In the context of the global emerging crisis of Antimicrobial Resistance (AMR), Bangladesh is particularly vulnerable due to the unregulated use of drugs within the large informal health sector. It is impossible to ignore the informal health sector in South Asia, therefore in-depth understanding of it is unavoidable (Nahar et al., 2017). Here we provide a case study from Bangladesh of social science approaches to AMR. These findings are based on in-depth interviews with 48 healthcare providers ranging from fully qualified medical doctors and veterinarians to unqualified drug shop owners in the human and animal sector. Full details of the study and research methods are reported elsewhere (Rousham et al., 2019; Lucas et al., 2019).
In Bangladesh, the informal sector makes up a quarter of private-sector healthcare provision. There are an estimated one hundred thousand licensed and a similar number of unlicensed retail drug shops. Unqualified health providers supplement the shortage of qualified health workforce, especially among the poor and in disadvantaged areas. Regulatory enforcement is relatively weak due to the limitations in human, technical and logistic capacity. The presence of a high number of retail outlets, unregulated drug shops, over-the-counter sales, and a “pluralistic” health system –where people use different types of health systems in parallel – compounds the complexity of AMR.
Although the mechanisms which lead to antimicrobial resistance are biological, the conditions promoting, or influencing these biological mechanisms are profoundly social. Therefore, both the problems and solutions of AMR are viewed as social issues, which need to be understood through social practice (Chandler and Hutchison, 2016). Given this context, we conducted a study to explore the pathways of use of antibiotics for humans and animals in Bangladesh using a medical anthropological conceptual framework established as “Social Lives of Medicines”. This framework considers medicines as “things” that have active social lives in today’s world through their dissemination (Whyte, van der Geest and Hardon, 2002). Medicines move from one meaningful setting to another; they are commodities with political and economic significance. The idea of “Social Lives of Medicines” is more concerned with medicine’s social uses and consequences than with their chemical structure and biological effects. “Social Lives of Medicines” focuses on medicine’s production and marketing, its prescription, its distribution through intertwined formal and informal channels, its “death” through one or another form of consumption, and finally its “death” in the form of efficacy in modifying bodies (Whyte, van der Geest and Hardon, 1996). This framework helps us to understand some of the social factors affecting the AMR crisis in Bangladesh since it focusses less on individual behaviours, and more on the structural processes that drive inappropriate antibiotic use with the potential to identify future interventions (Whyte, van der Geest and Hardon, 2002). This conceptual framework also hinges on the concept of the “socialisation” of antibiotics, meaning the framework explains how antibiotic integrates and forms social bonds within local communities and wider society. Our study explores the understanding of antibiotic provision by tracing the product through its various stages of socialisation—in particular at moments of production, distribution, marketing, prescription, knowledge and awareness, and consumption—among qualified, semi-qualified and unqualified health practitioners in rural and urban Bangladesh.
Following are the brief presentation of the results. These sections are based on four upcoming papers, which are either under review or under preparation (Nahar and Rousham, Paper in progress a, b, c; Nahar and Rousham, under review).
The production of antibiotics has some special features in Bangladesh. In the early 1980s a radical national drug policy restricted the expansion of multinational pharmaceutical companies in Bangladesh and strengthened the growth of local Bangladeshi pharmaceuticals (Reich, 1994). This gave rise to successful home-grown pharmaceutical companies, many of which went on to become multinational companies themselves. In parallel, however, other pharmaceutical companies producing low-quality drugs also mushroomed. This happened because the drug regulation policy and the application were and are still weak. Bangladeshi people are therefore at risk of AMR by consuming substandard antibiotics (Nahar and Rousham, paper in progress a,b).
In Bangladesh, there are multiple channels for drug distribution including government distribution channels, channels from big to small companies, and from large retail markets to small drug shops. Because there are no uniform distribution channels, monitoring the ways antibiotics enter into society from the factory is very difficult. The informal health sector and availability of over-the-counter medicines provide a major outlet for companies producing low-quality antibiotics in Bangladesh (Nahar and Rousham, paper in progress a,b).
The antibiotic needs to reach the society of the consumers to have a ‘social life’. In Bangladesh, this socialization of antibiotics takes place through a robust marketing process. We observed that certain forceful socialisation processes take place for antibiotics through robust marketing. In Bangladesh, medicine advertisement is not allowed in the media. As a result, special “marketing personnel” have emerged in the form of “Medical Representatives” (MR). The pharmaceutical companies employ MRs to promote their medical products. In the context of competitive markets, the companies set targets for prescription generation for each representative through a Prescription Potential Index. In order to fulfil their target of antibiotic prescription generation, MRs influence doctors to prescribe antibiotics through cash or various other innovative, in-kind incentives. They also monitor the prescription patterns of doctors by taking snapshots of the prescriptions and reinforce the marketing where needed. This profit-making mechanism promotes over-prescribing and unnecessary dispensing and consumption of antibiotics which increases the risk of AMR (Nahar and Rousham, paper in progress a,b).
If we track the pathways of the social lives of antibiotics, prescription it is the final phase of its socialisation. It is through a prescription that the antibiotics reach the hand of the patients. In addition to the formal written prescriptions by the doctors, there are various informal forms of prescriptions in Bangladesh. These informal prescriptions include verbal prescriptions, which are verbal instructions or advice about antibiotics given by the unqualified or semi-qualified providers instead of a written medium; reuse of prescriptions, where the same prescription, originally issued by a certain doctor, is used repeatedly by the dispenser for multiple different patients with similar complaints, and finally, self-prescription, where the patients themselves demand an antibiotic. It implies different kinds of socialization of antibiotics, as well as different forms of prescription, and will denote different kinds of social bonds with the community (Nahar and Rousham, paper in progress c).
Knowledge and awareness
Unqualified drug sellers have a significant role in the social lives of antibiotics in Bangladesh. The drug sellers’ misunderstandings about antibiotics, therefore, can contribute to the rise of AMR. Knowledge about antibiotics among the unqualified drug sellers ranges from gross ignorance and promotion of irrational use to relatively well-informed knowledge and practice. Most drug sellers understand drug resistance as a “side effect” of antibiotics. However, many semi- and unqualified providers have a misconception regarding the functions of antibiotics (Nahar and Rousham, under review).
The social life of antibiotics comes to an end when it is consumed by the patients or are disposed of. In Bangladesh, the end of life of an antibiotic will depend on local beliefs and practices. Purchasers and clients have various misconceptions about antibiotics, but as they want a quick recovery, they frequently buy antibiotics (Nahar and Rousham, paper in progress c).
This exploration of the social lives of antibiotics in Bangladesh reveals that there are challenges within all stages of life for antibiotics from production to consumption. To prevent the misuse of antibiotics, we believe the approach taken here, based on the work of the social lives of medicine, helps to understand the different stages antibiotics go through to “socialise” into the world. This perspective provides an entry into detailing monitoring mechanisms at these various stages. It is also important to standardise the training of providers and raise awareness among purchasers of antibiotics.
Medical Anthropologist at the Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
Biological Anthropologist at the Centre for Global Health and Human Development, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK