Global Health, HIV/AIDS, Public Health

Disease Surveillance: Lesson From Haiti

One morning, I went with two colleagues to Haiti’s direction of epidemiology in order to collect information for a research project. As we enjoyed some local coffee with a familiar executive at his office, he instructed us about “the good old days of disease surveillance in Haiti”. This is how he referred to the era where people from remote communities themselves reported cases of malaria to concerned authorities. They would cross through villages to identify people who were suffering from fever in their homes, he said in a melancholic tone. The past years, my research works allowed me to learn, through such anecdotes, about the systems we have set up to observe the dynamics of diseases in Haiti. While he spoke, I observed with no great surprise that the walls of the office were garnished with many US CDC (Centers for Disease Control and prevention) logos. But I couldn’t help wondering in my deeper self, how can global efforts learn from Haiti’s history of epidemiologic surveillance.

While there are many definitions for epidemiologic surveillance, the authority for this matter in the US- which is the CDC– considers it as the continuous collection of health information and their dissemination to stakeholders in order to make public health decisions. This process lies at the heart of a common commitment that some countries and institutions made in 2014, through an initiative called the Global Health Security Agenda. They work to ensure a level of preparedness to face global health threats similar to the Ebola epidemic that happened in Western Africa from 2013 until 2016. Local surveillance and global security are thus intertwined.

In Haiti, although the US military used sanitary surveys to assess the country’s situation during the 1915 occupation, a site-based surveillance system has been created only in 1990, thanks to the support of various NGOs. In fact, these organizations have been operating in Haiti since the 1950s. But soon after a coup-d’état exploded in September of that same year, the deteriorating political situation has occasioned an abrupt halt in foreign aid, crippling the public health surveillance system. Later, foreign partners supported the Haitian Institute of Childhood in relaunching the surveillance of the following conditions : malnutrition, vaccine-preventable diseases, diarrhea, acute respiratory infections and cholera.

The Direction of Epidemiology, Laboratory and Research where I was discussing with my colleagues, is now in charge of epidemiologic surveillance. The CDC and a couple of NGOs are its partners and help bring modern diagnostic tools and technologies and contribute to the training of public health professionals. The cooperation with the CDC was crucial in the aftermath of the earthquake in 2010- because many infrastructures were destroyed- and the introduction of cholera, months later. Moreover, it allows for the surveillance of polio, malaria, tuberculosis, HIV infection, respiratory diseases among other diseases and the launch of a bio-safety laboratory recently. It is worth mentioning that some NGOs run independent surveillance systems or activities whose priorities are not necessarily aligned with Haiti’s vison. From the 1990s to this day, such foreign entities have played a major role in Haiti’s epidemiologic surveillance. It has resulted in a lack of sustainability and State ownership over that matter.

This history hence raises the question of Haitian sovereignty. How can foreign actors intervene so largely in this sector ever since epidemiologic surveillance started here? Who set the priorities? How does availability of international funds affect it? In fact, with progressing globalization, sovereignty can no longer be assessed through the lenses of the past centuries world, marked by violent conquers. Some common issues call for a shared responsibility and thus comes a shared sovereignty. But such interdependency does not have to favor the donors and leave the beneficiary of aid vulnerable. It needs to respect and promote local culture, language, history and institutions. As Dr. Nahid Bhadelia put it in a tweet, “the global health security agenda is as much an insurance for the resource rich world as it is for the global south… We need to address the question of inequity in trade and how we support development of stable national governance.”

This is the ultimate lesson Haiti’s experiences of disease surveillance can bring to the current global efforts even though the country is not a member of the security agenda. While it soon passed midday, I cheerfully thanked our host at the office for his hospitality and the coffee. What I learned beyond the malaria anecdote and through the days following that conversation, is that Haiti’s epidemiologic surveillance has always been an object of foreign influence, although such entities perform on a global scale. At times, it was left vulnerable. But with respect to Haiti’s identity, the limits can be overcome for a globally healthy future.

