Shital Mehta

STAY WITH ME. A few years ago, a patient was referred to me because he was diagnosed with complicated cirrhosis. He had an infection which led to a condition called hepatic encephalopathy (brain failure due to high ammonia levels). The treatment largely involved ammonia reducing therapies. One drug was central to this - Rifaximin - a non-absorbable antibiotic that reduced ammonia in the body. I prescribed him Rifaximin for 6 weeks and advised him follow-up. He came back to me, not after six weeks, but in 4 weeks, this time, in liver coma (worst stage of brain failure - due to very high ammonia). He spent two days in the ICU and six days in total in the hospital. His hospital bill was close to INR 80,000. He had no insurance and his wife borrowed the money from neighbors and friends to clear hospital dues. Upon questioning, I found that he was not taking the Rifaximin drug I had prescribed. He was only on the other two drugs (one, a syrup called lactulose for improving ammonia clearance in gut). I was furious, because the patient spent a whole week unecessarily in the ICU and wasted so much money that he never had - just because he was "not compliant" to my orders. I decided it was time for me to school him a bit. But I was wrong. He was compliant. He had purchased Rifaximin and was on it. For 15 days. Thereafter, he could not afford it. He was an autorickshaw driver who shuttled school children every morning and evening. He could hardly make ends meet. He had two children of his own. The Rifaximin brand I prescribed him was 42 rupees per tablet. He had to consume two a day - which would mean 2520 rupees a month. He just did not have that money - so he skipped it - to not compromise on other important matters - childrens education and food. He was confused and scared about opting for a cheaper version of Rifaximin because one, he was unsure about the quality of Rifaximin that was not prescribed by me and two, he was "scared" that I would scold him for buying a cheaper Rifaximin and if that got him into trouble. I was confused and scared about prescribing a cheaper version of Rifaximin because one, I was unsure about the quality of Rifaximin that was not "a good promoted brand" and two, I was "scared" that his family would scold me for prescribing a cheaper Rifaximin and if that got him into trouble. It is heartbreaking that many doctors still simply don’t trust generic medicines. Too often, they worry that these cheaper options are lower quality or might cause more problems than the big, famous brands. This fear leads them to prescribe expensive drugs instead, and the real tragedy is that it pushes vital healthcare out of reach for the ordinary people who need it most - like my patient. This narrative, that generic drugs 'are never good' and that only big pharmaceutical marketed drugs are what works has been deeply ingrained into doctors and patients alike - I do not know by whom and since when. Looking back, these strong emotions were based on either opinions, testimonials or second- and third-hand information. Not evidence. Like I said. Stay with me. This is life changing and will disrupt the drug market in India. Here are the results of The Citizens Generic vs. Brand Drugs Quality Project. 1/11

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