Revolting: Tro-Tro Pharmaceuticals

Tiny little pills have become one of the most important currencies in medicine. Managing hypertension? Take X. Suffering from a bacterial infection? There is an entire alphabet of antibiotics available to you. Don’t underestimate these little pills, they have the power to completely alter a body’s normal processes, even the processes that keep the heart beating and you alive. As a result of this incredible power packed into pills, most drugs and pharmaceuticals are tightly regulated. Patients don’t have access to many of them unless a doctor’s prescription is provided to a pharmacist who then dispenses the drug to the patient. While the physician’s power of the pen has been criticized in the health reform discourse for driving up the health care costs in the US through overprescribing medications and ordering too many tests, my shocking experience on a Ghanaian tro-tro this morning sheds some light on a more positive dimension of a physician’s pen and the importance of health literacy among patients.

For the last three weeks, to cut down on transportation costs, I have been taking public transportation to reach the district hospitals that I visit and assess. Tro-tros are a widely used form of transportation and as a result of its common use, it is a main hawker target. All sorts of vendors selling bread, Ghanaian snacks, water sachets, toothpaste, flashlights, handkerchiefs, really anything come to the side of the tro-tro just before departure and almost every time the tro-tro comes to a stop (at traffic lights or pit stops) to sell items to passengers aboard the tro-tro. Occasionally, lay preachers will also board the tro-tro to preach the word of God or bless the journey. The swarming of hawkers has never bothered me since I’ve seen it as a convenient way to pick up the things I may need before every trip. The preachers also never seemed to bother me since I have a deep respect for the religiosity of the people of Ghana. But, this morning, I witnessed the grossest form of exploitation and felt powerless to intervene.

Pharmacies, called chemical shops in Ghana, dot the country and many of them are privately owned, through may or may not be staffed by pharmacists. They stock all sorts of drugs from common over-the-counter drugs, basic ointments, antibiotics, a handful of illegally stocked drugs, and all sorts of concoctions that claim to cure all ailments. Whoever staffs the shops freely provides medical advice and definitely does not work in coordination with physicians or medical institutions. Unlike pharmacies in the US, prescriptions are not required. This has HUGE implications on the misuse of drugs, not to mention the promotion of antibiotic resistant strains of bacteria.

So, here’s what happened. Just after the tro-tro door closed and we began our journey, who I thought was just an ordinary passenger stood up and began his energetic speech in twi. At first, I thought this gentleman was just another lay preacher, but every so often I’d hear words in English: “medical doctor,” “kidney,” “teaching hospital,” “brain,” and “X million Ghana Cedi.” Perhaps, he was blessing and praying for everyone’s good health. Then I noticed that he had an anonymously produced booklet titled, “Hepatitis B.” What was going on? Was he trying to sell this booklet about Hepatitis B? I then heard him say “prevention is better than killing” and he pulled out a package of drugs that he was selling for 1 Cedi. Like obedient students, almost everyone on the tro-tro handed him money in exchange for a tiny box labeled Ben-70s. I couldn’t believe it. How could they be so trusting of this salesman. I asked the student accompanying me to the district hospitals who he was and he said that he never introduced himself. The gentleman ended up selling two packages of drugs earning him at least 20 Cedi in just one tro-tro.

The closest thing we have to this in the US is direct consumer advertising. I’m not going to even open up the discussion of how manipulative the TV commercials and print ads can be. At the very least, these ads always end with the statement that consumers should ask their doctor about Y drug. While we can’t regulate the type of consultation patients receive from doctors about the drugs, at the very least, we can regulate their access to drugs that have the potential to be harmful if their effects and indications are not understood. A positive aspect of the power of the pen.

Embedded in my research this summer and critical to reducing maternal mortality not just in Ghana, but worldwide is health literacy and patient education. If only you could see the looks on the faces of the midwives and physicians that I interview who discuss abortion complications with me. At the root of these cases is a desperate and uneducated woman who takes some herbal concoction that causes her to bleed profusely and begin to circle death. Even though the human body has incredible defenses and regenerative abilities, would you really risk injury and death at the word of some stranger who doesn’t have the courtesy to mention his qualifications?

If the 1 Cedi drug was advertised to prevent Hepatitis B, what are the possible outcomes of this tro-tro transaction? Assuming the drug itself is a sugar tablet, the tro-tro passengers would take the drug and happily believe that they have succeeded in preventing contraction of Hepatitis B. They will not be interested in getting the Hepatitis B vaccine, proven standard prevention against Hepatitis B, and will remain unprotected. Down the road, they may come into contact with bodily fluids contaminated with Hepatitis B and become infected. Because one can live with Hepatitis B without immediate symptoms of liver damage, they will not seek care until their liver has been overtaken with cirrhosis. The most tragic part of this likely trajectory of events is that at the point they seek care, if treatment is still an option, it will be too expensive. Now it doesn’t surprise me that there are so many hepatitis and cirrhosis cases at the teaching hospital.

Perhaps it’s radical to say this, but the salesperson just earned 20 Cedi for committing murder. Never again will I ever complain about being forced to make a doctor’s appointment for a prescription refill. It’s a premium I’m willing to pay for receiving medical advice from qualified health professionals and peace of mind that others are going through this too.