31 minute read
From Nigeria to Benin
from Issue 17
Applying a Vendor Awareness Initiative to Combat the Counterfeit Drug Trade
Veronica Chan, Iris Lui, Grace Lun, Naushin Nagji received 88,000 meningococcal vaccine donations from its neighbouring western African country, Nigeria. However, due to suspicious batch numbers and expiration dates that conflicted with those recorded, the vaccines were later identified as counterfeits. 2,500 deaths were reported as a result of this.
This problem is widespread globally with severe consequences, yet it remains one of the most underreported global health issues today. A universal definition for the term “counterfeit drug” has not been formally developed. The World Health Organization (WHO) has offered the following as a starting point: ...one which is deliberately and fraudulently mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient (inadequate quantities of) active ingredient(s) or with fake packaging.
The vague definition of the term allows it to encompass the many different issues involved with counterfeit drugs, but at the same time, it acts as a hindrance to the formulation of much-needed laws and policies to mitigate the issue.
nigeria: a suCCess sTory
Nigeria is the central hub of drug trade in Sub-Saharan Africa. While drug counterfeiting still exists there, Nigeria’s
nigeria and benin are both countries that have faced a widespread epideMic of counterfeit drugs. nigeria with the use of an awareness prograMs and the patent Medicine vendors protocol was able to control the probleM. benin on the other hand, struggled with the application of this Model. this article will provide a brief introduction into and benin ’s strategies in coMbating this issue.
In 1995, Niger fell victim to a meningitis epidemic and one of the worst reported cases of counterfeit drugs. In an attempt to establish a vaccination campaign, Niger
the issue of counterfeit drugs and then coMpare nigeria successful attempts to resolve this issue set a solid example for neighbouring countries. Much of this success is due to the newly reformed National Agency for Food and Drug Administration and Control (NAFDAC), initially established to regulate and control quality standards for foods, drugs, and other products imported, manufactured locally, and distributed in Nigeria. Since Dora Akunyili’s induction as president in 2001, many changes have been made to combat the prevalence of corruption and counter the harmful effects of inadequate border surveillance, healthcare, and education system. However, the most effective solution against counterfeit drugs was the public awareness campaigns executed through a variety of media such as posters, radio broadcasts, billboards, fliers, and news articles. These campaigns worked to teach the poorly educated population how to recognize the differences between genuine and fake drugs (Akunyili, 2006). The success of NAFDAC’s efforts became evident and widely acknowledged in 2005 when an estimated 16 million USD worth of counterfeit drugs were voluntarily handed over or confiscated via tip-offs (Raufau, 2006).
Benin: a Work in Progress
Benin is another West African country that borders Nigeria to the east (Bernagou, 2008). Benin’s characteristics are similar to those of Nigeria with its low literacy rate, poor healthcare infrastructure, and lack of regulation of the pharmaceutical sector. In its economic capital, Cotonou, is Adjegounle, the notorious “kingdom of street pharmacies” that spans more than 10,000 square feet (Vidjingninou, 2009). This illicit drug market has been linked to at least 250 deaths and 340 cases
of chronic illnesses between April 2007 and June 2008 (Vidjingninou, 2009). In a country where many struggle to make ends meet, people turn to the counterfeit drug market to purchase cheaper drugs (Vidjingninou, 2009), because of the opportunity for bargaining (Bernagou, 2008). The counterfeit drug situation is further exacerbated by street vendors who go door-to-door to sell less expensive, unregulated medications (Bernagou, 2008). Since 2003, public awareness campaigns concerning counterfeit drugs have been carried out in Benin, but the primary limitation of these campaigns is that they did not target the vendors along with the rest of the population (Bernagou, 2008). The result was that as the number of visits from travelling vendors decreased, the counterfeit drug situation in the market worsened (Bernagou, 2008). Therefore, awareness campaigns need to extend beyond the general public to target vendors as well.
design oF The PaTenT MediCine Vendors (PMV) aWareness CaMPaign: aPPlying nigeria’s inTerVenTions To Benin
In light of the severity of the counterfeit drug trade in Benin and its similarity to the pre-2001 circumstances in Nigeria, a promising solution would be to borrow elements from one successful awareness campaign targeting PMVs launched in Nigeria and apply it to Benin. While local NAFDAC awareness campaigns have been reported to be more efficacious than improvements in government regulatory control, similar public initiatives in Benin have not been successful in raising awareness among medicine vendors in conjunction with targeting the public (Bernagou, 2008).
