Drugs’ Life: Accessibility and Use of Biomedical Drugs in Myanmar

Prevention: A Foreign Concept and a Non-accepted Practice

If Thandwe people frequently have recourse to biomedical drugs for the treatment of their diseases, they seldom, if ever, use them as a preventive measure. At least, they seldom do it of their own initiative. Medicines are considered mainly as curative tools, acting on the symptoms of a disease. Ingesting a medicine when there are no signs of a disease is a bit foreign to Rakhine people as to many Southeast Asians (Laderman & Van Esterik, 1988). Prevention is understood as a combination of social, spiritual, religious and medical practices (respect of dietary rules, prayers, recitation of formulas, offerings to the Buddha and the tutelary spirits, respect of social norms, wearing of amulets, etc.) acting on the potential causes of diseases and intended to maintain a general state of well-being. Therefore, the only preventive use of pharmaceuticals people make, at least out of their own initiative, is the consumption of tonic and vitamin pills to maintain their body’s strength and performance. This practice is indeed in continuity with the traditional consumption of specific foods and pharmacopeia products deemed to have tonic properties.

Most of the preventive practices based on pharmaceuticals are implemented, organised or imposed by the public health service. They are a part of the preventive actions included in the public health programme. Some are accepted by the population while others are less so. Preventive actions that include the delivery of medicines are mainly addressed to pregnant women, mothers and children. As part of pre-natal care, female health visitors regularly go around villages to identify pregnant women and invite them to visit health centres in order to receive advice on the preventive measures. At these centres, health workers distribute folic acid tablets, vitamins, and injections against tetanus, and also check blood pressure and the baby’s position. They also distribute delivery kits, provide explanations on HIV and how to prevent it, and explain the importance of pregnancy spacing and how to do it. Related to the mother and child programme is the Universal Children’s Immunization (UCI), which is carried out every month and includes vaccinations against DPT (diphtheria, tetanus and pertussis), tuberculosis, poliomyelitis, measles, and hepatitis B for children under one year of age, as well as vitamins B1 and E to prevent beriberi, and anti-tetanus injections for pregnant women. Another activity focused on children is the nutrition programme which consists of a yearly check of size and weight of primary school students and the distribution of iron supplements to all ten- and eleven-year-old girls to prevent anaemia. Besides this, there is a programme focused on school health; once a year the health staff goes to schools to check student’s health, delivering vitamins and deworming drugs, distributing medicines for minor diseases, referring the more serious cases to health centres, and educating the students about the environment and personal hygiene.

The success of these practices—the actual use of medicines by the local population—is not consistent. The reason is bound up in several shortcomings in the way they are implemented. Although these activities are theoretically part of the regular duty of the public health staff, for several reasons, these are not always accomplished with uniform efficiency or regularity. For instance, the health assistant of Lintha states that family, social, and transportation problems often prevent him and his colleagues from carrying out their regular rounds. Several practitioners also assert that the unsatisfactory salary received by the public health staff further prevents health workers from accomplishing their duties in a proper way.

Moreover, some practices invite specific shortcomings in their implementation and these can accumulate with other social and cultural obstacles to hinder their acceptance. This is particularly true for vaccination and prophylaxis practices. Concerning vaccinations under the UCI programme, the local health staff affirm that the large majority of parents agree to vaccinate their children and most of the people I have interviewed confirm this. But still, such acceptance is very recent and does not apply to the whole population. The first reason is that the principle of vaccination— taking a drug against a specific disease before any symptoms has appeared—is still quite strange to local people. Second, as a 38-year-old mother from Lintha explained that they did not want ‘to harm’ their children and ‘make them cry with that injection.’ They also greatly feared the side effects, mainly the fever provoked by the DPT vaccine. The LHV (Lady Health Visitor) of Lintha declared, ‘Although we explain that this is a normal reaction and that they can take a paracetamol tablet to reduce the fever, women still refuse to vaccinate their children.’ Moreover, shortcomings in the implementation of the practice as well as other socio-political barriers are also at stake. Indeed, villagers affirm that nurses rarely went to look for people who did not come seeking the vaccination, and if they did, they scolded them for not having come. This attitude has certainly increased the resistance against vaccinations and reinforced people’s mistrust of public health programmes. Indeed these programmes have long been considered as instruments of control—a form of biopower in Foucault’s sense (1988 [1963])—and expressions of false paternalism from the military government. ⁵ These feelings have accompanied vaccination since its introduction in the colony of Burma in 1811 (Naono, 2009).

