Perspectives on Global Health from Pharmacists Around the World

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, these roles accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. This initial segment focuses on medication access in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Throughout both developed and developing healthcare systems, access to medications is consistently a top priority for pharmacists and health care systems. As this health care profession attempts to provide services that meet the needs of their communities, access deficiencies habitually impede the ability to follow through with individualized and compassionate care. The lack of access to life altering chemical entities can affect anyone anywhere, from an affluent metropolitan city like Washington D.C. to a small rural Cambodian village in the province of Kampot. Despite the differences in these locations, each of these instances cause significant harm, breed mistrust in healthcare professionals, and create despair among those that seek healing. These frustrating situations are due to intensify because of the increased strain on medical resources who take a “do-what-has-always-been-done” approach. These following four pharmacists, all from various corners of this vast planet, will describe the barriers they consistently face regarding medication access and initiatives that are being undergone to ensure that a novel approach is commenced to address this looming medical tragedy.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Before discussing medication access in the United Arab Emirates, I would like to give a brief introduction about the United Arab Emirates (UAE). It is a middle eastern country with a population of 9.68 million. The country is comprised of seven emirates and healthcare in UAE is regulated both federally & at the Emirate level. 

Now, starting with the topic on hand about medication access in UAE, there are several factors that have an impact on it and I will touch on them individually and in detail. 

First and foremost, I think the most important factor is the number of medications available in UAE. The majority of medications available in UAE are imported drugs. UAE imports pharmaceutical products from 72 different countries. Of those, 10 countries constitute approximately 80% of the entire country’s supply. The domestic sector is rather small; however the UAE Ministry of Health (MOH) plans to increase the number of pharmaceutical manufacturing facilities to 30 by 2020 up from 16 in 2017. Availability of different medication combinations or different strengths are difficult to find due to the limited number of industries in UAE. One such example is oral prednisolone, which in UAE is available in strengths of 1mg, 5mg, 10mg & 20mg. In the USA, there are more strengths available including 1mg, 2.5mg, 5mg, 10mg, 20mg and 50mg. Tourists or expats coming from overseas that need a particular medicine or medicine combination or a particular strength may not find it available.

The second hindrance to medication access is the cost of medications. There are many reasons for the high cost medication. The aforementioned fact that about 80% of medications in UAE are being imported rather than locally manufactured is one reason. Another reason is an insignificant availability of generic medicines as the majority of medicines available are brand name. The final reason is the national health insurance model. Because all national citizens do not have to pay for their own medications, there is no incentive to keep the medicine prices low. As a result, individuals who are not insured under the public national insurance system, for example expats and tourists, face a huge barrier to obtaining medicines. 

With these barriers in mind, initiatives have started to take place in UAE to find a solution. The government reduced 24% of the prices for 8732 medicines over the course of 6 years. Another initiative which took place is increasing the number of generic medicines while also advising physicians and pharmacists to dispense the generic rather than the branded medicines. Through this initiative, generic medicines now account for 30% of the overall pharmaceutical market which has increased from 12% of the market two years ago. If the UAE can bump these numbers up to 70-80% of the overall market in UAE, the UAE will be seen in better position in terms of generic medicines. 

I am glad to be a part of a region where these issues are actively tackled, not just by the government but by private sectors as well. We are also seeing that pharmacists are playing a larger role, providing information on availability of cheaper alternatives on medicines. Pharmacists are the most accessible healthcare professional and it should be part of their responsibility to help make medicines as accessible as possible to their clients.

 Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

Although there are a host of issues surrounding access to medications, I will be focusing on oncology medications as oncology is my current specialty as a medical science liaison in the USA. 

To begin, I would like to highlight encouraging statistics that show the accessibility of oncology medications in the USA. A recent 2019 study found that 96% of new cancer medications were available within the United States, the next highest nation was at 71%. Furthermore, the average delay in the availability of cancer medications within the United States was 3 months, with the next closest nation being at 9 months.

