Bengaluru Apr 27, 2018, (Research Matters):
In this series, we explore the role of hospitals and the mirage of healthcare, in fighting antibiotic-resistant bacteria.
India is now facing an imminent threat of tiny, microscopic terrorists that are ubiquitous. Studies have proved that a high exposure to antibiotics favors the growth of superbugs. To top it, ill-informed and unscientific exposure to antibiotics is wreaking havoc on our society and is shaking up our healthcare. How does the Indian healthcare system fare? Is it equipped enough to face the reality and the challenge these drug-resistant bacteria throw?
The Indian constitution grants the ‘right to health’ as a fundamental right. To realize this, the government has set up a three-tiered health care system – primary, secondary and tertiary, to provide quality healthcare, free of charge, to all its citizens. Primary health care centers provide preventive and basic curative services and are often the first point of contact between a community and a medical officer. Secondary healthcare systems include community health centers and sub-district hospitals, which serve as referral units for primary health care centers. These are equipped with more advanced medical care and round-the-clock emergency services. Tertiary healthcare systems include district hospitals and medical colleges, which offer specialized consultative care.
On paper, the three-tier public healthcare system appears to be an elaborate, organized system based on increasing complexity of services. In practice, however, severe staff shortages, long waiting times and poor services plague public healthcare. The total number of doctors, nurses and midwives are 11.9 for every 10000 people, which is less than half of the World Health Organization (WHO) recommended value of 25.4.
Overall, the Indian healthcare system ranks 112 out of the 192 WHO member states, indicating a dismal state according to international standards. Clearly, the fundamental right to health is being compromised. Ineffective public healthcare coupled with an over-expensive private healthcare has forced people to self-medicate or seek medications from those who are not authorized to prescribe. This often results in taking the wrong medicines, at the wrong dose, for the wrong duration, and at the wrong frequency. This is particularly a problem, with antibiotics.
It is this abuse of antibiotics that is promoting the growth of superbugs, at the expense of our own. The rise of superbugs is just another downside of a dismal healthcare system. The hospitals, where you would hope to get cured of infections, are now breeding grounds for bacteria, especially those that are resistant to antibiotics -- the very drugs used to kill them!
Ineffective public healthcare, coupled with the liberalization of Indian economy and a growing middle class has led to a rapid expansion in private healthcare. In 2014, the private sector accounted for 70% outpatient and 60% of inpatient care. Private healthcare systems range from individual clinics that offer basic curative services to multispecialty hospitals that offer specialized consulting. The majority of private sector practitioners in rural areas have no formal training, yet charge exorbitant consulting fees. Poor government regulations have helped such phony doctors survive. Owing to many social factors, it is now a choice that people make to visit private healthcare practitioners for all their health needs.
But how good are hospitals in general in India? Are we equipped to fight a host of infections, especially the ones that are caused by bacteria that have developed drug resistance? Unfortunately, the answer may be a big NO. And here is why.
The problem stems from the poor sanitation practices followed in most of India’s hospitals, which favors the proliferation and propagation of these bacteria. It is a no-brainer to understand that sanitation measures become extremely important in places that deal with bacterial infections on a regular basis, and hospitals are one such example. But, how do we keep our hospitals? Overcrowding, unclean toilets and poor hand wash facilities are unfortunately still common in many Indian hospitals. These facilities, or lack of them, have repercussions in the quality of healthcare provided.
In a study, Indian and British researchers assessed the various infection control practices followed in 20 childbirth centers in the state of Gujarat. They found that surgical gloves, used in the process of delivery or surgery, were reused in 70% of these centers -- a sure shot recipe for the spread of massive infections. Also, 85% of these centers did not wipe the surfaces immediately after childbirth in labor rooms, and 33% did not have wash basins with hands-free taps! These poor infection control practices, the researchers say, result in the proliferation and propagation of bacteria. And in case any of these bacteria happen to be superbugs, poor sanitation helps it form more of its kind, spreading the infection epidemic like wildfire.
While hospitals in the country lack poor sanitation practices, medical waste disposal is a different story altogether. Medical waste, containing body fluids, usually are dumped in and around hospitals without properly treating them. Needless to say, there are very high chances that these medical wastes contain bacteria, including superbugs. Most hospitals get rid of the waste by releasing them to the natural environment -- water bodies, dumping grounds, etc. For airborne or waterborne superbugs, this serves as a haven. For us, not so much.
There are statistics to prove this. A 2017 study by researchers at the Aligarh Muslim University analyzed the presence of superbugs in sewage water from three distinct outlets at Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University. Their results revealed the presence of 32 different variants of superbugs in that water!
Similar to hospital sewage water, water sources around pharmaceutical industries that manufacture antibiotics have also been found to be contaminated with superbugs. A 2017 study by German researchers analyzed water samples from 28 different sampling sites in the vicinity of drug manufacturing units in Hyderabad. Their results revealed the presence of antibiotics in all 28 samples and the presence of superbugs in more than 95% samples.
The widespread presence of superbugs is concerning. The more their number, the higher the chances of getting an antibiotics resistant infection. If the number of superbugs continues to increase, our magic pills against deadly diseases like tuberculosis and typhoid will become obsolete and we will be transported back to the pre-antibiotics era! The healthcare and the promise of good health will be a mirage for one and all.