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EDITORIAL

The issue of giving aid to the developing world constantly sparks up fierce debate. In the developed world we are undoubtedly in a privileged position where it is our duty, in some ways, to give aid. However, the question arises - should aid be given as an altruistic measure or can it be given in a way that encourages innovation rather than reducing it? As an example, over the last 50 years, Africa has received more than $1 trillion in aid, with a rapid increase between 1970 and 1995. However, during the same period, GDP per capita growth in Africa has decreased. The unfortunate fact is that most African countries are poorer now than they were at the time of their independence from their respective colonial powers. Aid, it seems, may have lowered rather than increased their economic growth. Aid given for more specific causes such as malaria and HIV for example, is equally vast and whether it is really making a difference remains to be seen. The $300million annual funding for HIV in 1996 currently stands at $10billion. However the number of individuals with the virus stands at an all time high. In this edition, Elvena Guyett interviews Dr Mark Nelson, a leading HIV specialist, who brings this into perspective and discusses whether innovation and the way funding is used can play a role in eradicating this deadly virus. Whilst the West needs to revamp its strategy of giving aid and find innovative solutions to solve global problems, developing countries need to implement tighter and increased amount of regulation for the funding it receives. Additionally, more risks need to be taken by individuals and organisations - fear of failure should not be a hindrance but an opportunity to learn from one’s mistakes. This is classically demonstrated by the Bill and Melinda Gates Foundation through its Grand Challenge Explorations Scheme. Encouraging risk taking behaviour is part of the Challenge’s remit and vast sums of money are given for innovative solutions with further funding for projects that make progress. Challenges like these are extremely welcome as they contrast with industry-funded projects where we often have results which end up being very expensive and fails to be of benefit those who need it most. Secondly simply giving away large sums of money to poor governments is not the solution to the problem of poverty. This approach keeps people and their governments’ dependant on donors. Developing countries need to become more independent, self reliant and self sufficient. The developed world, as well as the low-income countries can do this by encouraging entrepreneurship and teaching skills which will eventually empower individuals. Aid is only effective and works best when governments put in population-centred economic policies, effective strategies for poverty reduction and measures for tackling corruption. The idea of innovation in health does not however only lie with giving aid or solving global problems. It is also very relevant for how healthcare systems are being run and whether we can save costs by being more efficient and productive. The US is currently in the middle of a historic healthcare reform where it will hope to provide healthcare to a much wider share of the population. Elishba Chacko discusses a similar theme and argues that perhaps healthcare infrastructures do need to be overhauled so that refugees and immigrants are not excluded. Carrying on with the idea of innovation, Elena Atkinson looks at the theme from a different lens. She considers the policies in healthcare and whether prescribing heroin for addicts is an innovative or an outdated idea. The good work at the LSJM continues and hopefully we have brought our readers a fascinating selection of articles. I would like to take this opportunity to thank all our authors, panelists and reviewers. The world, now advancing through the 21st century, needs its policies and ideas kept up to date. Let us encourage more risk-taking and let us help the less developed countries develop human and social capital for themselves. The impact of the credit crisis is weakening economic growth, reinforcing poverty, and eroding health and education systems. The future of developing countries should not depend on financial aid, but on its people and its governments.

Illustration: Ella Beese

Harpreet S Sood Section Editor Global & Community Health References 1. http://www.avert.org/worldstats.htm 2. http://news.bbc.co.uk/1/hi/sci/tech/4209956.stm 3. http://www.grandchallenges.org/Pages/default.aspx 4. UNAIDS (2008) ‘Report on the global AIDS epidemic’.

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NEWS Malaria Vaccine in Final Stages of Development Angela Fanshawe

Foundation, UNICEF and WHO, among others, would provide ongoing funds.

Manufacturers of a vaccine against malaria announced this week the start of the final stages of its clinical trial. The trial, which will take place across 7 sub-Saharan African countries, will involve more than 16,000 children under the age of 18 months.

