issue 165 - November 1986
Three times daily
- habits in India?
There is a curious camaraderie between the long-distance
drug salesman and the isolated rural doctor in India. Dr Trisha
Greenhalgh experienced this while studying the prescription
habits on the sub-continent. She describes a country where
the problems of poverty are neatly defined as illness,
and the solution distilled into a bottle of pills.
It is a colourful market street in a Calcutta slum. The roadside is packed with barrels overloaded with fresh vegetables and fruit. Sacks of rice, grain and beans are piled high on the pavement. I am watching from a pharmacist's shop having just eaten a wholesome meal at a local café for three rupees. A woman approaches, leading two listless children and holding a sickly infant. She tips out the contents of her begging bowl onto the counter: seven rupees, just enough money to buy a small bottle of vitamin drops. Outside the mother sits her three children on a wheelbarrow full of new potatoes and measures into a rusty spoon a half-teaspoonful for each of them.
I recently spent four months in India studying the prescription and sale of drugs. Introducing myself as 'a foreign doctor interested in the diseases in the area', I asked to sit in on doctors' surgeries, rural health clinics and pharmacy stores. Almost invariably I was welcomed, even in the poorest and humblest of settings. The doctors themselves were often struggling to make ends meet, and would work non-stop from dawn to dusk in a tiny surgery in the sweltering heat. I sat quietly in a corner, watching the patients come and go with their various complaints, and writing down which drugs were given. The queues were endless, and in a few weeks I had collected data for over two thousand patients.
What I found frightened me. I had read the statistics and knew that almost a quarter of India's children are dead by the age of five, I knew most deaths were from often trivial illnesses which become killers in conditions of overcrowding and malnutrition. But it was only when I had held in my arms a child dying of measles, and watched another die of diarrhoea, and another of influenza, that the statistics began to have any meaning,
There was no shortage of privately owned pharmacies and no shortage of brightly coloured pills and potions. In contrast the shelves of many of the publicly owned local clinics where medicines were free or very cheap were bare. Patients with tuberculosis, pneumonia, cholera and malaria were being sent home without treatment. Even the most basic essential drugs were not available. Vaccines which could have prevented tetanus, polio, measles and tuberculosis were often as not out of stock.
I found glossy advertisements for new and expensive antibiotics, which could cure exotic and rare illnesses. Qualified doctors, confused by the long lists of indications and misled by the pictures of smiling healthy children in the advertisements, prescribed such products for the common cold or where simple penicillin would have been a better choice - at a hundredth of the cost.
Drugs with potentially fatal side-effects were promoted for minor complaints and sold over the counter without restriction. Chloramphenicol, for example, is a powerful and reliable antibiotic. But it causes death from aplastic anaemia in perhaps one patient in 20,000 who takes it. Its use in the West is now restricted to life-threatening infections; I have prescribed it twice in all my years of practice. In my study in India it accounted for 11 per cent of all antibiotics sold and was the most popular antibiotic sold over the counter without a prescription. Generally a couple of tablets were bought rather than the full five-day course - not enough for effective medical treatment but sufficient to cause fatal aplastic anaemia in a susceptible patient. Although this side-effect is rare, with 750 million Indians using chloramphenicol as their first-line drug, the annual death rate from it may well run into the thousands. Several popular painkillers have similar side effects. Amidopyrine, dipyrone, phenylbutazone and oxyphenbutazone can all poison the bone marrow and are now virtually unobtainable in many countries in the West. One or more of these drugs was given to over half the patients requesting a painkiller from a general practitioner or a pharmacist, although for most types of pain none of the drugs are superior to aspirin or paracetamol.
Of the 16 general practitioners I interviewed not one took seriously the possibility of fatal side effects with amidopyrine derivatives or chloramphenicol. Doctors held the attitude that '... if I prescribe it 30 times a day and it is freely available across the counter, it must be safe'. This attitude cannot be condoned, but it is difficult to condemn. For the majority of rural doctors work in conditions of professional isolation and poverty themselves. There are no colleagues for discussion, no feedback, no system for reporting adverse drug reactions and no access to independent information on the drugs they prescribe. After qualifying, the only further knowledge the rural practitioner is likely to pick up is from the sales representatives of the multitude of pharmaceutical companies. Many salesmen are paid by commission on the drugs they sell. Liberally distributed free samples and financial incentives can be highly effective where the doctors themselves are living below the poverty line. I found the salesmen were often unaware of serious side-effects of the products they were selling. Their combination of genuine enthusiasm with personal financial incentive added a disturbing sincerity to their affirmations. Far from being disdained by doctors, pharmaceutical salesmen were welcomed with great ceremony as fellow professionals in an otherwise lonely subculture.
