Coronavirus: The Lockdown Has Caught Us Between Expertise and Common Sense

Expertise has been humankind’s way to quickly make sense of a world that has only been becoming more confusing – but historically, expertise has also been a reason of state.

On March 27, the Johns Hopkins University said an article published on the website of the Centre For Disease Dynamics, Economics and Policy (CDDEP), a Washington-based think tank, had used its logo without permission and distanced itself from the study, which had concluded that the number of people in India who could test positive for the new coronavirus could swell into the millions by May 2020. Soon after, a basement of trolls latched onto CDDEP founder-director Ramanan Laxminarayan’s credentials as an economist to dismiss his work as a public-health researcher, including denying the study’s conclusions without discussing its scientific merits and demerits.

A lot of issues are wound up in this little controversy. One of them is our seemingly naïve relationship with expertise.

Expertise is supposed to be a straightforward thing: you either have it or you don’t. But just as specialised knowledge is complicated, so too is expertise.

Many of us have heard stories of someone who’s “great at something even though he didn’t go to college” and another someone who’s “a bit of a tubelight despite having been to Oxbridge”. Irrespective of whether they’re exceptions or the rule, there’s a lot of expertise in the world that a deference to degrees would miss.

More importantly, by conflating academic qualifications with expertise, we risk flattening a three-dimensional picture to one. For example, there are more scientists who can speak confidently about statistical regression and the features of exponential growth than there are who can comment on the false vacua of string theory or discuss why protein folding is such a hard problem to solve. These hierarchies arise because of differences in complexity. We don’t have to insist only a virologist or an epidemiologist is allowed to answer questions about whether a clinical trial was done right.

But when we insist someone is not good enough because they have a degree in a different subject, we could be embellishing the implicit assumption that we don’t want to look beyond expertise, and are content with being told the answers. Granted, this argument is better directed at individuals privileged enough to learn something new every day, but maintaining this chasm – between who in the public consciousness is allowed to provide answers and who isn’t – also continues to keep power in fewer hands.

Of course, many questions that have arisen during the coronavirus pandemic have often stood between life and death, and it is important to stay safe. However, there is a penalty to think the closer we drift towards expertise, the safer we become — because then we may be drifting away from common sense and accruing a different kind of burden, especially when we insist only specialised experts can comment on a far less specialist topic. Such convictions have already created a class of people that believes ad hominem is a legitimate argumentative ploy, and won’t back down from an increasingly acrimonious quarrel until they find the cherry-picked data they have been looking for.

Most people occupy a less radical but still problematic position: even when neither life nor fortune is at stake, they claim to wait for expertise to change one’s behaviour and/or beliefs. Most of them are really waiting for something that arrived long ago and are only trying to find new ways to persist with the status quo. The all-or-nothing attitude of the rest – assuming they exist – is, simply put, epistemologically inefficient.

Our deference to the views of experts should be a function of how complex it really is and therefore the extent to which it can be interrogated. So when the topic at hand is whether a clinical trial was done right or whether the Indian Council of Medical Research is testing enough, the net we cast to find independent scientists to speak to can include those who aren’t medical researchers but whose academic or vocational trajectories familiarised them to some parts of these issues as well as who are transparent about their reasoning, methods and opinions.

If we can’t be sure if the scientist we’re speaking to is making sense, obviously it would be better to go with someone whose words we can just trust. And if we’re not comfortable having such a negotiated relationship with an expert – sadly, it’s always going to be this way. The only way to make matters simpler is by choosing to deliberately shut ourselves off, to take what we’re hearing and, instead of questioning it further, running with it.

This said, we all shut ourselves off at one time or another. It’s only important that we do it knowing we do it, instead of harbouring pretensions of superiority. At no point does it become reasonable to dismiss anyone based on their academic qualifications alone the way, say, Times of India and OpIndia have done (see below).

What’s more, Dr Giridhar Gyani is neither a medical practitioner nor epidemiologist. He is academically an electrical engineer, who later did a PhD in quality management. He is currently director general at Association of Healthcare Providers (India). – Times of India, March 28

Ramanan Laxminarayanan, who was pitched up as an expert on diseases and epidemics by the media outlets of the country, however, in reality, is not an epidemiologist. Dr Ramanan Laxminarayanan is not even a doctor but has a PhD in economics. – OpIndia, March 22

Expertise has been humankind’s way to quickly make sense of a world that has only been becoming more confusing. But historically, expertise has also been a reason of state, used to suppress dissenting voices and concentrate political, industrial and military power in the hands of a few. The former is in many ways a useful feature of society for its liberating potential while the latter is undesirable because it enslaves. People frequently straddle both tendencies together – especially now, with the government in charge of the national anti-coronavirus response.