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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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Global Health, Public health concern, Social Issue

On the shades of violence in Haiti

When we first moved to our current neighbourhood ten years ago, the sides of our impasse was occupied by poorly maintained shrubs and houses isolated from each other. Only one car could manage to go through a narrow path left between the trees. Acquaintances often quipped about us living in such a remote place, hardly accessible and sometimes dangerous, given the numerous cases of kidnapping that had occurred there in the past. Indeed, the main avenue was not even fully concreted and huge potholes spread along the road. But ever since the earthquake hit, people from diverse and unknown backgrounds have settled on unfenced lands nearby, slowly changing the settings. Retail sale of clairin, a popular alcoholic cocktail, has flourished since then and round the clock gambling also attracts many young unemployed. Gun related and gender specific violence were quickly added to the picture, outlined by injuries, addiction and mental health issues.

Over time, we got used to the times when drunken men cause inconvenience and to the days when quarrels over money or marriage issues block access to our home. But as an extreme example of how unchecked violence has spread, three young men were recently found dead on the streets, killed by heavy gunfire heard during the night. Surprisingly when it comes to violence, young people seem to be the most vulnerable. Violence claims the lives of 200,000 young people per year worldwide and represents the 7th cause of death in Haiti.

The disastrous political context of the country during the last decades has shaped the minds towards believing that violence is inevitable. Not only have people engaged in violent acts for the smallest rewards, but many accustomed to political turmoil think of violence as a substantial part of their daily life. The general public and the policy makers consider violence more as a banal indicator or trend, going up and down but never as an issue plaguing their own personal and community health. In our communities, the trivialization of violence is in fact, the result of inaction which results in more violence, repeating a vicious cycle and accumulating into increased cases of serious injury, chronic diseases and perhaps lowered life expectancy.

The popular culture has long encouraged violence against women through apologies of machismo and the objectification of women. It goes without saying that despite women’s rights activists’ campaigns, they remain the largest target of verbal and physical violence. Misogynistic words being too often valued and praised, they somehow abound in the media, accompanied by degrading images of women and hateful mocks. Even in my youngest years growing in Cap Haitian, the tendency to disregard women and LGBT communities’ values had already been deeply rooted in most boys my age. So it was not surprising that, as a medical intern in Cap-Haitian decades later, I couldn’t keep count of the cases of gender-related violence registered in the emergency service. There were even cases where serious burns were the consequence of such domestic violence.

Besides the factors mentioned above, structural violence seems an even more important cause of physical violence. The lack of education, unemployment, social and economic inequalities, exclusion, gender-based, racial or religious discrimination and poverty among other factors stand as complex mechanisms preventing many people from defining and fully realizing themselves. In the countryside, the absence of an efficient mean to uphold justice leaves enough space for violent conflicts over land tenure, often leading to deaths. Although there are no excuses to violence, it is rooted in a highly unequal society, which leaves very little opportunities through decent jobs and an environment to realize one’s potentials. As a matter of fact, the World Health Organization referred to concentrated poverty, easy access to alcohol, drugs and guns and weak governance as main risk factors for youth violence. And as far as we know, the daily lives of most occupants of cluttered neighborhoods in Haiti consist of much of these factors.

Although the population may rejoice in the brutal murder of robbers, these acts may not be more than a Band-Aid on a deep wound, if the core problems remain unaddressed. Perhaps it would be useful to keep engaging all communities proactively in order to expel the idea that violence is normal and inevitable in Haiti. Communication should counter the idea that the situation is acceptable today simply because it was worse 12 years ago, because no level of violence is suitable. It will be mandatory, to teach or keep reminding our communities the fact that women are equal to men both in their body and their mind. School children should be taught that violence makes orphans and leads to many health consequences. If young people are offered the opportunity to play a role in their country’s path to development, if they are able to support their families with dignity and respect for others’ property, it will certainly make a difference and that is definitely a worthy investment for the future.

Cluttered neighborhood

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Public health concern, Social Issue

The weight of social approval

During a short break from seeing patients, I was sitting behind the desk, enjoying an appealing novel. In the heart of the neighborhood of Jalouzi, in Petion-ville, the atmosphere was rather comforting, punctuated with laughter of children and chants of street vendors wandering outside. Betty, the nurse in charge of patients’ vital signs laid on the wooden bench in the waiting room looking preoccupied. At some point, she got closer to me and shared her concern: Ever since she started working at the center, she had gained several pounds and feared to have crossed the line of obesity, making her susceptible to the health threats associated with it (mostly cardiovascular diseases).

