Our children will die if government doesn't act

I am a worried mother — bordering on paranoia — ever since I read an article in last month’s edition of The Lancet. In a three-year long study of 88,600 neonates born in Delhi’s three main hospitals — All India Institute of Medical Sciences, Vardhman Mahavir Medical College associated with Safdarjung Hospital, and Maulana Azad Medical College — 14 per cent of babies had to be admitted into the ICU within 72 hours of birth due to onset of an infection (sepsis), not passed on from the mother but, rather, acquired at the hospital.

Worse, almost two-thirds of the infections were attributed to superbugs, resistant to even “reserve” antibiotics, a category defined by drugs more powerful than conventional antibiotics and with a broader range of microbial targets. Heartbreakingly, a quarter of these babies could not make it home.

The worry for a parent-to-be is real — the destructive toll of superbugs is predicted to grow 14-fold within three decades. Our current cavalry of antibiotics is fast being rendered powerless, and there is nothing of note in the pipeline to appear as a miracle replacement drug.

In the words of Dr Keiji Fukuda, Assistant Director General, health security, WHO, this would mean us going back to the days of the last century, when a minor injury or infection would commonly lead to death.

From the current 7,00,000 deaths per year, superbugs are estimated to kill 10 million people per year globally by 2050. India is one of the countries caught in the eye of the storm that will soon hit the entire planet. Of the 10 million deaths, 2 million are expected to be in India.

We face a more severe threat than the rest of the world.

We are the world’s largest consumer of antibiotics. More the concentration of antibiotics in our environment, stronger the level of duress and survival threat for the existing varieties of pathogenic bacteria, and higher the probability that these bacteria would evolve into antibiotic-resistant superpowers.

In other words, we are a rich breeding ground for creation of yet more superbugs, especially our hospitals that are the primary sites of high antibiotics usage.

A 2014 study from the Indian Journal of Basic and Applied Medical Research reported the rate of hospital-acquired infections to be 11-83 per cent in Indian hospitals as opposed to the WHO-reported range of 7-12 per cent globally.

The threat is real. And it is Code Red.

Compounding the risk associated with hospital ICUs is our habitat and environment. For those living in or near Hyderabad and Visakhapatnam, for example, one can’t be sure of the water one drinks, or the land under one’s feet.

These cities are mammoth production hubs of bulk-drugs, making us one of the world’s largest producers and exporters of antibiotics. The economic reality of this statistic would have maintained its cheery glean had it not been slammed by the Central Pollution Control Board of India’s rating for these industrial areas, as being critically polluted with pharmaceutical effluents.

Just 18 miles out of Hyderabad, at Edulabad, the chemicals-smeared soil goes into flames at the touch of a splinter, dead fish and white foam float in lakes, locals contract unexplained illnesses, and the area sheriff can’t help but break into tears at the predicament of his fellow-citizens.

The imagery sums up the plight of residents of many other districts (such as Pantancheru-Bollaram area) in the vicinity of antibiotics manufacturing units that are known to discharge effluents into the area’s water bodies that eventually land up into sources of water for domestic use and irrigation.

Back in 2007, a Swedish lab published results confirming unacceptably unsafe levels of ciprofloxacin in this region’s water samples - a whopping 1000-fold higher concentrations that are otherwise sufficient to kill disease-causing bacteria.

More recently, a 2015 study has confirmed the superbug hotspot status of the Kazipally lake and Asintuka tank in this area, harbouring 52 per cent of ciprofloxacin-resistant and 60 per cent of sulfamethoxazole-resistant bacteria compared to other Indian and Swedish lake samples.

Those who don’t have a lake for a view aren’t exactly luckier. The build-up of antibiotic resistance for the rest of us is just a tad lower and slower. In the case of pathogenic Escherichia coli - one of the seven bacteria in WHO’s key superbug candidates list - when tested for resistance against common antibiotics, over 91 per cent of Indians showed resistance to aminopenicillins, 82 per cent to carbapenems, and 85 per cent to fluoroquinolones.

The sample set of this study is an extensive one  — 700 collection centres from private hospitals, diagnostic laboratories, and home collection agencies spread across 26 states and two union territories. For Sweden and Denmark, the same statistic hovers slightly above zero.

The Centre for Disease Dynamics, Economics and Policy, has been tracking national and subnational data on antibiotic-use and resistance worldwide. India fares abysmally. We hold one of the top ranks in the list of countries with highest rates of antibiotic resistance in the world.

Over-prescription of antibiotics as the first line of defence against any suspected infection is the primary reason. Also, self-medication is rampant, fed mostly by unregulated dispensing of prescription-only drugs at pharmacies, and underpinned sadly by the necessity to save on the already back-breaking volume of out-of-pocket healthcare expense.

Cutting down on consultation fee for a repeat advice to tackle a seemingly familiar illness may cut the treatment expense up to 50 per cent at times. Is the poor Indian patient to be blamed?  

The government is apathetic.

Would it take a personal tragedy for our elected representatives to acknowledge the severity of the situation and shed their apathy? The danger has been staring at us ever since the world turned its attention to New Delhi in 2009 with the first reported case of NDM-1 (New Delhi metallo-beta-lactamase) antimicrobial resistance.

Predictably, it was dismissed as “wrong propaganda” and an “MNC conspiracy” by the then ruling government and the Opposition alike. Since then, NDM-1 has spread widely within India, and has been detected in several countries worldwide. Two years hence, as a feeble response, a national policy for containment of antimicrobial resistance was drafted in 2011. It has been on hold ever since.

In September of this year, the United Nations declared superbugs as the biggest global threat to our civilisation. When commenting on India’s implementation of the UN declaration, we heard of a response that reeked of tiresome procrastination from our Director General of health services: “We have not made any promises. In such a big nation, we cannot promise anything. We have promised surveillance, which we will follow through.” 

Is an issue as grave as this not worthy of making an urgent resolve by our government to tackle it on a war-footing? Evidently not. After all, we are such a big nation, we cannot promise anything.

Winter’s coming. Let there be war.

A disjointed approach to tackle the problem of antibiotic-resistance and the rise of superbugs will simply not do. The problem is daunting, and the adversary relentless. Dealing with this challenge needs a multi-pronged, well-orchestrated game plan, the essentials of which must constitute nothing less than a nationwide shake-up for one and all with awareness campaigns; strict regulation and penalty on sale of antibiotics (without prescription) by pharmacies and dispensaries; stringent infection control and surveillance in tertiary and secondary hospitals; mandatory antibiotic stewardship training for medical students and practitioners; and finally, heavy fines for pharmaceutical companies that disregard effluent norms.

A good starting point would be to adopt The Chennai Declaration. Prepared by the Clinical Infectious Diseases Society, CIDSCON, under the leadership of Dr Abdul Gafur, it lays down a detailed framework for launching a multi-stakeholder governed campaign against superbugs, with a pragmatic motto of “India needs an implementable antibiotic policy, not a perfect policy”.

Containing spread of superbug infections, and preventing all opportunities for newer and more powerful species of superbugs to emerge, is how India can join the global front against superbugs. The government needs to act. It is never too late to save a life.

Also read: Why spraying perfume should be banned in hospitals