The vaccine – which has been in development since 1987 – contains two genetically engineered proteins of the Plasmodium parasite, the causative agent of malaria, coupled with an agent to potently induce the immune system to react against these proteins.

Researchers are hoping that the vaccine – ‘Mosquirix’ – will reduce the number of malarial infections by 80% by 2025 and be effective for more than 4 years. Realistically, however, it has been suggested that the vaccine will not reduce infection numbers by more than 50% by this date. “Some may say, ‘50%, that’s not great,” says Dr. Dave Jones, US Army Colonel and director of a clinic in Kombewa, Kenya, “But at the same time, when you consider we lose 1 million kids a year, if you could cut that in half it would be a great step forward.”

The manufacturers aim to introduce the product onto the market by 2012, with infants receiving the vaccination as part of their standard vaccination program before their first birthday.

GlaxoSmithKline has developed the vaccine with financial backing from the PATH Malaria Vaccine Initiative, funded by the Bill & Melinda Gates Foundation. Dr. Joe Cohen, co-inventor of the vaccine and vice-president of research and development at GlaxoSmithKline, states that GlaxoSmithKline “is committed to making sure pricing will never be a barrier to access for this vaccine.” The Gates

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Sources: 1. The LA Times: http://www.latimes.com/news/nationworld/ nation/la-sci-malaria7-2009nov07,0,1735189.story 2. Associated Press: http://news.yahoo.com/s/ap/20091103/ ap_on_he_me/af_africa_malaria_vaccine_4 3. ABC News International: http://www.abcnews. go.com/International/extending-malariavaccine-reaches-africa/story?id=9004991

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INTERVIEW

Innovations in HIV research: An Interview with Dr. Mark Nelson Elvena Guyett, BSc (Hons) elvena.guyett@kcl.ac.uk Year 4 Medicine, King’s College London doi:10.4201/lsjm.gch.005

Source: Boehringer Ingelheim

Dr. Mark Nelson is a Consultant Physician for HIV inpatients at the Chelsea and Westminster Hospital. He is also deputy director of research, director of the HIV clinical trials unit, author of over four hundred publications, and also the principal author for the British HIV Association (BHIVA) guidelines for treatment of Hepatitis C co-infection. He has worked closely with several pharmaceutical companies as a Consultant and runs HIV programmes in twenty African and Asian countries, for which he was recently awarded the medal of honour of Vietnam. Elvena Guyett went to the Chelsea and Westminster Hospital to meet and speak to him about innovations in HIV research, treatment, and funding, and what the future holds in this field. The theme this issue of the LSMJ is innovation. HIV has featured again in the news this week with results of the vaccine trial in Thailand. What are your opinions on this and your thoughts on the fact that it was published in the press before a peer-reviewed journal? That is always going to be a problem. The press will always exaggerate findings, it is what the press do. They like things when they go wrong and when they go right and so you have to be careful of the results of studies like that. First of all, we have not seen the study and so we do not know the ins and outs, we have just got the numbers. It reminds me of the results by a man called Stanley Plotkin (one of the people who discovered the MMR vaccine). In my youth I went for an interview with him and he said the problem with the vaccine study is what to do with a result that is 30% effective which is exactly what happened there. Again, it is about numbers and significance – it is 30% protective, or more protective, but is that significant? Quite small numbers got HIV, which is a good thing, but then one of the issues with vaccines is do we want people to display risky behaviour? This highlights one of the other issues with vaccines - we also need to educate people concurrently. Say that we have a vaccine, what do you do with it, do you stop there? Do you give everyone that vaccine, with only 30% protection? What happens to people’s behaviour, once they know they have been vaccinated? Do you actually do more harm than good? So first of all we need to look at the results carefully and see what they show.

