Her name is Mehreen and she is 27. She has an unnerving habit of looking straight into the eyes of strangers during conversation until they get uncomfortable and look away. It is a wonderful thing, this assertion of her fearlessness, her right to the space she moves in.

She comes from a prosperous family that owns a 2-kanal (1,210 square yards) house in Defence Housing Authority next to a major academic institution. But at the moment, her job as vice president of a human resources company that operates in seven countries, her myriad family connections and her Ivy League education have all become irrelevant; for Mehreen is sick.

The fact of the matter is, Mehreen is dying.

Lying on the private bed of a large private hospital in Lahore, she stares at the ceiling with jaundiced eyes. Her body has been overwhelmed by septic shock — a state in which her blood vessels have widened to form tunnels incapable of supporting life-sustaining pumping pressure, resulting in a lack of oxygen supply to vital organs; her heart has weakened to less than 15 percent of its pumping capacity; her liver and lungs are drowning in her own body fluids. This is the frightening prequel to the inevitable collapse of her body’s organ systems, possibly culminating in death.

All this is the result of an infection that started inside her gut; her killer: a tiny stubborn bug that took residence in her body months ago.

Like Hitchkock’s Psycho silent at the keyhole, the bug waited in the shadows of her intestines for the right moment to strike; and the moment came when Mehreen picked up a pack of over-the-counter antibiotics from the drug store on her way home from gym. She had bad zukaam (flu) that was ‘just not going away’ and her doctor decided to prescribe a third-generation antibiotic for what was certainly no more than a common cold.

And now, in less than 48 hours, Mehreen will be dead.

Once upon a time you were a bug.

Some 3.7 billion years ago or so, you crawled out of a warm chemical soup composed of cooled gases and electrified clays.

You were a microscopic organism that — via kinetic movements and natural selection — withstood trillions of biochemical and electromagnetic interactions between particles of matter called molecules. Baked by the heat of a young sun, you made building blocks of proteins called amino acids, which began to come together in the right configuration. You were attacked by acids and alkalis, salts and heavy metals; nevertheless, you persisted.

Despite tremendous odds, because of tremendous odds, pieces of you gelled (call it love at millionth sight) and you became the composite you: the first stirring of Life on Earth.

Human beings are mostly bugs, over 100 trillion of them. From the inside of your mouth and intestines to the tip of your little toe, you are covered with this layer of benign microbes that makes you virtually invincible, possibly invisible, to billions of disease-causing pathogens.

With your awakening, came more attacks by nature and other organisms, which, too, were rapidly coming alive. Through trial and error, over billions of years, you figured that you could grow a tough outer membrane — skin — to protect your soft insides. You developed horns, nails and teeth to fight; flagella, tails and legs to escape danger if need be.

You negotiated with other peace-minded microorganisms and reached an effective deal worthy of envy by Pakistani political parties: these foreign bugs could live on and inside you, provided they paid rent in the shape of food or protection from more dangerous or pathogenic microbes. They were your friends and neighbours, ever ready to provide succour; and they covered every part of you.

Human beings are mostly bugs, over 100 trillion of them. From the inside of your mouth and intestines to the tip of your little toe, you are covered with this layer of benign microbes that makes you virtually invincible, possibly invisible, to billions of disease-causing pathogens.

This Cloak of Invisibility is called your ‘microbiota’ (all the genes in these bugs collectively called the ‘microbiome’) and it is one of the most exciting areas of research in medicine today.

We know that this symbiotic swarm of living things on our body reached this balance over a staggering amount of time. Enough time to reach an ecological homeostasis, a wonderful balance of give and take. We protect each other from hostile pathogens, we regulate each other’s metabolism. The bacteria in our microbiome help digest our food, fortify our immune system and produce vitamins to help correct our nutritional deficiencies. They even drive our craving for dark chocolate!

In short, they know our deepest darkest secrets.

