Global Health, Public health concern

On The Miscalculated Fear Of An Opioid Crisis In Haiti

Opioids are an essential class of drugs used in pain management. In recent years, complex mechanisms pertaining to their abusive use have prompted a deadly crisis which still unfolds in the United States. The US Centers for Disease Control and Prevention stated that 91 Americans lose their lives daily due to an overdose of opioid drugs. This public health crisis has inspired much apprehension even among Haitian diaspora in the United States. Although needed painkillers are notably lacking in developing countries, the fear of a similar path has led a high-profile personality to advise against their use in Haiti. Indeed, health professionals are alarmed about the addictive potential of opioid drugs used in the long run. But such fear-mongering statement could do more harm than good, especially for many suffering patients who desperately need opioid drugs. It also impairs trust in regulatory efforts to prevent drug misuse.

I often recall the days when René was hospitalized in Cap-Haitian’s hospital Justinien. What had him bedridden was a rare bacterial infection known as necrotizing fasciitis (or flesh-eating disease) which means that his right leg’s soft tissue was quickly dying. His daily wound care was particularly painful because a doctor or nurse had to unstrap his sticky bandage and clean all along under his skin, with no painkiller prior to or during the intervention. René used to scream his lungs out. In developed countries, patients are admitted to a specialized unit for such procedure and are given morphine (a common opiate) for pain relief. That wasn’t a chance available to René and many other patients who presented with acute conditions such as road injuries or bone dislocation. The lack of strong painkillers also affects chronically ill patients and those requiring palliative care. Patients dying from gastric cancer could suffer unbearable pain in their last days, relying only on first line painkillers. According to a study conducted in 2015, analgesics of all kind are available only in 63.8% of health centers in Port-au-Prince. When opioids are available, their use is strongly regulated.

Read my article on how we can fight drug resistance in Haiti

In Haiti, a collaborative initiative led by the Pan-American Health Organization is responsible to create a national list of essential drugs among which analgesic opioids are listed. They also procure from international market at low cost and distribute them through State-run institutions and programs and registered-NGOs, under regulation from the national department of drugs and pharmacology. In most institutions, prescription and acquisition of morphine requires filling a special record cart detailing the patient’s information, reasons to use the drug and the prescribing doctor’s signature. It helps to promote a rational use of such medicines. Despite these mechanisms, a parallel and less regulated market of pharmaceuticals has developed in Haiti which exposes people to unsafe products. However, there’s close to no empirical evidence that opioid drugs are sold over-the-counter on the street market or that over-prescription of such drugs is prevalent at large scale.

A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking.

It doesn’t mean that misuse and addiction to opioid drugs never occur in Haiti. This is why appropriate education is mandatory to mitigate such serious risks. Medical and pharmacological associations and societies in Haiti have the duty to address the use of medicines, train doctors and nurses and communicate in effective and innovative ways with the population. A deadly opioid epidemic in the United States, with no doubt, rings a global alarm, but opioid drugs are much needed for acute and palliative care in Haiti where they are lacking. On the other hand, fear-mongering statements made by influencers have the potential to alter trust in regulatory efforts to promote a rational use of opioid drugs and put patients at greater risks. To maintain or regain that trust might be a new challenge for the national department of drugs and pharmacology of Haiti.

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HIV/AIDS, Public Health

A New Approach is Needed for HIV/AIDS Treatment in Haiti

Published in Woy magazine 

At 28 years old, Mariette is a young energetic woman caressing hopeful dreams for her child. She mourns the death of her husband, who recently passed away from AIDS (Acquired Immuno Deficiency Syndrome). Also infected by the HIV virus, she regularly receives a triple-drug therapy at the Justinien Hospital at Cap-Haitian. Regularly, Mariette and her daughter make the 45 minute trip from her hometown Limbé to Cap-Haitian to receive treatment. Like Mariette, many HIV-infected patients living in areas around Cap-Haitian travel to reach the Justinien Hospital for regular biological and clinical follow-ups.

Mariette is one of the lucky few able to benefit from antiretroviral treatments. While antiretroviral drugs have been available in industrialized countries since 1996, it was not until 2002 that Haiti received a substantial donation from the Global Fund to Fight AIDS, Tuberculosis and Malaria which led to the first treatment programs by two organizations fighting the disease on the field since its early days. In that same year, the World Health Organization released guidelines for the treatment of HIV/AIDS for the first time in history.

Despite such tremendous progress, not every infected patient could benefit from therapy immediately after diagnosis, mostly because of the high cost of treatment and the lack of health insurance. As noted by United Nations Program on HIV/AIDS, “by 1998, while 95 percent of people with HIV were living in poor countries, almost none had access to antiretroviral therapy, which then cost $12,000 to $16,000 a year per patient.” Among other reasons, it seems that this is how the World Health Organization determined patients’ treatment eligibility because it was simply too expensive to provide medication to everybody; so they prioritized the patients who were in more advanced stages of the disease, those who were much sicker. Therefore, it was not until Mariette became very sick that she was finally admitted to the hospital and was declared eligible for drug therapy in accordance to the 2010 guidelines, which are currently used in Haiti. This delay, from the diagnosis time to the start of her treatment, increased the risk of transmission in addition to other health consequences. Unfortunately, this is currently the story of millions of other HIV-infected people.

However, to decrease the spread of HIV/AIDS and ultimately eliminate it by 2020, scientists are planning a bolder strategy, named “test-and-treat”. The suggested strategy entails the initiation of therapy immediately after a positive HIV test, regardless of the biological and clinical parameters, as it used to be. Regarding this new approach, a recent publication on the medical journal The Lancet stated that: “Instead of dealing with the constant pressure of newly infected people, mortality could decrease… Transmission could be reduced to low levels and the epidemic could go into a steady decrease towards elimination.” As of this writing, test-and-treat represents the core strategy in WHO guidelines for HIV treatment, published in September 2015, 13 years after the original publication. If the Haitian government works to apply this as part of the national plan to eliminate HIV/AIDS in Haiti, more people like Mariette can start therapy sooner than she did and will have a higher chance of survival, without passing the virus to another generation.

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Today, Haiti is at a crucial point in the history of the 30 year-old pandemic, but faces many challenges to achieve the desired goal. In order to meet the gigantic promises of test-and-treat, the Haitian government must work towards a sound reinforcement of the healthcare system with a focus on the people by preventing the massive exodus of qualified health professionals. The fight against discrimination and stigma must become a priority, because every man’s life is valuable no matter his status in society. The number of testing centers in Haiti must increase for early detection.  The government needs to establish adequate cooperation with international partners in order to have available drugs for every infected patient. And most of all, we must continue to educate the youth about this virus. Marie-Ange, Mariette’s daughter is only twelve years old. However, Mariette ensures that she transmits her knowledge and experience fighting HIV to her young daughter. At the end of the day, as the sun began to retreat, Mariette boarded another tap-tap with her daughter to rejoin their community in Limbé. Because of the antiretroviral treatment, Mariette continues to hope.

 

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