A requiem for antibiotics
Patients are doing more harm by demanding antibiotics or changing them, says DR GLADSTONE A D’COSTA
The Lancet of 11 August 2010 reported that a bacterium resistant to all antibiotics had been identified and described the inherent dangers of such bacteria. The origin of the bug was stated to be, at least in part, in India and the opinion expressed that “NDM-1 is likely spread worldwide.”
The Lancet is not a journal to be taken lightly; but the resultant uproar in this country focussed largely on the organism being named after Delhi, thereby missing the wood for the trees. The serious implications of the findings were lost in the cacophony of protests that followed; but the noise had barely died down when a new threat emerged. Researchers from Spain have tied up with SGPGI, Lucknow, to study yet another resistant organism; this time, it was salmonella (with the rmtC gene), which can cause severe diarrhoea and death. Once again the organism was found in patients, most of whom had recently travelled to India. A further complication came from a Chennai study; an organism had been identified with both the NDM1 and the armA (which is similar to the rmtC) genes; which is serious, because the organism is also resistant to all known antibiotics.
Recently, there was a spurt of upper respiratory tract infections along the west coast, including Goa, which caused an irritating dry hacking cough which lasted in some cases, for weeks. Most physicians felt it was a viral infection, though to my knowledge, no specific causative organism was identified. Yet the sale of azithromycin (an antibiotic) in one pharmacy alone doubled between mid-December and mid-January, at the peak of such cases. This incident illustrates the attitude of both patients and physicians in their approach to the use of antibiotics. Patients expect a prescription for antibiotics, and often demand the same even when there is no justification for it; and physicians are more than willing to prescribe it to “keep the customer happy.” The process of identifying the cause of the infection is too time-consuming, expensive, and often inconclusive. Therefore, a best guess choice (often choices) is made by the physician. If there is no relief within a few days, either the antibiotic or the doctor is changed. Paradoxically, such overuse is often matched by under-use. If the patient feels better in a few days, treatment is stopped prematurely for financial reasons. Hence, the outburst by Abdul Ghafur in the Lancet “The overuse of antibiotics is embedded in our Indian gene. Why should we Indians worry? We can always depend on honey, yoghurt and cow’s urine. At any rate, within a few years, these products may be more useful than antibiotics!”
Antibiotic resistant infections cause an estimated 100,000 deaths annually in the US alone, and are predicted to rise even further. This alarming situation has developed within a span of 60-odd years since penicillin was first introduced. How is it that after the initial advantage in the battle against infections, we are now in danger of losing the war? After all, NDM-1, rmtC, and armA will join a growing list of resistant organisms headed by MRSA (Methicillin Resistant Staph. aureus). In the past, resistant strains did not matter because research by pharmaceutical companies produced newer and more potent antibiotics. An estimated 200 new drugs were developed in 30 years, each more potent and toxic than the previous one.
Eventually hard economic realties hit the industry. In the period 1983-1987, 16 totally new drugs (as opposed to minor molecular variations) were approved. Since 2008, there have been only two. Only 5 of the 13 biggest pharmaceutical companies are actively engaged in antibiotic research; the rest have abandoned the field for more lucrative markets. This is certainly not because of lack of knowledge, expertise or clinical material. Deep sea exploration has turned up organisms that existed, which we never knew about.
The explanation lies in the balance sheets. When a new antibiotic is introduced, it is patented, and restricted to difficult infections in an attempt to preserve its efficacy. Sales figures naturally remain suppressed, till the patent runs out or the physicians start overusing the drug against all rational recommendations. Further, when used judiciously, the drug is usually prescribed for short periods like a week or two. Compare that with a new anti-cancer or anti-diabetic drug; the drug is used widely as soon as it is introduced and for months, years, or the rest of the patients life. The sales returns for such drugs can be up to twenty times the sales figures for antibiotics. In short, it pays to research and introduce drugs for chronic diseases, rather than antibiotics; even though infections are more common than cancer, diabetes or heart disease.
The conditions under which penicillin was introduced were dramatically different from the FDA restrictions of today. Vancomycin resistant enterococcus infections of the bowel and urine, is thought to affect 26,000 hospital patients annually in the US according the Centre for Disease Control and Prevention. However, research was abandoned because of inadequate sample sizes and clinical material.
Yet, when there are adequate financial incentives, there is no dearth of initiative, ingenuity or talent. As a result of the anthrax scare in 2001, there was a huge spurt in research of anthrax, even though most practicing physicians have never seen a case in their entire clinical careers. The National Institute of Allergy and Infectious Diseases spent $94 million in 2009, researching anthrax and plague; because they were potential agents of bioterrorism. In contrast, only $16 million was spent researching antibiotics for resistant infections. Such financial enthusiasm was feasible only because the government guaranteed purchase of any approved final product, as part of its counter-terrorism campaign.