Furthermore, a cross-sectional survey conducted in Benin regarding citizens’ drug purchase patterns reported geographic and financial barriers to access genuine medications from governmentowned health centres, placing PMVs as a first point of contact for both unofficial primary health care consultation and prescription of medicine (Abdoulaye et al., 2006). The majority of those surveyed do not commonly visit a physician prior to purchasing prescription medications due to high costs (Abdoulaye et al., 2006). Therefore, a novel approach would be to target PMVs in an extensive awareness campaign using peer-directed, participatory education to improve their knowledge of current treatment protocols, as well as to strengthen their commitment to providing quality medicines to their communities. The idea for this initiative primarily stems from a successful 2003 PMV awareness campaign which improved PMV knowledge of malaria symptoms and the responsible prescription of appropriate malaria drugs in the Nigerian communities of Aba North and Aba South (Greer et al., 2004). Given the reported positive outcomes of this intervention - including a three-fold increase in PMV knowledge about malarial prophylactic measures and a nearly sixfold increase in PMVs recommending the correct dose in treatment regimen – there is convincing evidence to support the application of the Nigerian malaria awareness intervention as a model to combat the counterfeit drug trade in Benin (Greer et al., 2004).
This intervention aims to target PMVs practicing in the community health district in which Adjegounle is found. The cascade peer training approach excels in resource-limited settings due to lowered costs and reduced time interval for the intervention to reach all PMVs in the community (Greer et al., 2004). Moreover, the cornerstone of such a model is its intimate small-community setting, which capitalizes on the established relationships of PMVs with neighbouring clients. Furthermore, a comprehensive review of 16 PMV interventions in subSaharan Africa concluded that features of the most efficacious campaigns involved participation of the entire community, material incentives for PMVs, and continued monitoring of performance – all of which are key components in this adapted model (Goodman et al., 2007). From the Nigerian PMV malaria awareness campaign (Greer et al., 2004), we seek to borrow and apply the following elements: 1) partnership coordination and baseline census; 2) peer-directed cascade training model; and 3) supplementary media, materials, and monitoring.
PHC District/ CAPA Area
-Community Leaders -Community Representatives (from NGOs, associations, etc.)
LGA
STATE
Figure 1 Essential components of the community health district committee which would coordinate logistics during the intervention and provide ongoing support to trained patent medicine vendors following the training. PMV Peer Trainer
PMV 1 PMV 2 PMV 3 PMV 4...etc Figure 2 Overview of the PMV cascade training model that will be followed throughout the intervention process
1) Preparation: Partner Coordination and Census
Consistent with the Nigerian PMV awareness campaign, coordination of various agencies is crucial to the campaign’s success in Benin. Development agencies - including BASICS (Basic Support for Institutionalizing Child Survival) and the Chirac Anti-Counterfeit Drug Initiative – would provide medical staff to act as master trainers as well as logistical and financial support. Benin’s National PMV Association is another key stakeholder as they would serve to mobilize and persuade PMVs in communities to attend awareness campaign sessions. Furthermore, another important preparatory step instituted in the Nigeria campaign that is also applicable to the Beninese context is the baseline census, assessing geographic distribution, pre-intervention practice patterns, and potential interest in participating in the prescribed awareness campaign.
2) Intervention: Peer-Directed Cascade Training
As seen in Figure 3, a peer-directed cascade training model was adapted from the original Nigerian campaign. First, master trainers (medical staff) from partner development agencies would conduct a workshop for the CHD committee (Greer et al., 2004). Each district’s committee - comprised of community leaders, NGO representatives, traditional health practitioners, and physicians, among others - subsequently select four PMVs as a core group of peer trainers for the community, depending on criteria such as literacy, possession of the secondary school certificate, and residence in the community for more than two years (Greer et al., 2004). Master trainers would then deliver an educational workshop to the group of peer trainers, who would each host awareness campaigns in their respective regions to small groups of local PMVs (Greer et al., 2004). This communitybased PMV training aims to teach each PMV to effectively identify genuine versus counterfeit packaging, understand standard treatment regimens for common region-specific diseases in Benin, and to recognize symptoms severe enough to require referral to a physician.
