Events in our life are indeed connected in weird ways.... as one leads to another.... it is almost like a chain reaction which extends far beyond the realm of one's imagination.
As a result of a discussion with a friend over a cup of coffee, i decided to write a blog about the "superbug" controversy sometime ago. Reading this blog, I was invited to extend the small blog into aan article for a students' magazine at IISc which is my home for now... And this collaboration resulted in the following article... written by A and me...
And thats how a lot of stories begin.... over a cup of coffee... :-)
--------------------------------------------------------------------------------------------------------
It all started with dramatic news flashes such as “Superbug from India?”, and “bacteria spreading from India to UK?” and by the next morning, the prominent newspapers had their theories up on the first page. Finally, it seemed that at least one piece of the daily quota of “breaking news” was indeed interesting (and alarming) and would get some rightly-deserved focus over the next week. However, it was only a matter of time that yet another “breaking news” came along and the primary issue was reduced to rubble and its true significance chucked off to the bin!!
For someone who has not been following the news regularly, the recent reports will only lead to complete and utter cluelessness due to the mind numbing rhetoric. It thus makes sense to first address the question of what the furore was all about. Briefly, the reputed journal LANCET had published a collaborative work, involving several groups from India, Pakistan the UK, which claimed that a bacterial gene that confers resistance to practically all the β-lactam antibiotics was widespread across the subcontinent. Furthermore, riding on carriers and patients, this “superbug” was traveling to other continents. Since most antibiotics, including the frontline carbapenems were ineffective against the bacteria that harbored this gene, it seemed to be an unstoppable medical crisis. This resistance conferring gene is mainly carried on plasmids (small, autonomous DNA molecules which can “jump” from one bacterial species to another) and was called the New Delhi β-lactamase (NDM-1).
While a fact based, dispassionate analysis of what ensued was necessary to gain some perspective on the matter, and it was exactly the component that was missing in the entire reportage! The media and the government were quick to denounce the findings of the report. It was labeled unscientific and unacceptable in addition to being the handiwork of a pharmaceutical lobby! The panel discussions on TV had doctors, bureaucrats and politicians, but rarely a microbiologist or an epidemiologis. The consensus seemed to be that the entire work smelt of a conspiracy. A treacherous plot by the west to destroy our burgeoning “medical tourism industry”! What is Medical Tourism? Well, a large numbers of Westerners come to India every year for various medical treatments ranging from cosmetic surgery to dental treatments as a cheaper alternative destination. This was also encouraged at the national level as an effective strategy to cut down on the expenses for the NHS (in UK) and other such health care providers in the west. Now, if these “tourists” could be dissuaded from travel by the fear of infection, then the medical tourism industry and consequently the influx of foreign exchange would be hit. This report was thus portrayed as an attempt by the Occident to paint a dirty and disease-spreading image of India, the rising economic power. Hence, it was implied, that it is the duty of every patriotic Indian to protest to this “national insult” towards restoring the “India shining” image.
Here, we try to present the issue as we see it with our limited perspectives, based on reading the LANCET paper and couple of other reviews and some of the more rational and balanced news reports. As researchers who have a clearer understanding of field, it is horrifying specter to see how the issue has been completely blown out of proportion and the crux of the research has been conveniently sidelined.
For the uninitiated, it must be stated that the development of antibiotic resistance in bacteria is not a new phenomenon. The development of resistance to conventional antibiotics in bacteria from clinical and non-clinical settings is not a new phenomenon and has been a potential problem for a long time. Since the bacterial life spans are short the development of resistance in bacteria was always well anticipated and this never ending arms race with the humans developing newer and more potent antibiotics and the bacteria developing newer means of resistance is the fundamental feature of biological evolution. It has been known for 50 years now, and academic and industrial research has always been on the lookout for newer antibiotics. A decade ago, there was a surge of concern about the Meticillin resistant S. aureus (MRSA), a gram-positive bacterium notorious for causing nosocomial/hospital acquired infections. Today, there is a lot of worry about how to tackle the several multi-drug-resistant gram-negative bacteria that pose the greatest threat to public health. Resistance genes spreading across different species either by piggybacking on plasmids (as in the case of NDM-1) or by horizontal gene transfer are increasingly considered dangerous as we run out of potent antibiotics. Human air travel and migration are at an all-time high and are naturally contributing to the spread of resistant bacteria.
With this background, it might make you wonder like we did about what the hue and cry in the media was all about?
