E-DRUG: Moving towards a new definition of essential medicines? (8)
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Dr. Manikanden raises a number of issues concerning the definition of an essential medicine in his letter and editorial. This is worthy of discussion.
The problems of health care in 1977 when the definition of an essential medicine was written were different than those of 2015. Then the focus was on helping developing countries improve the inadequate health care available for many people in these countries (Selection of Essential Drugs, WHO Technical Report Series 615, 1977). Infectious disease was upmost in people's minds. 39 anti-infective drugs were in the main list then along with 7 antineoplastic drugs. Around 1990, some middle income countries desired advice about cancer medicines. A WHO consultation was held and divided cancer medicines into 3 categories: drugs that significantly prolonged survival, those that improved quality of life, and those that did neither (Bull WHO 1994; 72: 693-8). An Expert Committee decided that those in the first two categories were essential. It appears that this determination that drugs in these two categories are essential continues to the present.
Relevant to this determination are some policies stated in 1977. Most important is that the list was seen as a Model List to illustrate how to implement the concept of essential medicines. The report stated that each country must develop its own list of essential drugs based on that country's needs and resources. Today the Model List is used in many other ways. If diagnostic and laboratory resources are unavailable to utilize some of the modern antineoplastic drugs that prolong life or give meaningful palliation of cancer, these drugs need not be on a national list. Their absence illustrates a gap between what can be done locally and what exists in medicine.
Another important issue is whether drugs for uncommon diseases are essential. The 1977 report stated that the proposal was to help countries obtain the drugs for the most prevalent diseases because this was the priority then. The priorities now are more diverse and numerous. The issue of whether it is right to exclude an effective treatment of a disease because it is uncommon should be considered. The principle of distributive justice states that the people who bear the burden should share in the benefits. If a drug for an uncommon condition has the same cost: effectiveness as drugs on the national list, it is unjust for people with that condition sharing the burden of supporting the health service to be precluded from sharing the benefits of treatment just because of the prevalence of their disease. (Bull WHO 2006; 84: 686).
There are many other issues, price being one, raised in Dr. Manikandan's editorial that are worthy of thoughtful discussion. Medicine has changed much since 1977. The Model List is being used for many purposes rather than just a model of how to implement the essential drugs concept, its original intent. The expert committees and WHO must deal with all the issues raised by Dr. Manikandan and the continuing advances in therapeutics. A thoughtful discussion of these issues and a new definition of an essential medicine may be needed.
Marcus M. Reidenberg, MD
Emeritus Professor of Pharmacology
Weill Cornell Medical College
New York, NY 10065
email: mmreid@med.cornell.edu
Notes on Therapeutics at: http://www.med.cornell.edu/cert/patients/notes_on_therapeutics.html
Other essays at: http://www.cornellpharmacology.org/faculty/MarcusReidenberg.html