Recently, an interesting article in this newspaper (What’s in a name, by Dr. Arshad Rehan, The News, February 15, 2017), talks about how the same medicine can be available in Pakistan under many different names. That is indeed correct and could lead to medical mishaps and to a particular type of corruption that I will come to a bit later. In the article I refer to the number of eighty is mentioned as under how many different names the same medicine can be available.

Eighty would mean that there are eighty different manufacturers that are making and selling that particular medicine. If there are indeed eighty or even more pharmaceutical manufacturers in the marketplace and all of them have been approved by the appropriate regulatory authorities and their products checked for quality then one must commend and even hail such marketplace competition. And that is important.

For the last many years, I buy and personally use medicines made in Pakistan. And I must admit that they work pretty much as they should. These include antibiotics and those for different medical problems. However, even though the medicines available in Pakistan are pretty much as effective as those I get from the United States, they often cost one tenth or even less than the equivalent generics available in the US. The low cost of standard medicines in Pakistan is due to many reasons but an important one being the fierce competition between different manufacturers.

From a purely medical point of view, too many different brand names for the same medicine can lead to problems for patients, the prescribing physicians as well as the dispensing pharmacists. A similar problem arises if different medicines have very similar ‘brand’ names. Considering the ‘extremely’ legible doctor’s handwriting, the pharmacy might mistakenly give a patient the wrong drug. That said if fifty different manufacturers have all been approved and checked by appropriate authorities then there is no legal or moral justification for preventing these manufacturers from selling their products in the market.

The problems with illegible prescriptions as well as inadvertently incorrect names of medicines on prescriptions have been solved to a great degree in the US through the use of prescription ‘apps’ and electronic prescription transfers to the pharmacies. Well trained and educated pharmacists are the second line of defense against improper prescriptions being accidentally given to patients. Of course none of these safeguards are available in Pakistan. So, an excess of prescription options and of medicine names that might be too similar can often be real problem.

So far, I have repeated more than once that medicines being manufactured and sold by multiple pharmaceutical companies that have been approved by regulatory authorities and their products have been checked for quality are totally acceptable.

The problem is that many medicines being sold are produced by unregulated manufacturers. These manufacturers might make and sell counterfeit copies of well-known brands of medicines made by reputable and established manufacturers. But these counterfeit medicines might not contain the expected dose of the active ingredients. The second problem is medicines sold by ‘approved’ companies that are of a poor quality and some might not even contain the medicine that is supposed to be there.

Both of these problems usually occur in pharmacies in small towns or areas that primarily cater to poor patients. Worse, both of the above mentioned problems also often involve government-run hospitals and dispensaries. Since these institutions are expected to buy supplies from the lowest bidder, therefore ‘inferior quality’ medicines are often bought because they are being sold at a lower cost compared to properly manufactured and tested medicines. Some under the table exchange of money between the sellers and the official buyers does go on for this to happen.

A medicine that is just chalk or almost just chalk is bad enough but when the medicine is contaminated with some other active ingredient then that can be fatal for patients. A few years ago, ‘free’ heart medicines supplied to poor patient at the Punjab Institute of Cardiology (PIC) turned out to be contaminated with a chemical called Pyrimethamine (Daraprim). As a result, quite a few patients died. Interestingly, these contaminated medicines were only given to poor patients for free so the ‘paying’ patients at PIC escaped being affected by this problem. Daraprim was recently in the news in the US but that is a story for another day.

Clearly, the manufacturing and selling of medicines mentioned above is illegal. Unfortunately, the regulation and checking mechanism for medicines and medical devices available in the marketplace is extremely inadequate. The problem can be summed up quite briefly. The regulators are usually underpaid government employees while the manufacturers and even the sellers are quite well off. Payment of a ‘few’ rupees can easily make the regulator look the other way. This is sadly true not just for pharmaceuticals but also for many other types of supposedly regulated items used by the general public. Of course, all this can be fixed if the regulating agencies do their job. But then this is Pakistan.

Now to the more interesting question of a profusion of different brand names for the same medicine. All these different brands can contain the genuine article and when used properly provide the expected benefit to the patients. As I have said above that if a properly registered and tested manufacturer provides a good quality product at a competitive price then there is no reason to limit such production. But then life is sadly not that simple.

Even in a well-regulated marketplace like the US, different pharmaceutical companies spend a lot of money on advertisement of their products and, until a few years ago, to provide perks to doctors that prescribed their products. Now that has become severely restricted but even so occasional scandals do surface. That is the US, but this is Pakistan. And in Pakistan, a different set of morality thrives. The relationship between pharmaceutical companies and many prescribing physicians can be best described as very friendly. The friendship is obviously of a financial nature and in a less civilised environment would be called ‘kickbacks’.

Different manufacturers and suppliers/importers of different medicines and medical appliances try to develop financial relationships with ‘high volume’ prescribers. Yes, money is often involved. A certain number of prescriptions (or stent implantations) in a year could either lead to a real ‘tax free’ financial reward or an indirect reward like an all-expense paid trip to an international conference in a nice place. And a bit of pocket money is often included. I can bet that almost all of the foreign trips to international medical conferences by our busy ‘consultants’ are such expense paid junkets.

There are two ways of looking at this problem. The first one is that if the prescribing doctors are prescribing appropriate medicines at the going market rate and providing proper medical care then what is wrong if they get rewarded for their prescribing acumen. The competing point is that such benefits are morally wrong and could lead to unnecessary prescriptions as well as procedures like unneeded stent implantations. Sadly, morality can rarely be legislated.