MEDICAL SERVICE VOL. 41 No. 9 OCTOBER-NOVEMBER-1984.pdf
Media
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Special Convention Issue on
''Towards a People Oriented Drug Policy"
"Physicians prescribe medicine of which they know little, to cure
diseases of which they know less in human beings of which they
know nothing".
— Voltaire - 18th century
vol 41
no 9
october-november 1984
medical
service
official house journal
of the catholic
hospital association of India
"the love of Christ
urges us" 2 cor 5 :14
vol 41
no 9
october-november 1984
contents
editorial board
dr c m francis
dr ravi narayan
dr prem chandran john
dr daleep mukarji
mr augustin veliyath
fr george lobo sj
prof george joseph
dr paul neelamkavil
fr edwin mj
1
2
3
4
5
6
editor
fr john vattamattom svd
cover design
7
printed at kalpana printing
house new delhi-110016
but some are more essential than others
ernst lauridsen
drug misuse in our hospitals
g d ravindran
2
4
6
8
12
13
16
medical ethics forum-36
fr george lobo s j
19
9
if there are no side effects, this must be argentina
22
10
a to z of drug policy issues
23
11
the crazy world of tonics
mukarram bhagat
28
12
consumer alert—consumer action
ravi narayan
33
13
towards rational therapeutics
37
14
irrational drug use prescribing
38
8
p m isaac bangalore
published by the catholic
• hospital association of india
c b c i centre, goldakkhana
new delhi-110001
editorial
drugs and the chai vision
c h d team
the drug industry in india—what our experts say?
misuse and overuse of medicines-—why ?
medication as a substitute for caring
"Articles and statements published in this journal
do not necessarily reflect the policies and views of
the catholic hospital association of india"
Guest EDITORIAL
let my people go
An editorial on "a people oriented drug policy"—what should it be ?
It could be an angry outburst
against the senseless proliferation of inessential brand drugs;
against the outrageous pricing of these drugs;
against blatant overproduction of drugs for the well to do and the
consequent underproduction of drugs most needed in the country;
against the unholy collusion between the
profession;
industry and
the
against the mindless misinformation that pervades the scene ?
against the heartless dumping of drugs in the
Countries.
Third World
It could also be a fervent plea
for the adoption of an essential drugs list;
for discernment between the essential and the inessential for some
kind of social control to ensure satisfactory production of drugs
most needed in the country for abolition of brand drugs;
for adoption of a global marketing code and a boycott of all compa
nies that violate the code;
for quick exchange of information among consumers, educators and
media personnel.
But as I survey the scene and look at the total control the industry has
over the profession and the people I can only say with Yahweh of the
book of Exodus "Let my people go'*.
WE PAY RESPECTFUL HOMAGE
TO OUR DEPARTED PRIME MINISTER INDIRAJI
''Even if I die in the service
• of the nation I will be
proud of it. Every drop
of my blood will contri
bute to the growth of this
nation and make it strong
and dynamic".
Ir
*
b
-Indira's famous last words, Oct. 30,1984
Now is the time for every Indian to work together towards
the fulfilment of Smt. Indira Gandhi's dream of a UNITED
AND PROSPEROUS INDIA and to pray to God Almighty for
an early fulfilment of it.
Drugs and the Chai Vision
The experience of a group of Social
workers in T.B. eradication and rehabilitation
programme in one of the slums in Bangalore
is an eye opener. Most of the inhabitants
of this slum were T.B. patients. After a
careful study of the problem and identifica
tion of the affected people the social workers
started distribution of free medicines in the
slum. To their surprise, the situation remai
ned the same, and infact observation proved
that, the health condition was deteriorating
day by day. Soon they found out that the
patients who received the drugs were selling
it out to the nearby medical stores for the
tiny income that it brought to them in order
to meet their basic need for food I
According to reliable sources, there are
over 25,000 drug formulations in India,
being manufactured by 5000 and' odd drug
industries. What does this abundence means
to the millions of the poor in our country,
who struggle in life to make both ends
meet ? Can they ever have access to the
modern health care system which has become
a business today, rather than remaining at
the service of the humanity at large. Do they
have essential and life saving drugs at their
reach with in a price range they can afford ?
Unlike in the past, today, health is under
stood as the total well-being of individuals,
families and communities as a whole and
not merely the absence of sickness. But
the over all view of the drug situation in our
country claims to provide ready-made solu
tions to all the problems to which the com
mon man is exposed today. These magical
solutions suggested by the drug industries
through the powerful media displays little
analysis of the economic, social, political
and cultural forces that are at work in society.
4
which make people sick and constantly keep
them in ill health. For instance, the ordinary
man is made to believe that Depsonil can
cure his depression, which in fact is caused
by various forces at work in the society to
which he has fallen prey.
The present medical system is based on
western patterns and emphasise more on
curative aspect.
It constantly generates
myths in the common man. Through these
process the control of health is expropriated
from the individual's hands and today it is in
the hands of the drug industrialists and the
medical personnel. Thus man is deprived
of his basic decision making power which is
unique to his species.
In the present situation where the whole
medical care has become a profit oriented
business, it seems to us that the real answer
to the problem is a political one. This would
consist of a process in which people are
made aware of their rights, duties and res
ponsibilities so that they can get organised
for appropriate actions to fulfil their basic
needs as human beings. Unless and until
this is brought about through grass root level
and people based activities, never will they
be able to counter act the challenges posed
by the drug industries, and participate as
people in the nation's movement towards
health for all by 2000 A.D.
Health care has become part of the ex
ploitative system in our country. The exploi
ters are the drug industrialists and the
exploited are the masses. The middle man's
role is played by the medical personnel, sup
ported by the media. The doctor is encoura
ged to prescribe a particular brand of drug
manufactured by a certain company. Medical
Medical Service
representatives of different pharmaceuticals
are lobbying around medical personnel and
health institutions, and naturally the more
medicines a doctor prescribes, the more
lucrative the profession becomes for him.
Depending on the stock emptied, the rewards
vary from paper weights to motor vehicles.
Side by side the media has brain washed the
common man to believe that more medicines
means faster cure; eventhough many of the
drugs available today are toxic dr with harm
ful side effects.
The dilemma involved in this problem is
better illustrated in the following conversa
tion. The patient was asked :
Q.
Why do you take so many drugs ?
A.
I take them since the doctor has
prescribed it.
(Then the doctor was asked)
Q.
Why do you prescribe so many diffe
rent, but similar and expensive
drugs ?
A.
I have to prescribe them since the
patients expect them.
The experience of one of our team mem
bers in a community health programme
clearly illustrates the interests of our health
institutions. The community health workers
through an intensive campaign successfully
dewormed a village that was adjacent to a
hospital.
In the following months, the
income of the hospital showed a steep
downward trend, which was reacted by the
hospital authorities.
The commotion that
followed ended up finally in winding up the
community health programme which was
initiated and supported by the same hospital.
October-November 1984
Who's interest is at stake here ? Who's
interests are we serving in our institutions ?
By gone are the days of right prescription
at the right time for the right sickness'. The
phenomena of over prescription can be
better understood today when we realise
that the medical industry is a business today,
and it has altogether lost its saving and
healing characteristics. As in any business
enterprise; what counts most is the sale of
the commodities and the total turn over. As
people interested in the cause of the hum
anity at large, how long shall we continue to
sit with hands folded and mouths shut, and
enjoy the fun? Is it not painful for us to
realise that we are also part and parcel of
this affair and that we will continue to be
so until we rise up to protest vehemently to
these dehumanizing situation.
The Indian drug market is always short
of life saving and poor man's drugs; because
it is not profitable to manufacture it. Of
late, the tendency seems to be for commer
cialising some of the age old and traditional
practices of the rural people. This again is a
subtle way of taking away from the poor
man's hand, what he has already, and this
adds to the hosts of myths that we have
already around the medical profession.
It is time for us to act. As people invol
ved in institutions based on Gospel values
and humanitarian concerns, it is high time
that we made a serious reflection on how we
respond to the growing misery and wretched
ness of our people. The questions that we
could ask ourselves will be; should we con
tinue to function the way we are doing today,
or should we search for new roles to make
our healing ministry more relevant to the
needs of the common man around us ?
CHD TEAM
5
The Drug Industry in India—
What our experts say
The Industry
Pattern of Prescribing
The total output of the industry increased
hundredfold-from Rs. 100 million in 1947
to Rs. 10,500 million in 1978-79. This was
due to expanded production, especially of
an ever-increasing number of sophisticated
drugs, and rising prices...
One of the most distressing aspects of the
present health situation in India is the habit
of doctors to over-prescribe glamorous and
costly drugs with limited medical potential.
It is also unfortunate that the drug producers
always try to push doctors into using their
products by all means—fair or foul. These
basic facts are more responsible for distortions in drug production and consumption
than anything else.
The drug industry has enjoyed a higher
man-average profitability so that investment
therein has increased substantially from
Rs. 240 million in 1952 to Rs. 4,500 million
in 1977.
There are about 125 large and medium
factories and nearly 3, 000 small scale sector
units engaged in this industry which pro
vides employment to about 100,000
workers.
Pattern of Drug Production
There is now an overproduction of drugs
(often very costly) meant for the rich and the
well-to-do while the drugs needed by,the
poor people (and these must be cheap) are
not adequately available. This skewed pat
tern of drug production is in keeping with
our inequitous social structure which stresses
the production of luxury goods for the rich
at the cost of the basic needs of the poor.
Out of a total production of Rs. 700
crores in 1976, 25 percent is taken away by
vitamins, tonics, health restoratives and enzy
me digestants, mostly consumed by the
relatively well-fed urban population. Twenty
percent is covered by antibiotics, only 1.3
percent by sulphonamides (a very cheap and
useful anti-infective) and 1.4 percent by anti
tuberculosis drugs...
6
Structure of the Industry
The existing drug policy rightly emphasi
ses the attainment of self-sufficiency in the
production of drugs, in increasing the share
of the Indian producers and in giving a more
significant role to public sector.
The foreign companies account for about
40 percent of the total drug production in
the country; their share in the production of
basic drugs was about 28 percent and that in
formulations, 44 percent (1978-79). This is
still high.
Price Control
The drug prices are high and continue to
rise. In some instances, Indian prices are
even higher than the international ones.
Packaging increases the cost of drugs
very greatly because the trend is to make it
attractive and highly elegant and to add
cosmetic embellishments to promote sales...
There may indeed be a glut of applications
for the introduction of 'Me-too Drugs' which
will not attract new legislation for another
five years in regard to price control...
Medical Service
Genuine 'breakthrough'
declined in recent times.
has
per year while in a Primary Health Centre, it
is about 40 paise per patient per year.
Existing prices of drugs including those
of essential drugs of everyday use is highly
inflated. For example, the cost of analgin
sold over the counter is 30 times the cost of
production.
An Overview
We recognise the value and significance
of drugs in the health care system. We fully
support the policy that all the essential drugs
should be produced in the country, preferably
in the Indian sector, and that they should be
made available to the people at reasonable
prices. T o realize these objectives, it is
essential to lay down and vigorously imple
ment a national drug policy which will
ensure that the pattern of drug production in
the country (barring drugs meant for export)
should be geared to its actual needs. While
the supply of drugs should be adequate,
eternal vigilance is required to ensure that
the health care system does not get medicalized, that the doctor-drug-producer axis
does not exploit the people, and that the
'abundance' of drugs does not become a
vested interest in ill-health.
research
Prices are often inflated by the use of
brand names.
Very often, prolonged controversy over
the price of a drug has resulted in stopping
its production.
The bill for import of bulk drugs, inter
mediates, solvents etc., has jumped from
Rs. 53.77 crores in 1976-77 to about Rs. 119
crores in 1979-80.
Quality Control
The standards prescribed are unrealistic...
are mechanically copied from books...and not
uniformly enforced in all parts of the country.
Consumption of Drugs
At present the supplies of drugs to urban
and. rural institutions within the health care
system is very uneven. Fn an urban hospital,
for instance, the drug cost is Rs. 6 per patient
October-November 1984
Source :
Health for All—An alternative Strategy :
report of a study group set up jointly by the
Indian Council of Social Science Research
(ICSSR) and the Indian Council of Medical
Research (ICMR).
7
Misuse and overuse of medicines—Why ?
Some Reasons
1.
2.
3.
8
Big business The production and
marketing of modern medicines is
one of the biggest, most profitable
business in the world. Drug compa
nies are continually inventing new
products to increase their sales and
profits. Some of these medicines
are useful. But atleast 90% of
medicine on the market today are
unnecessary.
Doctors
prescrible
them and people buy them, because
the drug companies, spend millions
on advertising.
False advertising Especially in
poor countries, much of the adver
tising, and even the information
published in 'pharmaceutical indexes',
is misleading or false. Information
on dangerous side effects is often
not included. Risky medicines are
frequently recommended for illnesses
less dangerous than the medicines.
(For example chloramphenicol has
often been advertised as a treatment
for minor diarrhoea and respiratory
infections).
Dumping
Drug companies in
wealthy countries sometimes produce
medicines that do not sell well in their
homelands. Or the use of certain
medicines is restricted or prohibited
because they have been proved un
safe. It is a common practice for
drug companies to ‘dump' these
medicines on poor countries—often
with a great deal of false advertising.
