Even with its questionable merit, the superbug study has identified the need for us to question the focus that we have on finding narrow solutions to health issues .It has also highlighted the urgent need to address the broader infrastructural needs of the country such as access to safe drinking water and sanitation
Image source: Wikimedia Commons 
The superbug study
New Delhi and the world was hit by panic last week because of a recent study published in the journal The Lancet Infectious Diseases , which found a high level of water contamination acquired from drains and public taps across India's capital city. The water was allegedly contaminated with superbugs, or what has been referred to as bacteria carrying the NDM 1 gene. Four percent of drinking water samples (2 of 50 samples) and 30 percent of drain samples (51 out of 171 samples) were found to be contaminated with superbugs [1, 2].
What/who are these superbugs?
Superbugs are basically bacteria that carry the NDM-1 gene, which stands for New Delhi metallo-beta-lactamase-1. If a bacteria carries the NDM-1 gene, it can develop the strength to resist all antibiotics, including the most potent ones. So for example, if a bacteria causing dysentery or cholera carrying the NDM-1 gene infects a person, no antibiotics given to the person will work and the disease stands the risk of being incurable, leading to a serious risk to the person’s health. Introducing rigorous methods for maintaining hygiene and prevention of uncontrolled use of antibiotics have been recommended to tackle the growth and spread of superbugs. Although the presence of superbugs has been confirmed in many countries recently, studies have traced the origin of the superbugs to India [1] and other countries from the Indian subcontinent [3].
Why has the superbug issue become so sensitive?
There are many uncomfortable issues, questions, dilemmas and inadequacies that have been brought to the forefront with the superbug debate, besides its importance as a serious public health issue requiring urgent attention. For example, it has exposed the rifts and disagreements within the scientific community in terms of the ethics of research and the insider-outsider dilemmas in terms of who was involved in conducting the research, procuring the samples, the methods followed to do the research, the validity of the results and the naming of the gene after New Delhi. It has also triggered fears of the economic repercussions of the findings for the medical tourism industry in India [7], and has clearly demonstrated how the findings of a scientific study can stand the risk of being politicised at national and international levels.
The debate has exposed the politics of denial, as well as the weaknesses and limitations of the existing health care system in terms of the excessive emphasis placed on curative models of health. It has also highlighted the urgent need to pay more attention to the preventive aspects of health, such as basic water and sanitation needs.
For instance, the government's reaction has shifted from initially questioning the methods and denial regarding the very presence of the superbug, to outright denial of the study's findings by an external agency. At the same time the government has also acknowledged the potential risks, and has attempted to conduct further studies to confirm the findings. Later reports state that the government has formed a scientific committee to look into the findings of the New Delhi superbug study. It is also working on the National Antibiotic Policy, which includes restrictions on usage of third and fourth generation antibiotics, continuous monitoring of drug resistance cases and over-the-counter sale of antibiotics in pharmacies [11].
The Indian Council for Medical Research (ICMR) has been planning to conduct scientific research in order to understand and provide evidence of the presence or absence of the superbug in New Delhi. The National Centre for Disease Control (NCDC) will also initiate a six-month long study in the capital’s three hospitals, Safdarjung, Ram Manohar Lohia and Lady Harding, to gauge the presence of this superbug in both Delhi’s ICUs and in its environment [6].
The findings of the study have led the Delhi Municipal Corporation and the Delhi Jal Board to take a defensive stand; they argue that there has been no problem with the water quality and that water has been regularly checked and monitored by the Bureau of International Standards [6]. However they have also stated that water surveillance mechanisms and monitoring mechanisms can be further improved, and emphasis should be laid on proper chlorination of water [6]. In the latest news, the city government has decided to distribute free chlorine tablets to people as a precautionary measure against water-borne diseases, while still insisting that the water is totally safe [14].
The reactions of the scientific community, public health experts as well as the medical community have been more cautious, but they have at the same time raised concerns over the presence of the NDM -1 superbug in eleven different types of bacteria, including those that cause dysentery and cholera and the implications of the presence of the superbug in these normally controllable diseases, which could make them potentially incurable and deadly. They argue that this would create a serious public health crisis in a scenario where indiscriminate prescription and use of antibiotics over the counter is very common [11, 12].