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Image: Electron microscopy of HIV particles budding from the surface of a CD4 cell. Another study on a microbioside showed exactly the same – 30% protection – but that was not significant – we interpret that how we want. So the problem with medicine is when something is just not significant. It perhaps gives us some ideas and a bit of hope, but it does not work perfectly, by any means. Of course, a lot of money has gone into vaccines, and is still going into vaccines, without any results. All those investors want to continue getting something. So you have to be careful spending when there is only a certain amount of money in the pot. Has there been a shift in funding? Early on, research into treating HIV was encouraged. Now with the success of available antiretrovirals, are we seeing more of a change towards research into prophylaxis? It depends on where you are, and where the epidemic is found. We do a lot of work in Africa and we can say the situation is still bad. People are being given drugs that we would not use in this country. Again, that is a question of where do you best spend your money? On more expensive drugs and treat fewer people, or do you treat more people with less expensive drugs. That is more about reducing toxicity rather than improving efficacy. I think there was a shift in the developed world into more research into prevention, but it varies. When you get negative results on microbiosides, vaccines and suchlike, it is difficult to say where the money’s going to go.

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INTERVIEW prevention. So rather than someone having to use a microbioside, or a man not happy with circumcision (which has been shown to work), you could get an injection of some relatively cheap, longacting anti-viral as a preventative measure. So I think really the true innovation actually comes from the researchers applying for grants. The pharmaceuticals are very good at doing research, but we have to accept that the majority of the time this will be based around their own products. With regards to effective measures such as circumcision, through seeing the patients here on a day-to-day basis, as well as your work abroad, do you find there’s more of a trend towards risk-taking behaviour? A lot of work has been done in the developing world on the risk of transmission. The latest research shows that your transmission risk is related to your viral load. There is also some data that if a patient’s plasma is negative i.e. fully suppressed with drugs, the virus also is suppressed in vaginal and seminal fluid. That does not mean definite suppression, but in some people’s sexual fluid there will be virus and that there will probably be a risk of transmission, but this will be less than 1 in 100,000. So a lot of work has been going into transmission of the virus which has led to people having more unsafe sex. In the academic circle, we see the gay community is having an increase in the transmission of Lymphogranuloma Venereum (LGV), Syphilis, Hepatitis C and more Hepatitis B which would suggest that there is more risk-taking behaviour. The question is whether this is between two HIV positive partners or just an increase in risk-taking behaviour generally. In the developing world, there is the ‘ABC programme’ promoting “Abstinence, Be faithful, Condomise”. But really the epidemic is so vast it ought to be concentrating on testing.

You have been involved with pharmaceutical companies and publishing guidelines. With funding coming from institutions such as these as well as charities such as the Bill and Melinda Gates Foundation, to name but one, does this tend to concentrate money on already-established research, or does it still leave room for innovation? If you look at pharmaceutical companies and spending you have to be honest: the company wants you to spend more and use more drugs, not necessarily the research into the population as a whole. I think they look for niches rather than innovation - a lot of the research will be about expanding where you would use that drug rather than being truly innovative. If you look at other non-pharmaceutical bodies it tends to be much more innovative, perhaps based more on basic science. There are two examples of that going on in this institution – a grant from the Medical Research Council for a therapeutic HIV vaccine to allow people to come off antiretrovirals, not as a prophylaxis. We have another grant in the pipeline to look at a novel preventative strategy giving an antiretroviral which has long-lasting sustained release which could be given by injection every few weeks as

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We have actually done a project where we have gone out to several African countries to see how best to test African populations in this country - knowledge of your diagnosis and HIV status in a population where you can get drugs really is a big thing. Certainly where there are roll-out programmes in Africa this has driven a lot of the testing programmes. However, they are being tested where nothing can be done. We are doing some really interesting things - in Malawi we were looking at how we can target the Malawian population and they said it is all about the chiefs. There will be a chief for some villages, and if the chiefs say everyone needs to be tested, everyone gets tested. And so there are lots of things we can learn from Africa that can innovate changes in this country which can promote testing, which is probably the most important thing. The first integrase inhibitor, Raltegravir, was developed about 2 years ago. Are you seeing a shift in the treatments available now, has there been an improvement with that? There was a big change two or three years ago because there were a lot of people who were failing terribly, who had been treated very badly. Now we know you have to give several drugs or the virus becomes resistant. Many people were treated with single agents with other agents added-on and developed multi-resistant viruses through necessity and a lack of our knowledge at the time. It was not just about the integrase inhibitor, a lot of other drugs came out about the same time. There were the CCR-5 inhibitors which