In terms of novel and innovative treatment options, oncology drugs have been increasingly approved by the Food and Drug Administration (FDA) throughout the last few years. The FDA has enacted policy changes to attempt to increase the efficiency of drug reviews. The results have been significant – in 2017 alone, 46 new oncology drugs were approved. Moreover, from 1991 to 2016 there was a 27% decrease in cancer related deaths in large part to the expanded and more targeted-based therapy. The chance that a patient will live for 5 or more years has increased by 41% since 1975.

Outside of regular treatment options of those living with cancer, patients have the ability to participate in a clinical trial. Currently, there are 24,351 clinical trials listed as active (defined as not yet recruiting, recruiting, enrolling by invitation, or active) – 11,813 of those trials are active in the United States. However, even with the surplus of ongoing clinical trials, it still seems there is a lack of patient enrollment. It is estimated that roughly 70% of patients are interested in clinical trials, and yet <5% of patients actually enroll in clinical trials. Some of these barriers to enrollment include: lack of availability at a specific clinic, lack of a specific trial available, patient ineligibility, physician is unaware of trials/not offering them to patients, and a patient deciding not to enroll in a clinical trial (perhaps due to a fear of receiving the placebo).

An aforementioned barrier to cancer treatment that needs to be emphasized is the locations of specialized cancer clinics. Studies have shown that patients who are diagnosed with advanced staged cancer are likely required to drive an hour or more to the nearest cancer clinic for the appropriate care they need. Additionally, travel distance may affect treatment decisions. A patient may select a slightly less efficacious therapy if that means they have to travel less often. 

Two initiatives have recently been instituted to further increase the accessibility of medications. First, in an effort to go towards value-based contracting, some companies are beginning to only charge patients if their medications are effective. While this is a rarity, it will be interesting to follow the impacts of this on other more costly treatments and to determine the impact on patients. Secondly, in 2018, the right to try act was passed. This essentially gives terminally ill patients who are unable to enroll in a clinical trial and have no other remaining FDA approved options, access to other treatments. While this is a relatively new policy and there are some restrictions, hopefully it will give patients hope and additional treatment options. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In rural Cambodia, access to medication is especially limited when compared to urban areas. Access is limited by two main factors in these communities. Firstly, many people living in rural areas have low incomes which means it is difficult for poor rural individuals to buy medicines for serious illnesses. Secondly, community drug outlets and public health facilities are generally concentrated in the provincial capitals/cities, making it difficult for people from rural, remote areas to get access to those places. 

Usually, medicines imported from other Asian countries such as India, China, Vietnam, Thailand, or Malaysia are cheaper and therefore, more accessible. These cheaper medications, however, tend to be held toward a lower quality standard which can lead to disease state progression, antibiotic resistance, and other situations that can inflict harm onto patients. However, western brand medicines, which are usually held to a higher standard of quality, are less accessible because their prices are higher. Locally, they are generally considered “medicines for the rich.”

The lack of access due to  these aforementioned barriers makes diseases difficult or impossible to treat in cases where medication is necessary to cure it. Patients may see their disease aggravated and could die of it.

In order to address these medication access complications, a specialized team should be created that assists patients or their relatives to get medication which is far from their home and provide a specific loan with very low or no interest rate for villagers who cannot afford to buy medicines. This approach has been initiated in Cambodia through the increased access of health equity funds (HEF). These funds, allocated to individuals unable to afford the out-of-pocket expenses for public services, are pooled from a variety of sources like the national health budget and various donors. These patients are then given a specialized card to receive these funds when public services are used. The HEF focuses on addressing low medication access through the initial financing as aforementioned, community support, quality assurance, and finally policy dialogue. The results of this project have been promising – there was a 28% increase of patients utilizing public services with HEF than before without the HEF. In addition, the patients were not perceived to be more stigmatized within their communities.  

Veda Peddisetti, B. Pharm.

