The social science of medicine
DAVOS—When I was a medical student in the mid-1980s, I contracted malaria in Papua New Guinea. It was a miserable experience. My head ached. My temperature soared. I became anemic. But I took my medicine, and I got better. The experience wasn’t pleasant but thanks to cheap, effective malaria drugs, I was never in very much danger.
The pills that cured me, chloroquine tablets, do not work anymore. Even at the time I was taking them, the parasite that causes malaria had already become resistant to chloroquine in many parts of the world; Papua New Guinea was one of the last places where the pills continued to be effective, and even there they were losing their potency. Today, chloroquine has basically disappeared from our medical arsenal.
The growing capacity of pathogens to resist antibiotics and other antimicrobial drugs is turning into the greatest emerging crisis in contemporary healthcare—and it is a crisis that cannot be solved by science alone.
Other pharmaceuticals are following in chloroquine’s wake. Multi-drug-resistant strains of tuberculosis, E. coli, and salmonella are now commonplace. Most gonorrhea infections are untreatable. Superbugs, like methicillin-resistant Staphylococcus aureus and Clostridium difficile, are proliferating. In India, antibiotic-resistant infections killed more than 58,000 newborns in 2013.
Today, malaria is often treated with a combination of artemisinin—a drug derived from a Chinese herb—and other antimalarial drugs. But these revolutionary medicines are now in danger of following chloroquine into obsolescence; resistant strains of malaria have been documented in Southeast Asia.
This is more than a medical problem; it is a potential economic disaster. Research commissioned by the Review on Antimicrobial Resistance, headed by the economist Jim O’Neill, has calculated that if current trends continue, drug-resistant infections will kill 10 million people a year by 2050 and cost the global economy some $100 trillion over the next 35 years.
Even that dramatic prediction may be a substantial underestimate, as it includes only the direct costs in terms of lives and wellbeing lost to infections. Many other aspects of modern medicine also rely on antibiotics. Cancer patients receiving chemotherapy take them to suppress bacteria that would otherwise overwhelm their weakened immune systems. Many surgical operations now considered routine, including joint replacements and caesarean sections, can be performed safely only when antibiotics prevent opportunistic infections.
The origins of drug resistance are a well-understood matter of evolution. If pathogens are exposed to the selective pressure of toxic drugs, eventually they will adapt. The Wellcome Trust, which I lead, has invested hundreds of millions of dollars into researching these mechanisms, improving diagnoses, and creating new drugs.
In order to address the problem effectively, this effort must be extended beyond the realm of biological science to areas not traditionally associated with medicine. In rich and poor countries alike, we have become systematic abusers of antibiotics. The key to combating resistance is to delay the rate at which the pathogens can adapt. But, by overprescribing antibiotics and failing to complete the required courses of treatment, we are exposing germs to just enough medicine to encourage resistance. In effect, we are vaccinating germs against the drugs we want to use against them.
That is because we have come to regard antibiotics almost as consumer goods—ours to demand from doctors, and ours to take or stop taking as we see fit. Even the most informed patients misuse these wonder drugs. Research in the United Kingdom has found that even people who understand how resistance develops often contribute to the problem by taking antibiotics without a prescription or giving their drugs to members of their family.
Changing such destructive behavior will require that we better understand the social and cultural factors that drive it. Disciplines like history, psychology, sociology, anthropology, economics, market research and social marketing can help.
This is true not only for antimicrobial resistance. It also applies to outbreaks like the Ebola epidemic. Combating the virus requires knowledge about its biology, the epidemiology of its transmission, and the drugs and vaccines that could potentially be deployed against it. But it also requires an understanding of the behaviors that have allowed infection to spread in Liberia, Sierra Leone and Guinea.
Explaining what made these societies so vulnerable requires learning about the region’s recent history and understanding why people there are deeply distrustful of public authorities. Isolation of patients and safe burial of the dead are crucial to containing Ebola, but both need to be introduced with cultural sensitivity, not just explanations of the science behind them.
Today’s great public-health threats have profound economic consequences. Minimizing the risks they pose requires recognizing that they are intertwined with the social, behavioral and cultural landscape. Science provides powerful tools. But we need more than science to use these tools effectively.
Jeremy Farrar is director of the Wellcome Trust, a global charitable foundation dedicated to improving health.
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