The author of the paper, Mark Toleman, in an interview has accused the government of trying to deflect attention from the issue and even cover it up by pressurising scientists and researchers in the country. He continues to insist on the importance of the study and the threat of the gene spreading even further in the context of poor sanitary conditions and contamination of water sources in the capital due to sewage and faecal matter [15]. According to the latest news, the World Health Organisation has said that it will assist India in finding out whether a multi-drug resistant "superbug" found in New Delhi's water poses a health risk [22] and the ICMR has invited research proposals on superbugs [23].
Image source: Wikimedia Commons
Concerns raised by the superbug debate
Amidst questions raised regarding the methodology and the ethical dimensions of the research, the study's validity and its findings, the economic concerns along with genuine concerns regarding the grave threat posed by the presence of the NDM-1 resistant bacteria to public health, this study does raise some very uncomfortable questions about exactly whose interests should be considered important in the whole debate, and also of the concept of health that we look upon.
It appears that the needs and the risks posed to the common people seem to be downplayed in what can be called ‘the politics of denial’ in the entire debate. The same is true of the concepts of health based on curative models that we still seem to embrace, which fail to take into consideration the preventive dimensions of health. The root causes of health problems in India can be traced to the dismal state of infrastructural facilities catering to the water and sanitation needs of the population. For example, figures indicate that as high as 55% of all Indians still do not have access to any kind of toilets in the country, 74% of the rural population still defecates in the open, three-fourths of India’s surface water resources are polluted, and 80% of the pollution is due to sewage alone [16].
Evidence also indicates that in cities such as New Delhi, existing sewerage systems are inadequate to manage the huge amounts of wastewater produced in the city [16]. Recent evidence from Delhi indicates reports of contamination of water supplied by the Delhi Jal Board because of faecal matter [17], and of 18% of the water to be unfit for consumption, increasing the risk of water-borne diseases [18, 19, 20, 21].
This poor sanitation situation, which already makes people vulnerable to a range of water borne diseases can have extreme consequences in the case of the presence of NDM-1 gene carrying bacteria, the most likely source of which is faecal matter. It could give rise to grave consequences where periodic infections could make these diseases deadly and virtually untreatable because of antibiotic resistant strains of bacteria.
It is important to understand the broader public health implications of this finding in the context of countries, especially developing countries such as India. Debates indicate that this threatens to have repercussions that could have an impact beyond clinical aspects to include a range of economic, social and political dimensions in the context of health care delivery in the country. This presents challenges as well as opportunities to address and set right the lacunae that the health care system has been facing and struggling to cope with, in recent years.
We can no longer rely on magic bullets - the chlorine tablets in this case - to temporarily take care of the issues at hand, while trying to push the broader issues related to poor water and sanitation in the country under the carpet. This study, even with its questionable merit, does identify the need for us to take a long hard look at the emphasis we place on curative biomedical models and urgently focus our attention on addressing the broader infrastructural needs of the country, such as access to safe drinking water and sanitation, before it is too late.
(The author is a public health researcher based in Trivandrum, and also works with the India Water Portal)
References
1. Walsh, T.R., Weeks, J., Livermore, D.M., Toleman, M. (2011) Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: An environmental point prevalence study. The Lancet Infectious Diseases, Published online April 7, 2011 DOI:10.1016/S1473-3099(11)70059-7. The full text of the article is available for download free of charge, from The Lancet's website, to registered users (registration is free).
2. Laurance Jeremy (2011) Deadly Delhi superbug poses risk to antibiotic treatment worldwide. Downloaded from the site: http://www.independent.co.uk/life-style/health-and-families/health-news/deadly-delhi-superbug-poses-risk-to-antibiotic-treatment-worldwide-2264969.html on 13th April 2011.
3. Wikipedia (2011) Plasmid-encoding Carbapenemase-resistant Metallo-B-Lactamase. Downloaded from the site: http://en.wikipedia.org/wiki/New_Delhi_metallo-beta-lactamase on the 13th April 2011.
4. Kumarasamy K. K., Toleman, M. A., Walsh, T. R. et al (2010) Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular,biological, and epidemiological study. The Lancet Infectious Diseases, 10(9), 597-602. The full text of the article is available for download free of charge, from The Lancet's website, to registered users (registration is free).
