By Soma Das
Unlike computing, the-re’s no Moore’s Law in the world of antibiotics, and humanity is dangerously close to a dead-end, where most antibiotics will just stop working, without new ones being found. This will start shrinking life expectancies, just as their discovery in the early 20th century had lengthened lifespan by two decades.
This is at the heart of Anirban Mahapatra’s When the Drugs Don’t Work, a book with a title that sounds like the lyrics of a chartbuster pop song, but buries within its pages a deeply uncomfortable warning —“the hidden pandemic of superbugs could end medicine”. We may already be regressing to a time when minor scratches will prove fatal as we are left with no antimicrobial medicines effective enough to treat infections.
From TB to pneumonia, even a minor strep throat will become untreatable. Women undergoing childbirth, first few months of the baby, cancer patients receiving chemo, kidney ailment patients receiving dialysis, patients in ICU, all of them become highly vulnerable if antibiotics stop working. Mahapatra takes us back to the prophetic speech of Alexander Fleming, who warned us of this scary future of ‘antibiotic resistance’ in 1945 when he was receiving the Nobel Prize for discovering Penicillin, the first of its kind antimicrobial drug. The author introduces us to six bacteria characters-—deadly six super-bugs which pose the highest known risk to humanity and are estimated to cause 80% all fatal infections from antimicrobial resistance.
Unlike Covid-19, where we dealt with a single virus which was easier to grasp, here we are up against a host of complex characters that make the plot difficult to summarise. Of special interest to the author, who is a microbiologist of Indian origin, is the case of India—for various reasons, including the way we produce antibiotics, and the way we consume them. Seen one way, antibiotics is to India, what oil is to Saudi Arabia, or Malaysia.
And just as these countries don’t mind spilling precious oil that is extracted from their backyard, in India we don’t mind popping extra pills just because they are easily available, because they are manufactured within the country. Over decades, ‘popping-a-pill over the first sneeze’, has turned from a habit to a culture in India, for which doctors, patients, pharmacies, regulatory system and pharma companies all are responsible. Despite stringent regulations now, it’s a mindset that is proving difficult to alter in the country. What is also true is that at times getting a diagnosis is more expensive and a bigger hassle than reaching out to the neighbourhood pharmacy for a dose of antibiotics.
In a resource-poor setting like India, that becomes a reason for choosing antibiotics over diagnosis, leading to misuse and overuse of antibiotics and causing resistance.
It’s little surprise that when countries were ranked for antibiotic resistance by a study published in BMJ funded by Bill and Melinda Gates Foundation, India topped the list with the highest antibiotic resistance.
The author estimates that hundreds of millions of people in the Indian subcontinent carry superbugs in their gut that are resistant to Carbapenems, one of the last-resort antibiotics. Outside of the gut, these superbugs can cause havoc. The book quotes a study that estimates that just under half the patients that walk into a doctor’s office in Delhi get prescribed at least one antibiotic.
The author warns against the disease of ‘self-medication’ in India, and against the flooding of what have come to be known as irrational combo drugs, also unique to India where pharma companies have mixed two or more antibiotics into one tablet and sell without testing them. It doesn’t strike our pharma companies that science is not common sense, where one drug can be mixed with another without consequence.
Indiscriminate use of last-resort and highly toxic drug Colistin in India’s poultry industry to fatten the birds till 2018, when the world had already banned it, is another disturbing trend the book covers. Finally in 2019, India banned it for poultry, aquaculture, food producing animals, and even animal feed. But how far has the enforcement been successful, remains to be seen. Worryingly across the world even today, 70% of all antibiotics, including last resort ones, are used as cheap food additives to fatten animals meant for human consumption.
The author neatly sketches the history of antimicrobials—where he tells fascinating stories around discoveries of antibiotics, most of them accidental and serendipitous. In 1796, physician Edward Jenner noticed that milkmaids after a bout of cowpox infection didn’t catch small-pox, leading to small-pox vaccines. German pathologist Gerhard Dogmagk discovered Prontosil to save his daughter from getting her limbs amputated; Fleming was back from a vacation to find one clean zone among dirty petri-dishes, and discovered the mould Penicillium notatum, the source of Penicillin.
Passion, controversy, jealousy, rivalries, PR campaigns and Nobel prizes, these discoveries are stuff of fast-paced fiction. But accidental discoveries do not always deliver heroic results. Biochemist Thomas Jukes, who worked in nutrition department of pharma company Lederle Labs, found trouts fattening in Pearl River at New York on antibiotic aureomycin residues. He tried it out on chicken-and succeeded beyond expectations-the consequences of which we are still suffering.
In some other chapters, Mahapatra explores the reasons for a failed market in antibiotics where companies have lost incentives to discover new ones-six start-ups that won USFDA approval for new antibiotics since 2017 have filed for bankruptcy. He discusses other alternatives, including vaccines against deadly six superbugs, good bacteria and role of AI in antibiotics discovery, and laments how this ‘hidden pandemic’ is pushing us irreversibly towards a ‘post antibiotic era’. For those associated with the health and pharmaceuticals sector, the information as well as insights in the book are not ground-breaking. But this refreshingly jargon-light book that simplifies science on this critical topic is a great prescription for all laypersons who have popped an antibiotic ever in their life.
The author could have done well to include in scope how quacks in Indian villages may have compounded the problem, and expanded a bit on global spatial distribution of the antimicrobial resistance. In such a broad-stroke popular science book, beaming focus only on India as the source and destination of the antimicrobial resistance will leave an uninformed reader confused on whether this is because the problem is solely concentrated in India, or because it is the geography author has chosen to focus for his storytelling. These are minor cribs in an otherwise comprehensive account on a topic that deals closely with our daily health but is often relegated to the realm of doctors, and scientists. It’s time we take informed decisions to save ourselves from a freefall from the edge of this antibiotic cliff. The alarm bell in this book is a timely reminder.
Soma Das is the author of The Reluctant Billionaire and an adviser to multiple agencies in the development space
When The Drugs Don’t Work: The Hidden Pandemic that Could End Modern Medicine
Anirban Mahapatra
Juggernaut Books
Pp 288, Rs. 599
