Category: Conversations

“I sleep with my hands in my pants”

On what seems like an ordinary Saturday call, I get a late afternoon page from the ED. It’s a young man presenting with “weird” lesions on his scalp. The emergency doctor wants to treat for syphilis but is not sure quite sure of the diagnosis and calls the ID consult team for help. I go to see the patient, a pleasant otherwise healthy 20-year-old man. He is visibly worried about the multiple unusual lesions on his scalp which appeared about a week ago. The lesions have a classic wet wart-like look of Condyloma lata, a classic genital rash seen in secondary syphilis. But why did they appear on his scalp?

With the initial pleasantries of the history taking out of the way I take a deep dive into the sexual history. It turns out the patient has had some recent unprotected casual sexual encounters with partners he met online, and is clearly at risk for sexually transmitted infections. A thorough physical exam reveals a similar rash on the patient’s genital area. My immediate thought is the lesions on his scalp are likely the result of   self-inoculation from groin lesions. Like any ID physician would, I ask even more strange questions and get the answer that confirms our hypothesis, “I sleep with my hands in my pants, it’s just something I’ve always done”. 

Mystery solved! I recommend empiric penicillin for presumptive treatment of secondary syphilis, which will be confirmed on his blood test results a few days later. I provide a well-rehearsed spiel on safer sex practices. The patient visibly shaken by an STI diagnosis, in the moment, is self-berating over recent choices he has made “hooking-up” casually with strangers from the dating apps in his phone. I nod in empathy with his moment of tinder regret and provide reassurance that his infection is curable and he will be fine. Months from now this whole episode will be a distant memory, but will he have the courage to swipe right again? Is the blame he is placing on dating apps really justified?

The Rise of STIs- Are Dating apps really to blame?

In 2018, the CDC released alarming updates on the rise of STIs in the United States. An estimated 2.3 million new cases were reported that year. Over a 4-year period between 2013 – 2017, the rates of syphilis have doubled, gonorrhea is up 67% and Chlamydia infections are at record breaking highs. Similar increases in cases have also been noted in Canada and many other countries around the world. This has prompted many to wonder what’s driving this growing public health crisis.

Figuring this out has not been easy, as is often the case with studying human sexual behavior. For example, in a food borne outbreak of infection, investigations usually involve benign questions and contact tracing to identify the culprit contaminated food. On the other hand, accurate and truthful reporting on sexual exposures and practices is often confounded by reticent and heavily biased self-reporting. The reason is simple, no one wants to talk about their sex life like that! This maybe is the reason why some have suggested a theory that shifts the focus away from individuals and the judgement it implies, to the dating apps uploaded to the millions of smartphones in our pockets. Does the evidence really bear this out as true, or are we picking on an innocent bystander and ignoring more important drivers? 

Love me Tinder, Love me true

The past 15 years have seen an explosion in the popularity of dating apps with an estimated 15-20% of adults in the United States found to be active users in 2017. These apps were mostly designed to facilitate connections and potential dates between individuals with shared interests and characteristics. They work, are easy to use and have led to many long-lasting connections and relationships. It is no secret however that the ease of locating potential partners with a swipe of the touch screen, also makes these apps ideal for locating partners for casual sex. Whether this use of online dating apps translates to higher rates STI transmission may be too simplistic an explanation for a complex issue.

The Nationwide Survey of Sexual Attitudes and Lifestyles carried out in the United Kingdom is the largest study to date that has attempted to explore adult sexual behavior in the digital age and its possible association with higher rates of STI diagnosis we are seeing currently. The study surveyed 15,162 individuals between ages 16-74 over a two-year period from 2010-2012. Finding sexual partners online was reported in about 17.6% of men and 10.1 % of women and was associated with higher number of new sexual partners and more unprotected sex acts. Surprisingly this was found to be associated to with only slightly increased rates of STI diagnoses and HIV testing in men but not in women who had a same chance of getting STIs regardless of their use of online dating technology. 

For many, this may sound like an open and shut case – the multiplicity of dating apps leads to more hookups, high risk sexual behavior and ultimately higher rates of sexually transmitted infections, right?  Well not so fast, although the UK study certainly suggested that the cultural phenomenon of online dating may be contributing to some of the rise in STI infections, association does not necessarily imply causation. Also, the numbers are too small to lay all the blame on the shoulders of online dating suggesting that there are likely other factors at play and only dating apps are just the tip of the iceberg. 