Betty is a short and curvy, 24 years old woman. She confessed to never doing exercise. Even back when she was at school, the court was too small and physical education wasn’t part of the curriculum. She also grew up in a family where women proud themselves on their thickness. According to her family and peers, it is a mandatory asset to attract a mate.

Generally, clinicians use the Body Mass Index (BMI) to assess the adequacy of weight in patients. This index, designated as indicator of fatness, is a ratio of the weight (kilogram) in relation to the square of the height (meter) of the person. A BMI score equal or greater than 30 is required to classify a person as obese while between 25 and 29.9, he/she is said to be overweight. In 2008, the World Health Organization reported an increase in the number of overweight and obese people, especially in developing countries where 115 million people bear the burden of disease due to obesity. It is important to note because in developing countries, including Haiti, the many health problems co-exist with poverty and a blatant lack of basic education, strengthening the vicious circle. As a consequence, the impact of obesity goes beyond the individual and also affects the State in terms of cost of related diseases.

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Betty had a BMI at 34; far along in the side of obesity. When I asked about her diet, she told me that she often consumes fried and greasy meals many times a day. Her sedentary lifestyle along with the popular culture that particularly promotes female thickness is also a factor. Other obese patients have even confessed to having resorted to self-medication and other practices to gain weight and develop a body shape, given the social standards, that is valued by most people. Bearing in mind the concept of health as defined by the World Health Organization, self-acceptance undoubtedly has an important role to play in the overall well-being of a person. But self-acceptance is sometimes too tightly dependent on social norms. Therefore isn’t it important in specific cases to question these norms and ideas of beauty that lead to self-flagellation and degradation of the body in the long term?

For instance, let’s go back to the origins of the Body Mass Index used to determine obesity. It was first described in 1832 by a Belgian mathematician and statistician called Adolf Quetelet. After the Second World War, it became crucial to develop a reliable index of normal body weight as the relation between weight and illness and death represented such a shattering concern in the medical world. But the researchers only referred to Anglo-Saxon populations to gather the data. Hence, the ideal Body Mass Index is not quite representative of the every person since African populations among other ethnics had been ignored in the studies. Another bias is that fat is not the only component of body mass. Muscle mass makes it even harder to generalize the obesity measurement standard. As a matter of fact, studies have shown that blacks have lower body fat and higher lean muscle mass than whites, so the same BMI score may lead to less obesity-related diseases. It doesn’t mean that the index per se is useless in African populations but the situation opens doors to further research which may lead to ethnic adjustments. In that vein certain groups have begun to lower cut-off points for the BMI of Asians.

After our exchange, Betty promptly acknowledged the challenge to merge her idea of beauty with her desired state of health. While the prospect of developing a perfectly objective standard for determining obesity and its health risks is still blurry, we need to keep in mind that the perception of beauty itself remains subjective. The balance between what is culturally preferred and what is healthy is also delicate and difficult to reach. Undoubtedly there seems to be a shift of consciousness among young women in Haiti. Hopefully properly designed and culturally tailored health communication campaigns are going to meet them halfway.

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Global Health, Public Health, Public health concern

Health communication in the time of Zika in Haiti

The day was coming to its end as I was dealing with annoying paperwork at an outpatient clinic in the area of Delmas, in Port-au-Prince. The attending nurse sharply knocked at the door and introduced me to Zoune, a woman in her mid-forties. Calmed by the fan in motion, the ambient heat hardly bothered on this particular afternoon. Even though January hasn’t seen any rain yet, puddles and piles of rubbish in the streets form a sure cottage for mosquitoes. The tropical temperature also stimulates their reproduction. Zoune presented clinical features of the Zika disease, urging me to initiate a symptomatic treatment based on my judgment and order a few screening tests. Ever since the confirmation of Zika cases in Haiti by the Health Department (and even before) the public carefully monitor themselves for signs of the disease and inquire with their doctor. Of course some prefer to get themselves treated with simple non-pharmaceutical interventions.

