Wednesday,
February 24, 1999
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No liberties with
medicines Nutrition racket Oral cancer epidemic |
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No
liberties with medicines “THE desire to take medicines is perhaps the greatest feature that distinguishes man from animals”. Drugs are an important part of the therapeutic process though not entirely. Drugs have been used alone or in combination with magical rites, indigenous systems of medicine, surgical operations and a host of other modalities. The problem lies not in the medicines but in the use of medications. Some pertinent factors are given below. 1. Patient compliance: “It is often said that the treatment is not what the physician prescribes; it is what the patient takes.” Is it possible to achieve greater compliance? Compliance determines medicine intake. Today, drug-resistant tuberculosis is posing a threat like a volcano ready to erupt. This resistance is due to faulty compliance with the dose and duration of the prescribed antitubercular treatment. Successive generations of antimicrobials have developed resistance due to faulty compliance. 2. Prescribing behaviour: There is tremendous individual variability in prescribing with the lack of adherence in practice to scientific evidence. An example is the long-term prescription of sleeping pills (bezodiazepines). There is no scientific evidence of long-term effectiveness, and yet they continue to be prescribed. This is done at the patient’s insistence or because or the prescriber’s ignorance. 3. Information: Information on drugs is woefully inadequate. Information-related to the analysis of problems in and prescribing solutions should be made available to the prescriber. It is imperative that such information must be unbiased, non-commercial and scientific. Not the sort provided by package inserts with medicines, or advertisements in journals! So, it is important that scientific claims are unbiased. This can be provided by seminars, symposia, drug formularies, bulletins and newsletters. These reach a limited number of prescribers. Keeping in mind the information required, it is a necessary to establish national and regional drug-information centres from where such data can be made available. Standard guidelines for treating a variety of conditions — e.g., malaria and amoebiasis — may be made available from such centres. 4. Narrow-vision approach: A middle-aged patient suffering from arthritis is not relieved of pain to his satisfaction. Radiologically the tests are negative. Antiarthitic drugs are given. But the patient does not have relief. So, he goes to a specialist (say, a neurosurgeon) who, after a number of expensive tests, admits nothing is originally wrong. The end result is that the patient is still miserable with pain, not knowing what to do to convince anyone that he is ill and unable to function optimally. This happens when the physicians concerned (two or three in this case) treat the part — and not the whole person. This is invariably the case. Each specialist views the patient through the prism of his/her own speciality and not holistically. It might have been better to explain, initially, the achievable goals to the patient and then see if these objectives had been achieved. This would have led to more rational prescribing, using the mnemonic POP (problem, options, plan) as advocated by a great medical teacher. 5. Social interaction: Prescribing is the outcome of a social exchange between the physician and the patient. The exchange is not confined to scientific knowledge or evidence as to how to deal with a particular problem. It is to manage the particular patient by learning consulting skills and managing the whole patient. A patient of depression goes to a psychiatrist, but he must be warned of the side-effects of the anti-depressant drug given so that he does not run to a cardiologist or a gastroenterologist when the side-effects surface. The efforts of the doctor should be to improve health through the use of medicine rather than just improving the medicine’s use. The scenario poses challenges and merits several corrective measures. The situation at present is such that more and more of the total proportion of medicines available falls into the specialist category (i.e. which can be used only under the supervision of a trained physician). This has contributed in large measure to the mystification of the medical process with the physician prescribing “a pill for every ill”. The doctors’ ignorance has also grown, most doctors being familiar with only a limited range of drugs used in their particular speciality. In needs to be remembered that the pharmaceutical industry is organised on the lines of pure business where the primary motive is profit. They, along with medical and diagnostic equipment manufacturers, have become the pace-setters in the health-care field, which is a highly skewed approach. It may not be out of place to initiate a people’s health awareness movement (like so many other movements taking place). Health is on the lowest priority till a calamity occurs. Hardly any effort is