Pillans, P. I.

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632 SAMT VOL. 73 4 JUN 1988
For this plan to be implemented fully, three conditions
must be met. Firstly, we must foster-me establishment and
growth in academic hospitals of geriatric units, where ex-
perience and research will generate me knowledge and expertise
for competent and relevant teaching. Secondly, we need real
determination on the pan of the appropriate aumorities -
rather man lip service - to establish mese facilities. Lastly,
we urgently require a measure of political confidence to be
injected into me future, so that those few who are struggling
to train doctors in caring for the aged do not continue to find
memselves in me unenviable position of expending a great
deal of energy in training their best personnel for the export
market.
P. de V. Meiring
1. Watermeyer GS, Bourne DE. Demographic imperatives in geriatrics in
Somh Africa. S AIr J Cone Med Educ 1984; 2: Aug, 21-26.
2. Meiring PdeV. A microplan for geriatric practice. S AIr Med J 1982; 62:
391-393.
3. Meiring PdeV, Benatar SR. The establishment of geriatric medicine at the
University of Cape Town. S AIr MedJ 1986; 69: 565-569.
4. Meiring PdeV, MitcheU PI, Bracken GL, Wingreen B, Kurren M. A
geriatric service in East London. S AIr MedJ 1986; 70: 288-292.
5. Meiring PdeV, White GdeL, Jameson C, Wylde RB. Geriatric medicine in
Grahamsrown. S AIr MedJ 1987; 71: 166-168.
Polypharmacy •ID South Africa
Although the extent of the problem of polypharmacy in
South Mrica is unknown, there is a close correlation
between the number of symptoms and the number of
medications that are prescribed for a patient. The number
of medicines used typically increases with age, l-3 although
overprescribing is as common in younger patients with
chronic illness as in elderly patients.4 The issue of
polypharmacy in South Mrica was recently addressed in
the Fifth Interim Report of the Commission of Inquiry
into Health Services (Browne Commission, 1987).
Although multiple drug prescribing is clearly indicated
in certain situations, polypharmacy implies the admini-
stration of too many medicines at dosages or frequencies
higher than therapeutically essential. The use of poly-
component medicines contributes substantially to the
problem. The excessive use of medicines was identified
by the Browne Commission as being potentially unsafe,
inefficient, and unnecessarily expensive.
Polypharmacy is one of a number of manifestations
reflecting irrational drug use, and contributes to the
national health bill directly and also indirectly through
its production of iatrogenic disease. This practice is the
result of the widespread mentality among the medical
and pharmacy professions, and the lay public, of a need
for 'a pill for every ill'.
The factors contributing to polypharmacy are
numerous - man's desire to take medicines, the expecta-
tion of medication at each consultation, the attraction of
novelty, habit, polysymptoms and polyphysicians.5 Where
more than one doctor attends a patient, practitioners are
often not fully aware which drugs their patients are
taking, and this may contribute to overprescribing or
unnecessary duplication.4 Prescribing for nonspecific
ailments inflates the drug regimen. Pressures on both
patient and doctor as a result of drug promotion are
substantial, and some of the blame for the current
inappropriate and excessive use of medicines in de-
veloping countries has been levelled at the industry.6
The number of drugs taken by a patient is frequently
increased by over-the-counter preparations, with up to
70% of subjects taking non-prescription medication in
overseas surveys.7,8 Polycomponent preparations further
compound the problem: cough and cold remedies are
often polycomponent, with irrational combinations.6
The outcome of polypharmacy may be poor compliance
because of too many pills, drug interactions, side-effects,
duplication, and increased cost. In geriatric medicine
the multiplicity of disorders, coupled with age-related
changes in pharmacokinetic and pharmacodynamic
factors, predispose elderly patients to toxic accumulation
of drugs and an increased susceptibility to drug inter-
• 89
actIons. '
The answers to these problems are not unique to
South Mrica. They involve a clinical commitment to
informed and simple prescribing, and an awareness of
the cost of medicines. It has been proposed that con-
siderable financial savings might be made if patients
were to bring all their medicines to each consultation.4,5
Doctors and pharmacists sJIould collectively hold them-
selves responsible for maintaining an accurate and
updated drug list, the drug card remaining in the posses-
sion of the patient.4 Faced with excessive bottles the
physician must establish priorities, but a doctor-patient
bond must be established before gradually stopping
optional, trivial and placebo medication. Patients can be
advised against unnecessary self-medication, and the
regimen reduced to the fewest drugs and the smallest
quantity of pills, with optimal dosage intervals to ensure
the desired effect. 5 Non-essential prescribing should be
avoided as it may be difficult to stop a drug once
commenced.
