Starting next month, the residents in the BMC IM global health pathway will be publishing pieces every two weeks on topics in global health. Should be quite enjoyable!
A group of Haitian medical students that my NGO works with produced this short, well-designed video that neatly captures key questions anyone should ask themselves before performing a volunteer medical experience. It’s great to hear what these partners of ours find most important.
In America, the overuse and misuse of opioids is a growing health problem. Morbidity and mortality associated with opioid use has increased substantially over the last decade and a half. Both prescription opioid use and heroin use are contributing to the problem, and the trend is concerning enough to have been coined “the opioid epidemic.” The statistics associated with opioid misuse are quite shocking. Between 2000 and 2014, deaths from from overdoses quadrupled, and emergency room visits related to misuse increased by 153%. In conjunction with this, the number of opioid prescriptions have also increased, from 76 million in 1991 to over 240 million in 2014 (1).
The use of opiates to treat pain dates back to the 19th century. During this time, medical interventions were scarce, and the cause of medical complaints was usually not known. As a result, morphine injections were often given to quickly alleviate discomfort. As medical knowledge progressed and other types of analgesia came about, the use of morphine decreased significantly. It wasn’t until the 1980s that opioids started to be used for chronic pain. In 1995, oxyContin, which is a long-acting opioid, hit the market. Shortly thereafter, pharmaceutical companies started taking a vocal interest in the use of opioids for chronic pain. They were key players in initiating the “Pain is the 5th Vital Sign Campaign,” which encouraged physicians to aggressively treat chronic pain and to assess pain with the “same zeal” as they would with other vital signs. To counter concerns about the safety of opioids, campaign advocates downplayed their potentially negative consequences, using poor quality studies to claim that addiction rates were less than 1%. They also endorsed that the risk of respiratory depression was short-lived (2). The rise in opioid prescription rates and the broader acceptance of opioids stemming from these efforts has led to a greater environmental availability of opioids and a subsequent rise in their nonmedical use. (3)
In India, opioids play a much less prominent role in medical care. In contrast to America, where two years ago there were more than three bottles of opioids prescribed per adult, the availability and administration of opioids is scant. The statistics illustrating this are as equally disturbing as the drastic rise in opioid-related deaths in the states. A review of India’s opiate policies by the Pain and Policies group at Madison, Wisconson estimated that only 0.4% of people in need of opiates for cancer-related pain or chronic pain actually received them (4). During our travels, we visited a rural center for HIV care. The head physician there lamented that when a patient was made CMO, the only pain relief they received was from a combination of NSAIDs, Tylenol, and Tramadol, as anything stronger than tramadol wasn’t allowed.
Unlike many developing countries, India’s dearth of opioids is not related to supply or cost. Three states in northern India produce over 90% of the world’s legal opium. Although most of this is exported, the copious and internally-produced opium supply means that morphine could potentially be manufactured and distributed at a relatively low cost. Instead, it’s the Narcotic Drugs and Psychotropic Substances (NDPS) Act that prevents patients from getting adequate pain control. Instituted in 1985, its main purpose is to prevent drug trafficking and drug abuse. It allows the central government to control morphine production, from the cultivation of poppy seeds to its manufacturing and selling. The most significant upshot has been a depletion of India’s opioid supply, with medicinal use of morphine dropping by 97% in the twelve years following the NDPS (5).
On top of this, physicians and pharmacists face both logistical and cultural barriers to opioid distribution. Doctors have to obtain up to six licenses to prescribe morphine, and even minor offenses of the NDPS’s rules and regulations can lead to harsh punishments, including up to twenty years of imprisonment. Both of these things dissuade offices and pharmacies from even carrying morphine, and many manufacturers have stopped producing it. A secondary consequence of this strict regulation has been a somewhat exaggerated fear among medical professionals of using opioids and a reluctance among the general public to accept them. Moreover, medical trainees aren’t educated on how to safely prescribe them, and palliative care education occurs in fewer than 20% of medical colleges (4, 5).