The Zika virus disease is transmitted by the bite of Aedes mosquitoes, infected by the virus. Identified in humans for the first time in 1952 in Uganda and Tanzania (Emerging point of Chikungunya virus which caused an outbreak in Haiti in 2014), it spreads especially in Africa and tropical countries. This non-fatal disease involves a febrile syndrome associated with lumbago (pain in the lower back), simulating Chikungunya or malaria which is endemic in Haiti. The emergence of Zika virus disease was foretold long before its introduction in Haiti. Climatic conditions punctuated by global warming as well as migration have positively contributed to its emergence.

Currently, one can refer to an epidemic in Haiti since Zika was simply non-existent across the territory. Even though it’s relatively simple to limit its spread- provided that hygiene and sanitation measures are met- difficulties particularly arise on this level. How to involve most of the people in this dynamic? Proactive communication is the first step in management of an epidemic. But between the limited resources and the outright flaws in the Haitian healthcare system, the public is far from being reassured. Communication weaknesses have already started to plague the good management of this outbreak, hence affecting trust even more. As a matter of fact, the confirmation notice of the presence of the disease in Haiti came late compared to expectations of the people who observed that it was rapidly gaining ground and awaited a word from the Ministry of Health.

According to my observations, the greatest fear of the public lies in the eventual complications of the Zika virus disease; mainly brain malformation in newborns and Guillain Barre Syndrome which causes paralysis of the body. Although scientific literature hasn’t confirmed any link between these complications and Zika yet, in some countries where Zika spreads, women are warned to delay pregnancy or to avoid areas affected by outbreaks. In the United States, the Centers for Disease Control and Prevention have elaborated guidelines for the screening of pregnant women by gynecologists. Some see this as a unique opportunity to revive the debate on abortion in countries where a modern law is lacking. But at the time of writing, no campaign whatsoever is officially launched in Haiti thus, no warning regarding pregnancy or increased promotion of contraception services has been issued by the Health Department. The public is therefore facing the fear of this epidemic with the feeling of being on their own.

In order to foster behavioral changes necessary to protect lives, it’s important to know the perceptions and existing practices of the population. A never-ending conversation with the public allows effective management and is worth more than sparse and scant monologues in times of panic. During the Chikungunya outbreak in 2014, the organization I co-founded integrAction was delighted to share ideas and experiences with the socio-medical staff of the Haitian Red-Cross (many of whom were infected) in Cap-Haitian during a conference. This initiative helped the organization conceive groundbreaking campaign with appropriate health communication to raise awareness via social media on the disease and the means to cope with it.

On a broader scale, the current turn of public health history is an opportunity to consider reinforcing leadership capacities from the bottom to the top, while investing in research and improving the public’s health literacy. For most of the population, there’s more fear than harm as in the case of Zoune. So engaging the people through proactive communication followed by prompt action is one of the best ways to halt the spread of Zika and its potential consequences. As they express much disappointment, the Haitian people can only hope for less vulnerability. But if today’s duties are unceasingly postponed, the future, undoubtedly, can only be more grim.

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador

A health worker fumigates the Altos del Cerro neighbourhood as part of preventive measures against the Zika virus and other mosquito-borne diseases in Soyapango, El Salvador January 21, 2016. REUTERS/Jose Cabezas

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Public health concern

How social factors affect life: a health history

The morning breeze filled the room, warmed up by the first rays of the sun. That day, Jacqueline was the patient who kept my attention the most with her story. She was shambling as she entered the room, tightly holding an iron cane. The purpose of her appointment at the clinic was a monthly follow-up examination for diabetes and high blood pressure. A sixty-four-year-old mother, Jacqueline is suffering from obesity. She spends her days selling retail fabrics on the bare ground at the “Marché du Port”, familiarly called Gerit in Haitian Creole. Most of the time, her business doesn’t do well and she has to count on her daughter’s generous help. During history taking, as I asked her when did she become aware of her cardiovascular diseases, she started telling me about her life. This is how I seized the power of the determinants of health, these social and economic factors that influence individual and group differences in health status.

As far as her memory goes, it started on a 1987 Sunday morning. This sad November 29, marked by ruthless massacre, was the first Election Day in Haiti after the Duvalier regime. Gendarmes crowded the streets. On her way through the “Ruelle Vaillant”, seeking comestibles to feed her family, Jacqueline brought herself to the bloodbath. To avoid the gunshots, she jumped in the nearest canal and broke her leg bone as she fell. The effects of her broken leg remain to this day prompting her handicap. But on another level, the aftermath of the tragedy was so strong that it triggered emotional disorders in Jacqueline. Shortly after the event, she was diagnosed with high blood pressure.

