Waiting room: AMR and the health System
Do you trust your doctors and pharmacists to give you the right advice about antibiotics? Episode 3 takes us inside the healthcare system to tackle the problem of overprescription. We investigate trust in the practitioner-patient relationship and what happens when that trust is broken – particularly for our vulnerable populations. We look at ways to rebuild it, including social media, working with communities and listening to patients’ lived experiences. We ask, who is responsible for the incorrect antibiotic use that contributes to the rise of superbugs? We find that responsibility is shared and requires empowerment rather than blame.
Theme music comes in strong: piano and soft chords building slowly under opening dialogue.
[Silvi Vann-Wall] And the doctors have never, like, you know, grabbed me by the hands and said, “You must only take it if it gets worse! Otherwise there’ll be resistance.”
There’s never been that conversation.
[Britta Jorgensen, Narrator] You’re listening to Rise of the Superbugs.
Theme music continues: an eerie, electronic melody appears in the mix.
[Lindsey Green] Ah I guess it’s just a matter of weighing up whether or not improved self-confidence that comes from really superficial things like your skin – whether or not that’s worth the long term health implications of potentially developing a resistance to antibiotics.
A podcast series about antimicrobial resistance.
I’m Britta Jorgensen – a podcast maker and researcher and for the past two years I’ve been part of a team trying to work out what many of us get wrong about how antimicrobial resistance works
what we can do as individuals
and what we need to change as a society.
We make this podcast on the lands of the Wurundjeri people – and the muwinina people from country around nipaluna.
They are the traditional custodians of these lands. We also pay respect to the elders both past and present, and extend that respect to any Indigenous Australians listening.
In this episode we ask
what do we know about antibiotics
Kitchen scene is set up – chopping, water running, quiet chatting between Britta and Jonathan.
I often cook with my mate Jonathan – an apprentice chef and amateur fermenter.
[Britta] You should include a step where you wash your hands.
[Jonathan] [Jokingly] Thanks for telling me how to do my job! Just make sure that your microphone’s on and are those over your ears?
Today he’s showing me how to ferment some radishes.
[Jonathan] Even before I went to school I knew you wash your hands before you prepare food.
I was an apprentice and um, like, when we started class none of them would wash their hands, they’d go straight into making all the food. And this is like future chefs, you know?
So like, there is a level of what some people like think there’s leeway to do and not to do.
I didn’t realise but anyone who got into making sourdough or brewing beer during the lockdowns will know that microorganisms like bacteria
good and bad
are in every kitchen.
and they will grow
[Jonathan – background] Salmonella, that’s another one…
Kitchen scene continues – chopping in the foreground.
We don’t notice that they’re there
unless we ingest the kind that is bad for us and it makes us sick.
[Jonathan – background] …and that’s another one that already exists inside the chicken itself.
Antibiotics are often prescribed as a kind of catch all for bacterial infection.
A broad spectrum antibiotic can be used to try and control that infection so that doctors can work out the underlying issue.
The range of infections caused by bacteria, parasites, viruses and fungi is constantly growing as these microorganisms evolve.
When they develop resistance to antimicrobials, infections become difficult to treat
they persist in the body
and the risk of them spreading to other people grows.
These resistant microorganisms are often called superbugs.
Crackling Zoom call.
[Silvi] Hello Steve!
[Steve] How are you going, mate?
[Silvi] Nice to virtually meet you.
Silvi Vann- Wall is one of our producers.
[Steve] Can you hear me okay?
[Silvi] You are cutting in and out so I was just gonna suggest a couple of things. Number one, do you have a set of headphones with a microphone inbuilt in them?
[Steve – fading out] Yeah.
10 years ago she was 18 and about to sit her final exams.
[Silvi] The high school I went to was a public co-ed school and I really wanted to be an actor, but there weren’t many opportunities there. So I would just really go for it in all the school plays and productions. I had the lead role in the theatre studies final performance. I actually really wanted to get into the VCA.
And I had started preparing monologues before I got sick.
Gentle, thoughtful music with piano and heavy reverb fades in and plays under Silvi’s story.
I ate some bad chicken at a food court. And that’s when I started getting really, really sick. So it started off as food poisoning. So I was vomiting, and I had diarrhea, and I felt really fatigued and I couldn’t go to school, I couldn’t do my exams. So that prompted my mum to take me to the ER.
