Antimicrobial resistance (AMR) has emerged as a critical public health issue in recent years as microbes develop resistance to life-saving antibiotics. According to the World Health Organization (WHO), globally 700,000 people die every year from AMR. If current trends continue, this number may rise to 10 million by 2050, more than cancer and traffic deaths combined, reversing much of the gains achieved by modern medicine and costing the global economy $100 trillion.
While this concern was mainly limited to public health professionals in the past, the COVID-19 pandemic should have raised its political salience by demonstrating that we ignore scientific warnings at our own peril.
AMR is most often associated with the misuse and abuse of antibiotics in the healthcare setting, but research increasingly shows that environmental exposures play an equally important role. Environmental exposures arise mainly from the healthcare industries and livestock operations. Pharmaceutical industries and hospitals discharge antibiotic-laden wastewater into water bodies. Fish and livestock operations routinely use enormous quantities of antibiotics, not only for actual disease treatment but indiscriminately—for disease prevention as well as for growth promotion through incorporation in the feed.
As the largest producer and consumer of antibiotics in the world, India has sadly been labelled the “epicentre” of AMR, with both substandard healthcare practices and poor water quality and sanitation contributing to the problem. In fact, alarming levels of drug-resistant bacteria have been detected by researchers in effluent, water bodies and farm operations all over the country.
Based on the adoption of the Global Action Plan on AMR in 2015 in the World Health Assembly, member states were urged to develop National Action Plans based on the global framework within 2 years and share data with the WHO on implementation steps and AMR trends. Though less ambitious efforts existed earlier, the Government of India (GoI) adopted the National Action Plan on AMR (NAP-AMR) in 2017, with the Ministry of Health and Family Welfare (MoHFW) as the nodal ministry and the National Centre for Disease Control (NCDC) as the key surveillance body. The NCDC has prepared guidelines for the development of State Action Plans but till date, only three states—Kerala, Madhya Pradesh, and Delhi—have prepared and submitted them.
A 2018 survey on global AMR progress by the WHO, FAO and OIE acknowledged some areas of progress in India but highlighted several shortcomings including the absence of monitoring of antibiotic use in the livestock sector, and limited capacity development and awareness among stakeholders. With the NCDC focused solely on AMR surveillance in the medical sector, a need was felt for specialized surveillance of the fish and livestock sectors. To fill this gap, FAO has facilitated the establishment of the Indian Network for Fishery and Animals Antimicrobial Resistance (INFAAR) in 2017 in collaboration with the Indian Council for Agricultural Research (ICAR).
A significant victory was achieved when the MoHFW banned the use of colistin which is a “last-resort antibiotic” in fish and livestock industries in 2019. It is important to keep building on this momentum by banning all antibiotic use as growth promoters in the livestock industry. In fact, the UN Interagency Coordination Group on Antimicrobial Resistance (IACG) has made exactly this recommendation in 2019.
Another important step was taken by the Food Safety and Standards Authority of India (FSSAI) in 2018 when it introduced maximum permissible antibiotic residue limits for meat, fish and milk. Unfortunately, there is no system of standardised testing of animal products before sale and the FSSAI hopes to rely on occasional surprise testing. As a result, frequent investigations by private watchdog groups throw up concerning results.
Arguably the most important step was taken by the GoI in January 2020, when the Ministry of Environment, Forest and Climate Change (MoEFCC) published draft standards for antibiotic residues in pharmaceutical industry effluents under the proposed Environmental (Protection) Amendment Rules 2019. The standards propose stringent limits for 121 antibiotics and are applicable to both standalone manufacturing units as well as common effluent treatment plants (CETPs) catering to the pharmaceutical industry. If finally notified, India will become the first country in the world with such standards, a significant development since India, along with China, accounts for the production of 90 per cent of the world’s antibiotics.
Unsurprisingly, the Indian Drug Manufacturers Association (IDMA) has objected to these stringent standards and proposed weaker ones, claiming that the absence of suitable technology will push the entire industry into non-compliance. Given the increased prominence of the pharmaceutical industry in the wake of the COVID-19 pandemic, there is reason to be concerned about the final fate of the proposed standards.
Even if some version of these effluent standards come into force in future, the monitoring capability of the State Pollution Control Boards (SPCBs) does not inspire confidence. In 2019, the National Green Tribunal (NGT) ordered the Central Pollution Control Board (CPCB) to conduct a nationwide audit of SPCBs, in light of widespread reports about a chronic lack of manpower and resources, unqualified personnel, inadequate scientific equipment, and overall failure to sufficiently hold polluters accountable. Also in 2019, the CPCB further directed 13 states to take corrective action against 124 CETPs for flouting pollution standards. Hospital effluent is also poorly regulated, with less than 45% of healthcare facilities in India having adequate wastewater treatment systems in place.
To sum up, sustained efforts across all the fronts outlined above will be needed to minimize environmental exposure and the fight against AMR should be seen as a marathon. The COVID-19 pandemic has demonstrated that mobilisation on a war footing against difficult and entrenched problems, such as the wet markets of China, can no longer be avoided if we are to avoid an AMR apocalypse.
The author is Associate Professor of Environmental Studies at O. P. Jindal Global University
The opinions expressed in this article are those of the authors' and do not purport to reflect the opinions or views of THE WEEK.