Medicines and culture—A double perspective on drug utilization in a developing country

Sot. Sci. Med. Vol. 34, No. 3. pp. 307-315, 1992 F’rinted in Great Britain. All rights resewed

t-1277-9536/92 SS.00 f 0.00

copyright Q 1992Pergamon Press plc

MEDICINES AND CULTURE-A DOUBLE PERSPECTIVE ON DRUG UTILIZATION IN A DEVELOPING COUNTRY LISBETHSACHSand G&AN TOMSON Department of International

Health Care Research (IHCAR), Karolinska Institutet, Box 60400, S-104 01 Stockholm, Sweden

Abstract-A double perspective, one medical-pharmacological and one social-anthropological, is used to understand the logic of drug utilization among practitioners and outpatients at a health unit in Sri Lanka. Both negative and positive aspects of local prks&ibing practices are highlighted. Western pharmaceuticals are integrated into therapeutic choices for outpatients in Sri Lanka by means of the Ayurvedic theory of balance and practitioners’ and patients’ behaviour in consultations results in their expectations being met, even if they do not use the same set of health ideas and interpretations of health intervention. The healing power ascribed to Western pharmaceuticals is described and their possible risks discussed from both a biomedical and an anthropological point of view. Key work-drug ance, culture

utilization, Western medicines, Ayurvedic theory, consultation, compliance/noncompli-

INTRODUCI’ION

Drug utilization in developing countries is a matter of growing interest. Studies stress a number of related problems: health care infrastructure is inadequate [11; governments have insufficient control of the d_mg supply system [2,3]; drugs are freely available on prescription [4,5], often illegally [6]; the use of drugs is often irrational from a biomedical point of view, and overconsumption of drugs and drug shortages occur simultaneously in the same countries [7J. Thus the availability of drugs and their role in medication in developing countries is documented, although often in a non-systematic way. The central notion in this documentation of ‘inappropriate’ uses of drugs is often ‘ignorance’ or ‘illiteracy’. However, the problem needs to be understood in a much deeper way. Drug use is a phenomenon within culture, and in this essay we consider the cultural implications of its use in the context of Sri Lankan medicine. Most publications on drug use provide information on macro-structural conditions, where the emphasis is on the production, marketing and supply of pharmaceuticals. The medical/anthropological perspective, with a case study approach through participant observation, has been used in a number of studies [g-13]. In these studies, it is obvious that usages perceived as irrational from a biomedical perspective may be meaningful and thus rational in their own context. We must also consider the fact that biomedicine is not a homogeneous system of iqeas shared by its practitioners around the world: Whti is perceived as rational drug prescribing in Sweden may be irrational for a Sri Lankan prescriber and vice versa. With this in mind we want to explore how a concept such as compliance may, or may not, be of positive value in a particular health care context. Compliance has been defined as “the extent to which

the patient’s behaviour coincides with medical or health advice” [14]. Obviously the concept must also be looked upon as an ideology mirroring cultural values in various health care settings and among various actors in the health care encounter [IS]. In recent studies focussing on compliance among patients in the West, a new view of this concept has been put forward and a welcome debate has developed. Compliance has been discussed as an ideology in health care which assumes and justifies the authority of physicians [15]. Non-compliance has been looked upon either as a rational form of self-control (161, or evidence that people regard medicines as anomalous and unnatural [ 171.These studies concentrate on the industrialized countries. We argue that the mere concept of compliance can help us see (1) where some of the problems in the use of Western medicines in the developing countries are hidden, and (2) how some of these problems may give new insight into the situation in the West. Our argument is based on a collaboration which allows us to look at the situation from more than one perspective.

THE DOUBLEPERSPECrlF’E We have already put forward the need for joint disciplinary research in studies concerning the use of drugs [ 181. In an earlier study, the medical-pharmacological perspective was applied by researchers from Sri Lanka and Sweden [19]. In this study, we work with a double perspective; one medical-pharmacological, one social-anthropological. When we, a medical doctor and a social anthropologist, started our field study to explore the logic of drug use among practitioners and patients in Sri Lanka, we observed over one hundred health care encounters during one day at a peripheral health