An immediately viable way to break this tension is to negotiate our relationship with experts themselves.

‘Sell More, Earn More’: Drug Company Reps Bribe Quack Doctors to Prescribe Anti-Biotics

Top drug company representatives give incentives to quack doctors to over-prescribe.

Two of the biggest names in the pharmaceutical world in India – Abbott and Sun Pharma are alleged to be giving inducements to “quack” doctors of gifts and cash to encourage them to prescribe large amounts of antibiotics, propelling the rise of drug-resistant superbugs around the world.

Undercover reporting by the Bureau of Investigative Journalism (BIJ) has revealed that the two companies promote antibiotics to healthcare practitioners who often have no formal medical training. Their products and devices are supplied and used in more than a hundred countries, including the US and by the National Health Service (NHS) in the UK. Although illegal to sell antibiotics to quack doctor in most parts of India, the law is seldom enforced. Moreover, there are no restrictions on promoting the drugs to them.

Due to lack of better healthcare facilities in impoverished communities, the quacks often take advantage of the situation and prescribe drugs incorrectly. By offering such incomplete and unnecessary treatments, they play catalyst in creating the superbugs which go on to kill thousands of babies in India alone annually.

Also read: India Must Carefully Navigate Regulatory Challenges Posed by E-Pharmacies

According to the BIJ report, an Abbott salesman suggested that he knew the drugs might be misused, but the monetary benefit lured him into it. Furthermore, a Sun Pharma salesman revealed to an undercover reporter that quacks and real doctors were given expensive gifts so that they stick to the same drug supplier. Ranging from gift cards, medical equipment, refrigerators, televisions to travel and cash, sales representatives would not stop just here. They went on to offer extra pills or cash as an incentive to buy more antibiotics, advancing potentially dangerous over-prescription.

With revenue of more than £3bn, Sun Pharma is the largest drug manufacturer in India. They supply drugs to NHS. NHS has no rule against buying from companies that give inducements to doctors, provided none are listed in the British supply chain. Moreover, NHS also purchases devices from Abbott Laboratories, a US company that pulled in more than £24bn in revenue last year. Abbott India, its Indian subsidiary, happens to be the second pharmaceutical industry in the country.

As confirmed by an Abbott salesman, the doctors and quacks were cajoled into buying in bulk, with gifts worth up to Rs 2,000 (£23), and encouraged to prescribe more regardless of the need. Several unqualified doctors in India, often from rural areas, earn so little that these incentives can raise their monthly income by as much as a quarter. Not just that, companies like Abbott also offers doctors a taste of luxury by throwing surprise parties for their families in five-star hotels.

However, the spokespeople of both companies denied any truth in these claims. They went on to say that they prohibit offering gifts to healthcare providers to propel prescriptions.

Also read: The Pharmacy of the Developing World is Under Siege and it is Modi’s Duty to Defend It

Antimicrobial resistance (AMR), one of the world’s greatest health threats, is a resultant of excessive use of antibiotics. Over the course of time, bacteria evolves resistance against the drugs and become superbugs. The inappropriate dosage speeds up the process.

Experts condemned the pharmaceutical companies for encouraging incorrect use of antibiotics and selling to quacks, who contribute to AMR when they wrongly prescribe the drugs. Lord Jim O’Neill, who led a global review of AMR, called the Bureau’s findings astonishing. He said, “Many pharmaceutical companies like to position themselves as being responsible and here is some rather frank evidence to the contrary.”

Professor Ramanan Laxminarayan, director of the Centre for Disease Dynamics, Economics and Policy (CDDEP), said, “When you consider that there are five times the number of rural medical practitioners in India as there are trained medical doctors, it should come as no surprise that the majority of antibiotics reach patients through this channel. It is no surprise that pharma companies push antibiotics through [them].” Laxminarayan further said that the biggest challenge is to balance the access to antibiotics and prevent overuse and abuse of the same.

This article first appeared in The Bureau of Investigative Journalism. Read the original here.

Prosperous People Are Helping Bugs in Their Fight Against Ourselves

The problem of antibiotic resistance hasn’t been the lack of new antibiotic drugs but irrational uses of the existing ones.

