The Wicked Web of Antibiotic Overuse
Antibiotic overuse is a classic example of what happens when soft, hard and messy problems collide.
Introduction: A Confounding Crisis
I have been working on my PhD dissertation, which deals with antibiotic overuse at the community level in rural India, specifically in underserved and impoverished communities. I have been thinking a lot of about how we, as policymakers, tend to oversimplify the issues at work. And I should know. Because I was a part of the team that drafted the background document informing the National Action Plan on Antimicrobial Resistance (NAP-AMR) in India!
It goes without saying, that at this point, few public health concerns are as complex and stubborn as the irrational use of antimicrobials at the community level. People worldwide routinely take antibiotics for viral infections, store leftover pills for future ailments, or pressure pharmacists, who are only too compliant keeping an eye on their bottomlines, into dispensing medications without a prescription. Each action, though seemingly insignificant on its own, magnifies the global threat of antimicrobial resistance. In 2019, the World Health Organization (WHO) designated antimicrobial resistance (AMR) as one of the top ten threats to global health, warning that drug-resistant infections could lead to 10 million deaths annually by 2050 if left unchecked.
Yet, it is not enough to just point fingers at public misuse or to simply mandate policy changes. Irrational antibiotic consumption is more than a matter of public ignorance; it is a tangled web of cultural habits, inadequate diagnostic tools, and political fragmentation. More formally, it exemplifies what Horst Rittel and Melvin Webber described in 1973 as a “wicked problem,” a concept further refined by multiple scholars, including Guru Madhavan in his exploration of systems engineering. Incidentally, I picked up Madhavan’s incredible book “Wicked Problems: How to Engineer a Better World” when I was flying out from Kolkata, heading back to Baltimore. Here’s two tips: first, it is an incredible read, what the Telegraph would characterize as unputdownable; second, do not read it while in a flight, mainly because of the number of examples he draws from aviation incidents. So, of course, I wanted to know more about Madhavan’s work, and ended up reading through his National Academies blog post, and this awesome discussion on the Oxford Martin School YouTube channel. Anyway, back to this problem, then.
Wicked problems resist clean solutions, are characterized by the “shifting goal posts” issue, and often become more intricate when we attempt to fix them. In this post, I will try to explore how irrational antibiotic use represents the intersection of three problem layers — soft, hard, and messy — that collectively produce a singular, deeply rooted quagmire. I will also argue that the one-dimensional fixes we have tried have, bya and large, failed to address the complexity of unrestrained antimicrobial usage at the community level.
Soft Problems: The Human Dimensions
Much of the chaos stems from human beliefs, attitudes, and behaviors. These soft problems manifest in the social norms, cultural values, and informal knowledge networks that shape antibiotic-seeking behavior. In many communities, antibiotics are seen as fast-acting “magic bullets”. If someone has a fever, cough, or any lingering malaise, the default assumption is often that antibiotics (and a steroid boost) offer the quickest route to recovery. A grandparent might insist on giving their grandchild powerful pills for symptoms that are likely viral, not because they are ill-intentioned, but because they rely on lived experience and folk wisdom passed down for years.
Deep-rooted beliefs about health, often influenced by family or social groups, can override more formal sources of knowledge. A person may know on some level that antibiotics do not alleviate viral infections, yet still reach for them in moments of desperation or uncertainty. A 2024 analysis of awareness campaigns conducted in Europe provides some discouraging insights. Most of the campaigns did not result in any practice changes (despite upticks in knowledge levels), and only two campaigns looked at long term follow-up data. They found that while there was a large reduction in antibiotic prescriptions in the immediate aftermath of the program launch, over time, this effect waned and antibiotic usage slowly trickled up. If this is the state of affairs in affluent western European countries, where access to healthcare is assured, and social welfare schemes are relatively generous, imagine what can happen in a more impoverished setting with none of these safety nets.
It has been our experience that knowledge campaigns alone fail to curb inappropriate antibiotic use in communities where trust in formal healthcare channels is limited, or where resources for diagnostics and follow-up care are scarce. Habits and cultural norms can be every bit as stubborn as biological pathogens. They are imbued with history, shaped by societal pressures, and resistant to the straightforward logic of medical science.
Another potent driver is fear. Where there is a history of limited healthcare access, people sometimes cling to antibiotics as an all-purpose safeguard against serious illness. That protective instinct is compounded by social hierarchies in which local leaders, elders, or more knowledgeable neighbors, rather than trained clinicians, who are often regarded with some level of suspicion, become key gatekeepers of health information. Any measure that seeks to address antibiotic misuse must engage with these community influences. If interventions overlook cultural nuances, they run the risk of being dismissed or, at best, partially adopted.