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unit in the highlands of Sri Lanka. Afterwards, we found that we had very different views on what had happened during the consultations. The medical doctor was disturbed by the lack of communication between the physician and the patients, the lack of physical examinations, the overuse of drugs and the use of potentially dangerous drugs, such as some pain killers for minor ailments like aches and pains, or antibiotics for common colds, all free of charge and prescribed for 3 days. All consultations ended with a prescription of at least one drug but more often of several drugs. Patients left the consultation room within a couple of minutes with their prescriptions scribbled on a piece of paper. To the medical doctor/researcher it seemed to be both a waste of money and, in some cases, an irrational and even unhealthy therapy. The anthropologist was of another opinion. Her view of the encounters was that they were quite smoothly functioning social events. Her impression was that the patients came to the outpatient department (OPD) to ask for something that the practitioners could give them, namely drugs. All the patients thus left with what they had expected and, in this way, the expectations of both physicians and patients seemed to be satisfactorily met. Very few words were uttered, yet a mutual tacit understanding of what was going on seemed to prevail in their joint participation in this particular social event. The anthropologist also was impressed by the way in which the female physician made her prompt diagnosis and choice of drug therapy. This experience motivated us to look at the use of pharmaceuticals in a more structured way. SRI LANKA’S

HEALTH

CARE SYSTE.M

Allopathic ‘Western’ medicine Sri Lanka is divided into three ecological sectors: the lowland dry zone, the wet zone and the highlands. The population is approx 16 million people; about 12 million are Sinhalese, almost 3 million Tamils, and 1 million Moors. The country is predominantly agrarian, 80% live in rural areas. Buddhists are in the majority, constituting around 70% of the population. Although the first contacts with Western medicine were through the Portuguese and the Dutch, the current medical system became established during the British period (1796-1948) [20]. In addition to building hospitals in large towns, the British began in the late 1870s to create a network of rural dispensaries with outpatient facilities. This infrastructure is now well deveioped,_and.the median distance travelled to a facility is only 3 km (211. The development of the health care system, together with the social welfare and educational systems, are the main factors behind the favourable health indicators of Sri Lanka. In the public sector, modern health care, including drugs, is free, and the prescribers are about 2000 qualified doctors and 1100 Assistant

Medical Practitioners (AMPS), the latter having had 3 years of medical education. Sri Lanka is a pioneer in drug policy and launched its Essential Drugs List for hospitals in the public sector as early as 1959 [22]. During the 197Os, several years before the WHO initiative [22], it was a renowned example of a developing country with a national drug policy based on generic drugs. Since then, the import policy has been liberalized in accordance with changes in general policy, and at present there are 2000 different brands and formulations on the market [23]. The public sector still regulates the availability and selection of drugs with restricted lists comprising varying numbers of drugs (100-500) according to the level of health care [24]. Drugs are dispensed free-of-charge to outpatients, and, with a few exceptions (e.g. hypertension), for 3 days. Qualified doctors also maintain private practices, and, since 1977, hospital doctors have been allowed to practice privately after hours. The Ayurvedic practitioners include practitioners ranging from those trained at college to those who are self appointed. In addition, there are also thousands of individuals practicing Western medicine without full qualifications. In a recent article, Caldwell et al. [21] described this pluralistic health care system. As a first resort, home treatment, Western medicine and Ayurveda, are employed for a very similar list of physical disorders. In this article, it is argued that Ayurvedic medicine (described below), far from offering resistance to Western medicine, is likely to have paved the way for it. Ayurveda

Both Western and Ayurvedic practitioners and pharmacies were within reach of the individuals in our study. How these resources are used by them is a question which lies outside the scope of this study. Other studies have pointed out the pluralism in the Sinhalese health care system [21,25,26]. The Ayurvedic medical system supports both formally trained medical practitioners, who have seven years of training before they start practicing medicine, and healers, who practice Ayurvedic medicine in a more informal manner. These practitioners mostly treat their patients with medicines based on herbs and natural products. This type of medicine has become more expensive than Western medicine. Popular health ideas which most Sinhalese peasants and unskilled workers share are heavily influenced by the ideas of Ayurveda. Ayruveda is more than a system of purely physical medicine; its underlying ideas have both permeated and been permeated by religion and ritual. Obeyesekere [27] analyses these metamedical concepts, starting with the fundamental and basic principles of Ayurveda. Within these principles is the doctrine of the five basic elements of the universe (bhutas), the three humours (tridosa) and the seven components of the body (dhatus). The five elements are both the basis of the universe and the constituents of all life.

