Ernakulam: Unlike before, 40-year-old Gopi’s mornings now begin with a grim routine: fishing out the bodies of foul-smelling fish and crabs. Puffed up like balloons, they float lifeless on the water surface. “The number of dead fishes are increasing,” says Gopi, sitting in a traditional canoe, in a shallow pond in Vypin Island in Ernakulam, Kerala.
For centuries, in Ernakulam on the western coast of India, fishermen like Gopi did not need any fish feed or fish seed to secure a good catch. The moon, the sea, and gravity were enough.
With the moon shining its brightest, high tides from the Arabian Sea surged inland, swelling the estuaries of an interconnected water system. Piggybacking on the high tides, a variety of fish, prawns, and nutrients travel inland.
Where the mouth of the estuaries narrow, fishermen put semi-permeable wooden gates to create traditional ponds. As the water retreats back to the sea, fishermen pull down the gates to trap fish and shrimp.
A traditional fish pond with a wooden gate set-up. Photo: Monika Mondal
Then they wait patiently for three to four months for the young fishes to mature, while the ebb and flow of the sea’s tides keep the ponds nourished, aerated and fresh.
But over the years, this zero-investment natural farming, with minimal environmental impact, has begun to falter. And along with the healthy fishes, the number of traditional fishermen like Gopi is also dwindling. Gopi is losing faith in the traditional method. He says, “Fungal and bacterial infection keeps killing the fishes.”
Gopi (left) setting up a net to catch fishes. Photo: Monika Mondal
Though modern medicines offer solutions to treat infections, lately that solution is backfiring. Drugs like antimicrobials (antibiotics, antivirals, antifungals) which treat diseases by attacking microbes (bacteria, virus and fungus), are not able to kill the pathogens.
Microbes are ubiquitous, but not all of them lead to diseases, instead they make life possible as we know it. But when microbes are constantly exposed to antimicrobials, they can self-mutate in response to the stressful environment, and develop resistance to the antimicrobials – a process called antimicrobial resistance (AMR). Overuse, misuse and the improper disposal of drugs like antibiotics in hospitals, livestock farms, fisheries and households, has allowed AMR pathogens to proliferate to far off spaces. And with the changing climate, more farm diseases are hitting production, resulting in the need to use more antibiotics.
In 2017, Kerala recognised the threat of Antimicrobial Resistance (AMR) in farming (with changing climate more farm diseases hit production and need more antibiotics), and set up the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP). Kerala, where Gopi practices fishing, is one of the few states in India, (apart from Delhi and Madhya Pradesh) which has an action plan to fight against AMR.
But researchers found that ponds like Gopi’s, which do not use any antibiotics, are also highly contaminated with antibiotics resistant gene microbes: these microbes are resistant to multiple classes of antibiotics, which are used to treat common infections and diseases.
AMR has a domino effect, impacting every form of life. Research shows that more and more microbes around the world are becoming resistant to drugs. In 2019, directly and indirectly, 4.95 million people in 204 countries died because drugs could not treat microbial infections. Recent estimates suggest if drug resistant microbes keep mutating and infiltrating boundaries, by 2050 microbial infections will kill one person every three seconds or 10 million annually, 20% of whom would be Indians alone.
Developing countries, like India, where polluting industries are expanding while waste management practices are not, are considered hot spots of AMR pathogens. India is not only the biggest consumer but also the biggest producer of antibiotics.
Kerala, the pioneer in AMR management in India, has made several strides including opening India’s first AMR-smart hospital, managing the sale and availability of antibiotics, and proposing better public health care. But rampant unplanned urbanisation, improper waste disposal and existing gaps in the healthcare system, have not translated plans and policies into the successful reduction of AMR cases. In recent reports, there is an uptick in AMR related cases in the state.
Researchers have pointed out that the solution lies in focusing on the relevance of the environment in the One Health approach — which according to WHO, is the interconnection amongst humans, animals, and the environment. But this approach often remains focused on human health and animals and rarely focuses on the environment and its compartments.
Investigating AMR
About 600 years ago, Vypin island came into being as a result of a major flood in 1341. Since then it has been a fishing village. Even today, fishing ponds appear at every other intersection of concrete roads – some are traditional like Gopi’s, some are pit ponds and some are modern aquaculture setups. Just a few kilometres away from Gopi’s pond, lives Abdulla Mohammed Hatha, a microbiologist at the Cochin University of Science and Technology (CUSAT).