put in for taking preventive measures and inculcating a health-oriented routine. Health is a fundamental right but unfortunately it is equated with medicine. To demystify one is to demystify the other. Certain factors perpetuating this are:- The social and cultural expectations influence the form, duration, self-medication, medical practice and formation of medical products to meet the perceived needs of the patient and the prescriber. The media — print and electronic — play a role in popularising medications for curing ailments. They can also be used constructively to disseminate unacceptable side-effects and limitations of the remedies. Medicines are marketed to capitalise on modernity, such as giving of parenteral forms (injections) and capsules in relation to the power of action. A lay person believes that parentral medications are more powerful and capsules have more punch than tablets. Self-medication of readily accessible prescription and non-prescription drugs over and under the counter is the order of the day. The prescriber then attempts to prescribe medicines unfamiliar to the local population. This creates a situation like medical experimentation both prior and subsequent to the prescription. The end result of such efforts may comprise the diagnosis by masking symptoms. Herbal and other medicines are not considered medicines and continue alongside. Most often, patients do not consider it necessary to tell the practitioners any thing about self-medication. A study done by the author has shown that the extent of self-medication in admitted patients is about 40 per cent. Unfortunately, the development of new products is targeted to the emerging health concerns such as aging, in competitive performance, beautification, gender differences, sexual performance and anxiety. The priority in our country should be to tackle rampant tropical infections and for newer drugs to tackle drug-resistant malaria, and drug-resistant tuberculosis, and the problems of various types of malnutrition. The market forces depend on those areas of consumer preferences and desires. Pharmaceutical use is not determined by knowledge alone because medicines like other commodities take on value in relation to status and identity. The potential will and government policy are very important factors. Politicians and bureaucrats are courted by the industry. They are also inspired by speeches of international health agencies. An extraordinary political will is required to champion the cause of the rational use of medicine. Where the rational drug policy has been undertaken, it has been difficult to sustain it and enforce it on the ground, giving in to market forces and the consumer demand. Economic constraints are internationally accepted and there is growing concern that the resources available for the provision of health services (an important component of which is the use of medicines) are limited. There are important considerations. It is imperative that cognizance of this is taken with a sincere effort towards the analysis of cost-minimisation, cost-effectiveness, cost-utility and cost-benefit. Such economic evaluation can help in facilitating decision-making. The awareness of economic concepts among physicians is urgent if scarce health-care resources are to be made available to the largest number at the lowest affordable cost. (An essential drug concept has been championed by the World Health Organisation). The Essential Drug Policy (EDP) is the mantra given by the WHO to countries like ours. A list of essential drugs is identified on the basis of the prevalent diseases. Attempts are made to make these drugs available at an affordable cost to the largest number. There are, however, compulsions for those in the pharmaceutical industry. Drugs constitute the concrete output of a long stream of complex processes involving research, testing, manufacturing and marketing. Enormous investments are made for development, production and promotion of drugs justifying the basis of the profit potential. The Government is interested in pharmaceuticals (as it is not only the single largest purchaser). It exerts regulatory authority and control to ensure the safety and efficacy of drugs available in the local markets. Drugs thus represent more than chemical/biological substances with therapeutic capacities. They are objects of study, discovery, vehicles of exercise of professional power, marketable products with intrinsic commercial value and instruments of the national policy. It is here that we need to come together in the interest of the ailing humanity, rising above those vested motives of manufacturers, institutions, governmental indecisiveness and consumers. The medical fraternity cannot function without drugs and the pharmaceutical industry’s lifeline is their production. Both need to come together, with mutual trust, to create a kindred spirit with common aspirations. With a dual commitment from the industry and the prescriber, and an informed consumer, I am confident that the next century will certainly take a major stride in a more rational use of medicines. Dr
Roma Uppal, MD, D.M., is a clinical pharmacologist and a