A second example is that of the prophylaxis against elephantiasis (limphatic filariasis), a disease caused by a parasite worm and characterised by an extreme swelling of arms, legs and genitalia. In 2008, the Ministry of Health in collaboration with the WHO started a prophilaxis action against this disease in Rakhine as well as in the regions of Magway, Sagaing and Mandalay where the diffusion rate is deemed to be high. Once a year, the public health staff or members of the village administration make a round of the villages to distribute three pills for each adult. The acceptance of this practice is extremely low. Most people don’t take the drugs; they simply throw them away. As with vaccination, people fear the side effects of the drug, which in this case is a sense of dizziness. They also largely ignore the cause of the disease and the fact is that this disease is incurable. This state of matters is much related to the way preventive action is implemented. When the officer in charge of the distribution visits a house, he simply asks how many adults live there, registers this number on a book and distributes three tablets for each adult. He leaves without explaining anything about the disease, its causes, or the fact that it is incurable. A villager from Lintha reports that when the village officer came to his house to distribute the pills he warned him and his family saying not only does the pill cause dizziness, it also worsens the symptoms a person is already suffering from. It’s interesting that the few people who consume the pills explained that they did it ‘because they have been donated by UNICEF [actually it is from WHO], and they have a value; it is stupid to throw them away as others do’. They thus consume it because it has a monetary and moral value, not because they understand its medical utility.

Looking for a Cure

If Rakhine villagers seldom use biomedical medicines as preventive tools, they often resort to them in their health-seeking process as a complement or alternative to traditional medicine. Traditional medicines include different kinds of products all composed of natural materials (vegetable, animal and mineral nature): aliments with medical properties, home-made remedies composed with materials easily accessible, remedies composed by traditional medical specialists using raw materials they collect in the forest or purchase in the market, ready-made products produced by private or state-owned companies and available in the market, and in services opened by specialists trained in a state-run institute.

The capacity of biomedical drugs to quickly erase symptoms is particularly appreciated. This characteristic combined with the shape of the medicines, their packaging and the context in which they are produced and distributed are seen as symbols of modernity and science that people highly admire. Consuming Western medicine is a way of embodying and being integrated into a modern world that people long for. This aspect seems particularly strong among the middle class as well as some young people such as a young hotel staff member from Myabin who claims ‘now we are modernized. When sick, we just use Western medicines, traditional medicine is something people used in the past’. However, in most cases, the exclusive use of Western medicines is more a claim than a fact. Indeed, the majority of villagers use both Western and traditional medicines. Nevertheless, the appreciation of the efficacy and modernity of these products does not erase the fear of the side effects they engender and more generally the potential harm related to their chemical and, in some cases, foreign nature. This tension between seeking for efficacy versus fear of harm characterises the way people appropriate these products.

Both products, Western and traditional medicines, can be accessed directly by self-medication—the act of consuming a medicine out of one’s own initiative and without the advice of a doctor (Fainzang, 2012, p. 3) or via a specialist. The choice between the two kinds of products and the modality of access is determined by different factors including the ability to define the disease, the nature and gravity of the symptoms, the age of the sick person and the accessibility of the recourse.

