Water, as we all know, is the utmost need of our survival. Human body comprises around 60% water and the fact that less consumption of water leads to various diseases in the future. Apart from facts and figure, one simple question we often forget to inquire is where this water is coming from? Surface water i.e. lakes, rivers and ponds or groundwater i.e. tube wells, bore well, well as these are the two sources that give us a glass of water.

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Our health concern and the credulous brainwash of our mind by the various available water filter present scenario and save our planet from the harmful effect of self-made destruction.Effective treatment and management of wastewater from the pharmaceutical industry will help in overcoming antimicrobial resistance. Advanced treatment methods such as reverse osmosis, nano filtration, and membrane bioreactors have shown to be promising processes for cleaning micro pollutants with nano gram per litre (ng/L) concentration levels.The nation where the trial/testing of most of the antibiotic occurs, there are rarely any constraints implemented on the disposal of pharmaceutical wastewater to the surface water. The current scenario of environmental issue foresees that in the near future there will be scarcity of drinking water and our hope was restored when global challenge was taken to in the market often diverts us from our prime concern of keeping our planet safe from water pollution. The pollution of water bodies has been initiated by us and still we are invariably helping it grow with every passing day. As discussed earlier, the various point sources from domestic to industrial pave the way for antibiotic to contaminate the water bodies. According to the latest report of UNICEF, 2.1 billion people lack the access to clean and safe drinking water.

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How do we remove the problem? What do we do to save ourselves from the harmful effects?

The encouraging words of Normal Vincent Peale, American author ‘Every problem has in it the seeds of its own solution. If you don’t have any problems, you don’t get any seeds’ gives us the hope that we will successfully overcome the present scenario and save our planet from the harmful effect of self-made destruction.Effective treatment and management of wastewater from the pharmaceutical industry will help in overcoming antimicrobial resistance. Advanced treatment methods such as reverse osmosis, nano filtration, and membrane bioreactors have shown to be promising processes for cleaning micro pollutants with nano gram per litre (ng/L) concentration levels.The nation where the trial/testing of most of the antibiotic occurs, there are rarely any constraints implemented on the disposal of pharmaceutical wastewater to the surface water. The current scenario of environmental issue foresees that in the near future there will be scarcity of drinking water and our hope was restored when global challenge was taken to curb the antimicrobial resistance from environment. Remedial measures taken towards eradication are further discussed.

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Political commitments: International efforts: World Health Organization Jaipur declaration on antimicrobial resistance 2011 recognized AMR as a serious public health threat. With the 2014 WHO Report, the extraordinary rates of AMR prevalent in India came into focus. After this report, joint efforts were made by India and WHO. While WHO labelled AMR as the Flagship Priority area for South East Asia Regional Office (SEARO), the Indian Medical Association launched an awareness programme to train the physicians and sensitize the general public. In 2015, the 68th World Health Assembly decided to incorporate the concept of One Health in the fight against AMR and a Global Action Plan was initiated. All member countries, including India, agreed to frame their own National Action Plans (NAPs) for AMR by 2017.

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National efforts: The Government of India formulated a Core Working Group on AMR that drafted a NAP for the country. Six strategic priorities were listed in NAP, all of which incorporated considerations for AMR in the environment, directly or indirectly. Further, each strategic priority has defined interventions, activities and outputs, the fulfillment of which is delineated by a timeline projected for the next five years. The NAP, although promising, has not yet come into full action in any of the Indian states so far. To curtail the prevalent malpractice of over-the-counter (OTC) sale of drugs, the Central Drugs Standard Control Organization implemented Schedule H1 in India in 2014. It, however, encompasses only a few selected antimicrobial groups. In June 2017, the Food Safety and Standards Authority of India (FSSAI) published the list of maximum residue levels for antimicrobials in foods prepared from animal, poultry and fish.

