MEDICAL SERVICE VOL. 41 No. 10 DECEMBER-1984.pdf
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significance of the theme • 41st national convention and workshop—
general report • welcome speech by the president chai • theme presentation
and convention highlights • towards a people-oriented drug policy •
professionals in the church—an introspection
vol 41
no 10
december 1984
official house journal
of the catholic
hospital association of India
medical
service
“the love of Christ
urges us" 2 cor 5 :14
vol 41
no 10
editorial board
december 1984
contents
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
1
editorial
2
2
significance of the theme
3
3
41st national convention and workshop
general report
fr edwin mi
4
5
editor
fr john vattamattom svd
6
welcome speech by rev dr ferdinand kayavil
(president, chai)
17
theme presentation and convention highlights
fr john vattamattom svd
23
concluding speech by rev dr ferdinand kayavil
(president, chai)
7
8
9
printed at kalpana printing
house new delhi-110016
41
towards a people oriented drug policy—what
can be done at the pharmacy level
al an crammer
published by the catholic
hospital association of india
c b c i centre, goldakkhana
new delhi-110001
27
professionals in the church-an introspection
dr george joseph
p m isaac bangalore
26
towards a people oriented drug policy
dr c m francis
cover design
9
47
“Articles and statements published in this journal
do not necessarily reflect the policies and views of
the catholic hospital association of India*'
EDITORIAL
Towards a people oriented drug policy
The 4 i st Annual Convention of the Catholic Hospital Association of India held
in Bangalore from 23rd to- 26th November 1984 had a special characteristic i.e. the
two day workshop on "tcwarde a people oriented drug policy". This issue of our
jtfwrwl
bringing ruit an -.account of what has taken place during those days. Due to
shwagefc-df'ispaoa w® CTdd. ^cz accommodate on account of everything that has
5ai0g^^ dJnrng:tlicB5®
/Va hope to complete it in the next issue.*
□/:.t..,V»..;-rrancfS(Dt/ailc'B gave the key-note address on the theme on
urrnaz, 22£th Jcnvember. Hfe
the participants a very exhaustive picture of the
isstor. rr own csQimtry. ^nvaris zr& end of his presentation dealing with other
omss haxL:rcnnt£Ute tc health an il'.z&azr... he touched upon chemicals in the environXt pesticides re sa'td "There are an estimated 375000 cases of
rmnr^
pesticide ir- developing countries every year with some 10,000
nurmir
kiSEk-ET ECCEerr m ttlE TODH IT 5U"3i w kers is an additional factor that makes
proud to be the largest manufacturer
tinsel tnemrucHs e*£SF rrjcre Gangemis, indra
a and Africa, with *a licenced capacity
uf xnssrnriuiiji sramtiosis rr the vrrwee ir Stmts ?
ct know". This statement of Dr. C.M.
□f
: r ccL c- numar. heatir. e
S days after that came the biggest
^finnrs&camH< is ttxeugr• as- a cce-nujnniaT., E
city of Bhopal, whose
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ive pointed out during
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Significance of the Theme
The Workshop is to help participants
understand the issues relevant to drug
prescribing, durg distribution and pharmacy
policy in our institutions in the context of the
ICMR/ICSSR warning and to challenge them
to participate in the growing national
response to the problem.
What does the 'abundance of drugs'
mean 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 humanity at
large ? Do they have essential and life
saving drugs at their reach within a price
range they can afford ?
Is our drug policy today more professionoriented, drug industry-oriented rather than
patient-oriented ? Whose interests are we
serving in our institutions ?
How can we move towards a more
people and patient-oriented drug policy ?
These are some of the Questions
which we shall respond to in our Workshop.
2.
To Create an Awareness of
Irrational use, over use and misuse of
drugs by health personnel.
3.
To Discover
The Social, economic, political, cultural
and other factors responsible for this
problem.
4.
To Discover
How all of us are part of the problem at
a personal level.
5.
To Consider
The various responses at national/regional
levels in the areas of:—consumer awareness
and people's movements; continuing profes
sional education; pressure group on policy
makers; search for low cost alternatives;
individual/group action; institutional policy
changes.
6.
To Discover
Ways and means by which we can
respond to this situation at individual,
institutional and regional/national levels.
Programme Highlights
Sessions on :
Objectives
1.
To Create an Awareness of
The health situation in India, the role of
drugs in health care, the pattern of drug
production in India vis-a-vis the people's
health needs, the dynamic of the drug
industry, the pattern of drug distribution
and availability in the health system, the
national drug policies and laws.
December 1984
Understanding the problem
Drugs and the healing ministry
Towards rational therapeutics
What to do to tackle the problem
Some initiatives in the country
The people's medicine
Group discussions on :
What/Why the problem in our health
institutions ?
What can we do to tackle this problem ?
3
Liturgy .
Reflecting on our calling and the faith
dimension of our response.
The Ten Commandments of the Drug
Industry—Augustine Veliyath (Full text will
be published later)
1.
Exhibition on :
2.
Socio-political dimensions Health and
Drugs
Rational Drug Therapy
Home remedies and Herbal medicines
Studies on :
Drugs for a Community Health Center
Understanding the injection/tonic culture
Use/misuse of drugs in surgery
Drug situation in small rural hospitals
Cost of treatment
Cultural Programme
Understanding the problem from the poor
man's point of view.
Synopsis of Papers
Drugs for Primary Health Care
C M Francis (Full text in this issue)
An integral part of our commitment to
primary health care is the provision of
essential drugs to all those who need them,
in adequate quantity and quality and at
affordable prices wherever the person is.
The various aspects of the drug problem
needing our attention include production,
what drugs are required, choice of drugs.
National Drug Policy, selection of drugs,
drug production and procurement, logistics
of supply, quality control, regulating the
drug trade, drugs for immunization, drugs for
cure, drugs for symptomatic relief, search for
new drugs, drug information and the need
for evaluation of the efficacy of primary
health care including drugs.
December 1984
3.
4.
5.
Thou shalt have tens of thousands of
drugs
Thou shalt not question the price of
a drug
Thou shalt not tamper with nature's
garden
Thou shalt respect they doctor more
than thyself
Thou shalt betray the people and the
nation for petty rewards
6.
Thou shalt not covet, court, or
subscribe to any other system of
medicine
7. Thou shalt never reveal company
secrets
8. Thou shalt first seek remedies for
fashionable ailments
9. Thou shalt be a dumping ground for
banned drugs
10. Thou shalt be a guinea pig for new
and untried drugs.
The Ethics of Prescribing
George Lobo, sj (Full text was already
published in Oct.-Nov. issue)
Discusses reasons for the unfortunate
situation related to drugs prevalent today,
viz., technological model of health care
leading to manipulation of the patient,
search and demand for instantaneous cure
of symptoms, mystification of medicine,
profit motive and 'free enterpirse' of the
pharmaceutical industry, a deep rooted
cultural alienation from the people, exploita
tion of dependent developing countries,
decreasing emphasis being given to preven
tive medicine and other systems of medicine.
The use of drugs should be regulated by
the principles of totality (overall good of the
5
patient) and of double effect (the good
effect overriding any harmful effect). It
suggests remedies for the development of
a person-centred and holistic approach to
health care.
Professionals in the Church—an intro
spections*—George Joseph (Full text in
this issue)
Serious questions have been raised about
the institutional witness of the church in
India, particularly its relevance in the social
context of today. In the case of the Healing
Ministry there is urgent need to critically
look at our priorities and commitment and
our style of functioning in the light of the
gospel. The role of the professionals have
to be reassessed as part of an overall effort
to bring back the true spirit of 'Diakonia'
into this ministry.
It is taking of a conscious decision to
boycott certain drugs and use others only
when needed. It means prescription with
awareness, to avoid as far as possible—
iatrogenesis (drug induced problems, drug
interactions, adverse drug reactions and
emerging drug resistance).
It is understanding the role of drugs and
rational drug therapy in the emerging health
movement.
What can be done at
Management of Pha macy Services
include involving the users of the
service; the Pharmacy Committee—
its constitution and functions, viz.,
implementation of hospital policy,
selection of medicines, sources of
medicines, cost versus quality, basic
drugs and formulations, medicines
banned in India and abroad, medi
cines from other systems; stock
control; prescribing discipline and
pharmacy discipline.
(b)
Good dispensing services involve
need for good professional service to
patients, proper presentation of
patient's medicines, preparation of
medicines in the pharmacy compared
to purchase, medicines in the phar
macy and at clinic level.
(c)
Relationships with suppliers, i.e.,
with representatives in the pharmacy
and an assessment of products
offered and their sources.
(d)
Educational
requirements—basic
courses, legal requirement, course
content, continuing education for
pharmacists.
(e)
Relationships with hospital colleagues.
What is Rational Drug Therapy ?—Mira
Shiva (Full text will be published later on)
It emphasises selective use of drugs
based on essentiality, efficacy, safety, easy
availability, easy administration, quality
drugs preferably of indigenous production.
Rational Drug Therapy recognizes the
concept of essential drugs and the concept
of graded essential drug lists for different
levels of health personnel. It recognizes the
right of health personnel and consumers to
drug information and its effective communi
cation.
6
pharmacy
(a)
The whole issue regarding the need for
evolving a 'rational drug policy' has to be
seen in this- perspective.
Rational drug therapy means practice of
socially conscious, relevant, concerned and
yet scientifically sound medicine. It recog
nizes the non-role of drugs in certain
conditions, the role of alternative systems of
medicine and recognizes the limitations of
Western Medicine in our social context.
a
level—Alan Cranmer (Full text in this issue)
Medical Service
Initiatives in the Country
1. Arogya Dakshata Mandat, Pune, has
been raising awareness about drug related
issues among medical professionals and the
lay public since the past 8 years. They
publish a monthly—'Pune Journal
of
Continuing Health Education'— on drug
issues and are also bringing out a book
'Rational Drug Therapy' in December 1984.
They launched a movement called
'Operation
Medicine' in
1977 against
irrational, prescription of vitamins, tonics and
tinned foods.
- 2. AU India Drug Action Network :
A number of groups have been working in
the field of drug related issues at various
levels during the past 3-4 years. They have
been in contact with each other and have
been working informally together sharing
information, putting forward a memorandum
(demanding a Rational Drug Policy), partici
pating
in campaigns,
lobbying with
government etc. In August 1984, they left
the need to have a more organised base and
have formed the All India Drug Action
Network. CHAI is also a member of the
Network.
3. Lok Vigyan Sanghatanat Maharashtra
or the People's Science Movement have
launched campaigns about anaemia and
irrational anti-anaemia drug preparations and
also about over the counter drugs. They
organize jathas, hold district/town seminars,
write in the mass media etc.
4. Kerala Sastra Sahitya Parishad, is a
voluntary
non-government
organisation
consisting of scientists, doctors, engineers,
social scientists, teachers, students, workers,
peasants, technicians who are committed to
popularising science and channelising it for
social revolution. The KSSP has recently
decided to take up the Drug issue and
December 1984
initiate a big campaign to expose the anti
people and exploitative tactics of the
Multinational
Drug
Companies.
The
questions of essential versus non-essential
and dangerous drugs, the inadequacy of
drug safety control measures, the rising
prices of life saving drugs and the non
implementation of the Hathi Committee
recommendations are the highlights of the
programme.
5. LOCOST, or Low Cost Standard Ther
apeutics is a collective voluntary enterprise
for rational therapeutics. LOCOST aims to
promote low cost, scientifically tested
medicine under generic names. LOCOST is
a response to a growing demand and
challenge of the voluntary health sector to
meet the needs of the deprived sectors of
the society for not only low priced but also
good quality medicine. LOCOST includes
procurement, quality testing and control,
distribution and educational efforts, „ and is
located in Gujarat. *
6. Bangarapet Mission Tablet Industry,
in Karnataka is a successful small scale
venture providing low cost, good quality
formulations to some mission hospitals in
the country.
7. Low Cost drugs and Rational Ther
apeutics Cell of the Voluntary Health
Association of India, New Delhi, has been
instrumental in bringing together various
groups in India on the issue of drugs. They
have been providing informational backing to
these groups, organizing meetings, informally
coordinating some actions etc.
8. Medico Friends Circle, is a group of
socially conscious individuals, interested in
the health problems of our people. Through
their monthly bulletin, they discuss drug
issues among others. They have formed a
Rational Drug Policy Cell and have launched
a campaign on antidiarrhoea Is.
7
9. The Kurji Holy Family
Hospital
Formulary, is the result of the accumulated
experience of the hospital over the last
10 years. It gives a comprehensive, list of
drugs to treat 98% of the hospital admis
sions. It also gives the generic name,
dosage, indications, contra-indications and
side effects of these drugs. Information
about comparative cost of treatment is also
provided.
10. State Forums, During the past year
drug action forums have been active in
Andhra Pradesh and West Bengal. Drug
Action forums are also being initiated in
Gujarat and Orissa.
11
The Pharmacology Department of
the Post-Graduate Institute of Medical
Education and Research,
Chandigarh,
provide unbiased technical information on
drugs and therapeutics through a monthly
publication 'The Drugs Bulletin'.
12.
Others, The following organizations
have also been involved in drug related
issues and are part of the All India Drug
Action Network :
Consumer guidance Society of India,
Bombay
Consumer Education Research Centre,
Ahmedabad
Federation of Medical Representatives
Association of India
Health Services Association, Calcutta
Delhi Science Forum, New Delhi
People's Participation in Science and
Technology, Madras/Bangalore
Centre for Science and Environment,
Delhi
Centre of Social Medicine and Commu
nity Health, J N University, New Delhi
What we can do ?
— Support them
— Join them
— Keep them informed about what you
are doing
CHAI—CORPUS FUND
Towards its self-reliance programme, CHAI has started a Corpus Fund. Donations, big or
small, are requested towards this Fund. It should be remembered that donations made to
CHAI will be exempted from income tax as per section 80G of the Income Tax Act 1961.
Please send your donations to CHAI-Corpus Fund only.
—Executive Director, CHAI
President CHAI, Dr. Ferdinand Kayavil
inaugurating the CHAI-Corpus Fund
by handing over a cheque to Fr.
