When people talk of corruption as an
incubus in the health sector, their eyes are often set on the consequences of
that large scale corruption at Capitol Hill, Malawi’s seat of Government, the scandal
that forced the donor community to withdraw budgetary support to the country, leaving
the poor to pay for the sins of their masters—a select elite entrusted with the
duty to defend and protect the public purse. It is true that following
revelations of corruption of obscene nature in the civil service, the Western
world had reacted by quickly withdrawing budgetary support, and this has dealt
the health sector a telling blow. Most hospitals and health clinics now run on inadequate
supplies. This is just one of those burdens corruption has brought on the
Malawi race. But to measure the true breadth and length of corruption in the
public health sector, we need to go deeper than this. This is what I will do in
this discussion, digging deeper in order to demonstrate that corruption, apart
from depriving the poor of the much-needed drugs and other equipment useful in
any hospital setting, also triggers a devastating undercurrent whose
consequences are dire and can harm alike both the culprit rich and the victim
poor. I will thus demonstrate that we are standing on the edge of a chasm, and
that if corruption in the health sector is not checked once and for all, the
evil threatens to bring upon us all a catastrophe nothing human can cope with.
Corruption,
hospital supplies and deaths
Corruption affects hospital supplies in
a number of ways, directly and indirectly. First, grand corruption in the
public sector gives the fatigued donor community a reason to flee the scene,
often abandoning projects mid-way, some of which were directly involved in procurement
and purchase of drugs and equipment for our hospitals and clinics. That way, the
health sector simply collapses, forcing hospitals and clinics to live in names
only. The unavailability of essential drugs and equipment in hospitals means
absence of treatment, and the result is that simple ailments end up getting
complicated, eventually leading to more complications and deaths. In this way,
corruption by a few greedy fools ends up punishing the poor masses, people with
nothing to hold on to. Eventually, through corruption by a few greedy foes, the
cycle of poverty continues, taking a more virulent strain at every turn.
Corruption also leads to further spread
of diseases which, otherwise would have been contained in the early stages. This
is exactly what happened in Sierra Leone some three years ago. Sierra Leone is
among the West African countries that were hard hit by Ebola then. In that
country alone, the disease killed nearly 4,000 people. Among this number were
200 health workers in that country.
Latest audit revelations in that country
show that some of those deaths could not have occurred if the funds from both national
coffers and private donations released towards fighting the deadly virus there
had been used for the intended purpose. But as it was, some people had diverted
a large chunk of that money for their own private end, accepting to see their
country go down because they wanted to earn where they did not sow. One can
just imagine what they say now after the level of devastation they had caused
upon their own people! So many thousands of people who should have contributed
in some significant way to the growth and development of Sierra Leone were sent
to an untimely grave, thanks to corruption in the high places.
In one article by Umaru Fofana of the
BBC entitled “Where are Sierra Leone’s missing Ebola millions” dated 23 January
2017 and available at www.bbc.com,
Alhassan Kemokai, a survivor from the disease wishes all the essential supplies
had reached the hospitals, for then many lives would have been saved. The
article says this gentleman had contracted the disease from his mother who was
a hospital worker and that she had contracted it while helping an unsuspecting
Ebola patient. Sadly, she mother succumbed to the illness, and article quotes
Mr Kemokai as saying his mother would not have contracted the disease if the
hospital where she was working had basic things such as gloves. In other words,
if those entrusted with disbursing money meant to contain Ebola in Sierra Leone
had exercised that high level of honesty expected of people in that position,
Sierra Leone would not have lost up to 4,000 people to Ebola.
According to Jamie Hitchen in “Sierra
Leone: Mismanagement of Sierra Leone’s Ebola Spending”, available at www.allafrica.com,
a report by the country’s Internal Auditor had found that as much as 30% of the
approximately US$19 million meant for the fight against Ebola in May-October
2014 alone, had been disbursed without proper supporting documents. According
to the article, in some cases, hospital ghost workers were created and paid for
using money meant to fight the disease.
In short, where people indulge in
corruption especially in a context of some health crisis, the result is devastating
especially among those front-line hospital workers as well as the people coming
to access the services. Because they are not being given essential hospital supplies,
these workers end up contracting the disease, in some cases leading to deaths,
all this in a context where it is a toll order to train medical personnel. On
the other hand, the people seeking medical help end up losing their lives after
receiving no proper treatment owing to lack of resources following diversion of
funds meant for the purchase of hospital supplies and drugs.
Another devastating consequence of
corruption to the health sector is something most of us do not take time to
think on—the issue of antimicrobial resistance or simply drug resistance.
Corruption
and drug resistance
According to the World Health
Organization “antimicrobial resistance happens when microorganisms (such as
bacteria, fungi, viruses, and parasites) change when they are exposed to
antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials,
and anthelmintics). Microorganisms that develop antimicrobial resistance are
sometimes referred to as ‘superbags’” (“Antimicrobial Resistance” Fact sheet,
available at www.who.int,
updated September, 2016, accessed 2 February 2017).