Growing up on Vypin Island in the 1960s and 70s, Hatha watched his uncles practice the same traditional fishing which Gopi now does. But since then, fishing became unsustainable, and many fishers left. Now, Hatha has a small pit pond, where he practices, “mostly experimental and recreational fishing”.
In the 1990s, Hatha began monitoring diseases in commercial fish stocks off the coast of Cochin and, in 2008, he and his PhD students started investigating traditional ponds. They found disease-causing pathogens breeding in the water. When they exposed microbes to various antimicrobials, such as antibiotics, instead of succumbing, the invisible-to-the-naked-eye microorganisms started growing around the drugs. Meaning, the pathogens had developed AMR.
Abdulla Mohammed Hatha. Photo: Monika Mondal
Over the years, he has observed “a rise in the population, diversity and resistance amongst pathogen species like Vibrio.” Vibrio pathogens live in warm coastal waters above 20 Degrees Celsius and are dangerous to both humans and nonhumans.
Vibrios that infect fish can lead to skin lesions, ulcer, fin rot or systemic infections and sudden death. When vibrios enter the food chain, through infected food or water, they can also infect humans. Between January 2023 to March 2024, the well-known species Vibrio cholerae, which causes cholera, infected 824,479 and killed 5,900 people, in 31 countries across Africa, America and Asia.
WHO considers cholera as an ongoing pandemic, which started in 1961 and largely affects people in Africa and Asia.
Eliminating the microbes is not the solution, as they are integral for the functioning of life as we know it, but experts have suggested a simpler method: keeping the environment healthy. “The crux of the problem is the water quality,” says Hatha, who has found AMR microbes everywhere he has ever looked, from the Arctic to Antarctica.
He suggests embracing the One Health approach, which recognises the health of humans, animals, and the environment as interconnected. To safeguard public health, a healthy environment must be ensured for all living beings, according to Hatha — especially for those at the bottom of the food chain: microbes.
Traditional ponds and untreated water
Gopi has never used antibiotics. No traditional pond does. He says, “Using antibiotics (or any medicine) in open traditional farms (where water keeps moving) is not feasible.”
Because his pond is part of an estuary, using any amount of antimicrobials to treat the fish would literally mean a drop in the ocean. His best option to tackle the illnesses is to physically filter the infected fishes. “But profit remains elusive,” he explains.
Gopi must now buy healthy fish seeds from the market and look after their diet. “If I spent 1000 rupees, I would make approximately 500,” he says. Earlier, laborers assisted Gopi, but not since profit dwindled.
Gopi says environmental change is weakening fish immunity to fight bacteria and parasites. “Disease is a serious concern, especially during the monsoon season, when water salinity varies,” he says.
Not too far away from Gopi’s farm, another farmer named Babu P.B. complains, “The nearby schools, factories, homes and hospitals all dump their waste in the water directly,” he says.
India disposes over 70% of its waste untreated directly into water bodies which end up in the sea through coastal cities like Cochin.
Such waste contains heavy metals and chemicals, but also antibiotics that come from treating human and animal infections, as well as the meat, poultry and seafood industries where they are used as growth promoters and to prevent diseases and increase shelf life.
Also read: On Gujarat Coasts, Muslim Fishermen Feel Alienated, Suicidal and Out of Business
“Disposal of inadequately managed or untreated waste (effluent), from antibiotic manufacturing units, farms, households and healthcare systems, containing AMR-causing determinants can lead them to reach larger as well as surface water bodies like rivers, lakes, ponds,” says Rajeshwari Sinha, Programme Manager of the Sustainable Food Systems Unit at the Centre for Science and Environment (CSE), a public interest research organisation, in an email to The Wire.
“Water, a key component of the environment, can be both a source and a sink of AMR determinants,” she continues. Research has found that water can act as a “gene exchange” medium that transports microbes across otherwise disconnected lands and habitats.
Shaffi Fazaludeen Koya, research fellow with the Boston University School of Public Health, adds: “If we really regulate the non-human health sector and use antibiotics appropriately in the meat industry, poultry, then it can slow down resistance, and probably reduce the burden of resistance.” Disease burden or the burden of disease refers to the intensity or severity of the disease and its possible impact on daily life. The burden of resistance, in turn, means the impact of antibiotic resistance on peoples’ lives. Koya’s comment therefore means that managing the non-human health sector can also lead to a reduction in treatment failures in humans.