Hard Problems: The Scientific and Technological Realities
Irrational antibiotic use is also entangled with scientific and logistical constraints. Antibiotics are remarkable pharmacological tools, but they are only as good as our ability to use them correctly. Bacterial populations evolve through genetic mutations and horizontal gene transfer, making them adept at dodging once-potent drugs. When antibiotics are overused or misused, the evolutionary pressure selects for hardy bacteria that can withstand standard treatments. The result is a world where lifesaving medications gradually lose effectiveness, turning once-minor infections into formidable foes.
To add to our woes, the pipeline for developing new antibiotics has weakened, largely because pharmaceutical companies find antibiotic research less profitable than chronic disease medications. This issue is complex enough to deserve its own post, but in a nutshell, the cost of R&D is high, and new antibiotics are prudently saved as last-resort treatments, limiting the potential for financial returns. Meanwhile, healthcare systems in many parts of the world struggle with inadequate diagnostic capabilities. When a patient arrives at a community clinic with a fever, there may be no rapid test to determine whether the infection is viral or bacterial. Clinicians, under pressure to deliver quick relief, sometimes resort to prescribing antibiotics “just in case.”
These gaps in diagnostics and drug development highlight the technical and infrastructural barriers that shape our daily use of antibiotics. Any policy aimed at curbing misuse must grapple with these structural weaknesses. Even if a region has robust public health guidelines, lack of access to rapid diagnostics can make following those guidelines difficult. Scientific advancements like the creation of low-cost, point-of-care tests could potentially transform the way we manage infections; sadly, progress remains slow, especially in low-resource settings. This leaves us in a precarious situation: we possess potent tools to treat bacterial infections, but we lack both the incentives and the infrastructure to ensure they are employed wisely.
Messy Problems: Policy, Governance, and Social-Ecological Quagmires
The misuse of antimicrobials also sits at the center of a messy policy and governance landscape. Governments vary widely in how they regulate antibiotic distribution, and inconsistent laws lead to further complications. Even where strict regulations exist, enforcement can be weak. Pharmacies may overlook the rules to maintain income, while officials might turn a blind eye out of fear of political backlash. Some communities function almost entirely in an informal economy, where the idea of a formal prescription process is largely alien.
In certain contexts, antibiotics are a livelihood. Sellers who supply them without medical oversight are not merely exploiting the situation; they might be meeting local demand in places where healthcare facilities are scarce. Smuggled or counterfeit antibiotics also enter the picture, distributed through unregulated channels that no public health agency tracks. Domestic or international borders, now a matter of great local and global political concern, become fluid when it comes to microbial threats, as resistant bacteria can move freely with travelers or through shared water sources, rendering local regulations irrelevant if neighboring regions remain lax.
These messy realities underscore the role of economics and governance in shaping antibiotic use. Even the most carefully devised policy can fail if it is not accompanied by mechanisms to ensure compliance and universal access to healthcare alternatives. A well-meaning push to clamp down on over-the-counter antibiotic sales might lead to the emergence of an underground market, potentially increasing the circulation of unsafe or substandard drugs, and driving the whole system underground, taking it out of the policy and public view. Solutions that ignore this interplay between economics, politics, and local cultural dynamics may end up exacerbating the very problem they aim to resolve.
The Wicked Collision: Irrational Antimicrobial Use as a Perfect Storm
When soft, hard, and messy problems converge, we find ourselves grappling with a perfect storm of complexity. Irrational antibiotic use stands out as a textbook example of this convergence. It is wicked because its parameters are always shifting, its definitions vary among stakeholders, and its interconnected factors often generate unintended consequences (I will write about this in more details in a future post).
Complexity begins with the question of what “irrational antibiotic use” even means. Some interpret it as taking antibiotics without a valid prescription, while others focus on incomplete doses or incorrect drug choices or incoherent fixed-dose combinations. Healthcare providers might frame irrational use in terms of knowledge deficits among the public, whereas community members might identify healthcare barriers, like cost or lack of trust in medical institutions, as a bigger headache. Disparate definitions spawn disagreements over how to tackle the problem, making it difficult to standardize any response.
