Polypharmacy and the Epidemic of Unnecessary Care

Medicines play a crucial role in the treatment of illnesses and most, if not all visits to the doctor, end with a prescription. However, doctors are alarmingly prescribing too many medicines and this can be more harmful than helpful to our health.

A recent study by the World Health Organisation showed that doctors in Kenya prescribe more medicines per patient than the recommended international standard.  The study showed that in Kenya, patients are given an average of three different drugs per hospital visit when the World Health Organisation recommends a maximum of two.

According to the report, such prescription of too many drugs leads to the use of many medicines by a patient, a phenomenon called polypharmacy.  The report also warns that polypharmacy is likely to result in increased risk of adverse drug interactions, dispensing errors and decreased patients’ knowledge of the correct doses of medications.

Dear reader, if you have ever gone to hospital for one complaint and walked away with more than two different drugs to treat that complaint, then you are a victim of polypharmacy.

In addition to polypharmacy, we are constantly being subjected to unnecessary and invasive medical tests and procedures that are very costly.  This is what is known as the epidemic of unnecessary care and the main motivation for this epidemic is, of course, money.

When I think about my interaction with polypharmacy and the epidemic of unnecessary care, a very unfortunate incident stands out clearly in my mind.

The month was June and the year was 2017.  My daughter had just turned 9 months old when she suffered her first illness.  Her little body was tormented by high fevers and she was afflicted by constant bouts of diarrhoea coupled with a lack of appetite.  Being a first time mother, I panicked and took her to Lowervalley Clinic for medical intervention.

The team at Lowervalley Clinic is very efficient and that is why it is my preferred choice for such emergencies.  This, together with the fact that it is just a stone’s throw away from my house makes it the most convenient hospital for me.

The standard operating procedure at the Clinic was, and still is, that a sick baby is given first priority over other patients.  We therefore jumped the queue, which was not long anyway, and went in for triage.  Her temperature was thirty-eight degrees Celsius and the nurse rushed her file to the doctor for immediate action to bring down the fever.

The doctor also recommended a stool test to determine the cause of the diarrhoea and a blood test to determine if there was any other infection-causing parasite.  The laboratory results showed that she had a bacterial infection that was causing the loose stool and the high fevers.  The blood test also revealed that her red blood cell count was low.  The doctor referred me to the nutritionist for nutritional therapy to address the low red blood cell count.

After the diagnosis came the prescription.  The doctor prescribed a paracetamol syrup and an antibiotic to deal with the illness.  The doctor also told us to take the baby back to hospital immediately if fevers and diarrhoea persisted and if she became dehydrated.

We saw the nutritionist who advised that the red blood cell count was not so low and could be managed by diet.  She recommended that we introduce red meat daily and add beetroot and green leafy vegetables to her meals.  She also recommended sorghum porridge throughout the day as it is rich in iron.

I took baby back home and administered the drugs according to instructions.  However, that night, her fevers did not ease and in fact, they shot up so high that we feared that she would convulse.  My husband and I rushed her to the next nearest hospital, which is St. Maria Goretti Hospital since the Lowervalley Clinic was closed at night.

At St. Maria Goretti, they took her quickly to the emergency room and gave her an injection to bring down her temperature.  Her temperature gradually came down and then we were referred to the paediatrician.

The paediatrician looked at the test results we gave him from our visit to Lowervalley Clinic.

“The problem is with the drugs that have been prescribed,” he said.  “This strain of bacteria that is irritating her gut requires a slightly stronger antibiotic.”

“So should we stop the one we are currently giving?” my husband asked.

“No,” the doctor said.  “It is recommended that one finishes the dosage of antibiotics given otherwise they become resistant to the drug.  So what I will do is that I will give you an additional antibiotic to enhance the one she is already taking.”

He wrote something down on his prescription notepad.

“Further,” he said.  “The baby needs a combined paracetamol and diclofenac drug do address pain and fever. This kind of bacteria causes stomach cramps that can be quite painful for baby.  I will therefore give you something to address this while at the same time addressing the fever.  You can discontinue the paracetamol originally given as this one will do the job just fine.”

The doctor paused as he wrote something down.

“I hope I am making some sense,” he said look up and smiling at us.