Clinical Pharmacist – Satya Sree Clinic & Diagnostics 

Hyderabad, India 

India is the largest country in South Asia and the second most populous country (1.35 billion) in the world. In addition, India is said to be in the third stage of demographic transition with birth rates declining and death rates decreasing. In the past few decades, India has experienced monumental population growth. This has led to many problems in healthcare management throughout the country, in particular, medication access. The direct cause seems to be the over-demand of medications. However, various indirect causes include poverty, varying per-capita incomes, unemployment, and out of pocket expenditures (India doesn’t have an established federal healthcare insurance system like Medicare in the USA, National Health Service in the United Kingdom, etc.).

In addition to the aforementioned causes, the literacy level in villages and rural areas are quite low. Many of the farmers and laborers from rural India are uneducated. As a result, many don’t know how medication can help them get better and how important it is to take medication every day to keep chronic conditions like hypertension and diabetes in control. In urban areas, all income classes are more educated and are given awareness more frequently about healthcare when compared to individuals in rural areas. So, they tend to use medication and other healthcare facilities more frequently. Accessibility is not a huge issue in cities but this creates competition among providers and results in high costs which turns into a problem for low and average income communities of the urban population.

Usually, regular medications like anti-diabetics, anti-hypertensives, common antibiotics, analgesics, vitamins are available throughout the country except in some deeply located tribal areas. Medications which are used for some cancer chemotherapies, auto-immune diseases, and some orphan drugs are not widely available. People have to go to highly rated hospitals in developed metropolitan cities to get these medications, and I believe this scenario is the same anywhere in the world. This kind of accessibility shouldn’t affect any patient or healthcare provider unless there is any medical emergency. And thanks to the continuous efforts of the Government of India, India is improving the accessibility of medication. Recently, various health benefit schemes were implemented like free supply of in-patient medications in civil hospitals and sale of reasonably priced generic medications in rural and urban communities.

It is a well-established fact that India is a potential supplier of medications to many countries in the world. India is a manufacturing and research hub for many reputed pharmaceutical companies. However, this often leads to pharmaceutical companies who are exporting their products in large quantities rather than supplying them domestically. These medications range from certain medications for chronic diseases like diabetes drugs to life saving medical devices like the Epi-Pen. These pharmaceutical companies more interested in profit are preventing the Indian population from getting the best medications.

With the lack of proper medications, healthcare professionals cannot take the proper steps in patient care that they could actually do if they had adequate access to medications. So, it is vital to educate people of India, especially the rural population, while simultaneously framing and implementing some regulations and limits on the export of medications by pharmaceutical companies in order to improve healthcare in India.

Too far to go still: India’s struggle against gang-rape continues

This was cross-posted to my professional blog.

In the worst news you’ll read today, yet another gang-rape – of another tourist, and the second one this week – has surfaced in India.

An 18-year-old German was allegedly raped on Friday after falling asleep on a train heading to Chennai in southeastern India, where she was going to do volunteer work with a charity.

“The young lady took several days to muster courage to report to the police,” Inspector General of Police Seema Agarwal told NDTV. “Though it’s too late for medical examination, we have handled the case in a very sensitive manner.”

The attack brings the toll of publicized rapes on foreigners in the country to two in just a week, after a 51-year-old Danish woman was allegedly gang-raped in New Delhi on Tuesday.

En route to do charity work – they say no good deed goes unpunished, but damn.

Rape in general, and gang-rape in particular, has been the subject of a lot of scrutiny, and (thankfully) a whole lot of national soul-searching in India since the report of a brutal gang-rape on a bus in New Delhi made international headlines in 2012. Naturally, the stories involving tourists tend to garner more attention that those of locals, but there have been plenty of those to go around. Take the case of the German tourist raped by her yoga instructor in December. Or the British woman who jumped from her hotel window to escape a rape by the hotel manager. Or the Swiss woman who was brutalized by five tribesmen while her husband was tied to a tree. All of these news article mention, and often link to, stories of multiple other women who went through similar ordeals. You could spend all day following the links and questioning the humanity of humanity, or seriously wondering if Antoine Dodson had it right after all.