And they put me on a drip and they started me on antibiotics to treat this food poisoning, which they said was a strain called Campylobacter.
It generally comes from undercooked chicken.
I was in there for about a week until the drip had rehydrated me and the antibiotics they put me on looked like they were working and clearing up the Campylobacter. So they said:
“Yeah, we reckon you’re clear to go, you know, not looking like anything else is going to happen. So go home.”
And I went home. And it was only about a day or two after I’d gone home that all the symptoms started again. And it was very difficult for me to do anything. I would just spend days on the couch watching TV.
Playful guitar riff comes in strong: scene of a TV playing in an echoey room.
As Silvi sat flicking through the TV channels, her goal to get into the Victorian College of the Arts was slowly fading away.
She had intense relapses of physical pain.
The illness hadn’t gone away.
Guitar riff continues under the next part of Silvi’s story.
[Silvi] I remember going to my high school graduation and I’d lost 14 kilos, over the whole process of being in and out of hospital, and not being able to eat very much. So in my photos at my high school graduation, I look like a skeleton.
It’s you know, it’s kind of terrifying.
And people tried to like – I guess not ask too much. They were trying to be very polite about it and not inquire too much. But I could tell they were like freaked out, like
What’s happened to Silvi?!
Silvi’s experience isn’t unique and like many of us she didn’t know much about antibiotics
even as she was taking them.
A funky, curious guitar melody comes in strong and plays under the following scenario.
The other day, I came home with a headache.
When I looked in my bathroom cupboard for some painkillers, I came across an unopened packet of antibiotics.
I think from when I had tonsilitis and the doctor told me to buy them “just in case”.
Even though she was pretty sure I had a viral infection that antibiotics wouldn’t treat.
She told me it was better to let my immune system fight off the infection for this particular case of tonsillitis.
You might find antibiotics in your cupboard too.
They’re a really common prescription in Australia. If you’ve ever had a bacterial infection – most likely an infected throat, infected ear, or a urinary tract infection – you’ve probably had antibiotics.
Mostly, these little tablets are various forms of common penicillin, cephalosporins, and clavulanic acid.
Back to my bathroom cupboard.
The label on these antibiotics said they were prescribed months ago, but didn’t say much else.
When do these things expire?
Do they expire?
And then another thought crossed my mind:
If I got an infection, could I take them?
Or do different antibiotics kill different types of infections?
Funky guitar music stops.
Davina Lohm is a research assistant at Monash University. She’s looking into what people understand about antibiotics and how they use them.
[Davina – on Zoom] What I found was that there’s a real disparity in understanding – from people who didn’t know what antibiotics were at all. People who didn’t understand the difference between antibiotics and other medications.
So they understood antibiotics in terms of things like so you’ve got a cold, and you take panadol, you know, we got this, we just take an antibiotic, and then you don’t finish it
to other people who were really very cluey, you know, people who had science backgrounds, who had a really clear understanding of what antibiotics were, what resistance was, how you should use them, why you should use them.
So there was a real sort of variation in understanding, which I think is really interesting, because it highlights the need for really nuanced messages rather than just general messages about what to do.
Davina and Associate professor Mark Davis conducted one-on-one interviews with 99 people.
Davina wanted to understand the depth of people’s knowledge, because the more we know about why and how people think about antibiotics, the better we can combat antimicrobial resistance
also known as AMR
[Davina] There’s an increasing risk with antibiotic resistant bacteria and they pose a huge threat, because there are more and more bacterial infections that are really hard to fight now with antibiotics, and if we lose the efficacy of a whole lot more antibiotics it then puts in jeopardy things like chemotherapy, transplants, surgery. So one of the aims is for people to use antibiotics less, and to use them only when they really need it.
But of course, we don’t know what people are doing and why people are doing it.
Chorus sings: “Antibiotics, we’re wonderful pills. But don’t ever think we’ll cure all of your ills! Caught a cold? Got the flu? Feeling under the weather? That’ll be a virus. We can’t make that better.”
A 2018 ad developed by the UK’s National Health Service is simplistic but the message is direct.
Chorus continues: “Take us for the wrong thing that’s dangerous to do. When you really need us we could stop working for you!”
