Sunday, February 04, 2007

Medicines madness

Our little hospital has an attached nursing school and lab technician’s school. There is a private university a mile down the road with another lab technician’s school, clinical officer students and medical students. These students are an interesting barometer of attitudes to health care and consumption. It’s not unusual to see a 20 year old who has had a tickle in his throat for an hour and would like to be given a course of antimalarials and a week of broad spectrum antibiotics. This request is regarded as normal and acceptable. I will spend 10 minutes carefully explaining the difference between a minor infection with a cold virus and a life threatening infectious disease and the dangers of taking unnecessary medications (with gory descriptions of the worst allergic reactions I have ever seen). The student will leave much wiser but empty handed. Taking pity on him the obliging clinic nurse will shunt him off to see a clinical officer who will give him what he asked for and throw in some omeprazole, magnesium trisilicate and deworming tablets for good measure.
Typhoid fever or rather people who think they might have typhoid fever is another bete noir. When people are slightly unwell and think that on balance this time it isn’t malaria they are convinced it’s either typhoid fever or syphilis. They can be completely well with no convincing symptoms or signs of either illness but they want the tests. The typhoid test, at 75p is a days average wage here and is notoriously unreliable. We persist in doing it even though the way we do it is probably about as good as tossing a coin for all its scientific reliability. I patiently educate, counselling the patient to not waste their money, the nurse and clinical officer do their bit again, and an hour and a half later a fit 23 year old is led back in to seem me, cheerfully clutching a scrap of paper confirming his entitlement to 10 days of noxious (and unnecessary) antibiotic treatment.
The problem is that these illnesses are still common, often enough fatal and easily cured (in their early stages) by the use of appropriate drugs. When 30,000 (mainly young children) of a population of 27 million in Uganda are dying from malaria every year it’s a bit foolhardy to ignore the non-specific illness that is early malaria or early typhoid fever. Of course mothers are encouraged to present their children early for treatment and many village and small town health centres lack even a stethoscope or a thermometer let alone a laboratory for more sophisticated tests.
The management of diseases with antibiotics according to symptom complexes suggesting malaria or pneumonia or typhoid saves many thousands of young lives every year. But the consequence is a spiral of inappropriate drug consumption among older and much less sick people, serious drug side effects, the emergence of resistant organisms and unnecessary expense for an impoverished population.
Where does the balance lie? Better and cheaper diagnostic tests would help as would appropriate public health measures. The use of mosquito nets by children under 5 would almost halve the number of malaria deaths in this age group. Access to clean water and a good pit latrine would prevent most typhoid illness. Listening to radio 4 the other day I heard someone suggest that a 10% climate change tax on fuels would comfortably provide the funds to meet the millenium development goals necessary to eradicate the diseases of poverty. Why are we so reluctant…..

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