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INTERVIEW prevent viral entry. Drugs in classes which we already had, such as proteases and non-nucleotides, but had activity against resistant viruses. Everyone in our clinic, or the majority, has had successful treatment of their virus and is actually very, very well. There are a few people that fail, still, that we do need new drugs for, but that was the really big breakthrough two or three years ago. Now we are looking at using these drugs more in naïve patients who have not taken any therapy at all. The problem with these drugs is that they are really expensive. Two drugs that are very similar, where one is slightly more toxic or one is under patent can affect things. And certainly because of the pressure of cost it is becoming more and more difficult for doctors to try things out - say if Raltegravir were the best drug for that patient it would be very difficult to give it to that patient if they had not taken anything else, because of the issue of cost. Where do you see the future of HIV research and treatment going? Will there ever be a place for something like gene therapy, for example? People are looking at gene therapy, ribozymes and nanotechnology to deliver drugs. I think it will change, but the question is in this country is, as the amount of money available falls and the cost of the therapies becomes more and more expensive, are we going to change from a developed, resource-rich world to a resource-poor health service? And this is the worrying thing, we can look at all these studies on interesting things but can we afford to actually give them to the patients? You have been heavily involved in research into co-infection with Hepatitis. Is that something that is causing a big problem now, or do you anticipate it being a bigger problem in the future?

Hepatitis C co-infection. The Phase 3 studies are almost finished and none of the companies will do studies in HIV positive people until they have been licensed, and so basically people are dying of it. What we are trying to do now is to get a big European group together to do studies with the aim of pressurising more research and funding. Hepatitis C will be an amazingly interesting field over the next ten years with similar issues to HIV - oral drugs being made available, how to give them, in what combination, what happens when they go wrong, resistance, and that is going to be the field to get into, it is going to be really fascinating. Carrying on from that theme, in the event of a new virus emerging, which potentially could happen in the future, do you think we have learnt a lot through our studies on HIV and the development of therapy, to better prepare us? In some ways, but I think actually we are all a bit slow and do not use common sense. When HIV first came out we used to give one drug and add in extra drugs on top of this. I can remember going to a meeting and someone said ‘I’m very sorry but I think you’re all mad’. We said ‘That’s the way to treat people!’ and he said ‘We’ve learnt if you do that even in TB, you get resistance’, but everyone proclaimed that this is HIV, not TB. Of course, he was absolutely right. Looking again at Hepatitis B, you have single drugs for it and there is a bit of a move towards using combination therapy here as well, but people don’t learn from the results of another disease they always think it is going to be different. So I think we need to take a long hard look at ourselves as physicians and think about what we can learn from other specialities and experiences. The frightening thing is, I bet if there is another infection like HIV we will be making the same mistakes again.

We have got epidemics of acute hepatitis C in this country, first described at this hospital in fact, and no-one believed us and in fact thought we were making it up - it was almost impossible to get it published. Then we saw it in another hospital in London, so it was a ‘London thing’ and then we saw it in Brighton so it was a ‘British thing’, then in Germany, Holland and France so it was a ‘European thing’ and then it was seen in Australia and America, so yes, it is on the increase.

Hepatitis C is really a bit of a disgrace - we have two drugs to treat it and there are 87 products in development in Phase 1 studies. We are looking at gene therapy, anti-viral compounds and immunomodulators, and not one of them has been given in a trial to an HIV-positive patient. Despite the furore in the early 80’s and 90’s by doctors and patients over the lack of HIV drugs, everyone’s looking a bit lethargic about Hepatitis C, and yet it kills people. The last two people that have died on this ward died from untreated

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Source: Boehringer Ingelheim

Hepatitis B is a ridiculous disease, really. When you do see Hepatitis B it is in the immigrant population, mostly, but it is a completely preventative disease. It is one of those things when talking about innovation and all these exciting breakthroughs, you have also got to look at the basics. It frightens me, sometimes, to look at the number of people who have not been immunized against Hepatitis B or have not finished their course of vaccination. We get a lot of co-infection in the HIV population - around 7-8% are infected with Hepatitis B in this country, around 20% with Hepatitis C. Hepatitis B is relatively easy to treat, with the same drugs used to treat HIV.

