E-DRUG: Why donations of sample/outdated drugs are welcome
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I have followed the chorus of damnation of donated drugs, especially
samples and outdated drugs, with interest and yet concern.
It seems that many of our correspondents are from European/western aid
organizations or managers of large Professional relief organizations, who
have different responsibilities and needs than front line health care
workers.
Some of us came from much humbler facilities. I worked for 12 years in
sub-Saharan Africa in rural mission hospitals. We cared for hospitalized
and ambulatory patients with whatever means we had. Many parcels of these
disapproved types of drugs came to us, and were usually most welcome and
beneficial.
Just to give perspective from a different point of view here are some
contrarian viewpoints:
a.) The expiry dating placed on drugs by the manufacturer is a drug
marketing decision, not a scientific dating. Almost all drugs are safe and
effective far beyond their arbitrary expiry dates. (3 years, 5 years, 10
years, 50 years?)
b.) Campaigns in developing countries against "expired drugs" are political
statements of pride, not scientific campaigns against dangerous substances.
As usual it is easier for a Minister of Health to make speeches condemning
"foreign imperialists" who are "dumping drugs", than it is for his Ministry
to provide the people with affordable antibiotics, analgesics, ointments,
and creams. So the poor patients end up with dogma, instead of drugs.
c.) "Dangerous Drugs" are also welcomed in "Desperate Situations". Every
physician knows that any given drug can kill, but we pay a lot of attention
to the frequency of dangerous reactions versus the probable benefits to be
obtained. Therefore in my western country with high levels of public
hygiene, hardly anyone uses chloramphenicol because of the rare, life
threatening reactions of a few "gray" infants-but during a typhoid epidemic
or meningitis, chloramphenicol would be used in a developing country with
great gratitude.
d.) Therefore a drug like "Trovan" would be a wonderful Godsend if we could
get the western manufacturer to donate their supplies to a third world
country (after it is withdrawn in the west because of liver damage to less
than a score of patients out of the tens of thousands who were helped by
it.) In a country whose drug budget is $10 per person per year, you could
save 10,000 lives with Trovan from life threatening pneumonias, abdominal
sepsis, PID, septicemia, for every 10 to 20 who might get liver failure
from the drug. Clearly a great benefit, if we could get the company to
"dump" this drug to us, expired or not.
[Trovan? Generic names, please, in E-drug messages as several people do not
know what is behind the brandname of another country! WB]
e.) Those who are shocked and outraged by these sentiment, may never have
been in a rural hospital or health care Centre at the bedside of a brother
or sister, a young father, a young mother, dying of an infectious disease
that could have been cured by a course of "outdated" or even "dangerous"
but very useful antibiotic.
f.) Sure we don't need all drugs from western countries, like Viagra
(except for the politicians?), or lipid reducing medications, etc. in most
of the third world. But large supplies of perfectly good but arbitrarily
outdated antibiotics, anti-virals, anti-fungals, anti-hypertensives,
antiseptics, ointments, drops, and lotions would be encouraged and welcomed
by a truly progressive Ministry of Health, and their frugal mission
hospitals, in much of this world.
So don't send your outdated antibiotics to Albania, or Yugoslavia. Or to
large western relief professionals writing from Brussels or Oslo and their
lovely warehouses. Send them to some enlightened third world country where
the Ministry of Health can tell the difference between appearance and
reality, and to front line health care workers struggling to save lives
with next to nothing. Their staff have the time to sort out the samples
that can save lives and use them to return health to their patients, using
the "dumped" "left overs" from wasteful and immoderate western societies.
This is not to oppose all the wonderful work done by e-druggers to have
rational, essential, and affordable drugs available in all the world That
is the ideal.
What you are saying is right: all donations should be fresh, appropriate,
well packaged, and free. But till then please allow drug companies to
donate and send (ok, call it "dump" if you want) their out-of-fashion /
outdated / dangerous but effective drugs to places who will be
still waiting for utopia to visit their village 20 years from now.
Dr. John B. Hoehn
HOME: jhoehn@bmi.net
Dr. John B. Hoehn
1111 S. Second Avenue
P.O. Box 1397
Walla Walla, WA 99362
[current affiliation? country? WB]
[we probably all agree that fresh donations are best. That should be our
policy and political demand.
Your question is basically: what is worse: no drugs or expired drugs? In my
view this is the wrong question. Of course the answer is 85% of the time
that an expired essential drug is better than no drug at all (if the
patient needs one, at least). But your proposal can only be a solution on
an individual basis, with an experienced doctor/pharmacist, who knows to
judge the risks of using aged drugs with strange brandnames in a different
language. It may have worked for you, but would this work for thousands of
nurses without your professional background?
I also worked in rural African hospitals (although not so long!) and also
got boxes full of small quantities of unknown brandnames, useless anti-acne
drugs, shampoo and occasionally indeed expired useful drugs. I had to spend
days shifting the useful from the rubbish. At best 10% was useful, and the
rest had to be destroyed. Those experiences actually made me an essential
drugs expert in the end, as I started to define the drugs that I really
wanted. I considered asking those goodwilling (but naive) mission sisters
to send me only those essential drugs, but decided in the end to buy them
in the next town, as they were quite affordable.
Developing countries have indeed also responsibilities, and maybe the
country where you stayed did not have a very committed Ministry of Health.
That is obviously deplorable. But how could we motivate such a Ministry to
become more involved in rational drug supply systems? Should our duty as
development worker not be more to improve drug supply systems, rather than
to rely on unsure donations? Being a clinical doctor in a remote rural
hospital is obviously helpful when you are there, but you cannot stay there
all your life. If you had designed a basic essential drug system in your
hospital, maybe they would have been better off after you had left?
Of course one could also help to sort out the drugs in USA that are
proposed for donations, and remove the useless and dangerously expired ones
before they are sent to colleagues in Africa. But I am sure they would
prefer you to send bulk stock of essential drugs.
So I think we all know those unique situations where such a donation could
work, but it is not a sustainable or replicable solution we can or should
promote. It is also illegal in many countries to export or import expired
drugs. Anyway, thanks for your contribution!
Wilbert Bannenberg
E-drug moderator (and ex-tropical doctor)
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