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The expanding role of the pharmacologist in the changing Indian scene.
In the last four decades, the subject of pharmacology has graduated from materia medica and animal experiments to a dynamic subject which forms the basis of modern human therapeutics. A pharmacologist can contribute a lot, not only by doing research, but also by helping the government in formulating the drug policy, in orienting the teaching programmes so as to make the students aware of their social responsibility, and in educating the community regarding the use and abuse of drugs, so as to achieve better health care which also would be cost-effective and suit our resources. There are not many pharmacologists involved in policy making at various governmental levels. I don't want to go into the reasons for that. Perhaps, we have not been able to create an image such that the government agencies cannot ignore us. Concept of essential drugs W.H.O. Director-General Mahler observed that the public health services of the 67 poorest developing countries, excluding China, spend less on all drugs than the rich countries spend on tranquillizers alone.[6] The per capita annual expenditure on medicines in Asia was £0.28, 30 times less than that (£ 9.00) in the U.K. India is no exception to this general trend. Because of our other priorities, our budget for health is relatively small (2.9% of the total annual, national expenditure for the year 1983)[4] and drugs consume a larger proportion of the health care budget (almost double) than the 8-10% utilized in developed countries. As the economy of our country improves, the demand for drugs will also increase. The demand for drugs is without limit, while budget has limits. Hence, if we have to provide effective treatment to millions in rural India, we have to accept the concept of essential drugs and implement it. Here, pharmacologists can play a major role. It is well known that in many developing countries, large number of unnecessary drugs and drug combinations are marketed; the number available many times exceeds that found in any developed country. One survey[7] showed that there were 14,000 drugs marketed in Brazil, 15,000 in India and 17,000 in Argentina. According to a very recent report,[1] published in "The Daily", Bombay, dated 12th June 1986. there are over 45,000 medicines used in India of which nearly 75% are either unnecessary or dangerous. Are they all necessary? We as the Indian Pharmacological Society must make our views known to various drug controlling and policy making authorities. It is our social responsibility. If you just look around at the chemists' shops or even glance through some of the directories of products available in this country, you will realize that the products are far in excess and could easily be taken off from the market without any harm. In fact, it will do lot of good. Consider drugs like sleeping and anti-anxiety pills, antihistamnics, pain relieving agents, antidiarrhoeal agents, cough remedies, tonics and vitamin preparations, many of them irrational combinations. Are they all necessary? Even in rich countries, a major share of all new drugs registered is, by any standard, non-essential and offers only a marginal improvement in health management or none at all. The pharmaceutical industry is geared to influence the decision-making of the health sector (who are quite often doctors) as well as public opinion in favour of an unrestricted drug market. The drug industry is, however, not solely responsible for this state of affairs. The prescription and requisition of drugs are totally in the hands of the doctors who bear the main responsibility for the use of drugs. It is the attitude of a doctor and the way he prescribes drugs that need a change. Pharmacologists can contribute significantly in changing these attitudes. Although we have a drug control authority in this country, effective control of drug promotion is lacking. Many of the present day advertisements in the medical journals or literature supplied to doctors mention only the brand names, without giving what the product contains. Information regarding toxicity, precautions, etc. is usually totally lacking and wrong claims are made regarding the properties of the product. This is in contrast to the advertisements that appear in standard western journals. The lack of effective control over promotion and the lack of alternative source of information mean that the pattern of prescribing and of drug purchase are often irrational. Over-prescribing is a rule whereas people have so little to spend. We who train the doctors in drug usage have a great responsibility in emphasizing these aspects of health care if the country is to provide the best of medical care, with the limited budget at disposal. Remember, the demand and budget will never match. However, the gap can be reduced considerably by accepting the concept of essential drugs. The concept of essential drugs has been successfully implemented by countries like Bangla Desh, Mexico, Kenya and even advanced countries like Norway.[5],[6] Why can we not do it? Research strategies On the research side, pharmacologists from this country must come out of their shell of traditional thinking and look at the realities of research. In 1976, the WHO estimated that the total world expenditure on research and development in tropical diseases was about 2% of the sum spent on cancer research.[2] Out of 5,000 million dollars spent by the industry on research and development in 1980, only 1% (50 million dollars) were spent on diseases relevant to the third world.