Rivers of Resistance: AMR, a silent pandemic in the making

By Dr. Suman Kapur
Why do we tolerate poisoning of our rivers by human waste and industrial toxins? asks British Journalist Victor Mallet to all Indians, in his book ‘River of Life, River of Death’ on Ganges. Our life-giving rivers are under life-threatening stress as they face severe pollution across the world in the past few decades. Some of the main polluting causes include practice of open defecation, discharge of inadequately treated wastewater from industries and pharmaceutical units that contain chemicals, discharge of untreated or semi-treated sewage, rampant use of antimicrobial pesticides for crops across farmlands, waste from animal husbandry industries, and large volumes of biomedical waste from hospitals and clinics.

This poses a threat not only to the environment, climate, and overall health, but significantly contributes to antimicrobial resistance or AMR- a silent yet deadly threat to humanity. AMR results when bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines developed to cure the infections they cause. These resistant microorganisms thereby make infections harder to treat and increase the risk of disease spread, severe illness, and death. While AMR is caused through a variety of interconnected factors, effluent discharge from pharmaceutical manufacturing plants and hospitals that have inadequate wastewater treatment mechanisms lead to substantial concentrations of antibiotics and their raw material– Active Pharmaceutical Ingredients (APIs) in surrounding water bodies, soil, and the overall environment.

In a recent study by Indian Institute of Technology Madras, researchers found the Cauvery River to be polluted with various emerging contaminants, which included pharmaceutically active compounds, personal care products, heavy metals, pesticides, plastics, flame retardants, among others. The research team monitored the rivers water quality over a period of two years to assess seasonal variations of emerging contaminants, especially the pharmaceutically active compounds. They found considerably high contamination levels of metals such as arsenic, zinc, chromium, lead, nickel. The team also found significant concentrations of pharmaceutical contaminants. These study findings add to similar findings of polluted rivers and water bodies in Himachal Pradesh, Hyderabad, and Vishakhapatnam, reinforcing the persistent challenge in India- contamination of water bodies and environmental pollution through pharmaceutical contaminants.

As the second-largest pharmaceutical manufacturing nation in the world after China, India bears a huge burden of AMR, particularly environmental AMR. While it is a matter of pride that India’s pharmaceutical industry has played a pioneering role in making medicines accessible globally and is considered one of the fastest growing sectors of the Indian economy, it’s contribution in hazardous waste production and subsequent negative impact on the environment cannot be dismissed.

Multiple studies have highlighted the pharmaceutical effluents in rapidly spreading AMR. In the past few years alone, diseases like pneumonia and typhoid have become challenging to treat, and in around 70% of cases, treatment needs to start with more expensive, third-generation drugs, which are administered for a longer duration than earlier. It is also estimated that in India, close to 60,000 neonatal sepsis deaths each year can be attributed to antibiotic resistance. While accurate estimates of the impact of AMR in India is limited due to lack of evidence and data, some proxy indicators such as prevalence of tuberculosis in the country brings to light that India accounts for 25% of the multi-drug resistant cases that are recorded world-wide. This threat of AMR has just become larger and more complex with the indiscriminate use of antibiotics during the Covid-19 pandemic.

It is important to highlight, the Indian government has been cognizant of the issue and in the past few years have taken efforts to address them. For instance, the National Action Plan (NAP) on AMR was developed to recognize this growing challenge and lay down crucial guidelines to prioritize actions against it. It acknowledged the “One Health” aspect, recognizing the role of various contributing sectors to AMR, including health, environment, animal husbandry, food security, among others. However, the “One Health” approach has largely remained theoretical and AMR challenges continue to be driven primarily by healthcare and allied sectors. Moreover, the Antimicrobial Resistance Surveillance Research Network set up under the Indian Council of Medical Research, predominantly focuses on the human health side, although, as the NAP on AMR in India notes, there are plans to expand the scope to include samples from environmental, animal and food sectors.

Moreover, regular, and continuous surveillance of water bodies will help identify “hot-spots” for antibiotic pollution, track growing incidences of AMR and support in identification of lapses in wastewater discharge from various industries. While the Government issued policies such as the Zero Liquid Discharge (ZLD) to treat wastewater which has been adopted by few companies, environmental risk management strategies largely remain outside the ambit of several smaller players who cannot afford to adopt expensive technologies such as ZLD. This coupled with weak public health infrastructure, high overall burden of disease, unregulated sales of antibiotics despite rules to limit their open sales, lack of awareness among patients and key stakeholders, help create ideal circumstances for a rapid rise in resistant infections across India.

To address this phenomenon, it is therefore of paramount importance for the government, industry, policy makers to develop strong synergies to holistically address the common goal. It is equally pertinent to invest in more research and evidence gathering around the impact of AMR, particularly environmental AMR which has not received its due attention. Setting standards for residue in pharmaceutical-manufacturing effluents for instance, would be instrumental in taking a step towards regulating untreated discharge into the environment. As a global leader in antibiotic manufacturing hub, India would be the first of its kind to set such standards to treat this silently growing pandemic through timely countermeasures. We cannot let our life-giving rivers turn into silent carriers of anti-microbial resistance.

The columnist is Senior Professor, Department of Biological Sciences · Birla Institute of Technology & Science, Pilani. Views expressed are the author’s own.