In 2013 the American Academy of Pediatrics began encouraging doctors to treat certain ear infections with what they called “watchful waiting,” an attempt to combat the skyrocketing incidence of antibacterial resistance that was due in part to the overuse of antibiotics.
For me, that meant when exhausted parents showed up in my ER halfway through a sleepless night with a child cradling a painful ear, I could explain to them that in 95 percent of cases the infection is viral and therefore not helped by antibiotics. We could talk about ways to make the symptoms better, how the infection would likely resolve itself in a matter of days. I could point out that starting antibiotics to treat a viral infection could, in fact, cause diarrhea, allergic reactions, and most importantly, antibacterial resistance that could reemerge as a severe and even life-threatening infection in their child in later years.
I could then give the parents a prescription for antibiotics and tell them that if the fever and pain weren’t gone in 48 hours—the point at which most viral infections would have resolved—they could fill the prescription and start the medication.
I have spent hours on these conversations: urging parents to be patient, reinforcing that antibiotic resistance is a real and dangerous side effect, and trying to convince them that waiting is in the best interest not only of their child but of their entire community. The drug-resistant bacteria that develop from unnecessary or inappropriately administered courses of antibiotics are a real risk to children and everyone children “share their cooties with.” I hand over my prescription, ask them again not to fill it for two days, and then call them back a week later to see whether they indeed watched and waited.
So far this year, not one has.
“Twenty years ago there was an attitude that we can use as much antibiotic as we wanted and there really wouldn’t be a problem,” says Timothy Flanigan, former chief of infectious disease at Brown University Medical School, responder to the Ebola crisis, and Christian father of five. “We’ve realized that that attitude is wrong. Antibiotics have side effects. We thought we could use them willy-nilly, and we know now that resistance does occur and that there is a cost to using antibiotics.”
Antibacterial resistance has burgeoned from a curious phenomenon noticed in penicillin’s early days into a full-blown global crisis, with experts warning that a return to the dark ages of medicine—where even common bugs will wreak havoc as the curative medications we rely on lose their efficacy—is just around the corner. Pushes to create newer, more potent drugs have accelerated the arms race between humans and the microbes that love to infect them. But even with some success in research and development, we are swiftly losing ground and—as with most other environmental disasters—the inescapable morbidity of these so-called superbugs is being heaped upon the poorest, sickest, and most vulnerable in our world.
While panic rises and the world frets about a looming era of rampant disease, the plan of attack heralded by experts around the globe is surprisingly non-aggressive. Rather than a miracle drug or a medical revolution, their strategy to save the world from superbugs involves a biblical and much frumpier concept: stewardship.
Stewardship is the careful and responsible management of something entrusted to one’s care. As a principle that Christ implores us to nurture, it is one of the reasons the Christian church is already leading the charge against antimicrobial resistance. “We understand that these drugs are gifts,” says Flanigan, who has worked alongside community leaders both in America and in the developing world to counter the effects of resistance on vulnerable populations. “Though they haven’t always been treated that way.”
When Alexander Fleming returned from vacation in late summer of 1928 to find a lump of mold growing in his petri dish of Staphylococcus bacteria, he was being handed a gift. While the discovery that followed would earn him the distinction of saving more lives than any other man that ever lived, he would later remark in his Nobel Prize acceptance speech that the development of penicillin was not due to his brilliance but to the contaminants of a dusty old building and a mind prepared to examine the results.
“It may be that while we think we are masters of the situation, we are merely pawns being moved about on the board of life by some superior power,” he said.
In antibiotics’ world-changing beginnings, some saw serendipity while others saw the hand of God. Suddenly there was a weapon against common infections that had wreaked suffering and death on all mankind. More women survived childbirth, more children survived to adulthood, and things like gas gangrene and tuberculosis—common killers in the early 20th century—became so infrequent that a modern doctor like myself may see only a handful of cases in her entire career.
Antibiotics changed our approach to infectious disease, but they also began to change the diseases themselves. The excitement surrounding them led to unbridled and unstructured use not only in healthcare but in any industry that could find a use for them. The drugs were pumped into people and the environment without caution—through medical mismanagement, agricultural use, and production of antibacterial consumer products, among other things—and the microbes around us were exposed to a low-enough dose that they began developing genetic resistance.
We were careless with our gift. Because of this, the microbial world around us has changed so drastically and resistance has become so common that penicillin—once the savior of millions—is almost useless for most clinical applications today. And as with many environmental catastrophes, the poor—those without access to advanced medications, medical technologies, or the infrastructure that prevents infection in the first place—will be the hardest hit.