Image: Structure of a HIV virus

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PERSPECTIVE

First do no harm: overcoming barriers to refugee health

Elishba Chacko, MA BEd emailelishba@doctors.org.uk Year 3 Medicine, University of Sheffield

Source: Flickr

doi:10.4201/lsjm.gch.006

Introduction Refugee:

So I have a new name—refugee Strange that a name should take away from me My past, my personality and hope Strange refuge this is So many seem to share this name —refugee Yet we share so many differences I find no comfort in my new name I long to share my past, restore my pride, To show, I too, in time will offer more Than I have borrowed For now the comfort that I seek Resides in the old yet new name I would choose—friend Ruvimbo Bungwe (9), from Zimbabwe, 20021

The issue of asylum is an emotive one. This article seeks to dispel some of the moral panics surrounding refugees, to shed light on their rich contribution to our society, and to highlight the crises they face in their struggle to survive.

The former home secretary David Blunkett raised fears in the British public when he claimed that Britain was being swamped by asylum seekers2. A poll indicated that people believed that the UK took 25% of the world’s refugees2. The UK, despite being one of the world’s richest countries, harbours just 2% of the world’s refugee population. In contrast, it is the world’s poorest countries that take in the vast majority3.

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Refugees have made many positive contributions to British society. Prominent people given refuge in the UK include Karl Marx, Sigmund Freud, Victor Hugo and Michael Marks (of Marks and Spencer). We even owe one of our national dishes—fish and chips—to 17th Century Jewish refugees.4 Many more have made positive contributions without rising to fame. Elizabeth Josephs, an asylum seeker who fled from Rwanda to the UK, is keen to integrate and make the country her new home if given the chance. She was a former teacher and businesswoman in Rwanda. She says, “I’m not a criminal, I’m an ordinary person— use us, some of us are professionals, I’m not contagious—think!”5 The United Kingdom has relied on migrants to build up its trade and industry, including the NHS and continues to do so6.

We even owe one of our national dishes—fish and chips—to 17th Century Jewish refugees. Categories of Immigrants The term refugee includes people at all the various stages of the asylum process. However progress through each stage bestows a different label on the individual6. Asylum seeker—someone who has fled to another country to escape persecution and has made an application for asylum. Refugee—an individual who has had their asylum application approved and therefore has a right to live and work in the UK. Failed asylum seeker—an individual whose application for asylum has been rejected, but who has not yet been repatriated. Illegal immigrant—a person who enters the country without the necessary governmental approval or extends their stay long after the designated period stated on their visa.

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PERSPECTIVE The asylum process is complicated and with the spectre of forced repatriation looming large over the applicant. In order to be granted asylum under the Geneva Convention, the seeker must meet specific criteria, demonstrating threat to personal safety - a difficult thing to prove6.

GPs who promote refugee health, the provision of interpreters in health centres, conversation clubs for refugees, national telephone interpreting services, maintenance of patient records and the development of health information packs with proof of entitlement to free treatment.

Common Health Problems Every face tells a story, some refugees have escaped horrific situations in their home country - violence, rape and torture. Many escapees suffer from post-traumatic stress, anxiety, depression, and somatisation as a result of the ordeals they have undergone7. Refugees may have other health problems such as hepatitis, TB, HIV/AIDS, malnutrition and other musculoskeletal problems as a result of neglect, sleeping rough, emotional distress, and trauma8. Only a minority of refugees arrive with these health problems, but treatment and conditions in the UK increase their prevalence in the refugee communities8. Though some form of screening exists for new arrivals, this is limited to communicable diseases and is more likely to be provided with an aim to protect the indigenous population from the influx of disease.