John Vattamattom SVD, Executive
Director, CHAI at Benziger Hospital,
Quilon, Kerala.
41st National Convention and Workshop
St. John's Medical College, Bangalore 23-26, Nov. 1984
Theme : "Towards a people oriented drug policy"
General Report
[It is customary that the issue of the
journal Medical Service following the con
vention contains the convention proceedings.
This is the only way that the proceedings can
reach every member institution as it is possi
ble or feasible for every institution to send
delegates to the annual convention. I appeal
to all to go through it seriously and make
definite plan of action for your own institu
tion along the lines proposed in the work
shop on the theme. —Editor]
The concept of convention in our mind
was always linked with the exhibition and
the 'glamour' connected with that. Though
it was decided last year that we will not have
convention every year, what was meant by
that was* we will not have the usual exhibi
tion etc. However, the annual general body
meeting or convention as it was called in the
beginning is a constitutional requirement.
This year's convention in a sense was a
follow up of last year's. This year's theme
and the workshop on it was a concrete follow
up of "Respect-Life". After this year's con
vention many a participant made the remark
"now we find meaning in CHAI convention*'.
Let us hope that we will be able to keep up
this spirit by giving more importance to
essentials than accidentalsjn the future.
It was after 11 years we had a convention
in Bangalore. As usual a local committee
was in action since quite few months. If
popular opinion is an indication again this
years convention was a great success. But
December 1984
the success of a convention should be
measured not by what happened during the
convention days, though that is also impor
tant, but by what is going to happen in all
our institutions, following the convention.
Let us hope and pray that this year's conven
tion will be a success in the real sense as
mentioned above. In spite of the fact that
this year there was no exhibition connected
with the convention, a factor that usually
attracted the crowd, the participation was
beyond our expectation. There were more
than 500 participants for the workhop, inclu
ding local participants. These came again
from all over the country including far and
remote areas of Assam. By morning of
November 23rd, St. John's Medical College
premises were full of delegates to CHAI con
vention, mainly sisters.
A concelebrated Eucharistic Sacrifice
headed by Archbishop P. Arokiaswamy of
Bangalore, at 3.00 p m. under a beautifully
arranged vast "Shamiana'’ (Pandal) marked
the beginning of the convention. Also pre
sent for the concelebration were Bishop
Gilbert Rego of Simla-Chandigarh 'and
Ecclesiastical advisor to CHAI, Bp. Abrose
Yeddanapalli of Beliary and several other
priests. The entire liturgy was prepared
based on the theme, organised and sung bea
utifully by the Franciscan Friars under the
direction of Fr. Sydney Mascarenhas, not only
for the inaugural day, but also for all the
days of the convention.
9
Archbishop P Arokiaswamy in his homily
during the Mass emphasised the need for
taking care of the sick unconditionally. Exp
laining the parable of the Good Samaritan, he
urged all health care personnel to serve the
sick with christ like love and commitem ent.
After the Eucharistic celebration tea and
snacks were served to all the participants
and guests.
Then followed the inaugural session at
5.30 p.m. Dr. Thimme Gawda, Minister for
Health, Government of Karnataka was the
Chief Guest. Meeting started with a beautiful
invocation song by "Janadhare" a cultural
troupe of twentyfive youngsters who are a
talented lot and socially involved. Bp. Gil
bert Rego, the Ecclesiastical advisor to CHAI
presided over the function. Dr. G.M. Mascarenhas, Dean, St. John's Medical College,
Bangalore accorded a warm welcome to the
Chief Guests and the delegates to Bangalore
and particularly to St. John's. He welcomed
the Chief Guest Dr. H.L. Thimme Gawda in a
special way to the function and to St.
John's. Thereupon Fr. Ferdinand Kayavil,
the president of CHAI welcomed everyone
and introduced the Chief Guests. In this
welcome address he emphasised the need
for bringing drugs within the reach of the
poor where it is not today. The full text of
his welcome address is printed separately.
Thereafter the inaugural address was
given by the Chief Guest, Dr. H.L. Thimma
Gawda, Minister for Health, Government of
Karnataka. He appealed to the doctors in
the State to desist from over prescribing
drug as it could prove to be dangerous for
the patients in the long run. He lamented
that over prescribing had become a fashion
for most doctors as was the prescription of
'glamorous' and expensive drugs. The minis
ter lauded the services rendered by the
Catholic Hospitals which were far superior to
those in other hospitals. He also lauded the
December 1984
dedicated services of the sisters and others
in Christian Hospitals.
The theme and convention highlights were
then presented by Fr. John Vattamattom
SVD, Executive Director, CHAI. He em
phasised the need for working towards a
people oriented drug policy and taking up
this challenge by all concerned. (Cf. the full
text).
Bp. Gilbert Rego, ecclesiatical advisor to
CHAI, in his inaugural address expressed his
happiness to be present for the workshop
which he felt would be most valuable and
relevant in the realm of medical profession,
especially in the context of the health ser
vices of the Church which are primarily to
respond to the needs of the poor. He con
gratulated CHAI for taking this bold step
and wished the workshop and convention
every success.
The next item in the agenda was the
inauguration of the exhibition by Mr. J. Alex
ander, IAS, Excise Commissioner, Govern
ment of Karnataka, who is a good friend of
CHAI. This was another speciality of this
years convention. The exhibition was not of
the usual type, but pertaining to the theme.
Presented by means of charts, drawings etc.
The exhibition had 3 parts i.e, that which
pertaining to the theme prepared by Drs.
Ravi & Thelma Narayan and their team; per
taining to the Herbal Medicines prepared by
Fr. Joseph Chittqor and Sr. Innocent from
Gudalore diocese of Mananthavady; and pertarning to the analysis of the present health
care system by Fr. Chacko Paruvanani and
his adult education team from Berhampur,
Orissa. The exhibition wes very informative,
enlightening and thought provoking and
most of the participants benefited much from
it.
After the inauguration of the exhibition
there followed the cultural programme, again
11
based on the theme, by Janadhare. . Through
a play depicting the present health care
system and the plight of the poor people in
it, and through songs etc. the group
was able to make the participants aware of
the gravity of the problem in the system of
health care. A powerful message was put
across by this simple means.
The inaugural function and the day’s pro
gramme were over with Fr. Joseph Kavalipadan, Vice President of CHAI proposing the
vote of thanks'.
Workshop
On the first day of the workshop, 24th
November 1984, the first session on 'Under
standing the Problem', was chaired by Prof.
S.V. Rama Rao, formerly head of Community
Medicine department at St. John's Medical
College.
Dr. C.M. Francis, Coordinator,
Continuing Medical Education, Christian
Medical College, Vellore, introduced the
theme by giving a comprehensive coverage
of the theme in his paper. He mentioned
about the Hathi Committee report, which
recommended 116 drug formulation as
essential ones for the Indian situation in the
place of 30,000 different drug formulations
available in the country today. He drew the
attention of the participants to the initiatives
made by various organizations to combat the
exploitation of the drug industrialists.
Domestic production of drugs in the place
of imports at exorbitantly high rates, effective
price control measures, promotion of man
research, promotion of drugs in the Indian
system, effective monitoring and standardiz
ing, making available essential drugs at
affordable prices, tax exemption of vital
drugs, production by generic names, exploita
tion of the public by advertisements, the
doctor-drug producer axis that exploits the
people, etc. were some of the areas touched
in the paper. The solution for the ill-health
12
of the India masses is basically linked with
the unjust distribution pattern which makes
people poor and denies enough food, safe
drinking water and healthy living conditions.
Smoking and alcoholism makes the situation
worse. Massive pollution of the water and
air by chemical plants, especially pesticide
factories erodes the health of the public.
All these too are certain areas of vital
concern.
This was followed by a paper presented
by Mr. Augustine Veliyath of Voluntary
Health Association of India, New Delhi.
Through his presentation of the 'Ten Com' mandments of the Drug Industry' he exposed
to the participants the exploitative practices
followed by the drug industrialists to
maximize the profits at the cost of the life of
the people. The third world countries give
the grave picture of being the dumping
ground for banned and hazardous drugs.
People of the poor countries are compelled
to pay high prices for essential drugs which
are available in rearer as compared with
tonics and vitamin formulations. Doctors,
through over prescribing, lack of under
standable communication with patients, and
through prescription patterns that are not at
all in keeping with economic situation of the
people, become part of drug issue and
generally they make themselves fit for
making profits for the drug industrialistsmultinationals and large scale domestic
producers. This part of the paper was
presented quite sarcastically and strikingly
as 'Ten diseases of doctors'.
Now it came to the second session of the
forenoon, 'Drugs and the Healing Ministry',
which was presided over by Bishop Gilbert
Rego. A paper on 'Ethics of prescribing'
was presented by Fr. George Lobo of Papal
Seminary, Pune. While making his presen
tation he mentioned about the attitude of
the people in taking medicines and situated
Medical Service
this in the context of the capitalistic and
consumer oriented values. This acts counter
to the health of the people. It makes the
health care dear and unapproachable to the
underprivileged masses. Widespread conscientization is the only answer to the
existing pattern of overprescribing and over
use of drugs which is coupled with an
attitude of the public to support these
unethical practices.
Prof. George Joseph, Executive Director,
CSI Council for the Healing Ministry, Madras,
made a presentation on 'Professionals in the
Church—an introspection'. He raised the
basic question—why we are involved in
health services ! ? Definitely the answer
would be to serve the least of the brothern
in whose face we should see Christ. But in
concern of time where have we landed up :
Through his paper he tried to help the
participants to pose these question against
themselves and make an effort to rededicate
and commit themselves to the actual cause
for which we initiated our health services.
Before the afternoon session there was
Eucharistic celebration. The liturgy for the
mass was also selected to be in line with
the theme discussed on the day. This was
the practice followed each day.
The afternoon session started with small
group discussion—the participants were
divided into 15 groups with 4-5 facilitators
distributed in each. The group discussion
was an attempt to develop more under
standing about the problem in the light of
the paper presented and identifying the
different dimensions of the same in ones
own hospitals and dispensaries and thinking
about each ones responsibility as persons,
professionals and institutions in the creation
of this problem. Each group prepared its
own reports of the discussion, and putting
together and consolidating, one common
paper was prepared at the close of the day.
December 1984
This was done by all the representatives of
the 15 groups together.
The next session during the afternoon
was on 'Towards Rational Therapeutics'.
Dr. Prem Pais, Physician of St. Marthas
Hospital, Bangalore presided over. A group
of interns and students of St. John's
Medical College had made 4 studies in the
city and outskirts of Bangalore to asses how
our hospitals and dispensaries are part of
the problem of drug issue, and how they
could come up to life above and contain
the issue, giving practical concrete sugges
tions. Thus, Dr. Navin Machado, Dr. Srinath,
Dr. Ravindran and Mr. A.J. Perumpanani
presented their studies. Dr. Ravi. Narayan
gave the summary and conclusion of all these
four studies. He then spent sometime on
rational therapeutics. He explained that
rational therapy is a dynamic concept based
on our any local situations. He reminded
that effectiveness, availability, and accessibi
lity and acceptance to the medicine should
be certain words while prescribing a
medicine. Most important of all it should be
affordable by the patient. Extravagant, over
prescribing, in-correct prescribing, multiple
prescriptions, under prescribing and useless
prescribing (of medicines whose expiry date1
is over) are certain thrusts to rational
therapeutics. He shared certain criteria for
rational therapy—it starts from a good
diagnosis, prescribing the efficient, safest
and lowcost medicine which is easiest to
administer, educating the use of the medicine
with an interest to follow up the prescription,
and educating patient and the preventive
steps for remaining healthy. The influence
of the drug company should never play a
role while prescribing and it should be the
independent decision of the medical practi
tioner.
In the evening there was a cultural
programme presented by the students of
Jyothi Nivas College, Bangalore.
13
If the thrust of the first day's session was
attempts to understand the problem the
second day, 25th November 1984 dealt with
'•What to do to tackle the problem?*’ Dr.
George Joseph chaired the first session.
Mr. Alan Cranmer, CMAI consultant Phar
macist, Mysore, shared with the group
what could be done at the pharmacy level
towards purchasing, stocking and administring of drugs. It starts right from following
a rational purchasing policy to giving medi
cines to the patients against prescriptions.
Dr. Quasem Chowdhary of Gona Swasthya
Kendra project of Bangladesh shared briefly
the progressive and rational policy adapted
by the government of Bangladesh to curb
the unethical and exploitative production
practices of huge companies and the,
unchecked import of bulk medicines. He
mentioned how a voluntary* organization as
Gonaswasthya Kendra was instrumental in
pressurising even a military government to
come out with a progressive policy control
ling and standardizing drug production and
how the Kendra is now actively involved in
the production of essential drugs at consider
ably low cost.
During the next session presided over by
>Dr. Daniel Isacc, General Secretary, Christian
Medical Association of India, certain initia
tives in containing the drug issue were
shared Dr. Vincent Panikulangara, lawyer
and general cenvenor of Public Interest
Litigation Society, Kerala, shared the advices
by him in fighting legal battles in the high
courts and supreme courts against drug
industrialists and reminded about the need
and relevance of the church health services
to emerge as a corrective and porphetic
force to contain the exploitative practices
followed by the drug industrialists and
commercially motivated health institutions.
Dr. Mira Shiva, Coordinator, of the All India
Drug Action Net work, narrated the evolution
development and activities of Drug Action
14
Net Work* at generating awareness at
different circles—policy makers, professionals
and general public about the existing
irrational drug policy and practice. Fr.
Joseph Chittoor from Kerala showed how
herbal medicines and home remedies could
be widely and successfully applied in dealing
with many of the common diseases of the
rural areas. His group has been actually
practicing that in the villages. Dr. Manunath
of Vellore Medical College explained the
effectiveness and relevance of Ayurvedic
Medicines and the need to integrate scientific
traditional practices with Allopathic medicines
in the treatment of diseases. Mr. John
Barnabas narrated the success story of low
cost health care using essential drugs
through village health centres. Activities of
'LOCOST* voluntary agency engaged in the
production drugs at remarkably lowcosts
were shared. This approach could pase a
meaningful challenge to the increasing
pricing policy of the large industrialists.
