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PRACTISING DOCTOR IN THE TROPICS
University ofGhana Medical School,
Most of the countries in the tropics may be referred to as developing countries arid
have certain features in common. Orthodox scientific medicine is relatively young
countries. The objectives of the drug exporting companies are not necessarily in the
best interest ofthe importing countries.
This paper highlights some of the problems encountered in the tropical world in
relation to drugs , and the examples quoted come mainly from Ghana.
There are three main sources of drugs in the tropical countries. Most importantly,
drugs are imported as fmished products. In Ghana 80 to 90% of drugs used in
orthodox medicine are imported (Botchway, 1980, unpublished observations).
Secondly, drugs may be imported as serni-fmished raw materials. They are then
formulated into tablets, capsules, syrups, and so on. Thirdly, a large section of the
population use herbai or traditional medicines.
This paper concentrates mainly on imported fmished products and on locally
manufactured drugs from imported raw materials.
Drugs found in countries like Nigeria and Ghana have been imported from a
variety of countries. Ghana for instance obtains its drug supplies from almost all the
Western countries, Israel , many of the Eastern European countries and China. In
1978 there were three hundred and twenty official drug importers in Ghana
alone. Each importing firm had its own favourite country and company.
The number of different proprietary drugs is necessarily large and there are many
brand name drugs containing the same pharmacological agent. Thus arecent survey
on the Ghanaian market revealed 15 different brands of ampicillin from different
DRUGS FOR DEVELOPING COUNTRIES 537
The assumption by the unsuspecting doctor in the tropics is that these different
brands, containing apparently the same pharmacological agent, are equivalent in
chemical and biological properties when equivalent doses are given.
The major questions to be answered in relation to drugs are: a) quality, b) cfficacy,
c) safety and d) quantities to satisfy national needs.
The great diversity of the sources and types of proprietary drugs available in many
tropical countries necessarily means th at there are likely to be wide differ ences in the
Chemical studies indicate that a number of the drugs circulating in the tropical
world are ofvery poor quality indeed (Binka, 1973; Ayim, 1977). Some ofthe drugs
arrive in these countries poorly packaged and already damaged at the port of entry.
A disturbing feature wh ich has been noticed on a number of occasions is that inert
substances are packed into, for example, capsules, and sold to the developing world
as specific drugs. These could be termed 'counterfeit' drugs.
During a pharmacy c1ass experiment in Ghana in 1972, a random sampie of
procaine penicillin in a government hospital was found to contain no antibacterial
activity. It was subsequently shown to contain an inert sub stance (Buadu, 1980,
personal communication). During a period when calamine lotion was in short supply
in Ghana, a large consignment of supposed 'calarnine' powder was shipped to the
country in 1976. The colour was pink on arrival and chemical analysis revealed no
calamine in the powder. In another study a sampie of imported fortified procaine
penicillin was found to contain one part procaine penicillin and five parts penicillin
G, the official requirement is the reverse ratio (Ayim, 1977).
Apart from 'counterfeit' drugs, the quality of the actual drugs may be very poor in
that the amount ofactive ingredients are more or less than the stated official values.
A systematic analysis was conducted in the Ghana Government Regional Medical
Stores between July and December, 1972. Penicillins, streptomycin, tetracyclines,
chloramphenicol, antimalarials and analgesic antipyretics were studied. The results
indicated that a large number ofsubstandard drugs were circulating in the hospitals
(Table I). Thus, 50% ofpenicillin sampies, 34.6% oftetracycline sampies and 41.9%
Table 1 Drugs analysed duringa quality control programme. From Binka (1973), with
of analgesic antipyreti cs were considered unacceptable. Penicillin co ntent ofsome of
the preparations was as low as 22.38% and streptornycin conte nt in one sa mp ie
studied was as low as 4.19% of the stated content. One sa m pie of chloram p henicol
powder for injection was found caked. What was even more disturbing was the fact
th at the sam p ie of substa nda rd streptomycin mentioned and most of th e drugs
studie d had not reached th eir stat ed expiry dates (Bink a , 1973 ). Chlora m phenicol
recently im ported from an Eastern Eu ropean country was found to conta in 58%
ac tivi ty (Buadu , 1980 , personal communicat ion).