3) Supplementation: Materials, Media, and Monitoring
One of the primary incentives for PMVs to attend the awareness campaign is the provision of a certificate upon completion. Trained PMVs must sign a pledge of accountability to sell only genuine medications in their community. Importantly, a key incentive is the provision of logos for PMVs to present on the walls of their shops to identify them as trained professionals, upon completion of the intervention program (Greer et al., 2004). As adapted from the Nigeria PMV intervention model, media promotion is an important adjunct to the central awareness component. Specifically, radio programs can serve to mobilize and encourage local PMVs to attend the peer-lead awareness sessions outlined above. Thus, representatives from all sectors of the healthcare system in the community jointly ensure that each PMV is responsible for guaranteeing the safe provision of medications to local districts.
underlying assuMPTions and ConClusion
Careful consideration has been put into re-designing Nigeria’s program for Benin in the hopes of combating the counterfeit drug industry. By applying many of the program’s components to the Benin model including the structure of the training course and the evaluation criteria, the model can be expected to experience similar success. This is based on the assumption that Benin is comparable
to Nigeria with regards to a low education level among PMVs and a reliance on PMVs due to poor accessibility to Primary Health Centers (Goodman et al., 2007). The proposed program is also likely to perform well in Benin due to its time and cost efficiency (Greer et al., 2004), thus reducing strain on the nation’s limited budget. In addition, it is believed that this community-centered program will increase the strength and awareness of community groups, leading to a more effective and collective framework in which problems can be dealt with (BASICS II, 2004).
Ultimately, if evidence suggests that a vendor-targeted training model such as the one proposed above is effective in reducing the distribution of counterfeit medications in Benin, there is potential to tailor the program to other countries plagued with counterfeit drugs. It is important to remember that PMVs only comprise a small portion of the counterfeit drug industry. Thus, interventions exclusively targeting PMVs will not completely resolve the problem as they are necessary but insufficient determinants to the suppression of such illicit activities. Moving forward, it would be important to implement regulatory protocols such as anti-corruption and border surveillance initiatives, along with stricter law enforcement, to further the potential progress of this PMV awareness campaign.
PosTgraduaTe ediTor in FoCus
Dr. Ryan Wiley Please refer to page 7 for Dr. Wiley’s biography.
reFerenCes
Abdoulaye, I., Chastanier, H., Azondekon, A., Dansou, A., &
Bruneton, C. (2006). Enquête sur le marché illicite des médicaments à Cotonou (Bénin) en mars 2003. Med Trop, 66, 573-576. AfDevInfo Organisation Record, (2008). Retrieved Nov. 27, 2009, from http://www.afdevinfo.com/htmlreports/org/ org_14033.html Akunyili, D. (2005, May). Counterfeit Drugs and
Pharmacovigilance. Paper presented at The 10th
Pharmacovigilance – The Study of Adverse Drug Reactions
Training Course, Sweden. Retrieved from http://www. fug.se/ovrigt/Akunyili.pdf Akunyili, D. (2006). Lessons from Nigeria: The Fight Against
Counterfeit Drugs in Africa. Diabetes Voice, 51(3), 41-43. BASICS, (2006). Retrieved Nov. 29, 2009, from http://www. basics.org/about.htm BASICS II, (2004). The CAPA Handbook: A “How-To” Guide for Implementing Catchment Area Planning and Action, a
Community-Based Approach to Child Survival. Arlington,
VA: State Ministry of Health. BASICS III. (2009). Improving Child Health in Benin: Final
Report. Retrieved from http://www.basics.org/reports/
FinalReport/Benin-Final-Report_BASICS.pdf BBC News, (2009, Oct 17). Country profile: Benin. BBC News.