In South Mrican hospitals consideration should be
given to the establishment of computer facilities that
permit drug audit, and provide an accurate basis for
. promoting rational drug therapy. The initiative has
already been taken in this regard by several groups,
including certain medical aid schemes. If doctors were
aware that their prescriptions might be scrutinised by a
medical committee they would be more inclined to
adhere to sound prescribing habits. Medical schools,
and in particular departments of pharmacology, need to
co-ordinate forces not only to combat polypharmacy,
but also to improve the quality of drug utilisation and
implement cost-saving in general.
The availability of the first South African drug
formularylo should encourage sound prescribing habits.
Much more could be achieved in addressing the problems
of polypharmacy and uninformed and irrational drug
use by a closer liaison between the Department of
National Health and Population Development and de-
partments of pharmacology and pharmacy as well as
clinical departments in teaching hospitals. Only modest
improvements can be expected until a co-ordinated
policy has been established.
I wish to thank my colleagues in the Depanment of Pharma-
cology, University of Cape Town, for their various ideas which
have been incorporated in this communication.
P. I. Pillans
1. Borda I, Jick H,. Slone D, Dinan B, Gilman B, Chalmers TC. Srudies of
drug usage in five Boston Hospitals.JAMA 1967; 202: 170-174.
2. Skegg OCG, Doll R, Perry J. Use of medicines in general practice. Br Med J
1977; 1: 1561-1563.
Opinion/Opinie
SAMJ VOL 73 4 JUN 1988 633
3. Skoll SL, August RJ, Johnson GE. Drug prescribing for the elderly in
Saskatchewan in 1976. Can Med AssocJ 1979; 121: 1074-1081.
4. Price D, Cooke J, Singleton S, Feely M. Doctors' unawareness of the drugs
their patients are taking: a major cause of overprescribing? Br Med J 1986;
292: 99-100.
5. Kroenke K. Polypharmacy: causes, consequences and cure. Am]"Med 1985;
79: 149-152.
6. Richards T. Drugs in developing countries: inching towards rational policies.
Br MedJ 1986; 292: 1347-1348.
7. Law R, Chalmers C. Medicines and elderly people: a general practice
survey. Br Med J 1976; 1: 565-568.
8. Hendriksen C, Lund E, Stromgard E. Intake of drugs among elderly people
in a Danish municipality, Rodovre. Acea Med Scand 1983; 214: 67-71.
9. Goldberg PB, Robens J. Pharmacological basis for developing rational drug
regimens for elderly patients. Med Clin North Am 1983; 67: 315-331.
10. Conradie EA, Straughan JL, eds. South African Medicines Formulary. Cape
Town: MASA, 1988 (in press).
Mediese opleiding - die basiese versus
die kliniese wetenskaplike
In Suid-Afrika se mediese skole word daar na die basiese
wetenskaplike (prekliniese) en die kliniese wetenskaplike verwys.
Die vraag wat ek wil vra is of daar in 1988 werklik nog twee
verskillende wetenskaplike rigtings bestaan? Staan hulle teenoor
mekaar en is hulle in wedywering met mekaar gewikkel?
Die meeste van ons weet wat met basiese wetenskap in
mediese opleiding bedoel word, maar die omvang, aard en
uitvoering van kliniese geneeskunde het die afgelope jare sulke
dramatiese veranderings ondergaan dat daar verskille tussen
ons bestaan met betrekking tot die betekenis van hierdie
terme.