Firstly, NDM-1 - a “bad” gene named after the nation’s capital is being considered a national insult! The media was whipping up a frenzy by capitalizing on this as an issue of national pride. But, naming a new organism or enzyme after its source, site-of-first-identification or discoverer is part of scientific convention, specifically, with regard to this particular group of enzymes! More than50 β-lactamases have been identified between 2000 and 2006 and thus it is not surprising, as one review says, that “β-lactamase nomenclature has been nothing if not creative”. And, anyways, we have so many other examples all around. The banyan tree is named as Ficus benghalenesis. One of the most virulent of pathogens, the causative agent for TB, is called Mycobacterium tuberculosis Beijing. A new frog species found in Sahyadari (Western Ghats) has been named Nasikabatrachus sahyadrensis. In 1961, a dinosaur was named as Barapasaurus tagorei as its discovery coincided with the birth centenary of Tagore. There are other bacterial pathogens christened as Clostridium botulinum strain Alaska and Anaplasma centrale strain Israel. Further, the restriction enzymes such as EcoRI and BamHI, which are the scissors of molecular biology, have long been named after their source organism. Does anyone recall any protest from Beijing when the TB causing pathogenic train was named after it? Did we shout when we had a cute little frog and the majestic tree named after our lands? No, we probably clung to that reflected glory just as we did when Prof. Venki Ramakrishnan got the Nobel (and as a token of gratitude, jammed his e-mail inbox!). Resistant bacteria arise all over the world, and no matter how much we consider ourselves to be superior to the rest of the world, we cannot deny the fact that India is still on planet Earth. So, why is there a problem in accepting that an enzyme has been named after it was first identified in a Swedish patient who had been treated at a hospital in New Delhi, and probably acquired the infection there?
Frankly, the hyper-emotive response shows how pathetic we are with respect to “science as a way of life”. Also, it is possible that by projecting it as an “identity crisis” it becomes a case of “India versus non-Indians” and then the main issue can be deliberately and conveniently sidelined. In fact, it is not too difficult to counter-postulate that, those who are “protesting” have vested interests in the medical tourism business. The recent “paid news” scandals have only further exposed such forms of corruption.
The important thing however which deserves all the attention is the prevalence of such deadly antibiotic resistant strains in our hospitals and that issue has been completely sidelined. This study shows that such NDM-1 harboring bacteria are present in patients in all parts of the country, not only Haryana and Chennai and also in Pakistan (most likely, they’ll spread after the recent floods, and cross the LoC undetected). Additionally, this is not the first or only study of NDM-1 in the country. In March 2010, another paper showed that 22 cases of NDM-1 positive patients were identified in 3 months in a single Mumbai hospital. The LANCET article, however, has provided the spotlight to the subject. It also says that most of the patients have “community acquired urinary tract infections, pneumonia and blood stream infections”. Is India that spotlessly clean and hygienic? Are our sanitation and waste disposal systems the most efficient? A lack of statistical analysis is a drawback of this paper. But, if indeed 17 out of 37 NDM-1 positive UK patients (46%) had been recently admitted to hospitals in India, isn’t it possible that these could be nosocomial/hospital-acquired infections? With this of course, one can just pause and wonder that if the hi-fi hospitals catering to foreign patients are a source of these infections, then how bad is it in the real India of the aam admi? Don’t we have high incidences of so many infections – TB, HIV, diarrhea, malaria, and dengue? We all know that our health system is appalling. And while bacteria don’t give a damn to caste and class, many pathogens certainly thrive in unhealthy conditions and pass on their plasmids and resistant genes such as NDM-1.
Questions have been raised about the role of funding agencies. The paper categorically states, as we all do when we write our own, that the funders had no role in study design, etc etc. Is there any strong data to doubt this? Then, we have to doubt the ways we ourselves write our manuscripts. And in the “conflicts of interest”, the authors are honest about their travel grants and their interaction with the industry. All over the world, including in India, academics are increasingly becoming part of the industries. Wouldn’t denouncing the LANCET authors result in slandering almost the entire scientific community? And misreporting can go to such ridiculous levels That the National newspapers consistently referred to the “Welcome trust” as a pharmaceutical giant till the trust finally came out with a clarification. The fact of the matter is that the media is trying to blow up a story without an accurate understanding and this is only diverting the public focus from the more important issue of the development of resistance in microbes to the other peripheral issues of private funding, national pride etc etc.
Despite the baseless furore surrounding this whole episode, it is important that this issue is not relegated to the back burners in a week. The situation is critical especially in India since resistance to extended-spectrum beta-lactamases (ESBL) drugs like the third-generation Cephalosporins is between 60 to 70% on average, compared to the less than 15% seen in the developed countries. Thus, a more common way of treating the severe form of ESBL infections in India is through the use of Carbepenem - which becomes the drug of choice as it has (or rather had!) the lowest resistance and the broadest action against gram negative infections. The emergence of resistance against Carbepenem is bad news undoubtedly but for the patients and physicians in India who now have to look for new antibiotics but this is a self created nuisance too. The spread of resistance is not surprising keeping in view the fact that very potent drugs like Carbepenem are overused by the physicians. The easy over-the counter availability of these drugs also makes the problem more acute as patients end up self medicating in sub-lethal doses (For the bacteria of course), thus, leading to the acquisition of resistance. These are problems which have been known to the medical community for a very long time but have not been addressed by the government, the media or the Public. It is easy for us to blame the whole world for our woes. And it is also easy to malign the lead author, a Ph.D student at the University of Madras as a “traitor”. We can also conveniently ignore these scientific data till it is too late to do anything. For our mind however, if the work is a true whistle-blower, then as the national emblem says, “truth alone triumphs” and it shall in this case too. Ignoring this problem only takes us closer to the inconvenient truth of the origin antibiotic resistant, untreated diseases and a resultant death for millions of Indians. Let us hope that the people, the media, the politicians and the health professions wake up and seriously address this not-so-distant crisis.
No comments:
Post a Comment