Dr Ted Lankester, now Director of Interhealth which is based at Mildmay Mission Hospital, worked as a doctor in India for a number of years. Though this article is written for health workers and doctors, we can all learn from what he writes. All of us need medicine at some time in our life – this article will help us to realise that medicine is not always the answer to our problems. The misuse and over-prescription of drugs is a growing problem all over the world and one that should concern all of us.
Earlier this year I visited a roadside pharmacy in a large Asian city. I was amazed to see the customer in front of me loading medical supplies into a large cardboard box. Later, as she handed over wads of banknotes, I noticed a prescription lying in front of me, written by the hand of her private practitioner. Neatly listed in two separate columns were no less that 24 medicines for her personal use.
One of the most dangerous problems facing patients today is being prescribed too much medicine.
As health workers one of our main duties is to fight the dangerous practices of over-prescribing and wrong prescribing.
To help us, we shall try to answer four simple questions:
1. Why do medicines work?
There are two main reasons:
a) They have a genuine scientific effect. For example quinine cures malaria, metronidazole cures amoeba. Oral rehydration therapy saves lives by replacing the fluid lost in diarrhoea.
b) They have a “placebo” effect. This means that the medicine works because the patient believes either in the medicine itself or in the person prescribing it.
The more a patient has faith in the medicine the better it seems to work. People in traditional societies, who believe in the power of magic, may change the form of their belief from the witch-doctor’s ritual to the doctor’s medicine.
Some medicines work entirely by the placebo effect. Others work part by placebo and part by science.
Here are some ways in which the form of the medicine may increase the placebo effect:
- Injections instead of medicines by mouth
- Capsules or syrups instead of pills
- Coloured tablets instead of white tablets
- Medicines in foil strips rather than loose in a bottle
- Expensive medicine rather than cheap medicine
Here are some ways in which the prescriber can increase the placebo effect:
- Posh clinic with expensive fees
- “God-like” attitude of the person prescribing
- Many initials after the Doctor’s name (whether true or made-up)
- White coats and long queues
Ordinary people are easily tricked by clever prescribers using these placebo effects. Throughout the world patients are being taught that they need a pill for every problem and a needle for every need.
As health workers, we need to be made aware of these facts so that we can fight against them more effectively.
2. Why are medicines over-prescribed?
Here are some reasons why doctors and health workers over-prescribe:
- They have been wrongly trained in their medical schools.
- They want to please their patient. If they don’t give medicines, the patient may go to another doctor.
- They may get a free handout from the drug company when they prescribe their products.
- Prescribing medicines is quicker, and brings more profit, than teaching prevention or explaining that medicine is not needed.
3. What happens when medicines are wrongly prescribed?
Patients may become dependent on medicines and doctors. (This is what some, but thankfully not all, doctors and pharmaceutical companies may want.)
When patients become dependent, other problems follow:
- Patients spend more and more money on medicines, soon slipping into debt.
- They don’t know what to do if no medicine is available.
- They develop a “Give me, Give me” attitude to health care.
4. What can YOU do to make sure medicines are used correctly?
DO use as few medicines as possible.
DO spend time teaching people to change their wrong health patterns so that they won’t need medicines so much.
DO treat causes rather than symptoms. For example, don’t give cough medicine to a patient with a chronic cough. Arrange a sputum test to see if he has TB then treat the illness if the test is positive.
DO use medicines because of their scientific, rather than their placebo, effect.
DO take time explaining that simple tablets in a bottle work just as well as coloured capsules in a wrapping.
For example: one doctor in India is sometimes approached by patients who say that the cheap medicine used by the Village Health Worker doesn’t work – could he please prescribe some proper medicine. He agrees to do so, first explaining that, when he suffers from this problem, he uses the VHW’s simple medicine, rather than the same medicine cleverly packeted, coloured and sold at three times the price.
DO draw up and use an Essential Drug List. Make sure that everyone, including project doctors, uses it.
DO use the right medicines in the right dose for the right length of time for serious illnesses. This is especially important in malaria, TB, Leprosy and acute respiratory infections.
DON’T give medicines when they are not necessary. Patients may not like this at first.
For example: a few years ago I met a doctor who had been running a clinic in North Africa. Frustrated by the large number of patients wanting medicines for minor problems, he decided one morning to use as few medicines as possible. Instead, he would take time to explain that the problem was not serious, that it would get better on its own and that the patient would be able to ease the symptoms by following some simple advice.
One patient that morning was a tribal chief. Furious not to be receiving any medicine, he stormed out of the clinic warning all the waiting patients that the doctor was useless.
A few days later the doctor was alarmed to see the chief approaching him in the town. Smiling, he told the doctor how his problem had improved with the advice he was given, even though no medicine was used at all. He would return to the clinic, no longer to curse him, but in order to commend the doctor in front of the waiting patients.
DON’T give injections if medicines by mouth would work as well.
DON’T give tonics to children. Instead teach the people how to feed their children correctly and to use any extra money on buying nutritious food.
DON’T GIVE MEDICINES JUST BECAUSE THE PEOPLE EXPECT THEM AND THREATEN TO GO TO ANOTHER CLINIC IF YOU DON’T GIVE THEM WHAT THEY WANT.
Every time you give in to this pressure you are cooperating with those who are exploiting the poor.
DON’T be discouraged if this advice seems hard to follow.
Health workers throughout the world are facing the same problem as you. Each time you refuse to prescribe an unnecessary medicine you are helping the cause of HEALTH FOR ALL and resisting the process of profit and greed.
And remember, even though your patients may complain at the beginning, in the end they will come to be healthier. They will come to trust you – not because you give them the medicine they demand, but because they know you are competent, caring and trustworthy.
Help your patients learn that it is better to spend their money on good food that on unnecessary medicines.