Something isn’t always better than nothing… but we’re here to help
Michael Nunan, Project Director
My Mum hates book vouchers. Hates them. My sister gave her a book voucher once and, well… it was ‘the worst birthday ever’ sort of thing. Fair enough – giving a book voucher to a person who can quite easily afford to buy themselves a book is laziness personified. If it’s the thought that counts, well, yeah… you haven’t put in any thought at all, have you?
Good work sis. Way to ruin Mum’s birthday 25 years ago.
Books on the other hand? Awesome present. I hope. God, I’ve given Mum a lot of books over the years. Some of them new.
New books rock out, but old books have a charm to them too – To Kill A Mockingbird? Timeless stuff, doesn’t matter when it was printed. Shakespeare – hell, the older the better!
Old medical reference books… not so much.
We got a ‘gift’ at work recently; a donation of reference books from an international medical company that operates here.They included such useful tomes as ‘Cardiovascular Survey Methods, 1968’ and ‘Intensive & Critical Care Digest, 1983’… 20 boxes of total rubbish that we could only incinerate. For the money they spent on freight, we could have bought a dozen really useful books in their current edition; but giving money wouldn’t have allowed a few retired doctors to clean out their attics…
If it’s the thought that counts, then the best that can be said about these books is that the donors were completely thoughtless. What’s worse is if they actually thought we would use them, throwing ourselves with grateful tears in our eyes onto classics like ‘The Kidney (1976)’. Thank god, thank god, we can finally READ SOMETHING!!
On a side note, we actually usually like books to be donated. If they’re less than 3 or 4 years old, if they’re relevant, if they’re in usable condition, medical reference books are gold.
Drug donations on the other hand…
A recent study I was sent has rekindled the donation debate somewhat; the authors found medicines past their expiration were ‘often’ still OK to use. OK, good. Somehow though, the authors didn’t use this to mount an argument about the miscalculation of expirations by manufacturers or to make the point that American hospitals could safely keep using them but to further the tired arguments about foisting more and more unwanted medicines on the poor.
So here we go… cue gasps, cue outrage – if there’s one issue that some people do not seem to be able to grasp, it’s that we run a drug supply system but we don’t like private drug donations. Here’s why…
You go to a developing country, to visit friends, travel, for work or as part of a church tour. It’s great, the people are welcoming, you go to a village, you go to a clinic. They don’t have ‘any’ medicines. It’s tragic and you resolve to do something about it because you know that ‘most’ medicines in your country are just thrown out.
So you go home and you organise some medicines. Some people gather up everything in their house or collect from local pharmacies. Some amazing people will put together a donation drive and accumulate huge amounts of drugs… they pack them, they send them… and in almost every case, their efforts will be wasted.
WHO base their guidelines for drug donations on four key principles. Paramount is that a drug donation should benefit the recipient to the maximum extent possible, which is a given; the donation should also be respectful, supporting existing government policies and administrative arrangements. Crucially, there should be no double standards in quality: if the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation, including expired medicines. Finally, there should be communication; donations should be sent only in response to requests from the responsible authority (not clinic nurses); specifically, unsolicited drug donations are to be discouraged.
So in the real world, the donations arrive – usually the freight has been paid to the point of entry; rarely, they’ve considered customs clearance and duty. Then there’s transport from the port of entry. Assuming these have been paid for though (and many drug donations are simply not declared by tourists, who illegally pack drugs into their bags and bring them through borders), they arrive at a national supply facility. They might be out of date, they might not be on the Essential Medicines List (the list of drugs available for use in a given developing country), they might not be packaged in the local language. They might not be in the same dose or dosage form that the country uses. They might not be in very good condition and even if they are, we have no way of checking how they were stored, prior to being donated.
But let’s be fair… let’s assume that ALL of those conditions are met. Usually they need to be sorted, which is time consuming; there might be a printed list and manufacturer information included. And maybe we were told in advance that they were being sent, giving us time to plan storage, data entry and distribution. Maybe they even asked us beforehand what we wanted!
Maybe all this was done…
But here’s an anecdotal stat – in 11 years, I have never seen a drug donation that met all of these conditions. Ever; and we see dozens of donations arrive each year.
And here’s today’s kicker (and this is the confusing part) – even if they have met the conditions and they’ve donated correctly… we still generally don’t want them.