After the Eucharistic celebration and
lunch break the participants went in small
groups to discuss what could be done at
the individual, institutional, diocesan, CHAI/
National levels to deal with the drug issue.
Concrete suggestions were brought out by
all the 15 groups. These were consolidated
and read out at the concluding session.
Following this, there was concurrent pro
grammes with video films on drug issues and
a demonstration class on herbal and home
remedies referred to on "People's Medicine".
The participants were to choose which
programme they prefer to attend.
In the concluding session, as mentioned
earlier, the consolidated paper on what could
be done at the individual, institutional, dio
cesan, CHAI/National levels were shared and
approved by participants. (A detailed note
on this will be published in the next issue of
our journal). The workshop had also drafted
Medical Service
a resolution expressing the concern over the
scarcity of life saving drugs, the excessive
enormity of 30,300 and old drug formula
tions etc. The full text of the resolution is
published in this issue.
The last day, 26th November 1984, was
the day of the General Body. The day began
with the Eucharistic Sacrifice at 7.00 a.m.
with Fr. Percival Fernandes, the Secretary,
CBCI Society for Medical Education in India
as the Chief celebrant. At 8.30 a.m. the
General Body meeting was held with Fr.
Ferdinand Kayavil, the President of CHAI
presiding. In his introductory remarks,
dwelling on the various deliberations that
took place during the previous three days,
he called upon all the members of CHAI to
take the deliberations of this years conven
tion seriously. (Full text of his concluding
remarks is published separately).
Thereafter the Secretary Sr. Isabella Mary
presented the report of the General Body
meeting held in Bombay on 9th November
1983. After that Fr. John Vattamattom
SVD, Executive Director, CHAI presented the
annual report of the association. Thereupon
Fr. Thomas Joseph, Programme Director,
Community Health Department of CHAI
presented the report on the activities of the
department. Then the treasurer Fr. Antony
Samy presented to the General Body the
audited statement of 1983 and the proposed
budget for 1985. Some clarifications were
made and the proposed budget was accepted
by the General Body.
Thereafter the final declaration
and
resolutions from the workshop was officially
presented by the Executive Director and
unanimously passed by the General Body.
Following was the declaration :
December 1984
We the 500 delegates to the 41st Annual
Convention of the Catholic Hospital Associa
tion of India (CHAI)
on the theme
-TOWARDS A PEOPLE-ORIENTED DRUG
POLICY", consisting of doctors, nurses,
pharmacists, hospital administrators and
health activists representing around 1900
member hospitals and health care institu
tions, assembled at St. John's Medical
College, Bangalore (23rd-26th November
1984) to express for deep concern over—
1.
the increasing scarcity of essential
and life saving drugs as against
wasteful abundance of non-essential
drugs and formulations;
2.
the excessive number of over 30,000
drug formulations—as against the
Hathi Committee and WHO Expert
Committee recommendations of 116
and 200 respectively.
3.
the continued availability of Banned
Durgs in spite of the Government
orders of bans;
4.
the continued availability of bannable
and hazardous drugs in spite of the
mounting scientific evidence and
even directives of various courts in
this country;
5.
the spiralling cost of
against the decreasing
power of people;
6.
the continuing domination by the
multi-national drug industry as
against the National Policy of selfreliance; and resolve—
1.
to fully endorse the Government of
India's list of banned drugs and here-
drugs as
purchasing
15
by accept to implement the same
in our institutions forth with and
urge all our sister institutions also to
do the same;
regulations of the association and appealed
to all to work towards that end and thereby
strengthening our association.
2.
to prepare a list of essential drugs
along the lines of Hathi/WHO Com
mittees for immediate adoption in all
our institutions;
The Executive Director then also intro
duced the subject of the self-reliance policy
of CHAI and the establishment of a CHAI
CORPUS FUND. He appealed to all to con
tribute generously towards this fund and
make our Association self reliant.
3.
to urgently take steps to reduce the
present unhealthy and unethical
influences of the drug industry on
the medical and allied professions;
4.
to mobilise public opinion against
the apparant lack of concern of the
State Governments and professional
and expert bodies on this vital issue;
and further resolve to appoint an
expert body to formulate a rational
drug policy which is people oriented
within the context of a health care
strategy and policy, befitting the
National Committment to Health for
all by 2000 AD.
We also authorise the Executive Board
and the Executive Director to take adequate
steps to implement the above.
Thereafter the Executive Director presen
ted the -revised membership fee on a deck
system regarding the bed strength of the
institutions. This revised membership fee was
already accepted by the Executive Board.
After some clarifications, the proposed revis
ed membership fee was unanimously accept
ed and approved by the General Body. The
Executive Director then also explained and
stressed the need for organising CHAI in the
diocesan level as per the revised rules and
16
There followed the election of the office
bearer. This year the offices of the President,
Secretary and Treasurer were falling vacant.
During the election that followed Fr. Ferdi
nand Kayavil was re-elected as President for
another term of three years. In the same way
Fr. J. Antony Samy was also re-elected for
another term as treasurer, unopposed. Sr
(Dr) Fernanda of Mariampur Hospital, Kan
pur was elected Secretary for a period of 3
years. She was also elected unopposed.
Sr. Isabella Mary, the outgoing Secretary
then thanked all. The Executive Director also
thanked the outgoing Secretary for ail her
services for the organisation during the past
3 years. He also welcomed the newly elected
office bearers. The President also thanked
the outgoing Secretary St. Isabella Mary. The
official vote of thanks was then proposed by
Fr. J. Antony Samy, the treasurer. He
thanked all those who helped to make our
this year's convention a success in Banga
lore. The Executive Director, Fr. John Vattamattom SVD also thanked individually all
those who worked hard for many days to
make the 41st National Convention and
workshop a great success in all respects.
At about 1.00 p.m. the General Body
meeting and also the 41 st Annual Conven
tion came to an end.
Medical Service
Welcome Speech Delivered by the President, CHAI,
Rev. Dr. Ferdinand Kayavil at the 41st National
Convention held in Bangalore
Your Excellency The Rt. Rev. Dr. Gilbert
Rego (Ecclesiastical Adviser to the Catholic
Hospital Association of India) Honourable
Minister Dr. H.L. Thimme Gowda, Mr. J.
Alexander I.A.S. Excise Commissioner for the
State of Karnataka, Dr. G.M. Mascarenhas,
Dean, St. John's Medical College, Your Ex
cellency Bishop Ambrose of Bellari, Your
Grace The Most Rev. P. Arokiaswamy, Arch
bishop of Bangalore, Fr. John Vattamattom
SVD, Executive Director of Catholic Hospital
Association of India, Fr. Joseph Kavalippadan,
1st Vice-President, Catholic Hospital Associa
tion of India, Members of the Executive
Board, Members of the Local Organizing
Committee, Members of the Press, Fellow
Delegates and Friends.
We are gathered here, in this beautiful
City of Bangalore for the Forty First National
Convention of the Catholic Hospital Associa
tion of India. Since 1943, when the Associa
tion was first founded, the members of the
Association have been gathering together,
year after year, from every nook and corner
of this vast country, to commit and recommit
themselves to the great and noble task of
providing Health Care facilities, to the
millions of this land, who otherwise would
not have had easy and quick access to the
much needed basic facilities of health.
For hundreds of years the Health Care
Institutions under the auspices of the Catho
lic Church assisted the nation considerably in
providing medical care to the people, espe
cially the poor people of this country. Ever
since the formation of the Association, the
participation of the Church, in the Health Care
December 1984
System of the country, through her net work
of agencies, has become better organized
and co-ordinated, more effective and rele
vant to a considerable extent to the concrete
situations of the people, even though there
is still a long way to go, before it can be said
that we are touching the common man of
the land. Dear friends, as of today, there
are 1871 member institutions in the Associa
tion. Hospitals 499, Dispensaries and Health
Centres 1274, Social Service Societies 45,
Associate Members 62. This is undoubtedly,
a great force in the Health Care System—
There are many more hundreds under the
Catholic Church Sponsorship. They are not
official members. But they too do the same
kind of work with the same kind of devotion.
We hope, eventually they too will become
members of the Association.
Once again dear friends, we have come
together for a National Convention. The
theme for this year's convention is Drug
Issues, rather towards a People Oriented
Drug Policy. This certainly is a most relevant
topic, in the context of the Nation's Health
problems. In .1982 the Ministry of Health
Government of India issued a statement of
India's National Health Policy. This policy
stresses the nation's aim to achieve the AlmaAta Declaration which wishes for Health for
all by 2000 A.D. This policy assigns high
priority—to promotion of family planning—
provision of Primary Health Care—control of
Leprosy, Tuberculosis and Blindness. The
Development of preventive, rather than cura
tive measures, is certainly one of the primary
objectives of this policy statement. Health
17
for all by 2000 A D. This in an ambitious
goal, though very fundamental and urgent I
—Is it possible of its definition within the
remaining short period of 15 years, in a
country like ours with 750 million people,
40% of which is still under the poverty line?
Most people believe that the magnitude of
the health problems of this vast and varied
land is too intense and complex to reach the
goal of Health for all by 2000 A.D. This may
be true. It may not be possible to reach the
projected goal within the short period. Ob
stacles and difficulties are there. But it is
also true that the determination of a nation,
the collective tenacity of a people, the wise
and timely policy decisions of a committed
government, should make the goal attainable
much earlier than it normally would.
Dear friends, we come together year after
year from the breadth and length of this
country, in Annual Conventions, to whole
heartedly assist the nation in its determina
tion of bringing Health Care Facilities to
every man and woman in this land I The
experts who will be addressing this conven
tion will enlighten us, on most of the issues
of the theme—Towards a people oriented
drug policy I. Drugs are one of the basic
factors in the Health Care System. During
the last 30 years drug production in the
country has multiplied a hundred fold. In
formulations technology, India occupies
prime position among all the developing
countries. According to reliable sources,
there are more than 25,000 drug formulations
in India being manufactured by more than
5,000 Drug Industries. The total output of
the industry increased from Rs. 100 million
in 1947 to Rs. 10,500 million in 1978-79.
Friends, what does this abundance and
over production mean ? Does it mean that
the poor millions of the country have an easy
and quick access to the Modern Health Care
System? Does it mean that they have the
December 1984
essential and life saving drugs, at their reach,
within a price rance they can afford? The
answer is shockingly No No ! Experts in the
field have shown with documented evidence
that the over production of drugs, most of
which is often very costly, is meant for the
consumption of the rich and the well-to-do,
while the drugs, so desperately needed by
the poor millions at cheap rates, are not ade
quately available.
Social Scientists point out, that this unjust
disproportionate pattern of drug production,
is only a part of the inequitous social struc
ture, existing in the country, which stresses
the production and promotion of luxury
goods for the rich and the well-to-do, at the
cost of the basic and more urgent needs of
the poor.
One does not have to hesitate even for a
moment to say, that the Health Care has be
come part of the exploitative system in our
country. The members of the Catholic
Hospital Association, inspired and touched by
the Association's motto—The love of Christ
compels us by the Gospel Values, certainly
do not want to be a part in this exploitation.
But, unfortunately, we too become, unknow
ingly perhaps, pushed into this unjust social
structure. Often we justify ourselves by say
ing what can I do, as an individual—what
can I do as an individual institution, before
the all powerful exploitative axis, prevading
the country often protected by an unjust
social structure.
During this convention as we become
more and more enlightened by the expert
team, of the injustices prevailing in the
Health Care System, we should ask our
selves, sincerely and humbly—Are we pre
pared to challenge the injustices perpetuated
in the Medical Care System against the
weaker section, against the powerless poor
man of this land ? Specifically I Are we
19
willing to take the consumer awareness buil
ding process, that will sensitise people to the
realities of the drug industry ? Mobilise
public opinion ? Educate the patients of their
rights ? Influence policy making decisions ?
Confront the medical establishment? and
Challenge the drug industry ? Friends, what
the Indian Council of Medical Research have
said in a joint statement must resound and
resound in the hearts and minds of our mem
bers—"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 vestted interest in ill-health." This eternal
vigilance demands that we—the members of
the Catholic Hospital Association of India —
take our position—firmly and uncompromisi
ngly, with the exploited millions until a
"people oriented drug policy" bring the
modern facilities of Health Care System
within their reach. If we are honest fellow
delegates with our motto—"The love of
Christ compels us"—we have no other
alternative.
This convention is being inaugurated by
the Honourable Minister for Health, Govern
ment of Karanataka Dr. H.L. Ihimme Gowda,
Dr. M. in his welcome speech has highlighted
some of the outstanding qualities of Dr.
Gowda. He is a Medical Doctor by Profe
ssion. Therefore he is able to understand
the Medical problems of the country with a
deeper knowledge and a better insight. He
is approachable to the common man. That
is a quality perhaps most of the high ranking
officials do not have. That is what we need
most in the country. I extend to you our
most cordial respectful welcome. Sir, we
are honoured by your presence. Your pre
sence and the words you are going to tell
us, will be a motivation and encouragement
to us to do our work with greater commit
ment.
20
His excellency, the Rt. Rev. Dr. Gilbert
Rego is presiding over the meeting. Bishop
Rego is the Bishop of Simla and he is here
today primarily in his official capacity as the
Ecclesiastical Adviser to the Association. The
Association, by its constitution, is an autono
mous body. But, by tradition and practice
the Association works under the guidance
and supervision of the Ecclesiastical Hier
archy. We are happy that such a link is
established between the Association and the
Hierarchy; Without the timely advice, guid
ance, supervision and control from the part
of the Hierarchy, our work will be less effec
tive and less fruitful. We are thankful to
Bishop Rego for his help, on behalf of the
Hierarchy. To you, Your Excellency, our
loving heartfelt welcome to the convention!
Mr. J. Alexander IAS : The exhibition will
be declared open by Mr. J Alexander, I.A.S.
Mr. Alexander needs no introduction to the
public of Bangalore and the Karnataka State.
At the moment, Mr. Alexander is the Excise
Commissioner for the Karnataka State. Earlier
he worked as Collector in one or two Districts
of the State. He has been the City Commis
sioner of Bangalore. He has been labour
Secretary, Social Welfare Secretary, Health
Secretary Labour Secretary—He served the
Government in many other capacities. Mr. Alxander is reputed to be an efficient, conscie
ntious hardworking administrator. Being an
intellectual genius, he is knowledgeable on
practically any subject. He is deeply religious!
