issue 165 - November 1986
Photo: Dexter Tiranti
Who killed Rosario?
The Philippines is not renowned for the good health of its people.
And so the expectations of the saving grace of modern medicine
run high. Yet Michael Tan finds that the chaos of the free-for-all
market is doing as much to endanger community.
ROSARIO lived and died in Tanyong. The youngest of four children, she resembled most of the other infants in the community: under-nourished and pot-bellied from intestinal parasites. She and her siblings were all fed on condensed milk, her mother having been advised not to breastfeed because a doctor said that she had a 'heart condition'. Rosario had constant bouts of diarrhoea and respiratory infections. But it was not until she went down with measles, complicated by coughing and diarrhoea, that her parents decided to take her to a health centre.
The physician there prescribed three drugs that would last four days. The cost of the drugs was $4.50, equivalent to three days wages for Rosario's father. Since Rosario did not seem to be responding to the treatment and because the family did not have the wherewithal to buy more drugs, the treatment was stopped. Rosario's condition worsened. After her parents had borrowed a further $7.50, they took her to a private hospital. The cost of the overnight stay plus dextrose and other drugs came to $15. She was brought back home and died within a week. Rosario was a year and a half old.
The story of Rosario is a factual case study used by Philippine health groups to explain the health care system. The setting is the barrio Tanyong, one of the more than 600 slum colonies of Metro Manila. Some 8,000 people are crammed into five hectares of land, living next to a polluted river which in the rainy season literally submerges houses with flash floods. In the summer stagnant water sends up a foul stench.
Whenever Rosario's story is told at health workshops and seminars, participants are asked why she died. The answers vary, ranging from 'complications due to measles' to 'poor sanitation' to 'poverty'. All the answers are, in part, correct and form a chain of causes involving the economic and political determinants of health and disease. It is rare however, that the drugs used to treat Rosario are questioned. Even highly politicized health professionals know little about the problems of irrational drug use.
Let us look at the three drugs prescribed for Rosano: Mucolex, Keflex and Guanamycin manufactured by Paediatricia (a local firm), Eli Lilly (a US subsidiary) and United American (a local firm) respectively.
Mucolex is basically glyceryl guiacolate, an expectorant. There are more than 40 other brand names with glyceryl guiacolate, many cheaper than Mucolex but less heavily advertised. Steam inhalation would have given the necessary relief from the dry cough, but such forms of treatment are considered outmoded by 'modern' physicians.
The second drug, Keflex, was the most expensive. It is prominently advertised on the cover of the latest Philippine Index of Medical Specialities for bacterial respiratory infections, 'tough on the infection, gentle on the patient'. It is one of the brand names for cephalexin, one of the newer antibiotics; older antibiotics are seen by many doctors as less effective. Often they are. A lot of resistance has built up to the earlier antibiotics, helped by physicians' indiscriminate over-prescribing. Today the Philippines has the world's second highest rate of penicillin-resistant cases of gonococcal (bacteria causing gonorrhoea) infections. Similar problems exist for tuberculosis and bacterial gastro-intestinal infections.
The last drug, Guanamycin, competes with almost a hundred other anti-diarrhoeals on the Philippines' market. It contains kaolin and pectin, which are absorbents, together with the sulfa drug and the controversial antibiotic streptomycin, which elsewhere is strictly regulated for use only with tuberculosis. Such combination of drugs are considered useless, even dangerous for diarrhoea.
Rosario's case is repeated every day. Like other Third World countries the Philippines faces a paradox: too many drugs on the market yet priced beyond the reach of most. For 32 per cent of urban and 41 per cent of rural people live below the poverty line.1 Not only are drugs too expensive, too much money is wasted on inessential medicine. Manila is full of drugstores with names like 'Mercury' and 'Miracure', often operating 24 hours a day. Yet you cannot help but notice the anxiety of the customers and the way they grimace when the bill is presented. How are they to sort the wheat from the chaff; which medicine is essential for their baby and which is useless or positively harmful? We have gone through Rosario's medications - all of them useless or dangerous. But this was no exaggeration. Indeed her prescription was fairly reasonable compared with others which could have included a vitamin, appetite stimulant and one or two antibiotics.
