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It is with a certain degree of anxiety that I contribute to this
never-ending debate on drug prescriptions. My anxieties are because some
of the letters and articles have bordered on being abusive and downright
objectionable. (For example, why should it matter whether a writer is
retired, is a physiologist or an academic? What ought to concern us to
get closer to the 'truth' who ever says it).
I have looked at the controversy from a different angle and wish to
submit my views for discussion. As I see it, there are four main actors
in this theatre of confrontation:
1. Persons who are ill (the general public) who wish to get the most
effective treatment at the lowest cost
2. Doctors, who ought to act on behalf of the patient
3. Private pharmacies and drug companies, that mainly wish to
maximize profits
4. The Government that ought to defend the interest of the patient.
In the ideal world the doctors and the Government should align
themselves with the patients and help to obtain them the best deal.
However, in the real world, some doctors are influenced by the drug
companies (and pharmacies).
This compromises their decisions and prescribing habits. There are
tons of articles in the literature which have repeatedly found this
statement to be true. Governments are also swayed by drug companies. A
recent example from Sri Lanka is how they successfully reversed a
Ministry of Health's previous decision to restrict visits to Government
hospitals by pharmaceutical representatives (i.e. drug reps.).
Thus the lines of demarcation in the confrontation are blurred
because of conflict of interests. In a simplified form, one can
visualize the confrontation in the following manner: On one side of the
line are patients, wanting to get the most effective treatment at the
lowest cost.
On the other side are the pharmacies (and drug companies) and in
certain instances doctors and the Government, acting against the
'interest' of the patients.
Previous writers contributing to this debate seem to have downplayed
the role that could be played by the general public. Why not help the
public to assert their wish to get the most effective treatment at the
lowest cost? They should be encouraged to request for an alternative in
cases where they feel that the one prescribed is too costly, or the one
being dispensed by the pharmacy is too 'inferior' for their liking.
Some may think that our patients are very humble and prefer to use
whatever drug recommended by the doctor or doled out by the pharmacy. I
leave it to the public to respond to this assumption.
By the proposed mechanism we are simply empowering our patients to
make the decisions, a foundation of medical ethics. It will also deal
with the concerns of some doctors who suspect that writing in generic
terms transfers the right of dispensing to the pharmacist. It need not,
if the patient is assertive.
If patient empowerment is the key, then generic names must be
included in the prescriptions. A prerequisite for empowerment is that
patients must be aware of the drugs they are taking.
It is in this instance that the drug's name be written using the
generic term (which is the same as the chemical or technical term for
the drug). One cannot expect the public (let alone a practising doctor)
to know the large number of trade names of drugs. (I personally think
this should also be in Sinhala and or Tamil for those who cannot read
the English words, but that's opening another Pandora's box!).
Awareness of the name of the drug one is taking is the minimum core
knowledge for any patient. Knowing the name of the drug may save a
person's life, because doctors can sometimes suspect a patient's
condition based on the drugs on the prescription.
For example, a person suffering from a severe headache and is drowsy
and brought to hospital would be suspected to have bleeding into his
brain, if it was known that he takes a drug called warfarin. A good
doctor would immediately suspect this diagnosis and arrange for an
urgent CT scan of his brain as a delay in diagnosis can be fatal.
Writing a generic term of a drug on a prescription does not mean that
the doctor cannot write a particular trade name in addition. They can
insert the preferred brand name within brackets below the generic term.
This will enable to accommodate a doctor, who wishes to prescribe a
particular brand name arising out of genuine concerns about a particular
brand.
However, there is a problem because the genuineness of the doctor's
intention will only be known to the doctor who prescribes. I think this
is at the heart of the acrimonious debate in the newspapers. Some
doctors believe that they write the prescription because they
'genuinely' feel it is for the benefit of the patient.
Others suspect such prescription decisions are based either on
unscientific reasons or playing into the hands of the pharmaceutical
industry. Perhaps all are correct! For example, a doctor may decide to
prescribe drug A (instead of its generic equivalent) because his
previous patient died while on a generic equivalent.
In contrast another may prescribe 'A' because he heard a drug
representative describing the virtues of 'A' during the clinical
meeting-cum-dinner sponsored by the particular drug company.
So what are the practical steps to promote patient empowerment in
this area? Firstly the Government (and maybe even the Sri Lanka Medical
Council) through appropriate instruments should ensure that
prescriptions of doctors must include the generic term of the drug.
The legal position should support a situation for a patient to
request that he or she be dispensed with an equivalent generic drug,
even when a doctor prescribes a particular brand name.
Secondly, the Government should educate the public that they have the
right to purchase a product of their choice from the pharmacy, provided
they express their consent. This could be in the form of a publicity
campaign. I am sure there are several organisations that would
financially support such an activity.
Finally, what should doctors do in this light? They have to prescribe
according to the law. In instances when they write a trade name of a
drug, they must justify to themselves as to why they are doing so.
Furthermore they can promote patient empowerment. For example, this
could be attempted by stating 'I am prescribing drug A to you which is
available under different names. You may buy a cheaper product from a
reputed pharmacy'.
In passing I observed that most of the doctors who wrote on this
debate were from Colombo. Colombo has enough reputed pharmacies, and a
large proportion of their patients tend to be more assertive than the
average village folk. I see no valid reason why Colombo based doctors
don't utter these two sentences to their patients and help the latter
reduce their drug expenditures.
DR. SAROJ JAYASINGHE, Department of Clinical
Medicine, University of Colombo
Last year the Chief M.O.H. of the Dehiwala-Mt. Lavinia Municipal
Council issued a notice in Sinhala to all households informing them that
garbage will be collected every Tuesday, Thursday and Saturday.
But what happens today is that garbage is collected at the whims and
fancies of the garbage collecting workers. Sometimes they come twice a
week or else only once a week and that too on a Sunday. But they never
collect garbage on the days stipulated in the notice.
This is the main reason why garbage gets collected in households and
also on the road sides. Through disgust and due to garbage uncollected
for days, giving off a terrible stench some people throw it on to any
roadside. It looks as though there is no supervision or the overseer is
being looked after, as they say, by the labourers.
A strict check by higher officers will see that garbage is collected
three times a week - something householders have been denied for so
long.
Would the genial Mayoress of D.M.M.C. look into this matter please?
VERNIE, Dehiwala
At a time when lots of people are trying to ape the West we are
fortunate to recall the character of Engelbrecht, a Boer prisoner. He
was of Dutch-German origin who lived in his home in South Africa.
Resenting the selfish attitude of the British for when he worked he
was deported to Ceylon (as it was then called) as a Boer prisoner, and
installed in Hambantota to work in the salterns.
Though being strong, arrogant and aggressive he made friends with
many and one of them was writer Leonard Woolf. Engelbrecht was then
posted to Yala as Superintendent which he carried out well.
Director Kapila Kumara Kalinga has undoubtedly succeeded in making
this one of the best tele dramas, with the research work done by
Wijesinha Beligalle. He has also very wisely chosen actor Roger
Seneviratne for the role of Engelbrecht, which he has done to
perfection.
The role played as his wife actress Surangi Ruwanmali is highly
commended. So all are the rest, in Vanabime Sirakaru, the teledrama.
Finally may I quote Engelbrecht "If once you get caught to the
British you are begged forever."
Ananda Kulatilleke, Mt. Lavinia
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