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THE discovery of penicillin in 1928 inaugurated the long reign of antibiotics. From its discovery onwards, antibiotics formed the front-line defence against disease and infections. The upshot was millions of lives saved and long-term health security ensured.
However, the reign of antibiotics was challenged in the 1950s when the first cases of penicillin resistance were reported. This prompted the development of a new line of antibiotics from the 1960s-1980s. From the 1990s, the production of new antibiotics almost dried up despite antimicrobial resistance (AMR) increasing. Part of the reason was low returns for the pharmaceutical industry on time-limited antibiotics, in comparison to long-use medicines for diseases such as diabetes and heart conditions.
The issue of AMR has been on the policy horizons since the late 1990s, but always on the back burner, until WHO produced its first report on the growing threat of AMR to global public health in 2014.
Pakistan is no exception to this worldwide trend. Though no comprehensive studies on the extent of AMR in Pakistan have been undertaken, the enormity of the problem is clear to any healthcare worker and patient. Many explanations can be adduced. The overuse of antibiotics is one of them; in Pakistan, the overuse and abuse of antibiotics is almost on an industrial scale.
Antibiotics are the first drugs of choice for all infections in clinical settings up and down the country. The practice of over-prescription is widespread, in part owing to the aggressive promotion of antibiotics by Big Pharma. The problem is further compounded by numerous quacks whose reputations rest on an unnecessary overreliance on antibiotics. Another reason lies in prescribing antibiotics for viral infections for which antibiotics are not indicated. Hospital-acquired infections constitute another contributory factor — an issue that is widespread and, worryingly, unacknowledged.
How do we prepare for this imminent public health crisis?
The easy availability of antibiotics over the counter and without prescription, and the socially embedded practice of self-medicating due to high healthcare costs add to AMR. Substandard and spurious drugs also flourish on an unquantifiable high scale; again due to poor regulatory oversight, thus exacerbating the AMR crisis.
More importantly, the widespread and indiscriminate use of antibiotics in agricultural and livestock sectors, where antibiotics are used as a growth promoter, is a much ignored aspect of the crisis. Given the extent of human-animal interaction on a daily basis, particularly in rural areas, human-animal transmission is an issue that must be urgently addressed.
However, many initiatives are under way. WHO has been at the forefront, as have other public health bodies. WHO has helped the Pakistani government with an action plan and surveillance system. A focal person for the AMR project is there. The London School of Hygiene and Tropical Medicine’s AMR centre is undertaking a research project focused on the behaviour of policymakers involved in AMR work. While these initiatives take time to cohere, the health authorities in Pakistan need to devise an AMR policy to deal with this growing problem. This should involve the following components:
First, the preparation of a comprehensive national plan to deal with the AMR threat. The plan should be formed in consultation with all stakeholders including from the agricultural and livestock sectors, which are still left out of this important conversation. Unlike all good plans on paper, the AMR plan would need to be implemented efficiently in the face of the gravity of the crisis and the dangers it poses to the health security of the nation. Second, an AMR surveillance system should be set up and laboratory capacities strengthened at all levels.
Third, the Drug Regulatory Authority of Pakistan needs to sharpen its regulatory bite and ensure that substandard medicines are taken out of circulation, alongside ensuring equitable access to essential and cheap medicines of assured quality. Fourth, rational and judicious use of antibiotics and standard prescribing practices should be promoted through a strict regulation regime and larger public health campaigns.
Fifth, better infection control measures at local regional and national levels should be put in place and enforced to prevent hospital acquired infections. Sixth, there should be improved coordination with agricultural and livestock sectors to address the linked human-animal connection in the spread of AMR.
Seventh, the regulatory regime governing medical practices should be improved and enforced to eradicate quackery. The regime should also cover the private health sector where regulation is lax, and which is not part of public health strategies.
Lastly, research into the various aspects of this multifaceted crisis is essential for the success of reducing AMR prevalence in Pakistan.
The writer is a consultant and policy analyst.
Twitter: @arifazad5
Published in Dawn, August 31st, 2017
