19 July 2013

Where is my spoon full of sugar?

Even for someone who works for an organization specializing in emergency health care, it’s been a medically-focused day. Prior to departing for the office, we had to re-load about 100 mosquito nets into the Land Cruisers for delivery to some clinics; we took them out when we went to dinner last night so that they wouldn’t get pilfered. Then, during the morning security briefing, we discussed whether our clinics had enough PEP (post-exposure prophylaxis, or what you take when you’ve been exposed to HIV/AIDS to reduce the chance of becoming infected) on-hand for the victims of the mass rapes that occurred in latest round of rebel attacks in Irumu. These assaults were totally separate from both the rash of M23 clashes with the FARDC north of Goma and the ADF/Nalu attacks east of Beni, which led some 70,000 people to flee to Uganda (I’ll have more on those soon, I’m sure). In this instance, Cobra Matata’s FPRI soldiers seemed motivated by the need to intimidate and control the local population when they told a group of women vendors not to go to a market held in an army-controlled area. The women snuck out and went to sell their goods (so that, you know, their families could eat) and the soldiers raped them upon their return.

Following that charming discussion, my first email of the day was a missive from the WHO that rather tersely requested those in the health cluster to please stop talking about Ebola, as there is any number of other hemorrhagic fevers that might be behind a given outbreak. It is apparently irresponsible to go around throwing out the E word. I was still ruminating on the fact that I now live in a country where only some hemorrhagic fevers are cause for panic when I was caught in a traffic jam in Bunia’s main square. Even those of us on foot had to pause for a demonstration regarding the importance of vaccinating children against Polio. Given that at home there are vocal protests against childhood vaccines, it was actually quite heartening to see that here vaccine proponents have motorcades and police escorts (though it didn’t exactly cancel out the risk of Ebola or horror of mass rapes).

Of course, the best awareness campaign in the world can’t overcome rampant stock-outs and wide-spread medical fraud. A recent visitor from our Swiss headquarters experienced the latter first-hand when he ill-advisedly bought some cold medicine at a pharmacy near one of the field bases. To be sure, his cold cleared up, but he was also left vomiting for days after taking the meds. Fraudulent drugs – what the WHO refers to as spurious/falsely-labelled/falsified/counterfeit, or SFCC medicines – range from pills that have been mislabeled to those that have no active ingredient to those that are flat-out toxic. This is by no means a new problem, but recent decades have seen it worsen in scope and frequency. In 1995 in Niger, 50,000 people were inoculated with fake vaccines during a meningitis epidemic, resulting in some 2,500 preventable deaths. The same year, cough syrup tainted with diethylene glycol (an ingredient more commonly found in antifreeze) caused the deaths of nearly 100 children in Haiti.

Industrialized countries are not safe. Indeed, the US, which probably has the most sophisticated consumer safety regime in the world, has had its fair share of SFCC scandals. In 2007 and 2008, almost 150 deaths were linked to a contaminated blood thinner while just last year a batch of steroids that were made in Boston infected more than 100 people with fungal meningitis, killing at least 11.

Though conclusive data on SFCC drugs is hard to come by (the global market is simply too large and unregulated) FDA guesses that counterfeits make up more than 10 per cent of the global medicines market. Unsurprisingly, the lion’s share of these cases (perhaps as much as 70 per cent) are found in the developing world, where officials tend to be more bribable, health systems more lax, and consumers more desperate. It is estimated that up to 25 per cent of the medicines consumed in poor countries are counterfeit or substandard.

Anti-malarials are a favourite target of counterfeiters, probably because they are so widely used. A study in The Lancet concluded that up to 40 per cent of artusenate products (those are among the best medicines to combat resistant malaria) contain little to no active ingredients and therefore have no therapeutic benefits. In Nigeria, Africa’s largest market for medicines, a WHO survey conducted in 2011 found that more than 60 per cent of antimalarial drugs were fake. Interestingly, those specimens that contain trace amounts of the active ingredient of artemisinin – likely so that they can pass the most basic quality tests – are actually more dangerous than those with none at all. Neither fake holds any benefits for the patient, but the former actually promoted resistance to artemisinin among exposed malaria parasites.

