Iwan Darmansjah, Jakarta
The start of the new millennium has been filled with calamities that affected the health of the whole world, including Indonesia. It is as if nature is against us and wants to remind us to take better care of the world we live in. As each new year approaches, we stop and think, full of hope and intending that the new year will bring a new and better life.
Last year Indonesia and the world were challenged by disasters that were too large to handle. A tsunami, floods, volcanic eruptions, forest fires, air, land and water accidents, the spread of avian influenza, AIDS and tuberculosis, the rise of drug addiction and the diseases that come with poverty and war.
Poor education levels and a lack of public health awareness contributed to the country's obesity levels, food-related illnesses and preventable deaths.
While for part of the population, being rich provides an opportunity to live a healthy and prolonged life, the opposite is also true for those who subscribe to the ""carpe diem"" theory of living. It is as if War, Famine, Pestilence and Death are still riding in Indonesia in the manner they did in Europe 1,000 years ago.
Medical science and technology have created improvements in health standards in Indonesia. Better diagnostics and modes of treatment, such as the development of newer, more efficient drugs have been made available in Indonesia over the last 15 years. The treatment required to lessen human suffering and prolong the lives of those suffering from hypertension, strokes, heart disease, diabetes, heart attacks and tumors now exists.
But there are still the diseases that are referred to as ""orphaned"" -- humans infected with the H5N1 virus, drug addiction, psychiatric illnesses and many forms of cancer.
The health of the majority of the Indonesian population is very poor. The main reason for this is because of the immense poverty much of the country lives in. In this state, it is difficult to follow a healthy life-style. For many, even the most basic health clinic is too expensive.
The state insurance company, ASKES, has worked to survive for 25 years, and has provided around 65 million people with money and health care -- government employees, for instance, who need heart operations are covered by the scheme. The very poor, who live well bellow the poverty line, are also covered by the Department of Health's fund. But there are others who are neither poor enough to qualify, nor rich enough to afford private health care. Another marginalized group is the forgotten older generation, who are regarded as too cost-ineffective for health insurance -- they're going to die anyway, is the rational. Health insurance companies do not accept them as clients; there are age limits set for the over-55s.
There are, of course, positive sides to health provisions, although they still need to be improved in the coming years. Public health services are still inadequate in Jakarta, and there has been too much in the way of commercialization. I once lost my scalpel and had to refer a patient to the hospital for a small incision on a 2 centimeter abscess. The surgeon decided it had to be done in an operating room and inserted a rubber drain, resulting in full narcosis and a stay in hospital.
The functions of the Puskesmas (the government's primary health care centers) and the general practitioner should be returned to their original purposes. They should be the first place of referral for the sick patient. These days we bypass them, preferring to go straight to a hospital and be attended to by a specialist.
But while specialists will know a great deal on something specific, they have less general knowledge of other disease groups. A general practitioner will not be an expert in one thing, but knows a little of almost everything. Both should know their competencies and refer patients to each other.
Speaking of competence, it is a must that this be tested and improved from time to time, not orchestrated by the drug industry -- but who should do it? Collegiums have been formed to do just that, but often they are non-functional education organizations that may only run a congress once a year. General practitioners must be able to manage professionally the common diseases of mass destruction. At my promotional ""un-ad"" (a term used to counter drug advertising) seminars across the country, which inform doctors on rational drug use levels, I have noticed that many have not even been able to identify the right treatments for hypertension and diabetes and do not know of the simple, but effective treatment for acute heart failure -- take away superfluous body fluid by giving the patient an effective diuretic.
Avian flu is still an orphan disease, waiting for an effective drug to be developed. Amantadine, rimantadine and oseltamivir are the basic influenza drugs currently available, but they have been infective against bird flu. Doubling the dose of oseltamivir (commonly known as Tamiflu, the name it is sold under by manufacturer Roche) is apparently futile and possibly dangerous, because the drug is absorbed through the blood-brain barrier.