Obser vation s ha ve indicated that th e co m me nts on subs ta ndard imported drugs
a pply to some ofthe locall y manufactured drugs. The main ca uses a re poor quality,
imported raw material s, poor formul at ion s and del iber at e ch eat ing. Thus, a capsule
on th e market in Ghana conta ined 30% of the sta ted ac tivity . lt was subseq uently
shown th at the supplier ofthe ac tive ingredient had adulte ra ted the drug with sugar
and duped the bu yer with a see m ingly authentic Certiftcate ofAnalysis. A pparently
suc h pr act ices are common on the European continent (Ayim , 1977). Caps ules of
cephalex in (250 mg) manufactu red in Ghana, contained impurities including tox ic
N-n-dimethyl aniline (Ohene-M anu, 1976, personal communication) .
The stability and hence the qual ity and biological properties of drugs are adversely
afTected by many factors. The rate of degradation of some drugs is increased by
conditions of high temperatu re, high humidity and high intens ity of light. These
envi ronme ntal condit ion s pr evail in man y tropical countries. Degrad at ion of th e
active drugs results in a decrease in poten cy, and the degrad at ory product s ma y be
toxic, for exam ple, tetracycline. The tro pica l conditions , therefore, ac ce lera te th e
Whilst ca re is tak en by so me ph armaceutical compan ies in pr esenting exp orted
drugs in suc h a way as to minim ise deterioration in th e tropical env iro nme nt, not
eno ugh is in vested in th is area by some com pa nies.
T abl ets, for exampl e cod eine co m pound, freq uen tly cha nge co lour. Hygroscopic
tablets and ca psules often so ften. Obser vat ion s indicate that poor packaging,
ina ppropri ate co ntai ners and faulty formulati on s ma y be major contributing factors.
For exa mple, diphenoxylat e hydrochl oride plus atro pine sulpha te tabl ets (Lomotil,
Searl e) packed singly in sea led ai r-tig ht a lumi ni um foil stay ' fresh' much longer than
when man y tablets are pack ed in glass co nta iners.
Apart from th e accelerated ph ysical and che m ica l degrad at ion of drugs, poor
sto rage facil ities, under the tr opical co ndi tions, render some of the drugs readily
contaminat ed by mi cro-org anism s. Thus, Boakye-Yiad orn & Buadu (1974) found
that 30% of 50 random sa mpIes of stoc k solutions of drugs for oral and topical
applications conta ined over 100,000 organism s mI-I. E. coli, Pseudom onas
aeruginosa and salmonellae wer e am ong the organisms ide ntified (Table 2 & 3). Such
contaminat ion s are therapeutically undesirable and dangerous. In another study,
Boakye-Yiadorn & Fukuo (1975) found a low degree ofbacterial contamination in
eye drops, nasal and ear drops, but, a high degree of bacteri al contamination in
Table 2 Total viable bacterial count in 50 randorn sarnples ofs tock solutions of drugs for oral
or topical application. Frorn Boakye-Y iadorn & Buadu (1974), with perrnission.
Viable bacterial count mt" % Nu mber of samples
DR UGS FOR DEVELOPI NG CO UNTRIES 539
mouth was h samp ies, du sting powder sa m pies and aqueous crea ms was ob served and
thi s was att ributed to high bacterial conta m ina tion ofthe raw materi al s used in their
pr eparations. The pre sen ce of sta phy lococci, Pseudom onas aeroge nase, Salmo nella
and E. eoli were also confi rrned. U mbilica l cord po wder has been inc ri mi na ted in
some cases of neonata l tet anus.
Table3 Path ogen count in rand om samplesofs toc k solutions. From Boakye-Yiadom &
Buadu (1 974), with permission .
Type ofbaeteria % Number ofsamples
Presu mpti ve coag ulase positive 18
Therapeutic usefulness and toxicity ofimported drugs
Undoubtedl y many of th e drugs imported ha ve been of grea t th er apeu tic value but
there is con sid erable room for improvement. There ha ve been man y insta nces of
failure of therapy in th e tropics. Wh ilst so me of the insta nces noted may be du e to
bacterial drug resistance , man y a re att ributa ble to poor qu al ity drugs, as have been
referred to abov e. T reatment of a case of infection with a 'counte rfeit' drug or
degraded drug is dangerous and has ca used th erapeutic disasters.