For example, several years ago the
U.S. government restricted the use
of Lincocin (lincomycin) because
it proved more dangerous, more
costly, and generally less effective
than penicillin. The following year,
thanks to massive advertising, Linco
cin became the best selling drug in
Mexico!
4.
Lack of adequate controls. Poor
countries, especially, have inadequate
laws controlling the production and
sale of medicines. As a result, many
poor countries sell up to 3 times as
many different medicines as rich
countries do. Most of these medi
cines are a waste of money. Many
are completely unreasonable combi
nations of drugs, yet they are widely
prescribed by doctors. For example,
in both Latin America and Asia, a
popular injectable medicine is tetra
cycline combined with chlorampheni
col. This is a senseless combination
because the two drugs are 'incom
patible' and should never be used
together.
5.
Bribes
and corruption. Drug
companies in rich countries pay
millions in bribes to.officials in poor
countries so that governments will
Duy their products. (A major US
Pharmaceutical
company recenty
admitted to having spent millions of
dollars on bribes to advance its
products in poor countries).
6.
Sale of prescription medicines
without prescriptions This is
common in many countries (partly
because poor people cannot afford
doctors' fees). Most people who
'self-medicate' try to use the medi-
Medical Service
7.
cines well, so they follow the patterns
set by doctors. Unfortunately, this
often leads to incorrect use.
For
example, in Latin America atleast
95% of doctors, prescriptions for
Vitamin B12 injections are among the
most widely used self-prescribed
medicines in Latin America—at a cost
of millions to a people too poor to
eat well!
8.
Health Workers not adequately
informed In spite of the tremen
dous amount of self-medication in
most countries, many programs
still do not teach health workers
much about the use—or misuse—of
commonly self-prescribed medicines.
As a result, many health workers to
meet popular demand, secretly pur
chase and administer a wide range of
medicines they know little about.
People not adequately informed.
Neither doctors nor the people are
adequately
informed about the
correct use of medicines. Most
doctors rely on the information given
in misleading 'blurbs' supplied with
sample medicines, while villagers
who self-prescribe often receive no
information at all. In Mexico, for
example, upto 70% of prescription
drugs are sold without prescription.
Yet the packaging of these medicines
generally contains no information
about use, dosage, or risks.
9.
Use of medicine to gain prestige
and power. Another reason for
medicine overuse is that many pro
fessionals use their ability to medicate
as a sort of magic to make people
grateful and dependent. This way
they gain special privilege and power.
In the same way. health workers
may be tempted to give injections
or expensive drugs when home
remedies or kindly advice would cost
less and do more good.
From Helping Health Workers Learn
—David werner and Bill Bower
This rare Himalayan herb will cure your headache. If it doesn't I'll give you a
pill prepared by a famous multinational drug house.
October-November 1984
11
Medication as a Substitute for Caring
Perhaps the biggest reason for over
use of medicines, however, is that doctors
and health workers often find it easier to
hand out medicine than to give the time and
personal attention that people need.
About 4 out of 5 illnesses are self limi
ting. This means people get well whether
they take medicine or not. Most health
problems can be better managed with
out medication. What often will help
people most is friendly advice and
understanding support.
doctor or health worker. They like to believe
that "there is a medicine for everything".
They are disappointed if the doctor or health
worker does not give them any, even when
medicines will do no good and the health
worker carefully explains why.
However, many doctors and health
workers get into tne habit of giving everyone
medicine—for any and every problem they
have. The less curable the problem, the
more medicines they give!
So a 'vicious circle' results in which the
doctor always gives medicine because the
'patient' always expects (or demands) it,
because the doctor always gives it. The
prescribing of a medicine becomes both
the symbol and the substitute for
human caring. This problem especially
common in places where doctors, nurses, and
health workers are over worked. The result
is not only a costly overuse of medicine, but
a failure to meet human needs on human
terms.
At the same time, people have come to
expect medicine every time they visit a
—Helping Health Workers Learn
David Werner and Bill Bower.
"The physician who sets about to treat a disease without knowing anything about it
is to be punished even if he is a qualified physician; if he does not give proper treat
ment, he is to be punished more severely, and if by his treatment the vital functions of
the patient are impaired, he must be punished most severely."
—Koutilya Arthashastra
12
Medical Service
But some are more essential than others.!
by Ernst Lauridsen
Essential drugs ? But aren't all drugs
essential 7
If a doctor in New York or New Delhi,
in Dhaka or Dongola, writes a prescription
for a patient, isn't that drug absolutely es
sential for the patient's health ? Aren't the
newest drugs better than the older ones ?
Aren't a lot of different drugs better than a
few drugs ?
Not exactly, says the World Health Organi
sation.
In 1977 WHO started a peaceful revolu
tion in international public health.
It asked
a group of experts which drugs were really
necessary to take care of most health pro
blems. This WHO Expert Committee came
to the surprising conclusion that about 200
drugs and vaccines could be considered
essential in good medical practice. Most of
them were of proven effiacy, with wellknown therapeutic properties. Most were no
longer protected by patent rights and could
be mass-produced at a reasonable cost to
patients.
The WHO Model List of Essential Drugs
was met with surprise, indignation and
opposition in some quarters, although it
offered a ray of hope in others. Many physi
cians, used to choosing among thousands
of brand-name items, felt that their freedom
to prescribe "their" drug of choice was
threatened. The research and technology
based pharmaceutical industry feared that
limitations in national lists of drugs and price
competition from manufacturers of generic
drugs would not only reduce profits but also
make if difficult, if not impossible, for it to
invest in research and development of new
pharmaceutical products (see page 10).
October-November 1984
The Model List of Essential Drugs has,
however, stood the test of time. Though
revised twice since 1977, it has needed only
minor adjustments and is still limited to
about 220 essential drugs and vaccines.
More than 80 countries in the Third World
have adapted the model list to their
requirements.
Today, we know from country experi
ence that using a limited number of essential
drugs in the national formulary poses no
threat to public health. On the contrary,
there are numerous advantages, as this issue
of World Health illustrates.
During the second half of the 1970s,
much information came to light concerning
the disastrous drug supply and drug use
situation in developing countries. Many have
been spending 20-30 per cent of their
meagre national health budgets on pharma
ceutical imports, and still the larger pro
portion of the population cannot get the
most needed drugs.
The drug supply situation is often an
imitation of the industrialized world. City
pharmacies stock a huge variety of the latest
antibiotics, combinations of vitamins with
antibiotics, and anti-allergic or hormone
preparations. Tranquillizers and tonics figure
prominently, as do a plethora of antidiarrboeal drugs. Some of these are effective,
many have no proven therapeutic effect, and
numerous drugs sold are ownright danger
ous, particularly when used without proper
medical supervision.
Governments face difficulties in procuring
drugs and vaccines at reasonable prices.
Storage and distribution pose major problems
for the public sector. Most developing coun
13
tries have found themselves in a paradoxical
situation where those with money often over
consume, whereas the rural population has to
go virtually without access to both old and
new medicines, "wonder-drugs" and vacci
nes.
In response to these problems, country
application of the philosophy of essential
drugs has become the centrepriece of a
global programme designed to make sure
that a limited number of essential drugs of
good quality are available at prices that
poorer patients can afford. A strategy drawn
towards the end of the 1970s eventually
became the Action Programme on Essential
Drugs and Vaccines.
This programme addresses the complexity
of the world of pharmaceutical products and
their utilization. In line with WHO's social
goals, it focuses on essential drug availability
in primary health care. If a limited number
of essential drugs cannot be delivered on a
regular basis to’» rural areas and the poorer
sections of cities, the whole strategy of
Health for all by the year 2000 will face
partial or even total failure.
want to pursue. Many of them have chosen
an essential drug policy and some have acclerated their programmes with external .
technical and financial collaboration. UNICEF
and WHO work together particularly closely,
supporting countries in analysis of the phar
maceutical sector, formulation of national
drug policies, selection of essential drugs,
procurement, quality control; storage, distri
bution and training of health staff. UNCTAD
and UNIDO support the transfer of pharma
ceutical technology and the development of
national capacity of formulate or produce a
range of essential drugs.
The mighty pharmaceutical companies of
the North are important partners in the im
provement of drug supplies to the Third
World:
The industry's decisions on research and
development determine which drugs we shall
have in the future. Its product marketing
and promotion exert a considerable influence
on drug consumption. Its pricing policy
determines to a very large extent how far
essential drugs and vaccines will become
available to ever larger segments of the
world's population.
It is not that drugs are the only important
element in health care, but drugs make the
The pharmaceutical industry is in a unique
health service credible because they can cure . position. It has amassed huge resources
disease and alleviate symptoms.
Once
which allow it to undertake the lion's share
patients are assured that their symptoms and
of pharmaceutical research and development.
diseases can be taken care of, they have con This concentration of power carries with it a
fidence in the health staff and in the preven special responsibility to support the develop
tive and promotive elements of primary
ing countries in their drive to make essential
health care.
drugs and vaccines available to their people.
Country Support
The Action Programme on Essential Drugs
and Vaccines is becoming a world-wide
effort, with many partners involved.
Countries, of course, decide for them
selves on the pharmaceutical policy they
14
The pharmaceutical industry is often criti
cized for being part of the problem. There
are indications, however, that the industry
would prefer to become part of the solution.
An increasing number of development
agencies also support essential drug pro
grammes, in partnership with countries that
Medical Service
some of the technical and financial resources
to draw up and execute national drug pro
grammes.
formation is being made available to lay
people in some countries and has aroused
considerable interest on the part of patients.
Prescribers and Consumers
There is some basis today for cautious
optimism : progress has been made in the
last few years. Many countries have adopted
essential drug policies or are already on the
way to having effective programmes. The
WHO policy and .strategy on essential drugs
have been demonstrated to be fundamentally
sound and feasible. The money to buy suffi
cient quantities of essential drugs and
vaccines is available—if not always allocated
to drug procurement—in most countries,
although some may require limited external
cooperation. Less than a dollar per year, it
seems, meets the cost per person for the
drugs most needed in primary health care.
Physicians and other health workers who
prescribe, and dispensing pharmacists, are
obvious partners for the Action Programme.
The individual physician's prescribing pattern
carries consequences not only for the
patient's but for the nation's health.
Superficial diagnosis and examination
followed by a shotgun drug approach are
unfortunately too common. Many explana
tions are offered for this, and it is not hard
to understand that a busy physician will
resort to polypharmacy in the hope that one
of the drugs may be the right one. But this
is of little comfort to the patient for the
patient's purse.
New information and training have to be
provided for students of medicine, pharmacy
and pharmacology before we can expect an
improvement in the fine art of prescribing
medicine. When drugs are prescribed only
when absolutely necessary, and with due
attention to the patient's understanding of
how to use them, we are within the confines
of good medical practice.
Patients, supported by better information
and follow-up, should also take more respon
sibility for their own use of drugs. Frequently
they travel long distances to a health centre,
wait for hours, go with their prescription to a
local pharmacy, return home—and take only
part of the treatment. This phemomenon is
certainly not restricted to developing count
ries, compliance or taking medicine as instru
cted, is often as poor in industrialized
countries as elsewhere, in curious contrast to
the ever-increasing demand for drugs.
Consumer unions can play an important
part in education of the public in the correct
use of pharmaceutical products. Useful in
October-November 1984
Many problems, however, remain to be
identified and overcome. The world is a long
way from making essential drugs available
to all its citizens. And would that be desira
ble ? Is it the ultimate medicalization of
humanity? Will "availability" pave the way
for an avalanche of drugs, so that we ima
gine that there is a drug for every human ill ?
Will drugs mask the real problems of poverty
and unequal distribution of the world's
resources ?
Will the pharmaceutical companies massproduce drugs for ever-increasing popula
tions at affordable prices ?
Will there be enough money to invest in
research and development to drugs against
tropical diseases, cancer and other conditions
for which there is today no satisfactory
treatment ?
These and many other questions have to
be addressed during the next few years.
WHO is doing its best to contribute to
the goals set by its governing bodies. It will
continue to work with all partners who share
these goals.
15
Drug misuse in our Hospitals
G, D. Ravindran
Drugs are one of the most powerful tools
which we have, to alleviate the physical pain
and suffering of humanity. Unintentionally,
we sometimes misuse these drugs. We hope
that they will alleviate suffering, whereas
they actually harm the patient. In India,
consumer awareness is low and the number
of malpractice suits filed against drug misuse
are negligible. Hence, we tend to be com
placent and go on misusing drugs.
Causes
The causes for misuse of drugs may be
due to :
a)
lack of knowledge of the pharmaco
logy of drugs;
b)
lack of understanding of the aetiopathogenesis of the disease ;
c)
tendency to experiment with new
drugs and combinations ;
d)
wrong techniques used to administer
drugs ;
e)
aggressive
companies.
salesmanship
by drug
To illustrate the above, I have chosen
examples of drugs which are typically misus
ed in general practice and in small hospitals.
I will not include vitamins and tonics as
enough has been written about them.
(iii) control atonic variety of postpartum
haemorrhage (PPH). Except in severe PPH
where it is not possible to set up an IV line
or PPH occuring in domiciliary practice, it is
not justified to give in intramuscularly. It
should always be given intravenously and
the dose should be titrated against the
severity of uterine contractions. However,
in practice sometimes 20-30 units of syntocin are given intramuscularly to initiate or
accelerate labour. It has been given to mul
tipara with fully dilated cervix when there is
failure of the secondary powers of labour. I
have seen it being injected intrauterine or
into the vagina. These types of misuse leads
to disastrous results for the woman. The
patient goes into uterine tetany, needing a
caesarian section. There have even been cases
where uterine rupture has occurred followed
misuse of the drug. This misuse often occurs
because the pharmacological knowledge of
ANM's nurses and sometimes even doctors
is poor. The drug is also freely available in
the market without any restrictions. If this
drug was controlled like the opiates then the
incidance of misuse may reduce.
