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NAIROBI, Kenya – Sharon Mbone decided it was time to try another medicine four days after her toddler's health deteriorated. Her tiny body was ravaged by fever, diarrhea, and vomiting.
Having no money to see a doctor, she took him to the local pharmacy, a corrugated hut near her home in Kibera, a vast slum in Nairobi. Shop owner John Otieno listened to the conversation, describing the symptoms of his 22-month-old son and preparing the pharmacological medication buffet he had given her over the previous two weeks. None of them, including four types of antibiotics, was working, she said with desperation.
Like most small traders who provide on-site diagnostics and treatments here and in Africa and Asia, Mr. Otieno does not have a pharmacist degree or any medical training. Despite everything, he managed to take two antibiotics that he had not yet sold to Ms. Mbone.
"See if it works," he said, handing him 1,500 shillings for both, about $ 15.
Antibiotics, miracle drugs that have saved tens of millions of lives, have never been more accessible to the world's poor, largely thanks to the mass production of generics in China and India. In most developing countries, the purchase of drugs such as amoxicillin, a first-line antibiotic that can be used against a wide range of infections, from bacterial pneumonia to chlamydia to salmonella. Strep throat and Lyme disease cost only a few dollars.
The people of Kibera are big consumers of antibiotics. A study found that 90% of households in Kibera had used antibiotics the previous year, compared to about 17% in the typical American family.
But the increasing availability of antibiotics has accelerated an alarming disadvantage: the drugs lose their ability to kill the germs for which they were created. Wired to survive, many bacteria have evolved to thwart drugs.
And as these mutant bacteria mingle with other pathogens in wastewater channels, hospital wards and animal pens, they can share their genetic resistance characteristics, thus making Other microorganisms insensitive to antibiotics.
Antibiotic resistance is a global threat, but it is often seen as a problem in rich countries, where comfortably insured patients rush to the doctor's office to ask for a prescription at the slightest sign of a cough or cold.
In fact, urban poverty is a huge and largely unknown factor of resistance. Thus, the rise of resistant microbes has a disproportionate impact on poor countries, where squalid and overcrowded living conditions, careless monitoring of antibiotic use and a dearth of affordable medical care fuel the spread of disease. infections less and less sensitive to drugs.
"We can not effectively mitigate the growing problem of antibiotic resistance without dealing with places like Kibera," said Guy H. Palmer, a researcher at Washington State University who studies resistance in Africa. "One billion people live in similar situations and as long as they do not have access to safe water and basic sanitation, we are all in danger."
Worldwide, resistant pathogens already claim 700,000 lives each year, according to a British study. Resistance here in Kenya is not just a potential calamity for future generations: the lack of effective treatment is already making thousands of victims every year, many of them young children whose immune systems are yet to fully develop, according to government figures.
Sam Kariuki, a researcher at the Kenya Medical Research Institute, who has been studying resistance for two decades, said nearly 70% of salmonella infections in Kenya had stopped responding to the most widely available antibiotics, up from 45% in the early 2000s.
Salmonella kills an estimated 45,000 Kenyan children each year, nearly one in three who suffer severely, he said. In the United States, the death rate is close to zero.
"We are quickly running out of treatment options," said Professor Kariuki. "If we do not solve the problem, I fear for the future."
"Who am I to deny them what they want?" Asked Lena Ochomba, a pharmacist who owns a pharmacy in Kibera, who earns most of her income by selling antibiotics, often three or four tablets at a time. one-third or more. less than the recommended course for most antibiotics. "Even when I can sell the whole box, my clients rarely take it because they think it's too many pills."
Poor sanitation, endemic disease
There is no human waste that escapes to Kibera. It flows from shallow hand-dug latrines, pools into streams and eventually turns into a black river.
At night, those who are afraid of venturing out throw plastic bags filled with excrement. Residents call them flying toilets.
Ms. Mbone and her husband have become insensitive to the sight and smell of untreated sewage that drains to their one-room cabin. Shane, their son, and his 3 year old sister, have no other place to play, sometimes end up frolicking. "They are children, they will always play outside," said Mbone, 19. "How can you stop them?"
A plastic bucket overflowing with store-bought drugs is a testament to Shane's years of suffering. Born prematurely, he spent his first weeks in a clinic and then in a hospital. Even with subsidized care, the medical costs amounted to about $ 200, the equivalent of 10 months salary that Ms. Mbone's husband earned as a guardian of the bus station. Since then, she has been reluctant to take Shane to a doctor. "I'm worried if I go to a bigger hospital, the bill will be bigger too," she said.
Mbone is not convinced that Shane's health problems are causing unhealthy conditions. Other children play in the Kibera drainage ditches, she noted, while few are overwhelmed by the constant diarrhea affecting her son.
Epidemiologists and public health experts who have studied Kibera say there is a direct correlation between poor community hygiene and infections in almost every household. The harmful bacteria present in the feces that seep into the surrounding soil can survive for months, and in densely populated settlements such as Kibera, veined by dirt roads, they are easily found in food and food. Water, often by residents who unconsciously carry pathogens. in their homes on shoes or unwashed hands.
"A lack of sanitation causes more illnesses, which leads to increased use of antibiotics, as well as increased resistance," said Marc-Alain Widdowson, senior deputy director of the Division of Health. Global Health Protection for Kenya from the CDC. surveillance in Kibera since 1979. "It's a vicious circle."
Sylvia Adhiambo Omulo, a researcher at Washington State University's Global Health Program, who spent several years studying antimicrobial resistance in Kibera, said she was stunned by the omnipresence of resistant pathogens such as coli.
