HWith her tiny body hooked up to machines twice her size, her mother standing guard beside her bed, Yusra was in a fight for survival. The baby had severe sepsis, meaning her body had turned on itself – her immune system was attacking her organs. Doctors tried several antibiotics, but none worked.
Yusra and her twin brother were born two months prematurely, by caesarean section, in Woldia, a hill town in the Amhara region of northern Ethiopia, where rebels and government forces are locked in a violent conflict. Two years earlier, the hospital had been raided by militia and stripped of essential supplies. At six days old, Yusra’s sister died from lack of a blood transfusion.
Fearing she would lose her second daughter as well, Yusra’s mother took her on a five-hour journey, past numerous military checkpoints, to a specialized hospital in Dessie.
Sepsis is responsible for one in three newborn deaths in EthiopiaThe condition, in which the body overreacts to an infection, can be stopped by fighting the infection with antibiotics. In Yusra’s case, doctors had treated her with “first-line” antibiotics – drugs used first to treat infections – which were ineffective.
As they tried other types of antibiotics, the baby’s condition worsened. Even if doctors found one that could save Yusra’s life, her mother might not be able to afford it.
Yusra has become a statistic in a growing global emergency. Infections that were once easily treated with antibiotics are increasingly unresponsive to the drugs.
In 2019, drug-resistant infections were linked to nearly five million deaths worldwide – more than HIV and malaria combinedMore than 20% of cases occurred in sub-Saharan Africa, where drugs that do exist are scarce, misprescribed and prohibitively expensive.
“It’s happening on a pandemic scale,” Prof Nicholas Feasey from the Liverpool School of Tropical Medicine told the Bureau for Investigative Journalism“African babies are dying in huge 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 cuts themselves from a fall.
Since Scottish microbiologist Sir Alexander Fleming discovered the first antibiotic in 1928, it is estimated that nearly 500 million lives have been saved by penicillin alone.
But antibiotics fight a moving target. The bacteria that cause infections respond to their environment and, given the chance, “learn” ways to ward off the drugs that are supposed to kill them.
Over the past 25 years, the amount of antibiotics used globally has increased by almost 50%. They are increasingly prescribed by doctors as a first resort for conditions for which they are not necessary, while wealthy patients can demand what they think is a miracle cure. Where resources are scarce, lack of access to diagnostic tests and vaccines can leave doctors with few options.
Overuse of these drugs – combined with a lack of clean water, sanitation and hygiene – has led to an alarming rise in antibiotic resistance, effectively negating medical advances against infections from typhoid to pneumonia.
Dessie’s neonatal intensive care unit has 50 beds. With referrals from all over the region, the unit is constantly full. In a separate room next to Yusra, a mother was breastfeeding her newborn baby, named Adonias, who was also battling 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 did not know which antibiotics would have the best chance of treating it.
They took a chance and prescribed Adonias the antibiotics most commonly used to treat sepsis. When days passed without improvement, Adonias and his mother traveled eight hours to Dessie.
But again, the hospital did not have the right tests and doctors had to guess.
“We usually have to treat them blindly,” says Tarekegn Bitew, a neonatal physician at the Dessie Unit. “If they don’t improve with first-line antibiotics, we suspect clinical drug resistance and blindly prescribe second-line antibiotics.”
The high concentration of sick people and the widespread presence of antibiotics in hospitals can allow bacteria to survive, grow stronger and spread between patients.
If the wrong antibiotics are prescribed based on guesswork, bacteria continue to multiply and the patient’s condition worsens.
In another newborn ward, this time in Lagos, Nigeria’s largest city, Eniyoha, just a few weeks old, had been abandoned by her parents.
Eniyoha’s file was filled with notes about her condition, complications and treatments. She had been born eight weeks premature with birth defects that would mean lifelong physical disabilities. Her parents left without explanation; hospital staff thought they probably wouldn’t be able to pay the hospital bill.
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Like almost all the babies admitted here, Eniyoha had drug-resistant neonatal sepsis. With limited resources, staff scanned the ward daily for bacteria and sent samples for testing at government labs; the results were collected and used to decide which drugs to use.
Even without the resources to test every baby, staff now had a cheat sheet: a list of antibiotics with a greater chance of success.
In Nigeria, one in 25 babies die before they are one month old. Sepsis is one of the leading causes. For premature babies like Eniyoha, the chance of survival from a drug-resistant infection is slim.
Eniyoha had not responded 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 were used to pay the bill.
“We come across parents who cannot afford the treatment every day,” says Folakemi Irewole-Ojo, the hospital’s medical director, referring to the costs patients face when they need antibiotics.
“It’s the long duration of treatment: by the time the premature babies are here for two weeks, the (parents’) wallets are empty.”
The same is true in Ethiopia, where hospitals cover some but not all drugs, so it’s standard to try the cheaper ones first. But if these don’t work and a baby needs so-called “last resort” antibiotics like meropenem, the hospital can’t cover the cost. A full course of treatment – about 20 vials – can cost five times the average monthly salary.
“If we had testing in this hospital, we could improve patient management,” Bitew said. “It would also reduce costs for families.”
Sometimes one bottle of meropenem is shared by three babies to make the most of limited resources, but there is a risk of promoting infections in multiple departments.
Undecontaminated equipment in hospitals with little clean water is spreading further contamination. “Having to share hospital equipment is a major source of drug-resistant infections among newborns,” says Jonathan Strysko, an epidemiologist in Botswana. “The fact is that hospitals have large reservoirs[of bacteria]such as equipment that can never be fully cleaned.
“We need different ways of looking at infection prevention and control in the hospital.”
In Lagos, the doctors’ extensive notes and observations had done their job: Eniyoha’s infection had disappeared. Social services are now trying to track down her parents.
Back in Dessie, Adonias continued to improve and was discharged. But Yusra did not respond to second-line antibiotics. Her mother tried to obtain meropenem. It was available at pharmacies just outside the hospital gates, but she did not have the money to pay for it. Yusra died five days later.
“Most patients die,” Bitew said. “Some of them improve.”
Patient access to testing equipment, vaccinations, clean water, sanitation and hygiene must be addressed, says Feasey, who warns that otherwise “the weakest members of African society will continue to die.”
This story was produced in collaboration with the Bureau for Investigative Journalism