All is not well.

While growing up in Lahore, there were text books of medicine in my house going back to the nineteen twenties. These belonged to my father’s eldest brother who went to medical school during that time. Then there were medical texts from the thirties belonging to my parents who attended medical school in the late thirties and the early forties. And then of my older cousins who went to medical school in the fifties and finally my own books from the sixties.

A medical text book from the twenties was barely a few hundred pages. And the treatment for most diseases consisted of opium (or one of its derivatives like morphine), aspirin, bed rest and dietary manipulations in different combinations. Not much had changed in the next decade. One interesting thing I remember reading in an eye disease book from the late thirties was the use of ‘milk injections’ for treatment of diseases that would now require steroids.

But for X-Rays and some basic blood tests there were few available means to diagnose many diseases. Medicine was still more of an art than a science and much depended on the ability and the experience of the treating doctor. The kind and caring TV doctors we grew up with come from that generation.

By the time we hit the fifties the books were fattening up and the treatments became more complex. Antibiotics had appeared, and many medicines were being discovered that could treat all sorts of problems. For the first time infections like Tuberculosis (TB) or pneumonias were curable. And micronutrients like vitamins were becoming a part of the medical ‘armamentarium’.

By the time I hit King Edward Medical College (KEMC) and graduated in 1970, things were really changing drastically. Perhaps most importantly we as medical students had started reading American medical texts instead of the British ones and most of us started planning to go to the United States (US) for further medical training. And American medicine was more a science than an art.

Enough of nostalgia! The main purpose of my article today is to talk a bit about medicine -- the sort we take for different types of medical conditions and the importance of sticking to the prescribed amount and duration. Most medicines we take can be divided into two types, those taken for a certain period of time and those taken essentially forever.

One of the attitudes I often encounter is that a medicine should not be taken for a long period of time because the body will become used to it. This is absolutely valid when it comes to medicines that are habit forming and that includes many pain medicines as well as medicines used for anxiety or other such problems. However, medicines must be taken for them to work.

Medicines can be divided into two main categories. First are those that should only be taken for as long as they are necessary and this is a decision usually made by a doctor that is treating a patient for a particular medical problem. And then there are medicines that once prescribed have to be taken essentially forever or at least as long as a medical problem persists. Of course based on the medical problem being treated, medicines might be changed but are rarely stopped completely.

The first type of medicine I want to mention is antibiotics. These medicines are indeed life savers and have changed how we live. But along with their proper use are instances where many antibiotics are not taken as prescribed or for as long as necessary. When an antibiotic is not taken for the right length of time, then it does not effectively kill all the germs that are producing an ‘infection’. If stopped before it becomes completely effective the antibiotic can leave behind germs that develop a ‘resistance’ to it if used again.

The development of resistance to antibiotics is a nightmare scenario and we are approaching a point in time where dangerous germs are becoming ‘resistant’ to usual antibiotics used to treat them. Once these resistant germs start spreading, they can produce epidemics that cannot be stopped through medical means and old fashioned methods like isolation and quarantines of infected patients might become necessary.

In Pakistan antibiotics can often be bought without a prescription and are often used for much less time than is necessary. I have been in a pharmacy where a buyer walks in and purchases antibiotics barely enough for a few doses. This widespread self-prescription and under use is a clear recipe for disaster.

In the west it is doctors who prescribe antibiotics unnecessarily that cause development of resistant germs but in Pakistan it is the people themselves that buy and use antibiotics improperly. This particular subject requires an entire discussion just about this misuse of antibiotics and of the ‘quality’ of antibiotics being sold.

In general if a person develops an infection, antibiotics will be prescribed. Most infections might also produce fever so some anti-fever medicines like aspirin or Tylenol (Panadol) might also be prescribed. Once the fever goes down, many patients think that the infection is gone and stop taking the antibiotics. This is a common mistake -- the full course of antibiotics must be taken.

Another serious medical condition where many patients don’t take medicines properly is in high blood pressure. I have seen many patients that develop high blood pressure and once put on medicines will wait till the blood pressure comes down and then they stop taking the medicines. High blood pressure is a lifelong problem and needs medicines essentially forever.

Another common problem that is often not treated properly is high blood sugar or diabetes in adults. I have seen many well educated people with diabetes who take the first medicine prescribed by a doctor and keep at it without seeing if they need increased doses or added medicines. Many people end up with kidney damage because they never treat their diabetes properly.

Here a point is worth making. In overweight people, exercise and weight loss can actually improve both high blood pressure and high blood sugar. And no, there are no ‘non-traditional’ medicines that can ‘cure’ either high blood pressure or diabetes. If there had been any such medicine it would have been adopted, purified, manufactured, and sold by the regular pharmaceutical establishment.

For common conditions like those I have mentioned above, new medicines are appearing almost every day. And many doctors as well as well-educated patients with access to latest information on the Internet have the urge to move to newer and often more expensive medicines. This urge must be resisted if the older and relatively inexpensive medicines are working well.

There are other problems with prescription and use of medicines that are also important. First is that of the cost of taking medicines for a long period of time. Many poor patients sadly have to make a choice between medical treatment and food on the table. A majority of patients we see in our major public hospitals belong to this category and must be provided free medicines by any future government. The second problem is a lack of medical follow up. More about that another time.