The term antimicrobial resistance is
thus an umbrella term for all drug resistance posed by bacteria, viruses, fungi
and parasites. If the resistance is caused by bacteria it is referred to an
antibiotic resistance.
Antimicrobial
resistance is becoming serious by the day and “medical pundits are now warning
of a return to the pre-antibiotic era; a recent database lists the existence of
more than 20,000 potential resistance genes (r genes) of nearly 400 different
types, predicted in the main from available bacterial genome sequences” (Julian
Davies and Dorothy Davies, 2010: 147). In other words, what is happening as far
as drug resistance is concerned is as if we are going back to the era before
various antibiotics were discovered, the era when a slight bacterial or viral attack
would end up in deaths of many.
But
what are the dangers of drug resistance?
According
to Dr Tom Frieden in Antibiotics Resistance Threats in the United States, 2013,
p 5: “When first-line (those standard drugs or
therapy ordinarily used for a particular pathogen or parasite) and then
second-line (those used after those we normally rely on have failed) antibiotic
treatment options are limited by resistance or are unavailable, healthcare
providers are forced to use antibiotics that may be more toxic to the patient
and frequently more expensive and less effective.
Even when alternative treatments exist,
research has shown that patients with resistant infections are often much more
likely to die, and survivors have significantly longer hospital stays, delayed
recuperation, and long-term disability.”
The
threat of drug resistance is real. According to the World Health Organization Antimicrobial Resistance: Global Report on
Surveillance 2014, “Globally, 3.6% of new TB cases and 20.2% of previously treated
cases are estimated to have multidrugresistant TB (MDR-TB” p xii.
The same report says
that “the yearly cost to the US health system alone has been estimated at US
$21 to $34 billion dollars, accompanied by more than 8 million additional days
in hospital” p xix. I am sure that estimates for an African country of the
stature of Malawi would be mind-boggling.
Today I read an
article by James Gallagher on the problem of resistance on malaria. The article
entitled “Malaria drugs fail for first time on patients in UK” says doctors in
the UK have said that “a key malaria treatment has failed for the first time
in patients being treated in the UK.” The article says between October 2015 and
February 2016, four people there were treated with artemether-lumefantrine (also
known as Coartem) which is a combination drug, and they responded to it only to
be readmitted when the infection reappeared. All the four had contracted the
parasite when two visited Uganda, one Liberia, and the other one, Angola. This
suggests that there could be a type of parasite spreading in Africa resistant
to malaria drugs. However, the article quotes a team at the London School of
Hygiene and Tropical Medicine that it was too early to panic.
On
the cause of resistance, Davies and Davies, say, “The development of
generations of antibiotic-resistant microbes and their distribution in
microbial populations throughout the biosphere are the results of many years of
unremitting selection pressure from human applications of antibiotics, via underuse,
overuse,
and misuse”
p 419.
The
World Health Organization 2001, also speaks of underuse, overuse and misuse
when it says, “The emergence of antimicrobial resistance is a complex problem
driven by many interconnected factors, in particular the use and misuse of
antimicrobials” WHO Global Strategy for
Containment of Antimicrobial Resistance, p 3. It is therefore important
that “antimicrobial drugs (i.e. the drugs we use against bacteria, viruses,
fungi and parasites) be used exactly as they are prescribed, or else they can
contribute towards antimicrobial resistance” (“What is Antibiotic Resistance?
What is Drug Resistance?” by James McIntosh, available at www.medicalnewstoday.com,
updated January 22, 2016).
Corruption
can force the people to practise underuse and misuse of antibiotics or indeed
any drug.
The other day a friend of mine working
in the health sector told me a story of how one security guard went to a hospital
where he was given some antibiotics after diagnosis. The security guard who was
able to read noticed a discrepancy between the prescription on the cover of the
medicine bag and the number of capsules inside it. He went to his boss and
asked whether this was normal. It was not normal, he was told, and the boss
took up the matter where it was found there was a kind of syndicate whereby a
few pills were being removed into a separate collection, for money.
The
guard in question was able to read and detect the discrepancy, but the majority
of Malawians are illiterate. In other words, they can take in whatever can be
given them, taking for gospel truth everything the nurse or medical assistance
or clinical officer can give them. Indirectly, such people can be forced to
‘abuse’ or ‘misuse’ the drug, a situation that can lead to drug resistance.