Interdependencies also multiply. Community-level behaviors shaped by social pressures will not change unless governance structures rein in unregulated sales, yet those same governance structures may be powerless without robust scientific tools to diagnose infections accurately. Every attempt to solve one element risks aggravating another. When regulations become too stringent, people may shift to clandestine markets. When new diagnostic tests remain expensive, clinics that serve underprivileged populations can’t adopt them, leaving prescribers to guess. This interplay deepens the tangle.
Irrational antibiotic use also fits the wicked profile because there is no clear “end point.” Even if inappropriate usage rates plummet for a time, new resistant strains emerge, and the challenge reappears in a fresh form. Nowhere is this exasperation better exemplified than in the persisting problem of tuberculosis and malaria. We have developed a number of effective and efficacious regimens against both diseases (HRZE for TB; chloroquine and analogs for malaria), which, over time, have lost their edge. Then we have come up with combination therapies to counteract these turbocharged resistant pathogens — for TB these included newer drugs like bedaquinine, pretomanid or delamanid; and for malaria, they included a range of Artemisinin based combination therapies. But our woes are far from over, as the microbial marauders are figuring out a way to resist these newer agents as well. So, where does this end? Which goal post are we targeting?
The complex evolutionary dynamics of bacteria ensure that antibiotic stewardship must be an ongoing, adaptive process rather than a finite effort. In the words of Rittel and Webber, wicked problems have no simple stopping rule, and each “solution” often begets a new wave of complications. While Paul Farmer said this in a very different context, I can contend that this is also like “fighting the long defeat”. In the end, as Pasteur foretold, the microbes will have the last word.
Why Simple Fixes Rarely Work
Education campaigns alone frequently fall short because knowledge does not always translate into practice. In fact, having seen what I have in the past decade, I would say that the knowledge-practice gap is more of an unbridgeable gulf in reality than researchers or policymakers will admit. People might read that antibiotics are ineffective for viral infections, but they are still going to seek them out when faced with uncertain symptoms or a lingering cough. Fear, social expectation, and personal anecdotes of “a one pill cure” can outweigh public health messaging.
Technological breakthroughs can quickly hit roadblocks if they fail to address affordability or come without the necessary policy and financial support. A cutting-edge diagnostic device cannot help communities that cannot afford it, and a new antibiotic does little good if profit-driven systems delay its development or limit its distribution. These scientific or infrastructural advances remain sidelined when market forces and policy frameworks are not aligned to ensure widespread implementation. However, while this is true, I do not, for one moment, believe that costs can be a way for gatekeeping access to a truly disruptive innovation. HIV drugs, for instance, started out being super expensive — to the point where even patients in the US were not able to afford it on a regular basis. In less than a decade after their market launch, we managed to bring down costs. And today, they barely cost anything. I don’t know what the pharma executives feel about this, but it has given us a way to approach costs and balance them with economies of scale. And considering the scale of the AMR problem, any effective intervention can be easily scaled.
But, till we have the silver bullet to target AMR, our best bet remains to target irrational AMU. Top-down policy changes can seem promising but may stumble if they ignore local realities. Restrictions on antibiotic sales might be promulgated by health ministries, but communities without the resources to see a trained clinician may find these regulations burdensome, or even contributory to higher levels of morbidity and mortality. In such environments, what starts as a sincere effort to protect the public can end up driving antibiotic use underground or encouraging the proliferation of counterfeit medications. Each of these one-dimensional solutions fails precisely because it underestimates the tangled web of soft, hard, and messy factors.
Case-in-Point: The Community Pharmacy Conundrum
A community pharmacy in a low- or middle-income neighborhood neatly encapsulates these colliding realities. Pharmacies are more accessible than hospitals, yet they often lack the resources and diagnostic tools found in larger health centers. Customers arrive seeking immediate relief, armed with cultural beliefs that antibiotics are a one-size-fits-all solution. Pharmacists themselves might be poorly paid, creating an incentive to sell whatever the clientele demands. Public health policies that restrict over-the-counter antibiotic sales can feel like a threat to the pharmacy’s livelihood, leading them to skirt regulations. It never gets old, when I tell medical students or healthcare professionals in the US that in India I can get a hold of ANY antibiotic at any time from almost any pharmacy. Even costlier ones, higher on WHO’s AWaRe list of antimicrobials.
So, it stands to reason, that even the most stringent of policies can dissolve into irrelevance if the community’s trust in official healthcare institutions is low. People in desperate need of relief may not only ignore rules but also view them as barriers to necessary treatments. That encourages an illicit market, where the drugs may be of dubious quality, potentially accelerating the spread of resistant bacteria. Attempting to solve one part of the problem, whether through stricter policy, better training, or public education, can backfire if the other dimensions remain unaddressed.
