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 While drug resistance is a problem in hospitals the world over,
early evidence from tracking by Medecins Sans Frontieres (MSF) in
the last two years suggests it may be acute in Afghanistan.
At the trauma center in the northern city of Kunduz, where Afghan
forces are battling Taliban militants, staff have identified nearly
100 cases of multi-drug resistant bacteria, or nearly 30 percent of
samples tested, since last year.
That is putting extra strain on the MSF-run facility already
struggling to cope with wounded combatants and civilians.
One hot morning in mid-June, the halls of the clinic quickly filled
with wheeled stretchers carrying around a dozen bloodied Afghan
security personnel hurt in a mortar attack by insurgents.
One man struggled for breath, and a waft of iron hung in the air as
staff wiped blood stains from the white-tiled floor.
Not far away, teenager Zemairy, one of whose legs had to be
amputated after a mortar round went off in his back yard several
days before, lay in a quiet isolation ward.
His wounds had become infected and the drugs he was taking were not
helping. Staff tested the wounds for resistant bacteria and started
treating him with a different drug, after which his health began to
improve.
By late June, he had been hospitalized for nearly 40 days.
"I thought I was going to lose him, or that maybe he'd lose his
other leg," said Ameer Muhammad, Zemairy's father.
Doctors in Kunduz do not have enough comparative data to chart the
long-term trajectory of the problem, but they are worried.
The hospital plans to expand its laboratory to test patients' blood
in order to better pinpoint which organisms are causing infection
and what drugs to use to treat them; at present, the lab can only
test pus from openly infected wounds.
"I'm sure the rates are higher, but we can't see it," said Kathleen
Thomas, head of the hospital's intensive care unit (ICU) and the
emergency room. "I think it's a big problem."
QUALITY CONTROL
In the southern province of Helmand, another Afghan region where
militant violence is common, staff at an MSF-supported hospital
noticed patients with respiratory tract infections and diarrhea were
not getting better.
An ensuing 2013-14 study showed high levels of resistance to widely
used antibiotics among those being treated at the hospital.
Doctors say the probable causes of the problem include
over-prescription and patients not finishing courses of treatment.
In Afghanistan drug resistance may be made worse by medicines of
suspect quality being illegally imported into the country.
"The general population has a big problem of resistance because of
self-medication and patients putting pressure on doctors (to
prescribe drugs)," said Abdul Qayoum Wardak, who oversees MSF's
laboratories in Afghanistan.
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Nearly 60 percent of medicine in Afghanistan enters through illegal
channels, said Abdul Khalil Khakzad, head of the Avicina
Pharmaceutical Institute in Kabul, possibly contributing to what
doctors suspect is a glut of ineffective drugs on the market,
including antibiotics.
Though many of the smuggled drugs may be fine, the lack of
information may already be contributing to drug resistance, as some
doctors try to over-correct for presumed low quality.
Officials in Afghanistan's health ministry blame the country's
porous borders with Pakistan and Iran for the proliferation of
unregulated drugs.
"We can control drug stores, but we can't control the highways,"
said Abdul Hafiz Quraishi, head of the General Directorate of
Pharmaceutical Affairs.
President Ashraf Ghani's government has worked to rein in the
sector, and Pakistan's drug regulatory authority said cross-border
cooperation was improving.
"The (Afghan) complaints are not going into the filing cabinet,"
said Muhammad Aslam, head of the government-run Drug Regulatory
Authority of Pakistan. "Either (the companies) will be given time to
improve themselves or they will be shut down."
ONGOING BATTLE
For hospital staff in Kunduz, trying to control life-threatening
bacteria in the midst of an escalating conflict requires extreme
measures, including flying in expensive drugs from thousands of
miles away.
Like other MSF facilities in Afghanistan, the clinic only prescribes
medicine from the organization's own stocks, and does not use drugs
from the local market.
It also means finding space to isolate patients in wards that are
treating nearly twice the number of war casualties as last year.
Earlier this month, doctors had to isolate two patients they
suspected had different strains of resistant bacteria in the ICU's
only isolation room and keep a third with ICU patients, potentially
exposing others.
Staff suspect some of the resistant bacteria are passed between
patients whose immune systems have been compromised, a common
problem in hospitals.
But the fact that the center treats so many victims with open wounds
means some may be already contaminated by the time they arrive,
suggesting the resistant bugs could also be living outside, in the
community itself.
(Additional reporting by Mirwais Harooni in Kabul and Katharine
Houreld in Islamabad; Editing by Mike Collett-White)
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