Treating asthma in developing countries: a problem of inaccessible unavailable essential medication.

Some people regard insulin dependent diabetes in a villager asthmatic patient? If the drugs are only held centrally, will a long journey have to be made to a distant specialist from a developing country as the equivalent of a death hospital at potentially great expense? In a study of rural sentence because it will be impossible to ensure a supply diabetics in northern Ethiopia it was found that over 36% of insulin. Is severe asthma any different? Indeed, in their had to travel at least 80 km (Alemu S et al, unpublished paper in this issue of Thorax Watson and Lewis show that data, 1997). The cost of such journeys could be cataappropriate medication is either unavailable, inaccessible strophic, and this raises a further dilemma for the physician. through cost, or inappropriately prescribed. The patient may be willing to pay the cost of a follow up What is the physician to do when the country where the appointment but may be unable to meet the cost without asthmatic patient lives has $10 (or very much less in some having to sell productive assets or sacrificing other essential countries) to spend per capita per year on health? The costs such as clothes, food, and education. The pathetic dilemma has been addressed from many angles. The need gratitude and agreement of the rural asthmatic patient may for an assured list of appropriate drugs led to the Essential conceal the expectant gloom of the sale of cherished cattle Drugs Programmes, championed by WHO, so that there or even land. would be basic remedies at the first level of primary care, One solution to the dilemma of costly drugs was for a a more generous list for the district hospital, and an major pharmaceutical house to give, over many years, additional list of specialist drugs for the few referral or all the ivermectin needed in the Onchocerciasis Control specialist hospitals. The system has worked well in theory Programme. Another is giving its latest antimalarial drug and has now enlarged its goals to include appropriate to specific countries under specific conditions of preprescribing. But this begs the question of access to drugs, scribing. But for asthma this would be impossible. There limited in supply by the poverty of the country or the is no obvious solution to the daily dilemma of how to poverty of the patient. The days of free drugs have effectacquire and maintain a supply of appropriate drugs. One ively gone; under the inflexible structural adjustment prostrategy, however, can be adopted; those who care for the grammes of the World Bank government spending has had patients can be taught how to manage cases well with what to be slashed and the most unkind cuts have been felt in is available. Such training and supervision can be given the welfare services of health and education. during follow up at health centres so that the best habits A further scheme was devised by UNICEF – the Bamako of care and management can be nurtured, and so that the initiative – in which a revolving fund for drugs would be few drugs are used as efficaciously as possible. established through an initial supply of foreign exchange In the future, as populations grow older and patterns of and the drugs would be sold at cost price at health centres. disease change, the problem may get worse, and this is an The proceeds would be used to buy further drugs and a even stronger argument for doing what can be done as revolving fund would operate. Again good, perhaps, in well as possible, and thus sustaining the highest standard theory, but deeply flawed in practice because management of attainable care. skills were often deficient, money was not recycled for