The story of antibiotic use in India has slipped from the genre of science to horror in such slow motion over the decades that we do not even realise the dangers of standing so casually on the antibiotic cliff-hanger — an edge of an era where bacterial pathogens are rapidly evolving resistance to existing drugs, while the development of new antibiotics has ground to a halt. This leaves us at a point where common infections and small wounds could once again become fatal, as they used to be in pre-antibiotics era. And India, one of the largest producers and consumers of antibiotics, may be the eye of that imminent antibiotic storm. This is the core message of a new book A World of Resistance: India and the Global Antibiotics Crisis by Assa Doron, an anthropologist from Australia, and Alex Broom, a sociologist from Australia.
Travelling through antibiotics history in India, the authors probe the context and conditions in which antibiotics are manufactured in India, prescribed and distributed across the country, used in its hospital settings — both public and private, and circulate in the food-chains —be it poultry, fishes, milk, or crops. What makes this book on anti-microbial resistance (AMR) distinct amongst a growing body of literature on the subject is the human lens deployed (given the discipline of authors are anthropology and sociology) in the study. What also makes it valuable is the field-research that has shaped authors’ unique understanding of the complex milieu in India where antibiotic use at times may appear to be ‘irrational’ or ‘misuse’ glimpsed from afar but may be the only available option to possibly save a life in practical terms.
Many times people at the bottom of the pyramid who are supposedly contributing to ‘irrational antibiotic use’ are actually in a survival mode who can neither afford to stay ill and lose a day’s earning nor afford healthcare services. Many times, pharmacy owners who appear as villains indulging in irrational use of antibiotics in biomedical terms are, in fact, compensating for primary healthcare services that are non-existent or non-functional for the poor in the remote areas. On ground, ‘pharmacies are often the central form of primary health care’, reckons the book.
While admitting that OTC (over the counter) culture for antibiotics is all pervasive in India across lakhs of neighbourhood chemists, and top drug retail chains, the authors prescribe that India-specific solutions must be found to restrain the use of antibiotics instead of imposing a top down simplistic ‘just stop all OTC sales’. That may have “profound implications for some of world’s most impoverished people”, the authors observe, claiming that self-medication in parts of this landscape reflects “critical and continued lack of access to qualified medical practitioners” and may be “the only viable option for many in India and beyond”.
In studying ‘community use of antibiotics’, authors also interact with RMPs, the unregistered medical practitioners in rural areas who are under the sway of medical sales representatives from pharma companies who, in turn, are only interested in profit maximisation. These RMPs serve outside the formal healthcare services network but remain the sole healthcare delivery points in underserved regions, so killing them is not the solution, observe the authors.
Similarly, a nuanced picture emerges when they study antibiotics usage in hospital settings in India, particularly public-health facilities. In the overcrowded and resource strained clinical settings, physicians often have to choose between preserving lives in the face of life-threatening infections in immediate context or adhere to best practices of antibiotic stewardship. In the absence of diagnostic clarity (which pathogen to address) and evidence-driven protocols, physicians often opt to save a life in immediate context vis-à-vis curb AMR in long-term. In corporate healthcare settings, individual doctors take their own decisions on prescribing antibiotics in the absence of uniform AMR protocols. Greed of financial kickback from pharma companies combined with pressure for quick results also nudge them to prescribe broad-spectrum antibiotics and the latest ones. These doctors also throw another googly — might we be needing broad spectrum and latest generation antibiotics because our food-systems are already compromised that make us resistant to existing antibiotics.
The authors dive into parts of food industry — and find that in chicken farming for broilers, antibiotics often act as growth promoters and used indiscriminately. It’s so common that in the heart of one of the largest poultry hubs in Hyderabad, people differentiate between ‘Mandu Kodi’ and ‘Natu Kodi’, where ‘Mandu’ refers to medicine while ‘Natu’ vaguely means ‘country-made’. Interestingly, while making animal sacrifices during rituals, people prefer ‘Natu Kodi’ considering it ‘unadulterated’ as ‘medicated chicken’ would be unpalatable to the gods.
Experts warn of an ‘antibiotic-soaked future’, citing studies that detected six different types of antibiotics in chicken tissues. The authors are welcomed by ‘antibiotic-free’ boards in Bhimavaram of Andhra Pradesh, but not antibiotic free practices, when they reach there to study shrimp farming. In dairy sector, they cite studies to show widespread antibiotic use among smallholder farmers who often struggle to distinguish between antibiotic and non-antibiotic pharmaceuticals.
Warning that we may have already entered the twilight of this once revolutionary medicines,the authors conclude that “India’s healthcare and food production ecosystems depend on antibiotics to function facing massive risks of ‘withdrawal symptoms’ — if indeed these pharmaceuticals can be withdrawn from everyday life at all.”
The strength of this book is that it takes our everyday life and turns it into stuff of investigative journalism, convincingly so. Many incidents the authors describe may seem “too normal to notice” for Indians, but their consequences are far-reaching and reflect in our population’s health and nutrition profiles. In a way, the rising aspirational currents of ‘antibiotic free’ and ‘organic food’ movements in urban India acknowledge these subtexts of realities we prefer to ignore every day.
In the lanes of pre-independence history, readers can discover interesting nuggets — such as how different Gandhi’s attitude was to antibiotics who wouldn’t allow them to be administered to Kasturba even on her deathbed versus Nehru’s, who embraced antibiotics as a symbol of science and progress. In the lanes of post-independence history, you will find a brief but comprehensive critique of the politics of ‘green revolution’ (that granted India rice and wheat security through water-guzzling high yielding variety seeds) and ‘white revolution’ (self-sufficiency in milk), which broke the intricate biological systems here and saddled the crops and milks with chemicals including antibiotics.
A world of resistance is an account both brave and sensitive, academic yet accessible. While the book has diagnosed the disease accurately, the prescription is missing. This is where it could do better: to suggest more pathways ahead, such as possible de-addiction centres India could visit to detox from the doom-loop of antibioticalypse and start afresh!
Soma Das is the author of The Reluctant Billionaire and an adviser to agencies in the development sector
BOOK DETAILS:
Book: A World of Resistance: India and the Global Antibiotic Crisis
Author: Assa Doron & Alex Broom
Publisher: Belknap Press
Pages: 256
Price: Rs 699