Jacqueline stared at the ceiling as the memories streamed in front of her eyes. As she counted, the Hyppolite market was her main station back in the 80s. In these times, merchants only had to contribute a small fee to occupy a decent place. Under the mayor’s term, a hygiene service regularly cleaned the place, thanks to the occupants’ contributions. But since 1990, she moved to the Gerit following the orders of a new administration. The aging woman experienced since then, the precarious sanitary conditions and successive arsons which stain the history of the Gerit. Nowadays still leading a hectic way of life, her stress levels have skyrocketed. As the years passed by, she hasn’t even noticed how hastily the country was regressing. When I told her that the general hospital didn’t admit women to give birth for a mere 5 gourdes anymore, she couldn’t help but laugh.

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Desperate merchant after fire destroyed her belongings at Port Market in Port-au-Prince. Source: BBC Pictures

Then, came the January 12. When the earthquake ripped her four-piece house, Jacqueline was left with nothing but courage. She never saw a home in the shelter an NGO provided her, but she still lives in it. Some days, she manages to make it on a 10 gourdes budget, hoping her daughter collects a decent paycheck in the USA. Diabetes hit in late 2010. She confessed: “As age and disease pile up, I don’t plan to rebuild the house. Medications are way too expensive and health is to be guarded like a precious gift”. The day I examined her, she was struggling with a sore foot which is oftentimes an indicator of bad compliance to an appropriate lifestyle and medications in diabetes patients. Her story was written on her foot.

Why does it matter? She did not predict the earthquake nor did she expect the many adversities she went through. But they acted as social, economic and environmental factors which have an important impact on her life and health. Many times, a single factor cannot determine the health issues a person or a community strives with. They prevail as the results of a cascade of events and behaviors which are deeply rooted in history and the way the society is organized. In Haiti, political instabilities and natural disasters played a pivotal role in the onset and development of many health issues. More than two decades after the “Ruelle Vaillant” massacre, the months following the 2011 elections, the cholera epidemic peaked in Haiti. One of the many reasons is the fact that Port-au-Prince was home to many cases and as rioters barred the roads, patients couldn’t arrive at the Cholera Treatment Centers on time.

The story of Jacqueline is similar to Jean’s, a 24-year old patient at the clinic. During a conversation, he affirmed: “I can’t explain why cholera struck me because I thought I was safe.” As scientific data show, the source of the epidemic lies in the unsafe disposal of Nepalese soldiers’ waste. Considering the persistent lack of sanitary infrastructures and the weak health care system, Haitians are more vulnerable than ever. This is factual because the social and political choices and events bear major impact on the population’s health.

For  a prosperous future, a stable society and the improvement of the living conditions represent the key stones. As a matter of fact, it is arduous to deal with bigger challenges like climate change, in a situation dominated by uncertainty, even though it also plays an important role in the health of tropical populations. By influencing the determinants of health, the next generation will be more likely to build a strong nation and plant a seed of reparation for Jacqueline and Jean.

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Public health concern

Drug resistance: What can we do?

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Bucket of drugs sold on the streets of Port-au-Prince, Haiti

This article originally appeared on Woy Magazine

Throughout history, mankind has suffered from several devastating epidemics caused by pathogens (disease-causing microbes). Even the bible speaks of the occurrence of epidemics such as leprosy and tuberculosis, millennia ago. Among the deadliest known in history, the plague epidemic, from 1347 to 1351, killed half of the European population. Centuries later, the Spanish flu of 1918-1919 has claimed more lives than World War I. On the American continent, around the same period, the epidemic of polio in the United States has killed 6 000 persons. For many years, Haiti has been known for the spread of deadly microbial epidemics and is still currently fighting one of the highest rates of tuberculosis, HIV/AIDS (despite the dropping prevalence) and malaria in the hemisphere.

However, the era of microbial epidemics has observed a halt since the development of antimicrobial drugs begun with the discovery of penicillin, an antibiotic, by Alexander Fleming in 1928. Nonetheless, in his Nobel lecture in 1945, he had to warn: “The time may come when penicillin can be bought by anyone in the shops. 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.”