He is a powerful speaker. He is universally
acclaimed to be a public officer of impecca
ble professional honesty. People who know
him will not hesitate to say that Mr. Alexan
der is rare acquisition in the public life of
this country To you, Mr. Alexander, a friend
and well-wisher of the Association, and an
Adviser to us—an affectionate welcome from
each and every member of the Association.
Medical Service
On the Dais are : Dr. G.M. Mascarenhas,
Dean, St. John's Medical College, Fr. John
Vattamattom SVD, The Executive Director,
Fr. Joseph Kavalippadan, 1st Vice-President,
welcome to you friends, dear colleagues!
Welcome to all our friends, who are here
graciously responding to our invitation to
grace this occasion. Welcome to the local
committee without whose devoted hard
work, it would not have been possible to
have this convention in Bangalore. Members
of the press are here! Hearty welcome to
you. Welcome to all those who have con
tributed to the holding of this convention
here. Finally, welcome to you, dear delegates
and co-workers! Without you this Campus
would be just a wilderness, a garden without
flowers—you and beauty, to this place! if
women make any place beautiful, sisters
make it hundred times more beautiful and
attractive. You make the Convention! You
take the message across the country, you are
the Convention, without you there is no Con
vention. To you all, delegates and co-workers
—hearty welcome to this August Assembly!
Thank you !
Have a nice stay !
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21
Theme Presentation and Convention Highlights
—Fr. John Vattamattom SVD
The Catholic Hospital Association conven
tion in Bangalore seems to be historical. Ele
ven years ago in 1973 when we had the last
convention here, we discussed about the
importance of Primary Health Care. One of
the concrete result of that convention was
the wellknown programme of 'Health for a
Million* by the Archdiocese of Trivandrum.
Today as we are beginning the 41st conven
tion of CHAI here, we are again at a
historic point. During this convention we
are going to deliberate on a number of
issues that have been agitating the minds in
many a people and organisation since some
years i.e. how to work towards a people
oriented drug policy. After the Alma Ata
declaration in 1978 of Health for All by
2000 AD, the 1980s is going to be a historic
period in the health care ministry and medical
profession.
As we are gathered here, representatives
of more than 2000 health care institutions
directly run by the Catholic Church all over
the country starting from a small health
centre in a remote corner of this our vast
country to big institutions like St. John's
Medical College Hospital and a few others,
together with various resource persons and
friends and also officials from the Govern
ment and the Church, it is a time for us to
reflect seriously our role in this one time
noble profession and ministry which, of late,
unfortunately has assumed a business nature.
It is also good to be aware of the warning
given by the Indian Council of Medical
Research and the Indian Council of Social
Science Research in their health for all
report—"One of the most distressing aspects
of the present health care situation in Indian
is the habit of doctors to over prescribe or to
December 1984
prescribe glamorous and costly drugs with
limited medical potential. It is also unfortu
nate that the drug producers always try to
push doctors into using their products by all
means—fair or foul.... If the medical
profession could be made to be more discri
minating in its prescribing habits there would
be no market fot irrational and unnecessary
medicines."
What is to be happening during the
coming couple of days should be a sole
searching exercise by all of us here : decision
makers from the Government, from the
Church, from the Medical profession, from
the teaching and training institutions, from
the aid giving agencies and above all from
the common man, to see where we stand, to
examine our attitude as to whether we are
pro-life or anti-life in our practice etc. etc.
It was Hypocrities, the father of Medicine
who said "for the sick, the least in best".
Is that the policy we adopt in our prescribing
pattern ? We need to discuss many things
during these days and discuss them seriously
with an open mind always keeping the good
of the people before our eyes. We need to
discuss about the pattern of drug production
purchase and distribution. Here the* guiding
principle for issuing' a license for drug
production, or purchasing and distribution of
medicines should be the life of the people
rather than the size of the donations or gifts
the decision makers receive. We need to
discuss the ways and means how to make
our health care less expensive in terms of
medicine and otherwise. We need to assure
the availability of essential and life saving
drugs to every one particularly those in the
remote rural areas where vast majority of
(Contd. to page 40)
23
Concluding Speech delivered by Rev. Dr. Ferdinand
Kayavil at the 41st National Convention
Your Excellency Bishop Rego, Members
of the Executive Board, Fellow delegates and
Friends;
The 41st National Convention of the
Catholic Hospital Association of India is
going to be over with today's business
meeting. We have been here for the last
three days. We have been listening, reflect
ing, sharing, discussing and deliberating on
the various aspects of PEOPLE ORIENTED
DRUG POLICY. To be frank, when we came
in for the convention, we were not fully
aware of the magnitude and intensity of all
the problems associated with a People
Oriented Drug Policy.
During these three days of study, and
reflection, stimulated by well prepared
scientific papers presented by experts in the
field, we have focussed our attention on :
The Health situation in India, role of drugs
in Health Care, pattern of drug production
vice-versa the People's Health Needs, the
dynamics of the Drug Industry, the pattern
of Drug Distribution and availability in the
Health Care ’•System, the National Drug
Policies and the laws and many other
related topics. We have broken together
the Lord's Bread—-the token of his love and
the source of our life and our strength. We
believe that the celebration of the Eucharist
these three days will keep us together in our
resolve to share the concern of the poor
millions of this country.
We have been told with documented
evidence how the people in the country are
exploited—by the proliferation of unessential
drugs—by the outrageous pricing of drugs—
December 1984
by the excessive blatant over production of
drugs for the well-to-do and the consequent
under production of drugs desperately need
ed by millions in the country. We have
further seen, how this exploitative structure
thrives on the unholy collusion between the
industry and the profession I We have seen
how people are confused $nd exploited by
the mindless mis-information that prevades
the scene. To our great surprise and shock
we understood that the mighty developed
conutries dump, in the developing, poor coun
tries of the third world, what is unwanted
and useless in their own countries. We have
observed that most of the poor countries do
not have adequate laws to control production
and sales of medicine. In the context of
this alarming situation, we have identified,
through serious thinking and study, aided by
masters in the field—most of the problems
prevailing in the medicare system—at the
Individual level, and at the National level.
Having identified the problems, we have
been able to come up with solutions to most
of the problems, again at the Individual,
Institutional and National level. We are now
ready to get back home. My dear fellow
delegates, all that we have deliberated here,
during these three days of the convention,
will be of no use, absolutely no use, if we
are not convinced beyond any doubt that
there is something seriously wrong with our
Health Care System and that we, as Chris
tians, inspired by the gospel values can't
simply stay unconcerned. We have therefore
resolved to take up the cause of the poor
and exploited, no matter what the cost we
will be required to pay.
25
I think the greatest contribution of the
convention is that an awareness has been
created in us that there is something seriously
wrong with the Medi-Care system in the
country, and that we, knowingly or unknow
ingly, are a party to the perpetuation of the
evils of the system, and that we, as Chris
tians inspired by the gospel values, can't
simply stay unconcerned of the situation.
Friends, in the beginning of the world we
hear God's voice resounding the universe
with two questions I When Adam and Eve
wanted to run away from God's presence
God's resounding voice was heard—"Man I
where are you ? "Man I where are you ?
Later
when
Cain killed his brother
Abel, again God's voice was heard—Man,
where is your brother ?
Man, where
is your brother ? From the beginning of
creation, until the consumation of the world—
God's voice will continually resound in the
universe with these same questions—Man,
where are you ? Man where is your brother ?
Our eternal reward will depend, my friends
on the kind of answer you and I will be able
to give to these two questions I Man, where
are you ?
Man where is your brother ?
When your brother was denied a human
existence, when your brother was exploited
to extend of making his life inhuman, Where
were you ? I
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26
Medica Service
Towards a people-oriented drug policy
Dr. C.M. Francis
The Government of India had enunciated
a New Drug Policy in 1 b78, based largely
but diluted to a great extent on the Hathi
Committee Report of 1975. Many of the
objectives of that Policy could not be realised
for a variety of reasons. Now there is a move
to have a newer Drug Policy. The Govern
ment had appointed the National Drugs and
Pharmaceuticals Development Council. Its
report is available. Most of the recommenda
tions seem to be a departure from the major
social objectives of the 1979 Drug Policy,
with pressures and threats from the manu
facturers. Health is a fundamental right. For
the achievement of that health for all, many
steps have to be taken. One of the first
requirements is to set our goals, enunciate
unambiguously the policies and initiate
appropriate steps to reach the goal.
2. Drug policy: Along with nutrition,
water supply, sanitation and housing, the
provision of standard drugs of good quality
in adequate quantities is a must for the pro
tection, maintenance and restoration of
health1. There is need for a rational
and optimal therapy and therefore the
need to have a rational drug policy. This
policy must be an integral part of the new
National Health Policy. Some groups of
active citizens, aware of the need to popu
larise the demand for action by Government,
have come together to form the Drug Action
Network. Among them are the Voluntary
Health Association of India, Medico friend
circle, Delhi Science Forum, Kerala Sastra
Sahitya Parishad, Arogya Dakshata Mandal,
Lok Vignayan Sanghatana and others. Now
the Catholic Hospital Association of India,
with its large network of Hospitals, health
December 1984
centres, dispensaries and community health
work, and a host of personnel working in the
Healing Ministry has taken up this problem
of making available to the large masses,
seeking health care, essential drugs of good
quality at reasonable prices. The problem of
drugs can be solved only if concerted efforts
are made by the people and the Government,
both central and state. There is an imperative
need for a comprehensive National Drug
Policy, based upon the socio-economic, poli
tical and other options and the practical im
plications of that policy.
2. 1. The present drug policy initiated in
1978 had the following objectives1 among
others :
1. Drug availability at reasonable prices
2. Indianising the industry
3.
Leadership role for the public sector
4.
Self-reliance in drug technology.
We are nowhere near the achievement of
these objectives. There has been a noticeable
drop in the growth rate of the industry during
the last 5 years. The production of bulk
drugs has increased by 70%, while the im
ports have doubled. The sixth Five Year .Plan
production target for bulk drugs was Rs. 566
crores; this has been slashed to Rs 500
crores; so also the target for formulations
has been reduced from Rs. 2,450 crores to
Rs. 1,950 crores. Even these reduced targets
are not likely to be met. What is worse is the
fact that the limited resources are often was
ted in the production, distribution and con
sumption of non-essential and useless drugs.
27.
a large, proportion being vitamin
tions and tonics.
combina
2. 2. Shortages have been felt in many
essential drugs. The industry had imported
75 tonnes of rifampicin in 1983 against the
normal requirement of 35 to 40 tornes and
yet there is a serious shortage for this drug,
which is important in the treatment of leprosy
and tuberculosis. There had .been a fall in
the international price in rifampicin (it has
gone up again) but the import price was cal
culated on the basis of higher price and cost
ing done on that basis; the public had to pay
more. There have been a number of ques
tions raised in the Parliament and on that
basis the firms have been asked to refund
"the unintentional profit", which comes to
more than Rs. 3.5 crores. But most of the
larger firms are refusing to give even the
date, inspite of the Government reminders,
let alone refund the excess profits.
Some progress has been made in the
Indianisation of Drug industry; there has
been abject failure in the leadership role for
the public sector and in self reliance in tech
nology.
2. 3. The recommendations of the steer
ing committee of the National Drugs and
Pharmaceuticals Development Council are
likely to revise, adversely for the public, the
national policy :
— Price controls for only 95 drugs ; 265
drugs at present on the price control
list to go off it.
— Higher "mark ups" (trade margins,
promotional costs and profits for the
manufacturer) on the production cost
of even these 95 drugs.
— End to the present ceiling on company
profits.
— Automatic price increases every year
based on a price index mechanism.
28
— Regularisation of excess
capacities installed
production
’ — No price control for 5 years on any
drug introduced for the first time.
2. 4. Our closest neighbour has tackled
this problem differently. In declaring the bold
New Drug Policy of June 1982, Bangladesh
followed 6 precepts3.
(1) Elimination of harmful and useless
drugs. As follow-up, 1,700 such drugs were
banned. (Similarly, in Philippines, about
6,000 out of an estimated 15,000 drugs in
the country would be phased out during this
year. In Mexico, over 10,000 drugs have
been closely evaluated and many duplica
tions, obsolete products and those with
limited or doubtful benefits have been elimi
nated, reducing the number of drugs availa
ble to 329, in 583 combinations.)
(2) Increased domestic productions of
essential drugs.
(3) Public distribution system of essen
tial drugs.
(4) Bulk importation of pharmaceutical
materials from different sources at competi
tive prices (Many countries have been able
to do this, achieving economy. Tetracycline
which used to be imported at 102 U.S.
dollars per kg. before the Policy was import
ed at U.S. S 27 per kg.).
(5)
Use of generic names.
(6) Encouragement of locally organised
applied drug research.
Mr. Vasant Sathe, Minister for Chemicals
said at the meeting of NDPDC earlier this
year that the motto of New Policy will be
"Medicines for the masses". This must be
seen in action.
Medical Service
3.
Drug scene in India
to be considered the inhibitory effect on the
development of technology in India.
The total production of pharmaceuticals
in India is estimated to be Rs. 2,005 crores
(3) Large Indian companies. These are
in 1983-84. This includes both bulk drugs very few but they have a number of benefits.
(Rs. 345 crores) and formulations (Rs. 1,660 There is a controversy between the FERA
crores). If we compare our production with companies who now claim to be Indian
the world-wide production, it is extremely
Companies and the Indian Drug Manufac
low. The world consum ption of pharmaceuti
turers Association. The FERA companies
cal products was estimated in 1981 to with high technology are given a production
amount to Rs. 763 billions. India's share ratio between ‘bulk drugs and formulations
comes to about one in fifty, while her p opuof 1 : 5, whereas, it is 1:10 for Indian
lation is about one in six. The growth of the companies. 1 : 5 ratio has not been reached
drug industry in India had been remarkable in most cases, being on the average 1:11,
earlier. From Rs. 10 crore in 1947-48 to
as the FERA Companies and the India manu
Rs. 1,545 crores in 1982-83, from being a
facturers find it more profitable to produce
mere trading industry to a manufacturing
formulations.
industry, the growth had been good. But in
(4) Small scale units which constitute
recent years stagnation seems to have got in.
about 92% of the manufacturing units. The
The growth in 1983-84 is only half of what
SSI units are exempted from the 1979 Price
was achieved in 1982-8 3, leading to short
Control Order. But this had led to misuse.
age of many vital drugs4. The Sixth Five Year
Many foreign owned companies and the
Plan had envisaged an annual growth rate of
large Indian companies set up associate
24% in bulk drugs (achievement in 83-84 :
small scale firms, with marketing tie-ups.
