bitter pills: medicines and the third world poor

8/7/2019 Bitter Pills: Medicines and the third world poor

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bi t terpillsMedicines and theThird World poorby Dianna Melrose


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First published in 1982 O XF AM 1982Reprinted June 1983

March 1984April 1987August 1987

ISBN 0 85598 065 6

Printed by Tekprint Ltd., England

Published by OXFAM274 Banbury RoadOxford OX2 7DZ

This book converted to digital file in 2010


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ACKNOWLEDGEMENTSThis book would never have materialised witho ut the invaluable help of experts, colleagues and friends.I am pa rticularly grateful to my colleagues David Bull and A drian Moves for their unstinting adviceand encouragement and for their sense of humour. Special thanks go to David Newell, Julu, Niaz,Saidur and others at OX FA M 's Dacca office and to m edical advisers , Dr. Ton y K louda and Dr. TimLusty. Many colleagues have helped, especially in the Secretarial Services Department, but one inparticular has laboured for many hours produ cing im macu late typescript - my special thanks to BettyHawkins. Thanks also to Alan Bell for producing the index.I wish to thank the OXFAM trustees and members of the Field Committees who devoted time andeffort to helping with improvements to the early drafts, particularly Dr. William Cutting, Dr. ChrisManning and Michael Rowntree, Chairman of the editorial panel.For their expert advice and for the many demands made on their time, 1 especially wish to thankDr. Humayun Hye, formerly Director of Drug Administration in Bangladesh, Professor Mike Rawlins,Head of the Department of Clinical Pharm acology at the University of Newcastle and D r. John Yud kin,Consultant/Senior Lecturer in General Medicine, Whitt ington Hospital , London.1 am grateful to the following for their contrib utions to o ur research and to some also for their helpfulcomments on the early drafts :Selim Ahmed (Voluntary Health Services Society, Bangladesh); Dr. Raj Anand (Bombay);Dr. F. S. Antezana ( W HO , Geneva); Dr. K.M .S. Aziz (Inte rnatio nal Cen tre for Diarrhoe al D iseaseResearch, Bangladesh); Dr. K. Balasubramanian (UNCTAD, Geneva); Sharon Banoff and RitchieCog an (BBC, L ond on) ; Dr. Carol Barker (Nuffield Cen tre for H ealth Services Studies, Leeds); DavidBeynon (Pharmaceutical Supply Officer, Madang Department of Health, Papua New Guinea); DoritBraun; Dr. P ascale Brudon (Geneva); Dr. James B urton and Bill Davies (E CH O , Ewell); Sue Cavann a(Sichili Hosp ital , Zam bia); Dr. Zafrullah Ch ow dhury (G onosha sthaya K endra, B angladesh); RalphCox (DHSS, London); Professor P. F. D 'Arcy (Head, Department of Pharmacy, The Queen ' sUniversity of Belfast); B harat D ogra (Delhi); An ne Fergu son (Michigan State University, USA ); FooGaik Sim (Head , Research and Inform ation, International Organisation of Consumer U nions, Penang);Doris Frizel (Bo Hospital, Sierra Leone); Dr. Jaime Galvez-Tan (Philippines); Dr. L. G. Goodwin(Director of Science, Zoological Society of Lon do n); Dr. C. E. Gord on-S mith (The Dean, Londo nSchool of Hygiene and Tropical Medicine); Bob Grose (British Organization for CommunityDevelopment, Yemen Arab Republic); Dr. Hassani (Director, Norwegian SCF Clinic, Ibb, YemenArab Republic); Dr. Andrew Herxheimer (Dept. of Pharm acy, C haring Cross Hospital Medical School,London); Dr. Ann Hoskins and sis ter Raymi volunteers (Brit ish Organisation for CommunityDevelopment, Yemen Arab Republic); Professor Nurul Is lam (Director, Insti tute of PostgraduateMedicine and Research); Dr. Vida Jelling (ex-VSO); Dr. Juel-Jensen (Oxford University MedicalOfficer); Dr. Sultana Khanum (SCF Children's N utrition Unit, Bangladesh); Dr. Sanjaya Lall (OxfordUniversity Institute of Econ om ics and Statistics); Dr . Jan e Mackay (ex-VSO); Charles Meda war (SocialAudit Ltd. , London); Ross Mountain (UNNGLS, Geneva); Linda Nicholls (pharmacist); ProfessorGeorges Peters (Insti tut du Pharm acologie, Universite de Lausanne); Dr. Ahm ed Rhazoui (U NC TC,New York); Dr. B. Sankaran (WHO, Geneva); Dr. Satoto (Indonesia); Dr. Martin Schweiger; Dr.Mira Shiva and S. Srinivasan (VHAI, Delhi); Dr. Milton Silverman and Mia Lydecker (Universityof California); Dr. Pawan Sureka (Bombay); Ken Temple (ODA, London); Dr. Wanandi (WHO,Geneva); David Werner (Hesperian Foundation, California); the pharmacists at Westlake Ltd.(Banbu ry Ro ad, Oxford ); and Stephen de Winter and colleagues (Belbo Film Pro duc tion s, Netherlan ds).I would like to thank all those representatives of the pharmaceutical industry who have providedhelp and information, particularly David Taylor (Deputy Director, Office of Health Economics,Lon don) ; representatives of the Association of British Pharm aceutical Industries and the InternationalFederation of Pharmaceutical Manufacturers Associations; and executives of Beecham, Boots, Ciba-Geigy, Cyanamid, Fisons, Glaxo, Hoechst, ICI, May & Baker UK, E. Merck, M erck Sharp & Dohme,Organon, Pfizer, Rivopharm, Roche, Sandoz, G. D. Searle, Squibb, Upjohn and The WellcomeFounda t ion .Finally, special thanks to Helen and Chris for encouragement when I needed it most.