What doesn’t kill them makes them stronger
When microbes are repeatedly exposed to antibiotics, their first response is not to die, but to fight. Bacteria can unleash a defense mechanism by mutating its genes—part of its DNA which performs a particular task. Through genetic mutation, bacteria can develop defenses against antibiotics, rendering them ineffective and allowing the bacteria to proliferate. In a true sense, for microbes, what does not kill them makes them stronger.
Unlike humans, who transfer genetic information from parents to offspring, or “vertically,” microorganisms can mutate and pass genetic information both vertically and horizontally, meaning they pass it not only to their offsprings, but also to their neighbors and to other species of microbes. All of this—from a microbe being exposed to an antibiotic, to adapting and sharing genetic information—can happen in a few minutes. For example, strains of E. coli bacteria which can lead to many diseases in humans from food poisoning to sepsis and meningitis, can reproduce every 20 minutes, passing on genetic information from one generation to the next. For a similar response, humans may take tens of years or generations.
“This is the natural way for bacteria to gain resistance because it has to survive. It is an evolutionary process. But our human interventions have enhanced this process,” says Koya from Boston University.
Once a resistant gene comes into the environment, it can jump from animal to human pathogens and vice versa. Meaning, there are no geographical or biological boundaries to the spread of AMR.
The movement of animals, birds and humans is one way AMR spreads. For example, the longest migratory bird flight is by the Arctic tern, which flies between the Arctic and Antarctica—about 20,000 miles each year or the equivalent of three round trips to the earth and moon in its 30-year lifespan. And scientists have found drug resistant microbes in its gut. Tracking 12 of these birds, researchers— including microbiologist Hatha from CUSAT—also discovered that they made 166 stopovers along their journey. Upon testing 17 antibiotics, they found the birds were resistant to all of them.
A separate study found several genes of resistant microbes at the north and south poles.
This is why experts regard AMR as a One Health issue, wherein an unhealthy environment unleashes a domino effect of reactions from the smallest microbes to the biggest mammals, to all parts of the planet.
What is the ‘Kerala model’?
Kerala, the state where Gopi fished since childhood, has implemented India’s most successful AMR control program, according to studies and experts. In 2018, it launched the Kerala Antimicrobial Resistance Strategic Action Plan, which includes stewardship programs for medical staff, awareness campaigns for citizens and advocacy for reduced antibiotic usage.
A health centre in Kakkodi, Kozhikode. Photo: Monika Mondal
Certifying hospitals as antibiotic-resistant is the latest measure in Kerala’s long fight against AMR. Located about 200 km north of the fish ponds of Vypin Island, Dr. Divya P.K. serves as the chief doctor in Kakkodi, Kozhikode. In November 2023, this Family Health Center (primary healthcare center) in a quiet, nondescript village achieved a significant milestone, becoming India’s first antibiotic-smart hospital.
Divya explains that to achieve recognition as antibiotic-smart, a hospital must meet a 10-point checklist, followed by review and certification by a government committee. She adds that if antibiotics are prescribed, they must be packaged in special blue envelopes, “making it evident for patients that antibiotics are not ordinary medications and they must belong to the ‘Access group.’”
“Access,” “Watch” and “Reserve” are the three categories of antibiotics recognised by the WHO, from low to high potential for resistance. According to the WHO, 60% of total antibiotic consumption in a country should be from the “Access” group. But in India, about 59% of total antibiotic consumption in 2022 was from the “Watch” group.
Data reveals Kerala is the only state in India with an acceptable Access/Watch ratio. It improved from 0.54 in 2011 to 0.72 in 2019. Koya suggests this is partially attributed to three reasons — an attempt to regulate farming, running antibiotic stewardship programs in the government medical fraternity and strengthening the public health sector.
Koya stresses the role of the public sector and strong government regulation in controlling AMR. “When the public sector is weak, the private sector takes its own road and does whatever they will,” he says.
Kerala is the first state in India to ban the sale of common antibiotics like colistin for non-human use. Colistin has been a drug of last resort, i,e. when other antibiotic drugs fail to treat diseases, colistin treats multi-drug resistant infections. But its easy availability over the counter, and use in poultry and farming have decreased its potency, a cause of concern throughout the globe. But access to other antibiotics without prescription remains a common mischief even here in Kerala, like in other parts of India.
