Drug resistance risks sending humanity back to the 19th century

Swine Flu is back, and it is spreading with a vengeance. The total number of recorded cases in India has crossed the 20,000-mark and it has led to more than 1,000 deaths. While this number is much smaller than the number of those killed by the 2009 swine flu pandemic, it is worrying because the new strain appears to be harder to treat. According to Om Jaslok, director of the infectious diseases department at Jaslok Hospital in Mumbai, patients need to be treated with anti-viral medicine oseltamivir for an average of 10 days, which is twice the length of treatment in previous outbreaks.

The World Health Organisation (WHO) had warned of such a swine flu outbreak as far back as 2013. The phenomenon of pathogens developing resistance to drugs is not new. Those few pathogens that survive the onslaught of drugs pass on their traits to the next generation, giving birth to a drug-resistant strain. What is worrying is that drug resistance is increasing at a much faster rate than the pace at which humans can come up with new drugs or treatments.

Disaster-in-waiting

While flu epidemics come and go, drug resistance in persistent diseases is even more worrying. Take the example of malaria, the biggest single killer of humans since our species began walking on this planet. In the last century, the increased attention to malaria produced drugs that could effectively treat the disease. One such drug is chloroquine, which was widely used across the world and saved millions of lives. However, since the 90s, chloroquine is no longer a weapon in the medical arsenal. Mosquito parasites—responsible for causing and spreading malaria—have become resistant to the drug, and we have been forced to develop newer drugs.

A bigger worry is the development of antibiotic resistance. Antibiotics, first discovered in the early 20th century, turned lethal diseases, such as pneumonia, into treatable conditions. These drugs have become the bedrock of effective modern medical treatments. They are used in surgeries to protect patients from acquiring diseases via open wounds, and given to cancer patients to help boost their immunity against pathogens. But fewer of them are as effective today.

These antibiotic-resistant microbes are referred to as superbugs, and they kill ruthlessly. According to a report in the respected journal The Lancet, more than 58,000 newborns in India were killed in 2013 because of these superbugs, such as Staphylococcus aureus and Clostridium difficile. One particular enzyme, New Delhi metallo-beta-lactamase 1 (NDM-1), which helps create superbugs has been named after where it is believed to have originated, and we currently have no way of countering the enzyme’s spread.

You can act

The economic cost of drug resistance is potentially huge. According to the 2014 Review on Antimicrobial Resistance, the accumulated loss to global output by 2050 can be as much as $100 trillion, which is more than 50 times the current GDP of India. Even such a dramatic prediction may be an underestimate, according to Jeremy Farrar, the director of Wellcome Trust, one of the world’s biggest biomedical charities, because the review only includes direct costs. For instance, if routine surgeries become impossible because of antibiotic-resistant bugs, they will have an effect on healthcare as a whole and lead to more deaths.

There are ways in which we can fight against drugs resistance. One way is to invest more in finding new and more effective drugs. But success down this route has become much harder to achieve. The pharmaceutical industry is undergoing a crisis, producing fewer new drugs. The other way is to slow down the march of drug-resistant microbes. This requires that governments, doctors and citizens to work together.

Farrar notes that we have been taking antibiotics for granted, treating them as consumer goods. They seem to be “ours to demand from doctors and ours to take or stop taking as we see fit.” This is a huge problem. People stop taking pills as soon as they feel well, but that doesn’t mean the microbes have been completely eliminated. Instead the partial course of antibiotics leaves a great number of mildly resistant microbes alive, which then spawn new generations and spread drug resistance.

If we are not to return our healthcare back to the 19th century, where infectious diseases killed rampantly, we must learn to respect these wonder drugs. Doctors must be conservative in giving out prescriptions. And, if there is no option, the least patients can do is take the full course prescribed.

First published in Lokmat Times. Image by NIAID.

Big Pharma cannot ignore developing world diseases anymore

We may not realise this but a lot of us today live better lives than those of medieval kings. Most people then died under the age of 40 and lived in constant fear of contracting diseases. The worst killers were infectious diseases, such as plague, caused by bacteria and spread by poor sanitation. The last century has seen us banish these evils with the help of antibiotics and easier access to better hygiene.

