A Toxic Cycle

As a student of global health, I pride myself on keeping up to date on the various challenges to public health around the world, especially the most potent issues. I know about AIDS and malaria, I know about the problems with health insurance in China, and I know the struggles resource poor nations face in giving care, to name a few. So imagine my surprise when I came across a topic I knew nothing about.

This past May, over 100 people died in a toxic alcohol outbreak in eastern and central Kenya. Others woke up blind after sleeping off the alcohol’s effects or lost their sight over the course of a few days. In Kenya, and other countries in the area, bootleg liquor is extremely common, as factory made alcohol is too expensive for most people to buy. Many of these locally made brews are laced, both intentionally and unintentionally, with industrial alcohol to increase their potency.

How does this toxic alcohol kill? What makes it so much worse than the ethanol that so many people across the world drink? I spoke with Dr. Patrick Lank and Dr. Vinoo Dissanayake in an attempt to wrap my head around this deadly poison.

Ball and Stick Model of Methanol. Source: Wikipedia

Dr. Lank, a toxicologist at Northwestern’s Feinberg School of Medicine, explained to me what happens to the body after one consumes methanol. Methanol, or methyl alcohol (CH3OH), is widely used as an industrial solvent and paint remover. It is also commonly used as a component of photocopying fluid, shellacs, and windshield-washing fluid. When ingested, methanol is primarily metabolized in the liver into formaldehyde via alcohol dehydrogenase. Formaldehyde is then metabolized into formic acid, which ultimately breaks down into folic acid, folinic acid, carbon dioxide, and water. Formic acid is responsible for the toxic effect of methanol in the human body.

In the United States and other developed countries, there are very specific treatments in response to toxic alcohol poisoning. These include hemodialysis, oxygen and breathing support, gastric lavage, and fomepizole, an antidote intended to reverse the effect of the poison. Another remedy is consumption of ethanol, or the alcohol we typically drink, like beer, wine, or whiskey, to name a few. When ethanol is ingested, it competes against the methanol to be metabolized, and the body digests ethanol instead. This prevents the formation of the toxic metabolites that result from the digestion of methanol. Often times when we see alcohol poisoning involving methanol in developed countries it involves individual cases: someone is suicidal, addicted, or another isolated cause. A hospital can focus on using all the available interventions to save a life. This is not the case in developing countries.

Dr. Dissanayake, a medical toxicologist at Loma Linda University Medical Center in Loma Linda, California, explains that alcohol poisoning is a good example of the struggle behind resource limitations in developing countries. There is often limited access to hospitals and doctors, and if one does make it to one, it is often at the very last possible minute, once they have exhausted all home remedies and they are still alive. Dr. Dissanayake has spent time in Uganda doing global health work. During her time there, she has experienced first hand the burden a methanol-poisoning outbreak would place on communities.

Uganda Waragi. Source: Wikipedia

In Uganda, illicit alcohol is called waragi, and was introduced by the British to give Ugandan soldiers courage to impose the Queen’s policy on their countrymen. It has since become the drink of choice for most Ugandans. According to a 2004 World Health Organization ranking of countries based on per capita alcohol consumption, Uganda has the highest alcohol consumption in the world, with adults consuming 19.5 liters of alcohol per year. “If someone in the village is sick from drinking, they are one of many drunk patients, and it would be nearly impossible to determine who may actually be poisoned rather than just drunk,” says Dr. Dissanayake. An additional strain on the already resource-poor medical facilities is created through excessive alcohol consumption.

With a high number of intoxicated patients and limited professionals, the most common response is to let an intoxicated patient sleep it off, and thus the cases of those who have been poisoned by methanol are often discovered too late. Alternatively, if the poisoning is discovered in time, and if a person does make it to a hospital, the best option is to fight the poison with ethanol. However, methanol has a half-life of 40 to 50 hours, so according to Dr. Lank, a patient must be kept drunk for about 10 days to survive the toxic methanol. Most patients do not have the resources to pay for this treatment.

The other option is to have the patient transferred to a referral center where hemodialysis can take place. Dr. Dissanayake explains that hemodialysis is a medical procedure that will filter the patient’s blood and remove toxins, preventing toxic metabolites from forming. This procedure would happen without hesitation in the US, however only certain hospitals have this capability in Uganda. “The closest referral center to Nyakibale Hospital [a hospital in Uganda where Dissanayake has volunteered] is 3 hours away by motorbike,” says Dr. Dissanayake. There are very few ambulances available in rural Uganda.

So why is this happening in places like Uganda and Kenya? Drinking is a highly political issue, as alcohol is one of the largest sources of revenue. Local politicians are reluctant to partner with law enforcement based on a fear that stricter laws will be bad for business. At the same time, the government doesn’t see toxic alcohol poisoning as a large public health issue. Drinking is viewed as part of the culture in Uganda. However, according to Ioannis Gatsiounis for Time Magazine, some observers estimate the costs of alcohol in the country, both economic and social, are worse than those of HIV and malaria. “It’s a double-edged sword,” Dr. Dissanayake says, “people are so depressed that they can’t make enough money to make ends meet so they drink. But then they can’t go to work the next morning and the cycle continues.”

Ultimately, the ripple effect of a failing economy is felt in the limited resources of the medical system as well. One answer to the problem lies in global partners to try and educate local providers on the best way to manage these poisonings and stop the cycle. However, enforcement of the policies by the government may play a more meaningful role.

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