WAAW presents an opportunity for us all—around the world—to reflect on our relationships with antibiotics, now and into the future
Every element of health seems to have a day, week, or month dedicated to raising awareness. This is not necessarily bad; awareness campaigns can have a lasting impact for patients, professionals, and the public—and the longer and more intensive they are, the more likely it is that they work.  Mass media public health campaigns can raise awareness of the ills of tobacco and increase people’s intention to quit smoking—although they seem not to increase the number who successfully manage to quit, according to the biggest review to date on this topic.  The same review found some evidence that sexual health public awareness campaigns effectively increased condom use.  This is not limited to strictly public health campaigns either; mass media coverage of climate change in Japan—linked to national campaigns—has increased the public’s understanding of, and concerns about, the same issue. 
Antibiotic resistance mass awareness campaigns are relatively new compared to many of these examples. The first World Antibiotic Awareness Week (WAAW) was launched by WHO in November 2015, centred upon European Antibiotic Awareness Day (EAAD), which is in its 12th year. The stated mission of WAAW was ambitious: to raise awareness about AMR, to halt its emergence and spread, and to encourage best practice by professionals and the public. Each year, WHO compiles a selection of posters and videos in different languages on their website. The scale and energy of implementation of WAAW activities then relies on national governments and local health organisations and their (already overworked) staff.
This year, NHS England has marked WAAW by sending a letter to commissioners and providers asking them to “engage” with WAAW (18-24 November) and EAAD (18th November), and to “register” their WAAW-compliant activities. It also exhorts staff to check their local antibiotic guidelines and seek additional training for antibiotic prescribing. On top of all of this, the “keep antibiotics working” campaign will run again for the month of November—readers may recall the advertisement with singing and dancing antibiotic tablets.
What work do these campaigns do?
It is unclear what impact, if any, these types of social marketing campaigns have in the field of antibiotic resistance. A 2010 review found that they can have some positive benefits, when done properly, over time, with a multifaceted campaign that targets both professionals and the public.  In this way, the English campaign gets it right. However, many of the key messages—such as “finish your antibiotic prescription”—are scientifically debatable, which can undermine public trust. [1, 4] The ways antibiotics and microbes are described in public media are understood to be confusing not only in scientific complexity, but in locating responsibility for action.  In different settings, knowledge of AMR does not translate directly to intended action—for example increasing use of particular antibiotics. [6, 7] Raising AMR awareness has also been shown to lead to negative consequences such as stigma of minority groups. [8, 9]
Given these challenges, the AMR community has welcomed a recent report from the Wellcome Trust, “Reframing Resistance,” which aims to support communication “based on the best available empirical evidence.”  Premised on an aspiration for a universal set of AMR messages that can work across settings, the report sits uncomfortably with evidence that information needs vary across contexts; a 2018 review of awareness raising interventions across different target populations found success varied markedly.  The same message that will draw attention from policy makers may not resonate with the public and care providers around the world. Indeed, Wellcome’s testing of the “antibiotic apocalypse” narrative across settings showed it to be at best confusing and at worst actively detrimental to the relationship between experts and members of the public. It is interesting, therefore, to recommend a universal communication message of AMR as “undermining modern medicine” together with a logic that raising public consciousness will result in political pressure to act, a context-bound assumption that is unlikely to hold across political settings.
It is true that campaigns can marshal support. An evaluation of European countries involved in EAAD found that the majority of governments allocated funds to EAAD activities, and media attention increased on the topic while the campaign was running.  However, in the context of overworked public health staff, the exhortations to “engage” may be causing other health priorities to fall by the wayside, all for the sake of a campaign that is likely to be only marginally beneficial, if at all.
Co-opting of public health awareness campaigns
Mass media awareness campaigns are, at their core, public health interventions. As such, they should be as evidence-based as other public heath interventions, and wherever possible, the potential negative consequences should be evaluated, and understood. Potential costs are that the involvement of industry may cloud the messaging, create trust issues with the public, and may even result in distortion or misrepresentation of the science. This has been shown for alcohol, tobacco, high fat sugar and salt foods, and baby formula in the past. This also happens with pharmaceutical companies who push so-called “disease awareness campaigns.” 
In AMR, it is often said that the pharmaceutical and diagnostics industries are part of the solution. However, as in all sectors, industries’ interests and incentives do not necessarily align with those in public health. WAAW offers companies the potential to highlight their particular products, and the opportunity to reframe the AMR discussion in terms that will benefit their corporate strategies, a clear conflict of interest that should be considered before offering industry a seat at the public health table. Corporate social responsibility (CSR) is one vehicle through which this potential can be realised. There is now a thin line between industry activities in informing the public (as part of WAAW), and pushing particular diagnostic tests or reframing the funding landscape as an impossible barrier for the private sector to overcome. This is not simply an abstract ethical comment—there are actual harms engendered. Capturing public money for industry led solutions and introducing early technologies that are under-evaluated or whose value is overstated are activities that capture public funding and investment that could be put to better use. There is also the question of crowding and skewing the policy agenda, such that policy support for industry-led or industry designed solutions come to be seen as preferable to public health systems strengthening and reform.
WAAW presents an opportunity for us all—around the world—to reflect on our relationships with antibiotics, now and into the future. As WAAW grows, we can make deliberate choices about AMR messaging tailored for different groups, in an evidence-based way, as with other public health interventions. One-size-fits-all messaging can confuse, and actively harm, our AMR efforts internationally. For policy makers, global level apocalyptic narratives may be required to out-compete other threats to health and security. For members of the public however, if we wish to engage curiosity and critical reflection rather than feed a “risk society”, different messages are required. Either way, WAAW campaigners are not responsible for industry’s use or misuse of messaging. Industries operating in AMR do not have the same agenda or bottom line as governmental and inter-governmental organisations. Without oversight of these industries, there is a risk of mission capture when collaborating with, and accepting funding from, organisations whose interests are to increase market share, push for deregulation, and, if possible, acquire public funds and policy space to subsidise investments and reap shareholder profit. For WAAW to be successful, and a means towards a public health end, is such a close relationship with the private sector required, ethical or effective? While the popularity of a public private partnership approach makes it seem inevitable that industry needs to be “at the table,” the public sector should not be cast as naïve for taking their regulatory role seriously; by being wary of offering industry a seat at the table, public health experts can prevent attempts to co-opt public awareness in order to capture and divert public funds.
Rebecca Glover, Head of Economic, Social and Political Sciences at the AMR Centre, LSHTM
Clare Chandler, Director of the AMR Centre, LSHTM
John Manton, Head of Humanities & Environmental Sciences at the AMR Centre, LSHTM
MP Petticrew, Professor, Public Health Environments and Society, LSHTM
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