Sadly the benefits of medicine haven’t been spread evenly throughout the world. In developing countries, there remain many diseases that were eliminated in the developed world decades ago. One of the biggest causes for this is that Big Pharma finds it unprofitable. Because it is not the rich world that they affect, the economics of drug discovery – which admittedly requires huge investments – to treat poor people’s diseases do not work out in favour of the pharmaceutical industry.

A matter of timing

Alexander Fleming’s discovery of penicillin – the first antibiotic – in 1928 was an accident, but the world had been waiting a long time for something like it. The timing couldn’t have been better. By then the pharmaceutical industry had begun to systematically search for new drugs. Governments had recognised the role that new medicines could play in improving health and, in turn, economic productivity. By the time World War II started, they had set up the right safeguards to allow the industry to mass produce drugs. Historical records suggest that Nazi Germany’s inability to produce enough penicillin may have played a role in their eventual loss.

As the decades rolled on, pharmaceutical industry, such as German company Bayer and British company Glaxo, grew bigger and bigger. Today, a bunch of these giants are collectively referred to as Big Pharma. And all of them have most of their operations in the rich world.

While India has a pharmaceutical industry, which is increasingly playing a bigger role in the global market, drug development is too big a challenge for it. That is because the price of drug development has been rising quickly. Today the development of a single drug can cost billions of dollars (lakhs of crores of rupees). And this has created a negative cycle, where Big Pharma mostly invests in the development of those drugs that will provide them a return on the billions of dollars they invest to develop it. The upshot is that poor people’s diseases are neglected.

Ignore no more

So severe has this neglicence been in recent years that the World Health Organisation now lists 17 diseases under a priority list of “Neglected Tropical Diseases”. These include dengue,chikungunya, rabies and leprosy. Even beyond that list, however, other diseases remain under-researched. These include malaria, tuberculosis and diarrhoea. All these don’t exist in the developed world, but cause millions of deaths in developing countries.

This must change. There are moral reasons for why letting millions die from preventable causes is wrong, but the nature of modern corporations is such that moral reasons work only in extreme circumstances. Fortunately, there is now a growing economic case. As markets in the west become saturated, pharma industry is looking to the emerging world, especially countries such as India and China, for a new market.

As they start coming they will first cater to the rich and the growing middle class, but these companies won’t be able to survive without serving the poor too. For instance, India’s patent laws force Western firms to provide compulsory licenses or provide their own drugs at cheaper rates, if the country’s courts find the drugs are essential but unaffordable. Instead of giving up their exclusivity, many firms are choosing the latter option. Profit margins will fall but sale volumes will rise.

With such changes underfoot, it is now time that Big Pharma also look to cater to poor people’s diseases. While the economic case to profit from such work is becoming stronger, governments could help through subsidies to attract these companies to begin their work sooner. The expertise and knowledge that they will bring could revolutionise healthcare for the poor.

First published in Lokmat Times.

India faces the unique challenge of dealing with both obesity and malnutrition

One Indian in every five is obese, according to a 2013 study in the renowned journal The Lancet. Most of these people live in cities, where rapidly changing lifestyle is contributing to an “obesity epidemic”.

An obese person, as defined by the World Health Organisation, is anyone with a body-mass index (BMI) that is greater than 30. BMI is a person’s weight in kilograms divided by the square of his or her height in metres. Although this measure is not perfect – for instance it sometimes fails when used on sportspersons – it is a good approximation to warn most people of the potential dangers.

When two worlds meet

Obesity, like smoking, kills slowly. It increases the risk of being affected by type-2 diabetes, coronary heart diseases, breast cancer, bowel cancer and even stroke.

And India faces a further, unique challenge. While obesity is a growing problem, the country is yet to deal with malnutrition and undernourishment. In fact, the 2014 Global Nutrition Report found that most developing countries are facing all three problems at the same time. The number of obese around the world has increased to 210 crores and the number undernourished and malnutrition remains at 200 crores.