Medicines and culturca Obeyesekere has provided excellent descriptions of how popular concepts of Ayurveda help create culturally defined syndromes. One frequent complaint, he says, is related to phlegm and is concentrated in the head. The head should be especially protected against rain, mist or drizzle: “to walk in the rain with one’s head unprotected is unthinkable; yet wet feet are of no cultural concern” [27, p. 21251. Excess phlegm is thought to cause common colds, as well as many other symptoms. Colds are treated with a careful balance of food, drink and therapy, such as medicines and bathing. The cultural preoccupation with the head and colds, together with the Ayurvedic theory that neglect of the head causes phlegm diseases, may make people especially vulnerable to specific diseases. Preoccupation with the head combined with the excess of tropical humidity and heat add up to a culturally defined disease complex with a kind of self-fulfilling prophecy. Another complaint highlighted by Obeyesekere has to do with dhatu loss. Dhatu loss includes loss of semen and constitutes a whole class of illnesses. Semen is the most highly refined element of the body, the vital juice that tones the whole organism. Women as well as men are believed to have semen, and several sicknesses are explained by dhatu loss. Dharu loss may be caused by sexual excess or “bad living”, but can also be a result of wrong diet or bad food. The symptoms are often that patients complain about weakness, that their bodies are thin, and that they quickly become fatigued. If untreated, dhutu sicknesses may develop into serious conditions, such as swelling of the joints or a burning sensation in the body. Treatment for dhutu loss includes a specific and balanced diet in combination with restrictions in bathing at certain times during the day. Phlegm excess and dhuru loss are two examples of cultural illnesses. MATERIAL

AND METHODS

Our joint experience of the health care system already described was preceded by medicalpharmacological studies in the area. Experience from ongoing drug utilization studies showed that prescription-only drugs were available over the counter at private pharmacies (51, a majority of patients admitted to hospitals were already taking Western drugs [28], and B-vitamins were commonly used for unknown reasons [19]. With few exceptions the outpatients at the 15 health units were prescribed several drugs at the same consultation. Field work revealed polyphatmacy and mechanical prescribing, which, from a biomedical perspective, seemed hi&y irrational. To go one step further and discover some of the meanings related to the prevailing situation, we decided to conduct an ethnographic study. In contrast to what has been reported by others [29], we had no problems in being accepted at the institution and

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were invited as researchers by the practitioners at the health care centre. One possible explanation could be that the medical doctor was already involved in collaborative drug utilization studies in the area and thus was known to the personnel at the facilities. The enquiry was made by the anthropologist, who initially analysed parts of the material separately [13]. The data were then coded, structured and analysed by both researchers. Data were collected at the outpatient department of a peripheral unit situated about 15 km from a major town in the highlands. The population in the area of the health facility under study did not differ in any major aspect from the population in the district as a whole. The people in the area live in villages and are paddy-field workers, brick makers and general labourers. They are of low caste and a majority are Sinhalese Buddhists. Large hospitals are available within travelling distance, and various private medical practitioners, pharmacists and drug shops are prevalent in the area. Ayurvedic facilities are also situated in neighbouring areas. The health facility studied had one Medical Ot%.er in charge of a male and female general ward and a central dispensary. The latter was run by two Assistant Medical Practitioners with 3 years of training. The outpatient department cared for 300-400 patients a day. In addition to the wards, the Medical Officer also cared for the well-baby and mother-care clinics, leaving the bulk of the outpatients to the Assistant Medical Practitioners. The three prescribers were all females, around 30 years of age, from high caste families and highly respected. These practitioners could select among 280 different drugs available at this level of care in a dispensary at the outpatient department. The drugs were dispensed free of charge and, with few exceptions, for 3 days at a time [24]. If prolonged treatment was needed the patients are expected to return for more treatment, also free of charge. During a period of 3 weeks 50 adult patients visiting the outpatient department were studied. Using the assistance of two Sinhalese research assistants, the patients were interviewed before and after meeting the practitioners. During consultations, patients/prescriber communication was observed, and conversations and actions were recorded using codes. The practitioners were asked to note the patient’s complaint, diagnosis and treatment on a special card. An equal number of adult males and females were selected. Patients were approached while they waited outside the outpatient department, and the purpose of our study was briefly presented. Participation in the study was voluntary, and anonymity was assured. Only one person refused to participate. The main focus of the questions was on symptoms, perceptions and the use of Western drugs and the outcome of treatment. Lengthy unstructured interviews were also conducted with the practitioners by the anthropologist. The Medical OlBcer and Assistant Medical Practitioners were later interviewed

