The Drugs Don’t Work

In the past week, I have seen two newborn babies with gonorrhoeal infection in their eyes. Putting this in perspective, I have only seen two cases in 25 years working in general practice and sexual health in England.

Most doctors believe that the infection occurs when the baby descends through the birth canal, but there have been reports of babies who were infected despite being born by Caesarian section. The bottom line is that the mother is also infected. And her partner, too.

The neonatal gonococcal ophthalmia did not improve with the standard antibiotic treatment, so I had to use injectable gentamicin. The local strain of gonorrhoea has developed resistance to most antibiotics, including all those used for “syndromic treatment” in the national prescribing guidance. Syndromic treatment is promoted by the WHO for situations where sophisticated lab tests are lacking. If someone has a urethral discharge, they get treated with a cocktail of drugs for all the diseases which commonly cause discharge. Unfortunately, Zambia lacks the drugs recommended as they are too expensive, and the alternatives just don’t work.

I realised this in the first week I was here when I saw some patients whose symptoms had not improved despite repeated courses of antibiotics. I persuaded Trognes, the lab technician, to perform Gram stains on slides of dried discharge, which all showed the classic signs of gonococcal infection: gram negative intracellular diplococci. The diagnosis was correct; the treatment was failing.

Why didn’t the drugs work?
Was the patient still having sex with an infected, untreated partner?
Was the patient not taking the drugs, but selling them?
Were the drugs counterfeit?
Or lacking in potency because they were bought cheaply from countries, where they had been manufactured without good quality control measures?

The most likely explanation was that the gonorrhoea was resistant to the antibiotics.

I checked on the internet and found an article in a reputable journal about treatment of multi-drug resistant gonorrhoea in the USA. The authors reported that over 400 patients with resistant gonorrhoea had been cured using gentamicin and doxycycline. They had no treatment failures. Neither have I since adopting this regime.

I asked the mother whose baby’s eyes were infected to bring in her husband and I would treat them both together. The following day, she returned for treatment but said that her husband had refused, because he didn’t have a problem. When I suggested that she should refuse to have sex with him until he had been treated, the nurse with me exclaimed, “Eeeh, Doctor! You can’t do that. It is her duty to submit to her husband by law. She cannot refuse him his rights. He would throw her out of the house in disgrace.”

The Kunda people who populate this part of Zambia have strongly held traditional beliefs about the role of women. Girls go through two “coming of age” secret ceremonies, one when they start puberty and another before they are married (in Zambia, the legal age for marriage is 14, legal age for sexual intercourse is 16). The first ceremony teaches the girls how to behave as women, how to deal with periods, how to show respect, etc. The second initiation is conducted by an older female relative, their granny or great aunt. She teaches them how to please their future husbands, using sexual techniques, how to demonstrate thanks when she has had sex or been given a present. Boys have no such training, but they know they have a duty to satisfy their future wives or this could result in divorce.

Let me stress that this is not universal in Zambia. There are over 70 tribes in the country, each with their own culture, language and traditions.

Yesterday, I was the medical officer at the local sports day. One of the events was a 100 metre race carrying a water bottle. Balanced on your head. Both sexes could enter, but it was won easily by the women. Over the sound system, the master of ceremonies praised the winner, saying, “And here in Zambia, we know the true value of a woman by how much she can carry on her head.”