Doubtful benefits

A major group of patients who come to us are those with non- communicable diseases being treated elsewhere who just cannot bear the cost of treatment. Of course, most of the extra expenses are a result of multivitamins and latest combination drugs which are expensive.

However, I was quite surprised to meet a well off gentleman who came to me last week. He was diagnosed to have diabetes and hyperthyroidism elsewhere. He was incurring a cost of 7000 INR every month just to purchase the medicines. Doctor consultation costs and blood tests were extra. He had met another doctor who told him that there was no need for so many medicines.

He came for a second opinion.

His original treating doctor was no small man. He was a senior cardiologist in a NABH accredited hospital in a state capital city of our country.

The best I could do was to call up one of my friends in the respective speciality.

The below snap shows the medicines he had with him. In the foreground is the medicines he absolutely needs and behind it are the medicines he could do without, which has not much evidence of significant benefit.

A close up of the medicines we stopped. The protein powder and the sucralfate syrup is included.

Now, this is a patient who can afford to spend 7000 INR. One can only imagine the plight of the poor who are given a similar prescription . . .

Well, I hope you looked at the second snap, which shows the medicines he stopped a bit close . . . In that bunch of medicines, I hope you noticed Tab. Faropenem 200 mg. The gentleman was having it twice a day since the last 10 days. I could not find any evidence of any sort of infection in the papers he had nor did he give any history of the same. 

So much for evidence based medicine and the dangers of antibiotic resistance that we talk about . . . 

Enterogermina

Many of you will be wondering what this is. Well, this is a medicine which I found written in prescriptions of many a quack for diarrhoea, especially in children. And most of them did not have a prescription for ORS, the mainstay of any treatment for diarrhoea . . .

Last week, I thought of looking it up. It is of course a medication with no clear cut evidence of any benefit. It was more interesting toto read the first paragraph in the product insert.

It looks like a very complicated way of saying that this medicine may not be a medicine at all . . . It is as good as eating chocolates or drinking horlicks . . .

Another medicine to dupe a poor sick man into poverty . . . Another interesting aspect. This 'medicine' is easily available, but we have difficulty getting stuff like plain doxycycline, buscopan, dihydrochlorothiazide etc . . . 

Interesting . . .

Since the lastweek, The Hindustan Times has been doing a feature on the billionaire Indians. 

I found this table along with the last article on it.

To have 28 billionaires (18 in pharmaceuticals and 9 in healthcare) who made to the list by making a business out of caring for the sick and dying is a bit disconcerting to me.

I wonder if this statistics bothers anybody else . . . 

Fixed Drug Combinations

It was about couple of weeks back that the store in-charge at our place informed us that a commonly used medicine - Doxycycline was not available for purchase anywhere. Instead, a Fixed Drug Combination comprising of Doxycycline with Beta-Cyclodextrin was available at almost 3 times the price of simple Doxycycline.

It was unfortunate. Along with Septran, Doxycycline is an antibiotic we regularly use. Contrary to popular thought, they are quite effective in managing bacterial infections at least in remote locations of the country. 

Today, there was this article in the Times of India about an article in The Lancet about India's Drugs Act aiding proliferation of harmful combination drugs. And of recent, me and my colleagues were debating about use of combination drugs in diabetes. To be frank, I'm yet to see even one diabetic patient treated elsewhere who is not on a combination drug. 

I'm glad that this issue has come in print. It seems meaningless to try to educate the pharmaceutical industry and the healthcare community about the vagaries of Fixed Drug Combinations. As I mentioned in one of earlier posts, the major challenge is that most doctors get information from the pharmaceutical representatives. 

I think that the only solution is to educate the public about the issue. 

Couple of other medicines with which we've had this issue is Hydrochlorothiazide, the first line drug for Systemic Hypertension and Butylscopolamine (Buscopan), one of the best drugs for abdominal spasms and cramps. Both very cheap medicines coming under the Drug Price Control. No supplier wanted to stock them as there was no margin. 

The issue is all the more serious for us since the prohibitive costs of medicines accounts for a major proportion of costs in healthcare. One can imagine about how much costs increase with FDCs when combination of doxycycline is 3 times the cost of plain doxycycline. 

One can only hope that the government takes up this issue seriously. 

Well, before I sign off, just a gentle reminder on how rich the pharmaceutical industry has grown. I quote a recent news item - 'India has leapfrogged Russia and the UK to third place with 97 billionaires, 27 more than 2014. Manufacturing and Pharma are the preferred sectors with 23 and 14 billionaires respectively. Combined wealth of the Indian billionaires comes to $266 billion. Mumbai is headquarters to most of the Indian billionaires.'

Crocodile Tears

Yesterday, I happened to read an article about Antibiotic Resistance . . . 

Almost the same time, I also had one medical representative come to me to advertise rather 'teach' me on modern antibiotic usage. 

I had told our Medical Representatives about how we use Septran, Ampicillin and Gentamycin to amazing results. It was only because of rampant use of Ceftriaxone outside that we have been forced to use in our treatment. 