6%) and 16% in formulations (achievement
4%). The manufacturers are reluctant to go
Because of pressures and for promoting
in for bulk drugs ; the profit margin is smal
competition, more and more units have been
ler. There are about 25,000 formulations
created ; we have over 5000 manufacturing
in the market in India, whereas many of the
units, many of them uneconomical or sub
advanced countries have only one-tenth of it.
standard.
4.
Drug Industry
There are different types of companies :
(1) The Public Sector—Central, State
and joint enterprises.
(2) Those with large foreign sharehold
ing, being part of the transnationals. The
shareholdings have been diluted or, are
being diluted in the majority of cases to
40% but there are still some with more than
40% shareholding. The foreign controls
remains. It was expected that these sub
sidiaries of transnationals will bring in their
complex, up-to-date technology developed
by their parent companies. Against this has
December 1984
There are illegal expansions of production
capacity in areas which are highly profitable,
with reduction in other areas (production of
essential drugs, where the price control
works).
5.
Public Sector
The public sector was to play a leading
role in pharmaceutical industry but its per
formance has been disappointingly poor. The
prices are often more than the price charged
by the private sector. Even since its establish
ment in 1961, the Indian Drugs and Pharma
ceuticals limited has been running at a loss.
29
the loss in 1983-84 being Rs. 21 crores ; out
moded technologies are being used. The
capacity utilization has been poor, being
about 65% of the installed capacity. There
are plans to improve the performance and to
break even by 86-87 ; this is yet to be seen.
The picture with the states pharmaceuticals
is also not bright. Even with preferential
margins, many of them have not been able
to do well.
It is necessary to tone up productivity in
the public sector industry, with better tech
nology and utilization of capacity. All
essential and life saving drugs must be
produced by the public sector on a priority
basis.
6.
Research and Development
There is a great need for developing new
drugs and improvement of technologies for
production. The pace of innovation in
Indian drug industry has been totally unsatis
factory. Innovation can be for new techno
logies, modification and adaptation of
imported technology and for import substition. Incentives must be provided for
research and development; guidelines must
be set for stimulating R & D activity; priority
areas must be identified, and there zshould
be co-ordination of research, monitoring and
evaluation.
6. 1. Indigenous technology should be
developed.
With sufficient number of
scientists and technologists available in the
country, there is no reason why we cannot
be self-reliant in technology. We have to
be very careful in technology transfer from
advanced countries, as very often we pay
exhorbitant amounts for obsolete technology.
IDPL resorted to the purchase of technology
from an Italian consortium for 5 antibiotics.
While preliminary results were good, it was
finally a failure. How does one get the
latest know-how from abroad if we are
paying for it ?
30
World’s leading pharmaceutical firms set
apart 10% of their turnover for R & D?
The search for new drugs being very expen
sive and time consuming, it is concentrated
in the hands of the large transnationals, with
commercial exploitation on a world basis.
Various steps are involved in the develop
ment of a drug; synthesis (or isolation from
natural sources), biological screening for
activity, preclinical studies for potency and
toxicity, pharmacokinetic and metabolic
studies, development of appropriate formula
tion, pharmaceutical development, clinical
trials, and development, of technology for
production and surveillance. In 1980, 83
out of the 100 leading medicines in the
world were developed and produced in just
5 countries—U.S.A., Japan, Switzerland,
W. Germany and U.K.C Our expenditure on
R & D is very low, being only 2% of the
sales turnover. It is essential that we step
it up. It must be made mandatory that
provision should be made to meet the
recurring expenditure on R 8- D on a percen
tage basis of the turnover; this should be
increased progressively to reach a figure
of say, 7% by the end of the Seventh Five
Year Plan, irrespective of the category to
which the industry belongs.
6. 2. Our R & D should also concentrate on
the search for newer drugs required to tackle
diseases of relevance to us. The trans
national firms are often not interested
in such drugs because they do not have a
ready market and high profitability. We
must also catch up on the newer natural
products of "biodrugs". These drugs could
be manufactured with the level of techno
logy available in our country.7
6.3. The Central Drug Research Institute,
Lucknow, the National Chemical Laboratory,
Pune and. the Research Laboratory, Hydera
bad are doing some work. 73 pharmaceuti
cal industrial units have been recognised by
Medical Service
the Department of Science and Technology.
But the quantum of research done is totally
inadequate and the results not worth mentio
ning. A larger research base is needed.
The Government must actively. stimulate and
encourage research into pharmaceutical pre
parations, essential to combat the diseases
most important to our country. Sizeable
grants should be given to Research Institu
tions, Universities, Medical Colleges and
Colleges of Pharmacy for search for new
products, processes and technology. Incen
tives for research must be provided to the
firms:
*
people use these traditional remedies9 and
there is need to ensure good, potent, genuine
unadulterated drugs at affordable prices.
There are about 2,700 pharmaceutical belon
ging to the Ayurvedic, Unani and Siddha
systems of medicine. The total number of
practitioners is also very big (institutionally
qualified or otherwise trained). The old
practice of physician manufacturing his own
medicines has become unworkable. In the
preparation of these drugs, it is necessary to
follow the traditional pattern also, in addition
to the modern methods of processing. There
is need for enquiries into the availability of
raw meterials, collection and sale, as also
(1) Pricing mechanisms should include
the cultivation of reputed plants of proper
research costs
species through the forest departments and
(2) Waiver of customs duty on import of drug farms.
i capital goods specifically for research
If quality can be assured, there are
(3) Weighted rebate of income-tax for
possibilities of export, especially to our
sponsoring research in approved ins
neighbouring countries. Standarization, safety
titutions and in-house research units.
evaluation and clinical testing must be carried
out properly. We have to take special care
7. Drug Evaluation
of efficacy, toxicity, quality control, keeping
Drug evaluation is the procedure by which qualities and packing and handling.
the true[value of a drug is determined. Many
westerners believe that Third World Countries
9. Quality control
lack in men and resources and therefore the
pre-clinical testing cannot be done in such
Quality control is of paramount importance
countries8. With its vast potential of scien
in the drug industry, because the very lives
tists and advances in Technology, this cannot
of the people depend on it. Unfortunately
be held against India. We must insist that
it is not being exercised to the extent it
the transnationals carry out the pre-clinical
should be. Industry has to be self-disciplin
testing in India in some drugs, at least
ed and responsible. High quality starts with
proportionately to their sales here. This
good manufacturing processes—established
would provide development of some expertise
and approved procedures and policies that
and knowledgeable experienced persons who
are adhered to in the production of drugs.
can help the Indian Drug Industry.
The proper norms must be adhered to.
Registering and licensing authorities have the
8. Ihdian systems of medicine
responsibility to ensure that the drugs offered
All that has been said will apply to the to the public meet acceptable levels of safety
pharmaceutical industry involved in the pro and efficacy. Standard procedures of testing
duction, distribution and marketing of drugs and monitoring should be carried out frequ
for the Indian systems of medicine. Most
ently and corrections applied as necessary.
December 1984
31
Counterfeit and substandard drugs are
plentiful. Their production and distribution
must be stopped, stringent measures taken
and exemplary punishment given. The Public
Accounts Committee of Uttar Pradesh found
some of the products of the Public Sector
Unit (UDPL) adulterated and substandard.
10,
Pricing
In a poor country like India, it is necessary
to ensure that essential drugs are available to
the people at prices they can afford. The
Drug Prices Control Order, 1979, placed the
drugs in 4 categories and the price was fixed
on the basis of essentiality and cost. Medici
nes in the fourth category were Tree of any
price control: other drugs have different
make-up values.
Government is planning to revise the drug
pricing policy which will mean that the public
will have to pay more for the drugs. The
mark-up for essential drugs is to be raised to
75% and all the rest will be for open
marketing.
Vital drugs may go tax free-central excise,
customs duty, sales tax and octroi, which
together now come to about 40% of the
retail price. This is a step in the right
direction.
11,
Foreign exchange
Situated as we are, with all the advan
tages, our pharmaceutical industry was
expected to earn foreign- exchange. But
there has been only net loss and what is
worse, the loss is increasing. These losses
are through the import of raw materials,
capital goods, royalties and dividends from
profits by the manufacturers with foreign
shareholdings.
11.1. One area which requires consideration
is the transfer pricing. This has often been
32
misused, boosting up the price of the raw
materials and intermediates. German Reme
dies imported dipyradimol from a Spanish
company: the price was marked as three
times the price other companies were paying.
Hoffman-La Roche had to pay back an
enormous amount to the British National
Health Service because it was found that the
transfer price charged for the raw material
for Valium was very much higher than market
price in other countries.
12.
Different standards
Other countries believe and our Govern
ment agrees that some harmful (or potenti
ally harmful) drugs could be marketed and
consumed in India. Is Indian life less pre
cious than the lives of ofher country men?
Drugs not approved for use in the United
States could be exported to other (third
world) countries10. They would even consi
der giving technical assistance to Govern
ments of developing countries to aid decision
making processl India should not allow,
under any consideration of the so called
benefit-risk ratio, the import of any drug
which is not freely registrablS, licensed and
marketed in the country where it is developed
and produced. They should not even be
allowed to be submitted for clinical trials or
marketing in india.
13.
Brand names
The drugs should be known only by the
generic names. The argument that the
physician, patient and public would like to
know the names of the firm which has produ
ced the drug can be satisfied, if the name of
the company is also printed. Giving brand
names confuses everyone and can lead to
mishaps. The pharmacist should be in a
position to substitute a quality drug produced
by another manufacturer, if the product of the
particular manufacturer is not available.
Medical Service
14.
Promotion of products
Social and economic damage is caused
by the indiscriminate advertising and market
ing activities11. There is no need for high
pressure salesmanship, with a large number
of salesmen, free samples, gifts and free
travel within the country and abroad for con
ferences or pleasure for those doctors who
push the products. These should be banned;
so also the advertisements in media for the
public. Even in advanced countries, where
regulatory measures are much more effective,
promotional activities sometimes go far be
yond what is reasonable, eg., the Benoxaprofen affair of the Opren scandal12. "A
combination of an unscrupulous pharmaceu
tical firm; feeble watchdogs and gullible
doctors had been responsible for the use of
an unnecessary and unsafe drug...key figures
were extravagantly entertained at sponsored
conferences in attractive venues”.
15.
Drug information
16.
Ethical
therapy
December 1984
problems
in
16.1. Doctor'. Therapy may result in
injury to the patient: physical, mental,
financial and others. A large number of
patients are treated in hospitals because of
iatrogenic diseases. In our country, almost
all such mistreatment goes scot-free. But
there are possible avenues of punishment:
(1)
Professional discipline—the doctor
may be reprimanded and even depri
ved of his right to practice, by the
Medical Council.
(2)
Proceedings for damages—civil law.
(3)
Criminal negligence.
The doctor may not devote sufficient
attention in the prescription of drugs and
prescribe :
(1)
Every drug is a poison. Drugs are pres
cribed because they give more benefit than
harm. One must be careful of the adverse
reactions and be especially Watchful in
infants and children (particularly small-fordate babies, protein-calorie malnutrition,
infections), elderly patients and pregnant
women. Adequate information should be
given to the patient about the drug. These
would include.
What is the dose; frequency of use;
route; relations to meals ?
Does it cure or give symptomatic relief ?
What to do if the drug is not working ?
Is there a lag period ?
How long to take ? When to discountinue?
What are the side-effects ? adverse
reactions ?
What are the precautions during work in
the field or the factory ?
How is it to be stored ?
and legal
unnecessary and potentially dange
rous drugs. The patient may be treat
ed with a range of drugs which have
potential adverse reactions and inter
actions. Some doctors continue to
prescribe drugs, even when the
adverse reactions and contra-indica
tions are known generally, because
they fail to keep abreast of the
literature. Sometimes, the doctor is
under pressure from the patient or
relatives to prescribe unnecessary
therapy.
An interesting question that can be
raised is : If drugs banned elsewhere
and allowed here by the Government
cause any injury which can be attri
buted to them, who will be responsi
ble?
(2)
inappropriate drug. Gross examples
can be prescribing aspirin for gastric
pain or a drastic purgative for sudden
constipation possibly due to intestinal
33
obstruction. The decision as to
whether the physician was negligent
would depend on what the physician
could have known, should have
known and infact did know and
acted upon.
(3)
careless and inaccurate. The prescrip
tion could beindecipherable, therecouId be confusion between micrograms,
milligrams and grains; there could be
be confusion between drug names,
especially trade names.
(4)
fail to prescribe essential treatment
ments. They are the people in a position to
know; the doctor, pharmacist and the public
depend on them. The regulatory authorities
are responsible for their decisions. There has
been a well-known ruling in Japan ;
••..... in view of the nature of administra
tive supervisory authority and in all other
relevant circumstances, the Government
stands in a position of quasi joint-and-several
liability with the other defendents who are
the direct offenders and therefore should
bear one third of the total cost of the
compensation that the court determines the
defendents should pay".
give inadequate or misleading infor
16. 4. Manufacturers : The pharmaceuti
mation to the patient about the
cal industry has to take all precautions to
treatment.
see that only safe (and effective) drugs are
Pharmaceutical
16.2. Pharmacist :
It is the duty of the released to the market.
industry should put a product on the market
pharmacist to
only if due care has been observed in all
(1) check the prescriptions before dispen aspects13.
sing
(5)
(2)
dispense the
correct medicine.
