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’.
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