[2] Most of the drugs produced by the industry are of more direct relevance to the rich countries and their high prices reflect the rising cost of research and development. As far as research in tropical diseases is concerned, Indian drug industry is still in infancy and their approach does not seem to be different from their counterparts in the West. We have to accept this challenge and develop our own expertise. We have over 110 medical colleges. Why not some of you join hands with your colleagues in chemistry department and pharmaceutical department in your institution or your university and form teams with specific objectives to develop research in tropical diseases? ICMR, CSIR, DST and even WHO will be happy to fund such long term projects. This should be the priority in our research. Recently, there is a sudden spurt in marketing various plant products and drugs used in traditional medicine. There is nothing wrong about it. Unfortunately, there are no firm regulations applicable to sale of such remedies unlike those which exist for modern drugs. The preparations are considered to be non-toxic, even without doing any toxicity studies and data on efficacy is usually vague. The promotional material is flavoured with many claims, either based on incomplete and irrelevant studies in animals or dubious clinical trials which could rarely be considered as scientific. Most of the time, such studies are published by the company in its own house journal. One such recently introduced combination contains 20 odd ingredients and is claimed to be effective in a variety of heart ailments. The promotional literature lists many unpublished reports by pharmacologists, which are neither available for reference nor for scrutiny. We must not forget that we have a major obligation to the community and the nation, and we must not allow ourselves to be used to exploit the people by supplying inadequate and half baked studies which are neither confirmed, nor published or available for scrutiny. Certainly, we need to re-think about our strategies in conducting research in traditional medicine. Fortunately, ICMR has already taken a lead in this direction. Both the research facilities and funding for research in our country are inadequate and the situation is not likely to change in the near future. Obviously, interdepartmental or even inter-institutional pooling of such facilities is needed. Pharmacologists can certainly widen their field of activity by reaching out for their colleagues in the clinical departments and participating in joint exercises meant for both students and staff (such as Journal Club, Therapeutic Rounds, etc.), to the benefit of both the departments. Those who have no facilities for clinical research could create such facilities with the help of the department of medicine. Student training The subject of medical education in India has been a topic for debate by experts on many occasions. Medical training in our country is based on the Western model. Besides other things, it does not prepare the graduate for the flood of information which will be received for the remainder of the doctor's career. Clinical pharmacology is a relatively new subject and many new medical schools put more emphasis on the traditional subjects than on clinical pharmacology. There are few statements of alternative view points available to many of our doctors; the drug company representatives and industries' promotional material are the major source of information for many doctors. As a result, the standard of prescribing by both doctors and medical auxiliaries is generally poor. Polypharmacy is rampant. As a result of the more extravagent prescribing by doctors working in urban hospitals, the costs per patient are increased and drug expenditure is biased in favour of these hospitals. As a consequence, in Tanzania, the teaching hospitals consumed 27% of the national hospital drug budget but treated only 5.1% of inpatients and 2.1 % of outpatients.[7] The result was that for most of the year, drugs (even essential ones) were not available for most people. We also have witnessed a similar situation, urban versus rural, in our country. It is not realised that the money spent on food provides more benefit to a person who is undernourished than the same sum spent on multivitamin, tonic preparations. Students must be trained not only in the effects of drugs, their toxicity, but also in how to assess information about drugs and how to discriminate between accurate information and promotional claims. Prof. Gaitonde in his Sir Chopra Memorial Oration said,[2] "We ought to bring in the social aspects of drug therapy in our teaching and make students cost conscious. Pharmacologists ought to play the role of consultants to physicians and to the society alike, in order to improve quality of medical care in the community. Pharmacologists should provide integrated, comprehensive approach to medical education in order to improve social consciousness about drugs and the quality of medical care. One of the factors responsible for polypharmacy is a lack of social dimention in our teaching programme. This situation needs correction and the pharmacologists role is crucial in this activity". Community education As the economic health of the country improves, so the demand for drugs will also increase. Doctors and patients desire and demand the latest drugs and their demands are reinforced by the promotional activities of the drug companies. Unfortunately, nearly all people associate drug quality with drug price. Pharmacologists can play a vital role in creating awareness regarding the misuse of drugs, their harmful effects and the cost burden involved. Every case of fever does not need an antibiotic and every little pain needs no potent analgesic. Emphasis has to be on preventive health. The impact of advertising and promotion on patterns of prescribing and also, on the purchase of drugs over the counter, needs no emphasis. In our country, many drugs even those that can be extremely hazardous, are bought without a prescription in spite of drug regulations. Consumer unions can play an important part in educating the public in the correct use of pharmaceutical products and pharmacologists can effectively put across such information through the consumer unions. Health for all by 2000 A.D. is our avowed goal and we are only fourteen years from the deadline. The task ahead is gigantic. So, let us, as pharmacologists, accept this challenge and be ready to face the 21st century.
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