The National Action Plan on Antimicrobial Resistance (NAP-AMR) was enacted in 2017 to curb the rising AMR. Do you think the plan has been successful in achieving its stated objectives? Given that the plan completes five years in 2022, what, according to you, have been its gaps?
Adapting the World Health Organization’s (WHO) Global Action Plan on AMR, India rightly laid down its National Action Plan (NAP) to combat rising antimicrobial resistance in 2017. Grounded in the One Health Approach, the NAP framework attempted to reign in AMR in a holistic manner in the animal, human and environmental ecosystems. Over the years, several initiatives have been launched by different ministries and departments to limit AMR in animal and human ecosystems. For example, to limit the misuse of antibiotics in the livestock and agriculture sectors, the usage of potent antibiotics like colistin, streptomycin and tetracycline is now prohibited. Similarly, the network of tertiary hospitals reporting data on AMR has been strengthened.
However, on the environmental front, initiatives have been limited. Despite one of the strategic priorities of the NAP-AMR being the development of the national framework for surveillance of antibiotic residues in the environment from farms, hospitals and pharma industry clusters, limited headway has been made in this regard. The absence of standards governing antibiotic discharge in the environment continues to drive up AMR and dilute the progress in the animal and human ecosystems.
AMR is a complicated problem as its build-up takes place across the inter-connected and tightly-coupled animal, human and environmental ecosystems. Therefore, the policy response to AMR must be driven by inter-sectoral coordination amongst different stakeholders. Even though the NAP-AMR endorsed the importance of inter-sectoral coordination, it has not been manifested on the ground. For example, the Delhi Declaration had recommended the setting up of a National Authority for Containment of AMR (NACA) for effective intersectoral coordination and monitoring of the existing initiatives. However, it is yet to be established. The lack of convergence to synergise the actions of different stakeholders and the deprioritisation of environmental AMR have been the biggest gaps of NAP-AMR, in my opinion.
Do you think that despite its growing threats, greater sensitisation is required about the detriments of AMR amongst different stakeholders in animal, human and environmental ecosystems?
The scientific community has been repeatedly warning us about the growing threats of AMR as the silent pandemic. It is estimated that an unchecked rise in AMR would induce 10 million deaths every year by 2050, triggering a five per cent fall in the GDP of low-income countries, thereby pushing 28 million people into poverty. Further, underscoring the growing menace of AMR, a January 2022 study in The Lancet estimates that 4.95 million deaths were associated with AMR in 2019. Moreover, the study pegs 1.27 million deaths in 2019 as a direct consequence of AMR. These estimates add to the growing instances of drug resistance being reported from different corners of the globe. These include the emergence of antibiotic-resistant of Gonorrhea in London and the presence of the MCR-9 gene in the sewer water of Georgia.
Even though AMR is one of the greatest threats to mankind, it often does not command the required policy prioritisation. Its mitigation requires synergy and sensitisation of the diverse stakeholders and communities across animal, human and environmental ecosystems. Apart from policies that deter the Over-The-Counter (OTC) sale of drugs, people should also be discouraged from overusing antibiotics for common infections. Further, given that the livestock sector has been traditionally misusing antibiotics; alternatives like ethnoveterinary medicine should be explored. Additionally, to limit the build-up of environmental AMR, enabling policies and monitoring mechanisms are required to deter pharma pollution. Most importantly, there is an urgent need to sensitise people and communities on a sustained basis about its adverse impacts on them. People respond only when they internalise that it is going to adversely affect their well-being.
How do you think the COVID-19 pandemic has impacted the shadow pandemic of AMR?
Indians have always had an affinity towards antibiotics. Between 2000 and 2015, our antibiotic consumption has more than doubled. Lack of awareness, coupled with the ease of availability of potent antibiotics over the counter are the main reasons behind this worrying uptick in the consumption of antibiotics. The advent of COVID-19 made matters worse. The pandemic witnessed an unprecedented increase in the consumption of antibiotics. In 2020 alone, over 16 billion doses of antibiotics were sold in India, an excess of 216.4 million doses when compared to regular times. Similar trends were witnessed even in the developed nations. A study conducted in the UK found that amongst 36,145 patients suspected of COVID-19, 37 per cent were put on antibiotics prior to hospitalisation.
Already, noted medical experts fear that such mindless usage of antibiotics during this pandemic could aggravate the problem of AMR in a post-pandemic era. An ICMR study also warned that the overuse of antibiotics for COVID-19 treatments could further accelerate and accentuate drug resistance.