Don’t blame it all on the Apps 

There is some suggestion that the higher rates of STIs are the direct result of more sensitive and sophisticated testing. We are simply finding more because we are testing more and better. This is true but we cannot ignore some of the more uncomfortable drivers that are probably contributing more to this problem than higher testing rates.

Funding cuts to effective prevention programs

In 2016 in the United States, the budget for abstinence only sex education was increased to 85 million a year. This program has been shown time and again to be highly ineffective in reducing the rates of teenage pregnancy and STIs. Furthermore, an estimated 87% of sexual health programs across High schools nationwide allow parents and guardians to opt of having their teenage children participate in this curriculum.  This had led to a generation of young adults who do not fully understand how the sexual landscape has changed and the basics of effective prevention and sexual practices.

Programs that have been actually shown to be effective such as comprehensive sexual education and contraception through organizations like planned parenthood have been indexed as drivers of “society’s moral decline” and are experiencing severe cuts to funding. Pre-exposure prophylaxis (PrEP) for HIV prevention though highly effective, continues to struggle for funding in several states. 

Ignoring the baby boomers

The focus placed heavily on millennials when it comes to sex and STIs ignores a major group – the baby boomers. Sub-group analysis of the rise in STIs shows rates which are just as alarming in those ages 60 and above. In some studies, seniors have been shown to have the lowest condom usage rates of any population.

With unwanted pregnancy no longer a concern and the advent of Viagra, baby boomers are even more liberated than ever. They often do not have the updated knowledge on navigating the risks that come with the territory of an active sex life. On the side of healthcare providers, there are intrinsic biases that make us assume that that older patients are not being sexually active, and we often do ask them about their sexual health or offer the same prevention and testing options as we do routinely for younger patients. 

Swiping happily ever after 

Ultimately digital dating technology is here to stay and a reality of the present times. The narrative of “swiping right for syphilis” is stigmatizing and unhelpful when it comes to a public health approach at curbing the rise of STIs. Do dating apps make it easier to find partners? – of course they do. Are people having more sex as a result? – they probably are. Their existence however, should not stop us from addressing the more urgent issues of better funding for effective prevention strategies and as a society, learning to speak more candidly about sex and safer sexual practices across all generations. Here’s to swiping right, and remaining cautious while casual.

Written by Boghuma K Titanji

Down memory lane …

My earliest excursions into the world of “neglected” tropical diseases takes me back to mass distributions of Albendazole in my public primary school. At the age of 8 it seemed like any other curious and exciting experience. Getting in line with my school mates and being handed two flavored pink pills to take – for the worms! At that time, I did not realize that I was actively taking part in a huge public health campaign, aimed at reducing the burden of helminthic diseases in school age children.

Though simple at face value, this intervention kept me and my peers on the growth curve, prevented us from getting anemia and gave us a shot at growing into healthy adults in an environment where the odds are often stacked against you.  Similar campaigns continue to this day and are pivotal in reducing the negative effects these diseases place on developing world populations. 

While simple interventions have proven invaluable in select cases, the vast majority of these diseases remain in the shadows, infrequently talked about and far removed from the consciousness of those not affected by them. Yet they continue to place an undue burden on the world’s poorest and most vulnerable populations. Having practiced medicine in sub-Saharan Africa, I know too well the realities of dealing first hand with the irreversible blindness caused by untreated onchocerciasis or the disfiguring and life-altering effects of filarial elephantiasis, just to name a few. 

Out of Sight and Out of Mind – A luxury not afforded to all 

I grew up knowing and fearing these diseases with strange names and devastating consequences, first as a child then later as a healthcare provider with limited treatment options for my patients. To me and many others these weren’t “neglected diseases” but real-life threats with potentially nefarious consequences. I currently live and practice medicine in a western country and now fully realize just how easily one becomes removed and unconcerned by issues that do not directly affect your daily life. Therein lies the central thesis of the “neglected” tropical disease – out of sight really is out of mind!  