Many countries are taking steps to fight the scourge of SFCC meds. The US has expanded the FDA, opening several overseas offices to inspect foreign manufacturers. Nigeria and India also beefed up their inspections procedures in imports and exports, respectively. Possibly the most zealous – if maybe not effective – response can be found in China, which has been linked to the majority of tainted medicines globally. Concerned for the reputation of its drug-export trade, the Chinese government has staged huge seizures counterfeit medication and detained thousands of people accused of being complicit in their manufacture. It also executed its top drug official in 2007 for approving untested medicine in exchange for bribes.

When suppliers in DR Congo are able to find good meds, they tend to go quickly and stock-outs are common (though whether it is worse to have tainted anti-malarials or none at all is difficult to say). This is even true of those distributors that are, say, funded by foreign governments and co-managed by international NGOs. I myself ran into the stock-out problem, as I have now had to restart my series of rabies vaccinations three times after the local distributer ran short of the last vaccine in the set and won’t have in back within the necessary time period (interestingly, it is better to have never been vaccinated against rabies than to not finish the set. In the meantime, I’m avoiding strange dogs and dreading the bats in the ceiling). The travel clinic I visited in the States wouldn’t even give me the vaccine (rabies? They asked. Why would you possibly need rabies? They said the same thing about cholera…and there’s a cholera outbreak here). It’s a good thing for me that the Swiss were more obliging, though that might have only been for the money. The doctor complemented me on being the most expensive person he’d ever treated at the travel clinic.

That is because rabies and cholera are far from the only shots I had to procure. They were joined by yellow fever, Tdap (Tetanus, Diphtheria, Pertussis), meningitis, polio, an MMR booster, and several others I know I’m forgetting. The Tdap was without question the worst – my arm hurt for days (though nothing approached the unpleasantness of the live-virus Small Pox vaccine I was given – for no apparent reason - for Afghanistan). Cholera was the most…interesting. It’s a liquid vaccine that you dissolve in water. It tastes a little like some sort of tropical Kool-Ade mixed with the smell of nail polish remover. There were two doses that were to be taken a week apart, and it had to be kept cold. I took the first in Switzerland and wrapped the second in ice packs and trucked it to Congo. I have no idea how I made it through airport security.

On-hand, I now have my own set of hopefully legitimate anti-malarials (Larium, specifically. And the dreams, while not unmanageable, were not exaggerated. Our resident nurse has comforted me that I have nothing to worry about until I start having them while awake). On top of that, I have a malaria ‘cure’, because (as everyone has told me) I’ll get it any way, eventually. Whereas at home, you treat most things as a cold, here you apparently treat even the slightest fever as though it is malaria and take the drugs. My favourite on-hand medication has to be the PEP, though. I have been assured – repeatedly – that no expat staff has ever been exposed to HIV through their work. Still, we all carry it at all times. One would like to believe that the major risk of exposure would come at the clinics, in the guise of an errant blood sample or misplaced needle. The fact that women are encouraged to carry a double dose, however, suggests that would be a naïve reading of the main sources of transmission. I have also been asked – again, multiple times – whether or not I was on birth control. If not, they would include emergency contraceptives with my PEP allocation. Of course, being with a faith-based NGO, I had to sign several waivers and memoranda on what I would like to happen in the event of an assault-related pregnancy.

Hmmm….how now to end this incredibly up-lifting post? Perhaps with the knowledge that, as a part of our emergency health programmes, we provide free care to survivors of SGBV and those suffering from STIs. It’s a great programme, with two really interesting trends. First, in general, the only men coming in for treatment are those suffering from STIs as they can’t seem to afford any other treatment. Second, 10-20 per cent of SGBV cases do not receive emergency contraceptives because they are not eligible. A donor inquired about that statistic in one of our reports. Our reply nearly broke my heart. Do you know what kind of SGVB survivor is not eligible for contraceptives? Those who can’t get pregnant, i.e., men, boys, and girls under the age of ten.