There are a large number of proprietary drugs whic h are of doubtful or unproven
therapeutic va lue circulating in th e tropics. Many of th ese are from th e European
continent. These drugs are unfortunately very popular and seil weil and are so called
drugs of ' vit ality' , th at is, bloo d ' to n ics', vita min com plexes, so ca lled neu ro-tropic
A no the r disturbing fact or is the rat e at which drug co mbinations of an undesirable
nature are read ily found in th ese co untries. Examples of th ese incIude br and drugs
lik e Ergertine (amido pyri ne + phenylbutazone) and Rh eumopyrine (phen ylbutazon e
+ amin ophen azon e). The rati on al e be hind comb in ing drugs whic h are highl y to xic
marrow depression (Table 4) following the use of drugs in Denmark bet ween 1968
and 1973 (Danish National Health Ser vices Report, 1974). Wh y are some exporti ng
firrn s pu shing such drugs in large quantities to the tropical world? lt is di sheartening
to note th at such drugs are very expensive and ha ve gained so much popularity that
th ey are readil y bought in the streets and markets, and are tr eated like tonics in the
When drugs and other ehernieals are either found or suspected to be toxic, some
exporting co mpanies shi p them to the developing countries. For exa m ple, ben zen e
hydrochloride ha s been show n to be carcinogenic in rodents and its registration ha s
been voluntarily withdrawn by the manufacturing firm in the country of origin. The
compound is found in large qu antities in G hana and is in th e form ofa lice-killer drug
(Donnar's lice-killer), and th is drug has caused fataliti es.
Table 4 Deaths caused by bone marrow depression following the use of drugs. Modified from
Danish National Health Services Board Report (1974).
Phenacetin is now restricted in some industrialised countries, for exarnple, Britain,
because of its nephrotoxicity, yet the compound is still being shipped in large
quantities to the tropical world .
Arsenic is hardly used in the developed world as a drug , but it is found here as
Stovarsol in the form ofvaginal pessaries or tablets. There is a lot ofbeliefin this drug
in Ghana and Ivory Coast and it is mixed with all kinds of herbai preparations.
Aplastic anaemia, agranulocytosis and chronic arsenic poisoning have been noticed
by the author, in three patients in Accra following the use ofStovarsol.
The therapeutic usefulness and the toxicity of some of the drugs circulating in the
tropics may be greatly modified by genetic factors . There is the need for a closer study
in this field, so that the appropriate drugs are imported into each country. For
example, the incidence ofglucose-6-phosphate dehydrogenase deficiency is very high
in African and Mediterranean countries. In Ghana this is estimated to be 23% in the
male population (Owusu, 1972b). People with this deficiency may develop
haemolytic anaemia following the use of drugs such as sulphonarnides, primaquine,
nitrofurantoin and co-trimoxazole. Unpublished observations suggest that West
African hypertensive patients respond weil to reserpine and related drugs without the
associated reported high incidence of depression. Evidence is also accumulating that
behaves paradoxically in African diabetics (Owusu, 1972a).
The inflation rate in many tropical countries is alarmingly high, reaching over 60%
in some cases. This factor and the determination of the leaders in many tropical
countries to provide better health care has meant that the health bill is very high and
is rising alarmingly. Thus, Ghana spends between 8-10% of her budget on health.
Between 30-50% of the health fund in these countries is spent on drugs. In 1969,
Nigeria spent 32 million and in 1979, 120 million naira on drug importation alone
The question is, are the relatively large sums of money spent on drugs being
effectively utilised in the importation or manufacture ofthe right types ofdrugs in the
right quantities? The answer is probably in the negative. The reason for this view is
that shortage of essential drugs , such as vaccines, chlorarnphenicol, anthelmintics
and antimalarials, in the hospitals and clinics is a regular feature in many tropical
countries including oil-rich Nigeria. In the face ofthese shortages, the shops, market
piaces and streets are usually full of an array of what may be termed non-essential,
but economically fast moving drugs, such as different types of analgesic agents, drugs
ofvitalitv', for example, vitamins and 'aphrodisiacs', and so on .
DRUGS FOR DEVELOPING COUNTRIES 541
There appears to be very little relationship between the drugs that are available
and the real health needs ofthe developing world. Several factors have contributed to
this state ofaffairs. Some ofthese are discussed below.