(b) Lack of understanding of the aetiopathogenesis of a disease
(i) Time and again I have come across
the misuse of antibiotics in the treatment of
fever. More than 2 or 3 antibiotics are given
without making an aetiological diagnosis.
(a) Lack of pharmacological knowledge
Frequently when the fever does not touch
One of the drugs frequently misused normal, antibiotics are changed 'midstream'
under this category is Oxytocin (synto- from one group to another without the full
cinon). Oxytocin is mainly used to (i)
course being administered. Often inadequate
initiate labour;
(ii) accelerate labour;
or micro-doses of antibiotics are prescribed.
16
Medical Service
In larger hospitals, the tendency is to use
the latest antibiotics that are available in the
market, irrespective of cost or necessity.
Misuse of antibiotics leads to the deve
lopment of resistant strains of the organisms
and sometimes to the development of idiosyncritic reactions.
(ii) Protein Energy Malnutrition
This common condition in India is com
monly mismanaged. I have seen uncomplica
ted cases of kwaoshiorkar being treated with
Frusemide (Lasix), (with the mistaken idea of
reducing oedema) followed by disastrous
results.
(777) Psychiatric conditions
Psychiatric drugs are another class of
drugs which are brazenly misused. The
average knowledge of a general practitioner
in psychiatry is very poor. Instances of major
tranquilizers e.g. largactil being prescribed
for neurotic conditions and of anxiolytics e.g.
calmpose being prescribed for psychotic con
ditions are quite common. There are ins
tances when palpitation due to anxiety neu
rosis has been treated with digoxin.
(c)
inadequate doses for varying periods in
various combinations and for various condi
tions. In our country it is not included in the
District TB Control Programme as a primary
drug in the treatment of TB—trials are still
being conducted; there are reports of resis
tant strains being produced. Till such time
that it is included in the DTC schedule, we
should refrain from using it indiscriminately.
(d)
Wrong techniques for administra
tion of drugs
Eg: (1) wrong techniques used for giving
injections
—intramuscular injections given
subcutaneously
—oily injections given in the arm
(2) using ordinary syringes to give in?
sulin, tuberculin etc. The does that
is delivered will be lower than the
specified amount due to dead
space in the syringe.
Experimentation with new drugs
Medical Science is progressing at a very
fast pace. New and powerful drugs.are en
tering the market everyday. A busy general
practitioner has very limited time for reading.
He depends mainly on promotional literature
supplied by the medical representatives for
his continuing education on drugs. These
highlight only the beneficial effects of the
drugs and in Third World countries the side
effects and adverse reactions are usually
glossed over: e.g. Rifampicin is rated as a
wonder drug in the treatment of tuberculosis.
It is freely available in the market and is
cheaper than streptomycin. Hence there is a
lot of scope for its misuse. It is given in
October-Novembe i 1984
17
Salesmanship of drug companies
(e)
As has been mentioned earlier, aggressive
selling techniques are a major cause for
misuse of drugs. Salesmen are interested
only in selling their products—often misinfor
ming and misleading practitioners. I remem
ber how a medical representative tried to
convince me to buy amidopyrine because
the government may soon ban the drug!
The pride of place for being the most
misused drug in medicine should go to the
steriod group. Steroids are used as a panacea
to treat all ills. All the causes for misuse of
drugs can be exemplified in their use.
endeavour to keep abreast of newer develop
ments in rational therapeutics. There are a
number of bulletins/journals dealing with
this subject CHAI has taken a lead in esta
blishing a drugs column in Medical Service—
People, Pills and Prescriptions. If we have
doubts, we could get them cleared through
this column. Always insist that medical re
presentative give product information and
not merely promotional literature. Regional
CHAI Units could organise Workshops in
their respective regions on rational therapeu
tics.
poor pharmacology—used indiscrimi
nately for allergies of all types, fevers
etc.
b. aetiopathogenesis—most commonly
seen in dermatology
a.
c.
experimentation—in neurological dis
orders
d.
wrong technique—aerosol form
steroids
of
How do we protect ourselves against
misuse of drugs ? We should constantly
Most ■ importantly, we should educate
patients regarding their rights. Let me end
by quoting Sir Robert Hutchinson ‘‘From
making the cure of the disease more grievious than its endurance, good Lord deliver
us".
One West African study showed that more appropriate prescribing could cut the drug
bill by 70 percent. Most of this money could be spent on generic drugs, but this is
resisted by the international drug companies who recruit leading doctors to their cause
with little difficulty. These specialists, heavily involved in private practice, unite with
the pharmaceutical companies under a banner of 'clinical freedom'
—David Morley, Professor of Tropical Child Health,
University of London
18
Medical Service
Medical Ethics Forum-36
Fr. George Lobo sj
Ethical Problems of Drug Prescription
Drugs are supposed to be prescribed for
healing or beneficent purpose. But the
harm done to the patient by the increasing
over-pricing, over-prescribing and misprescri
bing of drugs is becoming manifest. The
purpose of this short paper is to uncover the
reasons behind this unfortunate situation so
that effective remedies may be found • to
tackle it
1) Modern life is being increasingly
regulated by the technological mode!1.
Instead of technology being at the service of
• man, man is being ruled by technology. The
technical order, in the first flush of its
success, is entering into every nook and
crany of our life and seems to brook no in
herent limitations. Thus human existence
seems to be moving from qualitative progress
to mere quantitative development which has
little use for basic human values that cannot
be measured on the quantitative scale of
external results.
2) This has an effect on the understand-.
ing of health, disease and healing. Instan
taneous cure of the symptoms is becoming
the goal of medical procedures.
The
search is for wonder drugs which can provide
quick relief, but leaving the underlying cause
of the disease untouched or even aggravating
it. The apparent efficacy of drugs leaves
behind a host of what are called 'side effects*
when often they become the malignant 'main
effects'. Thus we have an increasing
number of 'iatrogenetic' (doctor induced)
diseases.2
October-November 1984
3) The personal model of healing is
being replaced by the manipulation of the
patients?. Instead of personal dialogue
concerning the deeper cause of the distress,
trust is placed on the efficacy of bio-chemi
stry. The concentration is on artificial labels
of sickness to be treated by mechanical
means. The value-free or value-neutral
model of science derived from physics and
chemistry is quite appropriate when it strictly
confines itself to these disciplines. But it
acquires a dangerous tone when the mani
pulation freely extends to the sphere of
human life. Man the manipulator ultimately
ends up being man the manipulated. Human
intervention, instead of serving the true
interests of man, tends the violation of basic
human values and rights.
4) The primitive witch doctor sought to
create an air of mystrification by his magical
incantations. The modern therapist creates
a similar effect by prescribing exotic drugs
with esoteric names and whose action he
himself scarcely understands.
5) Modern life tends to reduce the
capacity of man to cope with pain and other
forms of distress. Hence the desire for
quick relief. The patient looks for magi
cal results and seeks out those who will
provide them. The physician is tempted to
yield to this irrational urge without paying
sufficient attention to the long term conse
quences. There is thus a vicious circle of
mutual manipulation which diminishes the
humanity of the patient as well as the medical
practitioner.
19
' 6) The capitalist system with its insis
tence on the 'profit motive' and 'free enter
prise' leads the multinationals and local big
firms to exploit the consumer without caring
for his true interests. While the pharmaceu
tical industry is meant to cater to the health
needs of the people, the people become
means of easy enrichment. Human persons
become a means instead of being an end.
9) One of the consequences of mecha
nization of health care is that initiative in
drug development has passed from the
medical profession to the pharmaceutical
industry. Traditionally pharmacy was sub
ordinate to the physician. Now the physician
is constrained to perform the pharmacologi
cal task assigned them by the drug industry.
The inadequate pharmacological education
of the medical school graduate does not
7) The deep rooted cultural alienation,
provide the background to examine critically
which is an aftermath of colonialism the claims of the industry for its products.
and one of the more pernicious manifesta
Even research is often influenced by the
tions of neocolonialism, produces a glamour interests of the drug industry. Medical
for everything that is foreign The educated journals become the vehicle of promoting
and even the neoliterate regard with awe
the same interests. Companies use them as
the modern system of medicine because of
advertising media overwhelming the physi
its aline origin and with diffidence, if not cian not only with publicity, but also with
contempt, at systems that are indigenous.
article after article on the product that is
Hence the uncritical acceptance of potent being promoteo at the time. Thus they
allopathic drugs and the equally uncritical
hinder legitimate scientific enquiry by placing
rejection of local remedies. Superficial fasci
articles designed to reflect industry views.
nation for modern life enables drug compa
nies to push their products by cosmetic
10) Bourgeois competitive values in
embellishment and elegant packing for which
duce the physicians to seek the maximum
the poor consumer has to pay heavily.
advantage. Not only are they misinformed
8) The dependent status of develop by cleverly prepared and attractively got up
brochures regarding the efficacy of the drugs,
ing countries enables the multinationals to
but they are influenced by physician samples,
put undue pressure on the local authorities
(often sold), and other forms of inducements
to permit their nefarious activities. The
like pens, diaries and even conference attenmultinationals find a ready ally in local big
firms even when their commercial interests dence costs. It is indeed a sad fact that the
may to a certain extent clash. Thereby, continuing education of doctors is largely
carried on by medical representatives and
drugs that are unproved in the country of
their information material containing a lot of
origin or even those that have been proved
half-truths. Besides, an undue desire for
dangerous or ineffective can be pushed with
gain leads the physician to neglect the pin
impunity. The whole matter can be mysti
fied by false claims like of special 'bio pointing of the disease and to prefer 'fixed
combination' anti-biotics and 'broad spect
availability'. Any attempt at regulating the
rum' drugs to take care of multiple eventuadistribution and use of drugs or of banning
dangerous ones can be countered by visible “ ities and thus be able to process a large
and invisible pressures with the connivance
number of cases during a working day.
of alienated specialists. The present craze
Thus there is an unhealthy and in many ways
for uncritical opposition to all governmental
corrupt relationship between the medical
policies contributes to governmental inaction.
profession and the drug industry.
20
Medical Service
11) On the other hand, research on the
therapeutic value of medicinal herbs and
roots,
presented in some rare journals,
collects dust in reference libraries. However,
fortunately, the healing value of non drug
therapies like Yoga, Pranayama, Meditation
and Accupuncture is beng increasingly
recognized. Strangely, these are being
patronized by the well-to-do than by the
poor. .
12) The technological and manipulative
mentality i s a block against the promotion of
preventive health. It is yet to be fully reali
zed that clean water is much more important
than anti-biotics, wholesome food than
vitamin pills, vaccination than expensive
drugs or gadgets.
13) The technological mentality also
leads to the transgression of the legitimate
bounds of human experimentation. It is
not permissible to use a drug unless it has
been sufficiently tested in the laboratory and
on animals. Further, an experimental drug
may not be used when a certainly effective
remedy is available, the risk is proportionately
tolerable and there is at least the reasonably
presumed consent of the patient. The prac
tice of trying out experimental drugs on
patients in poorer countries is to be condem
ned as a grave offence against humanity.4
The Remedy
The very exposition of these evils regard
ing drug prescription suggests a programme
to combat them. However, some of these
will be here briefly mentioned.
1) There is need of evolving a more
humane and person-centred approach to
health care. This should above all seek the
true interests of the patients. For this the
time honoured principles of totality and of
double effect must be clearly understood and
applied.
2) The physician must regain the auto
nomy and ideals of his noble profession.
3) Cultural alienation and political inter
ference of foreign powers must be unmasked
and vigorously countered.
4) There is need for counteracting the
pernicious aspects of materialism and capi talism.
5) There should be a rYiassive movement
against the manipulation of drug companies.
While the more immediate perspective of
abuses in the field of drugs must be attended
to, the deeper political and cultural roots of
the problem need to be tackled.
6) The well-intentioned efforts of the
government to check the abuses in the pro
duction, distribution and use of drugs need
to be supported.
7) Especially urgent is the effort to
reduce prescription to roughly 200 essential
drugs (WHO estimate) with generic names so
that low cost, efficient and safe drugs are
available to everyone.
1. See Willaim Barett The Illusion of Technique, Garden City, N.Y. Anchor Press. 1978.
2. For Clinical Iatrogenesis and the Medicalization of Life, see Ivan lllich. Limits to
Medicine, Calcutta, Rupa, 1977.
3.
Concerning the modern tendency to manupulate human beings, see Bernard
Haring, Manipulation, Slough St. Paul Publications, 1975.
4. For a more complete treatment of ethical principles regarding Medical Experi
mentation, see my book, Current Problems in Medical Ethics, 3rd ed., 1980. pp.100-105.
October-November 1984
21
'If there are no side effects, this must be Argentina
DRUG COMPANY SPONSORED MISINFORMATION OF DOCTORS
In countries with less well-organized drug control mechanisms, studies have shown
that the same drug manufactured by the same multinational company is sold for more
indications.
with less contra-indications
less side effects
as compared to the information provided in U.S.A.
