The following is an excerpt from Anirban Mahapatra’s book When the Drugs Don’t Work published by Juggernaut Books.
Shortly before the onset of the COVID-19 pandemic, a team of researchers at a US non-profit organisation, the Center for Disease Dynamics, Economics and Policy, set out to assign a simple ranking of antibiotic resistance by country. Even though the problem of superbugs is a global one, there are disparities in healthcare and antibiotic use that have led to hotspots.
The researchers combined antibiotic consumption with resistance and assigned countries a number on a scale ranging from 0 to 100. The study was funded by the Bill and Melinda Gates Foundation and the CDC, and it was published in the BMJ Global Health journal. Sweden had the lowest resistance score of 8.1 while India had the highest at 71.6. A news story summarized the findings with the headline ‘India tops the list of countries with highest antibiotic resistance, finds study’.
We can argue the merits of the approach that these researchers took and the relative position of India in a global ranking of resistance and superbugs. But one way or another, we must admit that India has a serious problem with superbugs.
Earlier, in 2017, the same organization provided an indepth analysis of the superbug problem in India in a report titled ‘Scoping Report on Antimicrobial Resistance in India’. This report was a part of a collaborative effort between India and the UK and highlighted the critical situation of antibacterial resistance in the country. It identified key areas where research was lacking. It included a foreword by K. VijayRaghavan, who was the secretary of the Department of Biotechnology at the Ministry of Science and Technology of the Government of India at the time. VijayRaghavan would later become the third Principal Scientific Adviser to the Government of India, a position he held during the COVID-19 pandemic.
Anirban Mahapatra’s
When The Drugs Don’t Work,
published by Juggernaut Books (2024)
The report was comprehensive, merging known information from multiple sources. It was designed to assist scientists and policymakers in India to develop targeted interventions against antibiotic resistance. The report acknowledged that while resistance in all kinds of microbes was concerning, the subset of bacterial resistance (which is the focus of this book) was the most serious health threat.
The report summarized the scale of the problem: India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities. Resistance to the broad-spectrum antibiotics fluoroquinolones and thirdgeneration cephalosporin was more than 70% in Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae, and more than 50% in Pseudomonas aeruginosa.
The report highlighted that the issue of superbugs had reached critical proportions and that resistance to carbapenems was also rising in Gram-negative bacteria, especially in four of the Deadly Six superbugs. The situation was further complicated by the emergence of resistance to colistin, the antibiotic used to treat infections when carbapenems didn’t work (for example in superbugs that also contained NDM-1). The presence of colistin resistance led to bloodstream infections with Klebsiella pneumoniae with a staggering death rate of nearly 70% among Indian patients. Fortunately, at the time, plasmid-mediated colistin resistance through MCR-1 or its variants was not prevalent in India. The report also found high levels of antibioticresistant superbugs in chickens and livestock. Antibiotics are extensively used as growth promoters in agriculture.
Antibiotic-resistant superbugs were isolated from fish as well. Indian rivers, repositories of major biodiversity in the country, contained superbugs with high levels of resistance to critical antibiotics. Not only are antibiotic-resistant bacteria a concern, but the very genes that enable this resistance – including those resistant to last-resort antibiotics – were detected in major waterbodies, signalling an environmental crisis that accompanies the clinical challenge.
A considerable proportion of bacteria isolated from various water sources were antibiotic-resistant superbugs. Investigations across various Indian locales – from the historic stretches of Ayodhya and Faizabad to the bucolic landscapes of east Sikkim to the urban spread of Hyderabad – uncovered a disconcerting prevalence of antibiotic resistance among bacterial species like E. coli and Klebsiella pneumoniae.
The report highlighted the intricate web connecting humans, animals, and the environment and the threat to health, mainly as a result of rampant antibiotic misuse. India isn’t only the world’s most populous nation – Indians also have the highest rate of antibiotic consumption in the world with a median per capita consumption close to eleven units per year. (In this context, a ‘unit’ is the average daily dose of a drug as administered to adults, a standardized measure that allows for comparison of drug usage across different regions and times.) In fact, India single-handedly accounted for an astonishing 23% of the global retail sales volume of antibiotics. And the numbers only keep growing.
The widespread use of these critical drugs is a product of a combination of factors. India is often referred to as the ‘world’s pharmacy’ due to its massive drug manufacturing and distribution capacity. For a very long time, the country’s pharmaceutical sales lacked stringent oversight. As a result, India makes a lot of antibiotics, and it’s easy to get them without a prescription.
To understand how we’ve treated antibiotics in healthcare, I want to recount a folk story, supposedly about the seer Mullah Nasiruddin.
On a misty evening, with fog weaving through city streets, a young traveller trudged towards his home. The glow of a solitary street light was visible in the distance. As the traveller walked closer, he noticed that beneath that street light was a familiar figure, the quirky Mullah Nasiruddin. ‘Mullah!’ the traveller exclaimed, hurrying towards him. ‘What on earth are you doing down there?’ Nasiruddin looked up, eyes filled with concern. ‘I’ve misplaced my key,’ he said with a sigh. Seeing the Mullah’s distress, the traveller crouched down beside him. For a while both quietly searched for the key under the glow of the street light. After what felt like an eternity, the traveller asked the sage a pertinent question. ‘Mullah, it doesn’t look like we are any closer to finding your key. Are you certain this is where you dropped it?’ Nasiruddin casually pointed towards the engulfing darkness and said, ‘I dropped my key over there, inside my house.’ The traveller stared at him, dumbfounded. ‘Inside your house? Then why are we searching out here?’ With an unmistakable twinkle in his eye, Mullah Nasiruddin replied, ‘The light’s far better out here, don’t you think?’
This amusing story explains how we have come to treat antibiotics in India. We use them indiscriminately, not because they are always effective against the infections we suffer, but because they are easily available. Anyone familiar with the Indian landscape knows a major source of the problem. Antibiotics are sold over the counter at Indian pharmacies, with limited restrictions. Doctors prescribe them as a form of insurance often in low-resource settings.
One study estimated that just under half of the patients that walk into a doctor’s office in Delhi get prescribed at least one antibiotic. As a result, patients are psychologically primed to expect antibiotics from doctors. Many medical professionals, often due to the insistence of their patients, resort to prescribing antibiotics even when they aren’t necessary. People often believe that antibiotics are a cure-all solution and pressurise doctors to prescribe them based on prior experience or the incorrect notion that an infection that cleared up on its own was due to the effect of antibiotics. Patients may come to expect antibiotics.
Being prescribed medications is also seen as a sign of action as opposed to waiting to see if minor infections are self-limiting. Patients may also be reluctant to wait for diagnostic tests or they may lack the financial means to access them. What’s worse is that we often do this to ourselves, wilfully self-medicating with antibiotics at the first sign of illness. We all know how this process goes. After diarrhoea, or a cold, or a sore throat, many of us head off to the nearest pharmacy to ‘self-prescribe’ a course of antibiotics ourselves. And the neighbourhood pharmacy is happy to oblige the self-medication. How do we know that the sore throat we have isn’t the result of a viral infection or an allergy? We don’t. The only way to be sure is to get a diagnosis based on a test. But do we test or culture for bacterial infections to rule out viruses at home? No, we don’t. Despite the fact that the infection could’ve been caused by a virus, an allergy, or an irritant, we reach for the antibiotic because we can. No matter that it might be completely ineffective and worse, indiscriminate in killing off the bacteria that we harbour in our gut that are actually conducive to good health.
Anirban Mahaptra is a microbiologist.