As we emerge from the third wave of the pandemic, it is necessary that evidence-based protocols are laid down for the usage of antibiotics. Further, behavioural change campaigns are required to wean away masses from the liberal use of antibiotics even for non-bacterial infections like the common cold and flu.
Given the large expanse of India’s pharma industry, do you think formulating standards that limit the discharge of antibiotic residue into the environment would help control the spread of AMR? Additionally, do you think pharma companies should pivot to sustainable production and procurement practices?
India is one of the world’s largest producers of pharma products. While the expansion of the pharma sector is vital for India’s growth, the impact of pharma pollution on public health can’t be neglected. The discharge of untreated pharma effluents in the water leads to the environmental spread of AMR, a grave public health risk. Several instances of pharma pollution have been reported across the country such as that in Himachal Pradesh, Andhra Pradesh and Telangana. At present, due to the weak monitoring and surveillance mechanisms and the absence of standards governing antibiotic discharge, there is no deterrence for errant manufacturers. The unregulated discharge of pharma effluents not only erodes the progress in the animal and human fronts of AMR, but also degrades the environment. If stringent standards that limit the discharge of antibiotic residue into the environment are not formulated, it would be a body blow to our other initiatives of AMR mitigation.
If AMR blunts the efficacy of drugs, the future of the pharma industry can be threatened. Therefore, I believe that it is in their business interest that pharma companies must pivot to sustainable production and procurement practices. In what could also be a nudge for the government to formulate standards, industry leaders must take lead and shift to self-regulation. The AMR Industry Alliance has already stipulated safe concentration limits of antibiotic residues, it is up to the industry to see value in this proposition in terms of business enablement and sustainability. This, of course, would cover the efficiency and effectiveness of the monitoring mechanism to oversee the meticulous implementation of these standards and protocols.
Do you think there are sufficient checks and balances in place to ensure adequate privacy in the rollout of Digital Health Mission?
The National Digital Health Mission (NDHM) is a promising initiative that seeks to create a digital health ID containing all the health records of a person, which is relevant in today’s digital era. However, the rollout of the mission in absence of adequate privacy infrastructure is a cause of concern, since it not only threatens the privacy of individuals, but also the security of the health system. While the Prime Minister has assured the safety of these records, the mechanism to ensure safety has not been disclosed. The assurance of data protection, in the absence of Data Protection Law cannot be guaranteed. The draft Data Protection Bill is yet to be passed in the parliament. The bill classifies health information as sensitive personal data. Fears of data leakage in absence of such a law are not unwarranted given the recent occurrence of citizens being assigned digital health IDs, upon registration in the CoWin mobile app without their informed consent, with the purpose of such data collection not expressly and explicitly stated to the user.
To ensure the protection of sensitive health data, the enactment of the Data Protection Law is imperative. In my view, the law, in its current form, mandates a central nodal authority to which the states would be accountable. However, I believe that setting up state-level Data Protection Authorities (DPA) would enable a more comprehensive data protection regime while preventing federal veto. Besides, a state-level DPA would enhance access and provide quicker complaint redressal to data principals or subjects.
Especially, in the light of the COVID-19 pandemic, do you think provisions and announcements for the health sector were adequate in this year’s Union Budget?
I wonder if we have learnt any lesson from the COVID-19 pandemic for the need to strengthen the vulnerabilities of our healthcare infrastructure. This budget was a window of opportunity for improving our overall health systems; this would include the Primary Healthcare Centres (PHCs) as well as the Community Health Centres (CHCs), which are currently woefully underprovided and understaffed against future pandemics, like that of AMR. However, the total allocations increased by merely 0.2 per cent over the revised estimates of the previous year. As a percentage of the GDP, the expenditure on health is only 2.1 per cent. Compared to even the BRICS countries, our alternatives are far too less despite using our bed strength and nurses, etc. The strength to total population compares unfavorably with the global average and abysmally low compared to the developed countries and the Scandinavian nations. Further, no separate allocation has been made for the precautionary dose of the healthcare and the frontline workers under the National Health Mission (NHM). Despite the government’s repeated assurance of boosting the manufacturing of medical devices within the country, no measures were introduced to reduce the 80-85 per cent import dependence, end custom exemptions, and promote the growth of the Indian Medical Device industry. The only silver lining, in the announcements, was the launch of the National Tele Mental Health Programme with a network of 23 mental health centres of excellence; however, with an allocation of just 0.8 per cent of the health budget for a country where 70-80 per cent people with mental illness receive no treatment. This too seems like a half-hearted measure.