"It's in the soil, it's on the kale that people eat, but also in the hands of adults and children," she said one afternoon as she walked the trails Muddy Kibera, avoided children, stray dogs and occasional chicken. "It's no wonder people here are constantly sick."
When residents do not feel well, they often turn to people like Mr. Otieno, the roadside drug vendor, who wears a white coat and keeps the light bulb on late at night in his stand.
Ms. Mbone is counting on him for affordable medicine, but also for a listening ear and an occasional loan. "These chemists are my neighbors," she said. "I trust their advice."
Mr. Otieno, 32 years old, has been living in Kibera for a long time. Unable to find a full – time job after high school, he spent several years helping another chemist in the neighborhood until he saved enough money for his store.
With his light blue interior, his medical posters hanging on the wall and his wardrobe overflowing with bandages, Mr. Otieno's stand could be mistaken for a dispensary. Despite his lack of training, he said that years of practical experience helped him make his prescribing decisions, and he knew that antibiotics did not work because they often did not cure the people who bought them.
"There is a lot of antibiotic resistance here," he said. "That's why people keep coming back to get different antibiotics."
After cycles of antibiotics, limited options
If Ntihinyuirwa Thade had been aware, doctors at the Kijabe mission hospital would have asked questions about his medical history, including a list of antibiotics that he had taken in recent years. But Mr. Thade, a 25-year-old Rwandan migrant worker, fell from the top floor of a construction project on a fan and was unconscious. He was not wearing a helmet and suffered a serious head injury.
A week after the accident, he was faced with a more immediate threat: a Klebsiella pneumonia infection bloomed in his lungs. Since Mr. Thade's health condition did not respond to the three antibiotics already injected into his veins, his doctor, George Otieno (no relation to Mr. Otieno, the owner of the pharmacy), was preparing to administer the drug. final drug in its limited arsenal, a relatively expensive antibiotic called meropenem. "If it does not work …", he says, his voice goes off.
Klebsiella bacteria are ubiquitous in the environment – in the soil and in the human intestines – but they can become deadly to people whose immunity is worn out.
Dr. Otieno acknowledged that Mr. Thade probably acquired his own by the plastic breathing tube that kept him alive.
Many of the world's leading medical institutions are struggling against resistant microbes, and Kijabe, one of Kenya's best hospitals, is no different.
Nestled in a green valley on the outskirts of Nairobi, it features state-of-the-art equipment and a mix of Kenyan and foreign doctors drawing patients from all over the country. But being a referral hospital has a disadvantage: many people arrive sick and have already consumed a multitude of antibiotics. "Often, they took all the commonly available medications," said Dr. Evelyn Mbugua, an internist.
That day, Mr. Thade was one of the patients struggling to defeat resistant insects. In the pediatric ward, Blessing Karanja, a one-month-old baby, battled a worrying blood infection and, elsewhere in the hospital, Grace Mutiga, a retired nurse of 65, was back with a respiratory infection tenacious.
Having taken five different antibiotics in recent weeks – drugs purchased at the local pharmacy – Ms. Mutiga was running out of options. "We will have to see if we can get an antibiotic in Nairobi," said a doctor while Ms. Mutiga was struggling to catch her breath.
In Kenya and other emerging economies, the most effective antibiotics are not always available or affordable. Loice Achieng, an infectious disease doctor at Kenyatta National Hospital, shook her head as she recalled a recent patient, a 65-year-old kidney transplant patient who was infected with Pseudomonas aeruginosa, a bacterial disease often contracted at the age of one. hospital.
After the patient had taken all the appropriate antibiotics available in Kenya, Dr. Achieng told the family that their only hope was Avycaz, a four-year-old American-made drug. However, there were barriers, including paperwork for Kenyan customs officials and a $ 10,000 price for a 10-day course. After several days, her children managed to raise the necessary funds, but it was too late. The man is dead.
"I do not think we are going to solve this problem"
Kenya has formally adopted what public health experts call antimicrobial stewardship, namely, to combat resistance by reducing the excessive use of antibiotics, promoting immunization and encouraging an increase in antibiotics. better hygiene for hospital staff. In the past two years, many medical institutions in the country have put in place management committees. Wall mounted hand sanitizers have become a common sight in hospital hallways and patient waiting areas.
But the government has made little progress in enforcing laws that require prescriptions for the purchase of antibiotics, nor has it done much to stem the flood of illicit drugs that are spreading across the border. more than 400 km from Somalia to Somalia.
"It's more difficult than we thought," said Dr. Widdowson of the C.D.C., who advises the government.
Back at Kijabe Hospital, Mr. Thade's situation was getting worse and worse. While the nurses were preparing for a new x-ray, Dr. Otieno spoke about the challenges to fight against drug resistance.
Dr. Otieno, 36, is a passionate, open-eyed and expressive man who is the foundation of the hospital's recently established antimicrobial management program. But he expressed his frustration at the lack of progress, describing overworked nurses reluctant to adopt complex hygiene protocols and the hospital pharmacy, which, he said, continued to surpass antibiotics.
"To be honest, based on the past, I do not think we will solve this problem. I do not think our government thinks it's a big problem, "he said, as Thade's swollen body was transported on a wagon.
"I'm worried about my country, but also about my own family. One day, I could go home and infect my own children with one of these dangerous insects.
In the days that followed, Mr. Thade's condition stabilized enough for him to be expelled from the intensive care unit. Although his wounds prevented him from walking, he regained consciousness and seemed to recover, his doctors said, but the infection was stubborn and gave no reason for meropenem, the best antibiotic in the arsenal. hospital. Three months later, after the infection spread to his blood, Mr. Thade died alone in bed and away from home. "May God rest his soul," said Dr. Otieno.
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