Political andfinancial considerations
There are powerful political and business interests in both the exporting and
importing countries. The prime objective is profit-rnaking. So strong are these forces
that therapeutic considerations become secondary in the choice of drugs for export
A variety of methods are employed to perpetuate this confusion in the drug scene.
These include the use of powerful advertisement techniques which are sometimes
misleading , and direct or indirect bribery or politicians, doctors, Ministry of Health
personneI, Bank and Ministry ofTrade officials who are connected with approval of
funds and policies for drug importation or manufacture. Ministry of Health
personnel may favour pol itical favourites in the allocation of licences for drug
importation or manufacture, where award of licences are prerequisites to drug
In some instances, donor countries wishing to win influence in a particular country
dump drugs of dubious quality as gifts. Some ofthese drugs have expired at the time
of arrival in the receiving countries.
Non-registration 01drugs for export
With the exception ofvery few countries like Japan and New Zealand, which requ ire
that no drug should be exempted from certification or registration procedures, many
countries exempt all or some of the drugs meant for export from registration. The
laxity of the laws in the exporting countries actively encourages and contributes to
the manufacture ofpoor quality drugs for export to the Tropical World.
Absence 01effective drug s control agencies
Many tropical countries have poorly organised drug control agencies. Where such
bodies exist, the laws governing drugs are often outmoded and need drastic revision .
Laws governing the types and quality of drugs may be formulated in the tropical
world , but there are considerable difficulties in the enforcement ofthese laws. Some
of these include the shortage of qualified experts, such as, inspecting pharmacists or
chemists. Nigeria has a pharmacist to population ratio of 1:90,602 (Adenika, 1979).
Corruption and political interference in the horne countries may playa role. Another
major difficulty is the absence of good quality controllaboratories.
The distribution of funds, facilities and manpower for health care in man y tropical
countries is inversely related to the distribution ofthe population.
Emphasis has been placed on the provision of expensive institutional care which in
these countries covers mainly the urban population. Thus, only about 30% of the
population enjo y all the health facilities. Disease distribution in the rural areas is
very different from that in the urban areas . Diseases of infestation and infection
constitute numerically the major problems in the rural areas whereas degenerative,
chronic and metabolie diseases assurne great importance in the urban areas.
It is now generally realised that there should be emphasis on primary health care
which seeks to provide basic health amenities to the rural population. The primary
health care concept covers promotive, preventive and basic curative services at
health posts, health centres and satellite clinics .
Drugs which are found in these countries are mainly in the urban areas and thus
there is a tendency for drug importers to satisfy the requirements of the urban
There is therefore little relationship between drugs that are available in these
countries and drugs that are required to maintain the health of the majority of the
Given the present conditions of limited fmances, shortage of manpower and the
inappropriate importation ofmany substandard drugs, the tropical countries need to
formulate policies aimed at the provision of the minimum number of essential good
quality drugs for their health services .
a) As a first step, it is suggested that central governmental agencies should replace the
many business houses involved in the importation ofeither fmished drug products or
bulk pharmaceuticals. A drug importation committee which will give expert advice
to such a central procurement agency should also be formed .
b) The sources of drug procurement should be limited to companies with reputable
records. The types of drugs to be imported should be based on local knowledge of
morbidity and mortality patterns, population statistics and local environmental and
genetic factors. Emphasis should be placed on drugs for primary health care .
c) Drug control agencies should be modernised or established where they do not exist
and they should be made etTective. This will involve the training of more personnel
needed for the enforcement of drug regulations. There must be a willingness on the
part ofthe various governments to make such regulatory bodies etTective.
d) Quality control laboratories should be established or strengthened. All drugs
entering the country should be analysed for quality and stability under the tropical
conditions. As an initial measure, it will be necessary for the countries in identifiable
geographical areas to collaborate for the establishment of regional centres, since
many countries may not have the needed funds and person neI.
e) These countries should also cooperate with each other on the exchange of
information on drugs . They mayaiso seek the assistance of the World Health
f) Facilities for drug distribution and storage need urgent attention, as drugs
deteriorate quickly and microbes multiply readily in the tropical environment.
g) Local manufacture of good quality drugs could help to cut down the cost of drugs.
There should be a gradual shift from the importation of fmished products to the
importation of good quality bulk pharmaceuticals for the local manufacture ofdrugs.
