By Vidushi Kala
In 2010, news and media outlets the world over reported the discovery of a superbug in India. This news took the international community by storm, the reason being the immunity of the superbug to the most powerful line of conventional antibiotics. NDM-1, or New Delhi Metallo-beta-lactamase-1, first detected in a Swedish national after his visit to India in 2009, was later found in parts of India, Pakistan, Japan, USA, Canada and the UK. This bacteria has been detected mostly in patients who travelled recently to India or Pakistan.
The NDM is Nigh
NDM-1 is an enzyme carried by bacteria that makes strains resistant to a wide range of antibiotics. NDM-1 in itself does not cause the disease but can potentially alter the characteristics of the parent bacteria. It has the capacity to jump from one bacterium to another, and it is pan-resistant, which means there is no known antibiotic treatment, making it the perfect doomsday device. NDM-1 has been found in the bacterium most frequently encountered in the human population, E. coli, which is also the most common cause of bladder and kidney infections.
In other words, NDM-1 can cause a patient to develop Anti-Microbial Resistance (AMR). Once resistance sets in, patients stop responding to any medication administered, rendering them practically untreatable. The global proliferation of AMR means that serious and highly contagious illnesses like gonorrhoea and pneumonia may soon become incurable. With the number of untreatable cases racking up worldwide, doctors and medical staff are increasingly resorting to antibiotics as a last resort.
The Spread of NDM-1
The advancement of resistance is an ordinary transformative process for all species, including microorganisms like bacteria, parasites and fungi. It is an elementary example of natural selection, where stronger micro-organisms have more opportunities to survive, duplicate, and pass on their traits, while weaker ones are exterminated. The more these microscopic organisms interact with antibiotic agents – be it in animals or people – the higher the odds that antibiotic resistant microscopic organisms will increase and flourish.
There are three root causes attributable to the rise of superbugs like NDM-1:
Excessive Use of Antibiotics: Inexpedient use of antibiotics in humans, such as over-prescription, prescription for non-bacterial illnesses, or failure to complete a course of treatment, help bacteria strains like NDM-1 to thrive. Prescribing practices vary across the world, but in India doctors are notoriously callous. In order to combat the spread of NMD-1, responsible antibiotic stewardship is important.
Prophylactic Use of Antibiotics in Animals: Habitual, non-therapeutic use of antibiotics in intensive livestock farming also aids the spread of NDM-1 and other superbugs. Antibiotics in livestock are generally used as a growth stimulant and for protection from diseases. In other words, this makes it possible to rear large flocks of cattle and chicken in dirty, crowded and confined spaces. This prophylactic use of antibiotics is disquieting because regular low doses wipe out weaker strains, making it a perfect hub for stronger strains. This stronger bacteria is then released into the ecosystem when manure is used as fertiliser. The same manure washes away and seeps into local waterways, underground water, and other water sources, initiating a vicious cycle.
Pharmaceutical waste: One of the leading causes of the spread of superbugs is the release of antibiotic effluents into the environment through factory-discharge, improper disposal of medicines, or human and animal excretion. Hyderabad – the focal point of India’s pharmaceutical industry – is riddled with superbugs. The infant mortality rate is appalling, and unregulated discharge of pharmaceutical waste has lead to the rise of other skin infections and rendered the water unfit for consumption.
A Silent Epidemic
India is one of the largest exporters of generic drugs in the world. The pharmaceuticals market is teeming with profits, which are only expected to rise in the future. It’s main driver is the increased global consumption of antibiotics. Although the pharmaceutical industry provides a huge impetus to India’s economy, it has also become a breeding ground for superbugs.
A major study published in May, 2017, in the Journal ‘Infection’ found “excessively high” levels of antibiotics and anti-fungal drug residue in water sources in and around Hyderabad. Researchers tested 28 water samples around the Patancheru-Bollaram Industrial zone on the fringes of Hyderabad, where most of the world’s major drug manufacturing companies are based. These plants generate a gargantuan amount of pharmaceutical waste everyday, which is then dumped into the nearby water supply with no medical treatment. Collected specimens contained bacteria and parasites impervious to various medications (known as MDR pathogens, the specialized name for superbugs). The researchers then tested 16 of these specimens for drug residue and discovered 13 of them were contaminated with antibiotics and anti-fungals.
Ecological contamination and poor wastewater management in India is bringing on serious contamination of urban water sources, resulting in the creation of an environment which helps in the proliferation of superbugs rapidly across the world. Consolidated with the mass abuse of antibiotics and poor sanitation, superbugs in India are the leading cause of death in newborn babies. These infants are born with antibacterial resistance, and the rising death toll could seriously squander all efforts to improve India’s already-distressing infant mortality rate. According to the New York Times an estimated 58,000 new-born babies die from Anti-Microbial Resistant infections each year.
