VCU GH2DP Honduras Trip Update: Potpourri

Up early in Olanchito, working on our report for the Health Minister and waiting for the day to ramp up.

Here are a few additional (somewhat random) thoughts on some of the things we saw yesterday. 

One of the key pieces of advice I give my travel clinic patients is to be very careful not to ingest municipal water in developing countries (this is a major risk factor for developing diarrheal illness). This includes not eating fresh vegetables (which likely have been washed in bacterial-contaminated municipal water). The caveat to this is that these foods may be okay to eat if you know they were washed with clean water. 

Here is a picture of the lettuce for yesterday's lunch meeting being washed using a water purification system; I went for it, so far so good. 

Lettuce being washed by water purification system

Picture from local pharmacy

Another thing that always surprises me is how many antibiotics one can buy over the counter at pharmacies here; one can find almost anything, including injectables. You only need money to access these medications: they are available without prescription. 

I have never seen local data on antibiotic resistance, but I imagine it is high (at least in the cities) for some of the most common, cheapest antibiotics (such as amoxicillin, which is available here in supermarket checkout lines, like gum and candy are in the US). 

Beyond driving antibiotic resistance, inappropriate antibiotic use can lead to drug toxicity and treatment failure (prescribing the right antibiotic for the right condition for the right amount of time is often tricky for physicians; if the antibiotic is chosen without professional guidance the likelihood its use will be appropriate is low). 

Some good information from the WHO on the appropriate use of antibiotics (including in developing countries) can be found here.

You can learn more about the VCU Global Health and Health Disparities Program (GH2DP) and our work in Honduras here. 

Fake Drugs: A Global Problem

www.wikipedia.org

In my travel clinic I regularly counsel patients who are traveling abroad that they need to carry a full supply of any prescription medications they regularly take with them, and bring a small cache of over-the-counter medications they might need, as well. In the few instances patients have asked me whether it is safe to purchase a portion of their anti-malarial medications abroad (as the drugs are often much cheaper) I have recommended against this over fear of the quality of the medications they would purchase. Although my practice is consistent with guidance provided by the CDC, we don't know the true scope or nature of this problem.

Here is a link to a nice New York Times article discussing the issue of fake and substandard drugs. This article links to a detailed analysis of this subject by Attaran and colleagues that appeared in this month's BMJ (the full text of this paper is available here).

It is clear that many of the drugs available to consumers (especially in developing countries) are either fake or substandard. The true scope of this problem is unknown, but it has been estimated that half of some drugs for life-threatening diseases may be fake. The article by Attaran and colleagues cites the following real-world examples: > 120 people dying in Pakistan after receiving tainted medication for heart disease, an anti-cancer drug being distributed throughout the world that had no active ingredient and the distribution of substandard HIV drugs in Kenya.

Although this problem is widespread in developing nations, it is a problem for first-world countries, as well. An example of this is the aforementioned issue with the anti-cancer drug bevacizumab, wherein a fake version of the drug (that contained no active drug) was distributed in the United States.

Attaran and colleagues call for a comprehensive international strategy that universally defines what substandard and fake medications are, and that creates legal consequences for trafficking these products. We also need better information about the true scope of this problem.