The infectious disease society of America highlighted the increasing public health concern of drug-resistant infections and that there is No ESKAPE
(acronym for the pathogens Enterococcus faecium
, Staphylococcus aureus
, Klebsiella pneumoniae
, Acinetobacter baumanii
, Pseudomonas aeruginosa
, and Enterobacter
species) from this clinical super-challenge
of the 21st century. Recently, a new drug-resistant gene
, NDM-1, was identified in a Swedish patient of Indian origin who travelled to New Delhi and acquired urinary tract infection caused by Klebsiella pneumoniae
while undergoing treatment there in December 2007.
Since then, more cases have been identified. The Health Protection Agency of the United Kingdom (UK) reported
22 cases of NDM-1 in July 2009. From isolates collected between August-November 2009, a hospital in Mumbai reported 22 cases of NDM-1 with compromised treatment options
. Cases have also been reported from other places
and the first mortality
was reported in June 2010 for a Belgian patient with prior treatment in Pakistan. All these came to public limelight after a publication in the Lancet
that studies NDM-1 isolates identified in Chennai (44 cases), Haryana (26 cases), the UK (37 cases) and other cities of India and Pakistan (73 cases).
This is so because the media picked up an incidental observation indicating spread of superbug
from India to Europe, potential danger
to patients from the UK opting for hospitalization in India and its implication for medical tourism
in India. The lead author of the Lancet paper was put in a quandary with one newspaper quoting him that the report was fudged
. But, to be fair to the author, the discussion on potential danger to patients or medical tourism is not the conclusion of the paper; it is rather an observation in response to an earlier media report in the UK that highlighted the virtues of medical tourism that could save millions
to the NHS (National Health Service). This discussion missed some substantive issues.
First, the spread of NDM-1, in such a short span of time, is alarming. As the paper clearly puts it there is need for integrated global surveillance and there should be no two opinions about this.
Second, this gene sequence is multidrug-resistant for gram-negative bacteria. We do not have enough drugs even in the developmental stages that could address future needs, as indicated in Bad bugs, no drugs: No ESKAPE
Third, the UK isolates are nosocomial infections, but many of the Indian isolates were community-acquired infections indicating widespread prevalence of NDM-1 in the environment. An Indian medical journal’s editorial has written an obituary, on the death of antibiotics!
Fourth, and particularly an important concern for India, is the excessive use of antibiotics. This is on account of avoidable and irrational use
. Further, unnecessary prescriptions are linked with a cut back
method of payment to physicians. Along with this there are over-the-counter sale by pharmacists. These, in an economic sense, are indicative of market imperfections arising out of supplier-induced-demand that have serious implications for public health. The Indian establishment should address this at the earliest.
Fifth, a commendable aspect of this paper is that this is the result of a collaborative outcome between 31 persons spread across 13 institutions in five countries, excluding acknowledgements. Let us not trivialize this effort by stating that there is a bias against South Asia.
Last, but not the least, is designating the strain with ‘New Delhi’, which has ruffled Indian sensibilities; but this was done in an earlier paper that has some common authors. They could have been careful and, if possible, could still make a global appeal to consider replacing it with ‘New Drug-resistant’.
Having said these, one would like to comment on medical tourism. From the Indian perspective, it has the potential to earn foreign exchange. For patients from the UK, it will provide quality care at cheaper rates and reduce waiting time. However, from the point of public health in India
, it is insensitive to majority of the Indian population who cannot access medical care; it forgets that if common drugs develop resistance then treatment will be further costly and this is going to hurt the poor more, as treatment in India, unlike UK, is largely out-of-pocket; it ignores the fact that the developed countries like UK have four times more doctors and ten times more nurses than India for 100,000 population. In short, the poor and the sick in India are missing.
The arguments in favour of medical tourism are pragmatic considerations. It is a reality that cannot be wished away. In a globalized mobile world, restricting place of treatment would be difficult, but it does call for quality-care for everyone. It calls for responsibility of the developed world to millions of poor in Sub-Saharan Africa and South Asia. A suggestion proposed is that developed countries should invest in fostering medical care in these regions including India, particularly, in rural areas such that each and every district has a medical college. This will facilitate global surveillance, combine pragmatism with a human touch, and foster medical tourism with eco tourism.