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Urgent need to look at ‘availability, accessibility and affordability’ of essential drugs
Essential medicines – the shortages and their disastrous repercussions are the focus of the Sunday Times this week even as the COVID-19 pandemic is still around and Sri Lanka does not know what awaits at the next corner with regard to the new coronavirus.
“Availability, accessibility and affordability, are the very basics that we need to look at when focusing on essential medicines,” reiterates a former Sri Lanka Medical Association (SLMA) President and respected Family Physician, Dr. Ruvaiz Haniffa.
He stressed that for the very first time in Sri Lanka, not just essential medicines but also others are not available, let alone being accessible or affordable. At any given time, among the people, especially with a rapidly-ageing population, 20% or 1 in 5 have at least one non-communicable disease (NCD) and most often not just one but two or three. These people have to be on medications life-long and it is the responsibility of the state to make these medicines available to them.
Dr. Ruvaiz Haniffa
If these medicines are not available, the image Dr. Haniffa paints is stark and chilling.
- A person who is a diabetic will take medicine to control his/her blood sugar and prevent serious adverse impacts on his/her kidneys, eyes and other organs. The medicines help to postpone these adverse impacts and reduce grave risks to his/her life.
- With each NCD a person has, the risk to his/her life gets doubled or tripled and the one and only way to meet this danger is through the right medication.
- Without these essential medicines to control NCDs such as diabetes, hypertension (high blood pressure), cardiovascular disease (including heart attacks and stroke), renal failure (severe kidney disease) and more, some will die immediately. Others will suffer lingering illness. This will lead to a terrible quality of life.
Lack of essential medicines will “mess up” lives both the ‘quantity’ and ‘quality’, is the diagnosis of this Family Physician who sees a cross-section of patients – from babies through to adolescence, to middle-age and old age…….from cradle to the grave.
He takes up those with mental illness, many who are not in hospitals but are on medications at home.
Can you even imagine the impact on the home and family of having someone with mental illness sans his/her medications, he asks detailing how these patients would react at home, while also highlighting how abuse against such vulnerable patients could easily ensue. The family dynamics will certainly go awry and abuse could follow in its wake.
Without naming names, he says that some family members of mentally ill people have pleaded with him to “kohe hari dala denna” their kith and kin. This is because the family cannot cope with the pressure and that is understandable.
Dr. Haniffa also looks at other vulnerable groups –
- The elderly who are facing a terrible plight.
- Cancer patients who are getting their lives shortened for lack of drugs and dying sooner than they normally would if drugs are available.
- Children who are prone to illnesses.
Dr. Haniffa next looks at surgeries – routine and emergency. He takes up a simple and common emergency appendectomy needed if a person has acute appendicitis. This surgery is needed to remove the appendix when it is infected. If the anaesthetic drug neostigmine is not available, where does Sri Lanka stand? Is it back in the Stone Age? What of urgent emergency operations after a road accident? 
With regard to accessibility, people are expecting the health sector including their doctors to see to this basic need, he says, moving onto affordability which has also become a major issue for people.
“Many people have undergone severe hardship after the pandemic hit. Some have lost their jobs and others have got pay cuts. Online education for their children or online facilities due to their job requirements has also made inroads into their meagre resources. Now people are grappling with shortages such as food, fuel and gas further eating into their resources,” he says, looking at the dire state Sri Lanka is in.
Into this situation comes a sharp rise in drug prices, he points out.
The example cited is a person on a cocktail of drugs (at least 3 to 4, many take more) for NCDs. Metformin, an oral medication given to control blood sugar, has shot up in price 20-30% than what it was before.
Do you know what patients will do, asks Dr. Haniffa, pointing out that if a person has to take three tablets a day, he/she would take it only once or twice a day. Another way that a patient will handle the drug price hike will be to take the medicine prescribed daily on alternate days. It is the same with drugs to control high blood pressure and also high cholesterol.
He gives another example – many women are prone to urinary tract infections (UTIs). Some get it like the common cold. The medication which was not only cost-effective but also very effective in clearing UTIs was nitrofurantoin, costing just seven or eight cents per pill. Now it is out of stock and availability is zero. So doctors have to prescribe more advanced third or fourth generation drugs for a simple ailment.
The repercussions can be imagined with anti-microbial resistance (AMR) being an imminent threat. AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat.
Just this Monday, Dr. Haniffa had seen a person with intractable or long-lasting hiccups which is not a major illness. The less costly chlorpromazine is not available and now doctors have to prescribe gabapentin which is more expensive.
What happens then is – a family’s other urgent needs such as food which is costing a lot; children’s tuition fees etc will be met first and medicinal needs last, he adds.
| From Colombo to Beruwala, a father’s desperate search for paracetamol syrup Heartrendingly, Dr. Ruvaiz Haniffa recalls a recent incident where he prescribed paracetamol syrup for a little one which is the “gold” standard for fever. If fever in a very small child is not controlled the child may have febrile fits (seizures) which really scare and agonize parents. It is with much sadness that Dr. Haniffa says that the syrup is now like gold, for the father of a little patient of his had gone from pharmacy to pharmacy all over Colombo and then up to Beruwala in his desperate search. When he asked the father why he did not call him and get a substitute, which of course is paediatric paracetamol tablets, the father had said that to crush tablets and try to give it to his child would be impossible and also getting the right dose in would be a huge challenge. “Baba, beheth kudu karala dunnahama bonne ne. Beheth pethi kudu karapuwahama dose ekath waradinawa,” had said that father who preferred a long distance journey to get just one bottle of paracetamol syrup. What a sad state of affairs for paracetamol syrup, he adds.
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| Crucial to import at least essentials of the essential drugsWithout just highlighting the problems, Dr. Ruvaiz Haniffa talks of what doctors can do and also ought to do in this current crisis.“Let’s get-together, pharmacological experts, other doctors and pharmacists and send a fine-comb through the list of drugs which have been imported into the country. In these crisis times, we could see whether we could prune the list down to a few drugs in one variety,” he says. He points out that there are 52 essential drugs. Leaving aside personal gain and differences, a strong group should see, for example, whether without getting many drugs we can get about three for diabetes. This would help us to meet the vision of Prof. Senaka Bibile about availability, accessibility and affordability. Another is amoxicillin – do we need over 100 brands? Can we manage with 2-5 brands, he asks. “It would be getting essentials of the essential drugs,” he says, adding that then “we too as doctors have been proactive in getting vital medicines to the hands of the people.” Questions over viability, quality of drugs, vaccines due to power cuts Another startling disclosure comes from Dr. Ruvaiz Haniffa. He questions what happens to the mandatory requirement that all pharmacies should be air-conditioned to ensure that medicines retain their viability and quality. One of his patients had to go round and round the city because not many pharmacies stocked the tetanus toxoid injection as their fridges were affected by the lengthy power cuts. Even for larger pharmacies which had generators, there was no fuel to operate them. He is hesitant even to think about the fate of vaccines with massive power-cuts and fridges not working. These vaccines include those given under the National Immunization Programme and also those against COVID-19. Avoid trips to avert even small accidents As the New Year holidays come upon us, many doctors advised people to stay home and not go on trips as even a small accident could have a serious impact as hospitals had no medicines. Beware of road traffic accidents as the lack of medicines especially for surgeries could be a threat to lives, many said. They also cautioned people to be careful about what they ate as a simple tummy upset could have terrible consequences.
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