Antibiotics. Credit: oliverdodd/Flickr, CC BY 2.0

Credit: oliverdodd/Flickr, CC BY 2.0

The Centre for Disease Dynamics, Economics and Policy (CDDEP), a public-health think-tank out of Washington DC and New Delhi, has warned of alarmingly high rates of bacteria resistance to antibiotics that can lead to life-threatening infections around the world. Though wealthy countries still use far more antibiotics per capita, high rates in the low and middle income-income countries (where surveillance data is now available—such as from India, Kenya, and Vietnam) sound a warning to the world, the latest data shows.

In India, 57% of infections caused by Klebsiella pneumoniae, a dangerous superbug found in hospitals, were resistant to one type of antibiotics in 2014, which is up from 29% in 2008. These drugs are known as carbapenems and are ineffective against Klebsiella infections in 20% of cases in the United States and under 5% of cases in most of Europe. The bug is also some 80% resistant to third generation cephalosporins, 73% to fluoroquinolones, and 63% to aminoglycosides.

Similarly, E. coli resistance is high and going up for many drug types and in many regions across the globe. However, compared to all other countries, India is said to have the highest rates of resistance to nearly every drug used to treat it. Strains of E. coli are more than 80% resistant to three different classes of drugs. In simple terms, treatment options are running out.

The authors of the latest report, ‘The State of the World’s Antibiotics, 2015‘ (PDF), recommend six ways to check the spread of antibiotic resistance. While antibiotic stewardship was the key factor according to the authors, they also said the problem of antibiotic resistance hasn’t been the lack of new antibiotic drugs but irrational use of the existing ones.

The findings on antibiotic resistance were released through an interactive online tool that allows users to track the latest global trends in drug resistance in 39 countries, and antibiotic use in 60 countries. Dubbed ResistanceMap, it includes infections caused by 12 common and potentially deadly bacteria including E.coli, Salmonella, and methicillin-resistant Staphylococcus aureus (MRSA).

Antibiotic resistance of E. coli in India. Source: ResistanceMap

Antibiotic resistance of E. coli in India. Source: ResistanceMap

Introduced in the 1940s, antibiotics have been central to modern healthcare across the world. They’re used widely for treating and preventing acute infections, protecting patients during surgical procedures and on people with compromised immune systems. Increasingly, they’ve also been used to treat livestock – but at times indiscriminately enough to warrant concerns of encouraging antibiotic resistance. So while existing antibiotics are becoming increasingly ineffective, new variants are being pushed beyond the reach of those who need them the most.

According to the report, between 2000 and 2010, the total global antibiotic consumption went up by more than 30%, from approximately 50 billion to 70 billion standard units. While per capita consumption is generally higher in high-income countries, the greater increase in antibiotic use between this decade was in low and middle income countries.

The report also says that in most countries about 20% of antibiotics are used in hospitals and other healthcare facilities, and 80% are used in the community, either prescribed by healthcare providers or purchased directly by consumers or caregivers without prescriptions. Most community use is usually inappropriate, being taken for coughs and colds, a treatment that’s ineffective and only adds to the burden of resistance.

Similarly, in 2010, at least 63,200 tons of antibiotics were consumed by livestock around the world. Bt 2030, this figure is expected to rise by two-thirds to 105,600 tons, to meet the demands of an estimated 8.5 billion people who will inhabit the planet, the report’s authors warn. In turn, two-thirds of the projected increase is accounted for by an increase in the number of animals raised for food production and the remaining by the shift from small-scale to industrial-scale production.

“We are seeing unprecedented resistance to these precious antibiotics globally, and especially in India, If these trends continue, infections that could once be treated in a week or two could become routinely life threatening and endanger millions of lives,’’ says Sumanth Gandra, an infection diseases physician and CDDEP Resident Scholar in New Delhi.

The incidence of methicillin-resistant Staphylococcus aureus (MRSA), a highly dangerous pathogen that people can contract in the community and in hospitals, is also rising in sub-Saharan Africa, India, Latin America and Australia. In fact, estimates published in the report show that about 90% of MRSA was resistant to multiple antibiotics in 2013 in Latin America.

ResistanceMap also tracks rates of antibiotic use, and findings indicate that both human and animal antibiotic use is rising dramatically in middle-income countries, particularly in China, India, Brazil and South Africa. Per capita use in these countries is still less than half of what it is in the United States but the increase, driven by growing prosperity, includes a great deal of unnecessary and inappropriate use.

“A rampant rise in antibiotic use poses a major threat to public health, especially when here is no oversight on appropriate prescribing,’’ says Ramanan Laxminarayan, Director of the CDEP and co-author of the report. “Antibiotic use drives antibiotic resistance,” Dr. Laxminarayan remarked, adding that humankind will need to focus 80% of our global resources “on stewardship and no more than 20% on drug development”.