HEALTH
 Drugging
the Third World |
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Overdose
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).
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