If we are to prove Abdul Ghafur wrong, we will have to change our mind-set and implement what the BMJ terms “antibiotic stewardship programs”. Our future survival depends on it because antibiotics will gradually get more expensive and have an ever decreasing spectrum of utility.
The initiative must come from both the physician as well as the patient. Prescriptions have to be more rational and evidence based. Numerous studies have established that between 20-50 per cent of antibiotic usage is inappropriate by virtue of the drug, dose, duration or redundancy. Public education programs must sell the concept that patients are doing more harm than good by demanding antibiotics, or changing doctors and/or antibiotics willy nilly. The authorities must come down more dramatically and heavily on unauthorised over the counter sales of scheduled drugs, whose unbridled usage contributes to the problem.
Finally, there must be adequate incentives provided for exploring alternative pathways for research, by the pharmaceutical companies such as tax breaks, increased patent period discretion and guaranteed sales to encourage continued research. There are newer pathways like using other organisms, just waiting to be developed.
Otherwise, we really will have to depend on cows’ urine in the foreseeable future.
(The author is a member, National Executive Committee, Voluntary Health Association of India.)
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He, she and IT
By Anthony Simoes
Every evening, as the sun dipped below the tree line near the governor’s palace, the Kevnem-Nagalli section of the Taleigao plateau used to turn into a pleasant locale for a cool, invigorating, healthy walkabout. This was 10 years ago.
There were large stretches of wilderness criss-crossed by narrow mud pathways going in all directions. The profusion of shrubs and small trees often made one lose one’s way, but just look at some landmarks in the distance and one found one’s bearings. Across the Mandovi is the Reis Magos fort. Towards Altinho is the TV tower. And, of course, there is always the setting sun to the west.
Every so often one walked into a small vegetable patch. Some villagers from Kevnem or Nagalli had discovered a natural spring that allowed them to grow chillies, tomatoes… maybe even some Ragi. They had no title to the land or the water source, but it did not matter.
As one walked there was music in the air; with birds returning to their nests, but not before singing praises to the setting sun. They thanked the sun for making photosynthesis possible. It grew their food and made branches on which they could build their nests. Clothing they did not need.
As the joker on Prudent Media would say, “Just Imagine!” It took a bird-brain to remind me of the most profound lesson of the Sermon on the Mount: “Look at the birds of the air; they neither sow nor reap nor gather into barns and yet your Heavenly Father feeds them. Consider the lilies of the field; how they grow; they neither toil nor spin. Yet I tell you, even Solomon in all his glory was not clothed like one of these!” Somewhere to the south, I could hear the rumble of traffic on the Dona Paula-Bambolim road, signalling the gradual encroachment of development, modernity and progress.
Then 2006 brought Dayanand Narvekar and his now infamous IT Park, all 280,000 sq metres of it. Out went the small vegetable growing plots, along with the small peasants.
A few months later, the Italian Empress of India came with her entire entourage, not to mention the ubiquitous SPG (Sonia’s Praetorian Guard?). The high command took their suitcases, while the Empress did a Julius Caesar: “She came, she saw, she concurred.” The die was cast.
Once Daya got her stamp of approval, no one could stop him. Up came a fancy stone perimeter wall costing Rs4 crore, to keep out the hoi-polloi and walk-abouters. Internal roads were 50 per cent wider than the main road outside! Street lighting was like the Panjim-Miramar road. Properties within were sold to real estate Mafiosi who wouldn’t know the difference between a car park and an IT park; between software, hardware and underwear…
Then came a change of regime. Stop work! Suspended animation… The wilderness is now making a comeback. As the hoi-polloi takes a detour, IT has become a public toilet for workers at nearby construction sites. One sees these poor people with their ‘lotas’ making a beeline through a small break in the wall, to this unintended facility. You wouldn’t want to be downwind of our IT Park, which is now an S-H-IT Park!
There is also a dangerous side-effect.
Robbed of 280,000 sq metres on the plateau, the real estate lobby is being placated with plots on the steep side slopes of the plateau, which are being clandestinely terraced. With plots come roads, water pipes and power lines. From the road you may see a single-level bungalow, but go inside and it is a posh split-level home that costs a bomb and gives an unrestricted vista, from Fort Aguada to the Verem Bay.
Unfortunately, the ‘genius’ who began all this is also the architectural guru of the gang that wants to save the state from the TCP-builder nexus. No wonder Digu-bab operates RP2021 with such impunity. He knows that he can treat the words ‘Bachao’ and ‘Abhiyan’ with absolute and utter contempt.
Rajan Narayan will have to think again about who are the Monsters and who are the Rats.