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by the physician using a questionnaire that had been tested at another health centre. The focus was on professional background, working conditions, drug policy issues and their perceptions of their own prescribing. The prescribing pattern was then measured against the established treatment guidelines published by the Ministry of Health in Sri Lanka [24]. Five of the interviewed patients were asked to participate in follow-up interviews at their respective homes. Other family members were also used as informants. Weekly visits continued to these patients’ homes, where interviews in the form of causal discussions were conducted, usually by the research assistants, for up to 6 months. Patient interviews were conducted in Sinhala, the protocols being translated into English by a professor of Sinhala. The prescribers and their work

The two Assistant Medical Practitioners estimated the time spent on each consultation to be between 1 and 2 min. They emphasized problems with the few diagnostic facilities available. Blood samples for malaria and other tests could be sent to a central laboratory, but results were not given until several days later. Pharmaceutical company representatives were ranked by the practitioners as the major source of drug information. The practitioners did not have access to medical journals nor attend meetings or seminars. The estimated average _ number of drugs prescribed varied from 4 to 5 per outpatient. Tetracycline was perceived to be among the most commonly prescribed antibiotics. Placebo was an accepted concept, with one practitioner estimating that she prescribed placebos to 60% of her patients. The other two practitioners estimated that they used placebo for 25%. Multivitamins and vitamin Bcomplex were said to be commonly used as placebos. One of us, the medical doctor, was told that every patient expects drugs. If nothing was prescribed, the patients became angry and sometimes sent petitions to local politicians and administrators. Due to lack of time, the practitioners could not give non-drug treatment. They did not prescribe Ayurvedic drugs, but two of them stated that they used Ayurvedic drugs at home in their own families. The practitioners seemed very confident and proud of their prescribing. They said that most of their patients were poor and in need of vitamins. The practitioners proudly stated that with experience, spot diagnoses were possible, and they were proud to Table 1. The patients (n = 50) grouped according to number of drugs prescribed at the consultation zz Number

of drugs 0 1 2 3 4 5

Number

of patients 2 5 23 13 7

Table 2. Most commonly

prescribed (n = 50)

drugs among the patients No. of patients exposed

Drug Aspirin Chlorpheniramine (antihistamin) Tetracycline (broad-spectrum antibiotic) Ephedrine (bronchodilator) Vitamin B-combin

31 20 16 16 13

be able to treat so many patients each day. They thought that Ayurvedic treatment was not anything that had to be controlled. Thus, Ayurvedic drugs could be combined with Western drugs by their patients without risk. The most common diagnosis given by the practitioners was infection in the upper or lower respiratory tract, with almost 40% of the patients said to be suffering from this or other respiratory diseases. Less common complaints and diagnoses were malaria, worms, generalized weakness, anemia and gastritis. Only one patient had a cardio-vascular disease. All patients were prescribed drugs, on an average 3.4 drugs per consultation (Table 1). None of the patients were given injections. All drugs except vitamin Bcomplex were included in the Essential Drugs List of Sri Lanka. The five most commonly prescribed drugs are presented in Table 2. Chlorpheniramine, an antihistamin, is indicated for allergy, but only one patient had that diagnosis. The widespread indication for tetracycline, as recorded on the cards, is shown in Table 3, depicting the eight conditions for which this broad spectrum antibiotic was prescribed. A common pattern was to combine an antibiotic (preferably tetracycline) with aspirin, chlorpheniramine and sometimes also a B-vitamin. Antibiotics were also prescribed when it was clearly stated that the disease was of viral origin. The only condition where monotherapy was used was for worms. Only seven of the patients were given drug treatment that followed the guidelines issued by the Ministry of Health in Sri Lanka [24]. Let us now look at some of these patients in more detail. We have chosen two men and two women to represent this group of patients, which consisted of 25 men and 25 women, ranging from 18 to 60 years of age. Case examples

1. This female patient, in her forties, was asked about her expectations and stated that she came to

Table

3. Diagnoses given for patients prescribed tetracycline

Asthma (chronic) Bronchiectasis Bronchitis (acute) Bronchitis (chronic) Lung infection Tonsillitis Viral fever Wounds (infected)