Retrieved November 17, 2009, from http://news.bbc. co.uk.libaccess.lib.mcmaster.ca/2/hi/africa/country_ profiles/1064527.stm. Bernagou, P. (2008). La contrefaçon des médicaments et les moyens d’y remédier au Benin. Comptes Rendus Biologies, 331, 986-990. Bernagou, P., Teyssie, V. (2008). Pierre Fabre Foundation. [Brochure]. Castres: Fondation Pierre Fabre. Centers for Disease Control and Prevention. (2009). Health
Information for Travelers to Benin. Retrieved from http:// wwwnc.cdc.gov/travel/destinations/benin.aspx Central Intelligence Agency (CIA), (2009). In The World
Factbook: Benin. Retrieved November 15, 2009, from https://www.cia.gov/library/publications/the-worldfactbook/geos/bn.html Central Intelligence Agency (CIA), (2009). In The World
Factbook: Nigeria. Retrieved Oct. 25, 2009, from https:// www.cia.gov/library/publications/the-world-factbook/ geos/ni.html Central Intelligence Agency (CIA), (2009). In The World
Factbook: Nigeria. Retrieved Nov. 29, 2009, from https:// www.cia.gov/library/publications/the-world factbook/ maps/maptemplate_ni.html Fondation Chirac, (2009). Retrieved Nov. 27, 2009, from http://www.fondationchirac.eu/en/ Gale, J., Loux, S., & Coburn, A. F. (2006, April). Creating
Program Logic Models: A toolkit for state Flex Programs.
Portland, ME: Flex Monitoring Team. Goodman, C., et al. (2007). Medicine sellers and malaria treatment in Sub-Saharan Africa: What do they do and how can their practice be improved? American Journal of
Tropical Medicine and Hygiene, 77, 203-218. Graphic Maps, (n.d.). In Benin Large Color Map. Retrieved Nov. 29, 2009, from http://www.worldatlas.com/webimage/ countrys/africa/lgcolor/bjcolor.htm For a full list of references, please refer to www.meducator.org
As a drug that is routinely
prescribed for the treatment
of severe pain in cancer patients, morphine ironically may promote the spread of cancer. The opiate promotes the growth of new blood vessels which deliver oxygen and nutrients to tumors.
Danish scientists proclaim that there has been no substantial change in the number of adult brain tumors since
mobile phone usage sharply
increased in the mid-1990s.
A research team at Harvard University has successfully engineered a plastic implant, which, when placed under the skin of a rat, can kill cancer cells by inducing a systemic immune response. This
“cancer vaccine” technology
appears promising, but more research is needed before the technique can be used in humans.
A major European trial has shown that 1 in 8 men tested
positive for prostate cancer
using a prostate-specific antigen will, in reality, not develop the disease.
Researchers at the University of Chicago found an increased number of proteins in the urine of 90 children diagnosed with ‘dangerous’ snoring, thereby suggesting that the urine test can differentiate dangerous snoring from safe snoring. A study found that individuals taking angiotensin receptor blockers (ARPs) were 50% less
likely to develop dementia
as compared to other blood pressure drugs. It is known that high blood pressure is a risk factor for Alzheimer’s disease.
Dads should not be present in
the delivery room, according to French obstetrician Michel Odent. Odent blames the increasing number of Caesarean section births on the increasing number of fathers in the delivery room. He argues that the father’s presence makes the woman more anxious and slows the release of oxytocin, a hormone that stimulates uterine contractions during birth.
Jack Walborn, a six-year-old boy from the United Kingdom, became the first person in the
world to have a heart valve
opened using a magnetic resonance imaging (MRI) scan rather than X-ray. An MRI involves no radiation exposure, an important consideration for children.
A simple eye test may
detect Alzheimer’s and other diseases before symptoms develop, according to UK scientists. The technique uses fluorescent markers that attach to dying cells viewed from the retina, giving an early indication of brain cell death.
Drinking green tea may offer some protection against
lung cancer, say experts who studied the disease at a medical university in Taiwan. Recent research involving over 500 people adds to growing evidence point to the beverage’s anti-cancer effects.