This is the reason my brother or sister on antiretroviral therapy is entreated
to always take the medication as prescribed in order to keep the infection to a
mere chronic, manageable condition, thus enabling one to live as normal as
everybody else. Unfortunately, the moment one stops taking their medication,
the virus which is never eliminated but remains dormant or inactive in some
immune cells starts replicating or multiplying again, and the consequences can
be dire. This is why antiretrovirals have to be taken for life, the very point
stressed by the World Health Organization when it observes: “To limit the impact
of HIV drug resistance on the effectiveness of ART, it is essential to ensure high
quality treatment and care services” p 53. But how can we ensure high
quality treatment and care services when the resources meant to meet these
services are diverted through corruption? Indirectly thus, corruption can lead
to drug resistance through provision of low quality treatment and care
services.
But how can the situation affect those
practising corruption eventually?
Misuse of drug prescription can force
the virus or bacterium to acquire a more formidable appearance, forcing the
body to fail to respond to that new threat regardless of the nature of medicine
administered. The danger with this is that drug resistance spreads beyond the
one in whom the virus or bacterium has strained. Put simply, if a bacterium
turns into a strain or form that will not die after administration of a drug
that normally kills it, bacteria born from that bacterium will equally or even
more refuse to respond to that drug. If bacteria of that strain spread into
other people, their bodies too will fail to respond to a drug that would
normally kill or eliminate those bacteria. If this can spread in the
environment in which we live, the situation eventually becomes a danger to us all,
those practising corruption inclusive.
One way to
prevent drug resistance is to make a “commitment to always use antibiotics
appropriately and safely—only when they are needed to treat disease, and to
choose the right antibiotics and to administer them in the right way in every
case—(and this) is known as antibiotic stewardship” Antibiotic Resistance Threats in the United States, 2013, p 30. But
this is never easy where corrupt officials use people’s ignorance by giving
them low quality treatment and services, having diverted a large chuck of the
same to sell for their personal end.
Corruption has
also forces people to lose faith in public hospitals. As a result some people
just resort to finding their own means of getting the drugs through buying from
unauthorized dealers who can give them wrong prescription. This may end up
creating an environment in their bodies for microbes to develop resistance.
A person who
buys drugs from some unqualified person by the roadside, the drugs themselves
stolen from some public health warehouse, pharmacy or dispensary, such a person
may end up overusing or underutilising the drugs. It is common to find people
buying only a few pills because they do not have enough money, and stop taking
the drug once the pills they bought have been consumed.
It is important to note that “(such) societal factors accelerate the spread of resistance.
Undertreatment through suboptimal doses or inadequate treatment durations—for
example, when a patient does not complete a prescribed course of
antibiotics—leads to resistant strains of disease-causing microorganisms.
Resistance is also encouraged by unnecessary treatment of viral or
noninfectious diseases with antibiotics and the use of broad-spectrum drugs in
patients whose infections could be treated with more-targeted drugs” Health Affairs, September 2010, Aaron S
Kesselheim and Kevin Outterson, p 1690.
Although WHO and
other organisations rarely talk of corruption as a possible contributor to drug
resistance through forcing the people to abuse or misuse drugs, a deep tracking
of the link shows a strong connection between corruption and development of
drug resistance in viruses, bacteria, parasites, and fungi.
Conclusion
The fight against corruption though
crucial elsewhere, has a more telling implication in the health sector because
one can be forced into drug abuse and misuse out of poverty and ignorance.
Those indulging in the evil must realize that they are creating for this population
a dirty bomb of sorts in antimicrobial resistance, and GOD forbid, if such can
strike, we cannot escape each other, for nature always finds a way for us all
to interact in some form. I am talking about those forms.
References
Aaron S Kesselheim and
Kevin Outterson (September, 2010) “Fighting Antibiotic Resistance: Marrying New
Financial Incentives to Meeting Public Health Goals” Health Affairs
Fergus Walsh, “Why talk of a cure for
HIV is premature” dated 3 October, 2016 available at www.bbc.com
accessed 1 February, 2017
James Gallagher, “Malaria drugs fail for
first time on patients in UK” dated 31 January 2017, avaible at www.bbc.com
accessed 1 February 2017
James
McIntosh, “What is Antibiotic Resistance? What is Drug Resistance?” available
at www.medicalnewstoday.com,
updated January 22, 2016, accessed 2 February 2017
Jamie Hitchen, “Sierra Leone:
Mismanagement of Sierra Leone’s Ebola Spending”, available at www.allafrica.com,
accessed 1 February 2017
Julian Davies and Dorothy Davies, 2010, “Origins
and Evolution of Antibiotic Resistance” Microbiology
and Molecular Biology Reviews,74(3). American Society for Microbiology
Umaru Fofana, “Where are Sierra Leone’s
missing Ebola millions” dated 23 January 2017, available at www.bbc.com,
accessed 1 February 2017
World Health Organization, World Health Organization Antimicrobial
Resistance: Global Report on Surveillance 2014
World Health Organization 2016
“Antimicrobial Resistance” Fact sheet, available at www.who.int,
updated September, 2016, accessed 2 February 2017)
WHO 2001, WHO Global Strategy for Containment of Antimicrobial Resistance
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