By current World Health Organization data, 1 billion people in 149 countries suffer from one or more “neglected” tropical diseases which claim half a million lives every year. These diseases disproportionately affect the world’s poorest and most vulnerable communities and remain at the bottom of the priority list for new drugs and vaccines research.

The Curious Case of Sleeping Sickness

One of the most refreshing news headlines of 2018, was the rapid approval of a new and simple oral treatment for sleeping sickness. Sleeping sickness refers to Human African Trypansosomiasis (HAT), a parasitic infection caused by Trypanosoma gambiense and Trypanosoma rhodesiense, parasites transmitted by Tsetse flies.  An estimated 57 million people are at risk from this disease with 100,000 contracting it every year. Although sporadic cases do occur in tourists infected through Tsetse fly bites while on Safari, those most directly affected are the populations living in areas where the transmission of the parasite is endemic.

Sleeping sickness has severe consequences for those who contract the disease with symptoms ranging from fever, headache and joint pain in the early stages to behavioral changes and neuro-psychiatric manifestations in its later stages. Those affected undergo a horrific transformation and become aggressive, delusional and unrecognizable to their family members, before ultimately succumbing to death in a few months usually through coma.

For the longest time, the only available treatment options were severely toxic and difficult to administer regimens, which themselves could be fatal for the patient. The main drug used for treatment was Eflornithine which though freely supplied by its manufacturer Sanofi, required 4 infusions daily for a 14-day period. It is usually delivered in combination with an oral drug Nifurtimox. Administering this type of treatment in rural parts of Africa can be especially challenging. Hospital wards are often rudimentary rows of iron beds, severely understaffed and poorly equipped and most of the patient care is provided by relatives sleeping on floors next to their loved ones. Monitoring and safely delivering this type of treatment under such circumstances is hazardous at best and near impossible at worst.

In 2012 the world health organization created a road map with the goal of eradicating the disease by 2020. This galvanized international funding to pursue development of oral treatment candidates for the disease. The efforts have been fruitful with the approval of Fexinidazole, an oral drug that cures all stages of the disease within 10 days. Fexinidazole was developed by a German pharmaceutical company Hoechst in the 1980s but its development was halted when the company abandoned its tropical diseases program. It took almost 30 years to reignite the desire to see this drug through clinical trials leading to its approval for the treatment of sleeping sickness in 2018. 

This triumph is a real game changer in the treatment of the disease but is slightly tainted by the cost in human life and time it took to arrive at this point. The drive for the approval of Fexinidazole is the result of a 10-year partnership between the Drugs for Neglected Diseases initiative (DNDi), Sanofi and African Partners and cost an estimated 63 million dollars. This cost is dwarfed in comparison to the cumulative direct and indirect costs of the disease on affected populations through the years when treatment options were complex and limited.  More importantly it provides the proof of concept that setting clear goals and igniting global commitment in the fight against neglected tropical diseases can lead to concrete results and raise real hope to eradicate some of these diseases.

One Down, Nineteen to go 

As I reflect on the success story of sleeping sickness, I can’t help but wonder how many drug candidates for the other 19 neglected tropical diseases remain suspended in the research pipelines of pharmaceutical companies around the globe. These drugs likely will never see the light of day due to a lack of incentive to take them through expensive drug development processes. The reality is the 1 billion people who directly suffer the brunt of “neglected” tropical diseases are poor and represent the least profitable markets for pharmaceutical companies.

Eflornithine which has been until recently the mainstay of treatment for sleeping sickness, saw its supply threatened severely in the early 2000s. The patent holder for the drug abandoned production due to its failure to live up to its potential as a drug for cancer, a far more lucrative target. This left only a few thousand doses of the life-saving medication available to the thousands of invisible patients tucked away in remote parts of the African continent. The clock was ticking down with many fearing the worst.

The saving grace for this drug came through an alternative profitable cosmetic use being identified for the molecule. Eflornithine was found to be effective for facial hair removal in women, leading to a revival of the patent and ensuring its continued production and supply for the treatment of sleeping sickness.  In this particular instance, a happy compromise was made after intense international pressure. The pharmaceutical companies could continue to reap profits through sales of a lucrative facial hair removal cream and in exchange sustain production of the less profitable intravenous formulation of the drug needed to treat sleeping sickness. 

