Dr. Yeldandi: a participatory approach to medicine & health helps me help

2021-10-27

Dr Vijay V. Yeldandi is a specialist in infectious diseases with over 25 years of experience in transplant infectious diseases, public health, infection prevention and patient safety. He is also a faculty at Public Health Foundation of India and Director of SHARE INDIA, a non-profit organization working on health in India. Here he talks to ReAct about his views on antibiotic use and behavior.

Can you tell us about your idea of a participatory approach in medicine and health – particularly in the context of antimicrobial resistance?

– I have been an infectious disease clinician for 35 years. Where I trained, they were very big on a restricted formulary and trying to prevent emergence of antimicrobial resistance by rigorously policing their use. What I have learned – over the years – is that any kind of coercive intervention backfires. It is very difficult to persuade people to do something – or not to do something – when you use a coercive policy.

– Most humans do not like control, and if you try to control something, we will figure out a way to evade the control whether we do it overtly or covertly.

– However, if you really believe in it, you are going to do it no matter how difficult it is. Have you ever see somebody misbehaving inside a church, or a temple or a mosque? We do not. Whatever we might do outside – once we are in that particular environment – we are at our best behavior.

“What I have always felt is that we need to really sell the idea and persuade people – this is important. Anytime we want to persuade anybody about anything, the first question to ask why would anybody buy into this idea? If there is no direct resonance, nobody buys into it.”

– What I have always felt is that we need to really sell the idea and persuade people – this is important. Anytime we want to persuade anybody about anything, the first question to ask why would anybody buy into this idea? If there is no direct resonance, nobody buys into it.

– So I have tried to figure out: firstly, how can I understand what resonates with anybody. And then think about how that allows me an entry into persuading people about the wisdom of whatever I am proposing. I have got to be careful. If I project myself as the sole repository of the universe’s wisdom – then things are not going to work. So, I think that what one should do is have a participatory approach strategy – where we are going to partner – we are going to identify a way to build a shared vision and take it from there.

How would you apply these ideas specifically in the context of antimicrobial resistance?

– Let us be honest and acknowledge that antimicrobials have saved an incredible number of lives. When you are in a situation, whether you personally or somebody you care for, is facing a potentially life threatening infection, it is ridiculous to tell them: do not use the antimicrobial because you will encourage the emergence of resistance. That is not a message that goes across well. So I tell them, by all means, use it. And let me help you and let me ensure that these antimicrobials are available to you when you need them. They should be affordable, they should be available. So, once I have established a relationship of trust, that allows me to explore the other aspects of antimicrobial usage.

– There is a myth that people like to swallow antimicrobials. Actually, nobody likes it. You ask anybody, how do you feel when you take this medication, this antibiotic? They will tell you, it upsets my stomach, I feel sick, as terrible. In fact, where it is imperative that people do take the antimicrobials and take it for the requisite period of time, we run into problems of adherence.

– We would do well to always think about why do people do the things they do? Why do people not do the things that they that we think they should do? Once we understand that, then we are beginning to get to first base in modifying behavior.

“One of the things that we learned from the HIV epidemic is knowledge does not necessarily translate into behavior change. This is where we learn from our colleagues in marketing, how did Steve Jobs go around telling the whole world that they cannot live without an iPhone or an iPad?”

–  One of the things that we learned from the HIV epidemic is knowledge does not necessarily translate into behavior change. This is where we learn from our colleagues in marketing, how did Steve Jobs go around telling the whole world that they cannot live without an iPhone or an iPad?

–  When I talk to people about antimicrobial usage, the first thing I tell them is, look, if you do need it, you do need it. All right, let me help you mitigate the problems that you might have with an antimicrobial.

–  The first thing I tell, is about the biggest problem you will have with antimicrobials. It is invariably going to damage a very, very important organ in your body, an organ that is as important as your heart, your kidneys, your lungs, your liver. And that is the human microbiome.

– I explain to them what the importance of the human microbiome is – the gut bacteria that are so essential for maintaining a balance between a person’s capability to launch an immune response to pathogens, and at the same time, avoid any kind of autoimmune disorders where the immune system is attacking the body itself. Now we are beginning to recognize that the human microbiome actually plays a vital role in maintaining somebody’s body weight, maintaining hormonal balance and maintaining their mood. In fact, I can change somebody’s mood by changing their diet.