Self-medication

Most of the villagers—of any gender, social, and educational level—resort to self-medication when affected by problems they estimate as minor or common, such as indigestion, cough, and headache and for which they do not feel the need to consult a specialist. Self-medication is considered the cheapest and quickest way to overcome these troubles. For many people, self-medication is extremely common in the case of chronic diseases when recourse to a specialist is inaccessible.

Western medicine is generally preferred in the case of acute symptoms like headache and fever as it alleviates them quickly. On the contrary, there are a certain number of diseases for which people prefer traditional medicine. For example, articulation pain, digestive and skin problems, menstrual disorders, some forms of cancers and also chronic diseases like hypertension. Traditional medicine is said to completely erase the sickness by ‘cutting its root’ (myet phiette) and is supposed to be free from side effects. This last aspect is particularly appreciated in the case of chronic diseases which require continuous medication. Some families also prefer to use mainly traditional medicines for children because they consider biomedical drugs to be too strong for them. Finally, some economically disadvantaged people tend to resort to traditional products more than Western products because they are about 10 times cheaper.

The use of biomedical and traditional products is not mutually exclusive. Often villagers resort to both, either at the same time or at different stages of the same disease. Yet everybody acknowledges that one should wait at least two to three hours between the doses of the different medicine types because they are said to be incompatible (me tet bu) and mixing them could be harmful. My informants conceive the functioning mode of biomedical drugs according to the traditional terms, notably on the basis of the hot and cold principle. For instance, paracetamol is considered as a hot medicine, sometimes used to treat cold diseases. Mixing it with a hot medicine of the traditional pharmacopeia is likely to produce an excessive effect.

Although most villagers can purchase and consume Western medicines quite easily, they generally treat them with a certain caution. They buy biomedical drugs when they really need them. The majority will only buy products they are familiar with or which have been recommended by a specialist, a relative, or an advertisement in the media. They consume them quickly and never store supplies at home. All villagers stress their fear of side-effects of these drugs and affirm that they must be taken sparingly. A young woman from Giaiktaw, working as hotel staff, states, ‘if we take too much we risk to have a choc or become blind or a fool. If you take them too long, they destroy your stomach.’ This situation strongly contrasts to that of traditional products, with which everybody feels familiar and comfortable. They are easily bought and consumed without fear as they are supposed to be natural and therefore harmless. These are generally kept in the kitchen or in the common room where the family takes meals; thus reminiscent of the association between remedies and food. Anybody who needs them could just pick and use them as one would do with food.

While many villagers perceive some danger in the Western biomedical products, they are generally less aware of some risks related to the modalities through which they access them. First, the risk of buying expired medicine. This risk is particularly high in the small unlicensed village shops. The owners seldom check the expiration date of the products and sometimes put the medicines in boxes different from the original ones and hence lose any record. Many people ignore or don’t care about this; they patronise these shops mainly out of convenience—they do not want to spend money and time to go to licensed shops in town. As with most people, they seldom check the expiration date of the products they buy. The second risk is that of purchasing counterfeits. Educated people are generally more aware of this risk because they are more exposed to the media. Another risk is that of consuming unsuitable medication. People who rely on the unlicensed shops state that they know how to take the medicines or that, if needed, they can ask the seller. Yet the seller is not a health specialist but a merchant. Other people only purchase the medicines from licensed shops because, as a villager said, ‘sellers are professional and know the medicines very well’. Yet, according to my observations, clients seldom ask about the dosage in the licensed shops in town. This is because they are not acquainted with the seller, they do not want to be perceived as ignorant, or think they will be able to manage by themselves. Moreover, sellers rarely provide explanations, because they ‘lack the time, fear they will offend the customer (anadeh), or wish to respect his autonomy’, as explained by two shop keepers. Moreover, every shop sells medication in single doses (depending on how much the customer can afford), without the box (showing the registration number and the expiration date), and without the leaflet. Even if the leaflet is provided, it is incomprehensible to a large part of the population because it is in English. Finally, it happens that shops directly sell medicines for frequently requested prescriptions such as antibiotics, anti-malarials and morphine. This behaviour is illegal and theoretically punished by imprisonment. However, the weakness of legal control gives shop keepers a certain freedom. Most of them claim to respect basic rules with some minor exceptions. For instance, concerning morphine, a nurse owner of another shop explains: ‘I sell it only if I know the customer and know that he takes this drug regularly.’ This said, several villagers affirm that they have been able to purchase those kinds of products very easily.

