Getting bugged by a Superbug
Instead of getting xenophobic, we must address the excessive use of antibiotics in India, says Dr G A D’COSTA
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Says the ‘The Lancet’ of 11 August 2010: “Several of the UK source patients had undergone elective, including cosmetic, surgery while visiting India or Pakistan. India also provides cosmetic surgery for other Europeans and Americans and ‘NDM-1’ will likely spread worldwide. It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals.”
“KK has received a travel grant from Wyeth. DML has received conference support from numerous pharmaceutical companies, and also holds shares in Astra Zeneca, Merck, Pfizer, Dechra, and GlaxoSmithKline, and, as Enduring Attorney, manages further holdings in GlaxoSmithKline and Eco Animal Health. All other authors declare that they have no conflicts of interest.”
When Thomas Wakley founded ‘The Lancet’ in October1823, he announced: “A lancet can be an arched window to let in the light or it can be a sharp surgical instrument to cut out the dross and I intend to use it in both senses.” Since then, it has grown from a few hundred copies in 1823 to 1.8 million online users alone today. It has an impact factor of 30.758 and is currently ranked second in the general medicine category [ISI Journal Citation Reports, 2009]. It is, therefore, not a journal to be taken lightly.
Unfortunately, with the typical hypersensitivity of the Indian psyche, the second half of the first paragraph and the whole of the second paragraph quoted above have completely swamped the Indian mind. How dare the journal publish a travel advisory against India based on a false, biased premise that surgical patients have a high risk of serious infection in India; and that too, funded by vested interests… And they dare to name it after New Delhi? Shame on the colonial Britishers!
Let us, however, consider the facts. A bacteria has been identified that is resistant to all antibiotics. This finding has been backed by sound, solid scientific evidence, provided in great detail in the article, which is probably above and beyond the comprehension of the average clinician anywhere in the world, let alone a lay person. The inherent dangers of such a bacteria are stated quite correctly. Last but not least, the origin of the bug has been stated to be, at least in part, in India.
The first questions that arise in my mind are:
(1) What are we doing to do, to protect our people against this super bug?
(2) How did we ever get to this stage?
The answer to the first question is: very little. Our government hospitals are too busy trying to save patients from more mundane maladies like Swine Flu, Malaria, Dengue, Diarrhoea, maternal deaths, infant malnutrition, etc.
The private hospitals operate in a blissful atmosphere of a total lack of regulation. The ‘Clinical Establishments Regulation Bill’ has just been passed in the current monsoon session of parliament, after 63 years of independence. The rules are yet to come.
As a result, infection control officers (usually a function of a senior nurse) are unheard of in the majority of private hospitals. Indeed, most will claim a zero percent infection rate.
The use of antibiotics is totally unregulated and without any semblance of audit, both in the hospital scenario as well as at the out-patient level. In the average NHS hospital in the UK, for example, a prescription for a second or third generation antibiotic will invite a call from the pharmacist or the infection control officer asking for justification. And it is not as though this problem has gone un-noticed.
Abdul Ghafur was scathing in his editorial on the subject in the ‘Journal of the Association of Physicians of India’ (JAPI): “The Indian medical community has to be ashamed of the NDM-gene. Even though we have not contributed to carbopenem (antibiotic) development, we have contributed a resistance gene with a glamorous name. The overuse of antibiotics is embedded in our Indian gene. It is an Indian tradition. 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!”
The literature on irrational use of drugs is voluminous, particularly antibiotics. The ‘Indian Journal of Medical Ethics’ has been campaigning for years against it. The Voluntary Health Association of India (VHAI) has publications on the subject, and its local branch – the Voluntary Health Association of Goa (VHAG) – has been concerned enough to publish a research paper, and conduct workshops on the subject in Goa.
Every prescription survey carried out establishes the excessive use of antibiotics. In some cases, 50 per cent of the prescriptions had an antibiotic. In many cases, the dosages and/or the duration were inappropriate. The World Health Organisation (WHO) defines the rational use of drugs as: “The patients receive medications appropriate to their clinical needs, in doses that meet their own requirement, for an adequate period of time, and at the lowest cost for them and their community.” This is just not happening.
Worse still, this is only one arm of a triad. In India, we have more than 5,000 drug formulations, most of them irrational; the WHO lists just 350 as essential. The system of drug licensing in India is totally without precedence. It is state regulated, but most states do not have any means for testing or quality control.