Now, he told me about the better antibiotics available which were sure shots at infection. 

The drugs he told me . . . 

1. Cefixime + Clavulanate Potassium

2. Cefixime + Ofloxacin

3. Cefixime + Azithromycin

4. Cefixime + Ornidazole

5. Cefotaxim + Sulbactum

I wonder if we will achieve quite with regard to antibiotic resistance if all these newer antibiotics are brought under some sort of government regulation. 

There is no point crying about antibiotic resistance if pharmaceutical companies go around advertising about the benefits of these new antibiotics. 

In disadvantaged communities and impoverished populations where quacks are more popular than doctors and even among doctors, those who practice evidence based medicine is a minority compared to those who believe that they should be writing the latest medicines available in the market, be it antibiotics or anything else . . . it would need a miracle to stop antibiotic resistance . . . 

And that could spell doom to many a poor family . . . 

Medicines for all - DPCO

Couple of years back I had written a post where I commented about thenon-availability of cheap but effective medicines in the general market. The drug is question at that time was Hydrochlorothiazide, which is the first choice drug for uncomplicated systemic hypertension.

Recently, quite a few medicines were brought under the Drug Price Control. This means that the government has fixed prices for quite a lot of drugs. This resulted in drugs becoming more affordable. 

Many of us had expected problems for some time. We did not face any problems in the beginning.

However, now we are faced with a major issue. Over the last 2 weeks, we’ve a shortage of commonly used medicines. The list my store clerk sent reads – Injection and Tablet Hyoscine (Buscopan), Tablets and Injection Frusemide, Asprin tablets, Normal saline nasal drops, Salbutamol Tablets, salbutamol Inhaler, Injection Benzyl Peniciline (Crystalline Penicilline)and Injection Haloperidol.

All the above are quite commonly used medications. And also quite cheap.

And the latter is the exact reason they are not easily available.

‘No margin, sir’, the supplier says.

However, the pharmaceutical companies have come out in droves against the order.

A side effect of this issue . . . comparatively expensive medicines are easily available in the market. We were surprised recently to see even quacks prescribe medicines such as Cefpodoxime.

Unfortunate . . . but true. How long will it take for the government and now the judiciary to realize that the pharmaceutical industry can make a mockery of science . . . and that too medical science.

I’m sure about what is the latest on this. One of my friends told me that the industry has gone to the court and the DPC list is stayed. However, my suppliers tell me that after DPC, their margins have come down a lot. There were also news reports about this few days back.

My take on the matter is that the healthcare community needs to take a very strong stand against this move of the pharmaceutical companies. 

Unsung . . .

This post is just an attempt to bring to all of your notice about quite applaud-able efforts by a section of medical students and fraternity to maintain distance from the pharmaceutical industry when it came to a conference on medical research. 

It is quite well accepted that drug companies offer incentives varying from pens and letter pads to tours abroad in the garb of attending conferences. In fact, the popularity of a doctor is gauged from the number of medical representatives who visit him or her.  

I know of my colleagues who try quite a lot to keep medical representatives in good humor lest they spoil his/her practice. And when it came to research, most of the companies fall head over heels to placate doctors and their families. 

What startled me was the very little publicity that this conference got in terms of media coverage both print and electronic. I could only find one newspaper who reported about this.

I remember that there were 3 such stories including this, which I highlighted in my blog and it was disturbing that all 3 of them were reported in only one newspaper (each time a different one). The media falls head over heels to report misdemeanors in healthcare but remain largely mum when there are heroes who work silently without any applaud or rewards. 

And all the more when a National Conference is run without any pharmaceutical funding . .. ... 

Don't you think so? 

Flawed Pharmaceuticals

I wonder how many of us in India noticed about the news that the pharmaceutical giant Ranbaxy generic drug maker Ranbaxy pleaded guilty on Monday to federal drug safety violations in the US and will pay $500 million in fines to resolve claims that it sold subpar drugs and made false statements to the Food and Drug Administration (FDA) about its manufacturing practices at two factories in India. 

If you missed the news please read it either in The New York Times or Reuters or our own Economic Times. 

For a country which is obsessed with the Indian Premier League and the personal lives of it's film stars, I don't think this sort of news would garner much attention. Of course, there will one group of us who will be term it as US's vendetta on Indian business interests. 

The quality of drugs available in the Indian market has always been doubtful. The details from the news items is alarming . . . unreliable shelf lives, absence of proper quality and safety tests, batches of atorvostatin contained glass particles, lying to the FDA and falsified data. I wonder how much of this is true with the other companies. 

In the US, there is a FDA to keep a tab on the companies. Who does that in India?

We've all heard enough stories of how different brands of the same drug differ in their effectiveness. To make matters worse, the number of unethical combination preparations very much against the principles of any drug formulary has been an issue of major concern. 

In the corrupt scheme of things in the country, I wonder how much of a policing can one successfully do in the area of pharmaceutical regulations. 

