AS a family physician, I am increasingly confronted by a disturbing reality that should alarm every Pakistani. Children and adults are arriving in clinics with high-grade fevers that simply refuse to respond to treatment. Patients have already swallowed multiple courses of antibiotics. Many have received injections. Some have been treated by several doctors. Yet the fever persists. What we are witnessing is not merely another seasonal outbreak. It is the consequence of years of neglect, poor policy and reckless antibiotic use. Pakistan is now facing a growing epidemic of multidrug-resistant and extensively drug-resistant typhoid and far too few people are talking about it.
There was a time when typhoid fever was a disease doctors knew how to treat. The diagnosis was straightforward and effective antibiotics usually brought recovery. Today, however, we are increasingly encountering strains that resist many of the medicines that once worked reliably. In some cases, treatment options have become alarmingly limited. The tragedy is that this crisis did not appear overnight. We created it ourselves. For decades, antibiotics in Pakistan have been treated as harmless commodities rather than precious medical resources. They have been prescribed unnecessarily, sold freely without prescriptions and consumed by patients as if they were painkillers. During the COVID-19 pandemic, antibiotics such as azithromycin were prescribed on a massive scale despite limited evidence of benefit. Many of us warned that indiscriminate antibiotic use would have consequences. Those consequences are now arriving in our clinics and hospitals.
The usual narrative places all the blame on general practitioners, unqualified practitioners and self-medication. While these are certainly major contributors, the uncomfortable truth is that antibiotic misuse extends far beyond them. Specialists, consultants, pediatricians, intensivists, pulmonologists, gynecologists, dentists and many others must also examine their prescribing habits honestly. Antimicrobial resistance is not the result of one group’s mistakes. It is a collective failure of the entire healthcare system. Adding to the problem is our continued dependence on poor diagnostic practices. Despite repeated warnings from experts, the Typhoid test remains widely used across Pakistan. The test suffers from poor sensitivity and specificity and frequently generates misleading results. Yet it continues to influence treatment decisions even though more reliable approaches exist. The gold standard remains blood culture and sensitivity testing, which can identify the organism and guide appropriate treatment. Unfortunately, by the time cultures are considered, many patients have already received several courses of antibiotics, reducing the chances of obtaining useful results.
Pakistan’s own infectious disease experts have developed evidence-based guidelines for typhoid management. These recommendations emphasize rational antibiotic use, proper diagnostics and antimicrobial stewardship. Yet in many healthcare settings, these guidelines remain largely ignored. The consequences extend beyond individual patients. Families are forced to spend enormous sums on consultations, laboratory tests, hospital admissions and increasingly expensive antibiotics. Children miss school. Adults lose income. Complications become more common. What was once a treatable infection is becoming an economic and medical catastrophe for ordinary households. The problem is also larger than Pakistan. As highlighted in recent international literature, Pakistan has become the epicenter of extensively drug-resistant typhoid, with cases exported through international travel to countries including the United States, the United Kingdom and Canada. The world is paying attention because antimicrobial resistance does not recognize borders. A resistant bacterium originating in one city can quickly become a global threat.
Equally concerning are the environmental conditions that continue to fuel transmission. Unsafe drinking water, poor sanitation, inadequate waste management and contaminated water supplies create ideal conditions for typhoid to spread. Unless we address these underlying determinants, we will continue treating the consequences while ignoring the causes. Perhaps the most frightening aspect of this crisis is that it offers a glimpse into a future where common infections once again become lethal. Modern medicine depends on effective antibiotics. Without them, routine infections, surgeries, childbirth and cancer treatments all become more dangerous. The emergence of XDR typhoid is not merely a warning. It is evidence that the era of antibiotic complacency is over.
Pakistan urgently needs stricter regulation of antibiotic sales, enforcement of prescribing standards, wider access to blood culture testing, elimination of unreliable diagnostic practices, expansion of typhoid vaccination and major investments in water and sanitation infrastructure. Most importantly, we need honesty from the medical profession itself. If we continue to prescribe antibiotics irresponsibly while pretending the problem belongs to someone else, we will soon discover that there are no antibiotics left to save us. The fever is rising. The bacteria are adapting. The question is whether we will act before this preventable crisis becomes an irreversible disaster.
—The writer is Professor of Public Health, Shifa Tameer-e- Millat university,
Islamabad ([email protected])
