Personal views: First do no harm: does the Hippocratic Oath extend to developing countries?
Authors: Louise Woolrich-Burt
Journal: BMJ (2002)

From November 2000 until May 2001, I worked at a remote primary healthcare clinic in the Chitwan region of Nepal. The clinic serves a rural community of fishermen and subsistence farmers and is supported financially by a charity registered in the United Kingdom and Gibraltar.

Half of the population is under 5 years of age, with infant mortality running at 82 per 1000. There is a 1 in 10 lifetime chance of death in childbirth (compared with 1 in 5100 in the United Kingdom and 1 in 3500 in the United States).

The clinic aimed to improve the health of the local population by providing affordable health care and health education. But it soon became clear to me that, however laudable, this aim was not being met.

My introductory visit to the onsite pharmacy provided me with first hand evidence of the inappropriate nature and naivety of first world donations. Many drugs were out of date and obsolete. Some were substances that the World Health Organization had banned. These medications originated from several countries, and in many cases neither the clinic staff nor visiting doctors were able to determine the class of drug that they contained. Many bottles had handwritten indications on the labels, which had been incorrectly translated from English. Several prescriptions had been recently issued from containers simply labelled “cold cure” and “stomach pain.” Fortunately however, most of these items remained on the shelves, unused, since the staff did not know what they were for.

Many of the donations were unsuitable for a remote primary care facility because of the high cost or unavailability of repeat prescriptions, or the need for regular blood tests or for suitably trained personnel in the prescription of potentially dangerous medications.

Throughout rural Nepal there is an established culture of belief that everything Western is best. Patients at the clinic had been encouraged to place their trust in the Western doctor to the exclusion of any locally arranged health care. This undermined established local medical practice, and could unwittingly encourage patients to “shop” for medical advice, often accumulating large quantities of interacting drugs in the process.

Most of these patients had minor ailments—which could adequately have been dealt with by local clinic staff—or were already receiving appropriate treatment for serious conditions such as tuberculosis. For example, a patient presented with vague abdominal pains and fatigue. In the previous week he had been seen by one Indian, one Nepali, and one Western doctor and had been prescribed three antibiotics, two types of worming tablet, two antiulcer medications, one major tranquilliser, and one sleeping tablet.

A further problem was the common belief that the more drugs prescribed, the more valid the complaint. Some patients were upset if they did not get a prescription at the end of a consultation. “Digestive enzymes,” vitamins, and tonics were frequently dispensed as “psychological medicine.” While many of these substances were simply useless, some of them contained dangerous substances such as heavy metals and there was alcohol in some children's formulations. Also, paying for these substances ate into the incomes of the poorest members of society, who were already struggling to provide enough food for their families.

After consultation and agreement with the local staff, we disposed of drugs that were out of date, those that arrived unlabelled, and those that were not in their original packaging. We destroyed dangerous items immediately. We offered those that were unsuitable for use in the clinic, but otherwise safe and in date, to the local hospitals.

We rationalised the pharmacy list with a small yet comprehensive formulary of inexpensive drugs, drawn from the World Health Organization essential drugs list. These concentrated on items that were inexpensive, could be purchased locally, and were easy to store, preferably with a long shelf life. We avoided drugs requiring refrigeration since the electricity supply was erratic and could fail for days at a time. We labelled and placed in a lockable cupboard any extra drugs requested by the visiting local doctor, who attended every two weeks.

We asked the clinic charity to cease drug donations and concentrate on items that were difficult to obtain in Nepal, such as paediatric blood pressure cuffs and books. Drug donations are rarely appropriate since locally produced items are invariably cheaper, arrive in recognisable packaging, and do not involve shipping costs or storage during transportation. Something is not always better than nothing, and any assistance must be well conceived and remain sympathetic to the local customs and healthcare philosophies.

With planning and consultation with specialists in the field of remote area medicine, non-governmental organisations fulfil a valuable role. However, those that fail to take advice or persist in dangerous practices should have their charitable status removed.