Medicines and culture-a

get medicines because of fever, a cold and asthma. She also said she was tired, had a pain in her back, and she described breathing difficulties; She said that she would die if she could not get help. According to the patient, the cause of her symptoms was dhatu loss (see above), i.e. not enough semen. During the consultation with the practitioner, she said that she had pain in her spine, and the practitioner noted fever, coughing, cold and that the patient had vomited once. She was given the diagnosis viral fever. The practitioner asked if the patient was pregnant and, when she denied this, the doctor prescribed Tetracycline, Aspirin and Promethaxine. During the follow-up interview, the patient said she had had no information from the doctor about her illness nor the treatment prescribed, but she did not think that medicines had any side effects. She was still of the impression that she was suffering from dharu loss. 2. A 23 year-old man with no formal occupation was planning to start training others in karate. He had been to the health centre before and been cured. Now he came to get medicines for fever, perspiration, back-pains and loss of appetite. A home remedy with coriander and some other ingredients had already been tried, as was usual in the family when someone had a cold or fever. Only if there was no improvement did they go to get free drugs at the centre. The patient had also been to see a monk who gave him some oil and performed chants to cure the fever. He thought that he had something hot in the body that would be cooled by medicines. If he was not cured this time, he would visit an Ayurvedic practitioner. During the consultation he stated that he had a fever, coughed, had no appetite and thought he was suffering from malaria. The practitioner made a note of the cough and low appetite. The diagnosis given was lung treated with Tetracycline, Aspirin, infection, Ephedrine and Vitamin B-complex. After the consultation, the patient stated that he had had no information about his illness or the treatment given, and that he thought he had malaria. He thought that the Western drugs prescribed would cool the condition. He did not think that they could have any side effects. During follow-up interviews at his home, his mother stated that he took all his drugs and the Western medicines are preferred because of easy accessibility and effectiveness. 3. A 32 year-old man, married, with two children. One former child had died at an early age from seizures. The man was working as a watchman and had developed problems with fever, pains in the back and a cold. He had consulted an Ayurvedic practitioner and an Ayurvedic dispensary where he was prescribed oil, decoctions and preparations. -He had already tried home remedies and came to the health centre to get drugs for his cough, cold and a fever he had had for 3 days. The cause was perceived to be dharu loss, due to the cold and damp environment during night shifts. He stated that he had pain and fever and the practitioner diagnosed bronchitis and

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concluded that the patient had no fever. Tetracycline, Aspirin, Ephedrine and Chlorpheniramine were prescribed. According to the patient, no information about the disease nor the treatment was given. He thought that Western medicine gave quick relief and that he had to try anything to be cured. He also said that Ayurvedic medicine is expensive while drugs at the centre were dispensed free of charge. During the follow-up visits at his home he stated that, although he had taken all the drugs, he still had a dry cough which he had tried to cure with home remedies. He perceived it to be caused by increasing secretion of phlegm. Although Ayurvedic medicines were more difficult to take and required a longer time to be effective, he thought the illness would be permanently cured by them. Both he and his wife had earlier experienced heating effects from Western drugs, such as burning sensations in the stomach. In his view, Western medicine could bring new illnesses to the surface. The man expressed dissatisfaction with lack of information at the outpatient department: “we have no knowledge of anything, such as capsules and mixtures, in the Western system. The old Ayurvedic system gives us all such details”. 4. This 33 year old childless woman married 3 years ago and was now living with her husband, her mother and two younger sisters. She had earlier had unskilled work, but due to health problems had been unable to work recently. The woman came to the health centre to get medicines for pains in her stomach and back. She was getting thin, feeling ready to faint and also had some urine troubles. To the practitioner she said that she had stomach ache, blood and phlegm “omissions”. The practitioner noted a white discharge, loin and waist pain and diagnosed a vulva1 infection. The patient was given Metronidaxol, Multivitamin and Aspirin. According to the patient, no information was given, and she thought the cause of her trouble was semen loss. She believed she had too much heat in her body and said “some medicines might increase the heat, and therefore I prefer cooling tablets or mixtures. Capsules cause heat in the body. The larger capsules might cause burning sensations”. At home, the family stated that Ayurvedic or Sinhala medicines were more effective, but Western drugs were easy to take.

