Last year a study by New Delhi-based Center for Science and Environment (CSE) brought to fore the perils of antimicrobial misuse in poultry industry and how it was impacting human health. “The CSE’s lab study found high levels of multi-drug resistant bugs in and around poultry farms,” it said, highlighting that antimicrobial misuse in poultry was growing and was leading to development of “resistant bugs”. These bugs, the study said, were moving out of farms into human populations through litter. Contrary to the reaction that this study evoked, also in Kashmir, resulting in reduction in consumption of chicken for some time, the gross misuse of antimicrobials in humans has largely been ignored by policy makers, medical practitioners and general masses alike. “Irrational” prescription of drugs has grown as a serious concern in Kashmir with many medical experts voicing concern over “casual prescription” of antimicrobials, lack of monitoring on drug sale practices and self medication. Prof Parvaiz A Koul, head department of internal and pulmonary medicine at Sher-e-Kshmir Institute of Medical Scineces (SKIMS) argued that often antimicrobials are prescribed “without care” and even for conditions that do not require treatments with antimicrobial drugs. “Often, a cocktail of antimicrobials are prescribed by doctors, without any scientific approach,” he said. “We are running out of options in terms of effective antimicrobials since not many are in pipeline.” An antimicrobial development, from lab to the shelf takes 15-20 years. Prof Koul said owing to growing resistance of micro-organisms to a number of drugs, the choices for treatment were narrowing. “Very often now, we are left with no choice but to use drugs that are too toxic like Colistin,” he said. Prof Kaiser Ahmed, head department of pediatrics at Government Medical College Srinagar said that in winters, when incidence of cold and flu, usually viral in nature, goes high, patients are given “high doses of antimicrobials”. Similarly, he said, in spring, when there is a spurt in allergies of various kinds, antimicrobials, which have no effect on the sicknesses, “sell like hot cakes”. He expressed concern over “callous approach from all quarters” towards rampant use of antimicrobials in Kashmir. “A day will come when people will die of common cold,” he said, while underlining dire need to strengthen systems to monitor practices in medicine and pharma business. To discourage “unplanned, irrational, dangerous prescription of medicines”, in 2016, state government had sought framing and implementation of a standard treatment protocol for diseases by medical colleges. According to this plan, a doctor was required to prescribe drugs, including antimicrobials, using their generic names and as per a scientific protocol. This proposal never saw the light of day. However, the entire blame of antimicrobial misuse does not lie with medical practitioners alone. It is a common practice for salespeople at medicine retail shops to prescribe and dispense medicines of choice to people for treatment of all kinds of ailments. On one hand, the pre-requisite of having a qualified pharmacist is still a far-fetched goal, in both rural and urban areas, on the other medicines are sold like any other commodity. According to drugs and cosmetics Act, antimicrobials cannot be sold to anyone without prescription of a registered practitioner. But lax monitoring by state’s drug control department has resulted in lack of adherence to these rules. As a result, antimicrobials are sold without prescription, giving rise to the trend of self medication. A senior doctor working in a peripheral hospital said that most often, a local chemist shop was the healthcare provider for masses. “For common ailments, people usually avoid going to a doctor and bank on whatever the chemist suggests,” he said. Prof Koul acknowledged the fact that by the time he sees a patient at the Institute, he or she has tried “at least a couple of types of antimicrobials”. “People often ask for an antimicrobial from local pharmacy – the choice based on a previous prescription, a recommendation of someone with a similar sickness, or discretion of the salesperson,” he said. Moreover, the weak system that allows sub-standard drugs to reach consumer, doctors feel, is a major contributor to antimicrobial resistance. “When a drug which is expected to be effective against an organism fails to act, physicians are forced to experiment with many more,” a senior GMC faculty said. Deputy controller drugs J&K Irfana Ahmed said that chemists and pharma store owners have been “sentsitised” not to dispense antimicrobials without prescription. “We do get complaints about it (illegal sale of medicines),” she said, though adding that the issue of complacency towards drug sale was more in rural areas than in urban. The drug department had also initiated prosecution for flouting of Drugs and Cosmetics Act schedule H1, she said. “If we are able to get people to book for flouting rules, it will act as a deterrent,” she said. She said people were pushed to chemists for seeking medical advice due to scarcity of doctors, and, according to her, chemists were mostly driven by business goals. “We need to carry out mass awareness drives about why it is important to use antimicrobials rationally. We are on the precipice. But all stakeholders need to wake up to what we have gotten ourselves into,” she said. Misuse of antimicrobials, according to World Health Organisation (WHO) is leading to the growth of “superbugs”. According to WHO when bacteria in the body of a human or animal are exposed to antimicrobials, they change to resist the effect of the drug. That means if more antimicrobials are used, there are greater risks of organisms getting resistant to the effect of the drug. “Antimicrobial-resistant bugs then spread between humans and animals through direct contact, food, or the environment” it says. In 2018, WHO launched its campaign, “Change cannot wait – our time with antimicrobials is running out” to lay stress on immediacy of action required to combat irrational use of antimicrobials. “It (antimicrobial resistance) is growing as a ‘ticking time bomb’… immediate action is the need of the hour to avert a disaster,” said another senior doctor.
Steps to address antimicrobial resistance
• Stop self medication
• Strict monitoring of pharmacies
• Strengthen infection control practices in hospitals to decrease dependence on antimicrobials