Health Organization in India: To know the near-exact extent of AMR, AMR surveillance networks were initiated by the Indian Council of Medical Research (ICMR) and the National Centre for Disease Control (NCDC) in 2013 and 2014, respectively. In 2015, these two organizations along with the support from Centers for Disease Control and Prevention (CDC) USA, started a systematic assessment of the prevailing IPC practices in India with the aim of formulating new guidelines for preventing hospital-acquired infections.

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These activities, however, cater basically to the emerging AMR in the healthcare settings and do not include special provisions for AMR in the environment. Similarly, the National Health Mission’s National Health Systems Resource Centre and the National Accreditation Board deal with IPC practices and strengthening of laboratories/hospitals and not with the AMR in the environment per se. The importance of AMR in the environment has been realized recently by the national health authorities and The National Health Policy 2017 calls for a rapid standardization of guidelines regarding antibiotic use, limiting the use of antibiotics as OTC medications, banning or restricting the use of antibiotics as growth promoters in animal livestock, and pharma co-vigilance including prescription audits inclusive of antibiotic usage – in the hospital and community.

Innovative ideas: The National Health Mission of India started the Swachh Bharat Abhiyan or the Swachh India Mission to improve the basic hygiene and sanitation in all spheres of life. As a part of this massive programme, education was imparted through mass media on the health hazards of open defecation. UNICEF data shows that out of one billion openly defecating people in the world, 60 percent reside in India. It is further argued that it is a behavioural problem with the Indians as other poverty struck nations of Africa and South East Asia did not have the problem of open defecation to this an extent. To deal with such socio-cultural issues, innovative ideas along with mass media are needed in India.

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So far in India, antimicrobial resistance in the environment has been a topic of least priority. With an ever-increasing threat of AMR in the environment, immediate action is required to halt its progress and spread. A combined effort of multidisciplinary and multi-sectoral approach will be able to eradicate the problem in the near future.

About the author

Dr. Debleena Bhattacharya is an independent researcher. She is presently working as an Assistant Professor in the Department of Environmental Science and Engineering at MEFGI, India. She holds a doctoral degree in Environmental Science from IIT (Indian School of Mines) Dhanbad (India). Her specialisation is in the field of wastewater treatment and biotechnology.

Tanya Spisbah, Director with Australia India Institute, Delhi is a renowned and influential expert on Australia-India relations, particularly with respect to health and sustainable development. A career diplomat with the Australian Department of Foreign Affairs and Trade for more than a decade, Ms. Spisbah served from 2014-17 at the Australian High Commission in New Delhi, specializing in health and technology diplomacy for inclusive, sustainable growth. She notably led the health agenda resulting in the Australian and Indian Prime Ministers exchanging an MoU for Health and Medicine, paving the way for cooperation on digital health.

Upskilling Existing Medical Practitioners through Online Courses could Strengthen Our Health Systems – A Case Study in Anti-Microbial Resistance

Health innovations are necessary to alleviate the global burden of disease and the suffering and mortality that ensues. We generally think of innovations in health as advances in medtech, digital health and pharmaceutical discoveries. While in many areas, these kinds of technological advances have led to increasing enhancements in health outcomes, in some areas we have slipped backward through overuse of these medical interventions, threatening the gains in health from the Millennium Development Goals and negatively impacting the Sustainable Development Goals. Antimicrobial resistance is one such example. This article explores the notion of short-term online education as an innovative intervention to address unmet needs in the Indian health system as it affects antimicrobials.

Antimicrobial resistance (AMR) refers to the mutating ability of microbes – including bacteria, fungus and viruses – to adapt to pharmaceutical treatments and become resistant, reducing or eradicating the effectiveness of medicines as treatment of bacterial infection or disease. This means perceived advances in healthcare, such as treatment of tuberculosis, have faced setbacks as the bacteria causing tuberculosis becomes multi-drug resistant, leading to increased deaths. It is estimated that AMR will be the cause of 10 million deaths per year by 2050 – causing greater mortalitythan cancer.The issue is a global one and has led to the World Health Assembly adopting a Global Action Plan on AMR, requiring each member country to adopt National Action Plans.

The issue is a global one and has led to the World Health Assembly adopting a Global Action Plan on AMR, requiring each member country to adopt National Action Plans.

