E-DRUG: Drug donations (cont)
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Dear E-druggers,
Here are a few more points and questions to the discussion on donations,
mainly addressing the issue of donations in kind.
I find that the issue of why donations must be in kind is rarely addressed.
With the high price of brand name drugs in most donor countries, it seems
to me that cash donated to a well known NGO/PVO would be much better value
for money and would ensure the ''software'' as well. Unless somebody can
prove me wrong I will continue to view many donations as having to do with
''getting rid of'' stock or extend market. One example: donation of Trovan
(alatrofloxacin) a fluoroquinolone which was withdrawn by FDA because of
serious liver problems.
In at least one Balkan country it could be found donated as physician
sample in packages of 4 tablets!
Even if it is claimed that donating own drugs is cheaper (if so, it says
something about the real cost of drugs!), no-one can say the industry could
not afford to donate in cash or purchase generics. 150 000
hydrochlorothiazide tablets bought from an international non-profit
manufacturer cost 100-150 USD.
It can treat more than 400 people for hypertension for one year! Wouldn't
that make more sense than donating very expensive me-too drugs which,
because of the cost, may only be available for a few?
In Bosnia it is estimated that about 3000 people will be diagnosed with
tuberculosis in 1999. The cost of treating all of them and an estimated 300
relapses with the recommended 6 months' treatment is estimated to about
100,000 USD if generic drugs are purchased from an international
non-profit manufacturer. This is close to the DAILY increase in the
Norwegian drug reimbursement cost! Norwegian wholesale price would be about
1.3 mill USD.
So we are not talking about ''big money'' if we use the right sources.
Medication errors/safety issues:
In Norway as well as in many other countries an issue of much concern is
medication errors. Patients even die because names are mistaken (e.g.
Lasix/Losec). And several suffer because of wrong drug, wrong dose,
forgotten doses etc. Several reports have been published from a range of
countries. So, with highly educated medical staff and a limited range of
drugs we make mistakes, more often than we want to admit.
When we donate drugs, we claim to be doing good to the recipient. The
country may have its own manufacturer(s), but we choose to ignore them and
finally put them out of business. Why? Because we think they are not good,
because we don't like their selection of drugs - or? (these are the drugs
the patients are familiar with)
Many of the recipients are countries with a range of drugs quite different
from the donor countries, and definitely with different brand names. Even
countries of Western Europe have a range of drugs which is quite different
from that of USA. We have e.g. no Tylenol in 10-20 different versions! So
we decide to donate not only in kind, but we don't even bother to take the
time to even relabel them to make the generic names clear.
Then, having decided the recipients are stupid and we need to tell them
what to use, we then assume they are intelligent enough to know immediately
how to use correctly all these many hundred differently branded drugs
which they see for the first time in their life! Because I don't think we
want them to poison the people we want to help - or? This to me is a
paradox.
The other day I mentioned one example of a bad donation of medical supply.
Today I would like to give you another example of a drug which is not
necessarily a bad donation (although very often with short expiry), but not
necessarily a needed one either. The drug is insulin.
I will first go back in history a few years.
In Norway we used the 40 IU strength up to late 70's or early 1980's I
think.
Then we decided to change to 100 IU. This was assumed to pose such a
problem that we decided to stop using the 40 IU in order not to risk
mistakes being made. Simultaneously a big campaign was started for consumer
and doctor awareness.
Some years later human insulin was introduced. It was said that the pork
and human ones were interchangeable, but still there were many reports of
patients having a changed tolerance with the new one and if you search
Medline, you will find that the topic was heavily discussed. Even deaths
were claimed to have occurred.
In addition, insulin comes in different types according to duration of
effect.
In a competitive market, a lot of different types and brands exist and
during the last few years many manufacturers have introduced their own pens
as well, thus ensuring patient loyalty.
In some of the countries in need of donations lately, such as the Balkan
states, people are used to many different types of insulin, but not so many
brands. One brand is produced in one of these countries and used by most of
the patients. But patients use different types and combinations and,
different from Norway, both 40 and 100 IU are on the market. What happens
then when insulin is donated? Totally ignoring all the precautions that
apply to our patients, a different brand is being donated. It comes in one
strength and only in 10 ml vials and in two types, short- and
medium-acting. So for these patients, no regard is being paid to the fact
that they have been used to other types of insulin, they will now have to
be trained in using the old syringe and needle again, their blood glucose
is likely to be unstable, and who is donating them stix for measurement and
syringes and needles? Nobody! If the country instead had been given money,
patients would happily continue on what they were used to.
These are to me some issues of concern which are as important as whether
donated drugs are on the lists or not. It has to do not only with issues of
safety, but it has also to do with respect for other human beings. Who is
to decide what is ethically correct? When is the right time to start a
change of prescribing habits? Has anybody a monopoly on always knowing what
is the truth - about what is best for others?
Looking forward to donor comments!
Regards
Kirsten
Kirsten Myhr, MScPharm, MPH
Bygdoy alle 58B
0265 Oslo, Norway
Tel: +47 22 56 05 85
myhr@online.no
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