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Mid-life fever

A return to India prompts reflection on cycles of change in medicine and life

We return to our beginnings if we travel far enough on a straight course. I ponder this as I heave my rucksack into a rickshaw and we weave into the Vellorean night. In the driver’s mirror, I see my nineteen-year-old self smiling back. After 30 years I have returned to Tamil Nadu in India for an exam in Tropical Medicine. A line connects the decades like an arrow – a circle in time is complete.

On the plane from Oslo, I had scrolled through the Calcutta Rescue Fund Facebook page. There I found a two-minute film clip of Welshman Dr Jack Preger leaving his home in Kolkata for the last time, one evening in February 2019. Forty years previously he had roared into the city like a lion, tailed by the vicious child-traffickers he had exposed in Bangladesh. Watching the video, I felt a rush of tenderness at the sight of this stooped elderly man walking with a cane, his jacket a little roomy. A handful of his closest helpers were assisting him, a lady in a sari sprinkling blossom in his path as he was silently garlanded with jasmine. The caption claimed his flight home had been unexpectedly changed, preventing the anticipated big send-off, though I suspect this was how he chose to leave. I watched as, out on the hushed street, there were more flowers and people bending to touch his feet while he placed his hand on their heads.

Research into genuine antibiotic alternatives like phage therapy must be prioritised NOW, this year

It’s hard to find adequate words at the close of a career like Dr Jack’s. His heroic achievements have been widely documented: his stubborn determination to confront corruption and bring dignity to the poor of Kolkata. So too has the extraordinary start to it all – the day he was driving his tractor as a 35-year-old farmer in Wales and had an unexpected and “very inconvenient” moment of profound certainty that he had to become a doctor: he said his head “opened and closed and left the instruction permanently in place”. This I can relate to. I became a doctor because of him.

While carrying out undergraduate research into malnutrition and infection at Dr Jack’s Middleton Row clinic in Kolkata in 1992, I suddenly knew with absolute clarity that I was on the wrong path. That I should be studying medicine. Although the research was successful, for the next five years I felt I was carrying a shameful secret. I was wasting time, living the wrong life. I tried to assuage my longing with work in malnutrition in Venezuela, Rome and Ethiopia, and infectious disease epidemiology at the Communicable Disease Surveillance Centre in darkest Colindale. But eventually I had to face up to the torment. I had to become a doctor. I had to close my ears to the lie that had perched on my shoulder when I was a teenager and whispered that I wasn’t clever enough. It was a lie that finally flew away when my name was called for Distinctions on graduation day of the Royal Free Medical School, exactly ten years after that Kolkata summer.

Tuberculosis bacteria under the microscope.

The conditions I saw in the early 1990s – the overwhelming daily flood of patients at the street clinic – directly influenced my choice of specialty as a doctor: leprosy and tuberculosis, parasites and tropical sores. The history of infectious diseases is a rich story of human intimacy, suffering and endeavour. Each generation has its plagues, and our current most pressing crisis comes partly from failure to see our species in the context of its place in the ecology of the world. Thirty years ago antibiotics were relatively reliable – the main challenges at Dr Jack’s street-clinics were the physical threats from the Indian mafia and corrupt politicians. Now, in the lab and on the wards, we are fighting our own “culture wars” at the frontline of the battle against antibiotic resistance. Decades of misuse of antibiotics have led us on a circumnavigation back to the brink of the pre-antibiotic age. India is losing this battle badly, as are Russia and China, but as is the way with ecological systems, their problem is our problem. I imagine the bacteria chuckling like Bond villains at the opportunity we’re gifting them, the disastrous result of our failure to cooperate internationally over antibiotic stewardship practices and antibiotic development. In the last two years I have seen many cultured samples from badly wounded Ukrainian patients in my Norwegian hospital, full of bacteria that’s resistant to every antibiotic we have. This is another, hidden dimension to Putin’s war on the West.