In America, the overprescription of opioids has led to a crisis of addiction. In India, underpresciption has led to a crisis of pain. What ties these two crises together, though, is that they’ve resulted from marketing and policies that were driven by forces not so scientifically based. In America, economics helped push opioids onto the market. In India, fear of addiction and drug trafficking motivated creation of the NDPS. Each country honed in on only one aspect of opioids rather than emphasizing the medical benefits they have when prescribed judiciously for a specific purpose. Now, both countries face very different problems but are both struggling with populations that are experiencing unnecessary suffering.
- Wilson, et al. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. New England Journal of Medicine. 2016;374(2):154-163.
- Kolodny, et al. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annu. Rev. Public Health. 2015. 36:559–74
- The Opioid Epidemic: By the Numbers. Department of Health and Human Services. www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. Published June 2016. Accessed August 2016.
- Rajagopal MR, Joranson DE. India: Opioid availability – An update. J Pain Symptom Manage. 2007;33:615-622.
- Sharif, Ume-e-Kulsoom. An Epidemic of Pain in India. The New Yorker. Published December 5, 2013. Accessed August 2016.
Continuing Medical Education (CME) or Continuing Professional Development (CPD – increasingly the preferred term) forms a challenge for health care professionals in all settings. The literature on CPD in high income countries is far from reassuring that CPD has the desired impact of changing the behavior of physicians to match the latest information (Cochrane, McMahon).
Within this context, I found it interesting to discuss CME/CPD with several of the physicians on our trip. All noted a wide range of options were available, and many availed themselves of these (or were teaching within them) – when asked, several noted that the majority of these were funded by pharmaceutical companies and focused on updates in therapeutics, with a smaller group of CME offerings from academic institutions and departments. This is not surprising – as the import of low and middle income country markets grow for pharmaceutical companies, their outreach will shift towards those locations as well. It is somewhat perturbing, both in that we are using the same technical approaches in these settings that likely have little impact, and that we have allowed private companies to take the lead in providing education.
I don’t claim to have an ideal answer – yet – but the question of effecting effective education in low-resource settings is one of great interest to me, and I’m hopeful that the years to come will find an increasing focus on the topic. As is readily evident, health care professionals cannot provide the best possible care without knowing what exactly that entails!
Cochrane review of CPD meetings (there are several others as well)
McMahon NEJM perspective piece from the ACCME (which I read as glass half-empty, he reads as half-full)
Hey everyone we’re back after a brief stop in the hometown of my colleague Yuvaram Reddy and the amazing Sri Ranganathaswamy Temple. This World Heritage site is the largest functioning Hindu Temple. It covers an area of 631,000 square meters, has 7 enclosures, 21 Gopuram, 50 sub-shrines, 9 sacred pools, a Hall of 1000 pillars (though it is actually 953) and an origin dating back to the 1st century. As temples go this is some pretty impressive data and “data” is exactly where we’ll take today’s blog post.
In medicine we’ve become increasingly affectionate to data because it allows us to standardize care, improve interventions, and stop old practices that in reality didn’t work. Yet getting good data is tough business. It requires good research that takes time, training, and funding. In many low resource settings these items are in short supply. How often do practitioners have a moment to consider a research trial when their daily case load can be well over 100 patients? Further, with little available funding it is difficult to build the critical mass of research faculty, laboratory space, and advanced equipment. Biomedical research has been a luxury of high resource settings that continues to drive medical advances. However, it can also drive the gap in care between high and low resource settings. This is because the clinical trials, treatment guidelines, and the diseases that make it from the bench of basic science researchers are disproportionally focused on those in high income countries. Further, even if researchers in high income countries wanted to investigate a disease prevalent in a low income settings logistical barriers such as sample procurement, ability to process tissue and the investigator’s first-hand experience with the disease are severely limiting. This makes developing in country talent a critical piece of the global health solution, but how do we do this? One mechanism has been grants that bring interested students to high resource settings for research fellowships. This can be an effective means for exposure, methods training and mentorship. Yet if these trainees are to continue the pursuit of research there has to be a research infrastructure to return to. One outstanding example of infrastructure building was our visit to YR Gaitonade Centre for AIDS Research and Education (YRG CARE). The center was founded by Dr. Suniti Solomon who discovered the first case of AIDS in India. While initially focusing on prevention and early treatment the center quickly accrued a large cohort of HIV patients. This large cohort not only allowed YRG to develop a streamlined approach to treatment but also provided fertile ground for clinical trials. On the whole these trials benefited patients who had developed resistance to previous regimens and also generated the need and subsequent resources for advanced laboratory infrastructure. Through this progression YRG became an internationally recognized research center and now has a robust PhD program where projects ranged from economic analysis of treatment response to the antiretroviral effect on mitochondrial function. In essence YRG took what was seen as a massive burden, India’s epidemic of HIV and turned it into an asset. There are now doubt ethical concerns when leveraging patient populations for institutional gain, but the YRG method may be a model for other low resource sites.