Sadly, the world of big pharma is still largely commanded by the ability of new drugs to generate huge profits. As a result, most “neglected” diseases will not have a romantic ending like that of sleeping sickness and will remain in the shadows. Sanofi, through the role it has played in the development and approval of Fexinidazole has proven that the conversation does not always have to be solely based around profits. It can be a more human conversation that focuses on the real human lives at stake and finds the balance between profitable vanity projects and drug development for less profitable targets.

Until that time comes, in my little bubble of comfort I live in hope that a molecule in my daily facial cream is somehow sustaining the production or development of a drug that treats a “neglected” tropical disease somewhere far away. A highly improbable thought which makes me feel slightly better about my neglect of diseases which are way too real for millions of others with less fortunate circumstances.

Written by Boghuma. K. Titanji

To support the fight against neglected diseases consider donating to Drugs for Neglected Diseases initiative and Doctors without borders by following the links below:

https://www.doctorswithoutborders.org/what-we-do/medical-issues/sleeping-sicknesshuman-african-trypanosomiasis

https://www.dndi.org/donate/

Good morning I’ll be your doctor today …

These simple words mark the beginning of my relationship with Jay, as I usher him through the doors of my office. Jay is a black gay man in his twenties, living in Atlanta and newly diagnosed with HIV. He tested positive for HIV infection during an emergency room visit for a fever, three weeks ago.

As he settles into his seat his demeanor appears timid and withdrawn and he answers my initial questions mostly in brief monosyllables, barely making eye contact. The first visit is always the hardest both for the healthcare provider and for the patient. I feel the pressure of getting it right and gaining this patient’s trust as I am sure he in turn feels the unease of divulging to a complete stranger the most intimate details of his life.

As the encounter progresses Jay relaxes a little, he is still struggling to come to terms with his diagnosis and what it means for his life moving forward. He shares an apartment with two roommates and works at a fast food restaurant in the city. He admits to having some friends living with HIV, but he never thought he would be faced with the same diagnosis. I provide reassurance but mostly a listening ear which I feel is what he needs most at this time. I ask if he has a support network, someone he can talk to about his diagnosis and the adjustments of living with HIV. While he has family in nearby Alabama, he is estranged from his parents who do not know he is gay and he feels they would not approve of his “lifestyle choices”.

He wishes to keep his diagnosis to himself for now and reassures me he is a fighter and will pull through. We discuss treatment options and clinic resources available to support him. He leaves the office with his first prescription of antiretroviral treatment, marking the start of a challenging new chapter of his life: living with HIV as a black gay male in the South of the United States.

Jay, unfortunately, will not be the only new patient diagnosis of HIV infection I see in the clinic this month. In reality there will be multiple, mostly young, gay/bisexual, male and black making it impossible to ignore the epidemic unfolding in real time. I will go over the same scenario again and again, hoping to gauge every initial clinical encounter right and lay a foundation of trust in the healthcare system which will ensure long-term engagement with HIV care.

Some of the of the less fortunate ones, I will only see as hospitalized patients, battling for survival as opportunistic infections ravage their immunocompromised bodies, sometimes well past the point where their lives can be saved. The deaths are the hardest to deal with, especially knowing that it doesn’t have to be this way in 2018.

Against terrible odds

Worldwide, the incredible advances in treatment and prevention over the past 37 years, have transformed the face of HIV completely. What was once a death sentence is now a chronic and manageable infection with effective and simplified treatment options.

In cities like New York and San Francisco, once among the hardest hit by the epidemic in the early 1980s, infection rates continue to decline and HIV-infected individuals are retained in care at high rates.

Sadly, the same cannot be said for the epidemic of HIV in the South of the US where the virus continues to plough through the black gay/bisexual/trans community at an alarming pace. In 2016, the Centers for Disease Control and Prevention estimated that one in two African-American gay/bisexual males (men who have sex with other men-MSM) will become infected with HIV over the course of their lifetime, a staggering statistic when compared to the 1 in 99 lifetime risk of HIV infection for all Americans and the 1 in 11 lifetime risk of infection for white gay/bisexual men.

