Friday, March 07, 2014

The Needle and the Gun


            The recent announcement by the Egyptian government that the Armed Forces have discovered a device to detect and possibly cure hepatitis “C” and AIDS has been met with disbelief, ridicule and occasional contempt.  It was not met with a great deal of anger, but perhaps this was because Egyptians were all too aware of the context within which the device has been offered.  Or perhaps after three years of revolutionary upheaval many Egyptians are too exhausted. The foreign media has echoed some of the ridicule but with rare exceptions has been either willfully or blindly ignorant of the public health background of the last two decades. Whether these events were an indication of malice, hypocrisy, incompetence or simple lack of attention by the relevant authorities remains uncertain.

            Announced at a mid-February 2014 press conference by Ibrahim Abdel Atti, a general by courtesy, the device—named C-Fast—resembles a radio antenna connected to a trigger mechanism.  It is thus supposed to be instantaneous (whence its name) and non-invasive. Abdel Atti claims that he spent two decades developing the device, most recently with support from the Armed Forces.  Similar technology, he claimed, was at use in “complete cure” which ostensibly did what its name implied.  Several Egyptian scientists, including the president’s science adviser, have publicly announced that the device itself is most likely a fake and that neither the device nor the theory on which it was supposedly developed has any validity. 

            If the underlying health issues were less serious the events of the past week might have the quality of an arcane comedy or a peculiar vaudeville act. But there is every reason for Egyptians to be worried about hepatitis C.  It is a severe liver disease whose full effects may take decades to manifest.  These include cancer of the liver and cirrhosis either of which is fatal if untreated.   The most common medications are uncertain and require a course of treatment lasting months.  Even after government assistance, they may cost hundreds or thousands of dollars which puts them beyond the reach of many of Egypt’s poor who may subsist on $2 a day.

            As a story in the New York Times on February 26, 2014 coyly noted Egypt has “the highest prevalence of hepatitis C.”   The superlative here refers to the entire globe: the rate of infection among Egyptians is the world’s highest.  According to a report issued by the US Centers for Disease Control but largely authored by Egyptian specialists about 10 % of the Egyptian population, or 6 million people in 2008, had chronic hepatitis c virus (HCV) infection.   Egypt, with less than a quarter the population of the United States has twice as many people infected with the virus.  Another telling comparison is that Egypt with less than 1% of the world’s population has roughly 4% of the world’s cases of hepatitis C. 

            In general hepatitis C rates are higher in the countryside than the cities, among men than women, and among those who are older.  The same report indicates that between 2008 and 2011 the Egyptian government treated about 190,000 Egyptians with one or two medications that cure between 60 and 80% of cases.  However, about 40,000 Egyptians die every year due to liver cancer or cirrhosis (not all of which is attributable to HCV) and it is the second highest cause of death in the country after heart attacks.

There is every reason for Egyptians, especially the poor and the illiterate, to be concerned about hepatitis C and to hope that someone can develop a quick and inexpensive treatment.  That many Egyptians welcomed the claims about C-Fast is not surprising. There is no particular reason that ordinary Egyptians should have very clear ideas about the best science for the detection and cure of AIDS or hepatitis C.  Whatever the vices of General Abdel Atti’s device, it has the virtue of being harmless in itself.  This is more than can be said of a drug such as laetrile that was popular in the United States at least through the 1970s and is still occasionally touted as a cure for cancer.  Laetrile, made from apricot pits, has no impact on cancer but it does contain sufficient cyanide that patients taking it have a real risk of being poisoned. 

            The problem with a harmless treatment is that it induces a false sense of security among patients who will nevertheless succumb to a deadly disease.  It is not clear whether the peak incidence of the disease occurred in the past several years but it will be a severe public health problem for decades to come.

            That the epidemic itself was in large part the effect of an earlier Ministry of Health program designed to eliminate endemic schistosomiasis (also known as bilharzia) was well known and recently reported in The Economist.  Schistosomiasis also causes severe liver disease.  That campaign itself was necessitated by earlier decisions by many Egyptian governments (including those at the turn of the 20th century when the country was effectively under British control) to extend perennial irrigation.  Egyptians suffered from schistosomiasis thousands of years ago but perennial irrigation allowed a parasite that moves from snails to humans and back again to routinely complete its life cycle and infect large numbers of people.