Not only does the amount and style of exercise matter, but studies also show that differences in what you eat after exercise produce different effects on the body’s metabolism. Patients may have to be prescribed higher doses of
antibiotics because of rising
rates of obesity. Doctors argue that the standard “onesize fits all” dose may not eliminate an infection in larger adults, which can increase the risk of developing antibiotic resistance. The Potato Council is trying to reclassify the tuber as a “supercarb” – recognizing its “unique dual identity” as both carbohydrate and vegetable. Spurned by dieters on lowcarbohydrate regimens like Atkins, the vegetable also appeared to score poorly on the Glycaemic Index (GI) - which measures how quickly foods are broken down. The slower, the healthier - and the potato breakdown was quick. UK experts claim that carrying
extra weight on your hips, bum and thighs protects against heart and metabolic
problems. Hip fat mops up harmful fatty acids and contains an anti-inflammatory agent that helps prevent arteries from clogging.
Neuroscientist Hiroshi Kawabe has recently published a study in the prestigious journal, Neuron, showing that an enzyme, which usually
controls the destruction of
protein components, has an unexpected function in neurons. Nedd4-1 controls cytoskeleton structure and thus ensures that nerve cells can form the tree-like extensions necessary for signal
MED
transmission in the brain. Attractive women may have the competitive edge by letting their temper flare more, research suggests. Researchers found women
who rated themselves as pretty displayed a war-like
streak when fighting battles
to get their own way. Joel Nigg, a scientist at the Oregon Health & Science University postulated that lead, which is sometimes found in paint, may trigger
an underlying susceptibility
to ADHD and change it into a full-blown disorder.
Swapping a daily glass of wine for another with a slightly lower alcohol content may lower the risk of some cancers. An alcohol content of 10% rather than 14% may be enough to initiate such benefits, says the World Cancer Research Fund.
Brain blood vessels point to
Multiple Sclerosis (MS): A US study states more than 55% of MS patients have constricted blood vessels in their brains. Scientists are trying to mimic
the look, feel, and taste
of chicken with soy. Why? It costs less and has many health benefits, including lowering cholesterol levels and maintaining healthy bone structure. The 3D structure of the
vesicular stomatis virus
(VSV) was recently revealed in a paper published in Science. The bullet-shaped VSV has therapeutic potential in treating cancer and HIV. A small proportion of
extremely overweight
people may be missing the same segment of genetic material, claim researchers. The findings, published in Nature, could offer clues to whether obesity can be “inherited”.
Stammering has long been
recognized to run in families, but scientists now say they have identified three genes that may cause the problem to occur. They believe that mutations tied to metabolic disorders may also affect the way some parts of the brain function.
Professor Ina Weiner of Tel Aviv University recently found that the lateral ventricles and hippocampus were larger in rats that were manipulated prenatally to display schizophrenialike symptoms. Two drugs commonly used to treat schizophrenia, risperidone and clozapine, appeared successful in reducing ventricles and
hippocampus size to normal. Scientists at the University of Chicago’s Brain Tumor Center have developed
nanomaterials that may
help fight cancer. By connecting gold-plated ironnickel microdiscs to braincancer-seeking antibodies, the application of a light magnetic field triggers an oscillation whereby energy transfer induces cell suicide known as apoptosis. A mechanism, which incites sperm swimming when they get near the egg, could one day lead to new forms of male contraception, scientists have said. Tiny pores on the sperm’s surface allow it to change its internal pH, which in turn starts its tail movements.
Scientists in Cambridge have shown that an “artificial pancreas” can be used to regulate blood sugar in children with Type 1 diabetes. A trial found that combining a “real time” sensor measuring glucose levels with a pump that delivers insulin can improve overnight blood sugar control.
Vegetative patients can respond to questions:
Scientists have been able to communicate with the thoughts of a brain-damaged man. Awareness was detected in three other patients previously diagnosed as being in a vegetative state.
A recent study published Clinical Pediatrics suggested that behaviours relating to
how much and what to eat are developed as early as three months to about two
years of age. This makes this age period a tipping point in determining the future onset of obesity. A recent study mapped the effect of acupuncture on brain activity and may allow acupuncture to be more accepted in the scientific community. Researchers found that the sensation produced by acupuncture, termed deqi, MedWire deactivates areas within the brain associated with the processing of pain.
