The imminent collapse of healthcare

The right to healthcare is one that is guaranteed to all under Article 21 of the Indian Constitution. By logical extension, this right includes not only access to healthcare facilities but also to the effectiveness of the drugs. The future of the foundational antibiotics is now in our collective hands.

While many of us have heard of antimicrobial resistance (AMR), few have recognized its potential to disrupt health care and medical advancement. The use of antibiotics goes beyond just treating infections, and medical procedures like surgeries, organ transplants, burns treatment, and management of illnesses like cancer and HIV is dependent on the effectiveness of antibiotics.

Development of resistance in bacteria is an evolutionary trait, but human intervention on numerous levels has sped up its course. Typically, overuse or misuse of antibiotics has been blamed for leading to rising resistance, but in reality, there are many other drivers of AMR, ranging from use of antibiotics as growth-stimulants in livestock to the dumping of pharmaceutical manufacturing waste into the environment, and improper disposal of expired or unused medicines.

The time for brushing this problem under the carpet has now gone, and terms like “antibiotic apocalypse” and “medical dark age”, which scientists and healthcare experts had once viewed with cynicism, are now very real threats.

It is estimated that by 2050, over 10 million people could die of resistant infections annually. In 2014, roughly 700,000 annual fatalities were attributed to AMR. Increasing resistance also
results in longer hospital stays, reduced overall productivity (which affects the GDP), and ore expensive medication.

In countries like India, where a large part of healthcare cost is paid out-of-pocket, AMR could plunge lower-income families into further poverty. Moreover, with limited public healthcare resources, treatment of resistant infections would take up a larger budgetary. Many illnesses that are presently treatable with a 5-day course of pills will become deadly. Encouragingly, the Indian Government has taken cognizance of this public health nightmare and in 2017, launched the National Action Plan on AMR, which takes a “one- health” view and calls for concerted action by the ministries of health, environment, water, agriculture and science and technology to address it.

Since its launch, progress has been made on several fronts. For instance, the use of colistin, the last-resort antibiotic was banned in animals. The Food Safety and Standards Authority of India (FSSAI) regulated maximum permissible levels of antibiotic residue in meat and meat products. Guidelines also exist for appropriate prescription on antimicrobials by doctors and hospitals.

However, action on the environmental front is still lagging. Antibiotic pollution from pharmaceutical manufacturing units and hospital waste contribute results in the creation of ‘hotspots’ for antibiotic resistance to develop in rivers and lakes. India is the second-largest manufacturer of antibiotics and active pharmaceutical ingredients in the world, which translates into a higher environmental footprint and AMR burden.

Studies have shown that rivers adjoining pharmaceutical manufacturing hubs, such as the Musi river in Hyderabad and lakes in the Patancheru area are reservoirs of deadly multi-drug resistant bacteria.

The government has made clear its intention of instituting regulations to prevent or restrict the dumping of antibiotic waste into the environment, and already, the Central Pollution Control Board (CPCB) is working on draft Environmental Regulations for the pharmaceutical industry, which will prescribe maximum limits of various antibiotics in industrial effluent. It remains to be seen whether these parameters will be mandatory or voluntary for the industry to follow.

Meanwhile, the pharmaceutical industry needs to own up to its responsibilities. Instead of biding their time and merely complying with existing regulations, the industry should step forward and embrace sustainable manufacturing practices, because without those, no matter how much money is poured into it, it is unlikely that we will be able to outrun the monstrous issue of antimicrobial resistance which is looming merely a few paces behind us.