A looming health crisis

Ravindra Ramesh, a 45-year-old father of two, was admitted to a hospital for a routine hernia repair. During his hospital stay, he developed a severe infection. Despite the administration of antibiotics, his condition worsened rapidly. He was transferred to the ICU, but the infection was resistant to multiple antibiotics, leaving the medical team helpless. Tragically, Ramesh succumbed to the infection, leaving his family devastated.

Similar stories are reported every day in many hospitals, highlighting the growing threat of antimicrobial resistance (AMR) in India, where overuse and misuse of antibiotics have contributed to the rise of resistant infections. Ravindra’s story serves as a stark reminder of the urgent need to address this crisis.

What is antimicrobial resistance? AMR occurs when microorganisms such as bacteria, viruses, fungi, and parasites evolve to resist medication that was previously effective against them. This results in standard antibiotics, antivirals, antifungals, and antiparasitics becoming less effective or even ineffective in treating infections. As a result, the infection persists, increasing the risk of spreading to other parts of the body, spilling into the blood stream (septicaemia), and endangering life. Resistant microbes can also spread to others, posing a danger to other patients and the community.

The emergence of AMR is a significant threat to global health, leading to untreatable infections, longer hospital stays, and increased mortality rates. The World Health Organisation (WHO) issued a stark warning that, without global action, we may be on the brink of a post-antibiotic era where common infections could once again prove fatal. Routine medical procedures, such as surgeries, chemotherapy, and organ transplants, may become increasingly dangerous without effective antibiotics to prevent and treat infections.

What led to the emergence of AMR? In India, AMR has been influenced by several factors, including its high burden of infectious diseases and easy availability of antibiotics over the counter due to lax regulations, leading to their overuse and misuse; inadequate sanitation and hygiene practices such as open defecation; and poor wastewater treatment and biomedical waste management (especially in healthcare facilities). This releases antibiotics and residues into the environment via soil and water. Limited access to healthcare leads to inappropriate antibiotic use, including self-medication. Indiscriminate use of antimicrobials in agriculture (poultry and livestock breeding) and aquaculture for growth promotion leads to antimicrobial resistance spreading to humans. Less than half of healthcare facilities have adequate wastewater treatment systems in place, perpetuating the cycle of antimicrobial resistance. Effluents from pharmaceutical industries, when released into rivers or freshwater streams, can also lead to the emergence of AMR on a large scale.

Without effective interventions, AMR will be the leading cause of death, with an estimated 10 million deaths per year by 2050. The World Bank estimates that the impact of AMR could result in an additional US$1 trillion in healthcare costs by 2050 and lead to annual gross GDP losses of US$3 trillion by 2030. In 2019, India saw close to 300,000 deaths attributable to AMR. Addressing this issue is critical for the well-being of Indian citizens and global health security.

Recognising the gravity of the situation, the World Health Assembly adopted the Global Action Plan on AMR in 2015 as part of the tripartite collaboration with the WHO, FAO, and the World Organisation for Animal Health. The One Health concept highlights the interdependence of human, animal, and environmental parameters for the containment of AMR. In India, the rates of AMR in all three sectors have been rising disproportionately in the past decades. Recently, the addition of the United Nations Environment Programme (UNEP) has led to a quadripartite partnership, whose agenda of ‘One Health’ also includes concerted action on AMR.

During India’s presidency, the G20 urged effective global action on AMR as part of pandemic prevention and response. India’s National Action Plan (NAP) for AMR was released in April 2017 by the Union Ministry of Health and Family Welfare. The objectives of the NAP include improving awareness, enhancing surveillance measures, strengthening infection prevention and control, research and development, promoting investments, and collaborative activities to control AMR. Based on the NAP, various states have begun the process of initiating their state action plans. Unfortunately, as of today, only a handful of states have implemented them. Kerala and Madhya Pradesh have taken the lead in this important area.

It is essential that the strategy to combat AMR be comprehensive and involve international collaboration. Public awareness campaigns play a significant role in educating healthcare providers and the public about proper antibiotic use and the risks of misuse. Technology, which has been harnessed to improve quality and access to health care, can be leveraged to play a major role in the fight against AMR. Coordinated efforts from the government, healthcare providers, the pharmaceutical industry, and the public are necessary to effectively address antimicrobial resistance in India and globally. Taking decisive action now can help mitigate the impact of antimicrobial resistance and ensure the effectiveness of life-saving antimicrobial treatments for future generations.

(Dr Thomas is the founder & patron of the Association of Healthcare
Providers, and Reddy is a Distinguished Professor at the Public Health Foundation of India)