India has a complicated health environment – one of the highest burdens of infectious diseases, coupled with one of the lowest public expenditures on healthcare in the world. India is also the highest consumer of antibiotics, with the trend only increasing – in part due to the need to treat bacterial infections and to cover prescription, misuse and availability of antibiotics without prescription.

This health crisis requires a multipronged effort – a multidisciplinary approach by multiple actors in government, industry and educators. India’s National Action Plan identifies that key challenges to AMR include inappropriate prescribing practices and misuse of antibiotics by humans. India is working to set in place stronger health systems and has invested in a stronger primary healthcare system with the implementation of the National Health Policy 2017 and the establishment of the Ayushman Bharat. These national policy responses will go a long way in establishing a framework for primary healthcare strengthening but are not able to provide for a holistic solution to gaps in the health system. While the Indian government is also working to reform the MBBS through amendments to the Medical Council of India legislation and changes to the curriculum, the results of these interventions will take years to work through the system and won’t be able to make material impact today.

Short courses as a medical intervention for AMR Inevitably, interventions are required from a wide range of actors. While national and state governments and industry are often called upon for innovative responses, given that unnecessary prescriptions or misuse by patients is a major identified problem incontributing to AMR, a largely untapped resource is the role that educators can play in the upskilling of existing medical practitioners to respond to immediate weaknesses in the health system to address such global health challenges. While online education interventions may be potentially smaller in scale, it could have far greater direct and local impact in localities across India, particularly in smaller cities.

As an example, the Australian Institute of Medical Administration and Compliance (AIMAC) has developed courses to facilitate good prescribing and dispensing practices. Designed for health professionals, Seema Gupta and Veena Sehgal have created short courses that in just one hour would assist general practitioners in following proper prescribing processes. Courses are written to address an unmet gap that exists between longer term academic courses and the practical issues faced by doctors every day. There is pressure by patients to come away from a doctor’s visit with a prescription, instead of sound advice for medical treatment, which may include simple rest rather than a drug prescription. The courses provide GPs with a quick and easy suite of information and tools about where to obtain further information to increase the quality of their prescription methods and improves collaboration between doctors and pharmacists by having them better understand their respective roles and the instructions being provided to the patient.

Often, it is the social dimension that is underestimated and undervalued when delivering healthcare. While there is a greater focus on patient-centric care and the experience of patients in thehealthcare system, short online courses offer one way of improving awareness of the role each actor undertakes in the prescription process and builds a sense of teamwork between the different members of the healthcare team to provide optimal health outcomes.

Interventions like these may be small in scale, but by empowering our frontline health workers, GPs and pharmacists to better understand the role overprescription and poor use of antibiotics can have on global challenges like AMR, such local interventions can have immediate impact on the lives and health of individual patients, in their respective cities and panchayats, and on the health system as a whole.

Innovations in upskilling to increase the quality of health services to improve, not only patient care, but address gaps in the health system will go a long way to addressing global health challenges such as antimicrobial resistance.

About 72.6 percent of the rural population in India do not have access to basic oral health. Unfortunately, in our prevalent war against diabetes, cardiac issues, HIV/AIDS, et al, we ignore the seemingly less-important battles – like oral health, for instance – that can actually strengthen our chances of success. Enhancing access to affordable dental care is important in its own right, but is unlikely to be a sufficient strategy for reducing the burden of disease. The innovation that India needs today is an integration of public health solutions for oral diseases with those for chronic diseases and with the national public health programmes.

When we think of innovation in healthcare, most of us tend to look for the ‘Eureka’ moments. The wonder drug that can cure cancer, the surgical procedure that can revive a brain-dead patient, the hi-tech diagnostic tool that can predict cardiac adversities. But these innovations – no matter how spectacular – are of little value without the right healthcare delivery processes.

A very interesting article that appeared in the November 2013 issue of Harvard Business Review looked at how some Indian hospitals are able to provide world-class healthcare at as much as 95 percent lower costs than those at US hospitals. The answers, the authors argue, don’t always lie in grand designs, but in smart delivery systems.