The lack of nourishment leads to stunted growth, affecting bodily strength and mental prowess. Their poor immune system makes them easy victims to infectious disease such as diarrhoea, which is a leading cause of death among those under the age of 5.

The combined economic burden of obesity, undernourishment and malnutrition is probably greater than 5% of the gross domestic product (about ₹ 6 lakh crores). And any problem at this scale can only be tackled when both government and citizens rise up to the challenge.

A bag of tricks

Good proportion of the blame lies in people’s choices. Exercise and diet, especially done together, are effective to deal with obesity. Everybody knows that, but few people manage to get off their couch and leave high-calorie snacks unopened. Simple psychology hacks, such as making your goals public or setting them with your partner, can work. Group exercises or community centres can also help deal with the urban population’s addiction to a sedentary lifestyle.

Governments can help too, but they don’t have a single magic trick. Instead they need to rely on implementing many policies, each of which has been shown to have a small positive effect. These include healthier school meals, taxing high-calorie food and drink, and better physical training. For each rupee spent on implementing these obesity controls, the government is bound to receive many times back in economic benefits.

The poor don’t fair better on their own either. For instance, when they earn some spare cash, villagers choose to buy a TV or a mobile phone – a status symbol – rather than feed their young better food. Worse still, malnutrition trains the body to hoard fat, so when the poor eat calorie-rich food they become more prone to obesity as adults. Bad choices can become good ones through grassroots movements.

To be sure, malnutrition is not just the lack of food. India has enough to feed all its population, if it fixes its distribution network. It is more a problem because of lack of proper food.

Some governments can show others the way. In Maharashtra, for instance, stunting in children under 5 fell from 37% in 2006 to 24% in 2012. Factors that helped: economic growth, poverty reduction, nutrition programmes and better female education rates. The latter is interesting because uneducated women tend to give birth at very young ages, their babies tend to be underweight and fail to thrive. Simple education programs can also make them aware of the family’s nutritional needs, helping them make better choices. Women empowerment may be an empty political promise, but it can truly work.

First published in Lokmat Times. Image by filandfiloi under CC-BY-NC-ND license.

Asteroids are fascinating – not just because they can destroy humanity

Look up in the night sky, if you are lucky you might be able to see Vesta, the only asteroid—among millions that lurk between Mars and Jupiter—bright enough to be visible to the naked eye from the Earth. Given their dull (non)appearance in the sky, it is no wonder that the first asteroid was only discovered in 1801 when relatively powerful telescopes started to be built.

However, in the two centuries since, we have learnt a lot about these celestial bodies. They could prove to be both a curse and a blessing. A curse because they could bring about the end of human existence, and a blessing because they could be the launchpad for building human colonies in outer space.

The definition of an asteroid has changed over the years, but today we know them as small bodies found in the inner solar system. Asteroids can also be called failed planetesimals—tiny fragments that had the potential to grow larger under the influence of gravity and become a planet when the solar system was being formed billions of years ago, but couldn’t.

Living on a pale blue dot

We now know that these “failures” pose a high risk to life on the Earth. Only last week a half-kilometre wide asteroid passed by the Earth. If it had hit us, it could have caused human extinction. Fortunately it was about 1 million km away, which is three times the distance between the Earth and the moon. But the risk is real. In the past one such asteroid impact was responsible for extinction of dinosaurs and an older one caused even more destruction and made all the oceans boil.

4927597266_275e355960_oThe good news is that, with enough warning, we already have the technology to deflect asteroids. But the bad news is that we may not get enough warning, because there are thousands of asteroids—some of which could be on a collision course with the Earth right now—that we have not yet discovered.

This threat has spurred some to take matters in their hands, rather than wait for government agencies to do the work. The B612 foundation, for instance, is planning to launch a private space mission in 2018 that will discover and track hundreds of thousands of such asteroids.

If you can’t beat ’em, profit from ’em

Leaving the stories of doom behind, asteroids are fascinating for another reason: they hold clues about the formation of our solar system. For instance, according to theory, when the Earth formed into a planet, the process would have been too hot to have left any liquid water on the surface. So the current hypothesis is that water-rich celestial bodies, such as comets, brought the water when many crashed into the Earth during its early days.