These rates are among the highest rates of HIV infection in the world! The Southern States represent about 37% percent of the US population, yet per recent public health estimates account for just over half of the new HIV diagnoses nationwide, with most of these being in gay/bisexual black males. The odds are incredibly harsh for patients like Jay for whom a diagnosis of HIV at some point in their lives almost seems to be an inevitable outcome. The reasons behind this raging epidemic are multifaceted and extremely complex rooted in a history of racial discrimination, homophobia, economic and social disparities. These elements have come together to create a perfect storm and continue to feed an epidemic which is proving challenging to contain.

The deadly trifecta – Racial discrimination, Homophobia and Stigma

During the very early years of the HIV epidemic in the 1980s, white gay men very quickly became the face of the epidemic due to the sheer numbers of them who were infected and dying from AIDS. This led to a galvanization of public health efforts aimed at prevention, education and treatment resulting in a sharp decline of new infections as awareness of the problem grew. As the years went by and new effective treatments for HIV were developed, the focus and funding began to shift to other areas like marriage equality, with many considering HIV an issue that was largely under control.

In reality, the legacy of the focus on the white gay/bisexual male HIV epidemic in the US was a silent epidemic allowed to take root in the black gay community, where being identified as a gay/bisexual male was shrouded with taboo and stigma. The complacency could not have come at a worse time, laying the foundation for an epidemic at its peak today. The advent of the HIV epidemic in the black MSM community, joined the ranks of existing healthcare disparities which disproportionately affect minorities in the United States and the extensive stigma and discrimination associated with being black and MSM.

All of these factors are amplified several fold in the Southern States of the United States where deeply held Christian religious views promote and sustain homophobia and stigma. I continue to be surprised at the number of MSM patients I see in clinic who live a life of secrecy to preserve family ties and relationships with loved ones they feel may not be accepting of the sexual orientation. In many ways Atlanta is a safe haven and an oasis of acceptance for black MSM much like San Francisco for white MSM in the 1980s and 1990s but this virtue also makes it one of the epicenters of the Southern Epidemic.

The concentration of black MSM in the city has also increased the risks of HIV transmission. Sexual networks and the pool of potential partners tend to be closed within the black community with black MSM having sex with other black MSM. When infections do occur, access to healthcare services is hindered by a lack of education on available options for prevention, testing and treatment, homelessness and poverty, substance abuse issues and the stigma of being labelled as infected with HIV. It is estimated that 45% of MSM in the United States have never tested for HIV infection and about 40% of new infections are transmitted by people living with undiagnosed HIV.

The low rates of testing and diagnosis mean that we are seeing far too many people diagnosed with advanced disease and serious opportunistic infections which can have serious life changing consequences or result in death. In 2016, there were and estimated 1513 new diagnoses of HIV infection in the city of Atlanta, a number which has held steady since 2012. Out of these, 360 deaths of people diagnosed with HIV were recorded in the city. The numbers are stark and the picture, though somber, shows the true face of the HIV epidemic in the black MSM community, highlighting the need to do more if we hope to win this fight.

Winning the fight against HIV- Leave no one behind

As we mark yet again another world AIDS day this December 1st, there are many reasons to feel hopeful about how far we have come since the beginning of the HIV/AIDS epidemic. We have effective treatments that allow people infected with HIV to live normal lives and have essentially the same life expectancy as uninfected individuals. Also, there is effective pre-exposure prophylaxes which prevents infection from happening in high risk individuals. These advances are real triumphs considering where we were almost 40 years ago but also the reason why it is unconscionable that we leave anyone behind.

In 2015, it was estimated that in the United States about 49% of people infected with HIV were on treatment and about half of that number have effectively suppressed their virus. These estimates were even lower in the subgroup of black MSM, the group hardest hit by the current epidemic. We have incredible tools to curb the spread of HIV in our arsenal but we seem not to be getting them to where they are most needed. We cannot allow complacency to set in when the fight is far from won.

A copy and paste model from the early days of the epidemic has clearly not been effective in stemming the tide of the epidemic in black MSM. We must rethink our approaches to engaging the community, fighting stigma, social and economic inequalities. In my opinion this will only be effective through giving the community a voice and a seat at the table in developing innovative strategies for raising awareness on treatment, prevention and HIV care in general.

 

 

I am hopeful that Jay will return for subsequent treatment visits and will become one of the many success stories in the clinic. In a fight that’s far from over every little step forward counts and sustains the hope that we can beat this once and for all. No one will be left behind this time.