The following comparison of promotional literature for three drugs bears this out
only too well.
Drug :
Tetracycline (Antibiotic used against various infections; Lederle Loboratories)
Caution Against Use
Adverse reactions publicized
By infants, children; during
pregnancy : Liver or kidney
impairement (latter can be
fatal) or if overly sensitive
to light.
Vomiting, diarrhoea, nausea, stomach
upset, rashes, kidney poisoning, can
poison fetus.
Mexico
By infants, children; during
pregnancy or if overly sensi
tive to light.
Vomiting, diarrhoea, nausea, stomach
upset.
Brazil
By infants, children, during
pregnancy.
Vomiting, nausea, stomach upset,
rashes.
Argentina
None
None
U.S.A.
/
Drug :
Ovulen (birth control pills : GD Searle Co.) in US used for contraception only.
In some Latin countries, Searle recommends it also for regulating menstrual
cycles, premenstrual tension, menopausal problems.
Caution against use
Adverse reactions publicized
U.S.A.
If patient has tendency to
blood clot, liver dysfunction,
abnormal vaginal bleeding,
epilepsy, migrain, asthma, heart
problem.
Nausea, loss of hair, nervousness,
jaundice, high
blood
pressure,
weight change, headaches.
Mexico
If patient has tendency to
blood clot, liver dysfunction.
Nausea, weight change.
Brazil
If patient has tendency to
blood clot
None
(Contd, to page 30)
22
Medical Service
A to Z of Drug Policy Issues
A = Advertising
One of the main tools to drug companies to create a need
for their products. Includes appeals for status, modernity,
even unnecessary uses and cosmetic embellishments.
B = Bulk Purchasing
Buying of drugs in bulk by competitive buying of generic
drugs in the international market. It does away with brand
names and private importers.
Bulk Drug
This is the basic, active
formulation.
Basic Research
This implies fundamental and innovational process or product
research. A necessary step to prevent dependence on
foreign companies.
Bio-Availability
This means that the same chemical ingredient, may be thera
peutically different because of the way of formulation. A
common but unconvincing argument against generic prescri
bing by drug companies.
Brand Name
The registered trade mark name given to a specific drug
product by its manufacturer.
C = Consumer Alert and
Consumer Action
An important and growing need in the formulation of a safe
drug policy.
Combination Drug
D = Dumping
chemical ingredient of
a drug
A pharmaceutical product containing more than one active
ingredient.
Passing of old, unwanted, out-dated and banned or other
wise inferior products on an unsuspecting public. A common
practice of multinationals operating in third world countries.
Drug Price Control
Orders
Government orders to control prices of drugs and profits
issued in 1963, 1966, 1970 and 1979.
E = Essential Drug List
A list of medicinal products of proven efficiency, acceptable
safety and suitability to satisfy the health needs of the
majority of the population.
Expiration Date
The date appering on a drug product and established by the
manufacturer, beyond which the manufacturer will not
guarantee the potency, purity, uniformity, or bio-availability
of the product.
F = Formulations
October-November 1984
These are finished products which are directly consumed
and contains in addition to the active drug compound other
23
ingredients such as diluents, binders, flavouring/coloring
agents, gelatin shells, chemical bases waxes and preservatives.
Formulary
A list of approved or recommended drugs compiled by an
individual practitioner or a group of medical and scientific
professionals for the purpose of a specific medical practice
or supply system.
Foreign Company
In India defined as a company with foreign shareholding
exceeding 40% of the total share capital.
G = Generic Prescribing
Prescription of drugs using the official, international, non
proprietary name and not trade or brand names, eg : aspirin
not Aspro or Plusprin.
H = Hathi Committee
Report
An exhaustive report of far reaching importance, by the
Committee on
Drugs
and
Pharmaceutical Industry,
Government of India, published in April 1975.
1 = International Codes
These are codes of quality or safety of products or
business procedures eg.. Code of Ethical
Marketing
Practices of Health Action International. An important
step in pressurising multinationals to stop exploiting the
third world.
Irrational Prescribing
Extravagent prescribing, overprescribing, incorrect pre
scribing, multiple prescribing,
or underprescribing of
medications, as compared to good standards of treatment.
J = 'Junk* Drugs
These are newer drugs in the market whose only addi
tional value are cosmetic embellishments, elegant packing,
irrational combinations all of which help to increase its
cost.
K = Know-How
An important requirement for the technical improvement of
the drug industry. Often controlled by patient, royalty rules
and monopoly of foreign companies.
L = Labelling
Placing written or symbolic instructions on the immediate
container in which drugs are dispensed. Depending on the
motive this could be either a hall mark of consumer safety
awareness or a focus for consumer misinformation.
Level of Use
A classification of drugs according to the medical practi
tioners who use them and the clinical facilities at which they
are used.
M = Me-Too Drugs
These are products of research using molecular manipulation
which are profitable but .not necessarily a scientific advance.
24
Medical Service
Mark Up
Is the hike in the price above the oasic production cost and
is the amount used for selling costs, administrative expenses
and profits. It is presently fixed by government orders.
The less essential the drug formulation higher the mark up
is allowed in India.
N = Net Worth Returns
Is an expression of the profit potential of a drug company
and is one of the highest in the chemical industry in 1 dia.
It makes drug companies one of the most attractive invest
ments in the organised industrial sector of the Indian economy.
0 = Ort or Oral
Rehydration
Therapy
A very important need in the rational management of diar
rhoeas in children and its popularity will prevent use of
many anti-diarrhoeals that have doubtful therapeutic value.
P = Public Sector
Includes drug manufacturing companies owned by the central
government. These have pioneered the production of bulk
in the country. The government policy attempts to give it a
leadership role.
Patents
Exclusive rights given to manufacturers for fabrication of a
specific product, use of a specific process, or application of a
product or process in a specific way.
O = Quality Control
The testing of drug samples against specific standards of
quality. A very important step in manufacture and distri
bution of drugs. , In India this is organised by the drug
Controller.
R = Rational Drug
Therapy
A method of prescribing which is efficient, safe, low cost
and easy to administer.
Research and
Development (R&D)
A much neglected area in the drug industry. A very neces
sary requirement for a country to evolve its own indigenous
drug policy.
S = Sales Promotion
Techniques aimed at consumers, dealers or intermediaries to
increase short term sales and inspire goodwill. For drug
companies it includes bonuses with purchase, contests and
competitions, samples and give ways.
Samples
Commonest method by drug companies to woo doctors.
Other methods are advertising in medical journals, leafleting,
sponsoring medical events, hospitality and providing gifts.
Shelf Life
The length of time a material may be stored without affecting
the usability, safety, purity or potency of the item.
Symbolic
Labeling
A system for providing written instructions for patients using
sketches and other graphic representations.
October-November
25
T = Transfer Pricing
Importing of raw materials from parent companies by
multinational subsidiaries at rates higher than the prices in the
international market thereby transfering cost to the local
consumer.
Division of drugs according to their clinical use.
categories often have a system for assigning numbers.
Therapeutic
Categories
The
U = UN Agencies
These include UNIDO, UNCTAD, UNICEF. All of these are
gearing up to help developing countries evolve relevant drug
policies.
V — Voluntary Action
Only voluntary action and initiative can tackle many drug
policy issues. The Gonoshasthya Kendra and GK Pharma
ceuticals are one example of such an initiative.
W = World Health
Organization
Their expert committee reports and working group reports
are •. providing Jthe technical back up for the evolution of a
more health oriented policy in member-nations.
from
pioneers of Ayurvedic research in •Medical* Dental* Veterinary fields
Al
V Wfl
Oral Herbal Haemostatic & Coagulant
in all Bleeding Conditions of Gums, where
the patient needs systemic heamostatic
Pre-operative: as prophylaxis to minimise
bleeding.
Dosage can be adjusted according to the
severity of bleeding (up to 6-12 tabs a day
in divided doses)
for • GUM • DENTAL • ORAL Hygiene
as Gum massage. Dentifrice, Rinse 8 Gargle
Relief in 2-3 applications
Remarkable improvement in 2-3 days.
in easily crushable tablet form
for immediate Er lasting results in
• HYPER ACIDITY • ORAL ACIDITY
relief within 5-15 minutes even in severe
cases with 3-6 tabs at a time
Masticating trouble leads to: Indigestion,
Flatulence, Constipation, Hyper-acidity
syndrome (nausea, vomiting ptyalism)
SOOKTYN helps assimilation, degestion,
morning evacuation
GUMS Gingivitis : Bleeding, swollen, spongy, painful Gums
TEETH : Painful, Aching, shaky & Hypersensitive;
prevents plaque formation.
ORAL hygiene : in disease or drug induced conditions,
where oral hygiene has to be improved & corrected.
G32 is an excellent supportive & follow up treatment:
to consolidate the gains of Surgical & Systemic management
of Gum & Teeth conditions and ORAL Hygiene.
DOSE: 2 tabs tds between or after principal
meals.
for Rx all available in 50 & 100tabs PACKS at Chemists
for Hospitals 8t Clinics: Supply from factory only.
1000 tabs PACKS except G32.
as Anti-inflammatory, Analgesic & Antibacterial
Quicker relief without side effects Complete relief within 5-7 days
in all Inflammatory ft Painful conditions of Oral cavity:
after teeth extraction. Trismus, Odontitis, Dental Pulpitis,
Cellulitis, Periapical abscess, T. M. Jt. problems.
DOSE: 2 tablets tds for 7 days.
26
\\-,^-^.Therapeuticindex Price'■
I
ALARSIN MARKETING P. LTD.
V
12. K. Oubash Marg. Fort. Bombay-400 023.
Medical Service
The Crazy World of Tonics
Mukarram Bhagat
'Health' tonics are a craze with the afflu
ent in the cities with their supposedly hectic,
energy-consuming life-styles. Feeling tired?
Pop a pill or gulp down a spoonful and it will
keep you going (nobody knows where!)
The most commonly used tonics are
multi-vitamin preparations with highly exce
ssive quantities of vitamins.
Incremin C, the famous growth tonic with
the Giraffe logo, contains an important amino
acid lysine which the human body cannot
synthesise by itself. However, a teaspoon
of Incremin contains only about 300 millig
rams of lysine when just a handful of peas
contains about 1800 milligrams of lysine.
The advertising slogan that Incremin turns
"extra eating into extra growth" is medically
unsubstantiated and at best a half-truth.
The quantities of vitamin constituents of
Incremen are absurd: 10 times more vitamin
B1, 25 times more vitamin B12, 2 times
more vitamin B6 than required by the body
daily. (1)
The daily requirement of the human body
of vitamin C is about 50 milligrams, of
vitamin B1. one milligram and some others
in minute quantities of a few micrograms.
Against these well established norms, most
tonic preparations contain between 10 to 50
times the minimum requirements (2) which
are simply excreted away by the body—a
colossal waste of valuable nutrients in a poor
country. Further, most vitamins are needed
in small amounts to stimulate the processes
of normal metabolism, they are not energy
giving in themselves.
28
It is almost certain that the high-potency
multivitamin formulations consumed by the
well-fed are almost wholly rejected by the
body. For example, the daily requirements
of vitamin C can be obtained from a single
fruit or a salad helping. Vitamin A, supplied
by green, leafy vegetables, is stored in large
amounts by the body for proper vision.
Vitamin D is naturally synthesised by the
skin from daily sunlight. Despite all these
simple facts, the craze for 'health' tonics
continue unabated. (2).
Why ? Manohar S Kamath in his article
in THE DAILY MAGAZINE provide the ans
wers :
"The real culprits behind the 'tonic craze'
are the manufacturers of such formula
tions. The principal reason for their hard
selling of such products that the tonics
and vitamins fell in 'category four' of the
Drugs Price Control Act, which means
that there is no limit on profits made on
these preparations. With easy pickings and
a readymade market, no wonder then that
every new company entering the pharma
ceutical world wants to market its own
brand of tonic rather than any life-saving
drug;" (2)
Explaining how the 'tonic craze' is the
result of systematic campaigns of the large
companies, he says :
"The first part of the plan was the mount
ing of an intensive sales campaign to
influence doctors on the need for tonics
in their day to day practice. This was
followed by free sampling" (2)
Medical Service
"The other part of the marketing gimmic
kry in selling tonics was by directly adver
tising in the mass media, to catch the
public eye. Slogans like "Do you feel tired
at the end of the day? You need..." or "A
woman needs iron every day" gradually
made a deep impact on the people until
many were psyched into believing that
they could not do without a tonic."(2)
Waterbury's Yellow Label Tonic, a
brand leader in the Indian tonics markets,
contains only 3 milligrams of iron per teas
poon just 1/10 of which may be absorbed
by the body. The Indian Council of Medical
Research (ICMR) recommends at least 10
milligrams for women. The producer claims
that this tonic stimulates appetites and builds
bodies. But chemical analysis has revealed
that it has 10% alcohol content which is the
real appetite-stimulant: (1),
We have noted that these tonics are not
consumed by the poor but mainly by the
relatively rich whose ordinary diet adequately
meets their vitamin and other requirements.
