20 May 2012
Mumbai’s suffocating crowds, mounting filth, and the rampant abuse of antibiotics are creating deadly bacteria too strong for our medicines
SR Ramachandran, a senior citizen from Mulund, woke up to a pool of blood from a boil on his heel. After a few days of self-treatment, Ramachandran’s wife Shyamala noticed the wound was oozing pus and smelling foul.
The 69-year-old diabetic rushed to his doctor Ramesh Punjani, who scraped out infected tissue, analysed swabs of blackened skin and finally prescribed him some generic antibiotics.
Ramachandran’s bacterial culture and antibiotic sensitivity report threw up no cause for concern. But his wound, which should have healed in about 10 days, kept getting worse.
Six weeks later, the second report threw up a fearsome name - pseudomonas aeruginosa, a superbug notorious for its drug resistance and quick mutation.Dr Punjani says, “The bacteria were resisting many kinds of antibiotics and had made his heel their home.
A wound that should have taken 10 days to heal took 90.”
As he gets his wound dressed at a nursing home, Ramachandran shrugs, “I have no idea how I contracted such an infection.” Luckily for him, it was weeded out before it could cause serious damage. Others are not as fortunate.
An increasing number of patients are battling antibiotic drug resistance across the city’s hospitals, of which some are unable to survive them. Doctors peg Mumbai’s public hospital-acquired infections at more than 10 per cent, a chunk of which is caused by drug resistance.
While India gains notoriety for its abuse of antibiotics, Mumbai is emerging as the numero uno city cut out for serious trouble. It has everything it takes to bring on antibiotic Armageddon - a 1.25 crore plus crowd, staggering numbers of unqualified doctors, lack of sanitation and healthcare, among other things. Doctors agree that it has come to be the hyperactive nerve centre of drug resistance.
Antibiotic resistance, the Achilles Heel of modern medicine, is the ability of bacteria to become immune to a drug that once stalled them or killed them. The bacteria gather genes to evade the drug and multiply, mutate or share the resistant genes with other bacteria. What used to be a miracle cure has turned into a big scare and Mumbai, with its distinctive insouciance, is late in waking up to what it should fear deeply.
“It’s hard to establish how it is landing people in hospitals or causing so many deaths. But when a recuperating patient suddenly develops complications and doesn’t respond to most antibiotics, doctors know it’s a case of resistance,” says Dr Punjani, a laparoscopic surgeon at Fortis hospital. Dr Altaf Patel, a consultant physician at Jaslok hospital, says, “Antibiotics are increasingly failing in our hospitals’ infection-laden environment. You may suffer a heart attack and recover from it but catch pneumonia in the ICU and die of it.”
Big city, big trouble
Mumbai provides a near-perfect environment for bacterial proliferation. The weather is muggy, sanitation and hygiene poor, street food dodgy, drinking water suspect, hospitals choc-a-bloc, preventive measures non-existent and open defecation still a harsh reality.
Add to that indiscriminate prescriptions by fly-by-night doctors and eager popping of pills by patients in a rush and we’re set for disaster.
Instances of misuse abound. Last month, a 23-year-old Arts student from Ghatkopar was unhappy with the mild medicine her family doctor put her on for a fever. She switched to another doctor who hooked her on to a 10-day course of strong antibiotic injections. The woman thought she had recovered. But the day after she stopped taking them, she relapsed into meningitis and was rushed to a Ghatkopar hospital. Her recovery is taking weeks.
The trend of using antibiotics at every instance has spiralled out of control in the city in the past three years, Dr Amol Manerkar, a physician at Kohinoor hospital, believes. “Patients come in with viral infections and are given antibiotics even though these have no effect on viruses,” he says.
How an antibiotic is used is really important to its effectiveness. Dr Shivkumar Utture, Maharashtra Medical Council member and ex-president of the Indian Medical Association says, “It’s critical to prescribe the right dose for each case for the right amount of time, while keeping both body weight and age in mind.”
Dr A K Gvalani, head of General Surgery at KEM hospital, adds, “Non-MBBS doctors, who don’t understand the pharmacology of medicines or bacteriology, prescribe antibiotics blindly and help the bacteria grow smarter. Every time you take an antibiotic, weaker strains are destroyed and the stronger ones lurk. When you don’t complete your course, bacteria develop mechanisms to fight back against them and then multiply.” It sounds like we are fighting a losing battle. We are currently using the few antibiotics left effective.
The ideal response, many physicians say, is to let an infection run its course and treat it symptomatically. But our city conditions us to seek quick-fixes. Dr Manerkar says, “Pay cuts pinch, so patients want to recover instantly at the first chance. When a doctor doesn’t know what’s ailing the patient, he turns to antibiotics, the Ram-baan, as a cure-all because he is under pressure to deliver results.” Dr Vishwa Mohan Katoch, Director General of Indian Council of Medical Research (ICMR), says, “It’s a case of too many doctors prescribing too many antibiotics.”
What we urgently need is a policy restricting the abuse of pills. Meanwhile, we can begin with a tiny change at home. Dr Manu Kothari, an anatomy professor at KEM, says, “People should tolerate smaller infections. We need a change of mindset.”
The family doc
At his 90-year-old Girgaum clinic, Dr Krishnakant Dhebri pulls out random statistics from dust-laden files. His father, R P Dhebri, was the founder of the General Practitioners’ Association (GPA) in the ’60s. He says that almost 50 per cent of Mumbai’s GPs are under-qualified or quacks. “The idea of GPA was to address doctors’ problems and evolve a consensus on important concerns, such as drug resistance. Unfortunately, nobody has a say on what these doctors prescribe,” he says.