Writing this, I feel a tightness in my chest at the urgency and enormity of the antibiotic crisis – and a hesitancy as to how best to communicate it. Government handling of HIV, Ebola and SARS-Cov-2 epidemics has shown that when appropriate knowledge is shared it acts like a collective disinfectant, whereas poor communication spreads the emotional contagion of panic, fatigue and helpless apathy. Yes, Govey, we do need experts. And it is not enough for microbiologists to sit quietly in the lab observing the evolution of bacterial antibiotic resistance mechanisms with nerdy fascination. This is about human lives. No antibiotics means no safe surgery or cancer treatment. And while responsibility for prescribing drugs lies with regulatory bodies and the medical profession, patients also need to step up. Public awareness of our precious, dwindling antibiotic stocks and self-reliance in terms of hygiene, exposure and compliance with treatment must be improved. Meantime, research into genuine alternatives like phage therapy must be prioritized, NOW, this year. Developing new antibiotics with one mechanism of bacterial-killing action simply buys us time – the bacteria will always evolve eventually to get around it. To paraphrase Einstein – we can’t solve problems by using the same kind of thinking that got us into trouble.

What antibiotic resistant bacteria look like – the white circles are discs impregnated with antibiotics, if the bacteria were sensitive there would be big zones of “no growth” around them.

We tend to fear the things we don’t understand, and the invisible nature of pathogens can give them supernatural powers in the minds of an ill-educated public. Even doctors hate microbiology, I know I did as a medical student, as it was taught so badly. But I wish I could show you how our micro-world has more than enough wonder and jeopardy for an Attenborough series. My working day is like a trip to the zoo. Bacteria, viruses, parasites and fungi have evolved their own individual characters and potential for harm, just like animals, or people. There are the goodies and baddies, the silent passengers of your microbiome and the treacherous, friendly-looking agents that have the power to kill if displaced to the wrong anatomical niche. Sweet Streptococcus anginosus bears the aroma of caramel and looks innocent enough in its home in your throat, but it will bite fast and create an abscess in any organ, given half a chance.

Photo of the author on the road to Karigiri Leprosy Hospital. PHOTO: ASMA AL BALUSHI

My working day is like a trip to the zoo: bacteria, viruses, parasites and fungi have evolved their own individual characters and potential for harm

Pseudomonas aeruginosa shimmers like a metallic rainbow and lights up like flitting fireflies under UV light, but if it swims in your blood the outlook is bleak. Proteus mirabilis marches in beautifully coordinated waves across agar plates, as it does when it colonises your bladder. Scarlet Serratia marcescens thrives in our wet lungs, and also lends its musty odour to old Italian churches with leaky roofs. Miracles have been declared when the Madonna statue appears to weep tears of Serratia “blood”. If you let your dog or your lizard lick you and it gets infected, we will know – each animal has a signature flora. Toxoplasma parasites will set a mouse to chase the cat, and may bend people’s minds to take up risky behaviours too. Strongyloides will sleep for decades having squirmed through the skin of a barefoot child. If the immune system stops keeping watch for whatever reason, the worms will waken from their slumber and burrow through the gut, sharp as chopped tiger’s whiskers. The appearance of the fingers of fungal filaments in your blood is, I’m afraid, a sign that the earth is reaching to take you back… My poor children didn’t need Hilaire Belloc, they got their own cautionary tales at bedtime. What they don’t know about syphilis isn’t worth knowing.

Christian Medical College Hospital, Vellore, waiting area sign. PHOTO: DR PATRICIA CAMPBELL

So here I am again, nose in the frangipani, greeting the geckos on the road to Karigiri Leprosy Hospital. Along this journey I have come to terms with being prone to the fierce kind of love that afflicts those who are receptive to Damascene revelations. Back home my almost-grown children don’t need bedtime stories anymore, and I will soon be free. This is a febrile kind of midlife vertigo: what next? There are 38 years until I am the age Dr Jack was when he left Kolkata – time enough for two more careers if I dare, time to choose my next mission.

Dr Jack Preger may have left Kolkata physically, but he is a spry 93-year-old and his work and influence continue from England. Calcutta Rescue Fund is a UK charity supporting Calcutta Rescue in India. It provides free healthcare, education, vocational training and employment for the poorest people in Kolkata, as well as essential services such as clean water in slums. Donations can be made at calcuttarescuefund.org.uk/make-a-donation

Dr Patricia Campbell is an anthropologist and specialist in Infectious Diseases and Microbiology in Norway

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April 2024, Life

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