16 December 2019

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Every autumn the Diwali festival is celebrated with food, gifts and fireworks. Ramanan Laxminarayan, Chair of the Board of the Global Antibiotic Research and Development Partnership (GARDP) reflects on India’s efforts to reduce fireworks-related injuries, and what lessons can be applied to the efforts to address antibiotic resistance.

I was recently asked if I thought behaviour change around antibiotics was possible, particularly in low- and middle-income countries (LMICs), which have historically had limited controls around the use of these drugs. My answer is a qualified ‘yes’. Behaviour change is possible, provided it is evidence-based and with the understanding that meaningful transformation takes time. For a practical example of this, I often reflect on India’s experience with public attitudes towards fireworks during the Diwali festival.

A first step to addressing these knowledge gaps and changing behaviours will require LMICs to recognize drug-resistance as a priority public health issue. This is currently not the case.

Diwali, the five-day Hindu festival of lights, is celebrated throughout India with food, gifts, and copious amounts of fireworks. For much of my lifetime there was limited regulation on the manufacture, sale and use of fireworks used during this autumn festival. This both contributed to high levels of pollution and a high incidence of accidents and burns over the Diwali season1. In the early 1980s, a formative study across two Delhi hospitals found a single firework called the amar, a type of cone-shaped fountain, was responsible for 68% of fireworks-related burns. Only 5% of burn victims in the study reported using water as first aid before visiting the hospital2.

Studies such as these have motivated the authorities to implement a public education campaign on the safe use of fireworks, as well the importance of using cold water on burns. A follow-up epidemiological study on the impact of the campaign found a decrease in the number of fireworks burns and a marked increase in the number of people using water as first aid. A 10-year retrospective study of Diwali-related fireworks injuries published in 2009 also found a decrease in burns which it attributed to aggressive awareness campaigns by government and non-government organizations.

Changing behaviour

We know that new drugs alone are not enough to tackle the rising tide of drug resistance. A fundamental shift in how we use antibiotics is also required, including in LMICs where indicators point to a higher burden of resistance. So what do we know about knowledge and attitudes to antibiotics in LMICs? A recent survey of 2141 people in rural villages of Thailand and Laos3, found people generally had a high awareness of antibiotics (Thailand: 95.7%; Laos: 86.4%) and antibiotic resistance (Thailand 74.8%; Laos: 62.5%). However, there were important gaps in knowledge. Antibiotics were most commonly used to treat sore throats and were described as anti-inflammatory medicines. Some respondents reported using antibiotics to treat their plants, dogs and chickens.

A first step to addressing these knowledge gaps and changing behaviours will require LMICs to recognize drug-resistance as a priority public health issue. This is currently not the case. A WHO survey on antibiotic awareness campaigns found that, of the 55 countries that responded, 47 reported having run a campaign since 2010. Amongst these, only 16 were LMICs4.

Beyond the lack of awareness campaigns in LMICs, the WHO survey and study in South-East Asia point to another important consideration. Antibiotic resistance interventions must use accessible language and local terminology. While it is not necessary for every person to understand the science of bacteria and drug resistance, what is needed is easy to understand and compelling information and activities to support the appropriate use of antibiotics. In Sweden, the ban on antibiotics for growth promotion was the result of a newspaper article that drew attention to the fact that food animals were raised on antibiotics. The Swedish public was not responding to the problem of antimicrobial resistance – they just did not want their food to have been raised on antibiotics.

Behaviour change does not happen overnight, but as we have seen in India with fireworks, with political urgency and an empowered public, action is possible.


  1. Venkatesh R, Gurav P, Tibrewal S, Agarwal M, Dubey S, Mathur U al., Appraising the spectrum of firework trauma and the related laws during Diwali in North India. Indian Journal of Opthalmology. 2017;65(2):140-143. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5381293/ (Accessed 13 December 2019)
  2. Mohan D & Varghese M, Fireworks cast a shadow on India’s festival of lights. World Health Forum 1990;11(3):323-326. Available from: https://apps.who.int/iris/bitstream/handle/10665/44907/WHF_1990_11(3)_p323-326.pdf;jsessionid=7B658CB34299799B344CB24CFB02A52E?sequence=1 (Accessed 13 December 2019)
  3. Haenssgen MJ, Charoenboon N, Zanello G, Mayxay M, Reed-Tsochas F, Lubell Y al. Antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middle-income South-East Asia. BMJ Open. 2019; 9(8): e028224. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707701/ (Accessed 13 December 2019)
  4. Huttner B, Saam M, Moja L, Mah K, Sprenger M, Harbarth S et al. How to improve antibiotic awareness campaigns: findings of a WHO global survey. BMJ Global Health. 2019;4:e001239. Available from: https://gh.bmj.com/content/4/3/e001239 (Accessed 13 December 2019)

Ramanan Laxminarayan is founder and director of the Center for Disease Dynamics, Economics & Policy (CDDEP) in Washington, D.C., and a senior research scholar at Princeton University. He is an affiliate professor at the University of Washington and a visiting professor at the University of Strathclyde in Scotland and at the University of Kwazulu Natal in South Africa. He also chairs the board of GARDP as well as HealthCubed, which works to improve access to healthcare and diagnostics worldwide.

Since 1995, Laxminarayan has worked to improve the understanding of antibiotic resistance as a problem of managing a shared global resource. His work encompasses extensive peer-reviewed research, public outreach, and direct engagement across Asia and Africa through the Global Antibiotic Resistance Partnership. Through his prolific research, active public outreach (including a widely viewed TED talk) and sustained policy engagement, he has played a central role in bringing the issue of drug resistance to the attention of leaders and policymakers worldwide and to the United Nations General Assembly in September 2016.

Laxminarayan has served on the U.S. President’s Council of Advisors on Science and Technology’s antimicrobial resistance working group and is currently a voting member of the U.S. Presidential Advisory Council on Combating Antimicrobial Resistance.

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