Eddie Briercheck is a PGY-2 at Boston Medical Center and a member of the Global Health Pathway.You can follow him on twitter @eddiebriercheck or search #BMCglobalhealth to learn how the rest of the team is doing. And please tweet us your thoughts, questions and culinary suggestions.
I’ve been thinking a lot about HIV and stigma this trip after hearing accounts from several health care providers regarding the low availability of healthcare services, especially surgical, here in India for HIV positive patients. The reports have ranged from “we have a partnership with a number of surgeons in the area who will perform procedures for a higher price” to “no one will perform this procedure.” The most impoverished patients are the ones suffering the most from this stigma, as private hospitals will offer procedures but at a higher rate that the patients may not be able to afford. There is some legal recourse for these patients as the Indian government passed an HIV/AIDS bill in 2007 which prohibits discrimination in the work place and in healthcare against HIV positive patients. However there is little to no litigation on these matters as it requires money, and many people living with HIV are impoverished.
One physician we talked to lamented the fact that it was difficult for HIV positive pregnant women to find obstetricians so they built an operating theater in their hospital to perform C-sections, filling a need that was not otherwise being filled. As to why no one will operate on people living with HIV, I heard several explanations from several different clinicians. These explanations ranged from concern for re-using equipment and the need for “extra” sterilization to the desire to avoid excess personal risk. Further some clinicians have suggested that some of the avoidance of treatment is related to the stigma associated with caring for patients with HIV.
Regarding discrimination specifically in india among health care providers Eckstrand et al (2) in 2013 surveyed health care providers (nurses, ward staff and doctors) in urban settings in India to gain a better understanding of the underlying issues driving the stigma against HIV positive people and the extent of the problem. The results they found were startling.
57% doctors, 40% nurses and 71% ward staff surveyed would discriminate against HIV positive patients in low-risk settings where standard precautions would be sufficient to prevent any kind of potential transmission. When asked if they would become patients at clinics that treated HIV positive patients at least half of the participants in all the groups (59% of doctors, 61% of nurses and 50% of ward staff) said they would stop attending, or demand extra precautions, Indicating misconceptions about transmission. This bias is not just present in settings where the risk of transmission exists, there was also evidence of blame and social discrimination: 50% of doctors, 70% of nurses and 83% of ward attendants surveyed felt that patients who acquired HIV through sex or drug use (the main methods, especially in india where the illness is largely spread by heterosexual sex and, to a lesser extent, by IV drug abuse in the north) “got what they deserved”. A worrying 13% of doctors felt that health care workers should have the right to refuse to treat people living with HIV. The discrimination went so far as to say that positive men and women should not be able to marry (41% of doctors, 77% of nurses and 88% of ward staff felt that HIV positive men should not be allowed to marry) and 55% of doctors felt that HIV positive women should not be allowed to have children, despite the advances in medical care to almost ensure that they will not pass the virus on to their children.
