Excerpts from the interview.Q: What was the genesis of this book? Assa Doron: Alex and I have been working in India for around two decades and we’ve done collaborative research before on different aspects of health and public health in India. I did a book with professor Robin Jeffrey called ‘Waste of a Nation’. I found myself in Hyderabad alongside the Musi river and learning about the factory pollution that is discharged by pharmaceutical companies… I realised that samples have shown that there is a lot of bacteria resistant to antibiotics in the Musi itself. And when I was speaking to local people, they were telling me about bad smells, problems with skin diseases, and so on. And I realised that the issue of waste here is becoming also an issue related to antibiotic resistance… And I knew that Alex was working on this issue for over a decade now. So I asked him if we can team up. Q: How did you get your fingers dirty and get the data? Alex Broom: Getting your fingers dirty is actually a good metaphor… I was exploring lots of different health-related issues in India. I have family in India as well. So, I was going back and forth… Part of it was personal — I started to see myself the tension between purchasing antibiotics to try and get through whatever I was trying to get through and then knowing from my other work that ultimately these were a precious resource that we can’t really waste. And how do we actually make changes and make them realistic? Assa Doron: The paucity of data was something that we were struggling with. Fortunately, there’s enough scientific material out there to demonstrate that for a lot of places that are polluted — take the Ganga or take the Musi — there are enough scientists that have gone there and taken samples and have shown very clearly there is an issue of rising antimicrobial resistance. Whether it’s a result of poor sanitation and sewage going into the river as a result of factories that are discharging effluents, whether it’s pharmaceutical residues or heavy metals or tanneries, there’s multiple studies that demonstrate that. But our concern was not the hard data, as it were, in terms of numbers that you can find in scientific journals. What we wanted to do is to tell a story, because India really brings the global antibiotic story into sharp focus. It’s one of the world’s largest consumers of antibiotics. It’s a major producer of generic medicines and a place where antibiotics move through hospitals, pharmacies, farms, factories, households, with extraordinary intensity… India helps us to see something that is global but often hidden. That is that modern life is really kind of deeply dependent on antibiotics. Q: It is about emerging narratives of an emerging catastrophe which is staring us in the face. Alex Broom: We need a diversity of data. And what I mean by that is, for example, how much incentives might be given to the use of certain pharmaceuticals… We need data that shows what the drivers are of use of our diminishing resources, rather than just focus on the biological outcomes of that behaviour and that economy. So really, what we’re doing is trying to pan out. And rather than just focus on levels of resistance, we’re saying you need panoramic data in order to actually communicate the problem to everyday people. The data might actually be the fact that we can’t expect people to not consume antibiotics if they haven’t got secure work. Now, that wouldn’t traditionally be seen as a form of scientific data, but that is one of the reasons which drives high use of antibiotics and high levels of resistance. Assa Doron: I think one of the key concerns that we have in the book is to demonstrate that you can’t really blame people, because the crisis of antibiotics is not a biological one. It’s a crisis of inequality in many ways. Resistance emerges through microbes, but it follows these social fault lines, whether it’s across gender, class, occupation, housing. We know that there’s a lot of people that don’t have access to water or sanitation is poor or they’re exposed to a polluted environment... For example, for the household, women are the ones who may suffer recurrent urinary tract infections or reproductive tract infections, or other untreated health problems that delay care because their illness is treated as less urgent. So these are the stories that we want to tell — what delays proper care? Why is it that there’s a shortage of doctors in rural areas? Alex Broom: Much of the rise of resistance is embedded in the issue and the challenge of growth. Whether we’re talking about growth of production of food, whether we’re talking about economic growth, whether we’re talking about creating new markets for India to sell to the world, generics to the US and so forth. So it’s about a growth-centred world. And really you can’t have moderation, what we might call judiciousness, careful prescribing of antibiotics, if the entire system is centred around growth. In some respects, growth is wonderful. It uplifts people’s life chances and provides work and opportunities. On the other hand, unsustainable growth sees mutating effects and in many respects what we call selective pressure… What we’ve essentially learned is to produce more and more in order for others to consume and in unsustainable ways. And that’s not an India problem specifically. That is a truly global issue. Q: Your book was a wake–up call to the fact that we are on the brink of a situation where antibiotics won’tbe effective in treating even the most simple illness. Alex Broom: I think we are just years away from a global reckoning. And India is ahead of that, unfortunately, because of the high use and the easy access, which has really substituted for healthcare infrastructure… And we are starting to see failure of mainstay antibiotics across lots of different nations. India has challenges which we will all face in the end. And we feel very strongly that India is not just a cautionary tale, but ultimately it also holds wisdom in terms of what we can actually do. Assa Doron: It’s easy to say misuse, overuse, excessive use. It makes the problem sound like a matter of bad behaviour. The patient is demanding antibiotics. The doctor is prescribing too quickly. The pharmacist is selling pills without a prescription. Sure, those things happen, but that language of misuse really conceals the conditions in which these decisions are made. A doctor in an overcrowded hospital in India may see 200 patients a day, and they have little access to diagnostics. A poor patient might buy only a few tablets because that’s all they can afford. And they need to go to work tomorrow. And the same with farmers who use antibiotics because their livestock are raised in these crowded conditions, and disease can just wipe out about a whole stock of chickens or shrimp to be exported to the US. So the question is not why are people using antibiotics badly? The real, deeper question that we’re trying to explore is why antibiotics have become so necessary in the first place. Q: How do we create public awareness? Alex Broom: One way to do it is by consumer pressure. Very often, in a market economy, brands are quite sensitive to consumer preference. And creating awareness amongst the public of the health and the value of foods which are produced sustainably but also good for the body is an extremely productive way of forcing commercial actors to be more judicious about what they do.Assa Doron: There are also initiatives in India that really try and respond to this antibiotic crisis that India is facing, especially Kerala and Tamil Nadu. In Kerala, they’ve got an Operation AMRITH, in which they’ve tried to end over the counter antibiotic sale without prescription… The state is also trying to promote awareness at the community level, training ASHA workers that visit households and explain the problems... Alex Broom: In the hospital sector, the private environment has expanded radically versus the public sector… And what that means is that when you get a crisis like this which requires some degree of control, you then sit back and you say, we don’t actually own or run these institutions. Can we really tell them not to use antibiotics? And are they responsible then for the outcomes?