Researchers at MIT and Harvard University have developed nanoparticles
with the capability to cling
to the walls of arteries and release medicine. These socalled “nanoburrs” have the added ability to be targeted to specific locations and as a result, introduces an alternative to drug-releasing stents in patients with cardiovascular disease.
If you find playing video
games a struggle, it could be to do with the size of certain parts of your brain. US researchers found they could predict how well an amateur player might perform on a game by measuring the volume of key sections of the brain.
While most children like sweets, those with an extrasweet tooth may be at higher
risk of future depression or
alcohol problems. A report in Addiction indicated that children are especially drawn to very sweet tastes had a close relative with an alcohol problem or showed symptoms of depression.
Vaccinations in the Developing World
Matthew MacDonald
Consider tuberculosis (TB) as an exemplar to the vaccination paradox. It is estimated that TB causes three million deaths a year - more fatalities than any other bacterial pathogen - with an estimated 1.7 billion people worldwide currently infected. Tuberculosis in the developing world is so prevalent that the UN’s World Health Organization declared it a global health emergency and classified it as one of the three diseases of poverty, which also includes AIDS and malaria (WHO, 2005). Despite having a highly effective vaccine, ninety-five percent of all new TB cases are found in developing nations (Grzybowski, 1991). Most incredulous of all is that the vaccine for TB, Bacillus Calmette-Guérin (BCG) is a relic of the 1920s. The BCG vaccine has proven to be effective in 80% of patients, though its specific biochemical mechanism is not well understood (Soysal et al., 2005).
Vaccines are created when scientists create a harmless version of a pathogenic bacteria or virus to be injected into a healthy person. This procedure allows the patient’s immune system to identify the true and dangerous disease by virtue of having an antigenic memory stored in B-cells (CDC, 2009). Through trial and error, Calmette and Guérin discovered that subculturing virulent strains of Mycobacterium bovis in a media of glycerine, bile and potato created a less
vaccines exist for soMe of the Most devastating diseases in the world froM typhoid to tuberculosis, with an estiMated 3 Million children saved by vaccinations in 1991 (grzybowski, 1991). logic would suggest that those who encounter these pathogenic organisMs on a daily basis would welcoMe iMMunity to theM; however the question is Much More convoluted aMongst those in the developing world. in short, it is accurate to say that achieving by supply, social, and cultural factors.
satisfactory vaccination rates for any disease in the third world is deterMined virulent strain of TB. After painstakingly reculturing the bacteria for nearly a decade, they created a non-pathogenic version of TB (Fine, 1989). By 1921 the first inoculation was performed on a child; 90 years later, it is predicted
that 3x109 BCG vaccines have been administered worldwide. After almost a century of possessing an effective vaccine against TB, the developing world continues to suffer tuberculosis at pandemic levels (BarretoI et al., 2006). Much of the aforementioned statistics seem contradictory; despite having a viable and proven vaccine, TB continues to be a scourge to one out of every six human beings – “why?” is the question this essay will attempt to answer.
suPPly serViCe FaCTors
Before discussing underlying cultural and social resistances to vaccinations, the rate-limiting step of supply and service must be examined. One major consideration is the physical location of vaccination clinics as well as the hours they operate during the day; mothers will not take their children to be vaccinated if they must be working from 9 to 5. Therefore, vaccination planners must collaborate with the community in question in order to align their resources for maximum effect (Boniar et al, 1989). We also see a drop in vaccination rates when clinic workers are pressured to focus exclusively on the quantity of individuals they vaccinate to the detriment of the quality of service. In the same vein we observe a decrease in the population’s willingness to be vaccinated when organizational policy avoids any risk-taking even when it is in the best interest of the patient or the community. For example, clinic doctors refer critically ill patients to distant hospitals simply in order to avoid responsibility (Grzybowski, 1991). It is important to have both a readily available supply of vaccines and staff who are trusted to administer it, but this factor eclipses an even more intractable issue: does the public want the vaccine?
soCial FaCTors
Recent trends in establishing effective vaccination programs have moved towards a ‘social marketing’ approach to encourage compliance and self-motivated behaviour. Instead of focusing on factors that predict the
Figure 1 Implementing vaccine programs in developing countries involves overcoming several challenges.
non-compliance with vaccination programs, the model of social marketing works similarly to its consumer-marketing cousin in finding predictors of demand (adherence) and self regulation. Examples of such studies in North India and Nepal have shown that there is gender disparity: males are more often vaccinated than females and a positive correlation exists between the mother’s education level and her compliance in a vaccination program (Grzybowski, 1991).