Antimicrobial resistance is the fact by which, the pathogens become insensitive to the drugs used to kill them or to inhibit their growth. It is known as a natural phenomenon, but can as well be propelled by humans through overdose and improper use of drugs. In line with Fleming’s projection, antimicrobial resistance is an actual fact and a global health issue especially in our era of globalization and mass commercialization. As a result, in a near future, we may lack the most essential drugs to cure the simplest infections.

How is it today? In its 2014 report, the WHO has revealed that the Influenza A viruses (susceptible to cause the flu) are resistant to all available preventive drugs. Worldwide, 450,000 new cases of resistant tuberculosis have been reported.  And in Africa, resistance to a specific class of drug used in the treatment of AIDS has been observed since 2009. Concerning malaria, several countries on different continents experience some level of resistance to chloroquine (Main drug used in the treatment).

Imagine a world where anybody can die of a single skin cut, where more children under 5 years old die of pneumonia. Imagine a country like Haiti in such a world, with no available drugs to treat malaria and AIDS. Imagine a world where tuberculosis is an incurable disease, where doctors can’t practice surgery -because most of the time, there’s no surgery without antibiotics- and where children die of mother-to-child infections. To avoid such catastrophe, key attitudes are recommended in the face of this new global epidemic of resistance to antimicrobial drugs. Let’s lay down a non exhaustive list of four realistic and reliable precautions we can adopt in Haiti.

Encourage consumption of local foods

Most of the meat consumed in Haiti is imported from the Dominican Republic and the United States. In larger economies, antibiotics are used in animals, despite the advice of the WHO to cease such practices (Press Release WHO/39. September 11, 2001). When a person ingests meat containing antibiotics, they also consume the drug. This improper use of antibiotics contributes to bacterial resistance in humans. As a result, these drugs will lose their ability to produce the desired effect in sick people. The lack of antibiotics is one of the advantages of purchasing local Haitian agriculture. It is, therefore, recommended to consume local foods in order to decrease the spread of antibiotic resistance.

Fight self-medication

Concerned state authorities should take responsibility by enforcing the article 19 of the August 10th, 1955 law forbidding the sale of antibiotics without medical prescriptions. According to a study I conducted in March 2015 at the outpatient clinic of the General Hospital of Port-au-prince, almost half of the patients (45.4% of them) buy their antibiotics without any medical prescription from street vendors tubs, public transport buses and sometimes pharmacies. While we wait for a more modern law on the pharmaceutical sector in Haiti, the one cited above should absolutely be enforced in the meantime.

Typical meds vendor in the streets of Port-au-Prince, Haiti

Typical meds vendor in the streets of Port-au-Prince, Haiti

Practice better medical care

From the doctors, it is required to decrease the careless use of antibiotics and other microbial drugs. The choice of the most accurate drug to treat a specific infection, the appropriate dosage and duration, should be done with the utmost care. In all circumstances, following a well-conducted physical exam, the clinical judgement of doctors need to be accurate. It is best, however, to objectify an ongoing infection before initiating a therapy even if in most of the cases, the medical practice is challenged by the inability of the patients to pay for basic exams. No matter the limitations, it is the doctor’s duty to make the best decisions for their patients and for society as a whole, based on their judgement and scientific evidence.

Increase awareness and health literacy

As it is often said, prevention is better than any cure. It is in the best interest of the general population to increase their awareness of the situation and their health literacy. Unfortunately, in Haiti, information and health education campaigns are only held in times of severe outbreaks, and are transmitted in a language that excludes the majority of the population and fails to take advantage of the best communication channels. Basic health knowledge should to be taught throughout people’s lifetimes, beginning in elementary schools.  IntegrAction, a non-profit organization I co-founded, is totally engaged in this fight for effective health literacy for the Haitian population.

Awareness and a culture-oriented health literacy coupled with the best medical care can make a profound difference, in regard to this alarming situation. The state and local authorities should join their hands to enforce the existing law and encourage the consumption of local foods. With enough political will and global awareness, it is possible to get around the dramatic fate. One behavioral change at a time, let us, Haitians, unite for this cause!

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