Yet, once in a while, a pathogen breaks through the barriers of skin and the microbiota. It is dangerous and may cause severe infection with spread of the bug throughout the body. Fortunately, in most cases, it is detected by our immune system — a multipronged army of specialised cells — that chases, contains and kills these invaders. The body is quite vigilant and diligent, as it turns out.

In rare instances, though, the immune system is not able to control the infection; usually because our immunity is compromised due to disease (diabetes, chronic kidney or liver disease, for example), unfavourable environment (extreme cold, smog), breaks in protective barriers (heat or traumatic damage to skin) or because the invading army is just too big and powerful.

This is when an antibiotic (a drug against said bacteria) might come in very handy and may even be lifesaving.

Alexander Fleming discovered the first known modern antibiotic — Penicillin — in 1928. This ushered in the golden age of antibiotics. Suddenly we had a magical drug that could cure the worst infections in the world: tuberculosis, cholera, leprosy, the much-feared Black Death (bubonic plague). Doctors, nurses, medics and others began dispensing these drugs by the handfuls. Hundreds of thousands of people were saved from what would previously have been certain death.

However, much like the process of evolution (which gave rise to your own defences) bacteria — which divide and grow in numbers much more quickly than humans do — began self-selecting for antimicrobial resistance via natural selection. A bacterium with a gene that confers resistance against the antibiotic would be able to survive and birth more of its kind; the others would die out.

Did you know the World Health Organization has singled out Pakistan for an entirely separate treatment category? It is not because we are wonderfully unique, but woefully so: In 2016 thousands of cases of the world’s most dangerous strain of Salmonella Typhi — the bacterium that causes typhoid fever — were documented in Pakistan.

Therefore the same antibiotic that worked for, say, leprosy 10 years ago would become ineffective against it over time.

This has given rise to a full-blown arms race between the microbial world and the human world. Scientists are scrambling to produce new effective antibiotics; the bugs are rapidly evolving to become resistant to them.

And the bugs are winning.

Enter Pakistan:

Antibiotic abuse and the plethora of problems that follows it is one of the largest challenges facing the world today, but the issue is at a whole different scale in Pakistan where:

(a) Antibiotics are available over the counter without a doctor’s prescription,

(b) A pharmacist, hakeem, or your ‘samajhdar chaacha’ (wise uncle) can recommend and therefore dispense an antibiotic at the first twitch in your nostril.

(c) Antibiotic stewardship programmes (ASPs) — that dictate a hospital’s institutional use of specific and privileged antibiotics — and solid foundational training in the dangers of overuse are often nonexistent even in major cities (as noted in the 2018 GARP-Pakistan [Global Antibiotic Resistance Partnership] Situation Analysis Report On Antimicrobial Resistance in Pakistan).

(d) Complete absence of national surveillance programs for antibiotic use in livestock has led to indiscriminate use of antibiotics in farm animals and poultry for therapeutic, prophylactic and growth promotion purposes. This has added significantly to antimicrobial resistance (AMR) in bacteria isolated from these animals. Rates and mode of their transmission between humans and animals remain to be established, according to the GARP-Pakistan report.

Result:

Did you know the World Health Organization has singled out Pakistan for an entirely separate treatment category?

It is not because we are wonderfully unique, but woefully so: In 2016 thousands of cases of the world’s most dangerous strain of Salmonella Typhi — the bacterium that causes typhoid fever — were documented in Pakistan. Indeed, this bug is resistant not just to the first and second-line antibiotics but also third line (drugs that may be useful, but have doubtful or unproven efficacy). In fact, there are only one or two classes of antibiotics left with efficacy against this XDR (extensively drug-resistant) typhoid.

Which means, once our luck runs out and the bug develops resistance to these last two classes, Pakistani patients, regardless of their wealth and social status, will die if they acquire typhoid.

In recent years we have (inadequately) talked about ‘climate change (better termed the ‘climate emergency’), Lahore’s ‘Smog Apocalypse’ and the ongoing wildfire crisis raging across the world. But we are still not talking about the giant elephant in the room — The Post-Antibiotic Era, when all bacterial infections become completely and irrevocably resistant to current antibiotics.

What will we do then?

