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Finally, the government has stepped in to arrest the spread of antibiotic resistance that is now threatening our lives. It will soon have to ensure that laws are formulated to ensure that it works

~By Ramesh Menon

One of the scariest medical realities that have hit India and the world is the emergence of Superbugs. Overuse of antibiotics has made bacteria resistant to drugs. Increasingly, doctors are helplessly witnessing their patients battle diseases like tuberculosis and pneumonia with medicines not having any effect as the bacteria has developed immunity to antibiotics. Many just die.

India has the highest rate of antibiotic resistance in the world. It is, therefore, hardly surprising that it is the largest consumer of antibiotics. The State of the World’s Antibiotics 2015, a study by Delhi-based Centre for Disease Dynamics, Economics and Policy, points out that resistance to some medicines has touched almost 50 percent. According to a World Bank report, antibiotic resistance could push 28 million people into extreme poverty. A review by the United Kingdom predicted that anti-microbial resistance would end up killing nearly ten million people every year by 2050!

On February 22, India’s health and welfare ministry rolled out a strategy to fight anti-microbial or antibiotic resistance which threatens the effective treatment of numerous diseases like tuberculosis, malaria, typhoid, urinary tract infections and many others. It plans to enforce prescription audits to control careless consumption of antibiotics that are pushed by hospitals and doctors when they are not needed. Hospitals and pharmacists will soon be required to upload all the prescriptions issued and received by them for evaluation. It will start in select hospitals and then be extended to the rest of the country.

Justice Narendra Chapalgaonkar, who retired from the Bombay High Court, told India Legal: “The nexus between doctors and pharmaceutical companies should be investigated as both have pushed antibiotic use. Why has the Indian Medical Association not cracked down on doctors who unnecessarily prescribe antibiotics? Just having a law will not help as it has to be supported by public education that must be in local dialects and languages so that the messages gets easily absorbed.”

Today, the threat of Superbugs is global. But India is going to be most seriously affected as there is rampant and careless prescribing of antibiotics by general practitioners and even specialists. Doctors say that patients demand prescription of strong antibiotics as they want quick cures that will help them bounce back to work.

But with Superbugs on the horizon threatening our lives, doctors need to counsel patients and not get pressurised by pharmaceutical companies who also seduce them with gifts like foreign trips if the sales of their products rise in nearby medical shops around their clinics. Most of them are camouflaged as sponsored visits for overseas conferences.

Points out Justice Chapalgaonkar: “The concept of the family doctor has vanished who was trusted and genuinely did not advise for medicines that were not required. Now, we are all in the hands of specialists who over-prescribe.”

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What is the way out? Here are some of the steps that could help:

  • Crackdown on the over-the-counter sale of antibiotics
  • Get doctors actively involved in prescription audits to make them more alive to the threat that patients face
  • Promotion of delayed antibiotic prescribing strategies
  • Encourage doctors to spend more time with patients talking to them of the dangers of carelessly consuming antibiotics
  • Promotion of pragmatic studies in primary care which details out complications and clinical outcomes

That is why the recent government move to audit prescriptions is a move in the right direction. In fact, it should have come long ago as the threat of Superbugs started haunting India over a decade ago.

Union health minister JP Nadda says that the idea is to jointly strategise with nine ministries so that they are on the same page as far as the action plan was concerned. Health secretary CK Mishra points out that only a multi-sectoral approach would help to deal with the problem. He has a point as it is not just humans who are affected but animals too. There are environmental factors like overuse of chemicals in farming,  aggravating the problem. Clearly, antibiotic resistance is a frightening health threat that has no easy answers. Urgent action is called for if we have to fight infectious diseases.

Points out Sunita Narain, director general of the Centre for Science and Environment: “It is critical that environmental policymakers in developing countries are actively involved along with policymakers from the agriculture and health sectors to address environmental spread of antibiotic resistance.”

Another worrying factor is the increasing misuse of antibiotics in farming. Nearly 63 percent of the world’s antibiotics are used in farming. It is mixed with the animal feed or water used for irrigation to stop diseases spreading through cramped, unsanitary factory farms.

Meat from animals and chickens also contain antibiotics as it is mixed in their feed under the guise of preventing them from falling sick, but the actual goal is to fatten them before slaughter. The Superbugs pass from the animal’s dung and spread through the air, soil, and water into rivers and sewers.

Dr Vikram Sarbhai, senior consultant in chest medicine, critical care and sleep medicine at the National Heart Institute, New Delhi told India Legal: “The idea of auditing prescription to regulate use of antibiotics may be wonderful. But the question is how do we ensure compliance? The magnitude of logistics is huge and there is no apparatus to deal with it. India has not yet standardised healthcare and created even minimum standards format. We do not have health records for every individual. The question is how do we regulate prescriptions and then monitor its use; punish those who are not complying. It will be a logistics nightmare as we are not prepared.”

Justice Narendra ChapalgaonkarWhat are other governments doing?  Countries that took stringent actions and used regulations to control the use of antibiotics, have shown positive results. Penicillin, Streptomycin and Tetracyclines used as feed additives over 45 years ago were banned by European countries. Sweden banned all antibiotic growth promoters in feed in the mid-eighties. In the nineties, Denmark, a major livestock producer in Europe and the largest exporter of pork in the world, started regulating the use of antibiotics. Between 1995 and 1998, it banned Avoparcin, Virginiamycin, Tylosin, Spiramycin and Zinc Bacitracin that were used as growth promoters. Then it restricted the use of Fluoroquinolones, a crucial antibiotic for humans, in animals in 2002. The cattle and broiler industry voluntarily stopped use of all antibiotics as growth promoters in 1998. In 2000, the pork industry also stopped it.

There has been growing awareness in the US about the problem of over using antibiotics. Way back in 1977, the US Food and Drug Administration had proposed banning Tetracyclines and Penicillins as additives in food given to livestock and other animals. It said it wanted to phase out the use of medically important antibiotics in food-producing animals and bring therapeutic uses of such drugs under the oversight of licensed veterinarians.

Chandra Bhushan, deputy director general, CSE, points out that countries must concentrate on reducing environmental entry of antibiotic residues and resistant bacteria by managing waste from livestock and aquaculture farms, slaughter houses and meat processing units. Discharge effluents from the pharmaceutical industry, particularly in India, also need urgent attention to minimise antibiotic contamination of the environment, he said.

It is a worrying scenario. Antibiotic resistant infections are very complicated to treat. It also calls for long stays in hospital. Obviously, there would be fat bills that would be painful to pay.

It is not a pretty picture. The government does not have an easy job to execute.

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