The One Health Perspective: Beyond the Human
Wicked problems also transcend human medicine, particularly when discussing antibiotic use. One Health, an integrated approach that recognizes the interconnectivity of human, animal, and environmental health, highlights how antibiotic misuse in livestock can dwarf consumption in clinical settings. Livestock are often fed antibiotics at low doses to promote growth and prevent disease in crowded conditions. While that practice might enhance productivity, it also introduces antimicrobial residues in food and, over time, spawns resistant bacterial strains that can jump to humans through direct contact or via the food chain. This is a big enough problem to deserve its own book, let alone a blog post!
Environmental factors further complicate the landscape. Wastewater from drug manufacturing plants can contain antimicrobial residues that seep into local ecosystems. Rivers and soil contaminated by these residues become prime grounds for resistant microbes to thrive and spread. Even if human antibiotic consumption at the community level becomes more regulated, these environmental and agricultural reservoirs could still ignite new waves of resistance. No solution can be complete without addressing each of these interconnected domains.
Toward Multifaceted Solutions: An Adaptive Strategy
Given the wicked nature of the challenge, only a multifaceted, adaptive approach can hope to contain irrational antibiotic use. Rather than pinning hopes on a single remedy, successful strategies must integrate insights from anthropology, sociology, clinical medicine, veterinary science, and policy studies. Collaboration across these fields recognizes that human behavior is interlinked with scientific realities and shaped by governance structures.
Community engagement is one vital step. Instead of deploying top-down directives, public health officials must partner with local leaders, pharmacists, and clinicians to create interventions that resonate with local beliefs and practices. Understanding why communities value antibiotics so highly, and building trust in alternative solutions, can make a difference. Attempts to incorporate cultural practices into official healthcare channels are more likely to succeed than imposing external rules that feel disconnected from daily realities.
Strengthening health systems also remains crucial. Investment in diagnostic technologies that are affordable and user-friendly can empower clinicians to discern bacterial from viral infections, reducing guesswork and unnecessary antibiotic prescriptions. Training healthcare workers, both in the formal and informal sectors, on antibiotic usage and stewardship can help them resist social or commercial pressures to prescribe medication needlessly. Economic incentives for pharmaceutical companies to research and develop new antibiotics or better diagnostic tools are essential, but they must be paired with thoughtful policies that ensure equitable distribution and responsible use.
All such measures need to be iterative. A policy that proves effective in one setting may fail in another, due to cultural or economic differences. Periodic assessments of what is working and what is not, along with the flexibility to pivot in response to new data, are the hallmarks of an adaptive strategy. That approach aligns with the spirit of Rittel and Webber’s original description of wicked problems, which noted that solutions are rarely final and typically need constant refining.
Embracing Complexity for Real Impact
If you have managed to stick it out this far, congratulations, you, like me, are a fellow AMR nerd. And that is how I know this section will feel like a cop out to you. Because, it does to me.
Irrational antibiotic use at the community level illustrates the messy convergence of soft, hard, and messy problems, where human behavior, scientific reality, and policy intricacies fuse into a wicked challenge. The casual act of taking “just one more pill” when dealing with a routine cold is anything but harmless when replicated globally. To confront a wicked problem, we must abandon the idea that knowledge alone will transform behaviors, that new medical technologies will inherently solve structural injustices, or that policy mandates will work in isolation. Each dimension is crucial, but each depends on and interacts with the others. Cultural beliefs must be addressed with sensitivity, infrastructural gaps must be bridged with innovation and investment, and political and economic barriers must be tackled through nuanced, enforceable regulations.
Embracing the complexity of this wicked problem demands humility. There is no singular cure or miracle plan that will magically eliminate irrational antibiotic use. Instead, we can aim to navigate the storm more skillfully by weaving together collaborative, interdisciplinary strategies that respond to evolving patterns of resistance, community needs, and policy opportunities. That approach acknowledges the interconnected nature of our health systems, environments, and societies, reinforcing the fundamental reality that antibiotic stewardship is a shared responsibility.
So, the next time someone casually recommends you take a powerful antibiotic for a mundane sniffle, remember that the story behind that simple suggestion is steeped in cultural lore, scientific challenges, and policy gaps. If we truly wish to preserve the efficacy of these life-saving drugs, we need to confront the wickedness of the problem head-on, we need to understand it not as a puzzle to be solved once and for all, but as a continuous, dynamic process requiring vigilance, adaptability, and collaboration.