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Principles and Perspective [SOCIAL MEDICINE] 17 June 2010

YL6 CULTURE AND THE USE OF MEDICINE Michael L. Tan

OUTLINE  Note central role of pharmaceuticals as reflected in:


I. Learning Objectives - Medicine in medicine
II. Review of Frameworks  In the medical field, gamot/drugs/medicine is
III. Concepts of Medicine medicine. Outside it, medicine could be illegal
IV. SANE RDU (Rational Drug Use) substances.
V. Folk Concepts of “Safe” (Ligtas) - Gamot in manggagamot
A. Problems with Safety  With the term gamot in the word manggagamot,
VI. Effectiveness (Bisa) we always assume the medicine or gamot is
A. Total Drug Effect being used.
VII. Affordability (Abot-kaya)
VIII. Need
IX. SANE Inter-actions IV. SANE RDU (Rational Drug Use)
X. Additional Challenges  Safe
XI. Quiz Yourself!  Affordable
 Needed
 Effective
I. LEARNING OBJECTIVES
 Understand how society and culture shape people’s  “Rational” is often defined mainly from a linear, “logical”
perceptions of medicine framework that might leave out society and culture.
 Analyze how “rational” drug use might be promoted with a
socio-cultural context.
V. FOLK CONCEPTS OF “SAFE” (LIGTAS)
 The folk concept of “safe” is based more on experiences of
II. REVIEW OF FRAMEWORKS the individual and significant others.
 Phenomenology - In reality, however, even if a medicine is found safe
- personal meanings, often linked to personal experiences based on the experience of an individual, it can also
- medicines are full of meanings be dangerous on a case to case basis.
 Social interactionism - Example: A person breaks out in hives when she took
- learned scripts, from social interactions especially with the Alaxan, which she’d already taken before with no
family, peer groups, immediate community adverse effects occurring, not knowing that the Alaxan
 Political economy macro tablet has only reformulated recently.
- Issues, structures and power relations regarding health,  Some folk concepts should also be considered like the idea
including its regulators and sellers (i.e. advertising, the that “milligrams” cuts across all drug groups
medical profession, the drug industry). - Something like 10 mg diazepam might be seen as
“safe” because it’s “only” 10 mg.
 In family planning use, “safe” might actually mean “reliable”
III. CONCEPTS OF MEDICINE in terms of protection (ligtas) from pregnancies.
 Gamot, tambal  Public perceptions of contraceptives are a mix of the
- Medicine is given a certain cultural identity (i.e. the personal as well as macro, including the information and
Tagalog gamot and the Binisayang tambal) misinformation spread around.
 Bawal na gamot - Folk concepts also exist like the misconception that
- There are different nuances in the meanings of oral contraceptives leave residues (latak), which then
medicine become cancer.
- There is “gamot,” which pertains to that used
medicinally, and there is “bawal na gamot,” which A. Problems With Safety
refers to illegal drugs  There are regulatory challenges when it comes to
 Banned drugs the distribution and marketing of drugs in the
- Drugs that used to be available but were banned country because, in addition to some 17,000 (?)
because of catastrophic and/or unwanted side effects registered drugs, there are also
- Example: Cytotec was banned because it was being - drugs coming in from US
used to induce abortion - drugs coming in with overseas workers
 Drugs - drugs coming in from Thailand and India
- There is a difference in the usage of drugs, medicines (Viajeras)
and gamot and even in the terms used - alternative and complementary
medicines/supplements (usually registered
as food, rather than drugs)
- local Chinese medicines