It is important to remember that vaccination programs do not operate in a vacuum; compliance is a function of a complex interplay of regional history as well as how individuals perceive western influences and even their own government. A powerful example is in India; conspiracy theories have emerged among conservative Hindu and Muslim groups linking vaccination programs to hidden political agendas. Mahadevan’s 1986 study suggested that Indian Muslims feared that vaccines are not medicinal but are in fact a sterilizing agent designed to enforce family planning, thus curbing their population growth and limiting the number of Muslim voters. These fears stem from past events such as when, in the 1970s, the Indian government exercised ‘emergency’ state power in the name of population control. Then, in 1990 during heightened Muslim-Hindu tensions, vaccination programs that specifically targeted women and children were coincidentally intensified (Bastien, 1989). Such tensions also include Western influences, as many in India believe that vaccination programs are simply a modern day adaption of the techniques used by Christian missionaries who built hospitals and schools in order to convert Hindus. One leader of a prominent Hindu group in a South Indian city, as interviewed by Grzybowski, pointed out the visual similarities between a hypodermic needle and the Christian cross. He also believed that youths vaccinated against diseases would feel immune to the wrath of the gods they have forsaken when they abandon their heritage in favour of “Christian values, tastes, and desires.” In the most extreme cases, there are fears that vaccination programs are nothing more than a western attempt to gather biological data about immunodeficiencies in the developing world’s population in order to produce biological weapons against them, as was a heated controversy in India’s national press in 1987 (Scheper-Hughes & Lock, 1987). A comprehensive list of social anxieties and variables that inhibit vaccination programs is essentially impossible due to the complex and ever changing geopolitical and social landscape. An effort, however, must be made to compensate for concerns and fears that cultures produce when an external agent attempts to influence them even if it is with benevolent intentions.
CulTural FaCTors
While less appreciated for its importance than social factors (Grzybowski, 1991), cultural influences regarding the perception of vaccinations and illnesses in general as well as the idiosyncratically held role of medicine in producing and protecting health is just as pivotal in the success of any vaccination campaign.
One of the major stumbling blocks in creating a sustainable, wide-scale vaccination program is a poor understanding of what vaccinations do and what diseases they protect against which leads to unrealistic expectations. Grzybowski found that mothers either believe that vaccines are good for a child’s health in a general sense akin to a balanced diet or that vaccines are designed to protect against serious diseases but nothing specifically. While 40-50% of mothers thought vaccinations protect against specific illnesses, only 25% could name a local disease that is vaccinable. Another major folly is that mothers often see vaccines as a treatment instead of a preventive measure, and thus do not vaccinate their children on the reasoning that the child is healthy (Raharyo & Corner, 1990). These misconceptions are often caused by rapid explanations given by health care workers for why mothers should comply with vaccination directives
or why a more sophisticated explanation is outside of an uneducated mothers’ understanding.
Another cultural aspect to consider is the general view a population holds about medicine and the ethical dilemma of either attempting to explain vaccination in rational terms, or instead introduce the concept using existing cultural frameworks – essentially explaining vaccinations as “magic”. Should the significance of the raised skin of a TB test be described in terms of an immune response or that its purpose is akin to a mystic’s divination procedure? In this precarious line of reasoning, one must remember the distinction between attributing the effects of a vaccine to magic, which is indefensible, and simply elucidating expectable results using terms familiar to the target population. While one’s first instinct may be to favour the option that does not appear to involve the intentional spread of superstition, consider which is less truthful: using existing cultural frameworks to explain that BCG will protect against TB for some time like an amulet would protect against a malevolent spirit, or giving a vague explanation that ultimately leads to a mother who draws false conclusions about the purpose and ability of a vaccine (Grzybowski, 1991)?