Life-threatening sepsis rates in infants in India have soared as the cheap and available antibiotics that previously treated common perinatal infections lose their efficacy. Mortality for African children is rising as resistant malaria spreads through the tropics despite improvements in infrastructure and access to healthcare.
Even in my own practice at a hospital in mainstream Massachusetts, it is not uncommon for patients to need a second and sometimes a third or fourth antibiotic to clear an otherwise unimpressive infection, and the expense of the more potent drugs makes them out of reach for many in America. The microbes we have created—even those sculpted by the unnecessary medications we take for viral ear infections—are hurting our neighbors, both at home and abroad.
Last year, in a special meeting of the World Health Organization (WHO), a declaration was issued that “antimicrobial resistance has become one of the biggest threats to global health.” The call to action has been sounded: We have misused a precious resource, and we need to get serious about damage control.
The WHO is calling for a commitment to stewardship, stressing not action to find new cures but instead responsible and conservative use of what we already have by healthcare providers, the agricultural industry, and everyday citizens. It has recognized that, though humble and seemingly passive in principle, stewardship is going to involve something terrifyingly difficult: an about-face in the behavior of frightened humans. Using these medications conservatively means facing fears—fears that your livestock won’t thrive without them, fears that your patients won’t heal, fears that your child’s ear infection will become something worse.
But we are not slaves to fear. Surrounded by a marvelous creation, we are reminded that not only does every living thing—including ourselves and our microbes—belong to a God who loves us (Ps. 24:1), but that it pleases him to share both the wonder and the care of it with man. The loving hand that took joy in giving dominion over “the fish of the sea, the birds of the air, and every other living thing” to man in the early days of Genesis is the same one that guided that spore to a petri dish in 1928 and revealed an entire world of medical hope.
With the gift of dominion comes a request: Work it and watch over it (Gen. 2:15). The call to stewardship is a call to love. As we receive the gifts inherent in our God’s glorious creation—be they majestic mountains, laughing children, or medications that save the lives of millions—we are called to care for them out of a love rooted in gratitude to the Giver.
For decades we have handled antibiotics as though they themselves were the source of hope, and it has brought us now to the bottom of a rapidly depleting well. But shifting our eyes back to the God who owns it all—the bacteria, the antibiotic, and our very bodies themselves—we may find not only the strength to steward our most precious gifts but sustained hope in a well that never runs dry.
For a problem that re-quires both behavior change as well as distribution of medical tools, the greatest role of the church remains in being steadfast with the care we are already providing. In fact, as the largest healthcare provider in the world, as well as the supplier of the majority of healthcare in developing nations, the Christian church is in a prime position to provide hope.
“For Christians, we care because we have been called to follow in the footsteps of Jesus, and the two major things that Jesus did were heal and teach,” said Kevin Fitzgerald, a bioethicist and molecular biologist at Georgetown University, who addressed a recent conference organized by the US State Department to engage faith-based organizations in the fight against antimicrobial resistance.
“Here is a situation that screams for both the healing and the teaching,” Fitzgerald said. “While projections of disease and devastation from the impact of antimicrobial resistance abound, the solution begins with appreciation of what we’ve been given: incredible tools to reduce suffering and promote life.”
Fitzgerald believes that curbing antimicrobial resistance will mean confronting many traditions and cultural practices, which will require love and sensitivity that the church is well equipped to offer. “The church’s presence in the areas of most need is an asset in the quiet battle for stewardship,” he said. “[Local] people know that these people who represent these churches have only their best interest at heart.”
He says the church is a critical player in the fight against antibiotic resistance because it is both present and trusted in the impoverished communities that are being hardest hit. “Many faith-based organizations have been present in these communities for dozens and sometimes even hundreds of years.”
As the WHO enacts a World Antibiotic Awareness Week (November 13–19), it is hard to deny that we are again standing at the edge of a new era in medicine—though this time we are facing the fearful loss of a critical tool instead of the unbounded hope in its miraculous potential. But as with their initial discovery, the hand of God can also be seen in the preservation of antibiotics. Just as the right spore floated into the right dish in front of the right bacteriologist, so the right churches have been established in the right communities with the right understanding of stewarding the Lord’s gifts.
“I tell people that our immune systems are beautiful and wonderful and God-given,” Flanigan said when asked what he tells parents who are nursing a child with an ear infection. While the bacteria we change with our own use of antibiotics may be but a drop in the global microbial bucket, the call to stewarding the gifts—out of love for our neighbor and hope for our future—is one every Christian should take to heart.
“If things for that child get worse, or if it looks like it is becoming a more serious bacterial infection, they better high-tail it back to us,” he said. “And we will be able to prescribe antibiotics that work.”
Lindsay Stokes is an emergency physician in Pittsfield, Massachusetts.
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