DISCUSSION OF THE MEANING AND IMPLICATIONS OF TREATMENT

Our impressions from this study are different from much other research concerned with choices of treatment among people in developing countries. Such studies generally stem from a single kind of explanation, namely that because Western medicine is an introduced medical system, it is less well integrated into the society and culture of the users than traditional practices. The studies offer insight into how Western medical practices do not always meet the cultural expectations of the people. But they tend to

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have difficulty explaining how Western medicine, including drugs, can, and often does, meet local practitioners’ and patients’ needs from their own perspective, as integrated parts of health seeking behaviour. Our study has confirmed that Western drugs are a form of treatment in demand. This is consistent with findings in a recent household survey from Sri Lanka where two thirds stored Western drugs in their homes [21]. Our observations suggest that Western medicine is highly integrated into the local setting. People have definite ideas about how Western medicine works and often use it according to traditional medical theories and practices. We suggest positive aspects to what is generally described as malpractice. If we want to change some of the practices, our concern must be to examine how people interpret, perceive and, in their own way, make positive use of the practices available to them. How dangerous from a biomedical point of view are the practices we observed? The prescribing practices we observed seem to be similar to findings in drug utilization studies in the area (301. A majority of the patients in our study were prescribed three or more drugs, as shown in Table 1. Preference for injections has been reported as an example of irrational prescribing in other developing countries [4,31], but was not encountered here. Practitioners follow the drug policy in Sri Lanka in prescribing selected drugs (241. This means that no combination drugs (except vitamins) or obsolete products were prescribed. However, the way these selected drugs were prescribed was far from optimal. As shown in Table, both chlorpheniramine, an antihistamin and vitamin Bcomplex were prescribed to almost one third of the patients. The widespread use of antihistamins has been reported from other developing [32,33] and industrialized countries [34], and was also found in another study from the area [28]. Antihistamins have not been shown to be effective in respiratory tract diseases [35], which was the most common class of diagnoses and thus the most common reason for prescription. Also use of vitamin B-complex is not indicated, as no selected vitamin B-deficiency has been reported, and even if it had existed, the 3-day treatment practised would only have placebo effects. Tetracycline was the most commonly prescribed antibiotic, given to one third of the patients (Table 2). In a study from 15 OPDs in the same area, both penicillin and sulphonamides were more commonly prescribed [30]. However, in a recent study from Indonesia, tetracycline was also the most frequently used antibiotic [32]. The eight different diagnoses for which this broad-spectrum antibiotic was chosen in the present study are shown in Table 3. Viral fever is clearly not an indication for any antibiotic, but we also know how difficult it can be to differentiate this from an infection of bacteriological origin. Some of the other diagnoses are also questionable from a biomedical-pharmacological point of view. More-

GORANTOMSJN over, bacterial resistance to tetracycline is a very common finding among possible pathogenic bacteria, and its prevalence is much greater than previously encountered [36]. Also in Sri Lanka a majority of some of the common pathogenic bacteria was found to be resistant to tetracycline at an outpatient department of a major hospital [37]. Thus very few indications exist where this drug should be the first treatment of choice [38]. However, the practitioners studied ranked tetracycline as one of the two most useful antibiotics. This may be due to lack of updated knowledge, as drug information from sources other than drug companies was stated by the practitioners to be practically non-existent. Continuing with our biomedical perspective and applying the standard treatment, as recommended by the Ministry of Health [24], we found that only 14% of the cases were prescribed fully in accordance with that could be judged as rational drug use. When prescriptions were measured against diagnoses, the major deviation was the use of tetracycline instead of a narrow-spectrum antibiotic, such as penicillin V, and the addition of an antihistamin (chlorpheniramine or promethazine), and/or B-vitamin. These latter three drugs are, however, among the less expensive drugs available at this level of health care. No attempt was made to validate the diagnosis, as this was outside the scope of the study. Our aim was to study the accuracy of the prescribing in relation to the diagnosis given by the practitioner at the time of the consultation. To return to the question of compliance raised earlier, if people choose to comply with prescribed regimens in the situations described above, compliance may not be in their interest from a biomedical point of view. But if drug use is meaningful for both patients and practitioners, and as such is integrated into their world of experience, how then can their ideas be understood? From the biomedical point of view, the positive or negative results of compliance depend on whether the prescription is correct or not. As one example, a prescription of several pharmacologically active medicines for ailment means that compliance may be negative for the patient, and that non-compliance may contribute to the health of the patient. An example of such as case was a man with an allergic rash, who was prescribed two different antihistamins, cortison, penicillin and vitamins. However, polypharmacy is a central concept in Ayurveda. It is common practice to give many drugs in combination for one condition, both to increase efficacy and to let the different ingredients neutralize each other’s side effects [39,4O]. Many Sinhala patients consider some Western drugs to be hot, e.g. antibiotics, and some to be cold, e.g. vitamins. Could biomedical polypharmacy also be influenced by these Ayurvedic principles? Sri Lankan biomedical practitioners give as reasons for polypharmacy difficult working conditions,