And Davina says that messaging is needed because she found that unless someone was directly affected by antimicrobial resistance in their close circle there was a general lack of awareness.
[Davina] One of them had an antibiotic resistant infection, but most of them, they were talking about things that hadn’t really touched their lives. And I think that’s a difference too. Maybe if they really experienced the problem, or had close friends who’d had severe problems they might have known a bit more.
So it was kind of out there in the ether, but not a risk or a problem that I suppose confronted them on a day-to-day basis.
Part of Davina’s project focused on where the participants accessed health information.
It was mostly what you’d expect:
online, from their doctors, friends and family.
Gentle, thoughtful music fades in.
[Davina] Some of them talked about being in touch with mothers’ groups to talk about, you know, baby’s health and what was going on. And quite a lot of them and sort of googled health things a bit. But most of it was about other health issues, not about AMR at all. I know one mum in particular said that she is part of a couple of mums’ groups online.
And one of the things that they are adamant about was that they didn’t talk about health issues, because they didn’t have the expertise.
Guitar strumming comes in strong. A group is laughing.
Early on in the making of this podcast, our Executive Producer Mia Lindgren dropped in on a mothers’ group in Victoria’s Dandenong Ranges.
[Mia] Well, I brought some very unhealthy things. I wasn’t sure whether you guys were concerned about sugar! So I thought if we’re gonna be talking about antibiotics, you might also be concerned about sugar, I’m doing all the wrong things!
[Sasha] Especially if it’s chocolatey, sugar, I’m all about it!
Laughing and background babies chattering, toys being played with, parents talking to their babies.
Hello, my name is Sasha. I have Jasmine who’s a 15 month old little girl.
The parents’ group meets often.
And sometimes medical advice does crop up.
They’ve had varying degrees of experience with antibiotics.
Hannah’s daughter Cleo is 15 months old…
[Hannah] …almost 16 months. She’s a very active little bean!
I’m very reluctant to take antibiotics. I think I had mastitis four times and the first time it was really bad and I took antibiotics and the second time, they gave me a script for it and I didn’t fill it out because I didn’t want to and it wasn’t as bad the second time, and I was like I can just wait it out. And it passed.
And I’m worried about the world she’s gonna live in in 30 years, because we’re already down to our what, like one or two types of antibiotics left. And they’re not discovering new ones regularly like they used to. And it’s terrifying. She might live in a world in 20, 30 years where you know, she has a surgery and she gets an infection.
She won’t be able to get treated.
And that’s very scary.
A baby laughs and chatters. Toys, chatting and rummaging in the background.
[Rana] Hi, I’m Rana, I have Zoe who’s 16 months just chatting in the background.
I think it was three weeks ago. Zoe got pretty sick with an ear infection. And I think the worst part of it was I wasn’t home, I was at work and my mum took her to the doctors. And then they said she’s got an ear infection, she needs antibiotics and it was all go from there. There wasn’t even a second thought about it I guess.
And you know, I have a really good doctor that we go to. They don’t tend to prescribe things like that unless it’s really necessary.
So I just trusted that they would tell me, especially with a little one, what was necessary and not so.
And I actually felt pretty guilty not giving it to her earlier, not taking her to the doctor earlier because she had been in pain for a few days. And I felt bad for not acting earlier. But I guess we just wanted to see how she would go and if she if it was just something that she just needed to ride out or not.
That was the first time that she – like she’d been sick. That was the first time that she needed them. And I’m happy that it made her better for that time. But I definitely think if I was there, it would have been different.
Maybe I could have questioned it a little bit more with a doctor and just asked a few more questions about how required it was and make sure that it was the right thing,
But there’s a lot of trust there as well.
And that trust comes from knowledge.
The more we know about how microorganisms, bacteria and antibiotics work, the better equipped we are to deal with superbugs.
[Sasha] We are moving into a different reality to what we’re used to.
And, you know, you see there are reports of people with infections that they can’t clear. But you can’t put your life on hold and say, “Well, I’m looking to have a family” because I don’t know what the future has never been certain for any generation. So I just have to hope that we’ll adapt and evolve, and that they will come up with I mean, they’re always trying to develop new things. So you just hope that they can find something that works.