The story of damage from excessive antibiotic use and abuse does not end with drug resistance, however.

Remember your friendly neighbourhood bugs — your microbiota — that protects you from pathogens and nourishes you?

Guess what happens to them when you hammer your body with one antibiotic after another?

You virtually wipe them out.

Every single time you do a course of antibiotics or take one ‘kabhi kabhi’ (sometimes) after acquiring belly cramps from street food, or the flu, or common cold (which, by the way, antibiotics do not work against; most stomach, nasal and sinus infections are caused by viruses), you decimate your microbiome.

Physicians need to counsel their patients and junior doctors that not every cough or cold deserves an antibiotic. Not every fever or back pain is a urine or kidney infection.

Not every patient that hits the emergency room’s door with diarrhoea needs a broad-spectrum concoction of four third-line antibiotics. Suddenly, your antibiotic use has, paradoxically, left you defenceless against very dangerous organisms. This is precisely what happened to the unfortunate Mehreen.

The antibiotic killed a large chunk of beneficial bugs in her intestines, allowing a deadly pathogen called Clostridicum Difficile or C Diff. to exude a poisonous membrane that coated her colon.

Over a few weeks, it grew and grew with no powerful ‘good’ bacteria in place to prevent its colonisation. To top it off, this C Diff. was multi-drug-resistant as well: first- and second-line antibiotics failed to eradicate it. It multiplied until it became a hydra of disease with heads and limbs in all parts of her body, causing severe sepsis, then septic shock.

Mehreen died.

Yet more issues besides drug resistance and overgrowth of pathogenic organisms rise from antibiotic abuse.

The gut microbiota helps regulate our metabolism and programmes our immune system. Once you mess with it, cut out large swathes of it, you’ve disrupted an ecosystem that has evolved over millions of years.

Indeed, there is evidence that peculiarities of the microbiome and lack of diversity in it are linked with obesity, development of autoimmune disease, including rheumatoid arthritis and Type 1 diabetes, as well as other illnesses such as asthma and anxiety disorder. Some scientists have recently discovered that some skin bacteria may in fact help protect against skin cancer!

So what happens when you abuse antibiotics?

You increase the risk of all these diseases.

Raise your hand if you want terrible metabolism, skin cancer, obesity and mood disorder. No one?

If all this sounds alarming and terrible, it is meant to be.

Physicians and patients both need to be whistleblowers on the Antibiotic Armageddon.

Physicians need to counsel their patients and junior doctors that not every cough or cold deserves an antibiotic.

Not every fever or back pain is a urine or kidney infection.

Not every patient that hits the emergency room’s door with diarrhoea needs a broad-spectrum concoction of four third-line antibiotics.

Here are a few things physicians could tell our patients:

• Get vaccinated regularly and on schedule as per the guidelines issued by the World Health Organization, especially the ones pertaining to Pakistan.

• Get vaccinated against typhoid. This cannot be stressed enough. A typhoid conjugate vaccine (TCV) is commercially available, which can prevent this particular strain from doing damage to your body. In fact, the TCV was recently added to Pakistan’s routine vaccination schedule.

• Get vaccinated against all available strains of viral hepatitis.

• Please do not use antibiotics unless prescribed by a doctor.

• Raise your voice as responsible citizens and demand that the government ban over-the-counter availability of antibiotics. These should be dispensed only on a doctor’s prescription.

• Encourage your hospitals and healthcare providers as well as your medical students and house staff to let go of the ‘sab chalta hai [everything goes]: this is Pakistan’ mentality. They should engage in ASPs and wash their hands before and after every patient encounter.

The above are common-sense measures that are standard counselling recommendations all across the world, and for good reason.

Your children’s lives literally depend on this.

The writer is a graduate of the Aga Khan University Medical College and the University of Florida. A diplomate of the American Boards of Medicine & Rheumatology, Dr Malik is currently Assistant Professor of Clinical Rheumatology at Shalamar Hospital & Medical College.

Header illustration by Samiah Bilal

Published in Dawn, EOS, February 2nd, 2020