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Kudos for the Minister of Health Express – July 22^nd, 2002

There was a Chinese restaurant a few yards away from the Hotel Diplomatic where I stayed in Barcelona for the international Aids conference and where, for the affordable sum of US$5, one can have various choices of a four-course Chinese menu, including, mind you, a bottle of wine or beer.

Now, it was not a matter of not having a decent subsistence allowance for my stay in Spain which made me a frequent visitor of the Peking restaurant. It was simply a matter of principle. After all, what is the price here these days of a little pow with only five or six tiny pieces of pork? In fact, from my personal point of view, that restaurant was the only new discovery during the Aids conference in Barcelona!

Of course, as expected, Nelson Mandela, undoubtedly the most popular Head of State of the past century, made his pitch for easier accessibility of cheaper antiretroviral drugs for this, the most serious health threat since the plague of the Middle Ages.

He got great coverage internationally, but it seems as though the Ministry of Health here certainly needs more public relation officers to advertise the fact that the government is now providing these drugs free of charge to the citizens of Trinidad and Tobago, who cannot afford to purchase them. This has not been given due and appropriate headlines and coverage in the media.

Look, this is a major step in the local campaign against the HIV/Aids virus. But it is even more major in its achievement if only because, as I am informed by someone in Barbados, we started our programme of HIV treatment here before the government of Barbados started theirs. And so, we have beaten Barbados to the finishing line (in this case, the starting tape), which is somewhat unusual.

A reminder, by the way, for my friend Dr Rasheed Rahaman, Medical Chief of Staff of the Mt Hope Hospital, that Barbados has been offering cardiac surgery to its citizens free of charge for several years now, and, to boot, the surgery there is performed exclusively by local surgeons. Nuff said.

Now, apart from being the birth place of the famous three Ws—Weekes Worrell and Walcott— Barbados has boasted of having a better rum (Mount Gay), a better airport, better secondary schools Harrison’s and Combermere), better flying fish and even coo coo and, of course, beaches.

In fact, Barbadian pride and chauvinism (and I am not criticising that) was typically exemplified when England declared war on Germany and the British people, albeit defiant, were very worried. Barbados immediately sent a cable to Winston Churchill, saying: “Go ahead England, Barbados is behind you.” Much relieved, Churchill slept securely that night! And so, perhaps this time Barbados should probably send a cable to our Minister of Health in Trinidad and Tobago, saying: “Well done, Mr Minister, Barbados was ‘behind’ you this time.”

Look, to have and to provide HIV drug treatment is one thing, but, among other things, to have the laboratory infrastructure which is necessary to determine when to start treatment or whether the drugs are being effective and whether, for example, any drug resistance is developing, et cetera, et cetera, is another matter. In fact, there are also many other major problems associated with this major governmental gift.

Let me put it this way as one example. If you missed your daily doses of drugs, say, for hypertension or diabetes, no problems will occur with respect to developing any drug resistance. Indeed, how often have we heard of thousands of patients going to the outpatient clinics in the hospitals or health centres only to be told that central stores have run out of drug supplies. Patients then either have to buy them privately, which many cannot afford, or wait sometimes for weeks until the hospital supplies are replenished.

Let me tell you one time that such administrative inefficiency cannot be accepted when dealing with drugs for HIV. Let me also inform you that whereas many patients over the years have sometimes been guilty of careless non-compliance with respect to the drugs given to them, this cannot be tolerated in patients who are HIV-positive. In fact, anything less than a 95 per cent adherence rate with respect to taking their HIV antiretroviral drugs will soon lead to drug resistant viruses developing in this island. That will be hellish.

Likewise, whereas there is a habit among some patients in Trinidad and Tobago of stopping their drugs prematurely when they are feeling better, this must not happen with respect to HIV-infected patients.

On the other hand, and as an aside, there are some people who just love to come to hospital outpatient clinics or health centres. For some it is an outing which must not be missed at any cost and they find some reason to come even if they are told that they are already cured. For example, one regular clinic visitor, when once asked how come we did not see her at last month’s clinic, replied: “Sorry, doctor, but I was feeling sick. I feeling much better now, so ah come to see you!”

Indeed, the issue of drug resistance and its possible sequel, a drug-resistant virus in the world, which does not respond to any therapy whatsoever, could wipe out populations. This is not a pipe dream (nightmare).

In fact, I well remember in the early days of the epidemic when we had just discovered the virus, a Nobel laureate friend of mine, Dr Joshua Lederberg, who became the president of the Rockefeller Foundation in New York, speculated that perhaps with time HIV could genetically mutate to the extent that it might eventually spread by droplet infection just like the flu virus does.

This was a frightening perspective and prospective, especially coming from a brilliant brain like Joshua’s (by the way, percentage-wise, there are more Nobel laureates among the Jewish race that any other nation).

It was only when basic science researchers discovered that the virus had a tropism (attraction) only for certain white blood cells called T4 or CD4 lymphocytes, that it was realised that such a possibility of air transfer was unscientific.

However, I want to predict a serious and grim possibility. With the availability of cheaper drugs and its affordability by some third world countries, which do not have the infrastructure and the discipline, either of its medical therapists and/or patients, with respect to strict adherence in taking these drugs regularly, this welcome largesse by the pharmaceutical companies and governments could ricochet, and through careless compliance and maladministration, drug resistant viruses could emerge, especially in third world countries. This could decimate us.

In short, there is the potential for the emergence of an HIV virus that is not only much more lethal but also possibly associated with a shorter incubation period (the time from infection to disease).

Moreover, what is being noticed recently is that the relative successes of antiretroviral therapy has led to an increase in risk-taking by many people. And so, the lessons have not been learnt and will probably never be learnt, namely, that promiscuity must stop. Without that, let the world be prepared for the worst yet to come.

In the meantime, without waiting for a cable from Barbados, let me congratulate the Minister of Health for his gift to the HIV-infected population of Trinidad and Tobago. It is gift of life.

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