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CONTENTSIntroduction

1A Pill for All Ills? 5Diagnosis of Dl Health 5Malnutrition 5Communicable Diseases 6Tropical and Vector-borne Diseases 7Urbanisation and Disease 7The Underlying Causes 8The Remedies 9Essential Drugs for Primary Health Care 102Unequal Distribution 16Limited Health Budgets 18Hospitals or Health Posts? 20Inappropriate Training 22Public Drug Distribution 23Private Drug Distribution 253Producers' Market 27Rich World Con trol 28Placebos in Wasteful Abundance 31Multivitamin Tonics 32Essential Drugs in Short Supply 34Bangladesh: a Case Study 37Non-Essential and Not Sold in Britain 384 Poor Value for the Poor? - Drug Prices 4614 for 100 Aspirin 47"What the Market with Bear" 48It's All in the Name... 48The Competitive Race 49

Brand Proliferation 50Should the Poor Subsidise New Drugs for the Rich? 51Revolution Without the Poor 53An Irreversible Trend to Generics 54Opposition to Generics 56Overpriced Raw Materials 60High Transfer Prices to Bangladesh 60Choices Confined to the Rich? 625 Information or Misinformation ? - Drug Promotion 63The Costs 64Brand Loyalty 67Cost is Secondary? 69"Ac curate, Fair and Objective" 71Partial Information 73


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Cure-Ails 80Sales Inducements 83By-passing the System 85Samples Abuse 85Sledge-hammer Therapy 86Challenging Drug Dependence 90Buyers Beware - Uncontrolled Sales and Problem Drugs 91>You Get Sick, You Buy Medicine 92The Hazards 94'Problem' Drugs 97Antidiarrhoeals 98Bad Information Means Dangerous Drug Use 101Anabolic Steroids 102Painkillers 106Injections 110Antibiotics and Drug Resistance 112

f Traditional M edicine 117Good and Bad Practices 118Reassuring Rituals 119Herbal Medicines 121Plant-based Drug Industry 121Factory-Produced Herbal Medicines 122Local Self-reliance 123Grass Roo ts Integration 124Trail-Blazers - Sma ll-scale So lut ion s 12 9Gonoshasthaya Kendra 129Gonoshasthaya Pharmaceuticals Limited 133Volun tary Health Organisations 138Nepal Hill Drug Scheme 139Bhojpur Drug Scheme 140Village Theatre in Mexico 141

} Healthy So lution s - Third World National 146' and Regional PoliciesMajority Health Services 147Essential Drug li st s 148Safer, More Effective Drug Use 149Generic Names 150Centralised Procurem ent 150Local Production 153Distribution 155Drug Reg istration 156Imp ort and Price Con trols 157Controls on Marketing Practices 158Health Education 159Regional Cooperation 160


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Help or Hindrance? - The Rich World's ResponseInternational OrganisationsRich Worlds GovernmentsNon-Governmental OrganisationsDrug ManufacturersBrave New PoliciesHealthy Profits?Health No w - Action for ChangeThird World GovernmentsRich World GovernmentsInternational OrganisationsNon-Governmental OrganisationsManufacturersNotes and ReferencesAppendix IAppendix IIAppendix IIIADDendix IV