But it will be different.
Any time we get a bacterial infection, we’ll probably need to take a full course of antibiotics.
Australia’s consumption of antibiotics is among the highest in the world.
In 2013 more than 29 million prescriptions were given for antibiotics, with the drugs reaching 45% of the population.
Those numbers have stayed steady, with 22.7 daily doses of antibiotics being taken per 1000 people throughout 2017–2018.
There are some infections, like urinary tract infections, that can’t be cleared up without them.
In fact, UTIs are one of the most common reasons people take antibiotics.
But there are other valid reasons for taking antibiotics that aren’t life threatening.
[Lindsey] I have tried a couple of different things. I have been on doxycycline, I have been on the pill, which has gone through phases of working and managing it and other times where it’s not managed it at all.
I have tried a bunch of different skincare products like different cleansers, which just like completely strips your skin of any moisture and would permanently bleach all of the towels in our house and any clothes that you’re wearing. If that’s what it’s doing to your towels, it’s obviously not doing great stuff to your skin.
Topical creams and stuff I’ve dabbled with. I have changed my diet. I dabbled with cutting out dairy, which didn’t do anything.
Lindsey Green has acne. Most of us will experience acne in our teen years.
I remember feeling so self-conscious as a teenager. Looking back, there are almost no photos of me from the age of 14 to 16.
Lindsey only started to get pimples towards the end of high school.
[Lindsey] I went to high school in country Victoria. It was a co-ed Catholic school, and I had a really good experience of high school for the most part. I do have memories of my acne being bad in high school, but I would assume that I was self-conscious about it because like, when you’re a teenager, you’re just self-conscious about everything, but it wasn’t so significant that it stands out in my mind.
Lindsey’s acne never cleared up but it’s been manageable until 2019
when she moved to Sydney and her skin broke out.
[Lindsey] I just moved to a new city by myself to a new job when I was probably, like the most stressed and anxious and out of my depth that I have probably ever been in and it manifested in really bad acne.
Bad acne like Lindsey’s 2019 break out is classified as a chronic disease
As it got worse Lindsey went to see a GP, who prescribed doxycycline, an antibiotic that is used to treat a variety of infections
like pneumonia, anthrax, malaria, and
Lindsey had tried it before, but she was prescribed the drug a third time as a last ditch effort before being given a stronger drug called roaccutane.
[Lindsey] I wasn’t obsessed with the idea of going on roaccutane because there are a lot of side effects and it is a fairly long-term commitment. But at that stage, I was just willing to try anything, you take a lot of risk in taking both doxycycline as an antibiotic, but then also roaccutane as a really full on drug, but I didn’t really see that there was much of an alternative
For severe acne, a course of roaccutane will generally last from 4 to 8 months. It’s not an antibiotic, and it’s got some pretty nasty side effects.
[Lindsey] I think that there is definitely a level of like superficiality with taking hardcore medication to fix something cosmetic like your skin, when in reality the way that my skin looks is not like a life-threatening condition.
But on the other hand, it’s like, I’m a young woman who’s, like, going to work with other people and dating and doing all of these things and having really bad acne is just so debilitating.
Uh, so I guess it’s just a matter of weighing up whether or not the mental health benefits have improved self-confidence that comes from really superficial things like your skin, whether or not that’s worth the kind of long-term health implications of potentially developing a resistance to antibiotics.
So I guess that’s a choice that I’ve had to make. And if I had become resistant to them in the future, well I guess I’ve got good skin!
Lindsey won’t have to worry about her body becoming resistant to antibiotics, because that’s not what happens.
In fact, that’s probably the most common misconception about superbugs.
The problem is when microorganisms like bacteria evolve to resist the drugs designed to kill them.
And that’s why when people talk about antimicrobial resistance you often hear that term
When you’re a kid, it’s up to your caregivers to make the right medical decisions for you. As you grow, that responsibility gets put back onto you. And you hope you know enough to make smart choices.
Between her second and third hospital stay, before she received her diagnosis, Silvi Vann-Wall remembers being at home.
[Silvi] I got up in the middle of the night to go to the toilet. And I felt extremely dizzy. So I tried to sort of run back to my bed so that I would make it into the bed because I thought I might fall down. And anyway, I thought I’d made it to the bed. And then
I’ve woken up
and I’m on the floor
and my mum’s cradling me in arms.