Here again, regional cooperation will be of great advantage. Such a shift will
eventually decrease the local prices of drugs.
h) lt is estimated that about 70% of the rural population resort to traditional
medicine and indeed many people have a lot of confidence in indigenous drugs .
There is also some evidence for the usefulness ofsome ofthese local rcmedies. There
are many problems related to the preparation, evaluation, stability and dosage of
traditional drugs . Ghana, for example, has made a beginning by the establishment of
a Centre for the Scientific Research into Plant Mcdicine. More attention should be
i) Lastly, there are major obligations on the developed world . The developed
countries can greatly assist the tropical world in the transfer of technology and the
exchange ofmanpower. Most irnportantly, the developed countries should pass laws
which will prohibit the export of drugs which have not met their local registration
DRUGS FOR DEVELOPING COUNTRIES
Many drugs of poor quality and of doubtful therapeutic value are circulating in the
poor countries. Some ofthese drugs are inappropriate and may even be toxic.
It is a moral obligation on the part of politicians, medical scientists and
pharmaceutical companies in the importing and exporting countries to stop this
I thank the organisers of the World Conference on Clinical Pharmacology &
Therapeutics for inviting me and for sponsoring my trip, I am also grateful for the
Pharmaceutical Division of Ghana Industrial Holding Corporation for partially
I thank Mr A. Opoku for typing this manuscript.
Adenika, F. B. (1979). Problems of drugs usagecontrol in Nigeria. Nig . J. Pharm., 10, 132-137.
ofphenytoin. Brit. J. clin. Pharmac., 9, 282~283
Ayim, I. S. K. (1977). Drug manufacture and quality control. Ghana Pharm. J., 5,8-9.
Binka, J. Y. (1973). Quality evaluation of some drugs in the Ghana market. Ghana Pharm. J.,
Boakye-Yiadom, K. & Buadu, C. Y. (1974). Evaluation of the microbial contaminationof
pharmaceuticals in Government hospital dispensaries in Ghana. Ghana Pharm. J., 2,
Boakye-Yiadom, K. & Fukuo, Y. D. (1975). Evaluation of the microbial contamination of
pharmaceuticals in Government hospital dispensaries in Ghana. Ghana Pharm. J., 3,
Danish National Health Services Board Report (1974). In Adverse Reactions on Drugs. Report
Owusu, S. K. (l972a). Paradoxical behaviour ofphenylbutazone in African diabetics. Lancet, 1,
Owusu, S. K. & Opare-Mante, A. (1972b). Electrophoretic characterisation of Glucose-6-
phosphate dehydrogenase in Ghana. Lancet , 2,44.
Sofowora, A. (1979). Drugs from indigenous plants. Nig. J. Pharm., 10, (3) 115-124.
Me rck Sharp & Dohme Resea rch Laberatortes .
Two hundred yea rs aga a developing country in the western hemisphere
successfully fought a war to rid itself from colonial rule . The situation has some
parallels to the struggles of today's developing countries. While the leaders wrestled
with military, political , and economic issues, the greatest threat to the people was
disease (Abrams. 1976), The American Colonists suffered terribly from epidemics of
smallpox, yellow fever , dysentery, influenza, and measles. Five Colonial soldiers died
of disease for every on e killed by the British (Allen . 1970), A soldier had a 98%
chance of walking off a baulefield alive , but the odds on his leaving a hospital alive
were only three in four (Allen . 1970), In coping with these problerns, the American
government seemed to lack sufftcient understanding and funds to provide the needed
faciliti es, supplies, and organization. At thi s point, however, the paralleis end, For
one thing, there were no effective remedies for these devastating infectious diseases at
the time of the American revolution: there are today . For another, the American
Colonies had an adequate economic base to avoid widespread malnutrition, which
kills by itself and adds to the morbidity and mortality of disease . Finally, a health
Europe, the country was able to substantia lly reduce or eliminate from its shores the
also evident th at money had to be avail able through economic development to get the
new drugs, vaccines and public health measures to the people.
The world is still developing, but the site ofthe struggle has shifted to the emerging
countries situated largel y in the tropical and subtro p ica l regions of the earth. This
location introduces unique parasitic diseases to cope with in addition to those faced
by the developed countries over the past 200 years. The concern ofthe United States
Government for the development of pharmaceuticals to fight these diseases was
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