ANTIBIOTIC CRISIS - A TIME BOMB
Prof B M Hegde
Vice Chancellor ,
MAHE Deemed University,
Manipal - 576119
Nearly seventy years ago, when Alexander Fleming and Prof. Florey
discovered a mouldy growth on their culture plates to be a powerful antibiotic,
penicillin, a new era began in medicine. The predictions then were, as usual, that the end
of man’s fight against germs on this planet is drawing closer. Like all other
predictions in linear science this one has also been belied. Doctors have been predicting
the unpredictable all these years. That in itself is not bad! But we are now facing a new and formidable threat
in that many of the germs that were initially sensitive to antibiotics have now become
resistant and threaten to annihilate man from this planet. One example would suffice. One
common germ, the streptococcus, was the most sensitive germ to be killed by penicillin.
While 95% of these germs could be easily killed by penicillin to begin with, today 95% of
the same is resistant to penicillin.
The history of this universe is very closely connected to human births and deaths, but
illnesses do change history much more dramatically compared to the former two. The black
death due to plague in Europe in the sixteenth century, the white death- so called because
it killed most people with extreme anaemia and mostly young adolescents in particular- of
tuberculosis, have been the greatest tragedies of mankind. Tuberculosis still eludes a
cure despite our euphoria after the advent of antibiotics against the germ mycobacterium tuberculosis.
In fact, it has become much more rampant and dangerous now that AIDS abets and assists the former to ravage human life. Tuberculosis has assumed a different form these days because of the changing circumstances. Historical milestones of tuberculosis include the hunchbacks of Egyptian mummies, the phthisis (wasting) of the Greeks, and the English consumption of the lay public. Most diseases respected wealth and status to a certain extent, but plague and TB did play truant with even the rich and the famous from time to time.
The gravity of the situation is such that the Royal College of
Physicians of London organized a meet to discuss the Clinical
Implications of Anti-microbial Resistance on the 28th February 2001. It has been estimated that around 15,000 people die in
that small country every year from infections against which no antibiotic is effective. Such
of those germs that are resistant to most antibiotics are called the superbugs and, as of now, we have no defence
against them. One of the biggest hospitals in that country, Portsmouth Hospitals NHS
Trust, has been forced to shut down most of its operating theatres last summer because of
superbugs there. At the Queen Alexandra
Hospital the orthopaedic surgeons could not perform any operation around that time.
Another leading authority in the field, Professor Hugh Pennington of Aberdeen University,
feels that the next big problem would be that of drug resistant tuberculosis. They had an
outbreak of TB in Scotland recently, traced to a travelling family. He also feels that the
Russian prisons have many inmates who have drug resistant TB without proper treatment.
Since TB does not respect geographic borders this time bomb might explode anytime
anywhere!
The usual thinking in the West was that this kind of uncontrolled
infectious disease scenario could exist only in the poor countries like India and
sub-Saharan Africa. They are now in for a great shock. In a well researched book, Betrayal of Trust: The Collapse of Global Public
Health, Laurie Garrett from the USA, shows how the threat is not confined to the poor
countries but, is greater in the West, basically because doctors there over-prescribe
antibiotics so that bacterial infections are becoming increasingly resistant to the most
widely used antibiotics. She writes that "doctors who over-prescribe antibiotics
undermine the health care system by encouraging germs to become resistant." She is
dead right there.
The blame must also come on the consumers, the patients, as many of the latter, who think that they are well informed, demand antibiotics for the common trivial infections, most of which are viral to begin with. This adds to the problem. Doctors who follow ethics and refuse to give antibiotics are not usually popular. The fear of losing the patients makes many doctors to oblige patients with over-prescribing. Educating the public about the serious dangers of taking antibiotics for minor infections against medical advice should go a long way in reducing this menace.
Studies have shown in the USA that it is the rich kids that suffer more
from ear infections and other common childhood infections. Since antibiotics are very
expensive the poor parents do not bother to give their children antibiotics for minor
illnesses. This helps the child to fight the infection with the help of its own immune
system and, in the bargain, the child develops immunity against major infections. This has another very dangerous ramification to it.
Antibiotics given to minor viral illnesses of childhood make the immune system change its
response to infection in such a way that the cytokine response to infections, based on
their genes, changes from TH1 to TH2. The latter is the most important trigger for asthma
in later life. The slum dwellers kids, when they have enough to eat, have very robust
health and have very low incidence of asthma and many other common illnesses. Whenever
they do not thrive, it is only because they do not get enough nutrition in their diet.