Mrs. Winifred Greig, 64 years old
was prescribed pardale, a mild pain
killer for her arthritis; she was given
Priadel,
containing lithium. She
collapsed a day after she began
taking the drug and died. The
pharmacist had misread the prescrip
tion.
(3)
provide correct and adequate infor
mation to the patient.
(4)
store the drugs safely and properly,
so that there is no deterioration.
(5)
ensure that the date of expiry is not
exceeded.
16.3. Drug regulatory agencies
approve
new drugs and review old ones. They decide
as to what drugs are effective and safe and
what information should be available on the
package inserts, data sheets and advertise
34
(1)
The drug should have undergone ex
tensive preclinical and clinical studies.
(2)
Good manufacturing practices must
have been followed, with quality con
trol at every stage.
(3)
The drug should be promoted only
for valid indications and in a respon
sible manner.
(4)
Necessary precautions,
warnings,
indications and contra-indications
should be communicated to the
doctors and patients.
(5)
There must be efficient post-market
ing surveillance.
Discussions are going on in various
countries whether there should be strict
liability or no—fault liability. The New Drug
Policy must decide on the liability. In any
case, there has to be product liability (and
Medical Service
not merely process liability). The producer
shall be liable for damage caused by a defect
in the drug, whether or not he knew or could
have known the defect and without having
to prove that the defectiveness of the product
which caused the damage was due to any
fault on the part of the producer14.
prices, wherever the person is. The ability
to meet the cost or to reach the place should
not be considerations in providing the
essential drugs.
17.2. What are the drugs required ?
Drugs are required for prevention, cure and
symptomatic relief. The World Health
17. Drugs for primary health care : Organization has, in 1983, listed about 250
Primary health care is essential health care drugs as essential1*. This is a large scale
modification of the list prepared in 1977 and
made available to individuals and families in
revised and updated in 1979. The objective
the community and has to be
of WHO action programme on essential
(1) accessible, assuring equitable access drugs and vaccines is to ensure the regular
to all,
supply to all people of safe and effective
drugs and vaccines of acceptable quality at
(2) acceptable, based on the life pattern lowest possible cost in support of primary
of the people,
health care1?. They have also given a list of
(3) effective, in providing an adequate 22 drugs for primary health care, which "can
be used effectively and safely by responsible
level of care, and
individuals with little formal
medical
(4) affordable, without the imposition of knowledge". The report also states "'highly
excessive burden on the individual,
trained workers might use a wider range of
family or community.
drugs appropriate to their diagnostic skills"
and advocated that where there is no scarcity
It is'the first contact care, where most of
the usual, everyday health care needs can be of medical manpower; many potent drugs
met. Primary health care is an approach could be used. Primary health care is the
involvement of the practitioner (doctor,
which integrates at the community level all
nurse, medical assistant, auxiliary, or primary
the elements which are necessary to improve
health worker), to whom a person first turns,
the health of the people.
when ill or seeking advice. This varies from
17.1. India, a signatory to the Declara country to country and even within the
tion of the Alma Ata International Conference country. The W.H.O. expert committee
on Primary Health Care, is committed to observed "the preparation of a drug list of
uniform, general applicability and accept
provide an acceptable level of health for all
ability is not feasible or possible". The same
by the year 2000 AD. Primary health care
has to be defined in terms of function and the is true for a vast country like India. In India,
scope
and quality of care under each there is a reasonable ratio of trained doctors
function. It is also necessary to decide what to population in the majority of places; in
proportion of the GNP should be alloted to
many situations, they will be the persons for
health care and what part of it to primary primary contact; in others, these will be
health care, though this can present trained nurses, community health workers
problems.*5 An integral part of this commit
or others. Depending on who provides the
ment is the provision of all essential drugs health care in the first contact situation, the
to all those who need them, in adequate
use of drugs will vary. I shall take the
quantity and quality, and at affordable
situation where a qualified physician is
December 1984
35
available; in other situations, the list of drugs
may have to be drastically curtailed, being
nearer the twentytwo drugs listed by the
expert committee of W.H.O.
18. Policy : There is need for a clear
decision as to what diseases and symptom
complexes come within the purview of
primary health care. A purposefully deter
mined regimen of treatment should be
worked out for each disease and symptom
complex, leaving the rarer treatment regimes
to the specialists at the referral care.
19. Choice of drugs : The drugs for
primary health care must be well-chosen.
The choice has to be based on a survey of
the mobidity pattern in the area or region.
To ensure optimal benefits, the definition
and determined implementation of clear
national policies are required. The steps to
success in the choice and supply of essential
drugs have been listed18. They are :
(1)
A comprehensive
Policy
National
(2)
Selection of essential drugs
Drug production and procurement
(4)
Logistics of supply
Proper use of drugs
(6)
Quality control
(7)
Training of personnel.
19.1. The list of drugs should be drawn
up by a regional committee of doctors,
pharmacists and others interested and invol
ved in primary health care. Concise and
yet comprehensive drug information should
accompany the list. The common diseases
in our country are infectious diseases,
parasitic infestations,
acute
diarrhoeal
diseases and malnutrition. India, in common
with other less affluent countries, has a
young population with about 40% under 15
years of age. Hence the diseases common
36
(1)
proven efficacy; well tried drugs
should be preferred to newer drugs
whose efficacy, side-effects and
adverse reactions have not been fully
established.
(2)
low cost,
Commensurate
with
efficacy; the cost of the whole treat
ment should be considered and not
merely of single dose.
(3)
safety in the hands of the user.
Drug
(3)
(5)
among children have preponderance; drugs
required for their care must have priority.
Periodic revisions must be made to meet the
changing needs or based on better assess
ment of the needs and the availability of
more cost-effective drugs. It is better to
have only one effective preparation for each
indication, avoiding unnecessary duplication.
The drugs, where possible, are better
supplied in tablet from for ease of adminis
tration; they should also have keeping
qualities under the existing and often exact
ing conditions of temperature, humidity and
storage. The packing must be efficient but
not expensive. The choice of the drug
should be based on
20. Drug costs : The costs should be
kept to the minimum. The country should
as far as possible become self-sufficient in
the production of drugs for primary health
care. Where imports are necessary, they
should be pbtained on the basis of bulk
purchases on global tenders and selection
with due regard to quality and cost.
Considerable savings can be effected.
Even affluent countries have taken
measures to contain the costs19. The nine
countries in the European Community took
steps to reduce the cost of drugs. Among
them are
Medical Service
(1)
Fixing of prices or limiting profits of
pharmaceutical companies
(2)
Limiting sales promotion activity
(3)
Regulation of retail margins
measles,
whooping cough,
tetanus.
Newer effective vaccines may be added,
Circulation of information to doctors depending on the cost—benefit.
to encourage economical prescribing.
23. Drugs for cure *. Some of the more
essential drugs are listed ; a few more will
21. Logistics of supply’. An adequate
be needed, based on regional requirements
supply of the essential drugs must be ensu
red at all times, in all places and in suitable and other factors.
(4)
dosage forms including paediatric dosages.
The challenge is to devise systems that will
provide essential drugs where they are
needed, matching the supply to the health
care needs. It often happens that the essen
tial drugs are not available at all times,
leading to shortages. This has happened
often to the large scale treatment of tuber
culosis, leprosy and other diseases. Some
times it has happened because manufacturers
deliberately did not produce them or retai
lers refused to stock and dispense them, all
clamouring for a larger margin of profit.
Villages and regions may be cut off in
certain seasons for a variety of reasons.
Antimicrobials : Infectious diseases be
ing the commonest, priority should be given
for drugs to fight them. The proportion of
the pharmaceutical budget spent on antibio
tics and antiparasitic drugs was 24% in India,
compared to 4% in the Federal Republic of
Germany and 15% in Britain. Well-tried,
cost-effective antimicrobials from among
the many available, should be selected.
This would necessarily include the penicil
lins (crystalline, procaine and oral) and
ampicillin; one or two potent and safer
sulphonamides could be included. Drugs
like chloramphenicol and tetracyclines will
also be useful. The misuse of antimicrobials
is fraught with danger, especially the deve
22. Drugs for immunization : High prio lopment of resistance. Antimalarials'. Malaria
rity must be given for immunization in
is again becoming a major threat. From an
primary health care. The commonly preven
all-time low annual incidence of 100,000
table diseases must be prevented. This is
in 1965, it has risen to some millions.
high technology and highly cost-effective.
Chloroquine is a good drug. Unfortunately
Everyone knows of the success story of
resistant strains have developed especially in
small-pox eradication; it is estimated that the northeast and are spreading to other
about a billion dollars have been saved by
parts of the country. Primaquine may be
giving up compulsory vaccination. Infectious
provided for radical cure; quinine is also
diseases take a big toll in our country,
included. Antileprosy: Dapsone can still
especially of infants and children. The
be the basis of treatment, though multidrug
cost for treating the patients with these
treatment with rifampicin and/or ethionamide
infectious diseases and the complications
is common now and probably cost-effective.
and sequelae are very high. Among the
Antituberculous : It is estimated that there
common infectious diseases which can be
are about 10 million people in India suffering
effectively prevented today are
from tuberculosis with about one-fourth of
diphtheria,
them being infective. About 50,000 die
poliomyelitis.
per year from pulmonary tuberculosis. The
December J 984
37
drugs required for standard therapy such as
INH plus streptomycin plus PAS/Thiacetazone/ethambutal or the short course including
rifampicin must be available. Antiamoebic:
metronidazole; Antihelminthic: Mebendazole.
Antianaemic : Ferrous sulphate; folic acid.
Antixerophthalmic—Vitamin A. Antifilarial:
diethylcarbamazine. Antifungal : griseofulvin; Antikala-azar (in regions where kalaazar is present)^
ding spectacles will have to be provided).
Psychiatric conditions : Amitriptyline, chlor
promazine, fluphenazine.
In addition to the drugs mentioned, there
is need for intravenous solutions like normal
saline and 5% dextrose, surgical dressings,
suture materials and a local anaesthetic.
25.
Other factors
Drugs form only one of the factors con
24. Drugs for symptomatic relief: Anal
tributing to better health. There are other
gesic and antipyretic : aspirin; paracetamol;
more important requirements for Better
morphine in special situations. Inflammation:
Health for All. Among them are health
glycerine and mag. sulph; ibuprofen. Cough:
education
to lead a normal healthy life,
Noscapine; pheniramine maleate. Diarrhoea:
rehydration salt. Constipation: magnesium avoiding risk factors, good nutrition, safe
drinking water, sanitation and housing.
sulphate; senna. Vomiting: promethazine. Al
lergy : Chlorpheneramine. Asthma: ephedrine
25.1. Nutrition'. The most important
aminophylline and salbutamol; adrenaline inj health-threatening condition in our country is
ections for an acute attack or status atshmati- malnutrition, mostly protein—calorie malnu
cus. Angina : glyceryl trinitrate ; propranolol.
trition, though specific deficiencies are also
Hypertension and congestive heart failure :
present. Adequate food intake is the solu
hydrochlorothiazide ; digoxin. Epilepsy and tion. Food production in the country is
convulsive disorders: phenobarbito nel pheny
adequate but there is unjust distribution,
toin. Sedatives and hypnotics : diazepam.
poverty and lack of education; health care
Poisoning : atropine sulphate injections ; ac
should ensure adequate intake of balanced
tivated charcoal; syrup of ipecac. Antacid :
food, with easily available foodstuffs.
aluminium hydroxide. Colicky pain: Oxy
phenonium bromide. Diabetes mellitus : an
25.2. Water supply and sanitation:
oral hypoglycaemic like glibenclamide or met Water supply is not safe, especially in the
formin ; insulin. Uterine bleeding : ergome villages. There are still lakhs of villages
which are classified as problem villages
trine Oxytocin.
Urinary tract infections :
Cotrimoxazole.
(those which do not have an assured source
of drinking water within a distance of 1.6
Ear infections : Choramphemicol/gentamikm.). Disposal of excreta lags far behind;
cin drops (Other requirements for ear, nose
only 2% of the rural population has been
and throat conditions will have to be met).
covered by satisfactory disposal, while a
Skin condition : Disinfectant: chlorhexidine ;
neighbouring country like Sri Lanka has had a
gentian violet; iodine. Soothing agent;
remarkable progress in this area.
calamine lotion. Ringworm and other fungi :
25.3. Tobacco: The smoking epidemic
Whitfields ointment (benzoic acid plus sali
should be of great concern in health care.
cylic acid). Scabies and lice : benzyl ben
While cigarette consumption is declining in
zoate. Eye conditions : Topical antibiotics :
chloramphenicol—1 % ointment ; tetracyc
many affluent countries, it is increasing in
lines— 0.5% ointment (other materials, inclu our country. The tragic effect is increase
38
Medical Service
in lung cancer and cardiovascular and other
diseases related to smoking. A campaign
must be mounted as part of health care
against smoking.
25.4. Alcohol: The alcohol problem is
a growing threat to health. Between 1960
and 1980, alcohol consumption increased
by 500% in Asia. Alcohol-related problems
affect not only the individual drinkers but
also their families and the general community
and can be physical, mental or social in
nature.
25.5. Chemicals in the environment: A
class of substances are being added to the
environment; these are synthetic chemicals.
Many of them can be toxic and need to be
dealt with in the same way as poisons and
infections. Among them are pesticides and
insecticides (example : highly toxic organo
phosphorus compounds); their metabolites;
industrial effluents (an example is disease
produced in people who ate fish rendered
toxic by the presence of methyl mercury);
herbicides
(Agent Orange); Fungicides.
All these call for prevention, recognition
and management. There are an estimated
375,000 cases of human poisonings by
pesticides in developing countries every year
with some 10,000 deaths. Lack of protein
in the food of rural workers is an additional
factor that makes these chemicals even more
dangerous. Agricultural spraying (including
aerial) is common in the countryside but its
effects are not always known. India is
proud to be the largest manufacturer of
pesticidal chemicals in the whole of South
Asia and Africa, with a licensed capacity of
78,000 tornes20; its toll of human health is
not known.
The Catholic Hospital Association of India
can be a po werful organisation for the good
of the people. You can achieve your goal
in the Healing Ministry provided you are
December 1984
willing to work a little bit, willing to struggle
a little bit and willing to suffer a little bit..
