HEALTH Drugging the Third World
At least 25,000 different drugs — many useless or actually harmful — swallow up $9 billion of the Third World’s health budget each year. But WHO says 200 basic drugs are all that is needed to treat the majority of world disease. New Internationalist reports on this massive overdose.
Cartoon: Len Munnik
HOSPITALS all over the developing world should spring - clean their medicine cabinets and throw away 99 per cent of the drugs there. That is the prescription coming from the World Health Organisation’s essential drugs policy. WHO points out that a selection of just 200 drugs are all most countries need to treat the majority of diseases. But there are 15,000 available in India.
‘Essential drugs are those that satisfy the health care needs of the majority of the population’, says WHO. Until these 200 drugs are available to everyone who needs them, WHO believes that expenditure on the other 25,000-odd preparations on the market is a criminal waste of resources.
‘Importation of pharmaceuticals is one of the fastest growing drains on hard foreign currency for developing countries’, explains WHO. The Third World pays the rich world an estimated nine billion dollars a year for drugs. And prices are rising: four times as fast as GNP in many poor countries. In fact, some health ministries are spending over 50 per cent of their budgets on drugs alone. Though, with health expenditure as low as two dollars a head in some countries, 50 per cent doesn’t buy very much. Drug expenditure averages just 76 cents a head in the poorest countries compared to S53 a head in the rich world.
Keeping to a list of 200 basic drugs is part of a general policy aimed at reducing the costs, waste and dangers associated with unrestricted drug availability. The first effect of such a policy is a shift away from and tonics. Recent studies have disclosed, for example, that a fifth of North Yemen’s drug imports and a quarter of all drugs sold in India are tonics, vitamins or indigestion tablets. And in Nepal, where just 2,000 drugs are available, there are 63 types of cough syrup, 42 sorts of aspirin, 79 indigestion preparations and a stupendous 733 tonics.
Part of this flood of inessential drugs is due to the marketing practices of the international pharmaceutical industry. Says WHO: ‘promotion activities of the drug manufacturers have created a demand greater than the actual needs’. According to one estimate, many drug companies spend up to 20 per cent of their entire turnover on advertising. And much of that ts concentrated in the Third World. In Colombia, for example, the money spent on drug advertising is equivalent to more than half of the country’s health budget. In Nepal, Brazil and some Central American countries there is one sales representative for every three doctors — six times the number per doctor in the United Kingdom. And one Brazilian doctor reported that in just 21 working days he received visits from 69 salesmen, wielding 452 free drug samples and 25 gifts.
Not surprisingly this leads to overprescribing on a massive scale. A group of 100 patients in an Ethiopian village are reported to have consumed their clinic’s entire stock of antibiotics — 500 vials of penicillin, 500 of streptomycin, 4,000 capsules of tetracycline and 2,000 of chloramphenical — all in just three months.
As worrying as overprescribing is the fact that manufacturers sometimes recommend different doses or omit to print full information about possible dangers and side effects on the packets of drugs sold in the Third World. Halfdan Mahler, Director General of the WHO, has denounced these double standards as ‘unethical and detrimental to health’.
The dangers of obtaining drugs on prescription are clearly bad enough. But WHO estimates that three-quarters of all drugs consumed in the developing world are just bought over the counter. One researcher met a man selling a dangerous anti-cancer drug with often fatal side effects in a Dacca market place. The salesman claimed not only was it ‘safe’ but that it ‘cured all cancers’. Also with serious side effects is Lincocin, an antibiotic that was the second-best selling drug in Mexico in 1978.
But the dangers come not just from the side effects of hazardous drugs. When a family has to go without food to buy even a harmless tonic or bottle of vitamins, then those preparations are directly contributing to ill health. It has been estimated that just 20 tablets of antibiotic costs a poor family in Mexico the equivalent of two weeks’ basic food for four people.
The best way to cope with these consequences is to take control of drug production and distribution. As Halfdan Mahler puts it: ‘We can no longer treat these vital components of people’s health as normal commodities. They have to be taken out of the market place’. This is why, in addition to urging the adoption of an essential list of basic drugs, WHO is encouraging an increase in generic prescribing (that is according to what drugs contain, rather than according to trade name) and local manufacture. At present only an estimated 30 per cent of drugs are manufactured in the developing world, and this is concentrated in just a few countries — like India, Egypt, Brazil, Argentina and Pakistan.
One thing that has held back local production of drugs has been patents prohibiting anyone other than the company that developed a drug from producing it. But patents for nearly every drug on WHO’s list of 200 have expired. This enables countries to cut costs dramatically either by manufacturing the drugs themselves or by bulk-buying cheaper generic drugs on the world market. In Bangladesh, for example, diazepam made in the local factory costs less than a quarter of the brand-named equivalent Valium. WHO calculates that generic prescribing of essential drugs could save 70 per cent of the drugs bill in rich countries alone.
The international pharmaceutical industry is, not surprisingly, concerned at the widespread support for WHO’s new drugs policy, arguing that if their markets are cut back they will not be able to keep up the present volume of research into new drugs. But WHO points out that just $26 million was spent on research and development of drugs for tropical diseases — only two per cent of the amount spent on cancer research. In fact it has been estimated that only one per cent of all the pharmaceutical industry’s research is on drugs to combat the diseases of the poor world. As WHO comments ‘products are selected by manufacturers on the basis of profitability, not on country health needs’.