Medicines and culture-a

including little time for consultations and few diagnostic facilities; trying to cover various diseases in cases of uncertainty about diagnosis; and also satisfying the patients’ perceived belief that, ‘more is better for everything’. From a developmental and biomedical point of view, the major risk with this situation, especially in a setting with scarce resources, is the long-term effect of encouraging a population poorly educated in the use of Western drugs to develop a false faith in the infallibility of modem medicine and the magical power of prescribed drugs. While polypharmacy from a biomedical view has negative implications for people’s health, our data suggest that individuals look upon drugs as something positive that they readily prescribe and consume. One of the patients, the 32-year old man described above, with his traditional explanatory model of disease, had already tried both home remedies and Ayurvedic treatment. As treatment failed, he went to the health centre to obtain drugs for his cough, cold and fever. He was prescribed an antibiotic, an antipyretic, an antihistamin and a bronchodilator for 3 days. His symptoms continued for another l-2 weeks, but he did not return to the outpatient department to get more antibiotics. However some of his symptoms were positively affected by the drugs, at least for a few days. The health impact of this kind of prescribing may be of minor importance, at least when measured in morbidity and mortality statistics. However, either the pharmacological or the symbolic healing power, or both, may result in at least some positive effects for him and other patients. Otherwise, why should hundreds of patients consult the health centre daily? This means that the health system has both access to and the trust of patients, which has important implications for potentially more serious conditions where drug treatment or other interventions may be vital. In our conversations with the practitioners, it was clear that they were satisfied with the opportunity to give something to everyone, not least to the poor. People expect drugs, and that is what the practitioners can give. It was also obvious that their responsibility was focussed on consultation and was not perceived to encompass the conmmunity outside the clinic. Thus the ‘curative work’ was what was emphasized. A good prescrition for these practitioners varied from one to several drugs, depending on the condition and the patient, but in interviews their perceived average number of drugs prescribed per patient varied between 4 and 5. Thus, by their own account, these practitioners diverge from the biomedical ideal of one or a few drugs for ahiseise. A good prescription, according to the biomedical view, is one or a few essential drugs for a reasonably well diagnosed condition. One example was worms, diagnosed in two of the patients and treated with the appropriate drug. Another example was malaria, which was diagnosed in two patients, and the SSM 34,3--H

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recommended antimalarial treatment was given. In one malarial patient a benzodiazepine was also given for 3 days for unknown reasons. Another patient suffered from anaemia due to worms and was prescribed iron and vitamins. In these cases, from the biomedical perspective, compliance would be positive. Compliance is also positive in cases of antihypertensive treatment, antiasthmatics and the treatment of anaemia. According to some patients, however, one or two drugs are insufficient, and they try to increase their intake with the help of other treatments and drugs. Even if the drugs prescribed are taken, the perception of only one drug is negative and may mean that it is useless from the patient’s point of view, if not combined with other remedies. Forty-three of the 50 patients were prescribed 3 or more drugs. Seven were prescribed 5 drugs. The diagnoses for 5 of these patients were allergic rash, hypertension, generalized weakness, chronic asthma and otitis media. Two of them were given two diagnoses each, anaemia and eczeme and arteritis and lung infection. With the exception of weakness and rash, the conditions can be said to be relatively well defined diseases. A common biomedical view would be that polypharmacy here is irrational and bad prescribing in the sense that too many drugs are used for the conditions. None of these conditions could, however, be said to be minor, in contrast to several of the other cases. Thus non-compliance would not be good, even with this biomedical perspective. However, in almost all of these 7 cases, the patients could easily have done without one or two of the prescribed drugs, most commonly an antihistamin and a vitamin. But what does it mean for their intake of drugs that they got these drugs together with the ‘more essential ones’, if they otherwise would have combined the essential drugs with other remedies or manipulated their medication in various other ways, including not taking the drugs at all? Since it is obvious that the patients in our study have integrated the use of Western drugs into their health ideas and system for choice of treatment, it is in the future important to try to see how this can be positively perceived even from a biomedical perspective. Here, there is a sensitive balance between a pharmacological substance and the symbolism of healing in a very specific ecological and social context. The patients, as well as the practitioners, have strong and partly different ideas as to what the medicines contain, how they should look, and their effects. The patients consider Western drugs to give fast relief and be easy to take if compared with Ayurvedic medicines. They are therefore to be used both in acute cases, such as infections or pain, and in chronic cases, such as weakness and asthma. The power seems to reside in the drug itself as a symbol of healing. The drug is in focus, as it is expected and prescribed. Since the health care encounter does not include body contact or extended