Educating primary healthcare workers with cross-cultural medical education will go a long way towards improving current practices and attitudes to refugees. The NHS is already recognising and highlighting this need. The author contributed to the NHS 2009 National Conference for Nurses and Health Visitors Working with Asylum Seekers, which focused on the specific health care needs of these marginalised groups. There is a concerted effort to provide resources for health workers to co-operate that allows them to support one another (such as the national refugee integration website at http://nrif.org.uk). Healthcare practitioners who work closely with refugees are hungry for more information and skills that can enable them to provide complete and effective care. Outlook The future healthcare infrastructure will determine the quality of care afforded to refugees. Refugees form a valuable part of our society and restoration of their dignity will take considerable political will, courage and co-operation.

Source: Flickr

Proper access to health care is therefore essential. Sadly, asylum seekers in the UK, including children in removal centres, continue to receive sub-standard medical care and are often subject to abuse that is “widespread and systemic”.9

References Failed asylum seekers receive support that is limited to £35 a week of food vouchers. To quote research findings “the effect…can be devastating as the lack of cash support increases…isolation and exclusion and removes any opportunity to fill time with activities”. The enforced poor nutrition has serious consequences on their health. The supermarkets are likely to be some distance away: “three miles is okay if you are young and fit…if pregnant, asthmatic, diabetic or recovering from surgery…more than a mile can be difficult”.10 The Refugee Council has stated that this current support system also known as Section 4 support is inhumane and should be dispensed with and replaced with permission to work.

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Barriers to Health Refugees, asylum seekers (and after a 2008 high court ruling failed asylum seekers) are entitled to free healthcare under the NHS11. Despite this, many of the above categories of immigrants have difficulty accessing health care. Health care workers face a lack of time, cross-cultural education and the necessary expertise to provide suitable care to the refugee11.

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General practices too can differ in their attitudes to refugees, creating areas of unequal health distribution. Many practices are unaware of rights afforded to various categories of immigrant. There is a major language barrier during consultation; even working with an interpreter can be stressful and difficult8. Women are likely to be excluded from screening and other health programmes including sexual health, family planning clinics, and maternity care. This may be due to religious and cultural constraints and to poor compliance. What Can Be Done? Increasing spending on refugee primary care may never be implemented as it would mean prioritising refugees’ health needs over that of the native population. There are however positive steps that can be taken12,13: due recognition and additional funding for

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Teichmann I. Credit to the nation: Refugee contributions to the UK. London: The Refugee Council; 2002. Are UK asylum laws working?; 28 July 2003. Available from: http://news.bbc.co.uk/1/hi/talking_ point/3080129.stm. Accessed 23 October 2009. UNHCR — 2007 global trends: Refugees, asylum seekers, returnees, internally displaced and stateless persons; June 2008. Available from: http://www.unhcr.org/statistics/ STATISTICS/4852366f2.pdf. Accessed 17 August 2009. UNHCR in the UK — briefings and resources; Available from: http://www.unhcr.org.uk/info/briefings/asylum_ issues/myths.html. Accessed 17 August 2009. Josephs E. Video nation; 11 July 2003. Available from: http://www.bbc.co.uk/videonation/articles/l/leicester_ ordinarypeople.shtml. Accessed 23 October 2009. Burnett A, Peel M. What brings asylum seekers to the united kingdom? BMJ 2001, Feb;322:485-8. Available from: doi:10.1136/ bmj.322.7284.485. [Accessed on 7 December 2008] Jaranson JM, Butcher J, Halcon L, Johnson DR, Robertson C, Savik K, et al. Somali and oromo refugees: Correlates of torture and trauma history. American Journal of Public Health 2004, Apr;94(4):591-8. Available from: doi:10.2105/ AJPH.94.4.591. [Accessed on 7 December 2008] Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ 2001, Mar;322:544-7. Available from: doi:10.1136/ bmj.322.7285.544. [Accessed on 30 December 2008] Cohen D. Asylum seekers in detention centres receive poor medical care, MP says. BMJ 2008, Dec;337:a3022. Available from: doi:10.1136/bmj.a3022. [Accessed on 31 December 2008] Doyle L. Refugee council research report—more token gestures: A report into the use of vouchers for asylum seekers claiming section 4 support; October 2008. Available from: http:// stillhumanstillhere.files.wordpress.com/2009/01/rc_more_ token_gestures_oct_2008.pdf. Accessed 23 October 2009. Ford R. Ruling gives failed asylum-seekers free healthcare. The times 12 April 2008. Available from: http://www.timesonline.co.uk/tol/ news/politics/article3732002.ece [Accessed on 17 August 2009.] Jones D, Gill PS. Refugees and primary care: Tackling the inequalities. BMJ 1998, Nov 21;317(7170):1444-6. Available from: PMC1114300. [Accessed on 7 December 2008] General practitioners’ knowledge of issues relating to asylum seekers is poor. BMJ 2000, Oct;321:893. Available from: doi:10.1136/bmj.321.7265.893. [Accessed on 30 December 2008]