References
(1)
Lunde, P.K.M., The World Health
Organization, Essential drug conceptthree years
afterwards. Clinical
Pharmacology and Therapeutics, Paul
Turner (Ed), University Park Press,
Baltimore, 1980.
(2)
Drug Industry, India Today Oct. 1984.
(3)
Mostafa, A.B.M. Ghulam, The nettle
grasped, World Health, Geneva,
July 1984.
(4)
Drug output-yesterday and today.
The Eastern Pharmacist, 1984, 27
(320) : 29-30.
(5)
Adequate infrastructural support vital
for R & D. The Eastern Pharmacist,
1984, 27 (320) : 119.
(6)
Mitra, S.K., Pharmaceutical research—
future needs. The Eastern Pharma
cist, 1984, 27 : 49.
(7)
Lozoya, X., Biodrugs are coming,
World Health, June 1983, quoted
in World Health Forum, 1983, 4 (2):
171.
(8)
Salako, L.A., Problems of drug evalu
ation in developing countries. Clinical
Pharmacology
and
Therapeutics,
Paul Turner (Ed), University Park
Press, Beltimore, 1980.
(9)
Namjoshi, A.N., Indian system of
medicine-suggestions for develop
ment, The Eastern Pharmacist, 1984,
27 (320) : 129.
(10)
Kennedy, D., Food and Drug Adminis
tration and Pharmaceuticals for
developing countries, Pharmaceuti
cals for developing countries, Insti
tute of Medicine, Washington, 1979.
39
Regulating the drug trade in the
third world, World Health Forum,
1981, 2 : 423-426.
(12) Opren Scandal, The Lancet (Editorial),
1983, If : 219-2,20.
(13) Berde, B., The responsibility of the
pharmaceutical
industry. Clinical
Pharmacology
and
Therapeutics,
University Park Press, Baltimore,
1980.
(14) William, R.N., Principles of no—fault
or strict liability. Clinical Pharma
cology and Therapeutics, University
Park Press, Baltimore, 1980.
1983, (W.H.O. TRS 615, 1977 and
641, 1979).
(11)
(15)
Boland, R and Young, M., Putting a
price on primary health care. World
Health Forum, 1983, 4 (2): 131.-134.
(16)
The use of essential drugs. Technical
report series, 685, W.H.O., Geneva,
(17)
Diagnostic, therapeutic and rehabili
tative technology, The Work of
W.H.O. 1982-83, W.H.O., Geneva,
‘1984.
.(18) Seven steps to success inessential
drugs supply. World Health, W.H.O.,
Geneva, July 1984.
(19) Sharing the costs of health care:
conclusions of an
international
seminar held at Wolfsberg, Switzer
land, World Health Forum, 1981,
2 : 85-95.
(20) Krishnamurti, C.R., India's boom in
chemicals. World Health, W.H.O.,
Geneva, Aug-Sept., 1984.
(Contd. from page 23)
our people live. We need to revamp our
medical education and nurses training system
to make them relevant to the situation of
pur country and the life and culture of our
people. We need to focus our attention on
the sick person more than his sickness.
Hence the need for a proper attitude for our
health care personnel which is more person
oriented.
Fortunately for us we have of late,
sufficient and clearcut directives to do all
these both from the part of the government
and the church, through the new Health
Policy of the Government of India and the
various documents from the Church Leader
ship both national and universal. All what
is needed is the political will and commit
ment to people from part of all concerned, to
implement all these and make them a reality.
Hence this convention is going to be a
40
time of challenge for all of us. There is no
choice before us in the sense that whether
we should take up this challege or not. For,
our motto says "The love of Chrjst compels.
us" today to take it. What we need to
deliberate on these days is as to how we are
going to do this. We need to address
ourselves to the real needs of the people.
Let us hope that all of us together will be
able to find our way to give life to our
people and to give it in its fullness as Christ
wants us to do.
. Let me conclude this with another piece of
warning from the ICMR/ICSSR report :
"External 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."
Medical Service
Professionals in the Church—An Introspection
Dr. George Joseph
About a month ago, I had the privilege of
participating in a workshop under the CSI on
the 'diakonal ministry' of the Church, parti
cularly, viewing it from the angle of its scope
and relevance in the social context of today.
Let us examine the formation of the
'diaconate' in the early Church referred to in
the Acts of the Apostles. The Church
increased and the old patterns of the ministry
were found to be not adequate. There was
some grumbling about the way the Apostles
'served at the tables' in their service to the
widows. The Greeks complained that the
Greek widows were being discriminated
against, as compared to the native Hebrew
speaking widows. The Apostles therefore
suggested a new order to be instituted to
deal with this changed' situation. The
Apostles appointed seven 'deacons' to
efficiently organize the service to the
widows. For these deacons, the following
qualifications were prescribed :
— they should be the men of honest
report—of proven integrity and with
acceptability in the community
— they should be full of the. Holy Spirit
i.e. with a sense of call and commit
ment and motivation to serve
— they should be men of wisdom—the
ability to do the work applying their
knowledge and understanding.
Seven persons were chosen and anointed
and set apart for this task. It is said that
the community was very much pleased. The
word 'diakonia' is the same as used for the
activity of the Apostles, namely, the ministry
of the word, and also to refer to the ministry
December 1984
to the widows—i.e., serving them at the
table. Interestingly, both are considered as
part of the same ministry of 'diakonia'. This
is perhaps the earliest reference to the
professionals in the context of the Church.
Let us now, examine the role of the
professionals in the Church in our own
context from this perspective. Let it be
clearly understood that their role remains
the same today as in the days of the early
Church, as seen aganist the overall mission
of the Church. It should be a matter of
concern, that as time rolled by, the nonpastoral/non-sacramental ministries were no
more seen as related to the mission of the
Church and as a result, there was no sense of
call and commitment on the part of those
who served in the service institutions of the
Church including that of healing. Examina
tion of a few basic issues appears to be
germane to our discussions. Why, after all,
are we involved in the ministry of healing ?
Whom do we serve and how do we serve ?
Answers to these questions, hopefully, will
help to throw insights as we grapple with
this vital issue relating to a people-oriented
drug'policy.
Why do we serve ? What is the
relevance of the institutional ministry of
healing ? The answer is direct and straight
forward : we have the master's commission
to abide by, and his own example to follow.
'Heal the sick' and 'preach the Gospel'—
was the commission given to the disciples.
The Gospel is replete with examples of how
Jesus dealt with the* whole problem of
disease. He had compassion on the crowd
for He felt they were without leadership —
41
sheep without shepherd. He therefore
taught them and healed the sick—a masterly
illustration of an 'educational diagnosis1 of
the problem at hand followed by a combina
tion of approaches 'educational' and 'service'
to solve it.
He has demonstrated several approaches
in the healing ministry e.g. 'reaching out'
to bring hope and health to people—the oftquoted incident of how he went out to meet
the impotent man at the pool of Bethesda
waiting for a cure for 38—long years; bring
ing hope and health to those ostracised by
society as in the case of those suffering from
leprosy. He walked through Somaria—no
jew with self-respect would like to do that—
to meet a group of ten, afflicted with this
disease, of whom nine were Jews as they
could not have safety and freedom in their
own country and society. He used physical
remedies, at least once—the making of the
mud-paste with spittle and applying it on
the eyes of a blind man and making him
wash it in a particular pool-symbolic of the
use of a physical remedy in the cure of a
disease.
Whom do we serve ? A highly searching
question! Here we see the Master had
distinct priorities—-the priority for the least
of the brethren of Mine'—the poor, the
socially disadvantaged, the out-castes. He
identified himself with the least of these
brethren who have all along been neglected.
How do we serve ? What is the 'model'
of service we are provided with ? We find
here that the central emphasis" is on
'abundant life'—life in its fullness and
richness. He demonstrated care of the
physical body as well as those of the mind
and soul as an integral whole—the concept
of viewing health in its 'totality'. We have a
remarkable incident to illustrate this : The
woman who had an issue of blood for
twelve years whom no physician could cure
42
and who in the process had lost all
resources, took a bold step, a venture of faith
at that, walked through the crowd, and on
reaching Jesus, caught hold of the hem of
His garment. The story is familiar. She
was healed immediately. But the way the
Lord dealt with her helps us to gain deeper
insight into the wholesomeness of the
ministry. To the great horror and amazement
of the crowd He addressed her as 'daughter'
and by the use of that tender word He had
recognised her adoption into the family of
God. Jesus knew she was 'penniless, still
ostracised, through she was healed How
would society treat her ? How would her
family look upon her—and the religious
rulers ? Her acceptance back into society
was a matter of great concern to him as part
of the healing ministry. We have these
glimpses into the pattern of the healing
ministry of Jesus which provides a model
that has an all-time appeal. It has great
contextual significance to us who are
involved in the healing ministry in one way
or the other.
During the last two years, I had occasion
to closely observe the activities and the style
of functioning of a few 'popular' mission
hospitals in my own state of Kerala. The
issues regarding drugs in hospital practice
may be examined closely without any pre
conceived notion or bias. The issues relate
to the selection, purchase and procurement
of drugs and medicaments including what
is locally compounded for routine use; the
discretion exercised by the physician in the
choice of the drugs while prescribing, as a
part of clinical management, and the
dominent influences that guide these two
processes.
Most of our institutions do not have a
drug purchase policy, not even an approved
formulary on essential drugs is available,
with the result, the guiding considerations
Medical Service
in the purchase and choice of drugs are
purely in terms of financial or material gains
accruing therefrom. It is in this context, that
our doctors are influenced by the medical
representative and his biased literature.
Let us for a moment put ourselves in the
unenviable position of the doctor who is
working all alone in a remote rural area in
charge of a hospital. The communication
facilities in the area and the general develop
ment are such that he is functioning, as
though in isolation. There may be a ricketty
bus plying that way, that is more often than
not, sick and off the road. The doctor is
ungrudgingly and faithfully doing the difficult
job of tending to the needs of his poor
patients. He is cut away from society and
the companionship to which he is used to.
Then one day, drops into his O.P. depart
ment, a handsome young man, immaculately
dressed with a broad and winning smile on
his face and extending an unbelievable order
of courtesy in his total demeanour. This is
his first encounter with this young doctor.
He condescends to describe it as an event of
great significance and as a matter of pride
for him, and worth all the trouble of plying
long distances on his motor cycle, on mud
roads. The scene is familiar. The doctor
welcomes him with all the warmth. Then
follows an interesting 'scientific' session, on
the new products put in the market by his
'reputed' firm and major claims about their
therapeutic superiority—an excellent display
in effective communication (though often
one-way!) using well-produced, attractive,
highly colourful and appealing visual aids
(some even excel cine-adsl). The shining
leather bag bulging at the seams is laid open
and the display starts, of product after
product. He is liberal with samples. He
also leaves at least a few items which have
some attraction even to the doctor e.g.
tonics for his wife or parents or multi
vitamin drops for
his children (how
December 1984
considerate!). He Is also careful to gift-away
some trinkets. The doctor is overwhelmed,
this being a novel experience.
A new
relationship is born. The order book is pulled
out, concessions are announced which
includes 'deferred payment' and 'attractive
margins'. The deal is struck.
Let us dispassionately look at the scene.
Who is at fault? I would be rather careful in
my pronouncement. The ecounter described
has social implications more than anything
else. For the doctor, this is perhaps the
first occasion after leaving the medical
college when someone has attempted to talk
about the so-called 'recent advances' in
medicine and for no fault of his, the academic
isolation is going to continue for a long time
to come, till he is ultimately branded as a
'back-number' professionally. Continuing
education is something we usually talk about
during annual conference when the medical
educationists and health planners meet, but
no serious efforts till now, have been made
in this direction. I am certainly aware of
some major contributions in recent times in
this direction which is laudable. But it
calls for a tremendous initiative, on the part
of the Government as well as our teaching
institutions to become functional and opera
tive. Under the regionalised plan of health
services it should be the direct responsibility
of medical colleges and training* institutes to
maintain bridges with peripheral institutions
owing and adopting them, and providing
professional support which includes continu
ing education.
Let us look at the issue of drugs as a
source which can bring greater monetary
gains for the hospital. Let us frankly admit
that today success or otherwise of our
institutions are measured in terms of material
gains and financial stability and not in terms
of the quantum or quality of care they
provide. No wonder the doctors fall easy
victims to the temptation of looking at drugs
43
from this perspective, in spite of its
professional moral and ethical implications.
We believe no doubt, that rational therapeu
tics is based on as accurate a diagnosis
as possible. Taking into account the present
constraints of diagnostic facilities in our
institutions, the doctors, have to place greater
reliance on clinic history and physical
examination and also depend on the existing
lab facilities. Here again we are confronted
with the familiar problem about the need and
relevance of the investigations usually
ordered, for other considerations, need not
necessarily keeping the interest of the
patient as supreme. We are placed in a rut,
where we are ready to sink our values; the
doctors are tempted to order investigations
with the sole aim of material gains.
We often blame doctors for injudicious
use of antibiotics and chemotherapeutic
drugs, choice of which is often made through
purely arbitrary 'hit arid try' methods, often
with serious consequences to the patient.
How many of our hospitals, even the major
ones have facility for performing 'culture and
sensitivity tests'?
Let us admit that we cannot put the
blame on the professionals alone for the
maladies that plague our institutions. Our
institutions to be true to their 'first love' and
carrying on the unique role of caring and
service especially of the under-privileged
befitting their calling, need help and support
from the church in a large way.
No meaningful discussion on the futuristic
role of the institutional ministry of healing
can be initiated without a clear understand
ing of the role and responsibility of the
dioceses, i.e., the individual Churches and
the congregations they represent, in this
whole endeavour. At the outset, let it be
made clear that achievement of any measure
of success in the attempt to bring about the
44
much-needed awakening and community
orientation, depends largely on the positive
response to the call from within the Church
itself. At present the Church is involved
only at the 'decision making level' working
through the controlling bodies, i.e. com
mittees and the extent of actual involvement
of the congregations in the healing ministry
is, at best, only notional. Let me reiterate
that the new orientation we want to bring
to bear on the institutional ministry of
healing calls for a radical departure from the
past both organisationally and in terms of
values and wherein our congregations have
a major stake.
