Mental wanderings from India

September 17, 2006 at 6:47 am (Sarah's Posts)

I’m cheating a little and copying something that I wrote to my own blog a few weeks ago. For those of you who don’t know me, I’m a Brown grad ’05. I’m in Pune, India right now on a Rotary International Ambassadorial Scholarship (whew! mouthful!), on a deferral before I start med school a year from now. I’m studying in an MPH program, effectively the first one in India. It is bringing up tons of health questions, thoughts and issues. I’ll post as they come up.

Warning: This post is all things that I’ve been told without much collaboration. But, it brings up some very interesting ethical issues about health care. I’m throwing this out there for the brain-team to come up with an answer.

Hemophilia patients usually require regular treatment with a molecule called Factor VIII, which helps their blood to clot properly. Without this treatment, any cut or injury could potentially bleed indefinitely, so these folks sadly often have short lives. (http://en.wikipedia.org/wiki/Hemophelia) Here in India, Factor VIII treatments cost about 14R/unit (roughly $.30), at a total cost of about 7000R/month ($150). This is a prohibitively high cost for most families here (India is classified as a “low income” country by the World Bank with a GNI (gross national income) of $450.). So, a woman from the US began taking almost expired Factor VIII and shipping it to India where doctors like my professor (the initial narrator of this story) would distribute it for half the market cost, at just enough of an expense to pay to keep the supply coming in. At some point, the CBI (the Indian equivalent of the FBI) came in to stop the practice, citing it as unethical to sell products with unknown efficacy. Just to add a little conspiracy theory to the mix, as the expired supplies became unavailable, Bayer (a pharmaceutical company that supplies Factor VIII) saw a hike in the costs of the treatment.

So here are the (perhaps unanswerable) questions that I’ve been kicking around. Is it the job of the government to see that a life-saving treatment is available to the population? Does it matter if the patients affected are a small group? In a limited resource setting, should the government focus health priorities on highly prevalent/incident diseases? If it isn’t the government’s responsibility, is it ethical for them to prevent access to alternative sources of treatment? What if these treatments are unregulated or expired and thus are at best ineffective and at worst potentially harmful?

If anyone has the magic answers, let me know. India really needs them. And in order to sleep at night, so do I.

Wow. That was a whole lot of parentheses.

-Sarah Kimball-

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2 Comments

  1. msoule said,

    I don’t have magic answers but I did study in India and I think I might understand the political economics of what is going on.

    The first thing I wanted to know is whether the expired medicines are really expired. Sometimes in labs, you can keep using “expired” antibodies for long after their printed date and still have them work pretty well as reagents. I think medications are a different matter because you are using them on PEOPLE not dead tissue. So I think the government ought to step in when dubiously effective drugs are being sold. That’s the reason we have the FDA and it’s what those agencies are good for (there are plenty of super crappy things they do, too, but that’s a different argument). BUT. I also think that the efficacy of the drugs needed to be known before stopping the distribution. Well, really, ethically speaking the efficacy should have been determined BEFORE distribution started so that there couldn’t be a question about it. However, that calls into question the expiry dates that are placed on the drugs. Which calls into question the practices of the pharma corps that are making the drugs.

    Herein lies the quandary in my opinion. India is currently trying hard to play ball with the Developed Economies. Their big drug companies (Ranbaxy, Cipla) were making generic HIV treatments against the will (duh) of Big Pharma in the Western world. It is my recollection (please correct me if I’m wrong, I haven’t fact-checked this recently but I remember reading it, I think) that they are going to stop because they want concessions for trade from Big Pharma’s home countries and the HIV drugs for the poor are less important than vitalizing the rest of the economy. From our perspective, a travesty. From The Indian Government’s, a trade-off. A temporary drop in health that will hopefully be shored up when there is more money in the economy. While I think this is probably dubious logic, I will let Mr Evan Brown, the house economist, comment on that if he likes.

    In any case, the Government of India is probably wanting to quash any renegade drug sales that might be going on so it appears that they are on the side of Big Pharma. That’s an underlying idea about why they stopped this distribution. It may be a big, unnecessary tangent that doesn’t answer anything, but it’s what came to mind.

    Maybe I’ll come back later and try my hand at actually addressing the ethical issues Sarah brought up.

  2. misarita said,

    While I see yours points, I’m having a hard time divorcing the (decently legitimate) reasons for the gov’ts choices from the terrible situation that this places individuals who have no access to care.

    I heard the opinion once that that there are no drugs that will become harmful after their expiration dates, they will merely lose potency. I suppose that could bring up other points like whether using expired drugs would cause drug resistance. Nevertheless, I’m picturing the hemophilia patient who has no options other than to try to use a drug that is expired because nothing else is available.

    The problem with public health is that it, as a discipline, tends to focus more on the needs of the overall community than of the individual. They don’t necessarily come at odds with each other. But what do you do when they do? It may be better for India’s development to start actually regulating their drug market and to put some checks on situations that could allow the underprivileged to be taken advantage of. Still, how do you face that patient? What can you possibly tell them?

    Sarah

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