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Heroin on prescription for addicts: an innovative or old idea? Elena Atkinson, BSc Year 5 Medicine, Imperial College London elena.atkinson05@imperial.ac.uk doi:10.4201/lsjm.gch.007

Drug addiction, especially to opiates, has been around for centuries and many different treatment methods have been tried over that time with little success. Recently it seems the attention has shifted from treating the addiction to treating the social problems such as theft, prostitution and drug dealing that many addicts rely on to fund their habit. A Canadian study has found that 50% of those addicts involved in crime claim they would give up their illegal income if they didn’t need to fund their drug addiction1. This claim has been tested recently with a study in the South of England known as the Randomised Injecting Opiod Treatment Trial (RIOTT) which made national headlines for providing heroin addicts with diamorphine (medical heroin) at special clinics2. The addicts had to attend the clinic twice daily to receive a dose of the drug under controlled, supervised conditions and at no time were they allowed to take any diamorphine away with them. The RIOTT study, though in its early stages, appears to be mirroring the results of similar studies around the world, with the number of addicts involved in crime dropping by half and those addicts who continue to engage in illegal activities doing so less frequently (from a maximum of 30 times a month before the scheme to 13 times after six months of treatment)3. As well as the proposed benefits to the community there are obvious advantages to such a scheme for addicts, with users no longer running the risk of HIV or hepatitis C infection from needle sharing, less risk from unknown drug contaminants and a lower risk of overdose due to supervision. The fact that the aim of the scheme is not to cure is unique, but the estimated cost of £15000 per patient per year raises controversy. While those behind the scheme claim it will be only for the minority of addicts, who have failed on previous rehabilitation attempts, it is still hard to find justification for funding this from healthcare money, especially given the perilous state of NHS finances4. One way of avoiding the inevitable