What is the impact of private drug donations? This sounds harsh but we’re not just trying to get drugs and put them on hospital shelves; we’re trying to build a comprehensive drug supply and medicines information system – and random donations undermine that on nearly every level.
Firstly, the quantities donated are usually unhelpful. At the national level, even a few thousand tablets of an antibiotic pales in comparison to the millions we process every year. In a clinic though, even small quantities can adversely affect their stock system. At the primary level, where most donations are sent, imperfect tracking of stock coming in and out ruins quantification systems – if a clinic receives 1000 amoxicillin tablets we don’t know about, that will cover their needs for maybe a month or two. But it will ruin their quantification for 6 months… our officers use a simple formula to calculate the clinic’s needs but they need to know what has been sent to the facility in the first place. Consequently and most commonly, clinics that receive private donations have very good stocks of a few items and terrible availability of everything else – we see it all the time. The nurses become confused about ordering, whilst the provincial pharmacy officer is undermined and has no idea how much to send, as the real quantities aren’t being reflected in the clinic order sheets.
What’s worse is if a clinic receives drugs that might be quite common elsewhere but unavailable in the recipient country – many countries in the region do not stock, for example, Cephalexin, Amlodipine or Perindopril which are all very commonly used in Australia. If these arrive unsolicited in a clinic, at best they go unused and must be destroyed by burial or burning; without high-temperature incinerators (almost non-existent here), environmental contamination is inevitable. At worst, they are given out inappropriately to patients by nurses who haven’t received training in their use. Some donors surreptitiously give basic training – but unplanned training conflicts with strategic planning and local priority-setting.
I remember a departing tourist coming in, in 2009, with a box of random drugs. A cursory glance told us that the drugs were expired, you could see some of them were open and there were many we didn’t use. ‘Could we’, he wondered, ‘send them to a clinic he’d visited the previous month which didn’t have ‘any’ drugs’. I knew the clinic – I knew it well. We’d been stressing about it because we hadn’t been able to send anything there for six months; shipping services to the province had been suspended and air freight was way beyond our budget. We had an entire order at the warehouse – dozens of boxes of life-saving, in-date medicine – ready to send down but we had no way of getting them there. ‘Could we send his donation? No. We couldn’t.’
‘What we really need is money,’ I told him. ‘If you’re willing to pay for some air freight, we can send down emergency items from our warehouse to tide them over. But we will incinerate this box’. His face was stricken – not with concern but with anger; I was a total arsehole, I didn’t know what I was talking about and ‘had I ever even been to the clinic?’ I had actually – one of the 310 that we looked after at the time.
You see, what we generally need is not what people think. We need logistics, we need training, we need resources, we need desks, we need uniforms, we Needa Da Money! Across the Pacific, we usually have warehouses FULL of drugs and we’re working really hard to keep it that way. What we need is to get them to clinics, systematically train nurses how to use them and build a system that makes all of that sustainable. One box of expired drugs doesn’t solve our problems. 100 boxes of in-date drugs doesn’t solve them either.
Even in acute disasters, private donations simply aren’t necessary. In a WHO study of 4 post-disaster/conflict countries, it was found ‘in most instances, adequate drug supplies were provided during the acute phase of the disaster through the use of local buffer stocks, as well as by major donor agencies with expertise in providing immediate disaster aid of good quality’.
We’re not being mean, our heads are not stuck in the sand. We DO know what we’re talking about. We don’t want your drugs. If you can’t use them, why would we be able to? It’s like donating broken furniture… If you can’t use it for some reason, then why would anyone else be able to?
Remember – there ARE ways to help. The best, the most obvious, the most universal is money. Yes, it’s boring, there are so many traps… but donate to a major organisation like Red Cross and MSF or a smaller, reputable NGO in the country you’ve visited and the money will go towards helping the people who need it most, in a structured, long-term way.
The people that organise drug donations are the best. They’re kind, they’re going out of their way, they’re passionate about what they’ve seen… so in criticising them, we’re criticising really good people.
The thing is, they’re good people giving us book vouchers. We don’t need them, we’re not going to use them and getting rid of them is really hard when you’re surrounded by pristine rainforest and coral reefs. Book vouchers are thoughtless. Just ask my Mum.