With India’s Rs 620 billion pharmaceutical industry constantly pushing its brands, many GPs are reaching for broad-spectrum antibiotics that cost thousands even when a strip of Rs 30 would do the job.
“When you can kill it with a bullet, why call in a tomahawk missile?” wonders Dr Manerkar.
Dr Dhebri seconds this view. “For cold, fever or malaria, I prescribe Chloroquine which costs a rupee a piece and takes a day or two to get you on your feet again. Once a patient told me - Aap mujhe woh 200 rupye ka injection dijiye na. When I refused, he returned to the doctor who prescribes them.”
By turning to strong antibiotics, we are also throwing out the baby with the bath water. The human digestive tract is home to about 2.2 kg of ‘good bacteria’ or gut flora, which help in digestion and absorption. Dr Preeti Mehta, microbiology professor at KEM, points out that antibiotics flush out the good bacteria along with the bad. “Without the normal flora, the body is exposed to other pathogens,” she says.
The most alarming problem lies in the city’s gut. After taking antibiotics, we flush out billions of drug resistant bacteria into the sewers, aiding their spread and mutation. Dr Camille Rodriques, who heads Hinduja’s Microbiology unit, says, “Those defecating in the open also add to this. These bacteria find fertile ground, breed, multiply and become airborne, waterborne and sneak into our food chain. In the monsoons, there’s a bacterial explosion. Our close proximity to each other; at home, in local trains or in streets and markets, makes us easy targets.”
Not only are our streets crowded, so are our hospitals. And instead of being the solution, they have become hotbeds for drug resistant bacteria. Dr Abhay Chowdhary, Director of Haffkine Institute, says a common kind buzzing in our hospitals is Methicillin-Resistant Staphylococcus Aureus (MRSA), which causes painful skin infections and, if untreated, infects blood and organs and even causes death. “The situation is under our control right now but the future doesn’t look secure. A large outbreak of MRSA has the potential to turn pandemic.”
If doctors and staff follow strict practices, such infections can come down by about 80 per cent, believes Chowdhary. “Washing hands or a hand-rub with spirit after tending to each patient works wonders. While there is awareness, the staff is lax,” he says. In BMC and state-run hospitals, which have extra beds and even floor beds for the endless flow of patients, it’s hard to maintain sanitation.
For a country that has the highest TB cases and a quarter of the world’s pneumonia patients, India’s antibiotics-fixation is worrisome. A recent research by US-based Centre for Disease Dynamics shows that in six years, there has been a six-fold increase in the number of Carbapenems - powerful ‘last-resort’ antibiotics - popped by us.
Quinolones, which form the first and the most essential line of defence while combating tuberculosis are regularly sold without a prescription for everything from fever to the common flu. Such callous over-use of vital drugs have now rendered them useless for TB treatment.
Dr Zarir Udwadia, a consultant chest physician at Hinduja hospital who has extensively researched Multiple Drug Resistant (MDR) and Totally Drug Resistant (TDR) tuberculosis in Mumbai, says resistance to fluoroquinolones has increased from 3 per cent in 1996 to 35 per cent in 2004. “This alarming hike tells us they should be reserved for treatment of TB in TB-endemic areas,” he says.
A survey of more than 106 listed physicians in the Dharavi area was taken to see how they prescribed antibiotics to patients with TB symptoms. “Of these, only 46 were qualified allopaths. The rest were trained in alternative medicines such as homeopathy, ayurveda or unani and yet more than 50 per cent of them practiced allopathy. Of these, only five could correctly list the prescription and dosage for the recommended duration for TB. The rest either listed the medication wrong, or the duration, or the dosage or all,” he says.
Dr Katoch, however, says it is possible to conquer drug resistance. “In 1982, leprosy’s multi-drug resistance was more than 20 per cent. But through the years, with patients being treated by only qualified doctors and using only two antibiotics, it now faces virtually nil drug resistance.”
The drug dilemma
The biggest challenge, however, lies in familial sentiments. The logic of staggered and judicious use of antibiotics is lost on the kin of a patient writhing on a bed. Dr Krishnakant says, “Sometimes, you can’t blame doctors who feel the need to use all the measures they can.”
Dr Manerkar cites his own insecurities. “Despite all I say and practice, my parental anxiety makes me contemplate antibiotics for my two-year-old son if he is down with high fever. But my wife, also a doctor, reassures me that there’s no need. We really need to change ourselves, each one of us.”
What is antibiotic resistance?
Reams have been written about the extraordinary ability of certain bacteria to develop drug resistance. Antibiotic resistance is an outcome of what comes most naturally to bacteria - survival. Being the first forms of life four billion years ago, they have mastered this art.
The World Health Organisation (WHO) says antibiotic resistance is one of the biggest health challenges mankind will face this century. WHO Director-General Margaret Chan, at a medical meeting in March this year, pointed out that mankind was hurtling towards an era where common infections will no longer have a cure. “Things as common as strep throat or a child’s scratched knee could once again kill. We’re on the brink of losing these miracle cures.”
Superbugs, the most drug resistant bacteria, don’t relent to the toughest of antibiotics. At the heart of the superbug anxiety is the menacing NDM-1 gene, short for New Delhi Metallo-Beta-Lactamase-1, a reference to the capital where five years ago, a Swedish man was hospitalised for an infection that resisted standard antibiotic treatments.
Just as other mutant genes, the NDM-1 transfers itself among and across many kinds of bacteria. With the mutant rogue genes having settled down in more than 40 countries, the West is increasingly pointing its finger at India, dubbing it the epicentre of the drug resistance problem.