Failure to vaccinate is sometimes thought as a kind of parental neglect, that the parent does not care enough for the child’s health to have him or her vaccinated; indeed this is the opposite of the truth. Mothers who refuse to vaccinate often do so for fear of the child’s health, even if that fear is misplaced. When you subtract the supply issues involved and imagine a best-case scenario in which vaccines are available to all those who seek it, we are still hindered by the social environment that the vaccination program finds itself in as it must contend with non-health related issues such as racial tension. In addition to social factors, cultural factors such as a lack of education can lead to reduced compliance rates as patients develop unreasonable expectations of vaccines. Any successful vaccination regiment must contend with these three factors while never losing sight of that our efforts are humanitarian; forced vaccination compliance gained through a government’s directive is unsustainable and morally grey at best, so we must endeavour to educate and win the hearts and minds of those we are trying to help so that they seek vaccination of their own volition.
PosTgraduaTe ediTor in FoCus
Dr Farah Huzair is currently a part of the Technoscience and Regulation Research Unit (TRRU) at Dalhousie University. Her research interests include the evolution of science and biotechnology, and most recently she is a co-investigator for TRRU’s “Vaccines of the 21st Century” project.
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Santa Fe, New Mexico. Centers for Disease Control and Prevention. (2009). How
Vaccines Prevent Disease. Retrieved from http://www.cdc. gov/vaccines/vac-gen/howvpd.htm Fine, P. (1989). The BCG Story: Lessons from the Past and
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Deeks, J.J., Efe S., Staveley, I., Ewer K., Lalvani, A. (2005). Effect of BCG vaccination on risk of Mycobacterium tuberculosis infection in children with household tuberculosis contact: a prospective community-based study. The Lancet, 366 (9495), 1443-1451 World Health Organization. (2005). Poverty Issues Dominate
WHO Regional Meeting. Retrieved from http://www.wpro. who.int/media_centre/press_releases/pr_20020916.htm.
MedBulletin by Louis Winston
170,000 doses of the swine flu vaccine Arepanrix have been put on voluntary hold because of an above average report of anaphylactic reactions; this includes symptoms of difficulty breathing, skin rashes and an increased heart rate. It has been reported that one in 20,000 people suffered such adverse reactions to the batch. This is five times the expected number, although none of these patients suffered long term or fatal illness from the drug.
The manufacturers of Arepanrix, GlaxoSmithKline (GSK), said that the vaccine was being put on hold because “of a higher than expected rate of serious allergic reactions”. GSK also added that similar anaphylactic reactions were not seen in other lots.
To date some 15 million doses of Arepanrix have been distributed across Canada. The overall frequency of severe allergic reaction following immunization has been normal, with one case per 100,000 being reported.
Reference:
Canada’s doctors told to halt swine flu vaccine batch. (2009, November 25). Retrieved from BBC News: http://news.bbc. co.uk/2/hi/8376534.stm
Heart Damage: A Sexist Phenomenon?
MedBulletin by Mohsin Ali
Recently, Australian researchers have suggested that male sex hormones, collectively known as androgens, may play a role in helping the vasculature around the heart regenerate, thereby preventing heart damage. Men tend to suffer heart attacks that are more frequent, worse, and earlier in life than those compared to women. As estrogen is known to help blood vessels regenerate, it was assumed that the lack of the female hormones in men resulted in the heart attacks. However, recent work done by Sieveking and collegues have found that the heart attacks among men may be due to the drop in androgens as men age. Exposure to androgens caused cells derived from the umbilical cord of a male fetus to move and multiply, which are activities associated with new vessel growth.
Moreover, when researchers inflicted blood vessel damage on castrated mice lacking androgens, the mice responded poorly. But when treated with androgens, the recovery rate of the castrate mice was increased.
Taking all this evidence together, the authors suggested that androgen replacement therapy might possibly be a treatment for heart disease for men in the future. It will also be accompanied by increased energy and muscle mass, among other benefits.
The dark side? Androgens have also shown to play a part in helping tumour growth in prostate cancer, perhaps by the same mechanism: stimulating vessel growth.
Reference:
Rockefeller University Press (2010, January 16). Gender-biased heart damage. Retrieved from Science Daily: http://www. sciencedaily.com/releases/2010/01/100113172304.htm