From 1960 until around 1980 the government injections of tartar emetic were used to control schistosomiasis.  The decision by the government to employ re-usable glass syringes that were often not effectively sterilized between uses spread the HCV epidemic even as it began to reduce the incidence of schistosomiasis.  By the mid-1980s an oral drug had begun to replace the earlier treatment.  Unfortunately by then HCV was endemic and an unrelated hepatitis B virus had also begun to spread. 

There are other sources for the spread of HCV.  The growing incidence of adult diabetes has also led to a growing incidence of kidney failure (more formally, end stage renal disease).  As a consequence more Egyptians are undergoing dialysis which, when the machines are not adequately sterilized, has become another vector for the spread of HCV. 

Egypt has more than 1,000 dialysis units that provide care for patients with kidney disease.  Dialysis costs about $3200 a year for three treatments a week (in the US the cost is about 50 times as great and would also be beyond the reach of most who suffer from the disease if Medicare did not pick up the bill).  This is well beyond the income of most Egyptians with ESRD.  Needless to say 1,000 units is far from sufficient for a country with millions who have ESRD.  Recent estimates indicate that about 10% of Egyptians suffer from diabetes (about half of which is undiagnosed) and perhaps twice that many suffer from hypertension which is the other major precursor to ESRD.
Dialysis clinics are spread throughout the country but are most easily available in the large cities.  Thus there is relatively large dialysis center not far from Tahrir Square tucked into a small side street opposite an art gallery and not far from automobile repair shops.  In Giza, on the boundary between the upscale neighborhood of Muhandiseen and impoverished area of Imbaba there are several clinics specializing in kidney and liver disease.  At the height of the demonstrations in Tahrir Square, empty as the streets of Cairo and Giza may have been, the clinics were filled with patients, some from Upper Egypt and some from upper class Cairene families waiting to see their physicians and watching the news reports on television.  Neither kidney nor liver patients could let revolution prevent their search for treatment.  My only reason for being aware of this is that I spent most of a day there on several occasions waiting for my own appointment.

            Treatment of HCV has been expensive and until recently quite uncertain.  In December 2013 the English-language Ahram reported news of a trial in the US. These results were clearly well known to officials of the Health Ministry.  The US Food and Drug Administration has recently approved an orally delivered medication that is extremely effective when used to treat the particular variation of HCV common in Egypt.  Dr. Wahid Doss, head of the Egyptian National Liver Institute, was quoted in news reports (including the Ahram report) about the results of a study in the United States that showed Sofusbuvir in conjunction with Peginterferon and Ribavirin achieved a 97% permanent clearance rate of the virus after 12 weeks of treatment.  
            All of this information and more was available to the Egyptian government and Egyptian medical organizations and it was in the public record when the first reports of C-Fast were made.  In the space of a week and a half the emptiness of the claims of Abdel Atti and the C-Fast device had been revealed.  On the positive side it is apparent that the repressive as the new government may be and despite the danger of scientific quackery Egypt’s scientific community remains active.  It is easy to dismiss the value of expertise but for many Egyptians today in many areas of society there is a far greater problem in not having access to expert advice and care than in having too much of it.

The size of the public health tragedy that confronts the country and the very limited resources for dealing with it are truly daunting.  Much as been written of the macroeconomic challenges Egypt faces, the cost of fuel and food subsidies, the continuing problems with electricity supply and butane.  And of course there is repressive response of the state to public political opposition.
The 2011 electoral program of the Muslim Brotherhood’s Freedom and Justice party correctly noted the extent of the hepatitis and diabetes epidemic facing the country but proposed no immediate proposals to address it and no significant increase in funding already existing institutions or policy initiatives.  The current government is clearly aware of the extent of the crisis and of how it affects the lives of ordinary Egyptians.  Despite information available from the government’s own scientific advisers and the Egyptian professional medical community, the government promoted a quack response.  Had the C-Fast device not been critiqued, ridiculed and (one can only hope) withdrawn, its use would have been worse than doing nothing.  It is sobering to realize that every month almost as many Egyptians unnecessarily die due to the consequences of government incapacity and inaction as were killed in the public squares in the summer of 2013.  These deaths are unintended and clearly cannot be considered the policy of the state.  No violation of rights is involved.  They are nevertheless a significant human tragedy for which negligence may be a reason but not really an excuse.