I was buying some medicines at the local chemist shop a few months back. An elderly lady hobbled down the street to the shop and stood beside me. She opened her purse and took out a small piece of wrinkled paper. She stretched her equally wrinkled hand and showed the paper to the chemist. The chemist nodded and gave her the medicines for diabetes and hypertension. I managed to catch the date on the prescription. It was more than 5 years old. But she had no difficulty in procuring her medicines. Neither did I, standing in the queue just behind her for the same medicines and carrying no prescription at all. Although I must add in my defence that I test my sugar levels fairly regularly at home. But maybe she does too. Probably self-medication is endemic to us and we don’t care to distinguish between antihypertensives and antipyretics which bring down a fever.
For as long as I can remember, Paracetamol in one form or another, in one brand or another has been in my medicine kit. A replacement for aspirin, it was and is the go-to drug for millions of Indians for common aches and pains, and mild fever typically associated with common colds and flu. But still, it was a surprise to come across a news item the other day that one of the paracetamol brands – Dolo in a strength of 650mg is India’s best-selling product for 2021. Obviously, the Covid Pandemic played its part as many of us stocked up on this easily available drug which needs no prescription and continues to be the first line of defence in case a fever strikes home and we scramble to get Covid tests done at the nearest lab.
The demand for paracetamol is the tip of the proverbial iceberg. Indians are definitely prone to huge chunks of self-medication and the distinction between over-the-counter drugs and those obtainable by prescription alone is quite blurred. Neither the chemist nor the patient is too bothered. The chemist makes his sale and the patient hopefully has his supposed cure. The pharmacist in the chemist shop or the salesman also doubles up as a doctor. It is quite the norm for a customer to walk into a chemist shop and ask for a “ prescription” for a headache or a fever or an upset stomach. The medicine prescribed and sold has less or nothing to do with the diagnosis or the correct dosage and everything to do with the customer’s ability to pay. Based on the appraisal, the salesman can hand over one or two tablets of a pain killer or a few capsules of an antibiotic.
Buying Paracetamol and popping it like chocolate brings with it, a set of problems but it is nothing like the ease with which antibiotics and other drugs classified as Schedule H drugs are purchased and consumed. Schedule H drugs which include antibiotics but also a whole range of others are not supposed to be supplied by any chemist without a medical prescription. But less than a kilometer from my house, there would be at least half a dozen chemists who would literally supply anything I require without even the pretense of asking for one. For a few mood-altering drugs there is a modicum of asking but even here if you know the chemist long enough and buy your medical supplies from him, he will quite happily supply you all that you need. That antibiotics and other drugs that require to be taken for a prescribed duration or titrated and tracked from time to time to see if the dosage needs alteration should be so easily available for self-medication is the bigger concern.
Prescription drug abuse is a growing form of addiction in India. What’s worrying is that because many of these drugs are available over the counter, accessing them is easy. Doctors say it is as bad as alcoholism or heroin addiction. Addiction does not start with illicit drugs. People get addicted to lower-level available drugs like cough syrups and painkillers. Chemists break the law easily and sell without prescriptions because there are few health inspectors to supervise. Relaxed licensing has also led to chemist shops being set up in clusters, where drugs are sold liberally to gain a competitive edge. Medicine in India is transactional. A well-liked doctor hands over a prescription at the end of every visit. Why else have I paid cash to see the doctor, if not for relief? The precariousness of daily life leaves little room for downtime.
Sales of antibiotics as well as anti-viral drugs skyrocketed during India’s first wave of coronavirus, suggesting that they were being used to treat Covid-19 patients even though at least the doctor knows that antibiotics don’t work in viral infections and even antivirals need to be used when specifically indicated. Needless or excessive antibiotic use contributes to the growing threat of drug-resistant infections worldwide. But scientific data succumbed to patient pressure boosted by a stray Whatsapp forward or a friend’s advice.
The World Health Organization has declared antimicrobial resistance as one of the top ten global public health threats facing humanity today. Drug-resistant diseases could kill ten million people every year by 2050, and cause damage to the economy on par with the 2008-2009 global financial crisis, according to a report by the United Nations. By 2030, antimicrobial resistance could see up to 24 million people pushed into extreme poverty. Antibiotics are being prescribed for treating upper respiratory infections (URI) the most among all diseases though, most URIs are self-limiting and do not require treatment with antibiotics at all, according to standard treatment guidelines.
Why then are antibiotics being prescribed the most against URIs? These are common illnesses and keep occurring. Also, people often have a tendency to rush to big hospitals even for the common cold. These hospitals would anyway prescribe mostly costly drugs. The third line of antibiotics is to be prescribed only at the hospital level, usually in ICUs; only if the severity of the infection has reached that stage but that they are being often prescribed at the primary care level. This is totally unscientific and unacceptable. Most of these third-generation antibiotics are costlier than their first and second-generation counterparts. One of the primary drivers for these drugs being prescribed was the high profit that pharma companies made by selling them, The pharma companies are heavily pushing them in the market, with aggressive advertisements through medical representatives. In the private sector, not only were the antibiotic prescription rates higher but the choice of antibiotics for the treatment of uncomplicated respiratory infections too was inappropriate.
The National Sample Survey Organisation (NSSO) reports suggest that the maximum expenditure among the five major components of healthcare expenses — doctor’s fee, medicines, diagnostic tests, bed charges, and others are incurred on medicines. Given that most Indians don’t have any form of health insurance and the public sector is rapidly withdrawing from the playing field, the scenario can only get bleaker.
Dr Shantanu Dutta , a former Air Force doctor is now serving in the NGO sector for the last few decades.
