Infection
Watching Life and Death Evolve in the World
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In 1932 my grandfather's appendix became infected, burst, and had to be
surgically removed. He was then a child of 11, and antibiotics would not effectively be on the scene for sometime. Russell, my grandfather, told me many years later as an old man in his final years that his doctor told him and his parents that while he'd done this surgery many times, none of the patients ever lived. The surgery generally went fine, but opening the body cavity and removing infected tissue was as precarious as any illness — patients tended to die of infections raging across their bodies. In Russell's case, they kept the wound open for six weeks and washed it continually with saline. He was young and healthy and above all lucky. This boy was the first of his doctor's appendectomy patients to go on to have children and grandchildren and die an old man, weeks after holding his infant great granddaughter on his lap.
His daughter was born in 1953, and I was born in 1973, and neither of us knew a world so dangerous as the one of his boyhood. We both scraped our selves on everything, and needed medical attention for stupid accidents and bounced along our lives oblivious to the terrible dangers that cut down so many of Russell's generation of children. My daughter has mostly had the same childhood as me and her grandmother, though her doctors have had to switch drugs now and again when some little injury wouldn't heal: a little bell ringing for what is to come.
The world's response to nearly a century of antibiotics was ecstatic and unrestrained.
In no time we went from a landscape of doubt and death to massive production of drugs, factory farming, and extreme sports, all unimaginable in a world of infection. We spray antibiotics over animal feed, we give it out like candy. We use it so much it's detectable in our water supplies. We turned all of our medical attention to viruses, imagining bacteria was conquered. Everyone treated antibiotics not only like magic, but a final and permanent lifting of the state of humanity. The creator of Penicillin, Alexander Fleming even reflected some of this sense of magic in his Nobel prize banquet speech:
...destiny may play a large part in discovery. It was destiny which contaminated my culture plate in 1928 - it was destiny which led Chain and Florey in 1938 to investigate penicillin instead of the many other antibiotics which had then been described and it was destiny that timed their work to come to fruition in war-time when penicillin was most needed.
But Fleming also tried to warn that the miracle could not last forever.
But I would like to sound one note of warning. Penicillin is to all intents and purposes non-poisonous so there is no need to worry about giving an overdose and poisoning the patient. There may be a danger, though, in underdosage.... Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. Here is a hypothetical illustration. Mr. X. has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies. Who is primarily responsible for Mrs. X’s death? Why Mr. X whose negligent use of penicillin changed the nature of the microbe.
Moral: If you use penicillin, use enough.
Even used correctly, evolution would always march on. The tenacity of life was always destined to take penicillin’s magic away.
For me it started in Los Angeles when I was 18. One night I sat on the toilet for what seemed like hours, biting a towel to keep from screaming in pain while I pissed blood. I didn't want to go to the doctor. I was on my own and broke and terrified of the bills. The next day a friend took me for a visit to an office and paid; by then though, I was tired, but otherwise back to normal. It was a doctor I'd never seen before and would never see again. He listened, bored, and gave me a prescription for a basic antibiotic. These days I believe that wasn't an infection, but a kidney stone. I took my antibiotic faithfully though, and that, for a moment, was that.
By the time I was 24 bladder infections were a regular part of life. Every time it was cultured, which was not that often, the infection was E. coli. E. coli is a common bacteria that also lives in the digestive tract, generally doing useful things.
While E. coli can come from many sources, I am the most likely source of my infections.
There are various tips the doctors gave me over the years, uncomfortable conversations about hygiene and my personal life — everything from making sure I wipe right and wear the right underwear to how often I can drink coffee or alcohol or have sex — it was like my doctors wanted it to be my fault, because then I could do something about it. But all the doctors in all the talks eventually admitted the most difficult thing: that some women just get infections, and no matter how careful I was, I was one of these women.