 

Written by Boghuma K. Titanji 

( Names and timing of events have been modified to preserve patient anonymity)

From Guangzhou and Mumbai with love?

The sights and sounds of a busy African city are something when once experienced are never forgotten. Rowdy traders haggling prices with their customers, street food vendors assembling delicious meals at the roadside and motorcycle taxis zooming through, transporting people to their various destinations.  Everyone is in a hurry and everyone is busy trying to survive and make it through another day.

The imagery though chaotic, is a fond one for many who have experienced it first hand either through tourism or by growing up in Africa.  Buried amidst the chaos is the ever-present street “pharmacist”. Usually, a small makeshift stand or sometimes just a carton box packed with contraband medicines for all ailments. The stand is typically manned by an ordinary looking person everyone calls “docta”. Projecting an air of confidence on all things health-related next to signs displaying his or her areas of specialty. People stop by for consultations and prescriptions, a quick exchange of cash is made and they walk away with a supply of pills for whatever illnesses they seek to address.

The combination of poverty, high unemployment rates and lack of access to healthcare means that street medications are for many the only affordable option for healthcare, despite the associated risks. This is  fertile ground for the never-ending stream of counterfeit medicines, which pour unto Africa’s streets from China and India. The demand feeding this multibillion-dollar industry is driven by factors too daunting for corrupt governments with little will to effectively address. Crackdowns when they do happen, are mostly for show than a real attempt at effective regulation.

For many years the focus has been on the risk of sub-standard antibiotics driving antimicrobial resistance and ineffective fake treatments and toxic drugs killing thousands in these parts of the world.  While these issues continue to prevail, the last five years have seen a rise in contraband opioids, take the illicit medication market in Africa’s major cities by storm. This newcomer adds another crisis to the ever-growing list, one that the region is wholly unprepared for, with sinister implications for gains made in other areas of public health.

 Meet Tramadol – Africa’s Choice Opioid

Healthcare providers in developed countries have access to a wide array of opioid medications to treat their patients. 4 countries – the US, Canada, the UK and Australia consume a remarkable 68% of the opioids produced by pharmaceutical companies worldwide. This privilege, abused by some healthcare providers through overprescribing, has been the biggest segue way to the serious opioid crisis now facing the US. In staggering contrast over 150 countries have little or no access to these medications, which when used and prescribed appropriately are essential to address pain in patients with cancer and other chronic pain syndromes.

The main reason behind this inequality in distribution is a system for international drug control, led by the United Nations Office on Drugs and Crime (UNODC) and the International Narcotics Control Board (INCB). These organizations were created to regulate licit use of opioids for medical purposes. Unfortunately, in the process they have created rules of surveillance and accountability that are almost impossible for poor countries to comply with. This has led to severe access issues and very limited options to treat pain syndromes in patients living in developing countries.

Enter Tramadol, a weak synthetic opioid that unlike its much stronger cousins Fentanyl and Methadone is not on the list of medicines regulated by the INCB. For this same reason it very quickly became a favorite on the prescription lists in poor countries. It is frequently the only option to help patients deal with post-surgical pain, cancer pain and other chronic pain issues.Depending on the dosing, Tramadol can have a sedating or a stimulant effect and produce a high like that caused by heroin. The news of these “desirable” effects has quickly filtered unto the streets and docta’s medicine cabinet, driving the non-medical use of Tramadol through Africa’s major cities to new highs.

Young people doing physically demanding work to earn a living are seeking out the drug for its stimulant effects, to allow them to work longer hours only to quickly become trapped in the vicious cycle of addiction. It has also gained popularity in high school and university campuses as a sex enhancing party drug. Tramadol at the right dosing antagonizes serotonin receptors and as a result can delay ejaculation. 

The drug is very cheap costing only a few pennies to score a dozen 50mg tablets, and is readily available on any street corner. The illicit drug market responded to the growing numbers of Tramadol users, by smuggling millions of tablets from India and China into major African cities. The fact that this drug is synthetic implies that there is no limitation to its production by the suppliers in Guangzhou and Mumbai.