Appealing to a Specialist

If self-medication is a very common recourse, there are several occasions when people prefer to consult a specialist. This is the case when their symptoms do not disappear through self-medication, thus needing special tests or treatments, as well as when they are affected by problems they regard to be more serious, such as acute diarrhoea or strong abdominal pain. Rakhine villagers also consult a specialist in case of injury or if they need an injection or an operation. Injections are extremely popular because of their immediate effect. They are often requested by patients and often proposed by practitioners. This said, some people resort to a practitioner even for minor cases which other people would have self-medicated for. They do so, as a shop keeper from Myabin states, ‘because I am not familiar and even a bit afraid of Western medicines and I feel the need to have the advice of an expert who knows which is the appropriate drug for each particular case’.

The choice among the different providers is based in part on the nature of the disease and the ability of the different services to deal with that problem, but especially on factors such as the relation (familiarity and trust) with the practitioner, the geographical distance and the cost. For most problems ranging from common to relatively serious, most people resort to the private services or the AMFA clinic in Myabin. These services are preferred to the public ones, which are largely mistrusted and seen as the quintessential symbols of a government careless about the population. First, these centres are lacking in medicines, equipment and staff. The centres, people said ‘are only for pregnant women and children’ or ‘can deal only with fever, cough and diarrhoea’. Even the hospital, which is the best equipped service in the area, remains very deficient. Most of the doctors are general practitioners. Simple operations, basic tests and X-ray are available, but analysis of the tissues, ultrasound imaging, important operations and treatments of most serious diseases (cancer, HIV) are not. A second aspect people highlight is cost. In these services, a panel reports that ‘the patient can share the cost of the treatment’, but actually in the centres a payment is requested and at the hospital it is even compulsory. The main reason is that the government supplies the hospitals with medicines and materials intended to be given free to the patients, but these being very limited, the staff is compelled to buy other products from outside and charge them to the patients. Other complaints concern the fact that the patients are treated according to their social-economic status and the staff are quite careless and are often absent.

Private services are considered much better than public ones especially because they are provided with medicines, and doctors are said to take much more care of the patients regardless of their economic status, although everybody states: ‘they don’t do it from loving-kindness but because the service they provide is subject to payment and the money goes directly in their pocket’. Moreover, specialists are said to have all kinds of strategies in order to get more money: over-prescribing, requesting the patient to come back or diluting injection medication with water. Despite this, most people prefer these services to the public ones but not everyone can afford them.

Given this state of affairs, the dispensary of the French NGO, AMFA based in Myabin, providing free tests and treatments using high-quality Western drugs is highly appreciated, especially by very poor villagers who can’t afford other services and hence resort to it for several kinds of problems. Yet there are others, not necessarily poor, for whom the appeal of having FOC high quality Western medicine is so high that, as the doctor explains ‘they come to us even for very minor cases for which they could buy medicines from outside shops. They do so just because we have good medicines and we treat for free, but they should not this’. The dispensary also attracts people from remote villages who need to travel for up to four hours to reach it. The main disadvantage of this centre is that there is often a long queue and many people don’t want to waste their time waiting for their turn. ‘I have to work and get money for my family; I can’t wait so long’, affirms a shop keeper from Myabin.

Because of the extreme popularity of this centre, the stock of medicines yearly delivered by the NGO is not enough to cover its needs. The staff thus purchases products from local shops or simply gives a prescription to the patient so that he can buy medicines from a shop. Patients are aware of this and feel much disappointed when they don’t get European medicines.