As I mentioned in one of my previous posts, the plot thickens in a situation where doctors are educated and updated by the pharmaceutical industry on prescription practices. One can only imagine about the sort of flawed information they will end up getting. 

Now, what can the common man do about this. 

First of all, there is the well known fact that medicines may not be needed for quite a lot of conditions. It is time we asked ourselves about how serious we are to assimilate interventions such as lifestyle modifications, exercise and diet changes. 

There are enough stories about how drugs touted as miracle chemicals turned out to be big killers. 

Do recheck if you really need the antibiotic or the analgesic or the anti-histamine being prescribed. And you may not need the umpteen number of multivitamins and supplementary pills. Do query your doctor about why a particular medicine is being given. 

And when you have to buy a medicine, buy it from a government run pharmacy if possible. But again, in India you can never tell. 

The bottom line . . . prevention is better than cure.  

Pharmaceuticals - The Paradoxes in Indian Healthcare . . . Part 1

We are all well aware of how sick our system of healthcare is. While for the rich and the famous, it is nothing much of a major concern . . . for the middle class and the poor, healthcare is a major issue of concern.

However, what concerns me are reasons for the government being only hardly bothered about what sort of healthcare the common man has access to. One on side, we are proud of how good we are with tertiary care and we are looked upon as one of the major spots for health-tourism. We have states such as Tamil Nadu who are looking at up scaling of cadaver organ donation whereas on the other side, we've states where something as basic as availability of blood is a major issue.


I'm a bit concerned about the sort of media attention that issues such as cadaver organ donation, celebrity health issues garner compared to the status of basic public health care in the country. One issue which has been sort of been ignored is the state of tuberculosis in the country. I've taken up the issue many a time in my blog.

Well, you may say that we have the Revised National Tuberculosis Control Programme, a world award winning public health program which has won accolades at many a venue.

I take the issue of Tuberculosis today on account of one patient whom Titus saw in Outpatient today.

SDS was a unmarried 26 year old man who hailed from a village within 10 kms of our hospital. Hailing from a rich family, SD had been diagnosed to have Type 1 Diabetes Mellitus 7 years back. Then he had been diagnosed to have tuberculosis about 4 years back.

The sad aspect was that he did not access the free government tuberculosis drugs. He had quite a large file of his medicine prescriptions. It was quite a sad array of paper work he carried around.

Initially, he was started off only with Rifampicin and Isoniazid. Nobody was there to monitor his treatment. He took medicines for about 2 months and he left treatment when he started to feel better. Then, he became sick again. He went elsewhere and was started on medications again . . .

Unfortunately, by early 2010, someone had sent his sputum for culture testing. Below is the report.

But, I was in for a shock when I saw the prescription from the 'tuberculosis specialist'. All protocols of Multidrug Resistant Tuberculosis was thrown to the wind. It's more than 30 months. He's still on treatment.

And the worst shocker of all . . . He never had a sputum AFB done. . . of course, there was a sputum culture done about 2 years after the first diagnosis.

Well, you could blame SDS for not taking interest in the government run RNTCP programme.

But, I wonder why anti-TB drugs of all combinations and dosages are available in the open market when there is a government run programme to combat tuberculosis.

To make matters worse, there are quite a large majority of doctors who openly tell their patients that government medicines are of no good. SDS was told the same thing by every doctor whom he accessed for treatment.

Recently, the government has come out with an order on generic drugs. The pharmaceutical industry has already launched an all out cold war against this. They have even invented a term for generic drugs - 'unethical drugs'. And the branded drugs are called 'Ethical drugs'. So much to educate the common man on the terminologies of drugs.

Well, it was quite incidental that I came to find out that there is no Iron tablets in the Primary Health Centres around our place. But, Iron capsules are available in the Pharmacy shops and they were doing great business. Even, we are doing great business with Iron capsules. I remember that during my stint elsewhere in the South, the Medical Representatives were all out 'educating' us on how unpalatable the Iron tablets are compared to their 'double coated chocolate flavoured' and of course expensive Iron capsules.

SDS is most probably going to pay for his ignorance of the existence of a government scheme which would have monitored his drug compliance and disease progression. Now, he is getting a MDRTB treatment protocol which is totally out of line from what he should be getting.

I'm sure that this is part of the influence of private players who are very well aware of the inexhaustible gold mine of profits made in the name of healthcare. It is sad that the government is not realising the folly it is in by allowing such a back-door entry for private players in healthcare. The influence looks subtle, but the consequences are going to be disastrous for the common man.

The government order on making generic drugs freely available is a decision in the right direction. I was quite encouraged to see the 'Generic drug store' in the Latehar district hospital during a recent visit. I'm sure that the private drug companies and retailers would go on an all out war against it, at least indirectly if not directly. More initiatives such as these are necessary if the common man has to regain his confidence on public healthcare.

However, it is going to be quite a long journey for all of us who are mooting for a full fledged robust public healthcare. The question is how many of us are going to continue fighting to see a day when that happens.