Many people might be relieved to hear the news that by not finishing a prescription of antibiotics, we’re not accelerating the rise of drug-resistant bacteria. Writing in the BMJ recently, infectious disease experts turned the simple advice to always complete the course on its head: continuing to use antibiotics after an infection has cleared up can, in fact, increase the risk of bacteria becoming drug-resistant.
For those of us harbouring guilt for leftover pills in the medicine cupboard, it’s a weight off the mind. But having had the “complete the course” message drilled into me, I also feel disgruntled by the about-turn.
The medical establishment is clear about the looming threat of antibiotic resistance and the responsibility we all share in avoiding a future where minor infections can be a death sentence. Completing the full prescription has always felt like an important way individuals can help.
Of course, scientists and clinicians should always be willing to change their mind as new evidence comes to light. But according to the BMJ article, the “complete the course” message has never been based on firm evidence, and leading figures have been questioning the advice in medical journals for nearly 30 years.
Yet in 2016, before the World Health Organization’s global Antibiotic Awareness Week, the director of WHO’s secretariat for antimicrobial resistance was unequivocal. “If you take an antibiotic, always complete the full prescription, even if you feel better, because stopping treatment early promotes the growth of drug-resistant bacteria.”
In hindsight, these firm public health messages sound a bit hollow, and that’s a worry for anyone who believes in the authority of evidence-based medicine.
This kind of attitude among public health officials is at play in another controversial area: whether e-cigarettes are a force for good or ill. In Australia there is a federal parliamentary inquiry looking into nicotine-containing e-cigarettes, which are currently banned. Announcing its submission to the inquiry, the Australian Medical Association said there is “no evidence that e-cigs stop people smoking”.
It doesn’t take long to find major public health authorities that disagree. In the UK, both Public Health England and the Royal College of Physicians have published reports concluding that e-cigarettes can help people quit smoking, and New Zealand is moving forward on legalisation.
The evidence is still emerging on e-cigarette use, and is by no means conclusive. So far, the data suggests that where e-cigarette use is rising, the rate that people are quitting smoking is also going up. On the other hand, there is evidence that young people who try vaping are more likely to try smoking, so the evidence is not straightforward. But claiming there is no evidence linking e-cigarettes to quitting doesn’t give the whole picture.
If you’ve spent your career battling the malign tactics of big tobacco, you might be forgiven for an extreme level of scepticism towards anything to do with those companies. Philip Morris is pouring money into e-cigarette development, and is reportedly running an “astroturfing” campaign, encouraging Australian vapers to submit positive comments about e-cigarettes to the parliamentary inquiry.
But everyone expects big tobacco to skew the evidence purely for their own interests. Public health bodies work in everybody’s interests and are held in high regard, so we should expect them to be fair with the facts.
Some scientific bodies are breaking ranks and supporting legalisation of nicotine-containing e-cigarettes. The Royal Australian and New Zealand College of Psychiatrists has said maintaining the ban would withhold a potentially valuable method of quitting for people with mental illnesses, many of whom are heavy smokers.
It is impossible to overstate the importance of public belief that the medical profession acts in the interests of patients. Any suggestions that public health experts are not being completely open looks at best paternalistic and at worst plays into the hands of those, such as the anti-vaccination lobby, who have warped views about the medical establishment.
So when it comes out that public health messages such as “complete the course” aren’t backed up by evidence, it adds colour to the picture of a paternalistic medical establishment and risks undermining public trust.
Simple public health messages – wear sunscreen, eat five portions of fruit and veg a day – undoubtedly have positive effects on everyone’s health. But people are also capable of understanding nuance and the shifting sands of new evidence. The best way to guarantee people keep trusting experts is for experts to put their trust in people.