Mission not yet accomplished

The official statistics around Covid-19 are impressive and encouraging. What could have been a disaster has been averted, at least for now. But now is not the time for complacency or self-congratulatory speeches and tweets. Let it not be George Bush’s “Mission Accomplished” moment of May 2003. Instead, we should recognise we are probably on the right track, analyse what has worked so far, and ensure that we continue on the right track. Our problems in health, and even in infectious diseases, are not just limited to the coronavirus. Some of the nastiest challenges facing our most vulnerable communities have pre-dated the global pandemic and continue to pose serious threats.

While it may not be news anymore — Pakistan continues to have one of the world’s most serious typhoid outbreak. In June 2020 alone, doctors in Punjab reported nearly 20,000 cases of typhoid. The cases of extensively drug resistant (XDR) typhoid — a scenario where nearly all of the leading antibiotics (except two) do not work — have been continuously increasing. The unabated rate of XDR typhoid has led to warnings from WHO and CDC in the past.

A significant number of those who were suffering from XDR typhoid were being treated with Azithromycin, a drug that has been both efficacious and relatively affordable. The other drug, a carbapenem, is a lot more expensive and requires intravenous delivery, making it difficult to administer. While many other drugs were no longer working, Azithromycin has been a lifeline for hundreds of thousands. However, this is most likely going to change.

Earlier this month, a paper based on the research led by researchers at Aga Khan University in Karachi showed early signs of resistance against Azithromycin in the bacteria that causes typhoid. This is a dangerous new development. While the cases of Azithromycin resistance are few, resistance to Azithromycin would significantly complicate treatment options for people and both mortality and morbidity rates are likely to increase.

The causes of this new development rest squarely on our policy and behaviour. A major cause for antibiotic resistance is over prescription, abuse, and self-medication. Antibiotic resistance — a scenario where the drug is no longer able to kill the disease-causing bacteria — accelerates in places where antibiotics are used when they are not needed. Unfortunately, when it comes to government policy and our practice, we are creating a perfect storm for antibiotic resistance. Prescription laws are either non-existent or rarely enforced. Antibiotics are easily accessible and pharmacies are too keen to sell them without a prescription. People are eager to start taking antibiotics without consulting a doctor, often for viral conditions. Doctors themselves are complacent, and eager to prescribe antibiotics on the phone, without even seeing the patient. Combine this with the presence of substandard drugs and poor information, and we have the perfect environment for making our lifeline impotent. Unfortunately, like many diseases, the likelihood of XDR typhoid having a disproportionate impact on the poor is high. Once again, those at the bottom of our economic ladder are most likely to be thrown off.

While a lot is at stake, there is a glimmer of hope that comes from our recent success in controlling the pandemic. Fortunately in this case, as in many other public health crises that affect us, we know exactly what to do. We also have examples from other countries on what works. Serious policy combined with aggressive public awareness can turn the tide. The message that we need is simple — next time we take an antibiotic when we do not need one, we may be taking away someone else’s life.

The strange thing about public health is that the more we care about others, the better we all get.

Published in The Express Tribune, August 4^th, 2020.

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