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IN 64 BC, when Marcus Cicero was running for the post of Roman consul, his brother Quintus gave him advice on how to win an election. One piece of advice was to promise everything to everyone, but keep only those promises that benefited him.
It appears that our politicians have embraced Quintus’ advice. These days politicians are making all kinds of grand promises to everyone, including providing millions of jobs, clean water, a great education, and eliminating poverty. None of the promises go into detail.
Let’s just examine one issue: clean water. Every politician talks about giving people access to clean water, but the ‘how’ is missing. The lack of clean water, and a poor sewage infrastructure are so devastating that they have caused a deadly illness to spread in Hyderabad. This disease, as recent research by Wellcome Trust Sanger Institute and the Aga Khan University determined, is called Extensively Drug Resistant (XDR) typhoid.
XDR typhoid needs a certain set of conditions and a particular geography to emerge and spread. It requires a high burden of typhoid in the community. Further, it needs an opportunity through which typhoid bacteria can acquire additional resistance, most likely from another resistant bacteria, either within a patient or in the environment eg, broken sewage infrastructure. Finally, it needs a mechanism for spreading, through inadequate hygiene, the lack of safe water, and poor sanitation. All these conditions were there in Hyderabad.
Poor sanitation has contributed to the spread of XDR typhoid.
Poor sanitation and sewage infrastructure are important factors in the spread of XDR typhoid. Sadly, there is ample evidence that our environment enables the spread of such diseases.
The 2017 report of the commission of inquiry led by Justice Kalhoro of the Sindh High Court is an eye-opener. The report found that overall 85 per cent of water samples in Hyderabad were unsafe for human consumption. My assumption is that this rate is likely similar in some cities of other provinces too.
I recently had a conversation with the lead author of the study that identified XDR typhoid. The details are scary.
XDR typhoid is expensive to treat because it does not respond to first-line antibiotics. Patients with the illness are treated with second-line drugs, which are not only more costly, but may also be difficult to administer at home, requiring hospital admission. Presently, diagnosis of XDR typhoid is expensive and available in only a limited number of laboratories, potentially causing delay. Such delay results in multiple rounds of antibiotics before appropriate therapy can be started, resulting in higher risk of complications and greater out-of-pocket expenditure. Obviously, the poor suffer the most.
The misuse of antibiotics in our community has enabled antimicrobial resistance (AMR) to flourish, which is why first-line antibiotics are becoming ineffective. Pharmaceuticals provide incentives to doctors and pharmacies, leading to over-prescription. Easy, over-the-counter availability of antibiotics and low-quality medicines further contribute to AMR. The situation is exacerbated by inadequate access to quality healthcare, which drives patients to seek the care they can afford. The issue of AMR must be taken seriously, otherwise many common diseases won’t be treatable anymore.
XDR typhoid needs immediate attention. Between December 2016 and September 2017, there were more than 800 cases and four deaths. The updated figures are much higher. The disease has now spread beyond Hyderabad to Karachi and other parts of the country. Undiagnosed international travellers have caused the disease to spread beyond our borders, making it a worldwide public health issue. Recently, the US issued an XDR typhoid-related advisory for travellers to Pakistan.
So what’s the solution? In the short term, it is vaccination and better monitoring. Doctors need to be aware of this strain of typhoid, so they can treat it immediately. Moreover, medical laboratories should be well equipped to detect it. Particularly in rural areas, access to quality diagnostics is limited. The recent National Laboratory Policy is a welcome step towards ensuring quality practices. However, implementation of this policy is urgently required to ensure access to accurate diagnoses. It is also important that all cases of XDR typhoid be reported.
In the long term, the state has to prioritise citizens’ welfare. Access to clean water and good healthcare is a basic right. There seems to be a lack of government intervention and commitment, which has worsened healthcare concerns.
We must hold our politicians accountable. Instead of making grand promises, politicians should focus on providing citizens basic necessities, and demonstrate how they plan to do that. I hope they are not waiting for another catastrophe.
The writer is a freelance contributor based in Lahore.
Published in Dawn, July 22nd, 2018