Before I had insurance, I got my hands on antibiotics sometimes, often from friends, and when I couldn't I drank cranberry juice by the quart. One night 16 years ago the little E. coli made their way to my left kidney. My fever spiked and the kidney pain was excruciating. I was weak as a kitten. I wandered around in the place I was house-sitting crying and scared, almost as much of the debt I would incur as of dying.
I finally drove myself to the ER the next day and wandered in sweating and swaying on my feet. The intake nurse sat me down and put financial forms in front of me. It was too much. I was unemployed and terrified of not being able to pay, and they couldn't tell me how much I would be in debt for. I refused medical care and got up to leave. Another nurse chased me as I was going out the door, yelling in front of everyone that I could lose the kidney. I stopped, and must have given her a look of pure desperation. She leaned in very close and told me, "Just don't pay. They won't do anything." She led me back slowly and handed me the forms and a specimen cup.
Twenty minutes later a slightly bored doctor was giving me Keflex, another broad spectrum antibiotic. Without that nurse and the Keflex I almost certainly would have died, or been terribly mutilated from within. I drove home, and was back to normal within a few days.
A few years later I finally got insurance and a regular doctor that I saw more than once. He would culture the infection from time to time to decide what to give me. My little E. coli were resistant to Amoxicillin, which I found hilarious, because I wasn't — I am allergic to it. At some point, my E. coli had evolved resistance to a drug that could very well kill me. "My bug is stronger than me!" I joked with my doctor.
Then one day Keflex stopped working. On a report from the culture the little resistance box had flipped from no to yes. "No problem," my doctor told me, "Cipro will work fine," and it did, for a long time.
Over the years I kept losing drugs. I would get infections, take a drug for a while that killed it, but then one day I would take the drug and it wouldn't work anymore.
We, my doctors, my friends, and I would say that I've "lost that drug," as if I misplaced it while I was out.
It is such a gentle way of saying I kept launching killer chemicals at bacteria until they evolved the ability to ignore those chemicals, and could travel back to my left kidney and threaten to kill me again. They made the trip a few times, always to the left kidney. But I was never more than a few days from back to normal, because of those wonderful drugs. An infected organ was not even a reason to skip a day of work.
Cipro was supposed to be a reserve drug, a good antibiotic for adults meant to be on the second line of the battle, to be prescribed when we lost the first line drugs, which we largely have. Most people learned about Cipro after the anthrax attacks in 2001, and people started hoarding it and asking their doctors for it. Pretty soon it was a common antibiotic, and evolution did its thing. One of the last times I saw my doctor before I lost my insurance the little resistance box for Cipro had flipped too.
"No problem —" a drug called Nitrofurantoin was still working. Originally I took the round-robin of drugs my doctors preferred, but I have learned in the past few years to just ask for Nitrofurantoin. And I did, right up to two weeks ago, seeing a volunteer doctor in Hamburg, Germany. He nodded and gave me the drug. "Two times a day, for five days," he told me.
Five days later, a faint but familiar ache had invaded my left kidney, I was weak and had a very mild fever. I realized that I didn't know what drug came after Nitrofurantoin.
carbapenem-resistant Enterobacteriaceae (CRE), in 2001
These days, we are all “losing drugs.”
In the past few years we have come to understand that humans are not organisms on their own. Each body is host to a teeming scope of life that is not us, per se. While the majority of our biomass is us, genetically speaking, of the individual cells that make up our bodies only about half are human at all. (See correction below)
The rest are myriad flora and fauna for whom each one of us is a little galaxy. To our inhabitants we exist on a nearly geologic time scale. For E. coli, a generation can last somewhere between 40-90 minutes, and so a human of normal life span would seem to be around for more than 10 million (relative) years. This is why evolution can happen at the scale of my bladder.
Despite being so unimaginatively bigger than what I contain, I am not the god of this plane of existence anymore than God could ever be a box.
I am a mere container, only dimly aware of the multitudes I contain, who are in turn aware of me not at all. It is changes in this system, changes that take many generations, that we call infection.
