Globally coordinated governance needed

Caring about antibiotic resistance is similar with reducing the plastic waste or saving water

“Caring about antibiotic resistance is similar to reducing plastic waste or saving water”, says Dr. Windhi Kresnawati. She is a pediatrician and has worked in a remote area (Biak regency) in Papua Island in Indonesia for the past 4 years. During this time she managed to engage various stakeholders to support and participate in a series of activities to raise their awareness on antibiotic resistance. She also volunteers with Concerned and Caring Parents (YOP) in their educational activities.

ReAct Asia Pacific met Dr. Windhi Kresnawati for an interview. She is a true antibiotic champion.

Dr. Kresnawati, what got you interested in antibiotic resistance?

– Antibiotic resistance determines our future. Using antibiotic wisely is also one act of sustainable living and we need to try to sustain the earth. Caring about antibiotic resistance, to me, is similar to reducing the plastic waste or saving water.

What made you become active within the field of antibiotic resistance? Why do you find this work important?

– I believe that everyone is responsible. What one does (taking antibiotics) will affect others… this is a collective action.

– When I was in Biak, I spent more time educating people about antibiotic resistance than other issues such as the use of supplements or symptomatic drugs for children, because the impact of antibiotic resistance is more threatening. Over there, people maintain the belief that antibiotic is the cure for any diseases. The doctors are not confident if they don’t prescribe antibiotics due to, among others, the limited clinical diagnostic support and their lack of knowledge about differentiating infections caused by virus or bacteria. They lack proper facilities as well.

“When I was in Biak, I spent more time educating people about antibiotic resistance than other issues such as the use of supplements or symptomatic drugs for children, because the impact of antibiotic resistance is more threatening.”

– Previously, they had no doctors for a long time. As a result, the other health professionals (such as nurses, pharmacists) and workers/volunteers had been giving them antibiotics. I believe the main problems include the lack of doctors in the area, and that the existing doctors offer sub-standard services. Based on the quick survey that I conducted among the doctors there, one of the main reasons for them to prescribe antibiotics needlessly is the doctor’s lack of understanding and not because of other reasons, such as for “commercial” purposes.

Dr. Windhi Kresnawati and her team at 2016 World Antibiotic Awareness Week in Biak, Indonesia. Photo: ReAct Asia Pacific

A true Antibiotic Champion

  • On 2015, Dr. Kreshawati held educational session on antibiotic resistance for doctors, health professionals, and staff of district health offices in 2 districts.
  • During World Antibiotic Awareness Week 2016, she managed a street carnival for 3 days in a row and she gathered support through a petition to the local government to stop selling antibiotics without doctor’s prescription. She also arranged seminars to the teachers of Catholic and Islamic schools (also attended by representatives of parents association), she spoke at a one-hour talk show on the local government radio station (RRI) and held another educational session for the staff of district offices of health, agriculture, fishery, pharmacists, and nurses from surrounding villages and islands including the remote areas. She also arranged the local community to make videos to educate people to not use antibiotics for viral infections.
  • Dr. Kreshawati was also an active member of the local church in Biak, and had done a series of educational seminars for the church community on maternal/child health issues, such as breastfeeding and management of common problems in paediatrics, as well as antibiotic resistance.
  • When in Biak, she taught at the local nursing academy, and was active in empowering the students to disseminate information on antibiotic resistance to their community.

From your experience working in remote areas, what have you learned about the community?

– I have learned that we need to learn more from them, not the other way around. When I first arrived in Papua, I thought I would give something to them, but then I realized that I actually took more from them. Many of them lack of the ability to read or use the technology, but they know better than us about sustainable living. They treat the earth well, better than many of us. They catch fish for eating, not for sale, and they don’t use plastics.

What about access to antibiotics in Biak?

– Just like other medicines, antibiotics in Biak are sold by pharmaceutical wholesalers to pharmacies or drug stores (monitored by the National Agency of Drug and Food Control of Republic of Indonesia). However, the monitoring of the sale of antibiotics to consumers is lacking. As Biak is a remote area (the nearest pharmaceutical wholesaler is 24-hours away by ship), all drugs/medicines take time to get to Biak. Sometimes, the medicines are out of stocks or out of supply because of the time and the high costs required to deliver the medicines to Biak. These have resulted in the relatively higher prices of medicines in Biak (could be more expensive than the prices in Jakarta, for example).  The government-funded hospitals or health facilities do receive free medicines from the government, but the drugs are mostly for adults, so they are not for consumption by children.

