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Chapter 12 Prevention is Better Than Cure

Chapter 12 Prevention is Better Than Cure

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Chapter 12 PREVENTION BETTER THAN CURE? ISSUES OF CONCERN IN THE PRICING AND MARKETING OF VACCINES IN INDIA - Anurag Bhargava, Yogesh Jain
Microbes are nothing... the terrain everything. --Louis Pasteur.

How do you foresee the future of the drug industry?

Drug industries can grow in India faster than anywhere else because of the sheer number of patients here. We can't be proud of this, but that's a fact.

–An interview with Dr. Anji Reddy of Dr. Reddy’s Laboratories in the Financial Express, O
Chapter 12 PREVENTION BETTER THAN CURE? ISSUES OF CONCERN IN THE PRICING AND MARKETING OF VACCINES IN INDIA - Anurag Bhargava, Yogesh Jain
Microbes are nothing... the terrain everything. --Louis Pasteur.

How do you foresee the future of the drug industry?

Drug industries can grow in India faster than anywhere else because of the sheer number of patients here. We can't be proud of this, but that's a fact.

–An interview with Dr. Anji Reddy of Dr. Reddy’s Laboratories in the Financial Express, O

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Published by: S.Srinivasan ('Chinu'); Renu Khanna on Feb 25, 2011
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Chapter 12PREVENTION BETTER THAN CURE?ISSUES OF CONCERN IN THE PRICING AND MARKETING OF VACCINESIN INDIA
- Anurag Bhargava, Yogesh Jain
 
Microbes are nothing... the terrain everything.--Louis Pasteur 
.
    
How do you foresee the future of the drug industry?
   
Drug industries can grow in India faster than anywhereelse because of the sheer number of patients here.We can't be proud of this, but that's a fact. 
 –An interview with Dr. Anji Reddy of Dr. Reddy’s Laboratories in the
Financial Express,
October 20,2000 
 Background 
India offers good ‘growth’ prospects for the pharmaceutical industry because of the sheer number of patients – the largest number of patients with TB in the world, the secondlargest number of HIV infected, and a total number of patients with diabetes andhypertension which would be bigger than the population of many large European nations.When it comes to the question of vaccines, the ‘prospects’ are even better. Drugs aremeant for the diseased only to be used when they fall sick, but vaccines are for thehealthy who can be injected anytime. With a population of one billion, India offers a verylarge market for those in the business of making vaccines.
 
Vaccines are one of the key public health interventions for prevention of disease.Traditionally they have been developed and used for those diseases that are lifethreatening, or cause significant disease in a large number of people, or are notpreventable easily by specific public health interventions in the absence of significantimprovements in socio-economic indicators. Thus the classical vaccines against smallpoxtetanus, diphtheria, poliomyelitis, pertussis, measles, etc., could achieve if implementeduniversally the eradication or control of these diseases, even without significantimprovements in the socio-economic status of the societies that they were used in. Lately there has been the development and promotion of vaccines against diseases thatare not necessarily life threatening may not affect large numbers of people andimportantly could be controlled effectively by public health intervention, which arefeasible, and cost effective. The vaccine against chicken pox and the vaccine againsthepatitis A are cases in point. These vaccines do fulfill needs of particular individuals,and patients, and thereby represent an advance in medicine. However they cannot be saidto be tools of public health, because in the former instance chicken pox with its benigncourse is not a public health problem, while in the case of hepatitis A, a more cost-effective measure would be provision of safe drinking water.
 
 
 The selling prices of these vaccines as will be seen in this chapter  are priced way beyondthe means of the common person
. The price per unit of a vaccine or sera is among the highest in any category of drugs inthe market except anti-cancer drugs and drugs like streptokinase. 
The vaccines against rabies are an obvious example. Dogs in India bite a large number of people and a large number of such people develop rabies in the absence of proper vaccination. Sera of various kinds are also highly expensive. A poor patient with tetanus, rabid dogbite, or snakebite envenomation may be driven to destitution by the cost of the antiseraitself. The cost of anti-D sera for a Rh negative mother carrying a child by a Rh positivefather would not allow the majority of such mothers to access this intervention which isso critical to the health of her future children. 
Imagine this Scenario 
    Dhondubai Patil and his wife live in Dharavi, in Mumbai, proudly called Asia’s largestslum.  They have only 2 children. Dhondubhai is a carpenter, while his wife works as adomestic in the apartments nearby. They get water from a common tap that is perilouslyclose to the open sewage drain. They seek health care from a general practitioner whooperates within Dharavi itself. They find the general practitioner telling them increasinglyabout prevention of diseases by vaccines. A year earlier they were vaccinated againsthepatitis B, by the same practitioner who never sterilised his needles earlier, and who waspossibly responsible for the prevalence of Hepatitis B in that part of Dharavi.  A visit for diarrhoea (which most people in his neighbourhood have had) made them aware of vaccines for typhoid, and hepatitis A, which his GP said he and his family should take. Itwould cost them Rs. 3000 only, which they said they could not afford. It had beendifficult enough spending Rs. 1500 on those five injections to prevent rabies for their sonwho got bitten by a street dog. And now when their second child has been born the GPinsists that in addition to the vaccines supplied by the Government free of charge, theyshould get their child vaccinated against Hepatitis A, Hepatitis B, hemophilus influenzaeB, varicella-zoster,
if they love and care for her. 
The above scenario is not hypothetical, but a potrayal of what is happening in clinics intowns and cities all over India. In recent years the Indian drugs market has seen theintroduction of a number of vaccines and sera. Some of these like the safer cell culturebased rabies vaccines have filled a lacuna, whereas in the case of some others like thevaricella vaccine the justification for their presence is hard to understand. Many diseasesthat are of public health importance in India lack an effective vaccine: for instancefalciparum malaria, tuberculosis, and HIV disease.    
 
 
 
Cure better than Prevention?
 
The emphasis on vaccines to the exclusion and neglect of other public healthinterventions, their appropriateness for application on a mass basis in the light of theepidemiology of the diseases that they are supposed to protect against, the costs of thesevaccines and the government’s failure to intervene in the public interest, and thepromotional practices of the companies in marketing these vaccines --- are all cause for grave concern.
 1.
 
The emphasis on vaccines is sidelining other public health interventions that would be far more cost-effective and have lasting value
 
Rather than being a tool of public health to be used judiciously the use of vaccines arein fact undermining the processes of public health. The use of many of these vaccinesis a wrong solution based on a wrong diagnosis of the public health problem. For example vaccines against hepatitis A, has been developed and are beingaggressively promoted. Hepatitis A is usually a mild illness in children and also inadults. The disease is eminently preventable if one could ensure safe drinking water-an intervention that would protect the community from so many other life threateningdiseases like typhoid, cholera, gastroenteritis, etc. 

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