Hhis tiny body attached to machines twice his size, her mother watching over the side of her bed, Yusra was in a fight for life. The baby had severe sepsis, which meant her body turned on itself – her immune system attacked her organs. Doctors tried different antibiotics, but none of them worked.
Yusra and her twins were born two months early, by caesarean section, in Woldia, a hill town in the Amhara region in the north. Ethiopia where rebel and government forces are in violent conflict. Two years earlier, the hospital had been raided by a militia who stripped it of essential supplies. At six days old, Yusra’s sister died for lack of a blood transfusion.
Fearing that she would also lose her second daughter, Yusra’s mother took her on a five-hour journey, past numerous military checkpoints, to a specialist hospital in Dessie.
Sepsis is responsible for one in three newborn deaths in Ethiopia. The condition, whereby the body overreacts to an infection, can be stopped by treating infections with antibiotics. In Yusra’s case, doctors treated her with “first-line” antibiotics – drugs used in the first instance against infections – which proved ineffective.
As they cycled through other types of antibiotics, the baby’s condition worsened. Even if the doctors found one that could save Yusra’s life, her mother might not be able to afford it.
Yusra became a statistic in a growing global emergency. Increasingly, infections that would once have been easily managed with antibiotics no longer respond to the drugs.
In 2019, drug-resistant infections were linked to nearly five million deaths worldwide – more than HIV and malaria combined. More than 20% occurred in sub-Saharan Africa, where the drugs that do exist can be in short supply, incorrectly prescribed and too expensive.
“This is happening on the scale of a pandemic,” Prof Nicholas Feasey, from the Liverpool School of Tropical Medicine, told the Bureau of Investigative Journalism. “African babies are dying in large numbers from this very widespread and serious disease.”
Antibiotics are the cornerstone of modern medicine. Without them, the risk of a deadly infection is present every time someone undergoes routine surgery, gives birth or falls over.
Since Scottish microbiologist Sir Alexander Fleming discovered the first antibiotic in 1928, it has been estimated that nearly 500 million lives have been saved by penicillin alone.
But antibiotics are fighting a moving target. The bacteria that cause infections respond to their environment and, given the opportunity, “learn” ways to repel the drugs designed to kill them.
In the last 25 years, there has been an almost 50% increase in the amount of antibiotics used worldwide. They are increasingly being prescribed by doctors as a first resort for conditions that may not require them, while wealthy patients can claim what they think is a cure. Where resources are scarce, a lack of access to diagnostic tests and vaccines can leave doctors with little choice.
Overuse of these drugs – combined with a lack of clean water, sanitation and hygiene – has caused an alarming rise in antibiotic resistance, with medical progress against infections from typhoid to pneumonia effectively reversed.
Dessie’s neonatal ward has 50 beds. With referrals coming from all over the region, the unit is constantly at full capacity. In a separate room to Yusra, a mother was breastfeeding her newborn baby, named Adonias, who was also struggling with an infection.
After complications during his birth, Adonias showed signs of neonatal sepsis – difficulty breathing, fever, poor feeding and fatigue. The family’s local hospital did not have the tests to identify the bacteria causing the infection and therefore which antibiotics would have the best chance of treating it.
They took a shot in the dark and prescribed Adonias the antibiotic most commonly used for sepsis. When days passed without improvement, Adonias and his mother traveled eight hours to Dessie.
But once again the hospital didn’t have the tests and the doctors had to gamble.
“We usually have to treat them blindly,” says Tarekegn Bitew, a neonatal doctor in the Dessie unit. “If they don’t improve with the first-line antibiotics, we suspect clinical drug resistance and blindly prescribe second-line antibiotics.”
The high concentration of sick people and widespread presence of antibiotics in hospitals can lead to bacteria surviving, becoming stronger and spreading between patients.
The wrong antibiotic prescribed by guesswork means that bacteria will continue to multiply and worsen a patient’s condition.
In another neonatal ward, this time in Lagos, Nigeria’s largest city, Eniyoha, just a few weeks old, was abandoned by her parents.
Eniyoha’s file was thick with notes detailing her condition, complications and treatments. She was born eight weeks early with birth defects that would mean lifelong physical disabilities. Her parents left without explanation; hospital staff thought it was likely that they could not afford the hospital bill.
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Like almost all the babies admitted here, Eniyoha had drug-resistant neonatal sepsis. With limited resources, staff daily swabbed the ward for bacteria and sent samples for testing in government laboratories; results are compiled and used to decide which drugs to use.
So even without the means to test every baby, the staff now had a cheat sheet: a list of antibiotics with a higher chance of success.
In Nigeria, one in 25 babies die before they are a month old. Sepsis is one of the main causes. For premature babies like Eniyoha, the chance of surviving a drug-resistant infection is low.
Eniyoha didn’t respond to first- or second-line antibiotics, so doctors tried a third. In Nigeria, hospitals do not cover the cost of drugs, and for now, donations have been used to foot the bill.
“We come across parents who cannot afford treatment every day,” says Folakemi Irewole-Ojo, medical director of the hospital, referring to the costs faced by patients who require antibiotics.
“It’s the long duration of treatment – by the time the premature babies have spent two weeks here, [the parents’] bag is dry.”
It’s the same in Ethiopia, where hospitals cover some drugs but not all, so it’s standard to try the cheaper medicine first. But if that fails, and a baby needs so-called “last resort” antibiotics like meropenem, then the hospital can’t cover the cost. A full course – about 20 vials – can cost five times the average monthly earnings.
“If we tested in this hospital, we could improve patient management,” says Bitew. “It will also lower the costs for the families.”
One vial of meropenem can sometimes be shared between three babies to make the best use of scarce resources, but at the risk of encouraging infections across wards.
Uncleaned equipment in hospitals with little clean water runs the risk of further contamination. “Sharing hospital equipment is a major source of drug-resistant infections among neonates,” says Jonathan Strysko, an epidemiologist in Botswana. “It is the fact that hospitals have large reservoirs [of bacteria]such as equipment that can never be completely cleaned.
“We need different ways of looking at infection prevention and control measures in the hospital environment.”
In Lagos, the doctors’ extensive notes and observations did their job: Eniyoha’s infection cleared up. Social services are now trying to locate her parents.
Back in Dessie, Adonias also continued to improve and was discharged from hospital. But Yusra did not respond to second-line antibiotics. Her mother tried to get hold of meropenem. It was for sale at pharmacies just outside the hospital gates, but she didn’t have the money to pay for it. Yusra died five days later.
“Most of the patients die,” Bitew said. “Some of them do improve.”
Patient access to testing equipment, vaccinations, clean water, sanitation and hygiene must be addressed, says Feasey, warning that otherwise: “The weakest members of African society will continue to die.”
This story was produced in collaboration with the Bureau of Investigative Journalism