In November this year Roche issued a warning that the drug could give rise to neuro-psychiatric events such as confusion or unusual behavior, particularly in children. This is not surprising and had in fact been predicted. Three years ago, the American Food and Drug Administration's medical products reporting program, MedWatch, published a statement announcing that Roche had made public an animal study that showed that a single dose of 1,000 milligram oseltamivir phosphate (a very large dose) in seven-day old rats had resulted in death rates associated with very high oseltamivir concentrations that were 1,500 times those seen in adult animals.
This showed that oseltamivir can pass through young blood-brain barriers more easily than it can through adult ones. The findings can be extrapolated into the human brain, and therefore the small number of side effects observed in Japan to date is a reflection of the unsafe status of oseltamivir when given in larger doses and especially in infants.
This does not mean, however, that it is totally safe for adults either, because the blood-brain barrier may be influenced by some other factors, such as a concomitant infection of the brain and its membranes. The whole world is waiting for an effective vaccine against human avian flu.
In light of the benefit-risk assessment, I would disagree with using a double dose of Tamiful in treatment or prophylactically. Early human case identification and hygienic chicken farming sites remain the best and basic principles of human avian flu prevention.
The precarious drug situation in Indonesia is in need of reformation. Every party blames everyone else for contributing to the problem. Why can't we regard the drug problem as a national corporate ailment that is in the interests of everybody to solve? We need a sound drug policy. It should not be looked upon as an opportunity for profits but as in everybody's need and interest. Everyone gets sick at some point, sometimes seriously.
Reformation means rules and restrictions, possibly even a law. This could be a difficult task given the deregulations of the past. Cutting-edge practices have at times destroyed the long-term goal of becoming a healthy country.
The common use of ""food supplements"" that have no scientific backing by the general population is odds with efforts to regulate the drugs sold on the Indonesian market. The original laws for selling food supplements that originate in the United States Dietary Supplement Heath and Education Act of 1993 stated that users should be protected against mislabeling, so that supplements may not claim to cure or prevent diseases.
The education aspect of the above American act is completely lacking in Indonesia, leaving people asking silly questions in the media (and on my blog). Traditional medicines that are generally devoid of any evidence of a formal clinical trial are regarded as a class of food supplement, and advertise themselves as being cure-alls for ailments from A to Z. But I have conducted two clinical trials to test such claims, and found both ""drugs"" to be placebos.
Political pressure, however, may support local products, resulting in false statements being made to the media, such as that honey is good for diabetics. Honey is substantially fructose, which is converted to glucose in the body. A teaspoon would perhaps not cause any harm, but a fanatic could take honey in large quantities, raising a diabetic's blood sugar level dangerously. This is true for many supplements that claim to be safe for diabetics, but which actually contain a substantial concentration of pure sugar. These are deceptive evaluations and statements that the government should watch and act upon to protect the public. Producers should use healthy marketing techniques instead.
The ultimate concern about the drug situation is related in a recent article in the Nov. 23 edition of the New England Journal of Medicine, titled Dangerous Deception -- Hiding the Evidence of Adverse Drug Effects, in which the respected author describes how ""ethical"" drug companies are becoming more and more engaged in the deliberate hiding of data, which could lead to fatalities in the treatment of critically ill patients. Many other medical parties and journals have commented on the same subject, and the FDA is in the hot spot. It has reacted by asking the industry to provide more money (under the User's Fee Act) to be able to evaluate the drugs in a more accountable way. I have responded to the USFDA that it is not fitting for a regulatory authority to receive extra money for the evaluation of pre-marketed drugs because it would indicate a conflict of interest.
The year 2007 should be a year of introspection, remorse and real reformation for Indonesia. It is time that we walk hand-in-and, all parties communicating intelligently with each other for the sake of a nation in disorder.
The writer is professor emeritus of pharmacology at the University of Indonesia.
