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AMR: The silent, parallel pandemic

AMR concept. Antimicrobial resistance tests. Image credit: Dr Graham Beards, CC BY-SA 4.0 , via Wikimedia Commons, antibiotic resistant
Antimicrobial resistance tests. Image credit: Dr Graham Beards, CC BY-SA 4.0 <>, via Wikimedia Commons

Antimicrobial resistance (AMR) has emerged as a “silent pandemic”, commentators argue, as experts argue for a harmonised approach to mitigate the damage.

The COVID-19 pandemic has contributed substantially to the AMR crisis, with the prescription of antibiotics for the treatment of those affected by COVID-19 contributing to an increase in AMR cases. This is a worry, as projections suggest that ten million deaths could be attributable to AMR by 2050. 

According to the World Health Organization (WHO), AMR is one of the ten leading global health threats. The phenomenon, as explained by the WHO, refers to “when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat.” 

India is no stranger to the threats of AMR. Indeed, it is a subject Health Issues India has covered at length in the past. Last year, a study conducted by researchers at the Center for Disease Dynamics, Economics and Policy found global consumption of antibiotics increased by forty percent between 2000 and 2015. It pinpointed India as the second-worst offender, trailing only Japan. 

Consumption of the “Watch” antibiotics – these being those designated by the WHO as having “higher resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance” – in India stood at 65 percent. We noted that earlier research found the use of third- and fourth-line antibiotics, those intended to be used only as last resorts, are often used indiscriminately within the country. 

Malaria is considered one of the deadliest mosquito-borne diseases in India. AMR hinders efforts to control the disease. Image credit: Mr.Smith Chetanachan / 123rf

This alarming trend has a dire impact on India’s efforts to control diseases such as malaria and tuberculosis. In the case of tuberculosis, multi-drug resistant tuberculosis is projected to account for 12.4 percent of cases by 2040 compared to 7.9 percent in 2000. Extensively drug-resistant tuberculosis is anticipated to account for 8.9 percent of cases by 2040, compared to just 0.9 percent in 2000. 

It is clear that AMR represents a pandemic in parallel to the COVID-19 crisis. It is also indisputable that the latter is driving the former. Former director-general of the Indian Council of Medical Research (ICMR) Dr N. K. Ganguly has warned as much, urging “harmonious actions across human, animal and environmental health paradigms to deal with the impending public health crisis of AMR.” Ganguly, lead author of a white paper on the subject, said “AMR is a bigger threat than COVID-19…India and many low and middle-income countries are already seeing a surge in drug resistance, even in common infections. I worry that due to COVID-19, the AMR situation has worsened. We need collective and immediate actions to curtail the aftermath.” 

The paper’s second author, Professor V. Samuel Raj, said “to understand the emergence and mitigation of drug-resistant hotspots, we need better surveillance. Surveillance data in India is very limited as we are dependent on ICMR’s AMR surveillance network only. The effective antimicrobial agents are rapidly diminishing from the quiver of available standard of care treatment options. This is a major concern.” 

Research bears out Ganguly’s concerns. The pandemic saw antibiotics sales soar. A study found 16.29 billion doses of antibiotics were sold in 2020, with an increase in adult consumption from 72.5 percent in 2018 to 76.8 percent last year. Dr Sumanth Gandra, an epidemiologist and associate professor of medicine at the Barnes-Jewish Hospital in the United States who was involved in the study, went so far as to describe India as “a poster child for antibiotic misuse in low- and middle-income countries.” 

Health workers wearing personal protective equipment while caring for patients with coronavirus infection in the Indian state of Kerala.
Healthcare workers wearing personal protective equipment (PPE) to combat COVID-19. Researchers worry COVID-19 has enhanced the crisis of AMR. Image credit: Javed Anees / CC0

Researchers argue that more attention needs to be paid to the private sector, where regulation is lax but which comfortably accounts for the lion’s share – 75 percent – of India’s healthcare sector. “This unregulated and fragmented private sector accounts for ninety percent of antibiotic consumption, raising major concerns about the potential effects of Covid-19 on prescribing and dispensing practices,” the researchers said. 

AMR is a reckoning we will have sooner or later. It is in the best interests of public health that it be later. Not only will it cost lives and rupees, it could well present an impediment if and when we grapple with the next pandemic. In fact, according to some, AMR is in itself the next pandemic. According to the UN Foundation, “while global attention has been consumed by the COVID-19 pandemic, another pandemic is already simmering. The threat of…AMR, or superbugs that don’t respond to existing antibiotics, is not lurking in the distant future — it is already claiming at least 700,000 lives around the world each year…without effective antibiotics, surgical procedures will become so high risk as to be nearly impossible; compromised immune systems will make cancer patients vulnerable to common infections; and neonatal sepsis — a common, treatable condition — will become untreatable.

“It is not sensational or naive to say that the impending AMR crisis could have even worse consequences on global health and prosperity than the current pandemic.” 

We must innovate, enshrine, notify, and enforce best practices, and – perhaps most crucially of all – invest in healthcare. As Gandra notes, “Low and middle-income countries tend to skip diagnostic testing for respiratory illnesses because most patients cannot afford it. So, they receive antibiotics under the assumption that their illness is bacterial.” 

India, with a high burden of out-of-pocket spending on healthcare which has only increased during the pandemic and pushes many into poverty who are already bereft as a result of the disruption of COVID-19, must heed the warnings experts have proffered for years: fund healthcare, fund it well, and fund it properly. The alternative is the onslaught of drug-resistant infections we cannot treat – and we will reap what we sow unless we act and act decisively and now. AMR is not an ominous portent of catastrophe looming on the horizon. It is with us now. If it spirals even further out of control, we cannot say that we were not warned. 

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