India has one of the most advanced pharmaceutical industries in the developing world, manufacturing almost everything related to modern medicines, the related machinery and other accessories. It has also the human resources needed to set up pharmaceutical plants from the intermediate and basic bulk drug stages to finished formulations, as well as a vast pool of human resources in technology and science.

While this self-sufficiency in the pharmaceutical industry has been achieved in a relatively short time (since the 1970 Patents Act), our health services have not shown equal progress. There is a big mismatch between the needs of the vast majority and the inclinations of the medical profession which congregates in and around urban areas.

There is a similar mismatch between what the drug industry produces and what is warranted by the community’s disease profile. This is in no small way due to the medical profession’s prescribing unnecessary medicines, laboratory tests, CAT scans and surgeries. Aggressive marketing, by pharmaceutical companies, irrational, hazardous, and ban-worthy drugs has existed in parallel with the medical profession’s poor prescription practices.

The book under review analyses the supply and use of drugs in Maharashtra’s Satara district in 1991-93, and is the first such district-level study in India. It analyses prescription practices of public and private sector doctors comparing. them with standard prescriptions for 92 common conditions. It also estimates the financial costs of irrational prescriptions by comparing the estimated rational drug needs in Satara district to its current drug expenditure. Part I of the book, ‘The Indian Drug Tragedy’, surveys the medical profession and pharmaceutical industry in India. Part II, Drug Supply and Use in Satara District, reports on the study. The author and his colleagues have also examined issues of knowledge and practice among nurses. Chapter 9 provides a critique of the WHO-INROD indicators for good prescribing.

Irrational and excessive

Over drugging — defined as use of more than three drugs per prescription, and the use of unnecessary drugs — was found to be high in urban prescriptions, in the private and public sector. The use of irrational, hazardous drugs and unnecessary injections was highest in small towns — again, among both private and public sector doctors. Undesirable drug use decreased as one went up the educational ladder. RMPs (Registered Medical Practitioners) were found to indulge most in undesirable drug of use and only 25 percent of prescriptions issued by even MD doctors were rational. Patients were unable to get rational prescriptions even for common ailments.

What is the patient’s best option? MBBS doctors, preferably in the public sector, where medicines are free and the medicines stocked are reasonably rational. Except that public services are usually poorly stocked, which could leave the patient spending money for a bad prescription.

What is the quantum of waste? A whopping 69.2 percent of the money spent on drugs in the private sector (and 55.4 percent of money spent in the public sector in Satara district) was useless. Rs. 14.76 crore was wasted on irrational prescriptions in Satara district in a single year -67.58 percent of the district’s total drug consumption. This refers only to the costs of medicine. The study has not estimated the other costs to the patient: consultants’ fees if any, bribes paid to make public sector health functionaries work, costs of diagnostic tests, transportation, wages lost, costs of the adverse effects of irrational and hazardous drugs, and person-days lost due to delay in getting well.

The public sector in Satara district was (and probably continues to be) very poorly supplied. In 1991-92, a mere Rs. 55.37 lakh was spent on drugs -2.54 per cent of Satara district’s total annual drug consumption of Rs. 21.83 crore. Based on national morbidity figures, the author estimates the district’s rational drug needs to be Rs. 20.611 crore. It is also shown that a mere 12.45 percent increase in PHC allocations would solve the problem of drug shortages in PHCs (estimated to be about Rs. 40,000 per PHC per year).

The implication is that ill-health is affected not only by the inability to spend (at least part of the community spends on allopathic medical services and drugs) but also because of the irrational prescription and use of allopathic drugs.

The study explains the methodology, and choices of specific modes of research in detail, allowing the discerning reader to agree or disagree, on a more informed basis. Those needing more details are invited to go through the original report.

Both this book and the original report must be made compulsory reading in all medical, pharmacy and nursing colleges. The Indian drug tragedy continues; who will reprimand the doctors, who despite training and honoured status, abandon science for convenience, intellectual laziness and money? Will the Medical Council of India rein in the trained quacks among its tribe?

Drug misuse is only the tip of the iceberg. We need another study on the diagnostic abilities of doctors (in this study correct diagnosis was presumed, which is, of course, questionable), the practices of surgeons, the use of laboratory and other tests, and so on. Again, the medical profession’s apathy is just part of the uninformed indifference of middle-class professionals and well-off Indians to the life-and-death issues affecting the majority of our one billion population.

Finally, there is the question of human rights violations. Aided and abetted by the drug industry, the medical profession prescribes dangerous and unnecessary drugs to people made all the more vulnerable by their need for relief, their ignorance and their trust.