When germ becomes supreme

Mankind is falling victim to infections against which no antibiotic is effective. Over-prescription is to blame, says DR. B.M. HEGDE.

NEARLY 70 years ago, when Alexander Fleming and Prof. Florey discovered the mouldy growth on their culture plates to be a powerful antibiotic - pencillin - a new era began in medicine. The predicitions then were that the end of man's fight against germs on this planet was drawing closer. Like all other predictions in linear science, this one has also been belied.

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 pencillin. While 95 per cent of these germs could be easily killed by penicillin to begin with, today they are resistant to pencillin.

Illnesses change history dramatically. The black death due to plague in Europe in the 16th Century and the white death - extreme anaemia and tuberculosis - have been some of the greatest tragedies. Tuberculosis still eludes a cure.

In fact, it has become much more rampant and dangerous now that AIDS abets and assists the former. Tuberculosis has assumed a different form these days because of changing circumstances. Historical milestones of tuberculosis include the hunchbacks of Egyptain 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.

The gravity of the situation is such that the Royal College of Physicians of London organised a meet to discuss the "Clinical implications of Anti-microbial Resistance" in February. It has been estimated that around 15,000 people die in that country every year from infections against which no antibiotic is effective. Such germs are called superbugs. One of the biggest hospitals in that country, Portsmouth Hospitals NHS Trust, was forced to shut down most of its operating theatres last summer because of superbugs there. At the Queen Alexandra Hospital, 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 problem would be that of drug resistant tuberculosis.

An outbreak of TB in Scotland recently was traced to a family that had been travelling.

The usual thinking in the West is 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 (U.S.) shows how the threat is not confined to poor countries alone but is greater in the West, because doctors there over-prescribe antibiotics. She writes, "doctors who over-prescribe antibiotics undermine the health care system by encouraging germs to become resistant".

Consumers and patients, are to blame too as they demand antibiotics for common and trivial infections, most of which are viral to begin with. The fear of losing patients makes many doctors oblige patients with over-prescribing. Educating the public about the dangers of taking antibiotics for minor infections against medical advice is needed.

Studies in the United States have shown that it is rich children who suffer more from common childhood infections. Since antibiotics are expensive, some parents do not bother to give them to their children for minor illnesses. This helps the child fight the infection. This has another ramification. Antibiotics given for minor viral illnesses of childhood make the immune system change its response 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. Children in slums when they have enough to eat, have very robust health and a low incidence of asthma and many other common illnesses.

The other dangers of antibiotics are in commercial applications like farming and the dairy industry. The amount of antibiotics used in cattle and broiler sheds far outweighs that used in hospitals and operation theatres. Today it only takes six weeks to get a bird on the dining table from hatching. Birds come cheaper, but it means that we get a huge dose of antibiotics each time we bite a chicken lollipop. This does not take into account the hazards of excessive hormones used to fatten the birds.

Mastitis in cows is another danger. The incidence is around 10 per cent of cows in a dairy on a given day. The huge amount of antibiotics, like ciprofloxacin, injected into the udder (a dose costs Rs. 8,000) makes milk not potable for a week.

The House of Lords in Britain was worried about the largescale 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".

Recently, at the Prince Edward Hospital in Wales, a patient had an infection in his leg wherein the germs were resistant to antibiotics. Doctors had to use maggots to help the wound heal, a common way of controlling bacterial infections, evident even during World War II.

Minor wounds can be smeared with fresh honey. Honey coats the wound, preventing germs from multiplying.

The time bomb of tuberculosis is threatening to explode anytime now. The West is in the middle of its worst TB epidemic in the past 20 years. Sanatoria, good food, complete rest and a healthy environmnet were given up as being of no value. 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 multiple drug resistant germs of this deadly disease, waiting to produce another epidemic of the white death. In his treatise The White Death (The Hambledon Press), Thomas Dormandy narrates horror stories of the hoary past with even people like Napoleon Bonaparte having suffered its ravages.

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 extent of TB in the country. The anti-TB drug situation at that time was 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 conventional forms of treatment. The use of anti-TB antibiotics should be banned in the country for 10 years, he said as his reasoning was that those who die of the disease would die anyway and take the germs with them to be burnt or buried, ending the germ's life cycle. For the rest of the patients who survive, their immune system would kill the germs. In the following decade 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. The report was ridiculed in the Parliament and rejected. 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.

The writer is Vice-Chancellor, Mahe (Deemed) University, Manipal.

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