Go easy on the antibiotics to save lives

An alarming report published in The Lancet in January said that antimicrobial resistance was directly responsible for 1.27 million deaths and was linked to about 5 million other deaths worldwide in 2019. Antimicrobial resistance is when the bacteria that cause serious diseases, for instance tuberculosis, become resistant to the drugs used to treat the illness. The bacteria become resistant if a drug is overused in a particular community, which often makes the doctors prescribe even more powerful combinations of medicines and eventually all of them prove to be ineffectual. Most of the deaths were caused by drug resistance in lower respiratory infections, such as pneumonia, followed by bloodstream infections and intra-abdominal infections.

Conventional wisdom would have it that rich countries, with their modern drugs, wide availability and financial capacity, would be the largest victims of this resistance. However, antimicrobial resistance cases have been mostly found in two of the poorest parts of the world — sub-Saharan Africa and South Asia.

This is partly due to the fact that, in these two regions, relatively low-priced generic drugs are widely available without any prescription and without any supervision. This misuse, combined with a lack of clean water and sanitation, as well as an inability to prevent and control infections, leads to the spread of microbes, some of which are resistant to the antimicrobial treatment.

The spread of AMR, as the phenomenon is called, is so rapid that experts now believe they severely underestimated the dangers it poses. Initial predictions were of AMR causing 10 million deaths by 2050. But scientists now believe this tragic milestone will be reached much sooner, perhaps even this decade. No wonder, then, that the World Health Organization has declared AMR to be one of the world’s 10 most-significant threats to public health. The wildfire spread of AMRs witnessed so far will also seriously undermine the UN Sustainable Development Goal of development and health for all by 2030.

The blame for the widespread misuse of antibiotics can be laid mainly at three doorsteps: Governments and regulatory bodies, doctors, and drug manufacturers. Governments, especially in the developing world, have been lax to the point of criminality in terms of poor regulation of drug markets. In most of these countries, even the most powerful drugs, which are normally prescribed with caution and only in extremely rare situations by even the most experienced doctors, are freely available over the counter at local drug stores.

Over the decades, as populations and economies have grown, the number of pharmacies has multiplied and, with them, the availability of drugs has increased. The growth of drug-manufacturing industries in some developing countries, notably India, which has emerged as the hub of low-priced and high-quality generic medicines, is a real concern.

With the generics costing a fraction of the branded drugs, while having almost the exact same effect, the sale of generic medicines has boomed not just in poor countries, but increasingly even in the rich nations, where people are turning to them to keep their spiraling healthcare costs under control.

To push their drugs, pharmaceutical companies have long used dubious practices, developing extremely close relationships with doctors and rewarding them for prescribing their drugs to the point that the rewards are nothing short of bribery, including fully-paid overseas vacations thinly veiled as conference trips, fancy gadgets, and everything short of cash. As powerful antibiotics are more expensive than others, doctors are often incentivized to turn to them even when not needed or to prolong the prescription period for far longer than what is needed.

But it is not just doctors. Some patients, especially the wealthier ones, prefer that their doctors prescribe them the most powerful drug on the market — almost like a magic pill — irrespective of the costs involved. By doing so, doctors violate their Hippocratic Oath, which states that they must give patients the best possible care. It is the doctor, not the patient, who ought to know which drug best treats which condition.

If the situation of AMR deaths was already alarming in 2019, before the onset of the COVID-19 pandemic, then it may have since become more serious, even critical, due to two key factors. Firstly, both the global healthcare sector and national governments have been overwhelmed by the coronavirus, forcing them to largely ignore other preexisting and equally mortal health-related challenges. This has led healthcare activists to raise alarms about rises in deaths due to diseases like tuberculosis, measles and malaria, as well as falling vaccination rates for infants against the likes of tetanus and polio.

Secondly, over the past two years, doctors the world over have turned to extremely powerful drugs, notably corticosteroids like dexamethasone and hydrocortisone, which are for severe infections, to tackle the novel virus. In a desperate attempt to save lives, millions of doctors are believed to have used or prescribed these medicines. However, corticosteroids, which are mainly used to tackle the inflammation of blood vessels and muscles, are known to have serious side effects in most patients.

Their side effects are worse, even life-threatening, when patients already have other ailments like diabetes, which is especially prevalent in developing countries, notably India and the Middle East. Medical experts have cautioned against the use of steroids for patients with diabetes or borderline diabetes, as it could lead to other infections, notably bacterial and fungal ones.

Unfortunately, during the various peaks of the pandemic, these steroids were in huge demand, leading to a thriving black market as drug manufacturing companies could not increase their production to meet the exponential growth in demand. More often than not, though these drugs are meant to be delivered to patients by trained doctors and hence are mainly used in hospitals or clinics, the sales were recorded in street-side stores and often without prescription or a single prescription being used by dozens of people desperate to get hold of anything that might save their loved ones. The price of these steroids, at least in India during the deadly second wave in March-July 2021, shot up to more than 100 times the maximum retail price authorized by the government.

Now, as the pandemic has begun to subside, at least in parts of the world, some activists and medical professionals are starting to look at the potential long-term impact of this use. For example, the Indian Council of Medical Research is launching a study on the impact of steroids on bones.

It is time to rein in not just the use of steroids, but also other antibiotics, or else the world will be left facing many more deaths every year for years to come; more even than the number of lives lost in the battle against COVID-19.

• Ranvir S. Nayar is managing editor of Media India Group.