Superbugs attacks

Negligence of water and sanitation departments will inevitably result in growth of infectious, drug-resistant diseases

When I was a medical student in the 1980s we thought we had conquered infectious diseases with our wonderful weapons of antibiotics. I remember as young physicians, we were quite dismissive when someone asked for any other advice on top of the bunch of antibiotics prescribed. “Take the pills and you will be alright!” That was our usual answer. When I was a student in public health in the 1990s at the University of Washington, nearly all students picked cancer or chronic diseases as their speciality. HIV/AIDS was the only infectious disease which was a major interest for students. I was the odd person who picked typhoid fever, its diagnostics and antibiotic resistance as a Masters’ research topic. The reason I picked typhoid was that as a clinician working in Pakistan I was troubled by the lack of information on valid diagnostic tests and the real situation of its supposed resistance to antibiotics.

Little did I know, decades after I would be in Pakistan dealing not only with typhoid but a type which is resistant to nearly all antibiotics except two. That’s why it’s called Extremely Drug Resistant (XDR) typhoid. The first time, it was reported from Hyderabad in 2016, the Sindh government set up a surveillance system in Karachi and Hyderabad and identified some cases from Karachi too. Credit goes to the Health Department of Sindh, which didn’t hide the problem and started surveillance, sharing information with all. Until now Karachi has reported more than 7,500 cases and Hyderabad close to 3,000. Based on this, we could extrapolate that the actual cases in the community may be more than 50,000. Not only this, typhoid is difficult to treat and the cost of treatment has increased manifolds. Its mortality is higher than normal typhoid. The danger is that once we run out of these two remaining drugs what will be our options? Will we go back to the pre-antibiotic era when a diagnosis of typhoid was considered a very serious and life-threatening situation? Unfortunately, Pakistan exported this disease to multiple countries, which is why the US has issued a travel advisory for Pakistan specifying the threat.

A major donor agency is working with the Health Department of Sindh and trying to vaccinate children in high-risk areas of Hyderabad. But here is the problem — after vaccinating around 200,000 children (the most susceptible age group) over two years, the number of cases in Hyderabad this year is expected to double from last year. Vaccines are critically important for preventing diseases but they should be part of a solution and not the only solution. The US has reduced more than 70% of its infectious disease burden before the birth of vaccines and antibiotics by just providing safe and chlorinated drinking water and sanitation.

Typhoid and many other infectious diseases are not caused by inefficiencies of the health department. In fact, the department had to face the consequences of other departments’ failures. In this case, the negligence is of the water and sanitation departments. Until we fix these basic issues, we will keep seeing infectious diseases which are becoming drug-resistant. Pakistan has already seen its fair share of it and with our little spending on health, it will be a major drain on the system. In one estimate, Sindh may have already spent a billion rupees on combatting XDR typhoid through direct and indirect costs of longer and expensive treatments. Let’s come back to the basics, follow our mother’s advice which was to take care of the water you drink and do not litter!

Published in The Express Tribune, October 27^th, 2019.

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