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.

Genetic testing is all the rage, but its promise is limited

New technologies often take decades to reach Indian shores. Not so in the case of genetic testing. Within 10 years of the launch of the world’s first direct-to-consumer service, genetic testing has found a booming market in India.

Your DNA, unless you have an identical twin, is unique. The idea behind any genetic test is to understand whether the sequence of bases in your DNA have something useful to tell you. Those on offer in India can cost anywhere from ₹1,000 to ₹50,000.

Who’s your daddy?

One of the most popular genetic tests in India is used to test paternity. Be it a doubting husband or a long-lost son, these “peace-of-mind tests” can set the record straight. Their effectiveness is so high that Indian courts have used paternity tests as definitive evidence. Take the example of Congress politician ND Tiwari. In 2008, 28-year-old Rohit Shekhar claimed that Tiwari was his biological father. After a long-drawn battle, the court ordered a paternity test in 2012 and closed the case in favour of Shekhar.

This is how paternity testing works. A child inherits half their DNA from each parent. For the test, DNA samples in the form of cheek swabs are taken from all three individuals. These samples are then treated with restriction enzymes, which cut each DNA at pre-determined places. These cut-up pieces are then suspended in a solution and run through a gel, which lets shorter pieces run faster than bigger pieces. The pieces show up as dark spots on a light background. If the parents are indeed those making the claim, the child’s DNA patterns will appear to be a combination of the patterns of the parents.

This technique, called DNA fingerprinting, was developed in 1984 and has also been used to produce forensic evidence in thousands of criminal cases. Instead of comparing a DNA sample of a child with two others, say, it could be used to compare DNA found in some hair at a crime scene with that of the accused perpetrator.

Not the oracle

Not all genetic tests are so effective at giving useful information though. Many companies market genetic test results as a fortune-telling scroll. They claim that, based on your genetic information, they can predict whether you will get a disease or not. This is far from the truth. At best, genetic testing for health outcomes can be seen as a weather map, where predictions can be true but quite often they aren’t.

Even if genetic testing companies make this clear in their fine print, they haven’t done enough to correct public perception. For instance, a 2010 European survey revealed that nearly half of those asked felt “all children will (soon) be tested at a young age to find out what disease they get at a later age”.

While certain diseases, such as Huntington’s disease, have specific genetic mutations to blame, most diseases are a combination of environment, lifestyle and genes. There is no “gene for breast cancer”. Genes are indeed powerful, and they influence our appearance, intelligence, behaviour and health. But unlike what the public believes, genes do not determine those outcomes.

These public beliefs matter because they can and will affect policy. After 13 years of debate, in 2008 the US passed the Genetic Information Non-discrimination Act to ensure that insurance providers do not discriminate customers based on their genes. Before the genetic testing market in India explodes to ₹800 crores by 2018, as some predict, we need a similar act to safeguard people’s privacy. And even after that, treat any genetic test results with skepticism and care.

First published in Lokmat Times.