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CULTURE AND THE USE OF MEDICINE SOCIAL MEDICINE

- others (for example Seirogan, a Japanese  Hierarchy based on formulations


kampo medicine that is creosote-based, - IV injections > IM injections > Capsules > Tablets >
popular in Mindanao) Syrups
 Doctors’ comments (e.g. anti-generics), endorsements,
REMEMBER: even appearances in ads, euphemisms (“bitamina para sa
 Be careful with unregistered baga” for anti-TB drugs, “pang-UTI” for STIs) have influence
medicines; they can be dangerous.
on efficacy.
 Because people don’t understand
medicines, they can believe in
- Physicians’ samples are also perceived to be more
anything and think that it works. effective than those actually bought by the patient.
 In traditional medicine, the top  Macro factors are very important in shaping perceptions,
selling mineral is tawas. advertising in particular. Drug advertising is often
aspirational: You too can be like Richard Gomez, or John
Lloyd Cruz
 Improper storage at home  Off-label prescriptions
- Most families store medicines in the
medicine cabinet in the bathroom, which A. Total Drug Effect
actually speeds up the expiration process of  Active ingredient
the medicine because of the humidity in the  Name of medicine
cabinet.  Organoleptic criteria: color, taste, smell
 Low literacy levels, more problematic given  Formulation
complicated, obscure or missing (as in tingi  Mode of administration
purchases) instructions around preparation (i.e.  Prescriber, dispenser
reconstitution), storage, dosage, precautions.  Setting in which it is taken
 Miscommunications between provider and  Patient’s background
patient can become a cause for wrongful use of
 Background of patient’s significant others
medicines.
- Example: Anti-TB drugs for “weak lungs”
become “bitamina para sa baga,” which end
up being taken for a prolonged period. VII. AFFORDABILITY (ABOT-KAYA)
 High costs of drugs leads to:
- Illness hoarding, usually in urban poor women opting
to keep their illness to themselves rather than burden
VI. EFFECTIVENESS (BISA)
the family
 A mix of the personal, social and the macro.
- Consulting drugstore clerks, friends
 Indications for medicines can be bewildering  Prescription hoarding: people hide prescriptions
- Examples: pills as fertilizers, ferrous sulfate and because they share it with friends rather than
paracetamol for suicide spending money on a visit to the doctor
 Networks can also be convoluted - Tingi purchases, when patients buy just one
- Example: How did people learn about misoprostol tablet/capsule from the whole pad of eight
(Cytotec) and about nalbuphine (Nubain)? - Under-dosing: people never take the complete dose
- Concept of “leakage”: knowledge or products moving  People complain all the time about expensive drugs, but
from regulated environments to the informal sector will not trust drugs that are too “cheap” (mura).
 Effectiveness might be based on the color of the medicine, - Notice the Cheaper Medicines Act was renamed
taste or even the name. Universally Affordable medicines Act).
- The action of drugs is often reinterpreted in popular - Social norm: one shouldn’t scrimp on medicines for
culture (e.g. vitamins seen as sources of energy). loved ones.
- This means that the packaging of medicines should  When the costs of medicines drop, there can also be a
follow how they are culturally perceived. Sleepy-blue tendency to overuse.
tablets for the relaxing Diazepam and happy-yellow - What will happen when Zithromax (Azithromycin) 500
for Multivitamins. mg goes from P300 to P150 each? (Presume dose of
 Hiyang (“fitness”) figures prominently in perceptions of 500 mg per day for 3 days)
effectiveness
- Example: Junior is more hiyang to Tempra, which is a
specific brand of kids’ paracetamol, but Nonoy is not
VIII. NEED
and is more hiyang to another brand.
 Very controversial area, linked to debates around
 Polypharmacy, popular in traditional medicine (e.g. pito-
medicalization and commodification of health.
pito), is transferred into Western Medicine as a standard
for efficacy.  WHO calls for priority to “essential” drugs, based on safety,
- Example: Uneducated patients think that the more efficacy and need
drugs they are taking, the faster they would get well.  Do we really need vitamins? Anti-diarrheals? Shotgun cold
remedies?
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CULTURE AND THE USE OF MEDICINE SOCIAL MEDICINE

- Vitamins are not really needed if the diet is sufficient.


XI. XI. QUIZ YOURSELF!
- Anti-diarrheals should be used only when absolutely 1) Why is it considered incorrect to store medicine in the
necessarily and it is better to let the “dirt” pass medicine cabinet in the bathroom?
naturally rather than plugging it in. a) Family members forget that there is medicine in the
- Lots of water and rest will always be the best remedy cabinet.
for colds. b) Visitors might mistake it for something else.
 Lifestyle drugs: drugs that “…satisfy a non-medical or non c) Presence of microorganisms in the bathroom lowers
health-related goal”. Four biggest categories: the overall efficacy of medicine.
- Weight loss (i.e. Xenical) d) The humidity speeds up the expiration process of the
- Hair loss medicine.
- Sleep
- Sexual dysfunction (Sildenafil or Viagra) 2) Which concept pertains to the common misconception
that the more drugs a patient takes, the speedier his
recovery?
IX. SANE Inter-actions a) Polypharmacy
 Perceptions of safety, affordability, need and effectiveness b) Hiyang
will interface, equating expensiveness with effectiveness. c) Low literacy levels
 Safety and efficacy perceptions often tied to brand names. d) Drug packaging
- Alaxan is “hiyang” but do people know Alaxan was
reformulated? 3) Which of the following is the correct sequence of the
 Expensive drugs leads to tingi purchases and prescription hierarchY based on formulations?
hoarding, which affect both safety and efficacy a) IM injections > IV injections > capsules > tablets >
syrups
 Consider, too, psychology and the placebo effect:
b) IV injections > IM injections > tablets > capsules >
medicines’ perceived therapeutic effects often draw from
syrup
previous experiences.
c) IV injections > IM injections > capsules > tablets >
 Other factors to consider:
syrups
- Self-medication (especially with the Internet providing
d) IM injections > IV injections > tablets > capsules >
information and misinformation, medicines for sale)
syrups
- Perceived effects, including those on the body.
 Xenical and gas
4) High costs of drugs lead to the following EXCEPT:
 Depo-Provera and spotting
a) Tingi purchases
 Antiretrovirals and “buffalo hump”
b) Illness hoarding
(lipohypertrophy)
c) Overdosing
d) Prescription sharing

X. ADDITIONAL CHALLENGES 5) Which of the following is NOT one of the biggest categories
 Eclectic mixes: of lifestyle drugs?
- Local medicinal plants (also related to campaigns to a) Hair loss
use local products; fear of the “artifical”) b) Skin whitening and rejuvenation
- Imported food supplements (colonial mentality, c) Sleep deprivation
return to nature fad, ethnic identity as with Chinese d) Erectile dysfunction
medicines)
- Balikbayan medicines (extra caution with brand
names)
 Medical missions and donated drugs (especially from
abroad)
- Sometimes, this can be dangerous because, usually,
donated drugs are already expired or about to expire.
 Specific cultural adjustments:
- Chronic medication during Ramadan.
- Vegetarians’ insistence on medicines not having
animal products.
 DOH’s Food and Drug Administration is underfunded
 Attempts to regulate prices, quality, met with lawsuits
- Pfizer trying to block price regulations
- Distributors of dietary supplements suing the
Health Secretary for new regulations: “Hindi ito
gamot”.
ANSWERS: D, A, C, C, B

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