In recent years,’evidence has grown that the
excessive vitamins may not simply be dis
charged by the body but may even cause
severe disorders. Prolonged consumption of
excessive viramin C may form kidney stones,
excessive vitamin A may cause diseases of
the hair, skin and liver and vitamin D in
excess may cause disorders of the kindneys
and bones. (2)
Take this further example from South East
Asia. In the U K., Sanatogen is marketed
as a 'nerve tonic4 for old women who
believe in its doubtful ability to tranquilise. But Sanatogen Powder is marketed to
stuaents in Malaysia who believe in its
ability to stimulate their minds. "Worried
about exams?" says the advertisement. San
atogen will give you "Greater energy and
concentration". Can a drug both stimulate
and sedate? (3)
A person who eats well does not need extra vitamins.
THE BEST WAY TO GET VITAMINS:
Thus, the sheer irrationality and deliber
ate exploitation of consumers through this
sinister "tonic racket" is obvious. The fact
that many such, rackets* continue unabated
is a measure of the enormous influence and
power of the large pharmaceutical corporat
ions not only in India but in many other
countries, particularly the developing ones.
More than 20 years ago, the following
words were spoken before the Kefauver
Committee hearings on drugs in the U.S.A.:
"The incidence of disease cannot be
manipulated and so increased sales volume
must depend atleast in part on the use of
drugs unrelated to their utility or need, or in
other words, improperly prescribed. Human
frailty can be manipulated and exploited and
this is fertile ground for any one who wishes
to increase profits. The enormous sales of socalled tranquillisers are only a small part of
the crop reaped from this ground. The phar
maceutical industry is unique in that it can
make exploitation appear a noble purpose."
(4)
References:
1.
Health for the Millions, VHAI, AprilJune 1981
2.
"Some Boost, and at what price?".
The Daily Magazine, 7 May 1981.
3. The Impact of multinational corpor
ations on Health in Developing Countries, by
Charles Medawar, Seminar on Health, Food
and Nutrition, Consumers Association of
Penang, Malaysia, 15-20 Sept 1977.
4.
Drugs and the Common Man, Science
Today, November 1970.
Source'. Aspects of the Drug Industry in India
C E D.
(Contd. from page 22)
Argentina
If patient has tendency to
None
blood clot.
Drug : Imipramine (Anti-depressant, Ciba Geigy) In U.S. used for depression only. In
some Latin' American countries, Ciba Geigy recommends it also for senility,
pain and alcoholism
Caution against use
Adverse reactions publicized
U.S.A.
If patient has heart disease,
Hypertension, stroke,
stumbling.
history of urinary retention.
delusions, insomnia, numbness, dry
history of seizures, manic
mouth, blurred vision, constipation.
disorder or is on typhoid
itching, nausea, vomiting, loss of
medication.
Not recom
appetite, diarrhoea
mended for children or
during pregnancy.
Mexico
During first trimester of
Dry mouth, constipation itching.
pregnancy
sweating
Brazil
If patient has heart disease;
None
not
recommended
for.
children or during pregnancy
Argentina
May exaggerate response to
None
alcohol
(Taken from the Mother Jones, Courtesy—Health and Society, also mfc bulletin 73-4, Jan-Feb 1982)
30
Medical Service
Consumer Alert - Consumer Action
Ravi Narayan
The Problem
(v)
The Indian Council of Medical Research
.(ICMR)- and the Indian Council of Social
Science Research (ICSSR) have, in a joint
study group report entitled "Health for All —
an Alternative Strategy" warned that 'eternal
vigilance is required to ensure that the
health care system does not get medicalised,
that the doctor-drug producer axis does not
exploit the people and that the abundance
of drugs does not become a vested interest
in . ill-health'. This warning is a serious
indictment of the drug industry and the
medical profession in the country. It con
firms the growing evidence that drugs are
being pushed on an unsuspecting public by
devious methods which masquerade as
'sales promotion' of drug companies and
'professional prescribing practice' by doctors.
Promotion of drugs for indications
that are not clinically proved and are
often potentially dangerous eg:
Promotion of EP forte combinations
for pregnancy testing and induction
of abortion. There is well documented
scientific evidence that risk of foetal
deformity is increased by the use of
these hormonal preparations.
(vi)
Sale of spurious, adulterated or poor
quality drugs eg: Turmeric powder in
tetracycline capsules and poor quality
and reaction producing intravenous
fluid preparations have been reported.
(vii)
Sale of old, expired and unused
drugs. There is the double danger
of effects of denatured drugs as also
of inadequate dosage.
(viii)
Over-prescription and misuse of
tonics, high protein foods, hormonal
preparations and baby foods that
are both superfluous and a drain on
the family economy.
(ix)
Production of drugs for profits rather
than health needs of people eg: The
ICMR/ICSSR report highlights that
drugs for diseases like leprosy and
tuberculosis which affect millions
are produced at one third and one
fourth of the actual requirements
while tonics, vitamins and high
protein substitutes are being prod
uced in wasteful abundance.
(x)
Sale of drugs over the counter with
out doctors' prescriptions or the
necessary statutory checks.
A spate of reports have been appearing
in our newspapers and periodicals of late,
on drug related issues and a review of these
highlight that many of the following practices
are not at all uncommon in India.
(i) Sale of drugs banned in other
countries eg: Lomotil and Clioquinol
preparations.
(i) Sale of irrational combinations and
formulations eg: Hathi Committee has
suggested weeding out of atleast 23
such preparations.
(iii)
Sale of drugs without adequate pre
cautionary product information.
(iv)
Sale of drugs at highly inflated costs
eg: it is reported that Analgin is
being sold at 20 to 30 times the cost
of production.
October -November
33
It is evident then that what is needed in
the country today is a consumer awakening
and awareness building process that will
sensitise people to the realities of the drug
industry, mobilise public opinion, sensitise
policy makers, confront the medical esta
blishment and challenge the drug industry.
This process will have to the initiation,
promotion and sustenance of consumer
action to ensure that the drug policy in India
is more 'people' and 'health' oriented. Is
there any evidence of such an awareness ?
Consumer alert and action
Beginning in the late seventies; there is
an increasing number of organisations,
associations, projects and action groups
who have begun to create an awareness of
drug-related policy issues. These groups
are predominantly if not exclusively urban
based, consisting of young professionals and
intellectuals from different
ideological
backgrounds.
Since the. Medical Profession is the
'instrumental consumer' ie., they prescribe
the drugs, many of these groups have
directed their efforts particularly towards
them. Many others are health or develop
ment associations, science popularising
movements and consumer associations who
are increasingly taking up drug-issues as one
of their many activities.
The main types of action they have been
involved in are :—
1.
Meetings :
* 'The Drug Industry and the Indian
People organized by Delhi Science
Forum, Society of Young Scientists,
Federation of Medica I Representatives
Association of . India (FMRAI) and
others in Delhi, November 1981.
34
♦ ‘Drug Issues and Feasible Alternatives'
by Voluntary Health Association of
India (VHAI) at Pune, January 1982.
* 'Drug use and Abuse by medico
friend circle (mfc) of Tara, June 1982.
* At the AH India Convention of People's
Science Movements at Trivandrum,
organised by Kerala Sastra Sahitya
Parishad (KSSP). A health group was
formed to coordinate joint action
programme specially on drug issues.
* Seminar on ‘National Health Policy'
by VHAI, Concern for Correct Medicine
(CCM), All India Women's Conference
(AIWC) and others in Delhi, April 1983.
Drug issues were also discussed.
* Meetings on ‘Drug Policy Issues' were
held in Pune, Bombay, Trivandrum,
Madras, Bangalore and Delhi during
Dr Zafarullah Chowdhury's (of Gonoshasthaya Kendra) whirlwind tour of
India in November-December 1983.
These 'galvanised everyone into more
action'. National and local press gave
coverage right along the tour.
* FMRAI Annual Convention in New
Delhi, December 1983 made a 27 point
charter of demands which included
demands for Rational Drug Policies
relevant to the health needs of the
country effective drug control, ban on .
irrational and hazardous drugs.
* Misuse of Drugs — Seminar organised
by the Andhra Pradesh Voluntary
Health Association at Hyderabad in
February 1984.
* 'Drugs
vs.
People' — A Seminar
organised by West Bengal Voluntary
Health Association at Max Muller
Bhavan at Calcutta in February 1984.
* 'Low Cost — Cost effective health Care,
one day symposium organised by
Kerala Voluntary Health Services.
Medical Service
2.
Educational Campaigns
liberties grievances, health professional
associations.
* Arogya Dakshata Mandal (ADM) Pune,
launched a movement called ‘Operation
Medicine in July 1977 against irra
tional prescription of vitamins, tonics,
and tinned foods.
* KSSP launched a campaign for a
'People's Drug Policy' on April 7th
World Health Day. District level
Seminars were held in all the 1.3
districts of the State. On October 2nd,
the Sastra Kala Jatha was launched
with signature campaign, Slide shows,
art forms etc. Two seminars—"The
Indian Drug Industry' and the People's
Needs" and 'A Drug Policy for Kerala'
are planned for November 1984.
* VHAI along with many associates
launched a campaign in March 1982
(International Women's Day) against
the misuse of hormonal preparations
for pregnancy testing.
♦ National Alliance for Nutrition of
Infants (NANI) was formed to promote
breast feeding and prevent/control of
promotion of commercial milk foods
and substitutes.
* mfc launched campaign for rational
management of diarrhoea with ORT,
and prevent misuse/abuse of available
anti-diarrhoeals.
* Lok Vidnyan Sanghatana, Maharashtra
(PSM) launched a campaign about
anemia in women and irrational antianaemia drug preparations is the
market, in May 1983.
* FMRAI have launched a separate
campaign against irrational practices
and role of multinational corporations
in pharmaceutical industry in India.
* KSSP has organised jathas (Science
and Cultural Marches) through the
villages and towns. of Kerala in
October-November 1983 on 'War'. the
war against unscientific practices in
the field of drug industry.
* Drug Action Network launched a
nation wide signature campaign in
April 1984 to demand for a Rational
Drug Policy. This campaign involves
activist and consumer groups civil
October-November 1984
3.
Publications
* mfc published two anthologies — 'In
Search of Diagnosis' (1977) and
'Health Care Which Way to Go' (1982)
which included many articles on drug
issues.
* VHAI published special issue of their
bimonthly—Health for the Millions—in
1981. Thematic issue was entitled
'Medicine as if people mattered'.
* Centre for Education and Documenta
tion (CED), Bombay, published an
exhaustive well researched book called
'Aspects of Drug Industry in India'.
* Indian Social Institute (ISI) New Delhi,
brought out an Indian edition of the
book 'Insult or Injury' by Charles
Medawar of Social Audit (UK) which
is a study of practices of British
Pharmaceuticals and Food Industry in
Asia.
•
* 'Taste of Tears' is a recent publication
of VHAI on problems of diarrhoea and
its management.
♦Consumer Education and Research
Centre, Ahmedabad, prepared a well
documented report on Analgesics and
submitted it to the Drugs Controller.
35
This report deals with hazardous and
irrational combinations.
* Rational Drug Therapy — first volume
of the book by Arogya Dakshak
Mandal, expected in December 1984.
4.
Bulletins/Journals
* Pune Journal of Continuing Health
Education, by Arogya Dakshata Mandal,
sensitises its readers to the half truths
of medical advertising apart from
providing reliable scientific information.
* 'Drugs Bulletin' — of Pharmacology
Department of Post-Graduate Institute,
Chardigarh is a authentic and authorita
tive resource on drugs in India.
* Handouts of the Low Cost Drugs and
Rational Therapeutic Cell of VHAI
have covered an extensive range of
drug prescribing and policy issues.
5.
Low cost Drugs venturs
* Bangarapet Medical Mission Tablet
industry is a successful small scale
venture providing low cost, good
quality formulation to a limited group
of mission hospitals in the country.
* LOCOST a collective voluntary end
eavour in Gujarat for rational thera
peutics through the promotion of low
cost, quality generic medicines. It
also plans an educational effort for
minimum use of drugs and increased
awareness of
the socio-economic
implications of irrational therapeutics.
6.
Public Interest Litigation
* Vincent Panikulangara, a lawyer from
Kerala, .filed a writ petition in the
Supreme Court, regarding the ban of
the import, manufacture, sale and
distribution of drugs identified as hazardous
and or irrational by the Drugs Consultative
Committee of the Government of India. This
was done on behalf of the people of India.
7,
. Networking
* All these groups have now come toge
ther to form the All India Drug Action
Network. Regional and State level net
work are also forming up, eg : West
Bengal Drug Action Forum, Hyderabad
Drug Action Forum. DAN also bring out
the Drug Action Network Newsletter
which keeps the network up-to-date on
activities and ideas of all the groups.
DAN meets twice a year to plan and
coordinate its activities.
Towards a People's Movement
All the above efforts are small steps to
wards a much more wide based consumer
movement against drug use and abuse and
profit oriented drug policies. However, it must
be remembered that in a country like ours
when a very large percentage of people are
below the poverty line and when more than
75 percent of the people have little access to
basic health science a consumer action pro
gramme only on drug matters will continue
to be cut off from the needs and aspirations
of the majority.
Dr Norman Bethune, Famous for his work
in China, wrote 'The best form of providing
health care and health protection would be to
change the economic system whica produces
ill health-to liquidate ignorance, poverty and
unemployment'.
One hopes that eventually drug related
issues will become part of a much wider
people's campaign for health, development
and socio-political change because at the
root of the entire problem of drug production
and availability lies what Ivan lllich has aptly
described as 'Sociai-iatrogenesis-ie., health
policies reinforcing an industrial organisation
which generates ill-health'.