162162167172181190192194194196197198198201255262268271

Index 274


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INTRODUCTIONAS THE BOAT drew into the shore we heard a strange sound from the bank.A wo man was crying. We found her with a dead b aby in her arm s and a collectionof medicine bottles beside her. She had spent all her money on these expensivedrugs . She could not understand why they had not saved her baby. ThisBangladeshi wo man had never been told wha t was obvious to the doc tor w ho foundher. The baby had become severely dehyd rated from diarrh oea . H er death couldhave been prevented with a simple ho me -m ade so lution of water, salt and suga r.No amount of medicine could have kept her alive.Peop le in rem ote mo un tain villages in No rth Yemen are cut off from the co un try 'svery limited health services conce ntrated in the town s. D rug p edlars, know n locallyas 'health m en ', have a ready m ark et. They sell a wide range of sophisticated d rugswhich can have harmfu l side-effects. M ost of these medicines can only be obtaine don a do cto r 's prescription in Eu rope and No rth A merica. S ome have even beentaken off the market in rich countries because the possible risks outweigh theirbenefits. But in Yemen the drug sellers are unaware of the hazards or how thedrugs should be used. Most have acquired their training working as hospitalcleaners, or behind the counter in a drug store.On open market stalls in Upper Volta red and yellow capsules of antibiotics aredisplayed for sale alongside equally colourful sweets. Poor people buy just oneor two capsules at a time to treat themselves. They have no idea that antibioticsare not fully effective unless you tak e a com plete co urs e, or th at tetrac yclin e, leftout in the heat and humidity, can become toxic. But the main hazard from theunco ntrolled use of antibio tics is that bac teria build up resistance to drug s. A poo rcom mu nity can find itself with no alternatives to the drugs tha t no longer wo rk.In 1980 gov ernm ents and aid agencies allover the world respon ded to the plightof the Kam puch ean people by rushing in a mass of drugs they had well-meaninglyscrambled togeth er. But this jum ble of m edicines, labelled in dozens of differentlanguages, created chaos. In the absence of a team of multilingual pharmaciststo sift through them, many potentially useful and useless drugs alike had to bediscarded.Th roug hou t A sia, Africa an d L atin America millions of the poorest have no accessto life-saving drugs. But drugs are wasted and misused worldwide. In poorcountries those that are most needed are often the hardest to obtain, at least atprices the poor can afford. Where the need is for a limited selection of prioritydrugs at low prices, ma nufac turers and retailers come under comm ercial pressureto sell a mass of wasteful, often non-essential products. In some countries the

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market is flooded with an assortment of vitamin tonics, cough and cold remedies,and other expensive combination products, when single- ingredient, basic drugslike penicillin and chloroquine are in desperately short supply.The first-hand experiences of OXFAM colleagues and friends throughout theThird World have made us forcefully aware of the problems. Very few of thepoor benefit from the potential of modern medicines. Valuable drugs developeddecades ago could be used to prevent unnecessary suffering and death. But throughtheir uncontrolled sale and promotion in many poor countries, medicines oftendo little good and can be positively harmful.OX FAM's commitment to the relief of suffering made it our duty to investigatethe problems and publish our findings with the aim of pressing for action to benefitthe poor. This report is based on the experience of OXFAM field staff, projectworkers and friends in many very different countries. But what emerges is a strikingsimilarity in the problems worldwide. The report also draws on a wide range ofboth published and unpublished material in addition to research carried out bythe writer in North Yemen, India and Bangladesh.A doctor in Bangladesh told OXFAM that he is acutely aware of three contrastingbut equally tragic situations . There are patients he cannot help who are dying ofdiseases for which there is no drug treatment. Secondly, the poorest, who cannotobtain treatment or drugs, die of diseases that are curable, and often preventable.Thirdly, and seemingly paradoxically, some poor families make sacrifices andeven go without food to buy unnecessary drugs, when the 'medicine' they needis food.Rich and poor could benefit from new drugs to treat incurable diseases. But onlythe poor are denied the life-saving drugs available to the rich. This report attemptsto unravel the complexities of the medicines issue. The focus throughout is onthe needs of the Third World poor.Chapter 1 assesses the role of medicines in creating better health. Chapters 2 to6 highlight the special problems in the distribution, production and marketingof drugs in developing countries. Chapter 7 focuses on traditional medicine whichremains the major source of health care for most of the world's population.Chapters 8 and 9 describe constructive initiatives to improve health and the supplyand use of essential drugs both at project level and on a wider national andinternational scale. These and the following chapter are concerned both withattempts to rationalise drug policies to benefit the majority and with obstaclesto change. Chapter 10 also examines attitudes and policies in the major drug-producing nations and their impact on drug needs and policies in developingcountries. Finally, in Chapter 11, we put forward OX FAM's suggestions on actionthat is urgently needed to benefit the Third World poor.


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bitter pills: medicines and the third world poor

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