– So, I tell them, when prescribe an antimicrobial, I am going to hurt your microbiome. So can I work with you to mitigate that, and minimize that adverse effect. But would it not be nicer if I could tell you that you can do certain things to avoid the necessity of ever having to take antimicrobials.

– For example, let us take tuberculosis in India, 25 to 30 percent of Indians are infected with tuberculosis. If I detect early enough, which is at the stage of latent infection (before it has caused full blown disease), I can eliminate that latent tuberculosis and therefore the risk of serious illness and death due to tuberculosis by using one antibiotic for four months. Is not that so much better than having to take three or four antibiotics for nine months and sometimes even longer?

– Or if I can give you a vaccine against influenza, I will substantially reduce the probability that you will get a pneumonia due to pneumococcus or other bacteria that will reduce your need to take any antibacterials. I mean, there are so many strategies that one can use to reduce the need for anybody to take antibiotics. But then I have to first of all, not make a presumption that somebody wants to take antibiotics, and I have to prevent it, by using a coercive measure. It is better for me to sit down and explore what they feel about an antibiotic. Most of the time, I find that people do not want to take antibiotics.

So who is pushing antibiotics?
Why is there such a high volume of antibiotic use?

– I would hold the health care industry responsible for a large part of it. Part of it is a desire to do good – as most doctors want to do the right thing by their patients. And they honestly believe that they are doing a good thing by giving somebody an antibiotic when they have an indication of an illness that is caused by an infection. At large, the pharmaceutical industry has done a good thing by coming up with innovative products that save lives, no question about it.

– I think that the pharmaceutical industry goes a little overboard in pushing certain of their products through marketing, going to doctors and persuading them that their patients must get this antibiotic or they are going to die. And the more expensive the antibiotic, the better.

– Unfortunately, there is the seamy side of this entire business where there are incentives offered to people for certain behaviors. We have got to accept that there are there are certain doctors who have relationships with the pharmaceutical industry when they are rewarded or pushing the product of a particular purveyor.

But how do you change that kind of behavior?

– I think that one should get back to empowering people to take charge of their own health. I think that is the key, because everybody wants to have better health. Nobody wants to disease, nobody wants to be swallowing all kinds of drugs. And if I can work with somebody to promote their health – the better.

– Unfortunately, the healthcare industry, healthcare professionals are many times trained to think about the pathogenic paradigm of disease where they look at a patient as a functioning machine that needs to be taken apart to figure out what’s wrong, and fix that part that is defective. Which I think is an absurd and unnatural way of looking.

I prefer to look at people and ask:

• What does this person need to have in order to meet the demands of life?
• What is the biological attributes that they already have?
• What are they doing in their lifestyle?
• What is their understanding?
• What is their level of literacy?

And where can I strengthen all of these to help that particular individual, family or community. To have the ability to meet the demands of that individual, that family, that community, having the ability to have a purposeful life with autonomy and dignity. That is the goal.

“To have the ability to meet the demands of that individual, that family, that community, having the ability to have a purposeful life with autonomy and dignity. That is the goal.”

– And unfortunately, our healthcare industry has become a transactional relationship. They provide us a service. The consumer is a beneficiary. It is a transactional relationship and then it becomes mercenary. The worst example, of course, is our corporate hospital industry where they have invested enormous amounts of money in very expensive technology, and they keep pushing that.

– Sometimes there are other incentives or inducements for people to do all these things. And I cannot bring myself to the condone that kind of activity. So, I protest against it vehemently. I have spent a lot of time and energy educating my patients. Let me sit down with you, let us all come to a common understanding as to what is best for you – to have the ability to meet the demands of your life, your purpose in life is important. Let us focus on that. See what needs to be done? Where do we need to modify your lifestyle? Where do we need to modify your diet? What are all the drugs that we can stop? What are all of the interventions that we can stop?

– Technology, in my opinion, is a double edged sword, it can be very helpful, but it can also injure people. I think that one of the leading causes of hydrogenic injury or health associated injury is technology, of which drugs form a very large part of which antimicrobials unfortunately, upon a very large part.

– If you look at data from the United States, or emergency room visits, particularly amongst children who are below the age of five, the number one cause for a visit to the emergency department is an adverse effect of an antimicrobial. And 10% of these visits resulted in hospitalization. That boggles the mind when you think about the downside of a cavalier attitude towards prescribing antimicrobials.