Editorial 1: A manifesto for tackling the silent pandemic of AMR
Context: As the current G-20 president, and as a vulnerable country, India has a key role in ensuring that AMR remains high on the global health agenda
Introduction
- While the world is emerging from the acute phase of the COVID-19 pandemic, the very harmful but invisible pandemic of Antimicrobial Resistance (AMR) is unfortunately here to stay.
- Most countries understood in 2020 the clear and present danger of COVID-19, forcing governments, including India’s, to respond with speed and accuracy. The rapidly rising AMR rates also need an accelerated, multi-sectoral, global and national response.
Antimicrobial Resistance (AMR)
- The World Health Organisation (WHO) has identified AMR as one of the top ten threats to global health.
- It is the resistance acquired by any microorganism (bacteria, viruses, fungi, parasite, etc.) against antimicrobial drugs that are used to treat infections.
- It occurs when a microorganism changes over time and no longer responds to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death.
Concerns associated with the AMR
- In recent decades, while new drugs have revolutionised human health care, health experts have been struggling with disease-causing microbes that have become resistant to drugs. Global public health response has been threatened due to rising misuse and overuse of antibiotics in humans and animals.
- Microbial resistance to antibiotics has made it harder to treat infections such as pneumonia, tuberculosis (TB), blood-poisoning (septicaemia) and several food-borne diseases.
- AMR also imposes a huge health cost on the patient in the form of longer hospitalisation, health complications and delayed recovery.
- It puts patients undergoing major surgeries and treatments, such as chemotherapy, at a greater risk. Many times, patients recover from advanced medical procedures but succumb to untreatable infections.
- AMR adds to the burden of communicable diseases and strains the health systems of a country. An Indian Council of Medical Research (ICMR) study in 2022 showed that the resistance level increases from 5% to 10% every year for broad-spectrum antimicrobials.
India and the Muscat Conference
- The Muscat Manifesto recognised the need to accelerate political commitments in the implementation of One Health action for controlling the spread of AMR.
- It also recognised the need to address the impact of AMR not only on humans but also on animals, and in areas of environmental health, food security and economic growth and development.
- The conference focused on three health targets: reduce the total amount of antimicrobials used in the agri-food system at least by 30-50% by 2030; eliminate use in animals and food production of antimicrobials that are medically important for human health; and ensure that by 2030 at least 60% of overall antibiotic consumption in humans is from the WHO “Access” group of antibiotics.
- India has committed to strengthening surveillance and promoting research on newer drugs. It also plans to strengthen private sector engagement and the reporting of data to the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) and other standardised systems.
High levels of resistance
- WHO has increasingly expressed concern about the dangerously high levels of antibiotic resistance among patients across countries.
- The global epidemic of TB has been severely impacted by multidrug resistance — patients have less than a 60% chance of recovery.
- The Muscat Manifesto appears to respond to the AMR crisis by setting these three ground-breaking targets. The manifesto encourages countries to prioritise their national action plans for AMR keeping the One Health approach.
From policy to the ground level
- The National Action Plan on Antimicrobial Resistance (2017-21) emphasised the effectiveness of the government’s initiatives for hand hygiene and sanitation programmes such as Swachh Bharat Abhiyan, Kayakalp and Swachh Swasth Sarvatra.
- The government has also attempted to increase community awareness about healthier and better food production practices, especially in the animal food industry.
- The National Health Policy 2017 also offered specific guidelines regarding use of antibiotics, limiting the use of antibiotics as over-the-counter medications and banning or restricting the use of antibiotics for growth promotion in livestock.
Way forward
- The various G-20 health summits spread through 2023 offer an opportunity for India to ensure that all aspects of AMR are addressed and countries commit to progress.
- Some key areas for action are: surveillance — both phenotypic and genotypic — of priority pathogens and sharing of data, including through WHO’s GLASS platform; regulatory and policy action to stop use of antibiotics that are important for human health in animals; no use of antibiotics for growth promotion in animals; more government investment in research and innovation for new antibiotics; explore use of vaccines to prevent certain infections due to AMR organisms in humans and animals; special focus on combating TB and drug-resistant TB.
Editorial 2: Understanding India’s Mental Healthcare Act, 2017
Context: The government-run facilities are “illegally” keeping patients long after their recovery, in what is an “infringement of the human rights of mentally ill patients”, according to a recent report by NHRC
Introduction
- The National Human Rights Commission (NHRC) in a report flagged the “inhuman and deplorable” condition of all 46 government-run mental healthcare institutions across the country; out of which three are run by the Union government and the remaining by State governments.
- The facilities are “illegally” keeping patients long after their recovery, in what is an “infringement of the human rights of mentally ill patients”, the report notes. Moreover, the perennial shortage of doctors, lack of infrastructure, and proper amenities speak of a “very pathetic and inhuman handling by different stakeholders”, according to the report.
What does the Mental Healthcare Act, 2017 say?
- MHA’s predecessor — the Mental Healthcare Act, 1987 — prioritised the institutionalisation of mentally-ill people and did not afford any rights to the patient. “The previous Act provided disproportionate authority to judicial officers and mental health establishments to authorise long-stay admissions often against the informed consent and wishes of the individual.
- In 2017, the MHA in essence dismantled the clinical heritage attached to asylums. ys. As part of Section 19, the government was made responsible for creating opportunities to access less restrictive options for community living — such as halfway homes, sheltered accommodations, rehab homes, and supported accommodation.
- The Act also discourages using physical restraints (such as chaining), objects to unmodified electro-convulsive therapy (ECT), and pushes for the rights to hygiene, sanitation, food, recreation, privacy, and infrastructure.
- Importantly, the Act recognised “people have a capacity of their own — unless proven otherwise,” Fernandes adds. Under Section 5, people are empowered to make “advance directives”. They can nominate a representative for themselves, thereby potentially helping to eliminate absolute forms of guardianship in favour of supported decision-making.
Challenges in Implementation
- Almost 36.25% of residential service users at state psychiatric facilities were found to be living for one year or more in these facilities, according to a 2018 report by the Hans Foundation. Experts note three main reasons:
- non-compliance to MHA regulations,
- absence of community-based services,
- and social stigma that looks at a person with mental illness as a “criminal” deserving of incarceration.
- Under the MHA, all States are required to establish a State Mental Health Authority and Mental Health Review Boards (MHRBs), Ms. Fernandes notes that in a majority of the States, “these bodies are yet to be established or remain defunct…Further, many States have not notified minimum standards which are meant to ensure the quality of MHEs.
- The absence of MHRBs renders people unable to exercise rights or seek redressal in case of rights violations.
- While the Act says a person can walk out if they are recovered, in practice, people still need somebody– a caregiver or the state -- to take them out. People are either put in these establishments by families or through the police and judiciary. In many cases, families refuse to take them because of the stigma attached to incarceration or the idea that the person is no longer functional in society.
- Poor budgetary allocation and utilization of funds further create a scenario where shelter homes remain underequipped, establishments are understaffed, and professionals and service providers are not adequately trained to deliver mental healthcare.
Conclusion
- In the absence of rehabilitation, institutions are the only spaces available for many persons living with mental illness.
- According to Jasmine Kalha, a research fellow at CMHL&P, “this is not the first time NHRC reports have highlighted various challenges and human rights violations within these institutions yet nothing changes on the ground… the real question is where do we go from here- why aren’t we implementing rights and recovery-based approaches to change attitudes and practices on the ground?”