A MAN develops a blister on his foot and goes to a doctor for treatment. He is prescribed a food supplement that costs around Rs1,700.

Upon purchasing it, he is shocked to learn that the key ingredient in supplement he has been asked to use by the medical professional is essentially just turmeric extract, which is otherwise available in abundance at any local grocery store.

Any ordinary person would curse their luck and move on. But this is no imaginary story, and the person telling the tale is none other than the incumbent caretaker health minister.

“When I got home and read the list of ingredients, I was shocked to see that there was only turmeric in it. I could have purchased the same worth Rs50 from any ordinary grocery shop if I had known that is all I needed,” Dr Nadeem Jan told Dawn.

This is when Dr Jan realised that nutraceuticals — food supplements or extracts that offer a variety of health benefits — are priced quite high.

In a time when inflation is rampant and imported medicine costs an arm and a leg to procure, such behaviour is quite irrational.

While they may not be illegal, unscrupulous practices on the part of medical professionals and ‘unregistered’ pharma firms are adding to the woes of citizens already reeling under the burden of sky-rocketing prices and threats such as the proliferation of drug-resistant bacteria

However, things begin to make sense once you connect the dots between practitioners and commercial interests — it is the high profit margins in such cases that push doctors to prescribe these expensive treatments.

While any other person may have shrugged off this irregularity, Dr Jan reached out to the Drug Regulatory Authority of Pakistan (Drap) to get to the bottom of this practice.

In his words, he wanted to know why the regulator could not fix the prices of nutraceuticals, like it would with traditional medicines.

“Drap told me that it was not possible,” he said.

Dr Asim Rauf, who is the CEO of Drap, told Dawn that it was difficult to fix the prices of such items as they incorporate herbal remedies and other ingredients rather than drug molecules.

“Medical professionals are even prescribing chocolate milk and other food supplements, which is unethical,” he claimed, and suggested that this was a matter for the Pakistan Medical and Dental Council (PMDC) — the accreditation body for medical professionals and the arbiter of issues in medical ethics — to take up at the doctors’ level.

Dr Rizwan Taj, who heads the PMDC, told Dawn that the council was cognisant of the problem and planned to take steps to rationalise doctors’ practice by developing ethical guidelines that would serve as a yardstick for right and wrong practices.

Prescriptions ‘with benefits’

But prescribing nutraceuticals is the least of the sins being committed by a sizeable number of medical professionals in the country.

According to a senior health ministry official, who did not want to be named, both PMDC and Drap are aware that doctors receive benefits from pharmaceutical companies to market and prescribe their drugs.

“Doctors do get incentives, such as the renovation of their clinics, foreign visits and even cash. This is why they start irrationally prescribing medicines without looking into the requirements or even the financial condition of their patients. Some even recommend which pharmacies or medical stores patients should go to purchase their drugs,” he said.

Such practices, he says, are eroding trust in the sacred profession, which in turn causes another problem. “People have started self-medicating, which is especially alarming when it comes to antibiotics, whose irrational use is becoming one of the leading causes of the development of drug-resistant bacteria.”

Although data on antimicrobial resistance, as the phenomenon is known, is scant for Pakistan, scholarly articles on the subject point to the fact that the extensive use of antibiotics has “selected resistant strains, increasing the rate of fatal infectious diseases, and exerting an economic burden on society”.

One research paper, published in 2021, found that over the past decade, the most oft-reported Urinary Tract Infection (UTI) in Pakistan was E. coli, which had been showing high resistance to the first line of antibiotics, such as Methicillin.

According to Dr Rauf, medical practitioners can demand “furniture, cars and a number of other incentives from the pharmaceutical companies to prescribe their medicine”.

He told Dawn he had given orders to ensure that companies declare all the benefits they provided to medical practitioners, while the PMDC had been asked to make sure that doctors declare everything they get from pharmaceutical companies and labs.

The health ministry official referred to international regulation, such as the ‘Sunshine Act’ in the US, under which medical practitioners are bound to declare anything they have received from pharma companies. “We also need a similar law and a will to implement it in Pakistan,” he said.

‘Unregistered’ pharma firms

Pharmaceutical companies, however, maintain that while they have taken steps to educate practitioners about ethical prescription practices, they cannot do much if the health authorities do not take the lead.

Ayesha Tammy Haq is the executive director of Pharma Bureau – the representative body of multinational drug-makers operating in Pakistan. She said that there were over 600 pharma companies in Pakistan, but only around half of those were members of the Pakistan Pharmaceutical Manufacturers Association (PPMA), the body representing local drug-makers.

It becomes very difficult to stop these companies, who are not on the Pharma Bureau or PPMA’s radar, from indulging in unethical practices, she says.

Dr Quaid Saeed, the CEO of the Islamabad Healthcare Regulatory Authority (IHRA), told Dawn that they were working with medical professionals to educate them on the prescription of narrow-spectrum antibiotics, which can be doled out without testing.

“However, a number of antibiotics can only be prescribed after testing the blood or sample of wound and identifying the bacteria, which is called a sensitivity test,” he said.

‘Cost of doing business’

But even in the realm of laboratory testing, there is an associated ‘cost of doing business’.

“Some of the labs informed us that they were paying 40 to 50 per cent of diagnostic fees to doctors,” Dr Saeed said. He explained that the labs were not in a position to refuse, since their business was dependent on doctors who prescribe the tests.

“Labs believe that they will lose their revenue if they stop ‘bribing’ doctors. We have been trying to take all the labs onboard and convince them that no one should this commission, for the sake of the patients,” he said.

But this is easier said than done.

Senator Humayun Mohmand, who chairs the Senate Standing Committee on National Health Services, told Dawn it was quite difficult to prove that a doctor has recommended unnecessary test.

“A number of times, doctors do suggest a number of tests to analyse whether all organs of the body are working with full efficiency. However, questions arise when a patient, for example, goes to get their eyes tested, but the doctor prescribes other unrelated tests,” he said.

In his view, one solution could be an online registry where every doctor’s prescription is logged along with their licence number, and regulators are able to examine their records to identify irrational prescription practices.

Published in Dawn, January 6th, 2024