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discourse with thorough diagnositc interaction, e.g. pulse taking or any kind of examination, we hypothesize that the symbolic healing power is mainly perceived by both providers and patients to lie in the drug alone [41]. In Western medicine, the symbolic aspects of drug taking and its healing power have been neglected. There are reports on high prevalence of antibiotic drug resistance in developing countries [42,43]. Most studies concerning drug resistance have, however, been conducted with the highly selected population in hospitals, and may not necessarily represent the prevailing conditions in the community. Levy [44] has also indicated that the shorter the period of tetracycline treatment, the less the risk of developing drug resistance. The main reason for introducing the 3-day treatment schedule in Sri Lanka was, however, costsaving [45]. Perhaps this also will prove to have a positive impact on health in terms of lesser risks of ecological disturbances. CONCLUSIONS

Our study shows that the pattern of drug utilization in a local Sri Lankan clinic in many ways meets the needs of both practitioners and patients. Their prescribing style has clear advantages for the practitioners who cooperate with patients to produce the mutually desired outcome. They also show a responsiveness to the demands of their patients. What may be seen as irrational prescribing from a biomedical point of view may vary well be rational for the prescribers. Trestle [15] suggests that compliance is an ideology, assuming and justifying the authority of the practitioners. We have shown that patients come to the health centre primary to get drugs, and that they have integrated their use of these drugs into their system of choice of treatment and concept of health and disease. The patients have clear ideas of how the drugs should look and what effects they should have. At present, policies for the improvement of drug use in developing countries are being initiated, but the cultural complexity of drug use is poorly understood. In a recent article, Bennet [46] discusses the dilemma of essential drugs in primary health care. He emphasizes the problems with a rapid progression of use of essential drugs, from being a means of reducing case fatality rates-the transmission of certain communicable diseases-to also being a means of ensuring sustainability and expansion of health services. Community involvement and self-reliance, the cornerstones of the primary health care concept, are threatened by a system very dependent on drugs, a technology that comes from outside and represents macro-structures. Thus, what we describe on an individual level as a fairly well-functioning system, with positive pharmacological and symbolic effects, may, in fact, prove to be dangerous to the development of a sustainable primary health care and an ecologically sound and self-reliant system. Given the

complexities of this situation there is a greater need than ever for an analysis of drugs in their natural context which not only focusses on the micro-levels of individuals (people and bacteria) but also includes politial and economic issues (see, e.g. Singer [47]). Our perspectives reveals how medical pluralism in the community results in the integration of Western drugs into traditional concepts. It also highlights the risks of dependency and possible risks of ecological disturbances. By combining biomedical and anthropological perspectives, we come closer to a natural bridging of the micro/macro gap. In future studies, a critical focus on the micro-level could lead to a new perspective on political and economical issues at the macro-level and vice versa. Some questions for future research include the following: what happens if prescribing is changed from polypharmacy to monotherapy? Do patients change their behaviour, e.g. do they turn more to other practitioners? Would they comply less with, for example, immunization programmes? Should cheap and non-toxic products, such as calcium lactate or B-vitamins, be included as ‘placebos’ in essential drugs lists to avoid the misuse of potentially dangerous drugs? Do current prescribing practices affect health? How important is the provision of information for the outcome of consultations? What are the ecological risks with the prevailing use of antibiotics? Risks and costs, but also the positive effects, must be explored on the micro- and macro-levels in developing essential drugs programmes, before we can answer questions such as ‘is compliance positive or negative?’ Acknowledgements-This study has been supported by grants from the Swedish Agency for Research Cooperation with Developing Countries (SAREC). It would not have been possible without the dedicated work of our research assistants Mangala Karunaratna and Shelton Godigamuwa. We would also like to acknowledge the support by the Department of Pharmacology, Peradeniya University, Sri Lanka.

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