Source : Bulletin of Science December 83 Jan. 84 (up dated
36
Medical Service
Towards Rational Therapeutics
Extracts of a letter from a young doctor
in a small rural hospital in Madhya Pradesh.
Dear Friend,
...... About drug prescribing practices in
our hospital in the first few months of my
work I had ordered many new drugs. Later
I realised mainly because of financial condi
tions of the patients that only important
essential drugs and a minimum possible list
should be adopted.
Antibiotics
We use commonly Procaine Peniciliin and
Penidure. They used to use a lot of Streptopen, which I don't. I mainly use procaine
penicillin. Then I use a lot of septram when
there is double pathology, like respiratory
tract infection with urinary tract infection or
otitis media. We use tetracyclines very
rarely, injection Terramycin I don't use at
all. So also Chloromycetin. I never use
chloramphenicol. If I doubt enteric fever, I
start with septran. Then we have streptomy
cin only for TB patients. Crystalline penici
llin I use only in new borns. At present I
feel very confident regarding the usage of
antibiotics and I don't use two drug com
binations, so I have stopped using chlorostrep.
Diarrhoea
Now we make cough mixture in the
hospital for free patients and we have 3 other
brands of cough syrup
About tonics—it takes a lot of patience to
convince patients—they don't need tonics—
they can get the same benefit with proper
food and milk/eggs. Now-a-days very few
people ask for ‘'Thankath ka sissi" and we
have only two types of tonics...
I have kept multivite tablets, fersolate and
calcium tablets. Not a single brand of costly
vitamin capsules or tablets are stocked. They
used to use a lot of varieties. Slowly I
stopped even B-complex injections...
For TB patients we have pyridoxin. For
children we have Vit A & D and multivite
drops. Vit C. I hardly use—noor do I use
calcium injections except in tetany.
Antacids
We had lots of brands before. Now we
use Belladenal and two brands of antacids
only.
. One thing I have succeeded in pro
ving here is that you can run a small hospital
and treat patients successfully with only a
handful of d'ugs which are cheap and good
quality. Why do we insist on each doctor or
specialist having his own petty brand of
drugs in our large hospitals and even the
medical college hospitals ?.....
This is usually controlled with rehydration
salts and plenty of oral fluids . Slowly dis
continuing lomotil and other drugs.
Cough syrups/Tonics
When I Joined there were lots of varieties
of cough syrups, cough'cold tablets and
also lost of variety of tonics. It took me
nearly a year to cut down many brands. We
had 11 brands of cough syrup and 10 brands
of tonics.
October-November
37
Irrational Drug use Prescribing
IRRATIONAL DRUG PRESCRIBING
Type of
Irrational
Drug Use
Extravagant
Prescribe
ing
Occurs if a drug is prescribed
when:
* a less expensive drug would
provide comparble efficacy and
safety
* Symptomastic treatment of mild
conditions diverts funds from
treating serious illness
♦ a brand name is used where less
expensive equivalents are avai
lable
Overprescri
bing
Underprescribing
IRRATIONAL DRUG USE-CAUSES
In brief, the main causes identified by
those who have studied prescribing behavior
are the following :
1.
Inadequate training in clinical
pharmacology—Despite the daily
use of medicines in clinical practice,
formal training in-drug use is usually
brief and often limited to the early
part of medical training.
2.
Lack of continuing education
and supervision—For the medical
auxiliary as well as the practicin
physician, there is usually little
oppoitunity for regular review of
their prescribing habits. In addition,
there are few opportunities for them
to learn about new drugs from unbia
sed sources.
3.
The practitioner's inappropriate
desire for prestige—In some areas
a "good doctor" is expected to use
many different drugs and prescription
of multiple drugs is falsely considered
a sign of good care.
4.
Promotional activities of drug
company
representatives—The
role of commercial interests in
promoting irrational and costly pres
cribing has been well documented
and cannot be over-emphasized.
Even where the choice of drugs is
limited by centralized purchasing.
* the treatment period is too long
* the drug is given for an incorrect
diagnosis
prescribing
* the wrong drug is selected for
the indication
* the prescription
improperly
is
prepared
* adjustments are not made for
co-existing
medical,
genetic,
environmental, or other factors
Multiple * two or more medications are
Prescrbing used when one or two would
achieve virtually the same effect
* several related conditions are
treated when treatment of the
primary condition will improve
or cure the other conditions
38
not
* dosage is inadequate
* the quantity dispensed is too
great for the current course of
treatment
Incorrect
are
* length of treatment is too brief
* the drug is not needed
* the does is too large
* needed medications
prescribed
Medical Service
practitioners often try to "protect"
themselves against this uncertainty
by extravagant, multiple, or overpres
cribing.
company representatives frequently
promote overuse of drugs.
5.
Lack of time due to heavy patient
load—Medications are often given
out to help end a patient visit, or
prescribed "just in case", to avoid
a return visit.
6.
Pressure from patients—Even in
the most remote areas, patients
quickly come to expect that every
symptom has a medicine to cure it.
Because patient education can be
slow, time-consuming, and tiring,
practitioners often give in »to the
request for medicines.
7.
Fear-induced prescription—Diag
noses are rarely made with absolute
certainty and the course of an illness
cannot be predicted exactly. Medical
8.
Incorrect generalization about a
drug from limited experience-Unexpected favourable results/unfavourable side effects are sometimes
seen with the use of a drug. Al
though these results may be totally
unrelated to the drug, practitioners
may over-react and, depending on
the result, later overprescribe or
underprescribe on the basis of this
anecdotal information, rather than
on the basis of scientific evidence.
From MANAGING DRUG SUPPLY, Manage
ment Sciences for Health, Boston, Massachu
setts, USA.
YORCO KNOWN FOR RELIABLE SCIENTIFIC INSTRUMENTS
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YORK SCIENTIFIC INDUSTRIES
1325, Hira Lal Building, Ajmeri Gate, Fasil Road, Delhi - 110006
Supplement to Special Issue of
the Medical Service on
"Towards a People Oriented Drug Policy"
Widening Horizons—on Drug Issues
1982, Rs. 10.00 from : medico friend
circle office, 326, 5th Main, I Block
Koramangala,
Bangalore 560034
Raises relevant
issues regarding
peoples health. Questions why
is there a lack of political will
to solve pressing health problems
of the country. How detrimental is
the alliance between medical profe
ssionals and the drug industry to
people's health.
A. Books
1.
Hathi Committee : Report of the Com
mittee on the Drugs and Pharmaceu
tical industry. Ministry of Petroleum
and Chemicals, Govt of India, April
1975, Rs. 17.00.
The essential drug list suggested
here could provide the foundat
ion for a demand for a Rational
National Drug Policy.
2.
2
Health for All—an Alternative Strat
egy. ICSSR a ICMR, 1981, Rs. 18.00
Available from VHAI. In focussing
on a comprehensive national policy
of health and a new operational
strategy, the report is intended to be
a basic document to initiate a nation
wide debate on the subject as well
as positive action towards certain
radical changes to correct the present
imbalances in our health caresystem.
Has a very comprehensive chapter
on drugs and pharmaceuticals.
3.
Aspects of the Drug Industry in
India. Mukarram Bhagat, Feb 1982,
Rs. 19.00 From Centre for Education
and Documentation (CED), 3, Sule
man Chambers, Battery Street, Bom
bay.
4.
Insult or Injury. Charles Medawar,
1980, Rs. 18.00, 139 p. Social
Audit, England. Available
from:
Indian social Institute, Lodi Road,
New
Delhi 110003. Highlights
marketing and sales of British drugs
and food products. Illustrated easy
reading.
5.
Health Care Which Way to Go
Medico Friend Circle Anthology II,
6.
Under the lens: health and medicine.
Ill Anthology of medico friend circle
is due shortly and will be available
from VHA1 and mfc office (above).
7.
Kurji Holy Family Hospital: Formulary
and Therapeutic Guide. January
1983, w Rs. 12.00. Available from
VHA1. It is the result of the accum
ulated experience of senior medical
staff of the hospital over the last 10
years. It gives a comprehensive
list of drugs to treat 98% of hospital
admissions- it also gives the generic
name, dosage, indications, contrain
dications and main side effects in the
same page. Information about com
parative cost of treatment is also
provided.
8.
Drugs and the Third World. Anil
Agarwal,
1978,
$5.00.
From
Earthascan, 10 Percy Street, London
Wl PO DR. A very comprehensive
overview of the drug situation in
the third world and the problems
and causes.
9.
Prescription for change. Health Action
Internationals guide to rational health
projects, Virginia Beardshaw, Novem-
Medical Service
dation. Available from VHAI. An
excellent guideline for rational thera
peutics, giving special emphasis on
drug cost as criteria for choice of
drug diagramatico format.
ber 1983/ 85pp USS 10.00 from
Health Action International Clearing
House. PO Box 1045, Penang, Mal
aysia. Gives more than 40 ideas for
action research projects on drugs:
—a summary of the main elements of
the rational health issues and sugg
estions about how to campaign
on it;
—advice on how to talk to drug
companies and the powers that be
12.
Management schedules for dispensa
ries: A manual for rural health workers.
Peter Petit, 1983, Rs. 35.00. African
Medical and Research Foundation.
Available from VHAI.
13.
44 problem drugs: a consumer action
and resources kit on pharmaceu
ticals. IOCU, May 1981. Available
from HA1 Clearing House (see 9)
Gives information about 44 problem
drugs, along with articles by some of
the leading drug compaigners.
14.
A number of interesting papers to
keep you upto date about the drug
issue is available from'LowCost Drugs
and Therapeutics Cell, VHAI, C-14,
Community Centre, Safdarjung Deve
lopment Area, New Delhi 110016.
(write to them for a list)
—a reference section that lists the
main materials you need to rese
arch on drugs.
10.
11.
Pill-fering the poor: Drugs and the
third world. An information/action
pack on drugs and the third world from
Interfaith Center on Corporate Res
ponsibility, International Health Pro
gramme, 475 Riverside Drive, Room
566, New York, NY 10115. USS.
4.00 plus postage surface mail §2.70/
air mail S/4.70. It provides an over
view of the problems related to drug
marketing in the third world, it cont
ains articles on the need for essen
tial drugs, on the suffering wrought
overseas by some US made drugs
and on the high price the third world
poor have to pay for their medicin
es. This package includes an exte
nsive annotated bibliography, basic
facts and figures about the transna
tional drugs industry and an outline
of suggestions for action on how you
can get more involved in helping to
stop abuses.
Therapeutic guidelines: A manual to
assist in the rational purchase and
prescription of drugs. Upunda, Yudkin et al 1981, pp. 166, Rs. 35.00
African Medical and Research Foun
October-November 1984 (Suppl)
B. Periodicals
1.
Pune Journal of Continuing Health
Education. Presents scientific infor
mation and opinion on drugs and
health issues to stimulate thought
and further investigation. Annua!
subscription Rs. 10.00 or a five year
subscription for Rs. 45.00 from
Arogya Dakshata Mandal, 1913,
Sadashiv Peth, Pune 411030.
2.
Drug Bulletin
An informative monthly
giving
unbiased technical information on
drugs and therapeutics.
Annual
subscription Rs. 10.00 from Dr. V S
Mathur, Professor, Department of
Pharmacology and Editor, Drugs
3
Bulletin, PG I of Medical Education
and Research, Chandigarh 160012.
3.
4.
1.
4
ches, 150 route de Ferney, 1211
Geneva 20, Switzerland or VHAI,
New Delhi.
Medico friend circle bulletin.
A monthly which discusses issues
regarding health problems, the health
care system, medical education, drug
issues etc., from the point of view of
relevance to the needs of the majority
in our country. Annual subscription
Rs. 15.00. Write to Convenor, medico
friend circle, 326, .V Main I Block,
Koramangala, Bangalore 560034.
HAI News
A very informative bimonthly of the
Health Action International (HAI),
covering world drug news of special
relevance for the third world. Hai
is an informal network of health
consumer and development oriented
associations and professionals con
cerned with health and pharmaceuti
cal issues, particularly those that
adversely affect the poor. Annual
subscription : US$ 10.00 from HAI
Clearinghouse, regional office for
Asia and the Pacific, International
Organization of Consumer Unions
(lOCUj, PO Box 1045,
Penang.
Malaysia. A number of journals have
brought out special issues on drugs.
These may be available on request
for back issues.
Contact: from Christian
Medical
Commission, World Council of Chur
2.
a.
August 1981 No. 63 : 'Getting
Essential Drugs to the People'
with a model list of essential
drugs.
b.
June 1983, No. 73 : 'Strengthe
ning and regulating the supply,
distribution and production of
basic pharmaceutical products*.
Health for the Millions. From
Publications Department, Voluntary
Health Association of India, C-14,
Community Centre, SDA, New Delhi
110016.
a.
Medicines as if people matteredApril-June 1981
b.
Special Issues on diarrhoea and
tuberculosis
3.
The Journal of the Christian Medical
Association of India.
From : The GM AI Office, Christian
Council Lodge, Nagpur 1,
Maharashtra.
Sept 1983, Vol LX, No. 9, Drugs-Fact,
fallacy and fraud.
4.
World Health : The magazine of the
World Health Organization, Avenue
Appia, 1211 Geneva 27, Switzerland.
July 1984, Essential drugs for the
World.
Medical Service
Oral Rehydration - which method
is most appropriate ?
