Super bugs and the social responsibility
Dr. Ghafur is the primary author and coordinator of the Chennai Declaration, a document and initiative to tackle the challenge of antimicrobial resistance from an Indian perspective. He is also a Consultant and Adjunct Associate Professor in infectious diseases and clinical microbiology at the Apollo Hospitals, Chennai, India. He is a member of the Longitude Prize Prize Advisory Panel.
India is the largest antibiotic consumer in the world and at the same time has high antibiotic resistance. The statement seems self-explanatory and straightforward: if we use antibiotics too frequently, the resistance rate will be invariably high. Tackling the antimicrobial resistance crisis could have been a lot simpler if the equation was as linear as this. Unfortunately, the scenario is complicated by the lack of access to antibiotics by a sizeable proportion of the population in India.
The poor starve and the rich prosper. Isn’t this applicable to every social and scientific issue?
India has a very sophisticated and large industry for generic pharmaceuticals, making drugs affordable to the masses, at a fraction of the cost quoted by multinational firms. Unquestionably, this is a blessing to the low and middle-income population, not just in India but across the developing world. It is also true that the availability of low cost antibiotics, often at a price lower than that of a traditional test using microbiology culture, can foster over-use of these precious drugs.
How can we reverse the scenario? How can we rationalise antibiotic usage and at the same time ensure access to those that need them most? The antimicrobial resistance crisis is not just a scientific challenge but a political and social one as well.
Can we tackle the challenge without political and social reforms?
Can we reverse the inequality of access to antibiotics that exists in every part of the world, every continent and country?
Should the extent of the challenge force us to take a more detached attitude towards the responsibility of tackling antimicrobial resistance?
The medical community has a social responsibility to also get involved in the political aspects of health care delivery and policies. Politicians and bureaucrats should be mobilized and persuaded to implement all components of a policy on antibiotic resistance. Policies should be relevant to the economic, political and social context of the respective nation or region. Unrealistic recommendations will lead to complete failure of policy, as happened with the 2011 Indian ban on over-the-counter (OTC) antibiotic sales without prescription.
A step-by-step approach, starting with more liberal steps, will be the ideal strategy in countries with no functioning national program to contain antibiotic resistance. The success of the Chennai Declaration, an initiative across India to create an attitude change among stakeholders, was due to its step-by-step approach. The resulting attitude change made the antibiotic resistance issue less controversial and a more glamorous academic topic. However, this newly found popularity and de-stigmatisation of the topic unfortunately led to stakeholders focusing attention on less risky strategies. To my knowledge, there is no loud voice or serious pressure from any academic groups or organisations on authorities to implement the national policy. There is a dangerous shift in the attention towards purely educational and laboratory research strategies.
How many hospitals are there in India? Nobody knows the exact number! Estimations around seventy four thousand could be right, though I can’t back-up this number! Less than 500 hospitals are accredited by National Accreditation Board for Hospitals (NABH); with variable levels of infection control and antibiotics stewardship standards among them. Can we close down all the other hospitals? Of course not! Seventy percent of health care delivery in India is through the private sector, and the lion’s share of this is offered by unaccredited hospitals. These hospitals are the saviours of the large Indian masses living above the poverty line, but still unable to access corporate or other accredited hospitals.
India and neighbouring countries must implement rules over the sale of OTC antibiotics, supported by the pharmaceutical industry, and by pharmacists as well. Third line antibiotic use needs to be monitored in all health care institutions. Hospitals without documented and functional infection control strategies must be forced to follow basic precautions. Additionally, improving sanitation, which would also assist, is a responsibility of each and every citizen and not just the Government. Unless the sanitation situation is improved, the incessant spread of super bugs in community settings will be a reality forever.
How can we improve access to antibiotics across the developing world? There is no simple solution. Measures to improve socio economic status of those living under the poverty line is the permanent answer. Improving standards of public hospitals through better funding and skilful management, the provision of drugs, the introduction of national health insurance, and ensuring availability of all essential drugs to those in most need will be interim options.
Antibiotic resistance is a global challenge. As long as lack of access and present excess exist in the human world, bugs will flourish and win. Are bugs to blame for our own sins?