Superbug not invincible

Last week, “Superbug” swaggered onto the front pages of newspapers and primetime television with the dash of Superman. The circumstances that marked the occasion were packed with all the drama that it takes to be a headline-grabber.
Delhi was hosting the First Global Forum on Bacterial Infections. One of the British scientists whose study on New Delhi Metallo-Beta Lactamase 1 or NDM-1, the superbug, had caused a global stir last year was in town to present a paper.

He said he was not “sorry” about naming the gene after India’s capital city; argued that he was merely following established scientific practice — the Swedish patient in whom it was first identified had undergone surgery in a New Delhi hospital. The scientist asserted that more than 100 million could be carrying the NDM-1 gene, and urged India to do more to stop the irrational use of antibiotics in the country. The health establishment was quick to contest his claims. What complicated the matter, however, were recent studies confirming the presence of NDM-1 in the intensive care units in some of Delhi’s top hospitals.
Soon, the story about growing resistance to antibiotics had taken on a geo-political shade. Some said this was a global conspiracy to paint India in the blackest terms and dent the country’s burgeoning medical tourism business. Another view was that though India had a problem about antibiotic resistance, it was nowhere near the magnitude the British scientists were suggesting. Delhi’s health minister A.K. Walia said there was nothing to be alarmed about, that the studies in the Delhi hospitals pointed to a “very low prevalence” of the highly drug-resistant bacteria containing the so-called NDM-1 enzyme. The state government, however, directed all hospitals to activate their infection committees.
One evening inside a television studio, an anchor popped the question bluntly: Was India in a state of denial about the superbug? Like many countries, India has often downplayed health problems till they blew up as crises. For years, AIDS was a Western problem, an African problem, everyone else’s problem but ours. We argued that we were more “moral”, less vulnerable and so on. Then, statistics busted all our fond assumptions. Things started improving only when we got real, and stepped up action on the ground.
So with NDM-1.
The debate about the magnitude of the problem associated with NDM-1 will continue. But that should not stop us from doing all the things that need to be done. The problem is big enough. British scientists may have raised the global alarm about NDM-1, but Indian doctors and microbiologists have also been flagging up the issue about drug resistance within the country for quite a while now. The underlying reasons are well-known — widespread over-the-counter sales of antibiotics, self-medication, inappropriate use of antibiotics in hospitals, patients failing to complete the full course of antibiotics they have been prescribed, often due to lack of awareness about resistance mechanisms, and so on. The solutions are also known: rationalising the use of antibiotics, surveillance both on antibiotic use and antibiotic resistance, strengthening of laboratories, implementation of standard treatment guidelines, infection control interventions in hospitals which should be subject to audits, and spot-checks.
The Superbug controversy could be a blessing in disguise. It is spurring some action. India now has a new National Policy for Containment of Antimicrobial Resistance. It aims to improve infection surveillance in hospitals; monitor antibiotic resistance; promote rational drug use through education, monitoring, and supervision; curb antibiotic use in animals, especially those raised for human consumption; research new drugs; and develop and implement a standard and more restrictive antibiotic policy that will regulate use, and ban its sale over the counter. It talks about making certain high-end antibiotics available only at tertiary hospitals.
This is good news. But then comes the other “p” word — the policy has to be translated into practice, and sustained not just in Delhi’s top hospitals but all across the country. While inaugurating the Global Forum on Bacterial Infections last week, health minister Ghulam Nabi Azad spoke about the need to keep the condition of rural India in mind, the remote villages where people did not have easy access to medical doctors who could prescribe antibiotics. That is indeed a challenge but it is not one that cannot be surmounted. If health policymakers and practitioners put their heads together, surely a solution can be found. Training nurses to administer antibiotics of the basic kind and referring cases to hospitals if high-end antibiotics are needed is one option.
A report by the India Working Group of the Global Antibiotic Resistance Partnership (GARP) chaired by Dr Nirmal Ganguly, former director general of the Indian Council of Medical Research, points out that the bacterial disease burden in India is among the highest in the world. Therefore, antibiotics will play a critical role in limiting morbidity and mortality in the country. Pneumonia alone kills over 400,000 people in India each year. It is the number-one killer of children. Many of these deaths take place because patients do not have access to life-saving antibiotics when and where these are needed.
How do you balance expanding access to life-saving treatment with controlling the spread of antibiotic resistance? Antibiotic consumption is rising rapidly in developing countries like India and China. At one level, this indicates increased access to life-saving drugs. But the changing situation makes it vital to preserve antibiotic effectiveness as long as possible. Other developing countries offer inspiration. In Chile, for example, after a mass media campaign, regulatory measures were put in place to make antibiotics available by prescription only, resulting in an initial decrease of 35 per cent in antibiotic sales.
Antibiotic resistance is not unique to India but India’s unregulated health sector, and poor sanitation and hygiene, coupled with illiteracy and lack of awareness, make the task ahead tougher. The recent pilot studies conducted by some of Delhi’s leading hospitals are steps in the right direction. They help us get a better idea of the magnitude of the problem. The bottomline: Despite the big scare, superbug is no Superman. Action on the ground, instead of denial or panic, can thwart its course. That would also be the most effective way of boosting India’s image.

The writer writes on development issues in India and emerging economies