There are over 10,000 different brand names of drugs in the Philippine market. For the average physician the choice of brand will often depend on the latest promotion from the drug sales representatives deployed by the industry. Glossy brochures, scientific literature and free samples will all be thrown at the doctors. Some promotion has become so extreme that members of the Philippine Medical Association have denounced it as 'bribery'. Methods have included paying for trips abroad for doctors, meetings in five-star hotels, lavish gifts of medical apparatus and entertainment including 'girlie' shows - literally the 'wine, women and song' approach.
Little objective information is available to doctors and other health workers. During a recent conference of health professionals a snap survey was conducted. It included a question on the components of three common over-the-counter analgesics. Only 17 of the 70 participants returned the questionnaire, and only one - a nurse - had the correct answer to that question. Asked why they did not return their forms, the missing 53 admitted they were just too embarrassed about how little they knew about pharmaceuticals.
It is not just doctors' ignorance which plagues the health care system but also their arrogant elitism. Physicians are unwilling to admit gaps in their knowledge and resent intelligent questioning from their patients. Others, when told of adverse drug reactions, shrug off the reports with comments like, 'I've prescribed it a thousand times and never seen any side effects.' Those who suffer side effects, it is conveniently forgotten, do not return to that physician. Then there are the expectations of patients, bombarded with adverts on the 'newest, improved' version of an old drug. For a doctor to suggest a simple, low-cost pain-killer such as aspirin or paracetamol might be thought 'old-fashioned'. So the physician might, for example, be pushed to prescribe Zolben, the latest brand name for paracetamol introduced recently by Ciba Geigy and advertised as working more rapidly because it comes in a soft gelatin capsule. Zolben, incidentally, costs four times more than a generic preparation of paracetamol.
People's own misuse of medicine doesn't help. Old prescriptions are stored and recycled, to save on consulting the doctor again. Inessential or dangerous medical advice can therefore be multiplied, particularly when friends and relatives share the prescription - but with modified dosages based on their own experience or the depth of their purse. So the neighbourhood grapevine further distorts the uses of drugs. Drugs to treat tuberculosis, explained by the doctor as 'to strengthen your child's lungs', become vitamins when passed on to neighbours. Oestrogen-progesterone preparations 'to regulate your menstrual cycle' become abortifacients since the Tagalog (local language) euphemism for abortion pampabalik ng regla translates as 'bringing back menstruation'.
The chaos is not accidental. Although there are more than 300 drug companies in the Philippines, most of the market is controlled by a few giants. United Laboratories, owned by a close associate of deposed President Ferdinand Marcos, has about a quarter of total sales. Much of the remaining sales are grossed by a few multinational corporations - represented by the powerful Drug Association of the Philippines. It has effectively blocked the adoption of an Essential Drugs List and fiercely resists attempts to reduce pharmaceutical imports or to introduce stricter regulation of the industry.
Often the interests of physicians and industry are linked. There are physicians who receive useful incomes as medical directors or consultants of drug firms. Others operate private clinics or hospitals and feel indebted to industry for donations of free medical equipment and drug samples. There are also family interests to protect. In many rural areas it will be a close relative of the doctor who owns the pharmacy next door to the surgery. Corazon Aquino's new government has restored many democratic institutions, but the political clout of the drug industry remains intact. When the new health ministry announced they were considering an Essential Drugs List, the drug companies protested. One argument was that such lists were only adopted in 'communistic and fascistic' countries. At one discussion on pharmaceuticals, the consumer movement's rational drugs campaign was labelled as part of 'an international communist conspiracy'. Such red-baiting may seem comical. But it also shows how little has changed since the downfall of Marcos.