I remember staying with an elderly doctor in Tamil Nadu. Already given away were the textbooks I had brought from England and so his name was added to the growing list of doctors who begged for 'even some small book from your shelf.' He persuaded me to wait till Monday, when the 'drugs man' would call, and at six in the morning we climbed the little hill outside the village to watch for the dust-cloud of his motorbike. On arrival the three of us rode triumphantly into the village for a special breakfast served by the doctor's daughters. The drugs man did not let us down. He pulled from his dilapidated satchel a selection of red, yellow and brown pills and a small bottle of tonic - a special gift for the doctor's youngest child. He also had pictures, pamphlets, graphs and data sheets which he gave us generously - although he had to buy them from his company himself. He told us of the company's new product - a combination of an antibiotic with twelve different vitamins for children made weak from diarrhoea. The doctor rummaged through the drawers of his desk to find enough money to add this to his monthly order, and then we all climbed the hill to wave his friend goodbye.
The drug companies, I believe, gain more sales through this curious camaraderie than from any form of 'promotion' in the narrower sense. Many companies now produce package inserts with warnings of potentially dangerous drugs, and the indications where the drug is recommended. However this ignores the circumstances in which the drugs are used. Cleverly worded small print (in a language that most of the patients do not speak) provides the multinational company with legal immunity and transfers moral accountability for drug deaths onto the poorly informed, isolated Third World doctor. At the same time the dubious backstage behaviour of the company representatives is ignored.
A Medical Registrar at Whittington Hospital, London, Trisha Greenhalgh is a practising doctor and contributor to The Lancet and other medical joumals.
The promotion of vitamin supplements in India is probably the prime example of how public demand for drugs, and doctors' clinical consciousness, is cynically manipulated by the pharmaceutical industry in a hungry continent. I found a quarter of all drugs prescribed, and over half of those sold over the counter in pharmacies, are food substitutes - vitamin pills, glucose powder, and various types of 'tonic'.
About 90 per cent of India's children fail to reach their full physical and mental potential because of inadequate nutrition. A UNICEF study lists four problems. First and foremost an absolute, quantitative lack of food, which leads to protein-energy malnutrition, increases susceptibility to infection and makes the body unable to make full use of what vitamins there are. Second, anaemia, due mainly to lack of iron and made worse by worm infestation. Anaemia affects 50 to 90 per cent of growing children and 60 per cent of pregnant women. Maternal anaemia is the single most important cause of low birth weight in infants and a major cause of perinatal mortality. Third, iodine deficiency, which has led to an estimated 40 million cases of untreated hypothyroidism (under-active thyroid gland) in India. Fourth, vitamin A deficiency, which affects 5 per cent of people in rural areas and continues to blind 30,000 Indian children every year.
In my study, general practitioners proscribed vitamin supplements to over two-thirds of all patients. Not a single supplement provided an adequate daily dose of all the essential vitamins. General practltioners were eight times as likely to prescribe a product containing the relatively unnecessary vitamin B12 or C than one containing vital Iron or vitamin A. In 9 per cent of all cases less than a day's supply, and in 50 per cent of cases less than a week's supply of the supplement was given. It is difficult to believe that more than a handful benefited significantly from such 'medicine'.
Iron (ferrous sulphate) and vitamin A are classified as essential drugs in India; until recently legislation restricted the manufacturer's profit margin to 50 per cent. After paying for packaging and distribution, it is almost impossible to make a profit. On the other hand, multi-vitamins, protein and glucose supplements are classified as Inessential drugs and exempted from price controls. This, rather than the nutritional needs of the population, may explain the chronic shortage of vitamin A and iron in India.
India is one of the only developing countries which is potentially capable of feeding its population adequately. With the following simple alterations in the production and preparation of food, many, If not all, of the deficiencies discussed above could be avoided: increased production of green leafy vegetables, pulses and legumes, dietary diversification from polished white rice as staple to hand-pounded rice or mixed cereals, popularisation of brown bread, salads, fruits and sprouted legumes, and modifying cooking habits - for example, not adding bicarbonate (which destroys B vitamins) to the water, and not discarding whey or rice water. Cultural habits die hard, and such 'simple' changes could not be introduced overnight. But the products offered to India's poor by the pharmaceutical industry, in their composition and the erratic way in which they are taken, are nutritionally and pharmacologically valueless and serve only to divert people's attention from the problem of finding a balanced diet for a healthy life.
Dr Trisha Greenhalgh