Wake up! There’s a killer in our midst, and it is invisible

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While we are slowly emerging from the shadow of a wave of infections fuelled by the Omicron variant of COVID-19, the country of almost 1.4 billion people is heaving a collective sigh of relief. Even though the wave fuelled by Omicron is far from over, preliminary data emerging from across India show that the rates of hospital admissions, need for ventilator support, and deaths have been markedly lower than the ‘Delta wave’ of April-May 2021.

The virus is turning endemic, and it is largely expected that it will keep circulating in the vast metropolises and rural hinterland, in a more predictable way. Looking beyond the very unlikely scenario of a new, more lethal and highly-transmissible variant emerging, the future for the world is looking bright, though a total return to pre-pandemic scenario is improbable.

When the world seemed to be preparing for more good news, Lancet — one of the most respected medical journals in the world — published an explosive paper in mid-January. It was based on ground-breaking research done by a team primarily led by experts from the Oxford University’s Big Data Institute, and the University of Washington’s Institute of Health Metrics and Evaluation.

The team scoured through data sets and publications from 204 countries, looking at around 471 million individual records of microbiological tests, and came out with a startling finding. Antimicrobial Resistance (AMR), which is essentially a condition in which microorganisms gain defences against the antibiotics which are supposed to eliminate them, was associated with around 4.95 million deaths a year. They also found that around 1.27 million deaths are directly attributable to AMR.

This is shocking for the public health practitioners. Even though most of the experts are aware of the creeping impact of AMR, the scale of the issue could not be ascertained with reasonable confidence before. This is because AMR is still an invisible issue as its not generally considered or classified as a disease such as pneumonia or malaria.

Though AMR is mentioned in the latest version of the International Classification of Diseases (ICD), it is rarely mentioned in death certificates or discharge summaries, thereby significantly under-reporting the numbers. There has also been a significant lack of awareness about the issue among the healthcare fraternity, and in the general population, hiding it further.

The primary driver for AMR is misuse of antimicrobials. When micro-organisms are exposed to low levels of antibiotics that cannot neutralise them or when inappropriate antibiotics are used, these tiny disease-causing organisms acquire skills to resist these medicines. This can be through mutation or taking up genetic material from other skilful bacteria.

Whatever the mechanism is, this newly-acquired skills make these microorganisms more lethal, and they can escape the antibiotics used to treat them. The end result is that antibiotics are rendered ineffective, resulting in higher probability of treatment failures, and even death.

The problem we are facing is also compounded by a market failure. When more and more antibiotics are rendered ineffective due to AMR, it is reasonable to expect a number of newer medicines coming into the market. But that has not been happening for a few decades, primarily due to the apparently poor return-on-investment in antibiotics research & development. Therefore, we are forced to imagine a scenario in which even minor infections, which are easily treatable now with a course of antibiotics, becoming life threatening.

Another aspect of the problem is that AMR is multifactorial, as antibiotics are used for multiple reasons. Antibiotics are extensively misused in commercial agriculture and food animal production; and a lot of this finally ends up in the soil and water. This also helps to drive the AMR issue, and disseminate it widely. Deficiencies in the health systems also affect the evolution of the problem.

When access to quality healthcare is poor in some region, informal healthcare providers will take over. Most of the time, these informal care providers do not have any medical training and prescribe antibiotics inappropriately. Lack of systems to monitor sales of antibiotics or an audit system to look at the quality of prescriptions given out by doctors, also results in heavy misuse of antibiotics.

There is concerning news for South Asian countries in the Lancet publication. The burden of AMR in South Asian countries is very high, second only to Sub-Saharan Africa. Our region sees around 76.8 deaths per 100,000 population associated with AMR in a year, and has an estimated 3,262.6 years of life lost because of these deaths.

The study has not calculated the economic burden of resistance or loss of productivity associated with the preterm mortality, but we can just assume the scale. In 2017, the World Bank tried to estimate the economic impact of resistance. In the most optimistic scenario, it can result in a loss of around 1.1 percent to the global gross domestic product (GDP) by 2050, and can take away $1 trillion per year after 2030. In the worst case scenario, these numbers go up to 3.8 percent and $3.4 trillion respectively. This can be a very difficult proposition for the countries in South Asian region, who are making rapid strides towards economic prosperity.

The global response to AMR has been marred by fund shortages and gross lack of political commitment. The reason is the invisible nature of the issue, and lack of definite mortality statistics. The Global Action Plan on AMR, adopted by the World Health Assembly in 2015, spurred national-level action plans in most countries. But it has not resulted in concrete action in most countries, with only a small proportion of the action plans having identified funding sources. Even the National Action Plan in India has not taken off in the way that most public health enthusiasts would have wanted.

Now that we have good quality data on the impact of AMR, it’s time that we shifted gears and empowered the agencies mandated to implement the National Action Plan. A previous publication from the Big Data Institute and the Institute of Health Metrics & Evaluation showed that India joins countries such as Cambodia, Sudan, and Vietnam as places where antibiotic consumption has increased rapidly from 2000 to 2018. The way COVID-19 was managed in India would have made things worse now, considering the gross misuse of Azithromycin and other antibiotics.

As a country, we have done a remarkable job in ensuring that almost 70 percent of our population has received at least one dose of the COVID-19 vaccine. A total of around 1.7 billion vaccine doses have been administered till now, when many high income countries are struggling with vaccine hesitancy, and supply chain issues. But we need to replicate this success in other disease programmes too — be it for tuberculosis or diabetes.

Given the burden and the possible economic impact in the future, it is pertinent that we invest in containing the issue of AMR too.