In this report by Misbah Khan,The Bureau of Investigative Journalism (TBIJ), reports on the global antimicrobial resistance crisis, uncovering "disturbing first-hand evidence of what happens when the drugs stop working."
Naveed, a 25-year-old civil servant, lies in a Pakistan hospital recovering from major surgery after an accident on a building site. In the same ward, 47-year-old Malik, who cut his foot crossing the road, is now coming to terms with an emergency amputation. Ahamba, a nine-day-old baby in Nigeria, has been fighting an infection since she was born. And in the United States, Tamara, 39, lives in fear of the recurrent infections that have made her life a misery.
Separated by circumstance and thousands of miles, these four people are more connected than they know. All have fallen victim to infections that no longer respond to medications in the way they used to. Infections that resist the "usual" treatments. Infections that contributed to the death of an estimated 5 million people in 2019 alone.
The Bureau of Investigative Journalism (TBIJ) is reporting from the frontline of the global antimicrobial resistance crisis. What we uncovered was disturbing first-hand evidence of what happens when the drugs stop working.
While it's the world's most vulnerable people - the ill, young and elderly; those in poorer settings - who are in most immediate danger, the threat of drug-resistant infection puts everyone at risk. Deaths from antimicrobial resistance are predicted to reach over 10 million a year by 2050. And a global threat requires global solutions. Better testing of bacteria, improvements in sanitation and hygiene, and more responsible practices around prescribing antimicrobials can all help lessen the chance of people dying from resistant infections.
Experts warn that now is the time to take action. This September, the United Nations will assemble world leaders to address antimicrobial resistance. The aim of the meeting is to negotiate a political declaration for member states to curb the impact the issue is going to have on health, environment and development.Naveed's story: a serious side-effect of surgery
Speaking to TBIJ from his bed in an intensive care unit, Naveed is barely able to get a sentence out. The 25-year-old civil servant had to have his windpipe removed after he was injured on a building site at his home in northern Pakistan. But that wasn't the end of his ordeal: after surgery, he developed a drug-resistant infection that could be fatal without the right antibiotic.
Doctors testing Naveed found that the antibiotic needed to save his life was colistin, a treatment meant to be used as a last resort because of its toxicity and side effects. But in Naveed's case, no other antibiotic could kill the strong bacteria causing his infection.
Operations leave us open to infection because bacteria can enter the bloodstream through surgical wounds, so patients are often given antibiotics before and during surgery. But if the antibiotics don't work, bacteria are still able to infect us. This is what happened to Naveed. His infection consigned him to intensive care for several more days while the colistin fought back against his infection.
Hospitals are a major source of drug-resistant infections because of the high concentration of sick people and the frequent use of antibiotics. Many hospital-acquired infections are resistant to multiple drugs used to treat them.
The risk is even greater when healthcare workers are unable to properly sanitise the environment they work in. And almost 2 billion people around the world don't have access to healthcare facilities with clean water.
"There's still a huge lack of water, sanitation and hygiene capacity in the global south, and this is inextricably linked to drug-resistant infections, but also human dignity," says Nicholas Feasey, a professor of infection medicine at the Liverpool School of Tropical Medicine.
Ahamba's story: born into challenging circumstances
Like many babies in Nigeria, Ahamba was born outside a hospital, with the help of a traditional birth attendant. She was three months premature, and her underdeveloped immune system was unprepared for the battle she was about to face.
Just five hours after she was born, Ahamba developed a fever and started to bleed from a section of the umbilical cord still attached to her navel. She was quickly taken to a hospital in Lagos State where she was given antibiotics.
Anyone anywhere can get an infection. But not everyone responds in the same way. Newborns, whose immune systems are weaker, are among those at the greatest risk.
Giving birth with a traditional birthing attendant, as Ahamba's mother did, is sometimes a cultural preference but can also be an indication that the family can't afford to go to the hospital. Most hospitals in Nigeria charge patients for healthcare. Most of the babies in Ahamba's unit had not been born in hospital, and most had been diagnosed with an infection on arrival.
Days passed and the antibiotic given to Ahamba wasn't working. It became clear she had a drug-resistant infection.
Her tiny body meant that she was unable to handle the toll of too many antibiotics. Having already tried two different types, the doctors skipped straight to meropenem - a broad-spectrum drug that aims to kill a wider range of bacteria. Like the colistin given to Naveed, it's supposed to be reserved for only the most severe infections.
Vaccine strategies can also prevent drug-resistant infections, says Feasey. That's why you have vaccines against drug-resistant bacteria in the research pipeline that could be given to mums and would then also protect the babies. But this is still in its early stages.
Stopping infections in the first place means the antibiotics that are our last lines of defence, such as colistin and meropenem, can be preserved. When these drugs fail, people can die - and prevention is better than cure.