Medication at the Core of the Consultation

The nature of local services is highly deficient. They lack especially in specialised staff, equipment and material for performing tests, important operations and specific treatments. As such, the delivery or prescription of medicines is the main reason for resorting to practitioners and is thus core to the medical encounter. Resorting to specialists to get treatment and not just a diagnosis is also consistent with the fact that biomedicine is generally seen as a curative tool more than as a diagnostic one. In most cases, the villagers who resort to practitioners already have a diagnosis in mind; they form it by discussing with relatives and friends using the traditional etiological system as their basis. The same is attested in Cambodia by Guillou (2009, p. 122). Observing medical consultations, we realize how the focalisation on the medicine goes with—and is reinforced by—a strong contrast between the stress put on the technical act and a common absence of medical explanations.

Given the difficulty of conducting observations within the public health services, ⁶ I have been able to observe only by visits in the private sector. In most of the cases, the patient first explains his symptoms. The doctor then asks some questions, tests the blood pressure and auscultates. He often provides an injection and finally gives some medicines. He, or a nurse, shows the medicines, which generally are of two or three sorts, to the patient and explains the posology (only orally, nothing is written). He or she puts the medicine in a small plastic bag and hands it to the patient. Practitioners seldom provide details about the diagnosis and medication. Patients likewise seldom ask for them, except for some highly educated people or people who are very familiar with the practitioner. This lack of communication is explained by the practitioners by saying that ‘We don’t have the time for that’ or ‘anyway they would not understand’ while patients say that ‘I feel anade [feel bad] to ask, I don’t want to give the impression that I question his knowledge’. Or ‘they don’t like and even get angry if you ask.’

My observations do not allow me to consider the way this kind of interaction impacts people’s compliance with the doctors’ prescriptions. Yet I can state that it contributes to maintaining the hierarchical relationship and the social and the cultural distance between patients and professionals. Moreover, such interaction prevents the integration of biomedical knowledge into people’s conceptual world. Although the medicines delivered or prescribed in this way remain a sort of mysterious tool, they do not remain meaningless; they acquire new meanings by being re-framed through traditional concepts.

Since the prescription or the delivery of medicines, without explanations, represents the core of the medical encounter, the medicines thus acquire a very fundamental role. People tend to trust and believe only in specific medicines. Therefore, people trust doctor’s prescriptions and stick to them as close as possible. Saw Nyun, a medicine shop owner reports that ‘sometimes patients come with a prescription, but I don’t have that medicine. So I propose another one which is exactly the same, just maybe of another brand. Yet, many of them refuse and go to another shop because they want exactly the medicine prescribed by the doctor.’ This shows that not only is the doctor’s knowledge considered superior to that of the shop owner (whose advise is sometimes followed in cases of self-medication) but also that as soon as people depart from the safety of familiar medicines used for common disorders, the fear of biomedical drugs arises more clearly. Relying on the (best) experts’ advice is the only way to contain it.

Nevertheless, while the doctor is commonly seen as the person most knowledgeable about the appropriate medications for specific disorders and that people tend to follow his advice, there are some situations which seem to question the primacy of the doctor’s authority. The doctor of the AMFA clinic in Myabin reports that ‘some people get obsessed with our medicines; some are convinced that they can be cured only with one specific medicine; if the first time we give them one medicine and the second time we give another one, they complain, they say it has no effect or gives side effects’. A similar case which I have personally witnessed concerns a young woman from Lintha, a hotel staff, who resorted to the AFMA clinic because she was suffering from articulation pain. The doctor gave her medicine of a German brand. When she finished the medication, she felt she still had some pain, and went back to the dispensary asking for the same drug. However, she did not have the box the medicine came in so she didn’t know the name of the medicine. She just remembered it was a ‘German drug’. This time the doctor was not there and the nurse who was on duty gave her the medicine she deemed appropriate for her case. The patient wanted to make sure this was the same medicine she had received the previous time. She carefully looked at the colour and the shape and even smelled the drug (something people usually do with traditional medicines which generally have a very strong smell). Since the nurse insisted that the drug was suitable for her case and the patient was quite convinced it was the same one she had had the last time, she accepted it and left.