A current space mission, called Rosetta, to the comet 67P recently tested this hypothesis. It found that the water on that comet was not of the same composition as that on the Earth. So if not comets, then the other celestial body that could achieve this feat are asteroids. This hypothesis will be tested by the Hayabusa-2 mission, launched in December by the Japanese space agency, when it will land three rovers on the asteroid 1999 JU3, and also collect and return a sample from the asteroid back to the Earth in 2020.

Even if they aren’t the source of terrestrial water, asteroids could be habitable, or at least resource-providing, stations for human colonies in outer space. And this isn’t just a crazy idea. Two private companies, Planetary Resources and Deep Space Industries, are currently working on projects to mine asteroids. They aim to harvest not just water, but also metals such as iron, nickel, platinum and palladium. Apart from the moon, few celestial bodies can boast of having such a close relationship with humanity.

First published in Lokmat Times. Lead image by ESA and ATG media lab. Asteroid image by Emily Lakdawalla (under CC-BY-NC-SA).

Wear masks and plant trees—air pollution is killing us

India ranks 174th on air quality among 178 countries, according to the 2014 Yale Environmental Performance Index. Particulate matter in the air of 180 Indian cities was six times higher than the standard set by the World Health Organisation (WHO). Indoor and outdoor air pollution are now the third and fifth leading cause of death in the country, causing more than a million premature deaths ever year.

The main pollutants in the air are sulphur dioxide, ozone, various oxides of nitrogen and particulate matter of different sizes. Breathing polluted air slowly leads to diseases that affect the lungs, the heart and even the brain. That pollution causes these diseases may not be immediately evident, but the WHO’s large data collection points unequivocally to the causal link.

All shook up

What is probably more troubling is that the problem has suddenly got worse. The number of deaths caused in India by outdoor air pollution has increased six-fold since 2000. A number of factors have contributed to this rise: reliance on and increased use of coal-powered power plants, growing number of vehicles, improper urban planning and poor enforcement of regulations.

Just like clean water, clean air is a public utility and governments have a duty to ensure that these are available to its citizens. Central and state governments have been making some changes, but they haven’t helped much. In Delhi—judged by the WHO in May 2014 as the city with the most polluted air among 1,600 cities across 91 countries—the government has tried to implement various schemes, such as the use of natural gas for public transport, but without much improvement in air quality.

Air pollution has a negative effect on the economy, too. According to the World Bank, its ill-effects cost India ₹ 3.3 lakh crores annually, which is 3% of the gross domestic product. Not enough is being done to address the problem.

A little less conversation, a little more action please

I believe the problem is so huge that it is too late to wait for government’s actions to protect our health. Fortunately, there are steps that citizens can take to deal with air pollution, which can significantly increase the quality of the air we breath.

If you or someone you know burns wood for the purpose of cooking or heating water, you could improve your health by stopping or altering this practice. Most cookstoves of this kind do not burn the wood efficiently, releasing very harmful particulate matter. If you cannot afford to replace wood with natural gas for cooking, the cheaper option would be to buy a subsidised improved cookstove available from government outlets.

The easiest way to deal with outdoor pollution is to wear a mask. Look for N95 masks which are relatively easy to find and fairly cheap. Whatever mask you buy, ensure that it covers your nose and mouth fully, because any air gaps will render the effort ineffective. Masks are not as uncomfortable as they look, but they are definitely not stylish. Yet, by wearing a mask, you are not just taking care of your health but also making a public display of protest against the government whose duty it is to ensure that air quality be improved.

The final thing you can do to deal with outdoor pollution is to plant trees, specifically outside your house. A recent study by scientists at Lancaster University showed that a line of young birch trees outside the house can cut particulate matter entering the house by half. Trees are also highly effective when planted along busy roads, because they can absorb not just carbon dioxide but also ozone, sulphur dioxide, nitrogen oxides and carbon monoxide.

For too many years we have taken the air we breath for granted. We have ignored the risk that the tragedy of the commons could afflict this abundant public utility. Let’s hope we can fix it before it’s too late.

First published in Lokmat Times.