What actions has worked well for you to raise awareness about antibiotic resistance?

– Education to general practitioners was proven to be effective in changing their behavior of prescribing antibiotics. However, in the Biak case, the general practitioners were contractual employees and worked there for a short period of time (usually a year), so other doctors replaced them after one year. Therefore, I believe that educating the community is a priority, because the community members stay. After the campaign, the community started to ask questions to their doctors when they were prescribed antibiotics (“are antibiotics necessary?”). Previously, they believed that antibiotics cured all diseases. For example, the tuberculosis 2nd line antibiotics was very popular and in such a high demand for diseases like malaria.

“After the campaign, the community started to ask questions to their doctors when they were prescribed antibiotics (“are antibiotics necessary?”). Previously, they believed that antibiotics cured all diseases.”

– In Biak General Hospital, based on the reports from the Medical Director, there was a declining use and purchase of broad-spectrum antibiotics such as carbapenems. This means that the number of prescriptions on antibiotics is also declining. Doctors from other hospitals in Biak (there are 3 government-owned hospitals) also participated in the seminars on antibiotic resistance that we held because I had secured full support from the head of the local chapter of the Indonesian Doctors Association (IDI) and the Indonesian Pharmacists Association (IAI) for the seminars.

What has happened with the petition to stop selling antibiotics without doctor’s prescription that you put forward in 2016?

– Unfortunately, due to the political instability in Biak, many leaders of the district office, including the head of the district were replaced. The district head is currently in jail for corruption charges. When I started the intervention program in Biak, I thought that influencing regulators would be crucial, as we needed to change or create regulations on the prudent use of antibiotics. But this didn’t seem to work well because of political instability.

What is a greater challenge in your line of work and setting regarding antibiotic resistance?

– Firstly, conflict of interest: selling more antibiotics is perceived to be more beneficial to many parties. Secondly, a commonly held belief in the society that the diseases are not going to be cured without antibiotics.

3 advices to health care professionals who wants to engage in antibiotic resistance

  • As a healthcare professionals you must educate patients. The situation will become worse if the patients are kept in the dark about the issue.
  • Produce and disseminate IEC material to educate more people, especially when we have challenges in reaching out to them due to geographical reasons.
  • Partner with civil society organisations to spread the information and influence. We still need to push the regulators for more strict regulations on antibiotic use.

Why did you become a doctor?

–   I believe that health is the basic need for us to grow and develop, so we need to maintain our health for the generations to come. Health is our resources.

What are your hopes for future Biak?

–  For the future in Biak, I hope that the training of trainers (TOT) for school teachers conducted in 2016 could be followed up. Teachers are staying in Biak, at least they usually work there until they retire. So we can expect for sustainability of the program. Teachers can be expected to be the sources for information on antibiotic resistance to parents and students. But, of course, they need to be supported with materials and refresher or follow-up training.

Changes observed in Biak, Indonesia

Dr. Kresnawati did a pre and post research on the prescription of antibiotics by doctors in Biak General Hospital for children diagnosed with upper respiratory tract infection (URI). She monitored the prescriptions given in 3 months in 2014 (March, April, June) and compared them with the 3 months in 2015 (April, May, June). Windhi conducted presentation and workshop in March 2015 (the intervention program). The event was attended by 35 doctors (3 specialists, 2 dentists, and 30 general practitioners) working in the hospital.

For the pre and post study, the prescriptions analysed are those written by the 35 doctors who participated in the intervention. The presentation covered the following topics: the history of antibiotics, history of superbugs, and ways to manage superbugs. The workshop covered the following topics: ways to diagnose general infections in children, including identifying of cough and diarrhoea caused by viral or bacterial infections, fever with rashes, and emergency signs on sepsis.

The results of the study:

Pre: 1604 patients/cases
Post: 1637 patients/cases

Antibiotics for common cold: 44.9% vs. 23.4% (pre vs. post intervention)
Antibiotics for non-bacterial infectious diseases (malaria, fever, allergy, viral infection): 61% vs. 29% (pre vs. post intervention)