Further comments on the superbug controversy

Since I blogged about the superbug controversy in India, there have been a few other pieces on the issue. In particular there are two blogs that I would like to comment on.

Firstly, take this blog, part of the Indian National Interest community, which is apparently an attempt to refute my earlier post. I usually strongly endorse the opinions expressed in the INI domain, but I have to politely (not really, but I try to be nice) disagree with the viewpoints in the blog.

Before that, I must applaud the blogger for raising concerns about Indian health-care. I am in total agreement with the author about the need for India to employ stringent medical procedures to control the spread of this particular resistance and prevent future outbreaks.

What I disagree with and do not understand is the rest of his rather absurd arguments.

Especially, lines like:

…the exaggeration, the dramatization of the threat, the hyphenation with Pakistan, etc. (emphasis mine)

do not make sense. I hate as much as the next person, the collectivization of the subcontinental people under a single name. But I doubt bacterial organisms care much for geopolitical boundaries.

Anyway, the author goes on to say:

Scores of revelations (this blog has tried to document as many of them as it could) about the pharma industry in the last two decades literally implores us to treat any thing that they are behind, with scepticism first and acceptance later.

We need to adopt a two-pronged strategy going forward as these kinds of ‘attacks’ are bound to emerge. They are thinly-disguised protectionism from the economically beleaguered West, whether or not they are orchestrated at the sovereign level.

….

That does not mean I should accept this report with all its shades and hues.

The whole thrust of the blog’s argument – if one may accord that respect to the writings – is that pharmaceutical companies are not to be trusted. Ergo we shouldn’t trust this study and protest our heads off.

Firstly, the study was not a pharmaceutical company study. Yes, I am aware of the partial sponsorship by Wellcome and this ‘conflict of interest’ issue has already been explained in many places. [However, I do also ask how Wellcome gains anything from a paper that talks about superbugs in India when they (or any other pharmas really) do not have a drug to kill these organisms? But that is a separate matter]

Further, if we do extend this logic of the one bad apple, then, given the lack of stellar record of Indian scientists and doctors in the honesty department (let’s not even go into the politicians and the media), we should not really believe anything they say about the results in this particular journal paper!

What particularly bothers me about the post is that there’s hardly any attempt to directly engage the scientific merits of the article (other than use of quotes around the word ‘research’, which hardly justifies as a critique). Rather, the blog simply puts forward the nebulous idea of some Western extra-governmental entity insidiously planning to bring down the Indian health-care tourism industry one scientific journal publication at a time (why the same entities have not attacked other places such as Thailand, Singapore, Malaysia, Costa Rica etc which also has a thriving medical tourism industry, I do not know).

It is sad that a blog hosted by a portal that frames serious policy matters relating to India, deems fit to advance conspiracy theories on shaky grounds with zero evidence.

Note: I am not saying that India should sit back and not react at all to the publication. But doing so in the framework of ‘the west is out to get us’ media show is wrong.

———————-

On the other end of the spectrum, Charakan, an MD from India, has written a very insightful post on this issue, which explains a lot of the science behind the bacterial resistance and tries to separate the facts from myths. I highly recommend reading the article in full.

I do however have a comment to make about this section:

The article in Lancet says
‘It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals’.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.

The author of the article in Lancet seems to show undue haste in blaming medical tourism for antibiotic resistance in UK.

It is a valid argument weather the authors have overreached in ascribing all the bacterial infection in UK cases to South Asia. It is an unfortunate tendency on the part of scientific authors to sometimes over-interpret their data, usually in the Discussions section of the paper. Reviewers often let this slide as well.

However, in this particular case, I don’t think it is a huge stretch. The authors are commenting within the framework of a particular question: does NHS’ plan to reduce cost by outsourcing surgeries to India make sense? They conclude that this may not be cost-effective in the long run due to the dangers of superbug infections. Given the data showing incidences of such bugs showing up in India, it is perhaps not a wholly unreasonable point to make.

Still, the authors of the paper could have phrased it differently.

Superbugged

There has been much brouhaha in India during the last two days  over a recently published paper in the journal, Lancet Infectious Diseases. The paper outlines the emergence of major antibiotic resistance in enterobacteria isolated from patients in  UK, India, Pakistan and Bangladesh. The appearance of bacteria resistant to the strongest of antibiotics is a cause for global concern, especially in these days of globe-trotting and in light of lack of new antibiotics developed by drug companies recently.