5. Kant, S. and Haldar, P (2010) Is NDM-1 actually being imported to UK from India? Indian Journal of Public Health, 54(3), 151-4. Downloaded from the site: http://www.ijph.in/text.asp?2010/54/3/151/75738.
6. The Hindu (2011) No evidence of the presence of the superbug, April 13, 2011. Downloaded from the site: http://www.hindu.com/2011/04/13/stories/2011041363771100.htm on the 14th of April 2011.
7. Sharma, S (2010) Delhi superbug threatening world, claim UK scientists. Downloaded from the site: https://www.hindustantimes.com/Delhi-superbug-threatening-world-claim-UK-scientists/Article1-585442.aspx on the 12th April 2011.
8. The Telegraph (2011) Fears over drug-resistant New Delhi superbug gene. Downloaded from the site: http://www.telegraph.co.uk/news/worldnews/asia/india/8436833/Fears-over-drug-resistant-New-Delhi-superbug-gene.html . on the 12th April 2011.
9. Sinha K (2011) India objects to 'smuggling' superbug samples out to UK. Downloaded from the site: http://articles.timesofindia.indiatimes.com/2011-04-08/india/29396431_1_water-samples-ndm1-ndm-1 on the 12th April 2011.
10. The Economic Times (2011) No superbug, Delhi's water safe, says government. Downloaded from the site: http://articles.economictimes.indiatimes.com/2011-04-11/news/29406466_1_drinking-water-mark-toleman-lancet on the 13th of April 2011.
11.Shalini (2011) Govt to look into Delhi superbug study findings. Downloaded from the site: http://ibnlive.in.com/news/govt-to-look-into-delhi-superbug-study-findings/148861 on the 13th April 2011.
12. Sharma D (2011) Delhi superbug is new global health threat. Downloaded from the site: http://indiatoday.intoday.in/site/Story/108708/india/delhi-superbug-is-new-global-health-threat.html on the 13th of April 2011.
13. Deccan Chronicle (2011) No superbug: Delhi municipal bodies. Downloaded from the site: http://www.deccanchronicle.com/channels/nation/north/no-superbug-delhi-municipal-bodies-882 on the 14th April 2011.
14. One India news (2011) Superbug: Delhi govt to distribute free chlorine tablets. Downloaded from the site: http://news.oneindia.in/2011/04/13/superbugdelhi-govt-to-distribute-free-chlorinetablets-aid0126.html on the 14th of April 2011.
15. The Hindu (2011) NDM-1: 2010 results confirmed by others, Thursday 14th April, 2011. Downloaded from the site: http://www.hindu.com/seta/2011/04/14/stories/2011041450131400.htm on the 15th of April 2011.
16. Asian Development Bank (2009) India's Sanitation for All: How to make it happen. Water for All. Series 18. Downloaded from the site: http://www.adb.org/documents/books/water_for_all_series/Indian-sanitation/Indian-sanitation.pdf on the 14th of April 2011.
17. Indian Express (2011) Filthy water: NHRC sends notice to chief secy, DJB. Downloaded from the site: http://www.indianexpress.com/news/filthy-water-nhrc-sends-notice-to-chief-sec/632307/ on the 14th of April 2011.
18. Gits4u (2011) Water related news: 18% of Delhi water unfit for consumption. Downloaded from the site: http://www.gits4u.com/water/water11.htm on the 14th of April 2011.
19. The Hindu (2011) MCD seeks details of water contamination. Downloaded from the site: https://www.thehindu.com/todays-paper/tp-national/tp-newdelhi/article1542073.ece on the 14th of April 2011.
20. IANS (2011) Delhi Jal Board water contaminated with human faeces. Downloaded from the site: http://in.news.yahoo.com/delhi-jal-board-water-contaminated-human-feces-20110310-063930-067.html on the 14th of April 2011.
21. New Kerala (2011) Delhi Jal Board water contaminated with human faeces. Downloaded from the site: http://www.newkerala.com/news/world/fullnews-165377.html on the 14th of April 2011.
22. Asia One Health (2011) WHO to help India probe 'superbug': report. Downloaded from the site: http://www.asiaone.com/Health/News/Story/A1Story20110415-273729.html on the 16th of April 2011.
23. The Hindu (2011) ICMR invites research proposals on superbug. Downloaded from the site: https://www.thehindu.com/news/national/article1706583.ece on the 18th of April 2011.