Solving such problems will be tough. Objective information about drugs is required. Health professionals need to know the implications of every pharmaceutical preparation they prescribe. And the industry itself needs control. Whether the new administration will grasp the nettle remains to be seen.
Dr Michael Tan teaches at the University of the Philippines, has written two books on the medical properties of plants, and heads the Health Action Information Network (HAIN). The address of HAIN is 49 Scout Madrinan, Quezon City, Philippines.
1 The State of the World's Children 1986,UNICEF.
Brazil - where the President is a hypochondriac
'No fewer than 85 per cent of pharmaceutical sales in Brazil are without medical advice,' according to the Professor of Medicine at the University of São Paulo, Andreas Korolkovas. The most well-known case of self-prescription is the president himself; José Sarney. Breakfast guests frequently comment on the row of different coloured pills which appear on the table, as Sarney carefully doses himself up for the day.
Advice at the pharmacy is usually given by totally unqualified assistants; only 17 per cent of São Paulo's shops have a single qualified pharmacist. And that's in the city. These assistants frequently recommend antibiotics, even for trivial complaints. And the risks involved in the abuse of strong drugs are never mentioned. It is much worse in the countryside, according tot he president of the Regional Council of Pharmacy in the underdeveloped north-east. 'Some of the people who run pharmacies can scarcely read. I met one in the interior of the state of Bahia who had just sold his butcher's shop to set up a drugstore. It is indicative of the mentality.'
During 21 years of military rule, the government openly advocated self-medication as the only way those excluded form the health services could have access to modern medicine. Commercialization was welcomed. As a result medicines have become like chocolate cookies or hair shampoo - sold through advertising, particularly on TV. Pharmaceutical companies regularly launch new products - or products presented as new by adding an extra vitamin to an already established remedy - and promote them heavily. Such drugs, generally for the treatment of common ills such as colds or headaches, provide the bulk of sales turnover.
Though international health organizations say that only 200-300 medicines are really essential, Brazil has 25,000 different remedies sold in 45,000 different presentations. The profusion has reaches absurd proportions; there are 50 different remedies for a headache, 1,806 based on vitamin C, 1,749 remedies with riboflavin and 2,021 different forms of B-12.
Without the resources to supervise such a sprawling market, the health authorities shrug their shoulders. There is no real attempt to check out the products. 'It is director of bio-technology at the institute of Butana in São Paulo. Two-thirds of the remedies on sale don't have the effect they say, don't have any scientific basis. We urgently need new laws and effective controls.'
Furthermore, heavy advertising creates the dangerous illusion that modern medicine is both powerful and innocuous. People are led to believe that modern drugs are the answer to all their health problems. Shanty-dwellers are not aware that their asthmatic coughs and their children's chronic diarrhoea are probably the result of their harmful combination of malnutrition, air pollution and inadequate sanitation. Instead they are encouraged to run up heavy bills by purchasing expensive medicines. Many are disappointed if doctors do not prescribe them an abundant supply of drugs or better still, give them an injection. Very few, even among the better educated, have any ideas that medicine itself can create illness.
The pharmaceutical industry is divorced from Brazil's real health problems. Provoked no doubt by the country's severe recession of 1982 and 1983, in turn the result of the debt crisis, health standards have been falling. A number of serious illnesses have been growing at an alarming rate. From 1980 to 1985 number suffering form malaria doubled from 200,000 to 400,000. Cases of leprosy rose from 200,000 to 350,000. And between six and eight million Brazilians today are infected with Chaga disease - a form of sleeping sickness.
The only sector that benefits from such distorted health care is the pharmaceutical industry. Brazil is currently the seventh largest market in the world with an annual turnover of $1,600 million. In recent years the heady growth figures of the 1970s have dipped, with record sales of $2,000 million in 1982 dropping to $1,500 million in 1983. Even so, the multinational corporations who control 87 per cent of the national market, have been increasing their investments - with an eye to the future. Theirs projections tell them that by 200 AD, annual sales in the country will have reached $20,000 million making Brazil the third or fourth largest market in the world.