There are two kinds of infection. The first is the invader: a tiny foreign beast — in the case of viruses very tiny indeed — that breaches the perimeter of our body-galaxies and manages to grow and colonize spaces inside us. The other kind, the kind I have, is when some bit of our self-but-other population gets thrown out of whack, moved somewhere unwelcome. E. coli is a happy part of my gut flora, one of the millions of organisms that eats every meal with me. Moving to the urinary tract and reproducing, it becomes the nihilistic enemy of all life in Galaxy-me, not merely threatening Quinn, but the trillions of little residents of Quinn, all getting along in a precarious balance I carry around this world, which often seems so much smaller and simpler than the one inside me.
Walking around with my little galaxy at war with itself, I wish I could just tell it to be sensible and we'd all get on as best we could for as long as we could. But the process of infection makes it obvious that life is life, always tenacious and determined as it is delicate and frantic. Life is fractal in its desires and shortsightedness. Humans are so beautiful and clever and hopeful a species that we've exceeded all bounds, and as a result are slowly killing the biome of our precious host, so very much like the little E. coli that are unwittingly trying to kill me. Like us, my E. coli would have to understand that it is not the generation that invades that eventually kills the host, but their offspring, generations unimaginably far in the future, that pay with the death of their galaxy of me.
Ironically, antibiotics are one of the tools we've used to overrun our biome. Along with inventions like nitrogen fertilizers, vaccination, and sanitation, our ability to save and heal, especially for children, has let us become 7 billion. We are out of place and scope, eating and shitting and using everything we can get our hands on in a desperate bid to stay alive. It made us a kind of destructive surface infection for our planet. Perhaps the main thing we have over my E. coli is that we can talk about it.
We can imagine generations, and make different choices out of the abstract love of the unborn. We can perceive and even love our container.
I can only go to war with my infection, two forms of life fighting tenaciously in my body. Currently, my symptoms include some pain with urination, and a long, dull ache in my left kidney that seems like it has always been there and will always be. I am tired and I sleep a lot. I am getting little cramps in my feet, which may or may not be related. Sometimes I seem to have a low-grade fever, but mostly my body is under temperature right now, and I'm always cold.
I hope I find another drug in the next few weeks. I hope my kidney is ok. I have learned there are more drugs to try, but I have also learned that we as a species have given up developing new antibiotics.
I think Fleming may have seen his generation of scientists as the defenders of humanity, a sacred forward guard anointed to protect us from our most deadly enemy. I think he imagined that guard going on through human and microbe generations in an endless arms race against evolution, to save women and soldiers and childhood itself from the real deadliness of life on Earth.
Since Fleming's time fighting bacteria has gotten much harder. But we've taken drugs out of the academic and medical world and made them a product created for profit by a few pharmaceutical companies, and antibiotics never made a lot of money. We aren't looking for new ones. The spread of antibiotic resistant infections notwithstanding, there will be few new antibiotics as long as we are relying on drug companies. They are expensive to make, and per Fleming's warning, must never be taken for too long — the opposite of more lucrative drugs like antidepressants, which are taken indefinitely.
Perhaps this is good news for our biome, but it is bad news for humanity.
It is safe to say that there is nothing I can do about my relapsing infections. What I have will kill me when I run out of antibiotics that can kill it. I can only hope to outrun evolution until I die of something else.
These days I know there's a death waiting for me, that it's in my own body, and what I can hope for is that I get old first.
It would be wise for humanity to find another way, away from drug companies, to contend with infection, and to do it soon. But it would also be wise for us to find a way, a way that spans the centuries to come, to deal with our own infectious qualities. Because there is another death waiting in the world for my own grandchildren, but I believe it is a death we are inventive and creative enough to avert.
I hope I live to see that, too.
I will be on hiatus from Medium, with the exception of a few mostly-written pieces, until my kidney and I win this round.
This story has been corrected. It previously stated one in eleven cells in the human body is human in terms of DNA, the remainder being microbiome species that live in and on us. The real number is closer to one to one. I welcome the chance to correct the error.