In December 2017, Italian authorities intercepted a 50 million dollar shipment of Tramadol pills destined for Libya and in 2016, the US State Department declared Benin, a small West African country of 11 million people, the world’s second largest destination for Indian counterfeit Tramadol. Even more worrisome is the fact that producers have now increased the dosing strength of the pills being sold on the contraband medicine market. A drug usually prescribed in doses of 50mg and 100mg, you now find pills of 120mg, 225mg and 250mg being sold on the street. At higher doses, the nefarious effects of the drug are also increased. More instances of overdose and death as well as higher rates of aggressive and criminal behavior are being reported in recent months.

The agricultural industry has not been spared by the widespread abuse of Tramadol and it has filtered its way even into farming communities. Farmers in West and Central Africa have used the drug to enhance cattle feed, so the farm animals can plough for longer hours. This curious discovery was made when, researchers in Cameroon thought they had identified a medicinal plant source for Tramadol. They realized upon further inquiry that this was the result of direct human contamination from farmers feeding this medication to cattle.  

Several countries in the region have stepped up to try and fight the growing scourge of Tramadol addiction, though many others seem oblivious to the issue growing in plain sight. Egypt is now strictly regulating Tramadol use and cracking down on illicit shipments of the drug, after a study led by the Ministry of Health showed that  a staggering 70% of people seeking addiction treatment in the country were victims of Tramadol abuse.

Out of Sight is Out of Mind

Hardly a day goes by without a headline or an article on the opioid crisis that’s sweeping across the US, now considered to be one of the biggest public health crises facing the country. The United States, is one of the wealthiest and most powerful countries in the world, yet has struggled with effectively containing the ravages of the opioid crisis happening within its borders. Africa’s opioid crisis on the other hand is steadily growing and claiming more victims by the day with little attention paid to it both at the local level and at an international level.

The main reason behind this is the epidemic is affecting the poorest and most vulnerable groups in the society who mostly have no one to advocate for them at the national level. The thousands of addicted youth dying from overdose, or suffering the crippling effects of addiction are at the very bottom of the social strata. They rely on the stimulant effects of Tramadol to continue to do the kinds of physically demanding jobs, which allow them to make a living.  A lot of them are porters, motorbike taxi riders, manual laborers on construction sites in big cities etc.

Those of them who want to seek help for their addiction find that these services are not readily available or affordable for them. Centers for the treatment of addiction are few and far between and barely equipped to serve the growing numbers of victims of addiction in need of assistance. One can easily imagine the far-reaching effects of this growing epidemic extending to other areas of public health. Africa is a region that continues to bear a considerable burden of infectious diseases and mental health issues. The emergence of an opioid crisis would certainly erode the gains made in controlling these public health issues.

Is Tighter Regulation the Answer?

At the end of 2017, the UNOCD issued a statement raising the alarm on the increased trafficking and consumption of Tramadol and its health and security implications for the region. This has led to increased interceptions and seizures of Tramadol across W. Africa by government authorities. Despite these crackdowns, there has barely been  a dent in the supply chain of the drug, given the porous nature of borders connecting countries in the region.

The WHO has been shy in voicing its endorsement for a tighter regulation of Tramadol, a move that could essentially mean adding this medication to the list of internationally controlled opioids. While this may possibly decrease the illicit use of the drug by tightly regulating its importation and use, it will also penalize millions of patients with chronic pain who are for most part  sub-optimally treated and die in agony. Many also argue that a tighter regulation of Tramadol will simply open the way for other opioids to become the drug of choice on the illicit drug market.

These conflicting factors mean that there isn’t a straightforward answer to addressing the problem.  If governments in the regions hope to swing the tide toward winning the fight against the opioid crisis in Africa, they will have to take on the issue as seriously as any of the other major public health issues affecting the region.  This will require concerted collaborative efforts between countries in the region to target trafficking networks within and between  borders. Also more effective reporting systems will need to be put in place to capture the scale of the problem. Most importantly treatment facilities will have to be made available and affordable for persons struggling will issues related to addiction in order to break the cycle. Implementing these measures is certainly not easy in a region with a lot on its public health priority list.

A good place start is acknowledging that there is indeed an issue and raising awareness about it. Africa has a growing opioid problem and its not going away, the time to wake up and face it head on is now.

 

Written by : Boghuma K. Titanji