AMR genes thrive in a country like India because of it’s dilapidated and borderline lethal sanitation system. Most Indians defecate outdoors, and much of the sewage generated remains untreated, as a direct result of which Indians are the most likely to acquire a bacterial infection and collectively take more antibiotics. In the absence of proper sanitation and hygiene, doctors are forced to rely on antibiotics. Consequently, drug consumption is at an all time high, and neonates at risk of untreatable sepsis. AMR is now classified as one of the main threats to global public health. Superbugs across the world claim nearly 700,000 lives a year. Some figures even aggregate that the world shall witness over 300 million premature deaths in the coming three decades.
The New Face of Global Pandemonium
Anti-Microbial Resistance has been determined as one of the main risks to mankind by the World Health Organization (WHO) and governments everywhere. It was estimated that AMR could be the direct cause of death of 10 million people by 2050. Most of these deaths will be concentrated in densely populated areas of Asia and Africa, although Europe and the US are also bearing the brunt of the slowly gaining momentum of AMR. There is today a 14-fold increase in mortality related to drug-resistant infections as compared to the last century. Because antibiotics play such a critical role in surgical interventions and in treating diseases ranging from cancer to diabetes, AMR could lead to the obsolescence of many modern and life-improving medical treatments. Every year, 2 million Americans are infected with bacteria that are resistant to antibiotics, resulting in 23,000 deaths. In China and the EU, 80,000 and 25,000 people respectively die annually from hospital-acquired antibiotic-resistant infections.
Treating infections caused by resistant bacteria requires the use of antibiotics with catastrophic side effects. The longer the recovery period, the more complex the treatment. Additionally, frequent hospitalisations entail higher health care costs, imposing a greater economic burden on families and societies. It is difficult to measure the full economic effects of AMR, but studies that have estimated how increased resistance to antibiotics would affect the health and mortality rate of the labour force indicate that it has already led to a drop in the global GDP of up to 1.6 percent. Other studies have shown that the world could lose up to $100 trillion of economic output between now and mid-century if the issue remains unaddressed, lowering projected GDP by 2 to 3.5 per cent. The economic effects of antimicrobial resistance are unevenly distributed, with the lowest income countries paying the highest price.
Resistance is Futile
One root cause for the propagation of superbugs in India is the unchecked release of antibiotic waste in the environment. Although it is hard to pinpoint which companies are responsible for the contamination of the water supply, drug manufacturers vehemently deny that their factories pollute the environment. With an astonishing number of pharmaceutical plants springing up in multiple parts of the country, it is evident that most of our waterways have been infected and are carriers for superbugs like NDM-1.
After much hue and cry from the echelons of the global scientific community, and a chorus from independent researchers and journalists across the globe, it was finally acknowledged that pharmaceutical waste could lead to antibiotic resistance. Even though this pandemic is now settled science, the inaction of the Indian government is alarming. India’s sanitation and hygiene issues are not veiled from the world. The subhuman conditions in which most of India’s population survives, coupled with the unchecked use of antibiotics and the lack of monitory regulations, has created an upsurge of AMR which is taking on the world rapidly.
India is not new to the problems of AMR. In 2016, the bacterium K. Pneumoniae headlined in every news and media outlet. This bacteria caused vision loss in elderly patients across the country, and on further investigation it was found that the delinquent bacteria was in the RL solution used for washing eyes during cataract procedures. Ironically, hospitals in India are also now classified as breeding grounds for Anti-Microbial Resistant bacteria. These hospitals lack compendious policies – or practically any oversight – pertaining to the use of antibiotics and contagion control.
WHO has, in the past, pointed out the deficiency in India’s policies regarding the check on antibiotic usage, production and regulation. Furthermore, they have repeatedly hinted at the lack of a National Action Plan for AMRs. Amusingly, a policy to combat AMRs is already in place for almost half a decade. It includes a separate schedule of antibiotics to hinder sale without prescription, a hospital surveillance system to monitor AMRs, and regulation in the veterinary use of antibiotics. Alas, without a proper action plan, these policies remain dormant.
We’re All Bugged
The Indian government has to acknowledge that AMR is an imminent threat to the health of it’s citizenry. There is an urgent need for a pilot plan targeting the key areas of the spread of these superbugs. Pharmaceutical companies need to be put under the radar and must be held accountable for the damage caused to the environment and ecosystem. India also needs a well-defined action plan to combat its ever increasing sewage and sanitation problem.
Drug-resistant bacteria today can travel far and wide. They pass on easily through meats, spread via contaminated manure or water used to grow food crops, travel through the air, or thrive in the bodies of people who have been contaminated. We have moved beyond the stage where AMR was rare and mostly contained to hospital environments. Today, everyone is at equal risk.
The author, Vidushi Kala, is a Senior Editor at Indus Dictum. Her work focuses on public policy and legal reform.
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