Zeroing in on antibiotic resistance in Indonesia is imperative to fighting global antimicrobial resistance

The downside of a technologically developed world appears to be an incredibly high number of existing diseases, which is around 10,000. Therefore, it is not surprising that the global pharmaceutical market was valued at US$1.27 trillion at the end of 2020. Moreover, the global market size of antibiotics at 2020-end was US$ 40.7 billion, expected to grow 4.5% annually, from 2021 to 2028.

A primary reason for the rise in the antibiotics market, is the global rise in antibiotic-resistant diseases or antimicrobial resistance (AMR). For instance, the Centers for Disease Control (CDC) in the U.S., records over 2.8 million antibiotic-resistant infections in the U.S.

The Evolution of AMR

And so, AMR happens when microbes mutate and develop resistance to medications. Attributed to misuse or overuse of antibiotics, countering AMR, thus, requires more and stronger antibiotics.

Globally, 700,000 people die every year of AMR, making it one of the most urgent global public health issues. Professor Dame Sally Davies, UK Special Envoy on Antimicrobial Resistance, said, “If no action is taken, it has been estimated that drug-resistant infections will kill 10 million people a year by 2050.”

Meanwhile, the Foreign Policy and Global Health Initiative group of nations met in the recent past to discuss strategies to reverse this dangerous trend of bacteria resistance to antibiotics, known as “natural growth inhibitors.” Selman Waksman, the “Father of Antibiotics,” named these “antibiotics” in 1941. His discovery of streptomycin, the first antibiotic effective against tuberculosis, earned him the Nobel prize for Medicine in 1952, which was groundbreaking, among other bacteria-killing solutions such as blue light and UV irradiation.

Misuse of Antiobiotics in the Developing World

Yet, as seen mostly in the developing world, there is extensive and irrational use of antibiotics, with medications prescribed to over 50% of patients in these countries, often unnecessarily, according to a study conducted by Pharmacy World and Science.

Moreover, Indonesia being the fourth most-populated country in the world, and the largest among Southeast Asian nations, comprising over 17,000 islands, with around 260 million people, medical experts consider Indonesia’s role in reducing improper use of antibiotics would have a significant impact on scaling down the threat of AMR.

AMR Prevalence in Indonesia

As, Dr. Hari Paraton, head of the Antimicrobial Resistance Control Committee (KPRA) at Indonesia’s Ministry of Health in Jakarta, said, doctors are, now, compelled to prescribe new varieties of antibiotics or higher dosages of the same antibiotics, for lack of effect. As the country’s Health Ministry stated, there is “rampant abuse of antibiotics,” in Indonesia, giving rise to AMR. As Dr. Paraton said, “Diseases with stronger bacteria need stronger antibiotics that are harder to produce and more expensive. Existing antibiotics become ineffective or even wasted, so the issue is not only a problem for patients, but also pharmaceutical businesses and the nation's economy.”

The Indonesian Health Ministry calculated around 130,000 people die from AMR every year, which is markedly higher than other Southeast Asian countries. Thailand, for instance, only records about 38,000 AMR-related deaths a year. Furthermore, the World Health Organization, (WHO) includes Indonesia in a list of countries that still have no plan to fight AMR.

As Dr. Paraton observed, “The system used to diagnose patients in the country, even has yet to acknowledge such resistance as a cause of illnesses or deaths, so it is a challenge to map the prevalence.”

Mapping the Causes

However, research studies by the Health Ministry show that 10% of families in Indonesia have antibiotics at home, while at least 86% of them have no prescription for the drugs they have. Furthermore, only 27% of doctors in Indonesia prescribe the correct medications and dosages for particular ailments. More often than not, doctors prescribe antibiotics to ward off possible infections.

Chairman of the Indonesian Caring Parents Foundation (YOP), Purnamawati Sujud, said, “Sometimes, it’s the patients who force the doctors to give them antibiotics as they think they won't recover without antibiotics.” In Jakarta, 94% of young children are prescribed antibiotics although the doctors believe they have viral infections.

Moreover, a 2004 study by Germany’s University of Heidelberg found that 86% of the Indonesian population had no health insurance. This led to people having to pay in full for doctor visits. As the people are unable to pay for diagnosis, doctors tend to skip that step and just prescribe antibiotics, even as they are unable to confirm bacterial infection. Furthermore, many patients tend to self-prescribe as doctor visits cost money, which leads to use of wrong medication and wrong dosages.

Government Regulations and Unwise Medicine Practices

On the other hand, flimsy government regulations and weak law enforcement in Indonesia have led to drug stores and kiosks illegally selling prescription medication. Drugs sold in this manner are mostly not authentic or pure, and, therefore, are about 10-30 times cheaper than the genuine medication. Research conducted as part of Protecting Indonesia from the Threat of Antibiotic Resistance (PINTAR) project, found that two-thirds of pharmacies and kiosks in Indonesia sell unprescribed antibiotics to the public.

As it happens, this unwise practice continues because of widespread poverty. As a study in 2000 showed, 14.6% of Indonesians live in urban poverty, and 22.4% live in rural poverty.  This has led to a significant wealth gap among rural Indonesians and those in well-developed urban areas, and with that exist  totally incomparable lifestyles. For instance, urban women are three times more likely to deliver babies in-hospital, with rich women more likely to use safe, clean facilities. Poor women are more likely to give birth at home because the hospitals are not considered a priority in poor villages.

Moreover, with 75.6% of rural households consisting of uneducated people, they cannot really understand the benefits of the healthcare system, and, as a result are led to self-prescribing and to wrong use or overuse of medication, including antibiotics.

As Professor Dame Sally Davies said, “It (AMR) does not really have a ‘face’ because most people who die of drug resistant infections, their families just think they died of an uncontrolled infection.”

It is time indeed to prevent the world being pushed back into the dark ages of medicine.

Anton Lucanus (anton@neliti.com) is the Founder of Neliti and a former researcher at the Eijkman Institute for Molecular Biology in Jakarta, which plays a critical role in Indonesia’s COVID-19 diagnostic infrastructure. His research focuses on virology and viral epidemiology in Indonesia.