well-known teacher. |
Nutrition
racket FOR the better part of the past decade, alternative approaches to health care have been encroaching on the prevailing medical model. Acupuncture, homoeopathy, naturopathy, and other “complementary” therapies are no longer dismissed as quackish pursuits of New Age pioneers. And it is the rare pharmacy that doesn’t stock a healthy inventory of vitamin and herbal supplements. Indeed, according to recent surveys, about half the US adult population now takes some form of dietary supplement, creating a market that tops $4 billion a year. The savvy consumer can select any number of herb or vitamin alternatives to high-priced pharmaceuticals: Saint John’s-Wort for Prozac; melatonin for sleep aids; fish oil as a substitute for aspirin and other anti-inflammatory drugs; Vitamin E and selenium for heart disease and various cancers; milk thistle for liver diseases. These natural alternatives represent billions of dollars in the lost profits each year for the pharmaceutical industry. And since there appears to be no way for drug companies to corner the market on non-patentable agents, a new strategy is emerging: Take control away from the consumer. Spearheading this effort is a little-known international agency called the Codex Alimentarius Commission, a Rome-based organisation established in 1961 by the United Nations. Codex Alimentarius is Latin for “food and nutrition code”. But under the guise of protecting public safety through standardisation of food, nutrient, and botanical codes, the commission is regarded by many as a means for the pharmaceutical industry to eventually make all supplements available by prescription only. As Mitch Fleisher reports in Alternative Therapies (May 1998), the commission is considering a number of major rule changes that could directly affect the cost and availability of many vitamin and herbal supplements. Among the proposals: *No herb, vitamin, mineral, or natural agent could be sold for preventive or therapeutic reasons. (The Dietary Supplement Health and Education Act of 1994 already prohibits label claims related to the diagnosis, treatment, or prevention of disease in the USA, unless the claimed benefit relates to a nutrient deficiency disease.) *Supplements could still be sold as “food”, but only if they do not exceed the dosage levels set by the commission. This means that consumer access to supplements would be limited to the RDA dosage, which is designed merely to prevent nutritional deficiency diseases in most of the population. The RDA, deemed outmoded by most nutritionists, is not designed to promote optimal health or prevent chronic diseases such as cancer. *Supplements without an RDA (Chromium, selenium, bioflavonoid, coenzyme Q10, for example) would be classified as drugs; therefore it would be illegal to sell them without a prescription. This includes the majority of currently available supplements. *All new supplements would be required to undergo the Codex approval process before becoming available. All others would be banned. These rules were originally proposed by a German Codex delegation sponsored by three drug companies: Hoechst, Bayer, and BASF. And, in fact, elements of the Codex proposals already exist as law in Germany and Norway. In Germany, a number of high-potency agents are available only through pharmacists, and the prices are exorbitant. As recently as 1996, for example, one could buy vitamin C in 500 mg tablets. Today the highest concentration available is 200 mg; only pharmacists can sell the higher-dose supplement Vitamin E capsules cannot exceed 45IU; vitamin B1 cannot exceed 2.4 mg and so forth. Supplements are even more restricted in Norway. There, any nutrient supplement that exceeds the RDA is considered a drug. As a result, a vast number of natural agents are either not available or available only through a prescription at great cost. “In Norway, you must pay very high prices for supplements that otherwise can only be found on the black market,” says John Hammell of the International Asociation for Health Freedom. In Canada, earlier Codex proposals pertaining to herbal supplements are already in place. Such common herbs as garlic, ginger, and licorice are considered to be foods when they’re sold as spices, but they become drugs once any claims are made for a therapeutic or health-promoting effect. Herbs with medicinal effects that have been extensively substantiated in the biomedical literature include aloe vera, echinacea, gingko biloba, ginseng goldenseal, and milk thistle. All these agents are now branded by Canadian officials as either “a drug,” “a drug even in the absence of claims,” or “a new drug with claims.” To understand how the Codex reforms could play out in the USA, you need only to recall the case of trypophan. Once sold as a natural sleep aid for under $ 20 a bottle at health food stores, tryptophan was banned by the FDA (Food and Drug Administration) in 1990 after a contaminated bath caused 1,550 cases of a blood disorder known as Eosinophilia-Myalgia Syndrome. Today, the same tablet (in the same dose and quantity) is available only by