Malik's story: a simple cut gets complicated
In Rawalpindi, northern Pakistan, Malik cut his foot after his sandal came off when he was crossing the road. It seemed innocuous enough at the time: partly because of a previous foot injury, he hardly felt anything. But after several days, the wound began to ooze with pus. It was infected and wasn't healing.
The 47-year-old tailor has diabetes, and his blood sugar levels weren't well managed. It put him at an increased risk of complications from foot injuries, including problems healing.
When doctors in his hometown weren't able to get his infection under control, Malik was rushed to a hospital over two hours away. It was there he discovered his infection was drug-resistant.
Bacteria are able to adapt quickly to defend themselves against the drugs designed to kill them. The more that bacteria are exposed to antibiotics, the more chance they have to develop resistance to them. Some bacteria can defend themselves against multiple drugs.
This was the case for the bacteria that had infected Malik's foot. By the time he reached the hospital, the infection had destroyed the tissue in his toes. Two of them needed to be amputated. To stop the further spread of the infection, Malik was prescribed four antibiotics.
Globally, the consumption of antibiotics increased by almost half between 2000 and 2018. The rate of increase has been steepest in South Asia, where the proportion of people receiving antibiotics each day has more than doubled in the last 25 years.
The increase reflects the fact that antibiotics aren't always used in the right way. Sometimes they are used unnecessarily - for example, for a viral infection like a cold or flu, on which antibiotics will have no effect. Other times they are misused: someone takes the wrong type, dose or course of drug. These inappropriate uses of antibiotics are huge contributors to the emergence of drug-resistant bacteria.
"Drug-resistant infections are a global health threat. But more importantly, they're a preventable burden of disease that is a consequence of a misuse of resources," says Yvan Hutin, the director of surveillance, prevention and control at the World Health Organization.
Sometimes patients can't afford to be ill. Being sick can be expensive - and a quick course of antibiotics might look like a cheap solution, especially in countries where regulations are either lacking or unenforced. In some countries, including Pakistan, Kenya and Nigeria, antibiotics can be sold over the counter by untrained staff.
They can also promise a quick fix for the doctors themselves. Overburdened healthcare workers often lack the means or time to perform diagnostic tests, and that means prescribing antibiotics without knowing what type of infection they are treating. When doctors misprescribe antibiotics, giving patients broad-spectrum drugs when others will do, they present bacteria with the chance to build resistance.
"We have inappropriate use, we have misuse, we have misprescriptions," says Hutin. "We want the appropriate healthcare services given to the right people. We need the data to understand all of this. When we miss the information, the system cannot improve.
"We face a heavy burden of disease from drug-resistant infections that comes from all this misuse and weak health systems"
Tamara's story: the misery of chronic infections
While antibiotic use has risen most steeply in lower- and middle-income countries, it's in rich nations where their overall use has always been - and remains - at its highest. Much of this is down to drugs being given to patients who don't need them. In the US, for example, a third of the antibiotics prescribed are done so unnecessarily.
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Tamara's life began to go downhill just as Covid hit. In March 2020, her husband lost his job; the next month, she lost hers. She believes it was stress that started the chronic series of urinary tract infections (UTIs) that have dogged her for more than four years.
Anatomical differences mean women are 30 times more likely than men to contract a UTI. Pregnancy, menstruation and sex all raise the risk. And a higher chance of infection means a higher chance of a drug-resistant infection.
Tamara had contracted UTIs before - but none this persistent. Now, she suffers from excruciating pain and the constant urge to go to the toilet. It has been debilitating. She has tried multiple antibiotics. Some helped reduce her symptoms temporarily, but the infections would always come back.
UTIs are among the most common bacterial infections worldwide - yet when it comes to recurrent UTIs, clinical understanding is lacking. Despite having seen multiple doctors up and down the country, Tamara couldn't find anyone able to cure the infections. In her desperation, she tried various other treatments, including surgical procedures, herbal supplements and medicine she self-administered through a catheter.
A preventable catastrophe
AMR is a threat that stretches over borders and across continents. But this month's UN meeting represents the chance to mount a much-needed global response. Hutin, the WHO director, stressed the importance of urgent action.
"It's important to address [drug-resistant infections] not only for the threat of future things to come but also because the current burden is imminently preventable," he said.
Naveed, Malik, Ahamba and Tamara have already lived through the consequences of the growing crisis. Both Naveed and Malik had been discharged from the hospital when TBIJ last spoke with them. Ahamba had put on weight and was stable and thriving, according to her doctor, but her gastrointestinal problems were still causing issues. And Tamara still carries antibiotics with her wherever she goes. She lives in fear of her next infection.
For Ahamba and Tamara, the future remains uncertain.