She’s beside herself. And it takes me a few seconds to realise I have actually fainted.
Yeah, so that was when we called an ambulance and I went to the hospital for the third time.
Any concern the doctors had that third time mostly was directed at my mum. It would be like in those hushed tones, you know, in very, very serious like:
“Yeah, something. Something is wrong. Like it’s not food poisoning. We know that because it hasn’t cleared up.”
And by now, it’d been going on almost a month.
Silvi finally received a diagnosis: Ulcerative Colitis, a chronic inflammation of the bowel.
Ulcerative colitis has no cure. It can’t be fixed with antibiotics and it requires a strict regimen of anti-inflammatory drugs and steroids.
[Silvi] I honestly don’t know if I had different antibiotics or the same. Because the thing is, when you’re chronically ill, you’re predisposed to all sorts of other illnesses. I’m immunosuppressed. So my immune system can’t fight against a lot of common things. So almost every year, I take antibiotics for something or another. There’ll be some reason I need to take them.
And the doctors have never, like, you know, grabbed me by the hands and said, “You must only take it if it gets worse! Otherwise there’ll be resistance.”
There’s never been that conversation.
Before Silvi’s diagnosis, she says she rarely paid attention to the amount of times doctors prescribed antibiotics, or what exactly they were for.
She hasn’t had a superbug, but it’s one of her biggest fears.
Because people with chronic illnesses or compromised immune systems will always be more at risk of getting infections that are resistant.
There often isn’t a choice about whether or not to take antibiotics.
The unused antibiotics in my medicine cupboard that I bought for my tonsillitis “just in case” weren’t needed, because my body did fight off the infection.
But understanding how and when to use antibiotics, and what risks to yourself and others using them might cause
isn’t always that simple.
[Silvi] I’ve had so many different types of antibiotics over the years.
How do I know when I’ve become resistant?
How do I know when, you know this dose is going to be the one that doesn’t work?
And how do I know if I’m, you know, furthering the danger of superbugs?
Because of the fact that I have to have so many antibiotics, you know, am I responsible, in a way, for driving that increase?
And that’s the question we kept coming back to in this episode:
Who is responsible?
The World Health Organisation’s global action plan on antimicrobial resistance says:
Antimicrobial resistance threatens the very core of modern medicine and the sustainability of an effective, global public health response to the enduring threat from infectious disease. System misuse and overuse of these drugs… have put every nation at risk.
It’s very first objective is to:
Improve awareness and understanding of antimicrobial resistance.
This podcast series is a direct response to that call to action.
But do we need to take responsibility for informing ourselves about how antibiotics work?
And how do we make sure we’re getting the right information?
Should we feel guilty for using antibiotics out of fear, or “just in case”?
Is it really up to us, as individuals, to weigh up the global health impact of overusing antibiotics against protecting our own health?
Over the course of this series you’ll learn about the most common sources of resistant infections in Australia and the world, from people with first hand experience of those infections, the doctors who treat them and the scientists researching them.
We’ll be taking you inside hospitals, vet clinics, gardens and waterways.
We’ll take you into the past
and speculate on the future
because, as you’ll come to find out, antimicrobial resistance is present in almost every aspect of our lives.
And the task of improving awareness and understanding of superbugs
is a tough one.
In the next episode.
We’re moving away from the medicine cupboard and antibiotics to follow the spread of superbugs around the world.
This is Rise of the Superbugs.
In this episode we heard from Jonathan McKenzie, Silvi Vann-Wall, Davina Lohm, the Dandenong mother’s group (Sasha, Hannah and Rana) and Lindsey Green.
We’d like to thank Daniel and Rebecca Fay who also shared their story with us.
Original music by Dan Golding.
Additional music by Blue Dot Sessions.
Cover art and website by the Swinburne Design Bureau.
This podcast series is funded by an Australian Research Council Discovery grant via Swinburne University of Technology.
This episode was produced by Silvi Vann-Wall, Sarah Mashman and me, Britta Jorgensen.
Our Executive Producer is Mia Lindgren.
Our sound engineer is Melissa May.
You can read more about the project, links to our research and sources of credible health information at riseofthesuperbugs.com.