and their grandparents and mothers sitting at the benches having their afternoon chit-chat. It’s unsettling to imagine that there is a possibility that years from now, I may no longer see this same scene, for the post-antibiotic world will be one enveloped in fear. But if we remain idle now, we would all perish in the post-antibiotic world. While death is inevitable, to die because of the failing human ecosphere, whereby our immune systems and medicines can no longer protect us, may be the humblest way to die.

Let us overcome that fear or immobility. Open our eyes to see both Earth and humans as ecosystems. Both are just as fragile, and we should do our part to protect us, first.

I knew I wasn’t going to sit still and wait. When my friends asked, “What are you writing about?” I told them what I knew to the best of my ability. I told them what we should and should not do. My only hope is that they tell others too, so there is a chain effect. Raising awareness is what I am capable of. But I know that when I grow older, I can do so much more than just that. And I will.

This is my new purpose in life. The battle against antibiotic resistance has already begun. And I have made my first move. Join me, fellow human ecosphere!

References

Kwon, D. (2017, January 18). A Drug-Resistant Superbug May Be Stealthily Spreading. The Scientist Magazine. Retrieved from http://www.the- scientist.com/?articles.view/articleNo/48051/title/A-Drug-Resistant-Superbug-May-Be- Stealthily-Spreading/

Lin, W., Zhang, W. (2009). The Effect of Patient Knowledge and Involvement on Antibiotic Abuse and Health Care Services-Evidence from an Audit Study in China. Retrieved from http://cowles.yale.edu/sites/default/files/files/conf/2010/aam_lin.pdf

Littmann, J., Viens, A. M. (2015, September 30). The Ethical Significance of Antimicrobial Resistance. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638062/

Mercola, J. (2014, April 23). FDA Fails to Protect Against Antibiotic Resistance, Guarantees More Needless Death and Suffering. Retrieved from http://articles.mercola.com/sites/articles/archive/2014/04/23/agricultural-antibiotic- overuse.aspx

Nahman, C. (2014, April 17). Antibiotics Without A Prescription?. Retrieved from http://www.coreynahman.com/antibiotics.html

Tan, H. Y. (2016, November 12). Antibiotic abuse killing thousands in Thailand. The Straits Times. Retrieved from http://www.straitstimes.com/asia/se-asia/antibiotic-abuse-killing- thousands-in-thailand

United Nations Treaty Collection. (2017, July 1). CHAPTER XXVII ENVIRONMENT. 7. d Paris Agreement. Retrieved from https://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=XXVII-7- d&chapter=27&lang=_en&clang=_en

U.S. Department Of Health And Human Services. (2016, January 1). CDC: 1 in 3 antibiotic prescriptions unnecessary. Retrieved from https://www.cdc.gov/media/releases/2016/p0503- unnecessary-prescriptions.html

World Health Organisation. (2017, February 27). Antibiotic-resistant priority pathogens list. Virtual press conference, 27 February 2017. Retrieved from http://www.who.int/mediacentre/news/releases/2017/Antimicrobial_resistance_VPC_27FEB2 017.pdf?ua=1

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