There is historical evidence to support the physicians’ concerns over spreading HIV by re-using medical equipment. The beginning of the HIV epidemic in Africa, as well as its propagation in many parts of the world, has been linked and, in some cases driven by, iatrogenic spread from improperly sanitized medical equipment. I just finished a fascinating book “The Origin of AIDS” by Jacques Pepin which proposed a theory for the early spread of HIV in Africa by colonial government programs to eradicate illness (Yaws, TB and many other treatment campaigns). These treatment programs were driven, in part, by the advent of machine made glass syringes which made treatment more accessible to the colonies while at the same time posing the same sterilization conundrum when you have 2 or 3 syringes but are trying to treat 40-100 people in a day; often they were not adequately sterilized between administrations and thus likely contributed to the spread of HIV. However this is (or should be) no longer relevant because of disposable syringes and standardization of sterilization protocols.
We have come a long way in terms of setting up adequate sterilization protocols with proven elimination of pathogens for reusable instruments. The WHO puts out guidelines, as does the CDC (https://www.cdc.gov/hicpac/Disinfection_Sterilization/3_2contaminatedDevices.html) and the CDC recommends, in general, that the disinfectant processes be standardized. This is also known as universal precautions, which assumes that everyone is potentially infected with a blood borne pathogen and that the methods of disinfection should not be tailored to if a patient is known to have HIV or not. In my medical training to date (Which is admittedly limited) that has been my experience. The standard (or universal precautions) should work universally and if there is concern over their effectiveness either they are not being implemented correctly or there is a fundamental lack of knowledge.
Universal precautions are used throughout the US and it is easier to find a willing surgeon to operate on an HIV positive patient there. When I first started writing this blog post I had assumed that in the US there would be some hesitancy and perhaps extra caution when operating on known HIV Positive patients but that this would not prevent the surgery from happening. (Because as a medical student I have been in the OR while HIV patients were being operated on) however when I looked into the data I was shocked. The Williams institute at the UCLA school of law put out the results of a survey they conducted from 2003-2005 where they called up different providers in the Los Angeles county area and posed as patients asking standardized questions regarding availability of treatment for HIV positive patients. What they found was upsetting, 55% of the obstetricians phoned would not provide treatment for HIV positive patients and 26% of the plastic surgeons would not treat HIV positive patients (5).
The law in California prevents discrimination against people living with HIV and mandates treatment unless one of three criteria are met: 1) they would not perform the requested service for a person who was HIV-negative, 2) the requested services would pose a “direct threat” to the safety of the health care provider or the patient, or 3) a legitimate referral to another provider is warranted. The excuses given in the survey included “we are not set up for that here,” and “ the doctor has no experience with that.” In some cases the obstetrics receptionist questioned whether or not the patient wanted to keep the baby. Indicating a startling lack of knowledge and misconceptions about transmission. Further, in order to meet one of the three criteria legally listed above, the respondent should have asked more questions (such as the health of the patient, their CD4 count to ascertain if the procedure would be injurious to the patient) few of these extra questions were asked once it was found out that the patient was HIV positive. This study was from over 10 years ago, i would be interested to see what the misconceptions are like now and what the availability of treatment is. In my limited search I was unable to find newer surveys or articles regarding discrimination in the US, Im sure they are out there and if anyone finds any I’d love to read them.
There is always the threat of accidental injury to the provider when performing an operation and its easy for me to sit here and say that surgeons should not care about HIV status and perform the procedure regardless of status when I, as an internal medicine physician, will have limited potential exposures. To that I would say that any operation is a potential exposure (with 4th generation tests there is still a window of 15-17 days during which a positive patient will not test positive while the virus is present and replicating) and, worse, the unknown HIV positive patients will have high viral loads making their infectivity much higher and stressing even more the importance of universal precautions.
This is a global problem. If even the people who are most educated, and should know the most about HIV and the likelihood of spread will not care for the patients, who will?
We should know better
We need to do better
- Rutala, william and Weber. “Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know” Clin Infect Dis. (2004) 39 (5): 702-709.
- Eckstrand et al “Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions” J Int AIDS Soc. 2013; 16(3Suppl 2): 18717
Sears, Brad and Deborah Ho. “HIV Discrimination in health care services in los angeles county”