The authors conjecture is that patients in the UK who were found to harbor this ‘superbug’ picked it up during surgeries – some during health tourism visits – from the subcontinent. Needless to say, the results of the study  has been (excuse the pun) a bitter pill for Indians. The medical community is upset, the politicians and media are outraged and screaming ‘Western conspiracy‘.

Unfortunately most of this anger is highly misplaced. I strongly recommend reading Bhalomanush’s well-argued (and in the face of some of the stunning ignorance out there, highly restrained) response debunking much of the media outrage.

I just wanted to add a few words of my own.

1. The main problem I see with the Indian reaction is the  usual cry of victim-hood  (MNCs and the ‘West ‘are out to get us and our health tourism industry) that is unbecoming of a country that wants to be global player.

The mature (and the right) way of dealing with such a publication would have been a statement explaining that India has taken serious note of this study in major journal and will be conducting its own investigations, at the same time reassuring people with numbers (number of cases small compared to the vast number of patients in India) etc. Instead we’ve taken on a jstrange ingoistic tone mixed with juvenile petulance: blaming the scientists for spreading falsehoods and finger-pointing like a school kid (suggesting that the virus is everywhere, why point to us?).

The best (worst) example of this over-the-top reaction is the idiotic notion that naming the protein that confers resistance to the bacteria (NDM1 = New Delhi metallo-beta-lactamase 1)  after our capital is somehow a huge insult to our nation.

National pride that is so easily dented is not really a pride worth having.

2. There seems to be no concern in the media about the actual consequences of antibiotic resistant bacterial strains. The rise of resistant strains is a real, fearful possibility in our antibiotic munching culture. What is anyone doing to ensure that such strains do not turn into a large public health problem in our country?

The medical tourism industry and most private hospitals in India are restricted to an elite population. These are the places where disinfection and sanitary methods are at their best. One wonders about the consequences of these bugs turning up in regular hospitals.

I am quite surprised that the supposed champions-of-the-underprivileged Indian media is rather silent on this (OTOH, actual medical and health concerns such as this don’t make good screaming matches on TV).

(Sakshi has a longer post detailing this concern)

3. This is not to say the western media is not totally guilty of hyping things a bit and spreading panic and fear. As Bhalomanush has pointed out, the misrepresentation of the UK and other international media is equally disgusting.

But again, a kicking and screaming response to such smearing doesn’t do anyone any good.

But, do also read the very balanced pieces by LA Times and Discover Blogs

4. The Indian media claims that the lead author of the study, an Indian doctor, Karthikeyan Kumaraswamy, has ‘retracted’ the study or at least distanced himself. If this is true, then there has been gross misconduct on the part of either Dr. Kumaraswamy or Lancet. As is true for any scientific publication, final manuscripts have to be vetted by all authors. As the footnote in the paper says:

All authors were involved in the compiling of the report and approved the final version.

If something was added after Dr. K looked through the draft and it was something he did not agree with it, he can and should take it up with Lancet. Retracting is not done in front of TV.

[actually, if you see the actual video of the interview with Dr. Kumaraswamy, he doesn’t really say anything that’s related to dissociating himself!]

5. Finally, thrown into this conspiracy theory mix is the fact that Glaxo-SmithKline recently published a paper in the online version of the journal Nature, where they have identified a compound that binds to a bacterial processive enzyme. It is possible that such a compound could escape the antibody destroying enzyme of the resistant bacteria and kill them.

Firstly, do note: the paper describes the snap-shot of the protein in its inhibited state i.e in a state where it is in a crystallized form. How such a compound succeeds as a drug is anybody’s guess with details such as efficacy, safety and stability that needs to be worked out (over a period of years).

And to those seeing another conspiracy in this, I really doubt that GSK could have pulled off the timing of their publication  (which btw is currently an advanced publication online only, has not come out in an issue) to coincide with the Lancet publication. More likely, it was a fortuitous occasion and the GSK PR department has jumped on it seeing a great opportunity to raise share prices. This is borderline dishonesty because, as I mentioned above, there is really no way to determine if the compound will be an actual drug and such drugs aren’t expected to be produced in a short time.

There are few other issues e.g the constant touting of the supposed ‘conflict of interest’ that have been covered by fellow bloggers, so I am not going there.