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PERSPECTIVE debate, whether the NHS fund a self inflicted condition, could be to subsidise the scheme with money from the police force and local councils as both these bodies stand to benefit financially from the reduction in crime and anti social behaviour. Prescribing heroin is not a new phenomenon; the current trials in the UK follow those conducted in Switzerland in the mid 1990’s where they were deemed to be such a success at tackling the drug induced social problems that a recent referendum has led to 68% of voters calling for it to be part of the government’s drug policy5. Also when the reduction in crime and addiction associated healthcare costs were considered against the scheme implementation and maintenance costs, the programme was actually estimated to save Switzerland’s economy US$26 per addict per day6. The front-runner in prescribing heroin to addicts though is Britain. In this country it has been legal since the 1920’s, and many drug clinics around the country still retain this right7. If this is the case why are we not leading the way with heroin prescription for this purpose? The truth is many of the doctor’s legally able to prescribe diamorphine simply choose not to. This is not to say these professionals find it detrimental to the addicts or an outdated method of treatment. On the contrary the findings of a questionnaire based study in 2002 showed that many of those doctors eligible to prescribe believe it to be beneficial but there was little consensus on what dose should be used and which patients should be considered for it8. While much of this confusion may be cleared up by the renewed interest in studying this method of treatment, an overriding reason for low levels of prescribing is resource availability. Both the Swiss and British study into heroin clinics involved substantial social and psychological support for the addicts which led to an impressive reduction in street heroin use for not only the cohort receiving heroin but also in those receiving methadone when heroin prescription had previously failed. This suggests manpower and increased support may have a more important role than it has previously been credited with and methadone, the treatment mainstay, may not be finished with just yet. The lack of people trained in such close supervision of addicts and the funding issues described above mean that, for the short term at least, these clinics are not going to be rolled out on a national scale in Britain. However they are a feasible way of minimising the damage from drug use by the difficult to treat minority. Other methods which have been shown to reduce crime, overdose rates and other drug related sequelae, are; making it almost impossible for addicts to get hold of heroin or legalising it. This is illustrated by a case in three Australian states in 2001 where street heroin was in short supply for three months leading to a drop in fatal overdoses by 40% and by Portugal, where decriminalisation of drug possession has caused HIV infection rates to fall by 17% in addicts9,10. Practically, it is almost impossible to fully stop the illegal trade of heroin and it is unlikely given the furore surrounding cannabis reclassification that heroin possession will be decriminalised here in the near future nor am I suggesting it should be. With other options largely dismissed, heroin drug clinics may provide part of the answer to minimise drug related problems in this country. More of a fresh perspective on an old idea than something completely new, it creates new ethical issues of doctors providing a service whose main aim has changed from curing the addict to reducing the social harms of addictions. A discussion of such issues

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is warranted, though outside the remit of this article. There are funding issues, implementation difficulties and likely media uproar that mean this innovative idea is still in its infancy. However I feel that if these problems can be overcome and the data from trials continues to be encouraging, this could be a way in which heroin addiction treatment is managed in communities in Britain in future.

References 1. DeBeck K, Shannon K, Wood E, Li K, Montaner J, Kerr T. Income generating activities of people who inject drugs. Drug and alcohol dependence 2007 Nov 2;91(1): pp. 50-56. 2. Lintzeris N, Strang J, Metrebian N, Byford S, Hallam C, Lee S, et al. Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK. Harm reduction journal 2006 Sep 27;3: pp. 28. 3. Siva N. Heroin clinics reduce street drug use and crime, shows study. BMJ (Clinical research ed.) 2009 Sep 18;339: pp. b3845. 4. Batty D. Q&A: Herceptin. The Guardian. [Online] . Available from: http://www.guardian.co.uk/ society/2007/jan/05/cancercare.health. 5. Swiss approve prescription heroin. [Online] Available from: http://news.bbc.co.uk/1/hi/world/europe/7757050.stm. 6. Brehmer C, Iten PX. Medical prescription of heroin to chronic heroin addicts in Switzerland - a review. Forensic science international 2001 Sep 15;121(1-2): pp. 23-26. 7. Carnwath T. Prescribing heroin. The American Journal on Addictions / American Academy of Psychiatrists in Alcoholism and Addictions 2005 Jul-Sep;14(4): pp. 311-318. 8. Metrebian N, Carnwath T, Stimson GV, Storz T. Survey of doctors prescribing diamorphine (heroin) to opiatedependent drug users in the United Kingdom. Addiction (Abingdon, England) 2002 Sep;97(9): pp. 1155-1161. 9. Degenhardt L, Day C, Dietze P, Pointer S, Conroy E, Collins L, et al. Effects of a sustained heroin shortage in three Australian States. Addiction (Abingdon, England) 2005 Jul;100(7): pp. 908-920. 10. Greenwald G. Drug decriminalization in Portugal, Lessons for creating fair and successful drug policies. USA: Cato Institute; 2009.


Global health and community medicine --2  

global health, hiv, community medicine

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