Added to this is the problem of spurious drugs. Sting operations have been shown on news channels where journalists posing as customers, enquiring about the price of a consignment, are brazenly told that that depends on what concentration of the drug they want. If it is 50 per cent, it will obviously cost more that if the capsule contains 30 per cent!
The third arm of the triad is the curse of the over-the-counter trade at pharmacies. Though there is a comprehensive list of drug schedules that defines what may or may not be sold without a doctor’s prescription, this is more of a joke in practice. One can buy virtually any drug without a prescription. This issue is slightly more complex. The patient has an incentive for buying over the counter, as he saves the cost of seeing a doctor. For the pharmacist, it means an additional sale. In the bargain, we contribute to the mess that results in the findings reported by ‘The Lancet’.
Quite frankly, I agree wholeheartedly with the editorial in ‘JAPI’. We should hang our heads in collective shame, do some serious introspection, and institute corrective measures immediately. Otherwise we may be making a morbid contribution to the population control program of the Ministry of Health and Family Welfare.
(The author is a member of the National Executive Committee, Voluntary Health Association of India)
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Forgetfulness? What’s that?
By Jagmohan Chopra
The girl behind the counter looked at me sadly. “Your booking is for PVR Gurgaon, sir,” she told me. “Gurgaon? But I had booked seats for PVR Delhi.” “No Sir, your booking is for Gurgaon. You may speak to our manager if you like,” she said.
“How could I make such a mistake?” I asked my wife apologetically. “You forgot to see the print-out of the ticket before leaving home,” she said, disgusted at my having spoilt her evening. “Your reflexes have become weak and your memory is fading. It’s time you did something about it.”
It was not the first time we had been turned away from a window. Not long ago, my wife and I were tersely told by Indian Airlines staff that the Mumbai flight we had come to board at Delhi airport had left the day before…!
“It’s a sign of old age,” said Arvind. It’s natural and happens when we get to the wrong side of sixty. This disease is particularly common in vegetarians, because a vegetarian diet is deficient in Vitamin B12. It will be better if you consult your doctor.”
He was right, I thought. My forgetfulness started just after I turned sixty. To start with, I didn’t remember the route I had followed while returning from the club. Then, while leaving home for an errand, I couldn’t remember where I had parked my car.
I was also forgetting to pay the electricity, water and telephone bills. The car was not being serviced on time. There were occasions when I opened the fridge and didn’t remember why. There was also an instance when I paid the shopkeeper, but forgot to take the things I had bought. And, for the first time ever, the Income Tax Department slapped a penalty on me for filing my return 15 days after the due date.
The only redeeming feature of this affliction was that I was not the only one affected. My wife Sudha, two years younger than me, spent half a day searching the entire house for her almirah keys one day, only to find them tucked into the waist fold of her saree. She regularly asked my help to find where she had left her reading glasses.
My forgetfulness reached a tipping point (or was it flashpoint?) when I forgot our wedding anniversary; I remembered the month, but not the day. Were it not for the almighty barging I got from my wife, I would not have made a serious effort to solve the problem.
I finally decided to take the bull by the horns. My family doctor was kind enough to tell me that forgetfulness can be treated if detected early. He said I was supposed to have a diet rich in vitamins, particularly Vitamin B12; exercise the brain with teasers like crosswords, sudoku, kokoru, etc; bid adieu to my favourite beer; and develop a habit of associating things or events.
For example, when I park my car, I must try and remember the pole, tree or car adjoining it. Or if my wife asked me to fetch some things from the market, I must try and remember significant features like colour, smell, size, etc. “And what if I still forget…?” I asked the doctor. “Come and see me again,” said the doctor smoothly. He didn’t have an answer to that one.
While my wife and I were fuming and fretting at each other, I was amused at the way my friend Arvind handled it – by reminding his friends about the party they owed him on their birthday, but forgetting to talk about his own. He reminded his friends to return books they borrowed, but forgot to return those he borrowed from them. He came over for dinner and ate with gusto, but forgot to invite us over. And, last but not least, doing only those chores that suited him and telling his wife he forgot the others. He says he isn’t doing anything wrong – he has a doctor’s certificate to prove he’s suffering from forgetfulness!