The tradition and practice hitherto have
been to visualise the entire activity of the
healing ministry as an exclusive domain and
preserve of a handful professionals, both
men and women, who ungrudgingly continue
to perform their professional role in generat
ing a variety of the much-needed services for
the sick.
Our congregations, and the
members of the church have to visualise a
totally different role for themselves vis-a-vis
the ministry of healing a role that calls for a
sea-change in their very attitudes and
conception. From being exclusively the
'beneficiaries of care', and holding a position
of advantage at that, or at best being
'passive onlookers' in the total scenario,
they are to be elevated to function as
'providers of care' and as 'partners' in the
mission of the ministry.
It is said that people of the nations are
going to face the Son of man as the King on
the final day of judgement, where the only
yardstick to be employed is in terms of the
individuals' contribution to heal the sick, to
feed the hungry, to clothe the naked etc.
The 'qualifying service' it is further clarified,
is what you render to the least of these
brethren of MINE. Let it be understood
that even as related to the ministry of
Medical Service
healing, it does not draw any distinction
between the role of the professionals and
that of the laity, for the King's sacred com
mission binds all alike.
I have very often felt that we have
hitherto failed in putting across this challenge
to the fellow-christians in our congregations.
Let it be made clear that the responsibility
of caring for the sick and the suffering has
to be perceived as a joint venture of the laity
and of fu.c professionals playing a role com
plementary to one another and both pooling
and sharing their 'resources'
towards
achieving the same objective. The work and
mission of the healing ministry both in
breadth as well as in depth has to be
perceived in this light, where not only each
congregation, but each Christian family and
each member of the congregation is a share
holder in this prestigious gilt-edged security
which pays rich dividends.
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45
Towards a people-orientated drug policy
what can be done at the pharmacy level?
—Alan Crammer
Underlying what is to be said here is the
fundamental principle that the service offer
ed to patients must be a quality service.
Striving for a rational drug policy must not
go against proper presentation of work which
must be the best that can be achieved with
the available resources.
To achieve a quality service in accordance
with a rational drug policy in the Pharmacy,
control of that service professionally and
administratively is essential. To achieve su
ccess it become necessary not only to involve
the Pharmacists, but also the users of the
service which in this context means the med
ical and administrative staff of the Hospital.
The Pharmacy Committee
Of necessity that subject can be dealt
with only briefly here. The objective of the
Committee is to involve the users of the Phar
macy services, and administration in its con
trol and development. The non-Pharmacist
professionals should not be expected to
advise on the technical aspects of the work
for which they do not have the experience.
This simplifies the choice of persons to serve
on the Committee, and this we will consider
before its functions.
The constitution of the Committee might
be in a 300 bed Hospital :
1.
Medical Superintendent, chairman
2.
Chief Pharmacist, secretary and con
venor •
3.
Medical Specialist
4.
Pediatrician
5.
One other senior doctor
6.
Administrator
December 1984
7.
Other staff by invitation when sub
jects of special interest to them are
to be discussed
8.
Where possible, a second Pharmacist
Meetings should be held regularly even
if it appears that there is not a lot of business
because very often something of importance
does come out in discussion. A meeting
once a month may be sufficient, but they
may be more frequent in the early months
of the Committee's existance.
Functions of the Pharmacy Committee
in relation to the Drug Policy
1.
To implement the medicines policy
of the Hospital management.
2.
To prepare and publish a Formulary
of approved medicines, including the
rules for prescribing.
3.
Examine requests for medicines to
be added to or deleted from the
Formulary.
4.
To set out the detailed purchasing
policy, including :
a)
deciding which medicines are to
be purchased
b)
deciding which basic medicines
are to be purchased and which
fixed dose combinations, if any,
bearing in mind the fixed dose
ratios and unnecessary ingre
dients.
c)
deciding which manufacturers are
to be preferred bearing in mind
quality and cost.
47
d)
considering if drugs banned in
other countries should be purcha
sed, for example, analgin and
oxyphenbutazone.
professional interest lessened with the decre
ase in medicines being dispensed.
3. Nurses may feel that their work is being
affected if medicines prescribed for their
e) whether medicines from other patients are not readily available in the Phar
systems should be purchased
macy.
since these are frequently multi
4. AH Staff who attend the Statf Clinic
drug formulations and no works
seem to expect that they will receive any
of reference about them are
medicine that is prescribed for them and
available.
not infrequently press the doctors for expen
5. Producing minutes of the meetings
sive formulations. If these are not stocked
and publishing them and ensuring
in the Pharmacy and not prescribed for other
that decisions made are conveyed to
patients, it will indicate that the rational
the persons affected by them.
medicines policy is really being implemented.
6. In the early days of the life of the
All persons working in the Hospital must
Committee much time will be needed
be kept informed of every stage of the
to examine the list of medicines
rational drugs policy. This does take time
stocked and to decide whether or
and requires meetings* and some printed
not each one is to be retained.
material from time to time. This investment
7. To ensure that proper stock control
in time will repay the effort and achieve the
measures are carried out such as
understanding and co-operation of most of
ABC analysis, re-order levels, econo the staff.
mic order quantities, etc.
There is going to be a need for a sense
8. Non-Formulary purchases must be
of discipline among the medical and Phar
kept to a minimum.
macy staff if the* Pharmacy Committee is
going to succeed in implementing a rational
Introduction of Changes decided by the
drug policy. Senior staff will have to take
Pharmacy Committee
great trouble to supervise properly the
* There is likely to be some resistance to juniors in their prescribing, and thus teach
changes recommended and such may include. this policy's requirements. This should be
1. Medical Staff probably will not be founded on the Formularly and Prescribing
of one mind on all the decisions made. For Rules, a copy of which each medical officer
example, adhering to formulary medicines in
should receive, and must read.
prescribing may be interpreted as interference
The Pharmacists will have to be disciplin
in the jealously guarded freedom to prescribe ed in implementing the Policy, and full
the medicines the doctor considers necessary
suppport must be given to them by the
for the patient. Frequently prescribing non Medical Superintendent, and members of the
formulary medicines will make the work of
Pharmacy Committee, when it is necessary
the Pharmacy more difficult, and sending
for the Pharmacists to take any action when
prescriptions outside in the first instance may
the Policy is ignored by other professional
lead to errors and delays in treatment.
staff. In their dealings with the manufactu
2. The Pharmacists may feel that their rers and suppliers they must behave correctly
volume of work is being reduced and .their at all times.
48
Medical Service
Dispensing Services
As stated there must be and must conti
nue to be a high standard of professional
exellence in the service to the patients. The
compoinding activities should be continued
and expanded where this is found to be
economically feasible. Dispensing of medi
cines to patients should be correctly carried
out including the use of correct containers
and seals, packaging, and complete labelling
preferably in a language known to the pati
ent, and for those who are illiterate suitable
symbols should also be used.
Contacts with the patients gives opportu
nities to explain the meaning of a rational
drug policy, and what it can mean for them
in terms of successful treatment and econo
mically. Time thus spent is valuable to try
to persuade them that expensive formula
tions, or a prescription with many items, are
not necessarily the sign of a good doctor or
a certain cure. To further such efforts a
member of staff may be given the responsi
bility for addressing the patients in groups
or individully, and a series of posters giving
information on the proper use of medicines,
and the dangers of self medication with
potent medicines, could be displayed in the
waiting areas.
Pharmacists should be encouraged to
sujvey critically the medicines in the Phar
macy, and elsewhere, and to discuss their
merits and demerits with their colleagues.
Medical staff can help the Pharmacists by
explaining the reasons for prescribing medi
cines in. special cases.
Medicines in Community Health
grammes
Pro
The medicines to be supplied to the
Community Health Workers will have been
worked out by the Community Health staff,
and the Pharmacists and should be approved
December 1984
by the Pharmacy Committee. The Pharma
cists will prepare the indents for the CHW and
they will have to take care that there is no
addition of unauthorised medicines. It should
be clear in the experience of the CHW and
the Pharmacists, that the simple medicines
they are asked to use for their patients to
treat common ailments will also be used for
their patients to treat common ailments will
also be used for patients who come to the
Hospital with the same conditions Too often
patients .reporting directly to the Hospital
get much more expensive medicines which
certainly is not national.
Relationships with Suppliers
The Pharmacist's contacts with the sup
pliers is through the literature they produce
and through visits by the companies' repre
sentatives. Meetings with the representatives
are influenced by what the doctors prescribe
or promise to prescribe, and what is stocked
in the Pharmacy. The Pharmacist will have
his own opinion about suppliers and their
medicines and these should be listened to
in the Committee. It is not only quality of
the medicine about which he will have
knowledge, but also cost, delivery time,
record of business of which he will have had
experience’.
In meeting the representatives, the Chief
Pharmacist should keep in mind the Hospital
Medicines Policy, and make it clear in what
types of products the Hospital is interested.
Often Pharmacists do not know how to
handle meetings with representatives, and
they need help, as do the Medical staff, on
how to do this. It must be remembered that
many representatives are trained in 'high
pressure' salesmanship, and the results of
this can be seen in many Hospital, where
there are excessive stocks of medicines, or
unsuitable items have been purchased and
then not utilised.
49
Training in this aspect of Pharmacists' work
should include:
1.
Making plain the Hospital medicines
policy
2.
Learning to assess special Offers,
and discounts.
3.
Learning how to seek scientific litera
ture rather than the glossy, unimformative papers generally offered.
4.
Learning the type of questions to ask
representatives on pharmacology,
and the rationale behind formulation.
5.
Learning to make it clear that he has
no interest in personal inducements
to place orders which some compa
nies unfortunately resort to at times.
6.
7.
8.
Learning not to divulge any of the
Hospital's private business which
may then be used to exert sales
pressure.
Learning how to terminate an inter
view. Too much time is taken in
many Hospital pharmacies on enter
taining representatives, and this time
is therefore denied to the patients.
1.
Does it fit in with the Hospital medi
cines policy ?
2.
Does this product merely replace on
already in the Pharmacy ? If so is
there any valid reason for considering
a change ?
3.
Did this company originate the
medicine ? If not, has any research
and/or clinical trials on bioavailability
been carried out ?
4.
Is there any good scientific literature
available for the product ? Does the
literature include toxic effects and
contra-indications in a clear and
complete manner ?
5.
What is the experience of the Phar
macy with this company ? Are quality,
availability delivery time, etc satis
factory ?
6.
What is the appearance, of the pro
duct ? Is it satisfactory or does it
leave doubts as to quality ? Can any
tests for quality be carried out ?
7.
What is the pack size? Is it a normal
dispensing size or a bulk back
requiring packaging in the Pharmacy ?
Are suitable packing materials avai
lable ? Is the packaging unnecessa
rily expensive ? Does it properly
protect the contents ?
8.
Is there any possibility of compound
ing a similar preparation in the
Pharmacy that would be as good and
less expensive ?
Learning not to give orders to repre
sentatives since this can become a
source of difficulty at every visit.
These points if remembered do help the
Pharmacists (and doctors) in these contacts
which may be useful in other ways.
Assessment of Sources of Medicines
The Pharmacist will need to assess the
medicines that he is being asked to consider
recommending for inclusion in the Hospital
Formulary. He will have to find satisfactory
answers to the following questions, and
perhaps to some others in special circums
tances :
December 1984
Education
This is important for the basic education
of Pharmacists in their degree or Diploma
courses needs to prepare them for a rational
medicine policy. It is doubtful if this is
sufficiently emphasised at present. The
51
majority of diplomates do not go into Hospi
tal service but in to medical shops where the
emphasis is placed on the business aspects,
and their contacts with prescribers are mini
mal. Both groups need to be taught the
need for a rational drug policy, and to per
suade them that the legal requirements
relating to the supply of medicines must be
strictly followed. The present 'free for all'
in the prescribing and supply of medicines
must be contained if real progress is to be
made in achieving health for all by the year
2000.
It is necessary to stress the same princi
ples in the basic education of doctors and
nurses also. The ignorance of, and some
times contempt in which the law is held is
extremely serious, and has moral implications
too. All three professional, groups must
realise that each one is responsible before
the law for what he does and writes, and
that he alone can answer in the court should
a serious mistake be made. Perhaps all
should be encouraged to understand this
before setting out on a career in medicine,
nursing or Pharmacy.
Continuing Education
Already this has been mentioned in the
case of introducing the rational drug policy
to staff of the Pharmacy. A wider sphere of
training should be encouraged by providing
opportunities to attend Workshops and
seminars to increase knowledge and under
standing of their work. It is to be hoped
that if there are no sessions on a rational
drug policy that it will be an underlying
principle of the programme. What the
Pharmacists gain from such courses his
institution gains in his developing service.
Readin
We expect Pharmacists to know about the
rational drug policy and something of the
national compaigns to bring this about, and
even more to know about the medicines he
prepares or purchases and dispenses. Yet
52
how many Hospitals provide any reading
material ? Many have books in the Pharmacy
which are of historical interest, but of little
current value! Books in recent editions must
be kept in the Pharmacy for quick andeasy
reference, and not in the Hospital library
where there will seldom be a chance for the
Pharmacist to refer to them. Senior staff
must encourage others to read and study
what is available.
Relationships with Hospital Colleagues
Some changes are needed here for the
rational drug policy really to work. Relation
ships depend upon individual character, but
too often team work is not seen, but rather
separate groups working on promoting their
own interests. These groups are often pro
tective of professional interests, but some
things not directly related to these have
effect on Pharmacists :
. 1. Social differences between different
professional groups often makes it
difficult for him to express his
opinions.
2. His comparitively short course, of
training and often lack of useful
experience do not allow him to give
detailed reasons for his opinions
These cause shyness, often experien
ced as total silence in meetings where
his experience and opinions would be
helpful.
These may also cause him to be
under pressure from members of
other groups to circumnavigate
clearly laid down Hospital rules
because he finds it difficult to poli
tely and explain and carry out Hospi
tal procedures.
These types of problems have to be
worked at positively by all groups involved
so that the implementation of the rational
drugs policy may be successful not only
for the institution, but much more for the
benefit of the patients whom we seek to
serve.
Medical Service
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