Die antieke mite wat tans glad nie meer aanvaar word en
wat geen plek meer het nie, moet finaal afgekeur word. Dit is
naamlik die M.D.- versus die Ph.D.-gegradueerdes, met die
M.D.-gegradueerdes wat die basiese wetenskaplikes sien as
mense wat 'n suiwer Ph.D.-graad behaal het, wat in geheim-
sinnige (verborge) navorsing betrokke is, gebruik maak van
ingewikkelde apparaat, wat glad nie gemoeid is met die menslike
situasie nie en wat groot bedrae geld koso Die Ph.D.-ge-
gradueerdes se siening van medici in navorsing ·is die van 'n
vae entoesiastiese groep oppervlakkig opgeleide navorsers, deel-
tyds en soms heel amateuragtig, wat totaal behep is met hul
poging om iemand anders se waarnemings op die terapie van
menslike siektes toe te pas. Hierdie twee sienswyses is verouderd
en skadelik tot die status en waardigheid van die mediese
wetenskap.
Kliniese wetenskaplikes is myns insiens gewone basiese
mediese wetenskaplikes wat net op die probleme rondom
menslike siektes en die mensbiologie konsentreer. Hul doelwit
verskil nie, dit moet steeds menslike nuuskierigheid bevredig.
Die metodes wat aangewend word, intelligensievlakke benodig,
fundamentele vereistes van presiesheid, van kwantitatiewe
meting, gekontroleerde waarnemings en bo alles van meditering
en verbeelding is dieselfde in beide groepe.
Die omvang van geneeskunde verskil van 'n vorige geslag
hoofsaaklik deurdat die wetenskaplike inhoud vergroot het.
Namate moderne ondersoekrnetodes meer bekend geword het,
het ons begrip van die fundamentele prosesse van gesondheid
en siekte meer noukeurig geword en kan die geneesheer kennis
met 'ingeligte raaiwerk' vervang. .
Geneeskunde verander net so vinnig en die taak van die
geneesheer het in baie opsigte die van 'n wetenskaplike geword.
Navorsing rondom probleme van menslike siektes word in
werklikheid basiese navorsing in so 'n mate dat dit nie sin
uitmaak om 'n mediese skool in twee dele te verdeel en die een
preklinies en die ander klinies te noem nie. Die basiese mediese
wetenskaplikes kan nie agtergelaat word die oomblik wanneer
studeme die saal en kliniek binnegaan nie, want dit is juis dan
wanneer hulle die meeste benodig word.
Dramatiese deurbrake in molekulere biologie wat die afgelope
jare behaal is en wat tot omvangryke nuwe kennis oor normale
sellulere struktuur en funksie gelei het, is dikwels deur be-
studering van abnormale (patologiese) funksies behaal. Dit
bewys die imerafhanklikheid van 'basiese' en 'kliniese' weten-
skaplikes.
Kliniese depanemente ontwikkel tans hul eie basiese weten-
skaplike afdelings (laboratoria) in 'n paging om die hele veld te
dek. Dit is die mode vandag, maar slegs die grootste en
fmansieel welvarende kliniese departemente kan sulke bree
dekking bekostig. Sal dit nie miskien veroorsaak dat die pre-
kliniese departemente se begrotings skade lei nie? Wie sal vir
die belange en die entoesiasme van die mediese studente in
hulle prekliniese jare omget?
Elke jaar verdwyn die rykste poel van jong talent vir beroepe
as mediese interns in die land se hoof opleidingshospitale om
nooit weer as fakulteitsraadlede gesien te word nie. In die
meeste van ons prekliniese departemente is daar te min medies
gekwalifiseerde mans, en die getal neem elke jaar af. Dit word
dikwels gese dat dit te wyte is aan die relatief laer inkomste in
die prekliniese departemente. Hierdie dispariteit van inkomste
is in die meeste mediese skole uit die weg geruim, danksy die
vooruitsiendheid en harde werk van sekere dekane.
Ek dink dat met daadwerklike propaganda jong mans sal
besef dat die erkenning en beloning van 'n basiese weten-
skaplike loopbaan die soetheid van vryheid, tyd om te dink en
'n Yewenslange gevoel van avontuur behels. Balans kan verkry
word, nie om die een teen die ander af te speel nie maar om
gesonde ontwikkeling by beide aan te moedig sodat 'n dinarniese
ekwilibrium wat vir beide voordelig is, verkry kan word.


Polypharmacy in South-Africa

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Polypharmacy in South-Africa

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