Pushing out the drug pushers
Diana Melrose chronicles a poor country’s fight with the international pharmaceutical industry for control of the national drugs market.
The 1978 turnover of the pharmaceutical manufacturer Hoechs was one and a half times the entire gross domestic product of the Yemen Arab Republic. This gives you some idea of the challenge facing poor countries if and when they decide to take on the multinational drug companies.
With a GNP of just $130 a head in 1980 and an economy heavily dependent on outside aid and investment, Bangladesh’s efforts to initiate and maintain an ‘essential drugs’ policy in line with WHO’s 1977 recommendation, stand out as nothing less then heroic.
Bangladesh’s ‘drug history’ makes familiar reading: three-quarters of locally consumed drugs produced by subsidiaries of eight foreign-controlled multinational drug corporations; one-third of drug expenditure ‘on unnecessary and useless medicines such as vitamin mixtures, digestive enzymes, palliatives, gripe water and hundreds of other similar products’ according to an expert committee reviewing the Bangladesh drug market in May 1982; ;imported drugs costing about $25 million a year – nearly twice the 1979/80 health budget; three-quarters of the population with no regular access to vital drugs.
Bangladesh’s new drugs policy was introduces by decree in June 1982. With more than 4,000 drugs on the market, but serious shortages of the 150 drugs the government thought essential for local needs, the decree banned 1,700 preparations. In many developing countries essential drugs policies have been confined just to government facilities – leaving the majority of people, with irregular access to those facilities, still buying expensive, useless or harmful drugs from private pharmacies. But Bangladesh’s policy is almost unprecedented in hitting private as well as public sector drug sales. In Bangladesh private drugs sales are almost 90 per cent of the market.
To give just two examples of the kinds of drugs banned in Bangladesh – and hence the sorts of dangers averted: Amongst the top-selling tonics was Hoechst’s Polytamin Tonic ‘one of the most abused drugs on the market’, according to the May 1982 expert committee. N support of Polytamin, Heochst argues that ‘Bangladesh is in a chronic state of malnourishment: the vital supply of polyvitamins is essential in countries where a balanced diet isn’t available.’ Another drug on the market in Bangladesh, Orabolin – produced by the Dutch company, Oraganon – is a steroid said to ‘help the child grow’. Promoted as one of a number of similar preparations specifically for ‘use in conditions like marasmus, malnutrition, poor weight gain, retarded growth, kwashiorkor etc.’, Orabolin comes as a ‘raspberry-flavoured liquid… especially meant for younger children and infants.’
But to treat malnutrition with a drug rather than with food is ludicrous. As one doctor working in rural Bandladesh pointed out: ‘Malnutrition is treated with food. People will die from lack of calories long before they die from lack of a particular vitamin’.
The Bangladesh government’s action rang alarm bells in corporate board rooms all over the world as directors began imagining the effect on their sales if other countries took a similar initiative. They immediately went on the offensive.
In a concerted campaign to discredit the new policy, raise the hackles of the medical profession over a loss of so-called ‘prescribing freedom’, and enlist public opposition, a succession of alarmist articles appeared in the Bangladeshi press (see illustration).
The threats spelt out were: factories would have to close; foreign companies would pull out; workers would be made redundant; acute shortages of essential drugs would follow; people’s health would be endangered, as would the future of foreign investment in Bangladesh. This echoed the barely veiled threats made almost a decade ago to the ten Prime Minister of Sri Lanka, Mrs Bandaranaike, by the US Pharmaceutical Manufacturers Association hat her new drug policy called into question ‘any future private investment in the country’.
In Bangladesh as in Sri Lanka, the US Embassy was called in to defend the interests of the multinationals. The British High Commission and embassies of other major drug-producing countries also pitched in. A UK government health spokesman explained that they could not support the Bangladesh policy because: ‘there are aspects of the new Bangladeshi policy which are causing concern to the pharmaceutical industry.’
A US expert mission consisting of four member – all representatives of the US pharmaceutical industry – flew in and recommended a substantial watering down of the new policy. And fears for its survival grew- based on the industry’s history of success at blocking legislation that threatens to harm their financial interests. One Minister of Health in Bangladesh was even replaced in 1978 when he sought to tighten up the country’s drug laws.
But this time the Bangladesh Government has held firm, making only minor concessions to opponents of the policy. And companies have since begun discussions with the health authorities on changing their product ranges to comply with real health needs.
But opposition to the policy has continued to surface. For example, despite the fact that some manufacturers have considerable unused capacity and despite the unmet demand for essential drugs, some companies have made workers redundant. In a dismissal letter on one of 90 fired by Hoechst, the company states: ‘In view of the promulgation of the new drugs policy on 12 June 1982 by the Government . . . and consequent upon its impact, the company has lost 58 per cent of its business. Your services therefor stand terminated with immediate effect.’
Workers facing dismissal have had little support. It is not hard to see why. The President of their union – the Bangladesh Pharmaceutical Industry Sromik Federation – is none other than the sales manager of Heochst.
Diana Melrose works in Oxfam UK’s Public Affairs Unit and is author of ‘Bitter Pills’, a book about drugs in the developing world (see NI Books in March this year).