Diarrhea is one of the main causes of
death in small children. However, most of
these children actually die from dehydration—the loss of too much water. It is
generally agreed that the most important
way to manage diarrhea is to replace the
liquid that the child is losing. But there
is less agreement about how to do this.
* The baking soda prevents 'acid blood',
a condition that causes fast, heavy
breathing and shock.
* The potassium helps keep the child
alert and willing the drink and eat. .
A few years ago, most doctors treated
even mild dehydration by giving intravenous
(I.V.) solution. But this was expensive, and
many children died in diarrhea epidemics
because there was not enough I.V. solution,
or not enough skilled workers to give it.
Today, most health planners recognize
that oral rehydration—or giving liquid by
mouth—is the best way to manage most
cases of diarrhea and dehydration. Even in
clinics, where I.V. solution is available, it
usually makes more sense to replace liquids
by mouth. This way parents learn how to
prepare and give liquids so they can begin
treatment early, at home, the next time a
child gets diarrhea.
A Special Drink or Rehydration Drink
can be made from water mixed with small
amounts of sugar and salt. It is even better
if the drink contains a little baking soda
(bicarbonate of soda) and a mineral called
potassium—found in orange juice, coconut
water, banana and other foods.
* The salt in the special drink replaces
the salt lost through diarrhea, and
helps the child's body to keep liquid.
* The sugar provides energy and also
helps the body absorb liquid more
quickly.
What is now about sugar salt-solution ? Since ages
we doctors have earned money by selling if as medi
cine for various diseases, though not for diarrhoea.
Courtesy—Health care which way to go MFC Anthology.
6
Medical Service
The amounts of sugar and salt in the
Special Drink do not have to be very exact.
In fact, there is great variation in the
amounts recommended by different experts.
However, too little sugar or salt does less
good, too much salt can be dangerous.
The Range of Rehydration Methods for
Children with
Diarrhoea can
be
divided into two Broad Groups :
children never receive the liquid, or
are given it too late.
Group 'B'
1.
Homemade drink made with plastic
measuring spoons
2.
Homemade drink made with spoons
found in the home
3.
Homemade drink made with home
made spoons
4.
Homemade drink with salt and sugar
measured with the fingures or by
another traditional way
Group "A'
1.
2.
3.
4.
Intravenous solution (I.V.)
Factory prepared oral solution
Factory prepared packets of rehydra
tion salts for mixing in water
Bags with salts, prepared at the
health centre for mixing in water.
Advantages and Disadvantages
— Control and responsibility mainly in
the hands of professionals, institu
tions, and drug companies
—7 Measurement
more
precise and
"controlled' (atleast in theory)
— More magical; acceptance may be
quicker but with less understanding
— More dependency—on high technol
ogy, on outside resources,
on
centralised services, and on local and
international politics
— More expensive
— Easier to gather data on, and prepare
statistics about
— Reaches, fewer people; supply often
uncertain and inadequate
— Sometimes causes delay in treatment,
because special materials have to be
obtained; affect is more curative than
preventive
— Focus is on materials and supply (so
cost goes up each year)
— May give better (safer) results for
individuals treated in time, but has
worse results overall since many
October-November 1984 (Suppl)
Advantages and Disadvantages
— Control and responsibility mostly in
the hands of the family
—• Measurements less precise,
less
"controlled'
— More practical and easier to under
stand
— More self-sufficiency; uses local
resources (whatever is available in the
home or in stores)
— Cheaper
— Harder to gather data on, and prepare
statistics about
— Reaches more people; supply is local
and almost always available
— Treatment can begin at the first sign
of diarrhea; more preventive than
curative.
— Focus is on people and on education,
so the people's capacity for self-care
increases over the years (cost goes
down)
— May be less safe in individual cases
due to the possibility of errors in pre
paring or giving it, but it probably.
saves many more lives—since it
reaches more children more quickly.
— Helping Health Workers Learn
David Werner and Bill Bower
7
A to Z of Problem Drugs
(A check list of hazardous, banned, bannable and dumped drugs in India).
A = Analgin
Amidopyrin
is a potentially toxic drug and may cause agranulocytosis.
Fixed dose combinations (FDC) of any other category of drug
in oral dosage form are considered harmful.
was used as an analgesic anti-inflammatory agent for over 7
years.
. It has now been found to increase the risk of agranulocytosis
and in large doses to be associated with renal tabular necrosis
(Banned July 1983).
8
Ancoloxin
a widely used anti-nausea drug which is reported to have
teratogenic potential and hence is a hazard to pregnant women.
Sold in India without warning.
Anabolic Steroids
Synthetic derivatives of male sex hormone which have an
androgenic and anabolic (body building) effect. It is chiefly
indicated for treatment of senile and post-menopausal bone
disorders and a plastic anemia. In India it is advised for
malnutrition, appetite stimulant and for increasing growth. All
these are foolish especially in the light of irreversible harm it
can have on children's growth and sexual development. After
much publicity of these side effects, Cl BA Geigy has with
drawn Dianabol. one of the commonest. Many more prepara
tions continue to be marketed in India.
B = Bromides
On prolonged administration, they replace chloride ions in the
body, cumulative poisoning manifests as conjunctivitis, gastro
intestinal symptoms, dermatitis and mental disturbances. It
was a commonly used hypnotic of low potency but unreliable
(Banned in July 1983).
C = Chloral Hydrate
used as a hypnotic has found to be an irritant of the gastric
mucosa causing nausea, vomiting, flatulence and epigastric
distress. It can also cause hepatic or renal damage. It should
no longer be used as a hypnotic (Banned in July 1983).
Clioquinol
or hydroxyquinolines have been popularly used for prophylaxis
and treatment of gastro-enteritis amoebiasis and traveller's
diarrhoea. Ever since the report of its association with SMON
^subacute myelo-optic neuropathy) its use has been restricted
or banned in many countries. In India they are supposed to
be prescription drugs but are obtainable over the country. A
Medical Service
warning in English small print does occur on the product but
it hardly succeeds in warning consumers.
D = Dipyrone
is the sodium sulphonate of amidopyrines having similar pro
perties and adverse effects particularly fatal agranulocytosis.
The incidence and risk of this hazard far outweighs any benefit
that can be derived from its use.
E = DP Forte
these are high dose estrogen-progesterone combinations which
are dangerous for use in pregnant women because o f the as
sorted fetal malformation. In spite of the banning of produc
tion and sales of these drugs by the drug controller in March/
June 1983 these continue to be missued for hormonal
pregnancy tests and for induction of abortion.
Enzymes
A very wide range of enzymes preparations are available in
India as digestives and for specific conditions. Though by
themselves they are not harmful, their production in large
amounts along with tonics, vitamins and health restoratives are
an indication of our irrational drug policy at the cost of larger
social needs. These are mostly consumed by the relatively
well-fed urban population.
Ergot
is an alkaloid effective in the treatment of migraine. However
fixed dose combinations with drugs like paracetamol, pro
chlorperazine etc., have no therapeutic advantage and hence
are irrational (FDCs of ergot are banned in July 1983).
F == FDC or Fixed
Drug Combinations
These are formulations where two or more drugs are combined
for the following reasons : (a) synergistic action; (b) corrective
action; (c) two or more drugs normally prescribed together
and taken by patient simultaneously; d) when dosage of each
drug need not be individualised; e) where combination ensure
better patient compliance due to convenience of administration.
Conversely FDCs are irrational and should not be permitted if
(a) adverse interactions occur; b) when one of the combined
drugs becomes toxic on prolonged use (c) when abrupt with
drawal of one causes withdrawal symptoms; (d) if sub-thera
peutic doses are used in the absence of clinically demonstrable
synergism; (e) when pharmacokinetic behaviour of individual
agents is different. (22 FDCs were banned in July 1983—refer
Government order).
G = Gripe Water
These are popular preparations promoted for colic in children.
Contain alcohol and sodium bicarbonate. Chronic use of the
latter can cause milk-alkali syndrome. Uncomfortable but
October-November 1984 (Sppl)
9
rarely dangerous gastric distension can also occur. Despite
toxicity and side effects gripe water does a thriving business
through medical and consumer ignorance (Banned in Bangla
desh in June 1982).
H= Hydroxyquinolines
Hormonal Pregnancy
Tests
or halogenated oxyguinoline derivatives which include iodochlo-hydroxyquinoline, proxyquinoline, halquinol, diodohydroxyquino ine, chlorquinaldol, chiniofon). For hazard see clioquinol.
Oestrogen-progesterone combinations have been indiscrimina
tely used in pregnant women as a hormonal test to detect
pregnancy. (See EP Forte) Since there is an increased risk of
foetal abnormalities and the test is false positive in one out of
five women these tests should not longer be done. Drugs
controller had issued a directive to strengthen warning on
packages (March 1982) and banned manufacture (Dec. 1982)
and sale (June 1983). Due to legal controversy, and profes
sional and consumer ignorance it still continues to be used.
I = injections
have played a very important role in the modern medicine and
form one of its most distinctive features. However, it has also
lent itself to a very large degree of misuse-overuse because
of the mystique associated with it in the minds of the public
and the temptation of the medical practitioners to pander to this
need and pressure for their own economic gain.
J = Junk Drugs
these are newer formulations in the market whose only
additional values are cosmetic embellishments, added flavours,
elegant packing, irrational combinations—all of which help
to increase its cost.
K = Kaolin
is hydrated and purified aluminium silicate, a common addition
in antidiarrhoeal mixtures. Along with pectin and bismuth
salts it forms a group called adsorbents, astringents and bind
ing agents. These drugs may cause loss of electrolytes by
preventing absorption through gastrointestinal tracts. If at all,
they are of cosmetic value and may actually mash the severity
of disease.
L = Lomotil
or di phenoxylate and Loperamide are drugs whose risks of
treatment outwigh their benefits especially in children. They
are commonly used is diarrhoeas and the dangers of paralytic
ileus leading to inaccurate assessment of fluid loss and toxae
mia if associated with gut infections make them especially
dangerous in pediatric practice. The use for children under
10
Medical Service
six has been banned in India.
in banned altogether.
In most other countries its use
M = Methapyrilene
and its salts (Banned in July 1983)
N = Nialamide or Niamid
a MAO inhibitor used in the treatment of depressive disorders
(Banned in July 1983).
0 = OTC drugs
or over the counter drugs. These are drugs that are available
to consumers without prescription and are mainly painkillers,
anti-cold, anti-cough preparations, cough mixtures, tonics,
food substitutes and protein powders. Many of them are
costly compared to the benefits they render, have some ingre
dients which are unnecessary or useless but helping to push
up cost and are widely advertised with false claims to push up
sales. Their scientific scrutiny is a need as also a systematic
campaign against their irrational ingredients or claims.
Oxyphenbutazone
P =» Phenacetin
these are a group of non-steroidal antiinflammatory drugs
which also have mild antipyretic and analgesic properties.
The dangers associated with use are bone marrow toxicity and
liver toxicity. They are widely used/overused/misused group
of drugs and there is great need for building professional
awareness and consumer alert on this group of drugs. Recen
tly these drugs have been banned in the U.K.
was a commonly used analgesic/antipyretic agent which has
been reported to cause kidney damage and failure and hemo
lytic anemia. Hence fixed dose combinations containing it
are now considered outdated and hazardous. These have
been recommended for weeding out by the Hathi Committee.
Phenylbutazones
another group of non-sterodial antiinflammatory drugs which
give only symptomatic relief and in no way alter the course of
the illness. Its main indications are for ankylosing spondylitis
and rheumatoid and gouty arthritis though they are being
widely promoted and used for non-rheumatic disorders and
aches, pains and fever. Bone marrow toxicity is a real danger
with the use of this drug and hence its use should be severely
restricted. Its present availability—freely over the counter
should be drastically controlled and its deadly combinations
with amidopyrin, analgin, paracetamol, diazepam, vitamin B,
dextrapropoxyphene acetaminophen should be banned or
adequate warnings in labels instituted.
Practolol
(Banned in July 1983).
October-November 1984 (Suppl)
11
Penicillin
still an important constitutent of antibacterial therapy in spite
of the risk of anaphylactic reaction and allergic reactions.
(Its combination with sulphonamides and its preparations as
skin/eye ointments are banned from July 1983).
Q = Quinine
was the sheeti anchor of anti-malarial treatment till safer 4
aminoquinolines and 8 aminoquinolines were developed. Its
use leads to black water fever so is restricted now-a-days for
treatment of chl.oroquin resistant cases or sometimes in cereb
ral malaria.
R =. Rational Drug
Therapy
is the art/science of prescribing the best suited drugs to indi
viduals who need them taking and not to those who merely
want them. Its takes into account factors like efficiency,
safety (low incidence of side effects), cost and ease of admini
stration. It scruplously avoids extravagant prescribing over or
under prescribing, multiple prescribing or incorrect prescribing.
S = Sulphonamides
These have an important role to play in the therapy of infec
tions. The combination with penicillins is undesirable because
of the antagonism of antibacterial effect when bacteriostatic
and bacteriocidal drugs are given together. (FDCs of sulpho
namides and penicillins are banned since July 1983).
12
Streptomycin
Since it is one of the most effective drugs in anti-tb treatment
its use should be limited to TB treatment and mixed infections
of the gut. Its combinat’on .with penicillins is undesirable
since its use in small doses promotes development of resis
tance.