The other dangers of antibiotics are in commercial fields like farming
and the diary industry. Broiler sheds use a lot of antibiotics to not only treat the
infections in chicks but also in the fond hope of preventing infections in them. The amount of antibiotics used in cattle and
broiler sheds far outweighs all that is used in hospitals and operation theatres! Today it
only takes six weeks to get a bird on the dining table from the egg stage, about half the
time normally required. The farmers, therefore, make double money and the birds come
cheaper. But it means that we get a huge dose of antibiotics
each time we bite a chicken lollypop! This does not take into account the added hazards of
excessive hormones fed to fatten the birds. In short, we are only eating a slow poison.
Mastitis in cows is another danger. The incidence is around 10% of the
cows in a diary on a given day! The huge amount of antibiotics, like ciprofloxacin,
injected into the udder (one udder dose costs Indian rupees 8,000) makes the milk not
potable for a week. But the farmers might use the milk earlier to reduce loss of money. So
the milk that we drink from large pools in larger diaries might also contain unacceptable
doses of antibiotics.
The House of Lords in Britain was worried about the large scale abuse
of antibiotics in farming and spoke of a "vicious
circle repeatedly witnessed in which the value of each new antibiotic has been progressively eroded by
resistance." Very dangerous indeed. In a shocking incidence recently at the
Prince Edward Hospital in Wales a patient had an infection in his leg wherein the germs
were resistant to all the antibiotics available. Doctors had to go back to Nature to get maggots to help cure that infection! Now they are
routinely culturing maggots to treat resistant infections there. In Nature this is a very
common way of controlling bacterial infections, evident even during the Second World War.
Minor wounds could be smeared with fresh, clean honey. Honey gives a
coating to the wound to prevent germs getting in and the germs already there are prevented
from multiplying, as honey stops the nutrition
needed for growth and multiplication in the germ world. Therefore the existing germs die
out and the new ones can not get in.
The time bomb of tuberculosis is threatening to burst anytime now. The
West is in the middle of the worst TB epidemic in the last twenty years. Tuberculosis
never went away. It was only lying low because we depended on the powers of the anti-TB
antibiotics too much and did away with the methods to enhance the capacity of the immune
system as we used to do before the advent of antibiotics. Sanatoria, good food, complete
rest, and a healthy environment were given up as useless. Surgery, which in the olden
days, helped to get rid of the infected part of the lung, thereby reducing the risk of
death and bleeding, took a back seat. Now we are threatened by the MDR, multiple drugs resistant germs of this
deadly disease, waiting to produce another epidemic of the white death. Thomas Dormandy in
his treatise The White Death (The Hambledon
Press) gives us the horror stories of the hoary past with even people like Napoleon
Bonaparte having suffered its ravages.
TB is no respecter of status or position and even money power for that
matter. Many were the victims such as leaders, poets (Keats was the leading one), writers,
soldiers, beggars, children, adults, mothers and also the medical and the nursing
professionals. Many careers had to be either terminated or changed in mid-waters when TB
struck. Things could be gloomier with the added burden of AIDS reducing the potency of the
immune system of man. Vaccination against TB came and went without much fanfare. May be we
need to look more carefully into this aspect of TB prevention.
This article should alert all good Samaritans about the time bomb
ticking away threatening to explode any time now. While
I am sure the situation is worse in India, I have no scientific data for the whole country
to give you the true picture. Earlier we wake up from our deep slumber the better for our
progeny. We have never been using antibiotics scientifically for well over half a century
in this country and the results could be disastrous to say the least.
Prof. J.R.Bignall of the Institute of Chest Diseases (Brompton
Hospital, London) was requested by Pandit Nehru's government in 1956 to study the TB
situation in the country. He came, he saw and then
he gave a very sane suggestion. The anti-TB drug situation at that time was very
pathetic with very few drugs trickling into the country and being abused by even quacks.
Dr. Bignall wrote to the government suggesting that the 2,50,000 odd TB patients in the
country at that point in time should be allowed to have the conventional treatment
available then. The use of anti-TB antibiotics should be banned in the country for ten
years! His scientific reasoning was that those that die of the disease would die anyway
and take the germs with them to be burnt or buried, ending the germ’s life cycle. Rest of the patients who survive,
their immune system would kill the germs. In the following ten years India would have been
rid of TB germs. With hindsight it looks like God's advice.
That advice could have worked even for the West. Our Netas of the time
ridiculed this report in the Parliament and rejected it. The results are there for all of
us to see. "Truth" said Aristotle, "could influence only half a score of
people in a given time or age, whereas falsehood and mystery would drag millions by the
nose". How true!
This is the long and short of the story of the germ and man,
the two friends, that depend on one another for better or for worse.