In response to the 2012 Delhi case and subsequent uproar, the Indian government worked very quickly to strengthen existing rape laws and increase punishments for perpetrators. However, while cases involving foreigners are seen through, too many cases reported by Indian women are just dropped, or completely ignored. Meanwhile, no one can really explain why this keeps happening.

A few obvious things spring to mind. Feminists in the west wage a never-ending battle against rape culture and victim-blaming, but the terms take on a whole new light in Indian culture, which is dominated by men and dictated by strict social rules. In the Delhi case, the defendants’ lawyer offered this gem to the press:

“Until today I have not seen a single incident or example of rape with a respected lady,” Sharma said in an interview at a cafe outside the Supreme Court in India’s capital. “Even an underworld don would not like to touch a girl with respect.”

Sharma said the man and woman should not have been traveling back late in the evening and making their journey on public transport. He also it was the man’s responsibility to protect the woman and that he had failed in his duty.

“The man has broken the faith of the woman,” Sharma said. “If a man fails to protect the woman, or she has a single doubt about his failure to protect her, the woman will never go with that man.”

A spiritual guru and a politician offered a different perspectives:

A spiritual guru, Asharam, sparked an outcry earlier this week when he said the New Delhi victim was equally responsible and should have “chanted God’s name and fallen at the feet of the attackers” to stop the assault.

Mohan Bhagwat, the head of the pro-Hindu Rashtriya Swayamsevak Sangh that underpins the country’s main opposition political party, said rapes only occur in Indian cities, not in its villages, because women there adopt western lifestyles.

Pearls of wisdom, to be sure.

One factoid that has been indicated is the stark gender imbalance, propagated by sex-selective abortions and female infanticide. Another issue is the widespread prevalence of abject poverty; the perpetrators are bored, desensitized, and have nothing to lose. An October article in the New York Times examined the issue in depth through coverage of a case in Mumbai:

One problem is that perpetrators may not view their actions as a grave crime, but something closer to mischief. A survey of more than 10,000 men carried out in six Asian countries — India not among them — and published in The Lancet Global Health journal in September came up with startling data. It found that, when the word “rape” was not used as part of a questionnaire, more than one in 10 men in the region admitted to forcing sex on a woman who was not their partner.

Asked why, 73 percent said the reason was “entitlement.” Fifty-nine percent said their motivation was “entertainment seeking,” agreeing with the statements “I wanted to have fun” or “I was bored.” Flavia Agnes, a Mumbai women’s rights lawyer who has been working on rape cases since the 1970s, said the findings rang true to her experience.

“It’s just frivolous; they just do it casually,” she said. “There is so much abject poverty. They just want to have a little fun on the side. That’s it. See, they have nothing to lose.”

MNCH Innovations: Video Review

This new video from UNICEF starts with the story of an Indian woman who safely delivered a healthy baby in a clinic, under medical supervision, thanks to a partnership between UNICEF and her local government. Prior to their intervention, the majority of women in her district in the Indian state of Madhya Pradesh were delivering babies at home because health facilities were few and far away, and there was no transportation available.

Over five years, UNICEF worked with the Madhya Pradesh government to make major changes, including:

  • Upgrading health centers
  • Providing new equipment
  • Hiring new nurses
  • Improving hospitals with a newborn care units
  • Funding an ambulance service
  • Creating a call center to coordinate ambulance trips

Now, five years after UNICEF began their work, the woman’s district reports the lowest maternal mortality rate in the entire state. Every year, half a million women use the ambulance service to ensure safer deliveries, and 50,000 newborns are saved in the newborn care units. UNICEF’s work has been so successful that the Madhya Pradesh government is scaling up and replicating it elsewhere in the state and other Indian states are also interested in implementing the programs.

One of the newborns in the video had a lung problem and was also underweight because his mother had not been eating properly. The narrator mentioned that many babies in the unit were underweight. While the video focused on the help the new care unit was able to provide to these newborns, my thoughts went elsewhere. UNICEF’s work has made a big difference, but the small fact about the prevalence of underweight newborns reinforced the fact that there are many larger underlying factors and social determinants at play that will continue to challenge progress and positive changes in developing countries. UNICEF’s innovative programs were definitely successful in tackling the delivery and newborn care issues in the region, but the video also (unintentionally) illustrated the general complexity of global health and development challenges.

