Drug-resistant typhoid and govt’s apathy

The typhoid fever outbreak has continued to grow with at least 4,500 cases in Pakistan in 2018 alone

On December 27^th, 2018, the World Health Organisation (WHO) issued its disease outbreak news. This time, the news was about Pakistan and not particularly an encouraging one. The typhoid fever outbreak, first seen in Hyderabad and then Karachi in late 2016, has continued to grow with at least 4,500 cases in Pakistan in 2018 alone, most of them in Karachi and Hyderabad. There is good reason to believe that this number is significantly underreported since many of our public hospitals lack the ability to do analysis properly and the reporting mechanisms are weak and often dysfunctional.

From a public health perspective, the situation in Pakistan is one of the worst scenarios possible. The strain of typhoid is what is called “extensively drug resistant (XDR)” — meaning that nearly all existing antibiotics are useless for treatment. In Pakistan’s case, the only drug available is Azithromycin or in very severe hospitalised cases Carbapenems (given through IV). The challenge is particularly acute since most drugs available in the market (that are still prescribed for a variety of reasons) are not just ineffective, they make the problem much worse. There is a danger that even these drugs may soon become impotent. This has led to travel warnings by US for its citizens in the recent weeks. The US Centers for Disease Control and Prevention (CDC) have also reported that nearly all patients in the US who have had XDR typhoid lately have come from Pakistan. The situation in Europe is similar as well.

In a strange, and perhaps very telling way, the outbreak of typhoid and the presence of these XDR strains, is a reflection of our society as a whole. The microscopic bugs are, in an uncanny way, showing us the mirror on who we are. Let us hear what these microbes are telling us about society at large.

Sanitation and hygiene: First, the rise of these so called “superbugs” is correlated with poor hygiene and sanitation. Trash, sewage and poor hygiene dot our cities — a problem that we just do not seem to be resolving in any serious way. Superbugs are rising not because of some medical miracle, but because of how we choose to live.

Ignorance and arrogance: Second — the rise of antibiotic resistance tells us that we choose to live between ignorance and arrogance. The rise of superbugs is correlated with over-prescription of antibiotics as well as with self-medication. The culprits are not just consumers who buy antibiotics without prescription, but also doctors who prescribe them unnecessarily. Ignorance about the threat of antibiotic resistance, and arrogance to change our ways remains a potent mechanism to create a problem that is fast becoming the biggest health challenge of our time.

Fraud: Widespread prevalence of substandard and fake drugs also drives antibiotic resistance. Research, including those from our lab, has shown how the prevalence of poor quality medicines drives emergence and proliferation of antibiotic resistance. Once again, there is little doubt in the fact that our businesses are able to get away with a lot of unethical practices.

A weak state: Finally, and perhaps most importantly — the rise of resistant bacteria is due to a weak state that is ready to support entrenched interests but fails to enforce laws to protect its most vulnerable. From lax prescription drug laws that would minimise over-the-counter sales to no control of antibiotics in the veterinary sector, the state, its plans and its institutions have remained weak, or absent, in enforcing commonsense acts. The rise of resistance is not just a threatening public health crisis, it is also a powerful social commentary on our current affairs.

If we pay close attention, through their rise, we may get to see the reflection of our choices, values, politics and priorities. 

Published in The Express Tribune, January 15^th, 2019.

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