prescription at a cost of more than $ 120. Under new Codex guidelines, other currently harmless supplements would be replaced by themselves, but sold as expensive, over-the-counter prescription drugs. Codex opponents admit that we need a regulatory system that ensures public access to safe, effective, and pure supplements. But, as Fleisher notes, “Such regulatory oversight, both national and international, will only be effective if it is undertaken in a spirit of cooperation and with the full representation of all parties affected. This should include the natural health care product industry, the pharmaceutical industry, conventional and alternative/complementary medical organisations, govermment agencies, consumer interest groups, and the general public.” — Third World Network |
Oral
cancer epidemic Medical experts fear that North India may face an epidemic of oral cancer due to the widespread habit of chewing areca nut that is the main constituent of “pan masala”. A recent house-to-house survey in Bhavnagar district of Gujarat shows a high incidence of “oral submucous fibrosis” or OSF — a precancerous condition in the mouth that can lead to oral cancer. The survey by the epidemiology research unit of the Tata Institute of Fundamental Research (TIFR) in Mumbai found an increase in prevalence of OSF — double of that three decades ago. Another disturbing trend was the high prevalence of OSF in the lower age group, with 84 per cent of the OSF patients less than 35 years of age. This could be directly attributed to the use of areca nut products, the TIFR team led by P. C. Gupta reported in the National Medical Journal of India. Both areca nut use and OSF were concentrated in the lower age group below 35 years. The findings on over 11,000 men and 10,500 women point towards an evolving epidemic of OSF in the rural population in Bhavnagar, which could hold true for most of North India. Areca nut is the main constituent of “pan masala”, a product which attracts low government taxes as it contains no tobacco, and is the target of high-profile aggressive advertisement campaigns. The low taxes and wide publicity has led to an enormous increase in the use of all types of areca nut and smokeless tobacco (that is chewed or inhaled as snuff) among Indians, especially North Indians. Areca nut is also mostly used in “mawa”, a mixture of tobacco, lime and areca nut. One-tenth of “mawa” users had OSF, the TIFR survey found. “Thus the perception of a substantial increase in the incidence of OSF in the North Indian population appears to be real”, the report says. The
epidemic needs to be stemmed urgently by taking measures
to discourage the use of products containing areca nut or
tobacco, it warns.
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A
rejoinder IN an article published in Health Tribune on "Quackery: tricky trade" (February 12), homoeopathy has been shown in poor light. The homoeopathic fraternity feels hurt. The writer, Mr Roy Eagleton, has talked about quacking or barking in ignorance. He knows nothing about this divine medical science. Mr Eagleton must learn that there is no dilution in homoeopathy. Only the spirit-like dynamic energy of each medicine is preserved in a "vehicle", preferably spirit. Dr Samuel, Hahnemann, the founder of the homoeopathic system of medicine, asks: "What is dynamic power"? Here is the answer: Our earth, by virtue of hidden invisible energy, carries the moon around it. Alternately, the moon raises our northern seas to flood tide and again correspondingly lowers them to ebb. Apparently this takes place not through material agencies but through the action of one substance on the other "without being able to recognise a sensible connection between cause and effect". For the benefit of the intelligent general public, including Mr Eagleton, we explain here the concept of disease in homoeopathy. It is not something material which can be put in or taken out. Disease is caused by some emotional or "spirit" causes which are dynamic. The power of the medicine alone is capable of curing the disease. It is obtained by the process called potentisation through the vehicle in which it is preserved. Only if Mr Eagleton had done his homework on the latest research in homoeopathy before writing his article, he wouldn't have created so much misunderstanding. To ignore government research agencies like the Central Council for Research in Homoeopathy (CCRH) is an unwise act. There are more than a hundred homoeopathic medical colleges in India. Many of these are being run by the government. A great deal of research-based information on homoeopathy is available on the Internet from the West. One cannot afford to ignore it. Homoeopathy is an advanced system of medicine. It heals the body and the mind in a holistic way. It believes in the basic principle that medicine energizes the body's own healing system. This stream of science must not be ridiculed. It saves thousands of lives daily — nay, hourly. — Representatives of the homoeopathic fraternity in Chandigarh (There
will be no further discussion on this issue — Editor) |
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