I suggest that this kind of behaviour on the part of the patients can have at least three explanations. First, patients’ past experience with medicines is very important and it’s a factor which is taken into account in the acceptance of the drug which is prescribed. Because not all drugs are deemed to be suitable for everybody and many drugs are feared for their side effects. If someone had a good experience with a particular drug, it’s understandable that, when needed, he wishes to get the same drug. In this sense the patient’s experience can count more than the doctor’s advice, all the more so if the doctor who prescribes the medicine the second time is different from the one who prescribed it the first time. Second, my observations suggest that this kind of behaviour is particularly strong with Western medicines. Rakhine villagers deeply believe in the superiority of power, efficacy and safety of drugs produced in Western countries. It’s thus possible that when they guess that the medicine given the second time is not a Western product, as the first was, they are worried about the effect they can get. Third, there is also a question of trust. People trust Western medicines but they don’t necessarily trust the practitioners of the dispensary as they seldom trust practitioners in general. At the dispensary, when people are not given Western medicines they are very upset and comment (with friends and relatives) ‘the staff keep the good medicines for rich patients or for serious cases’. They thus believe that the staff does have the medicines; it’s just that they refuse to give it to them.

Given that local services lack many medicines and instruments, patients are often referred to Yangon. Yet most of them can’t afford the cost of the trip and of the health care. And for those who manage to go, because they are wealthy or because they sell or pawn some precious belongings, the problem is not necessarily solved at once. Some diseases require regular medication. In some cases, like for So Thun, a 40-year-old fishermen from Watankwai, who suffered from a liver disease, the families must arrange a periodic delivery of the medicines from Yangon. Unfortunately, this is not always possible as some treatments and medicines can be accessed only in Yangon and the patient has no alternative but to go there to receive it. This is especially the case for HIV, which is a serious concern in contemporary Myanmar. Next to Thailand and Cambodia, Myanmar has the highest rate of HIV infection anywhere outside Africa. According to a controversial estimate (highly disputed by the government) 687,000 individuals are affected by HIV in Myanmar. Drug use, commercial sex work combined with a low health education level and low rate of condom use among the population all fuel the epidemic. Because the government has long been unwilling to acknowledge and handle the problem, and has even hindered the work of NGOs operating in the sector, the accessibility to the treatment (antiretroviral medicines) is very low. The current situation is that the HIV test is available free of charge or at low charge in several public and private services all around the country while its treatment is highly limited. It is provided free of charge by a few public hospitals and international NGOs mainly based in Yangon. The main provider has always been the Dutch branch of Doctors Without Borders, but other NGOs such as the French Médecins du Monde also play an important role— even more so since the opening up of the country, which has allowed several new NGOs providing antiretroviral drugs to enter. Nevertheless, they too are only based in Yangon. Besides them, there are several private clinics which provide such treatment. However, their fees are unaffordable to the majority of the population.

Another problem besides the centralisation of the treatment (basically in Yangon) is the fact that services provide the medicines only for one or at most three months. During the first month of the treatment, the service has to see the patient once a month. Each time, it delivers the medicines for the following months. The frequency later decreases to once every three months. For many people living far from these services, it is very difficult to sustain treatment because they cannot afford to travel to Yangon so often and stay there for the duration of the consultation (usually a few days).

It must be noted that the accessibility of this treatment is further prevented by the strong stigma associated with the disease and the avoidant behaviour its diagnosis provokes. If educative campaigns exist, they are mainly organised by NGOs and do not reach remote areas. Those provided by the public services are poorly attended.