“Don’t let complexity stop you. Be activists. Take on the big inequities. It will be one of the great experiences of your lives.”
– Bill Gates

Mahila Mandals: Case Studies from Mumbai, India

The following post was written by Sarah Simpson, MPH-Epidemiology Candidate at the University of Medicine and Dentistry New Jersey. Sarah is an IH section member who has contributed to the blog previously. The following post is about her winter internship in Mumbai, India.


ssimpson_mumbaiHome to more than 18 million people, India’s most populous city, Mumbai, continues to be an attraction for millions looking for a better life for themselves and their families. Migrants from different parts of India, religions and cultures end up in the crowded slum communities around Mumbai. This past winter I had the opportunity to learn about urban health issues in these slum communities along with 20 other students from around the US and the world for three weeks at the Tata Institute of Social Sciences (TISS) in Mumbai.

My project group and I sped around town in rickshaws, trudged through sludge, and dust to study urban health issues in the slum areas of Shivaji Nagar. Located in the M Ward and home to some of the largest slums in India, about 600,000 people live in this area, which is located near the Deonar dumping ground, a man-made mountain of debris and trash. The health of the urban poor is complicated by many issues ranging from waterborne illnesses to infectious and communicable diseases, and when compounded by inadequate nutrition and overcrowded and poorly constructed living conditions makes for a dire situation for millions of people.

During our first day, we were introduced to the “Mahila Mandals” or women’s groups there are instrumental to addressing these public health issues. Parts of Shivaji Nagar are plotted slum areas recognized by the government; however they have minimal access to facilities and services provided by the Brihanmumbai Municipal Corporation (BMC). Imagine sharing 28 bathroom stalls (14 for men, 14 for women) with 1,000 other people and as you can imagine they quickly become unsanitary. The breakdown of government services has lead to the organization of community based organizations such as Mahila Mandals.

Instead of using a needs-based or problems-focused approach which would highlight only the worst aspects of a community, we decided to highlight the community’s assets by writing a case study using SWOT (Strengths, Weakness, Opportunities and Threats) Analysis to help us investigate how to best utilize these important community assets. We interviewed 6 Mahila Mandal groups consisting of some registered and unregistered groups and varying in size and number of members. We concluded that not only do the Mahila Mandals work to solve issues with sanitation, but they also promote immunization of children, maternal and child health education and resolve domestic violence issues. However, their impact is limited mostly due to funding and support from the local community.

At the end of our study, we recommended that the government provide more funding and implement community-based participatory research programs which would allow the communities to identify, support, and mobilize existing resources to create a shared vision of change and encourage greater creativity in solving community issues. Two community organizations like these groups and community engagement are important for continued public health and social change. Further research is needed on how to best utilize these valuable community assets.

Our internship presentation can be found at: http://prezi.com/i0lbgveimbyc/copy-of-indian-urban-slums/

References:

  1. Mili, D. Migration and Healthcare Access to Healthcare Services by Migrants Settled in Shivaji Nagar Slum of Mumbai, India. TheHealth 2011; 2(3): 82-85
  2. P A Sharpe, M L Greaney, P R Lee, S W Royce. Assets-oriented community assessment. Public Health Rep. 2000 Mar-Jun; 115(2-3): 205–211.

Novartis: Court Case in India Begins (MSF Video)

This post was written by Nicolle Rueras.

A recent court case between the Indian Government and pharmaceutical company, Novartis, has caused a stir in the global community. Novartis is challenging Section 3(d) of India’s Patent Act, which requires companies to prove that their drug is more successful than alternative treatments for a disease to receive or extend a patent.

To get around this regulation, many companies begin “evergreening” – making minor changes to a drug that may not improve its efficacy but claim it does in order to extend its patent. If Novartis succeeds, this may open the door for other companies to follow suit, ultimately driving up prices for crucial medicines produced in India and needed around the world.