In the area surrounding the Kakkodi hospital, pharmacies denied antibiotics without prescription. However, only a few kilometers away, in different districts, The Wire found that getting antibiotics without prescription is not a problem.
“Unprecedented antibiotic use is just one cause of AMR; the primary issue is lack of sanitation and hygiene practices,” Divya from the Family Health Center asserts. “Lack of clean drinking water and sanitation remains a challenge, and we need to address all aspects.”
She notes it’s not just about antibiotics; fungal and viral infections are also on the rise. Research has found that Kerala’s One Health approach in tackling AMR issue, or the ‘Kerala Model’ still lacks the environment component, as unplanned urbanisation leaves waste untreated. Though Kerala is one of the most urbanised states in India, almost 94% of its sewage goes untreated in the water bodies, in absence of proper drainage and treatment facilities.
Jesmi Yusuf, another researcher at CUSAT, who studied the presence of AMR microbes in drinking water sources, has found strains of AMR microbes in both surface and groundwater in coastal regions. “Antimicrobial resistance has penetrated throughout,” she says. And as climate change brings more rains and floods, it dilutes the differences between safe and unsafe waters, leading to the easy proliferation of AMR microbes.
Keeping track is a way ahead to prepare
In 2016, Hatha from CUSAT went to a sewage treatment plant near his office, collected raw sewage water, noted some readings and flew a bottle filled with sewage waste over 7,000 km from Cochin to Copenhagen.
He was taking part in the Global Sewage Surveillance project run by the Technical University of Denmark, which received sewage samples from more than 100 countries and over 240 cities, to build a database of AMR genes across the planet.
Patrick Munk is part of the research group at DTU that uses supercomputers and modern DNA techniques to investigate how frequent and widespread antibiotic resistance is by analyzing wastewater.
“Sewage is a good place to start,” asserts Munk. It encompasses human and animal waste, as well as waste from industries and households, offering insights into the urban environment. “That’s a beautiful one health concept that tells you what’s going on in the urban environment.”
Munk and his team are nearing the end of their eight-year research journey and they’ve gained valuable insights. Many AMR genes they discovered were previously unreported, highlighting historic under-sampling from low and middle-income countries.
Apart from antimicrobial use, sanitation was a big factor in the spread of AMR. Clean drinking water, hospital infrastructure, health care and how people use medicines all contribute to the spread of AMR, Munk says.
‘We need to coexist’
As India becomes a global leader in the fisheries sector and expands its business, there are growing concerns about the negative impact of fishing on the environment, including chemical use, greenhouse gas emissions and increasing warming of the planet.
In a first of its kind report, researchers surveyed fisheries across 12 states in India (including Kerala) and discovered many fish contained microbes resistant to common antibiotics.
A traditional fish pond in Kerala. Photo: Monika Mondal
Farming practices like Gopi’s, which do not use any chemicals or mechanised boats for fishing, are environmentally friendly, however these traditional skills and techniques are at risk of being replaced by unsustainable technologies that damage riverine ecosystems, as traditional fishermen — faced with poor water quality and low profits — move to more intensive aquaculture.
A few years ago, Gopi leased a small pond in Vypin where he runs a commercial intensive shrimp farm, in addition to his traditional ponds. Though Gopi did not mention using any antibiotics, microbiologist Hatha says using chemicals, supplements and antibiotics are common at commercial farms in the region.
Also read: The Drowning Jewel: Tapestry of Dal Lake’s Decline and Fishing Community’s Struggle in Kashmir
In a system where drugs are limited and microbes are evolving fast, it becomes imperative to track and understand how AMR is developing and spreading. “We need multi-level monitoring,” Koya from Boston University emphasises. “Because of the constant evolutionary process of microbes, we need to continuously monitor the use of antibiotics, the emergence of resistance and have closer studies from the environmental sample.”
He suggests something like WHO’s tricycle project, which analyses samples in the human health, food chain and environmental sectors. That way we know “what is happening with antibiotic use, what is happening with the resistant bacteria, how it is happening in the environment, and how it is happening in the clinical patients,” he says.
According to Hatha, it is the microbes’ ability to adapt that makes them the most successful form of life on the planet. “In this world, species are created for existing with other things, we need to coexist with other living, non-living, micro and macro beings.” That’s the one health concept, he claims.
Akhil Prakash assisted the author with translation.
This story was supported by Internews’ Earth Journalism Network’s One Health Reporting Grant.
Monika Mondal is an independent journalist who writes about science, society and the environment.