Addressing the Issue

In a recent interview, US-based surgeon and bestselling author Atul Gawande called India’s public health system one of the “most complex things” in the world. And that’s true, given the sheer magnitude of the burden of infectious diseases as well as non-communicable diseases that the country has to tackle.

Unfortunately, in our prevalent war against diabetes, cardiac issues, HIV/AIDS, et al, we ignore the seemingly less-important battles – like oral health, for instance – that can actually strengthen our chances of success. According to the WHO, the risk factors for oral diseases include an unhealthy diet, tobacco use and harmful alcohol use. These risk factors are the same for the major chronic diseases – cardiovascular ailments, cancer, respiratory diseases and diabetes.

Studies have shown that periodontal diseases (also known as gum diseases) pose a risk to general health, especially for patients with other chronic diseases. Among patients with diabetes, periodontal disease can accelerate the chances of pancreatic failure, stroke, myocardial infarction and renal failure.

Similarly, maternal periodontal disease during pregnancy is sometimes associated with increased risk of pre-term delivery and low birth weight. Yet only 50 percent of pregnant women with a dental problem visit a dentist during their pregnancy. Despite studies affirming that most dental care procedures are safe during pregnancy, myths of perceived risks still prevail even within the medical fraternity.

Integrative Approach

The innovation that India needs today is an integration of public health solutions for oral diseases with those for chronic diseases and with the national public health programmes. Say a patient is seeking treatment for HIV, it’s significant to examine his oral health condition too. Research has shown that inadequate oral healthcare can undermine the success of HIV treatment regimens.

World Health Assembly in 2005 included Oral Health with other non-communicable diseases for health promotion and disease prevention strategies. However, most of our policymakers as well as medical practitioners are still in the dark about the burden of oral diseases in the country and their impact on our overall health and wellbeing. Although there has been no nation-wide study to determine the burden of oral health conditions in India, individual studies indicate that the average prevalence of dental caries is 40-45 percent in all age-groups; periodontal diseases is 90 percent; malocclusion is 30 percent.

In 2000, the US Surgeon General identified oral disease as a “silent epidemic”, wherein a significant amount of money is spent on expensive, invasive treatments that could have been either avoided with simple preventive measures or at least treated at a lower cost and lower risk if identified earlier.

Reality Check

The biggest challenge in implementing an integrative approach vis-a-vis oral health and other diseases is the dismal dentist: population ratio (1:8,000 in urban areas and 1:50,000 in rural areas). About 72.6 percent of the rural population, says the data from Dental Council of India, do not have access to basic oral health.

Enhancing access to affordable dental care is important in its own right, but is unlikely to be a sufficient strategy for reducing the burden of disease, states a white paper on Oral Health commissioned by the National Interprofessional Initiative (Oral Health: An Essential Component of Primary Care). Sometimes, we just need to go back to the basics. Prevention is still better than cure. Primary care providers, such as general physicians, nurses and midwives, need to be trained to expand the disease prevention workforce. Children, pregnant women, diabetes and other patients who visit the hospital regularly are ideal candidates for preventive healthcare.

There are several examples of promising healthcare delivery innovations. The challenge is to ensure that they are successfully and widely adopted. And this calls for a change in the attitudes of medical practices, healthcare organisations and policymakers. We need to move away from the traditional doctor-centric healthcare setup and make it patient-centric. Thanks to the advances in information technology, it’s now possible to deliver medical care to patients at a time and place of their convenience. Telemedicine makes the remote delivery of healthcare over the phone a reality, while electronic health records facilitate easier access to expert medical opinions.

Innovations in diagnostic technology, pharmaceuticals, surgical procedures and medical devices are undoubtedly important. But what’s more important is inventive methods to deliver these services in a timely, safe and effective manner to patients. Obviously, this can’t happen overnight. But as Bill Gates so succinctly put it, “We overestimate what we can accomplish in two years, but we underestimate what we can accomplish in 10.”

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