Steroids
one of the most misused drugs in general practice because of
acute onset of beneficial effects. Patients are exposed to a
wide range of toxic cumulative effects and adrenal insuffi
ciency due to adrenal suppression. Its a life saving drug to be
used in special circumstances. Their doses should be adjusted
to the minimum that can produce the effects. Fixed dose
combinations with other drugs are therefore irrational and
objectionable since this individualization of the dose cannot
be done. (FDCs of steroid for internal use except for treatment
of asthma are banned since July 1983).
Strychnine
This was a drug formerly used as an appetiser. Its use in
tonics can induce convulsions particularly in susceptible indi
viduals. An absolete drugl (FDCs of strychnine with caffeine,
yohimbine, testosterone and vitamins are banned since July
1983).
Medical Service
T = Tetracyclines
One of the most commonly misused/overused broad spectrum
antibiotic mistakenly thought to be free of dangers. Reports
of its ability to cause discolouration of teeth, catabolic effect
on protein synthesis, diarrhoea, increased intracranial pressure
in children, Fanconi syndrome (if outdated, degraded drug is
used), liver damage in pregnant women have put it in the list
of hazardous drugs. It should not be used in paediatric
practice and in pregnant mothers. its manufacture is supposed
to be banned from January 1982.
Tonics
Apart from being an economic waste, most tonics in the
market contain alcohol which is the main appetite stimulant
and also vitamin and mineral constituents in amounts greater
than the, physiological absorptive capacities of average GT
tracts. Their overuse thus mainly help to vitaminise our
sewage systems!
U = Unani and Ayurvedic
drugs
These are difficult to standardise since official standardisation
methods are not available FDCs of these with allopathic drugs
have no therapeutic rationale or justification or proven efficacy.
(FDCs of ayurvedic and unani drugs with modern drugs have
been banned since July 1983).
V — Vitamins
a typically misused/overused group of agents especially as
combinations and tonics. They are essential nutritional requi
rements but most people get adequate amounts in a balanced
diet. Specific and separate preparations are required for
specific di deficiency states or as adjuncts to therapy. (Their
FDCs with analgesics, tetracyclines, anti-inflammatory drugs,
tranquillisers have no proven therapeutic effects and have been
banned since July 1983).
is one of the brand leaders in the tonic market whose main
effects if any are because of the 9-10% alcohol content. It
contains insufficient amounts of iron and creosates and guaicols whose role in man has not been definitively established.
Like incremin, phosphomin, hemiphos their advertised claims
for surpass their actual chemical content. Advertisements of
such tonics are the most symbolic of high pressure, half truths
gimmicry of medical advertising.
W =Waterbury's
X=
Y == Yohimbine
a drug often combined with strychnine, vitamines, testoste
rone, arsenic, iron and vitamins has been found to penetrate
the CNS and cause centra excitation including rise of blood
pressure, heart rate, hyperexcitability and tremor (Its use
especially in such combinations is banned since July 1983).
Z =
(Contd. to page 20)
October-November 1984 (Suppl)
13
Prescribing Drugs
Questions to ask yourself before writing a prescription.
1.
Need
Is this drug really necessary ?
Is it being given to make the patient feel that something is
being done ?
2.
Aim
What aim is to be achieved by this drug ?
What disorder of function is to be corrected ?
What symptom/s have to be relieved ?
3.
Knowledge
What is the approved or generic name ?
What class does it belong to ?
What are its characteristics ?
Do I have the requisite experience or knowledge to use it ?
Have I weighed the potential toxic effects against the
benefit ?
4.
Route and Dosage
By what route, in what dose and at what intervals is the drug
to be given and why ? In what form/s does the drug come ?
5.
Alternatives
Have I selected the best agent available for this particular
purpose ?
What other remedies might have been chosen ?
How do these compare in efficacy, safety, cost ?
6.
Duration
For what period of time, days, weeks or months will it be
advisable to continue therapy ?
When and how could a decision be made to stop ?
7.
Observations
What observations can be made to judge whether the aim has
been achieved ?
When should they be made and by whom ?
What laboratory investigation if any would help in this
assessment ?
8.
Elimination
How is. the drug eliminated ?
Will the patients illness change the usual pattern of distri
bution, effects or elimination of the drug ?
9.
Unwanted effects
What are the side effects or toxic effects of the drug ?
Are they acceptable ?
How frequent are they ?
How can they be modified/managed ?
14
Medical Service
Precautions
10.
Have I checked for the following :
a.
possible allergic risks
b.
possible idiosyncratic reactions
c.
patients drug diet which may interfere with the drug
What precautions can I take to ensure continuation of therapy.
Are there any conditions in which this drug is contraindicated ?
Are these 'absolute' or 'relative' ?
Are there any drugs which should be avoided when the
patient takes this treatment ?
Which and why ?
11.
Contraindications
12.
Patients point of view What does the patient believe about the drug ?
What has he been told about it ?
And what has he remembered ?
Does he need additional information ?
13.
Patient reliability
Does his relative need additional information ?
Is the patient reliable for this type of therapy ?
Will he need/get proper supervision by relatives or attendants ?
14.
Cost
Is the drug the cheapest drug of that type ?
If not could a cheaper drug do the job as well ?
15.
Finally is there anything else I need to know about this drug ?
Adapted from :
i.
A Herxheimer:
The Lancet II 1186-1187, 27th Nov 1976
ii.
Formulary and Therapeutic guide—Kurji Holy Family Hospital
Hi.
Prescribing drugs — MNAMS Handout, Dept of Pharmacology, St John's Medical
College, Bangalore
October-November 1984 (Suppl)
What Can We Do ?
1.
Educate ourselves
We should make an effort to avail ourselves of all the
available materials on drugs.
We should purchase some of the books and subscribe to some
of the journals and bulletins mentioned in 'widening
horizons' to keep ourselves upto date.
2.
Share and
Disseminate
information
We should circulate all the information and resources to all
our staff and to other colleagues and centres through all
possible channels of communication. We could share our
own initiatives and experiences.
3.
Adopt essential
drug list
We should draw up an essential list for our institution in
which cost, efficacy, safety and quality will be important
criteria (refer to WHO's suggested list)
We could purchase and stock drugs in accordance with this
list.
4.
Adopt generic
We could use/adopt the generic drug concept during pur- ■ j
chasing, prescribing or dispensing drugs.
5.
Stop Irrational
prescribing
Could stop prescribing drugs whose only advertised values
are :—
a.
cosmetic embellishments
b. elegant packing
c.
irrational combinations
d.
imitative drugs
e.
inadequate evidence of greater value
We could weed out 'banned drugs' as well as restricted
drugs.
We could stop 'injection and tonic' practice.
6.
Avoid Drug
industry Linkages
We could refuse to take gifs and physician samples
We could avoid allowing drug companies to sponsor events/
meetings
We could beware of unethical trade discounts or other forms
of inducement
7.
16
Adopt Rational :
Drug Purchase
We could adopt bulk purchasing
Support cooperative purchasing or production endeavours
Produce drugs in your hospitals,'dispensaries.
Medical Service
Learning io use antibiotics wisely
nous) antibiotic.
However, it is
usually not dangerous to give higher
doses of an antibiotic that is not
poisonous (penicillin or ampicillion).
Tetracycline becomes more poison
ous when old. It should never be
used beyond the expiration date or
in more than the recommended dose.
First guidelines
1.
Use an antibiotic that kills bacteria
rather than one that just slows them
down. This usually gives quicker
results, and prevents the infection
from becoming resistant to treatment.
2.
Use an antibiotic that causes fewer
side effects and is less risky. For
example, if the person is not allergic,
it is safer to use penicillin or ampicil
lin rather than an antibiotic like
erythromycin that can cause poison
ing.
3.
4.
When possible, use a narrow-range
antibiotic that attacks the specific
infection rather that one that attacks
many kinds of bacteria. Broad-range
antibiotics cause more problems—
especially diarrhoea and thrush—be
cause they attack good bacteria along
with the bad. The good bacteria
prevent the growth of harmful things
like moniliasis (fungus that can
cause diarrhoea, thrush, etc.)
Use a broad-range antibiotic only
when no other will work, or when
several kinds of bacteria may be
causing the infection (as with infec
tions of the gut, peritonitis, appendi
citis, some urinary infections, etc.)
7.
Do not use an antibiotic that slows
down bacteria together with an anti
biotic that kills them. The combina
tion is often less effective than one
alone. (Once the bacteria are captur
ed or slowed, they stay hidden where
the other-antibiotics cannot kill them).
For example, never use tetracycline
in combination with chloramphenicol.
8.
Whenever possible, avoid using a
toxic medicine for a person with
diarrhoea or dehydration. A dehy
drated person's body cannot get rid
of poisons as quickly in the urine.
Even normal doses of a toxic medicine
may build up and poison the person.
(Sulfas are especially riskly for treat
ing diarrhoea. Unless the person is
making a lot of urine, sulfa can form
crystals in the kidneys and cause
damage).
9.
Do not use toxic medicines during
pregnancy—especially during the first
three months. Some medicines can
cause severe birth defects.
10.
Use a medicine the family can afford.
When choosing between medicines,
always consider the relative cost, and
weigh this with other advantages
and disadvantages.
Additional guidelines
18
5.
Use antibiotics only for bacterial
infections. Do not use them for
viral infections, because antibiotics
do nothing against viruses (common
cold, measles, chicken pox etc.)
6.
Be careful to give more than the
recommended dose of a toxic (poiso-
—Helping Health Workers Learn
David Werner and Bill Bower
Medical Service
Seven Steps to success in essential drugs supply
“Essentia! drugs at
hose that
satisfy the health care needs of the
majority of the people. They should,
therefore, be available at all times in
adequate amounts and in the appro
priate dosage forms/'
(1)
National Drug Policy
Every country's comprehensive health.
Policy should include a National Policy on
Essential Drugs. WHO's role is to inform
governments about the basic concept and
the benefits, then to provide technical support
for policy formulation,, selection of essential
drugs, a plan of action, procurement, quality
control, programme management and aspects
such as training, evaluation and legislation.
A national essential drug policy can provide
more drugs to more people at the same cost
or even less.
(2)
Selection of Essential Drugs
Essential drugs are those that satisfy the
health care needs of the majority of the
population. Selections are based of the
most common local disease and conditions
and on the capability of the health care sys
tem. More than 80 countries have now adop
ted lists of essential drugs based on WHO’s
Model List of Essential Drugs, as have various
non*governmental
organizations and UN
agencies.
(3)
Drug Procurement
All too often countries pay more than they
need for their drugs. They can get better
value for money by putting out bulk orders
to international competitive tender on the
world market. UNICEF and WHO help
countries to strengthen their procurement
October-November 1984 (Suppl)
systems and to secure, if necessary and
possible, reliable financing—internal or exter
nal—for their purchase.
4.
Logistics of Supply
WHO's goal is to make sure that people
can get the 20 most needed essential drugs
whenever they require them, within an hour's
travel. The supply chain must work; correct
ordering, packing and storage; less waste
through deterioration, loss or theft, regular
transport to the remotest dispensary despite
climatic and geographical conditions or fuel
shortage. Several countries have established
efficient drug supply management systems
with support from WHO, UNICEF and bilate
ral agencies. The pharmaceutical industry
also provides expertise.
(5)
Proper Use of Drugs
Both health professionals and the general
public are in need of better information and
education about when and how to use drugs.
Common problems are that the former tend
to overprescribe while the latter may fail to
follow the prescribers instructions or dose
themselves. Drug information sheets are
being considered by WHO that would give
the indications, contra-indications and side
effects of essential drugs. Several countries
have produced their own therapeutic guides
and standard treatment schedules for use by
health workers. Consumer groups do valu
able work among and on behalf of the
general public.
(6)
Quality Control
Essential drugs must be of reliable quality
as well as efficacious and safe. Quality has
to be assured upto the time that the drugs
19
are administrated by good manufacturing
practices and by monitoring of products at
all stages in the supply line. The IFPMA
member companies provide training in quality
control for nationals of developing countries.
Any country lacking quality control laborato
ries can obtain an assurance of the quality
of imported products at the time of export
through the WHO certification scheme on the
quality of pharmaceutical products moving in
international commerce.
Training
(7)
formulation, selection, procurement, manage
ment and use of drugs, in drug legislation
and regulatory control and in production and
quality control. WHO is approaching univer
sities, training schools, non-governmental
organizations and the pharmaceutical industry
for help with training materials and courses.
At seminars and workshops, countries that
have developed successful national essential
drugs programmes demonstrate to others
"how it's done".
Many countries lack staff trained in policy
from World Health, July 1984
(Contd. from page 13}
Further Reading
1.
Banned Brand Drug List
2.
Hazardous Banned Bannable and Dumped Drugs
3.
Rationality in Banning Fixed Dose Combinations
4.
Some painful facts about a pain killer called Amidopyrine
5.
Why not to prescribe anabolic steroids ?
6.
Irrational use of antibiotics
7.
The clioquinol controversy
8.
Using tetracyclines for children and pregnant women
9.
Consumer Altert-Phenylbutazone and Oxyphenbutazone
10.
Scientific scrutiny of some over the counter drugs
11.
The case against EP Forte
12.
National Drug Policy guidelines and list of banned drugs (Bangladesh)
Available from Low Cost Drugs and Rational Therapeutic Cell, Voluntary Health
Association of India, C-14 Community Centre, SDA, New Delhi 110016.
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Medical Service
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