We nodded.

“Alright,” he continued.  “Now, antibiotics unfortunately do not discriminate the good and the bad bacteria and baby needs good bacteria for the good health of her digestive tract.  I will therefore give her a probiotic to add some good bacteria to her gut.  This will counteract the effects of the antibiotics.”

We nodded.

“Probiotics sometimes lead to nausea and vomiting in babies,” he continued.  “This is because the system is suddenly flooded with too many good bacteria.  I will therefore prescribe an anti-nausea drug which she should take together with the probiotic”

“Finally,” he said.  “I recommend a blood booster to address her low red blood cell count.  From the numbers I see here in the laboratory results, her red blood cell count is rather low and diet alone will not work especially because with her age, she eats small quantities of food.  Further she is still taking a lot of breast milk and the calcium in milk is known to inhibit the absorption of iron.”

Wow! This was getting confusing for us.  One says the red blood cell count is not too low and can be addressed by nutritional therapy, another says that it is too low and needs to be boosted by drugs.

We went to the pharmacy with the prescription for five different drugs to address one bacterial infection in baby.  Due to the age of the baby and the number of drugs prescribed, the pharmacist went as far as to sit as down and give us long but clear instructions on when and how to administer the drugs.  I recorded his instructions to avoid mistakes.

We took baby back home and administered the drugs as instructed.  After fifteen minutes of taking the drugs, she started vomiting.  It was the first time I had seen her vomiting and it was distressing.  I cuddled her and tried to breastfeed her so that she could get back some of the fluid she had lost through vomiting but she simply did not want to feed.  The pharmacist had advised that we give her a repeat dosage if she vomited less than half an hour after taking the drugs.  I gave a repeat dosage and she vomited again.  I decided to let her rest and wait for the next dose.

Lunchtime came and it was a repeat of the morning, she vomited immediately after taking the drugs.  I also noticed that she was dehydrated because she did not produce any tears when she cried and she had not wet her diaper since morning.  I took her back to Lowervalley Clinic (with all the drugs in tow) and explained the situation last night and the further prescription of drugs at St. Maria Goretti Hospital.

The doctor said that since she was a general practitioner and not a paediatrician, she would defer to the prescriptions by the paediatrician at St. Maria Goretti.  However, she advised that we take the baby to Lowervalley Main Hospital for an overnight stay where she would be rehydrated intravenously.  She further advised that we seek a second opinion from a paediatrician at the Main Hospital on the need for all the drugs prescribed at Maria Goretti.

We arrived at Lowervalley Main Hospital at about four in the evening and since we had an urgent referral letter, we were seen to immediately.  I noticed that my daughter was now actually more settled and at least had a little appetite for her milk.

The paediatrician on duty logged into the system and accessed the records from the Lowervalley Clinic.  She immediately jumped on one of the test results.

“So your daughter has a low red blood cell count?” she asked.

“Yes,” my husband and I responded in unison.

“For how long has she had this condition?” the doctor asked.

“Her fever and diarrhoea started two days ago,” I responded.

“No the anaemia,” said the doctor.  “How long has she had it?”

“We only found out the other day when she fell sick so I can’t tell how long she has had it,” I responded.

“Does she regularly attend her post-natal clinics?” the doctor asked.

“Yes,” I responded.

“And the doctor did not notice any anaemia?”

“No,” I responded.

“Let me have a look at her clinic book,” said the doctor.

I handed over the clinic book and my husband and I sat silently with baby as the doctor looked through the book and took one or two notes on her notepad.

“Well,” the doctor said, handing back the book.

“Do any of you have any chronic diseases in your families?” the doctor asked.

“What do you mean by chronic diseases?” asked my husband.  “Diabetes? Hypertension or what?”

“I mean like any chronic blood diseases,” the doctor clarified.

“We don’t know what chronic blood diseases are,” I said.  “Could you give examples?”

“Anybody in your respective families with diseases such as sickle cell anaemia?” she asked.

“Not from my family,” I said.

“We also don’t have that condition in our family,” said my husband.

“Are you sure?” asked the doctor.  “They may be having it but you do not know.”

“Where is this interrogation leading to?” asked my husband getting impatient.

“It’s just that babies do not get anaemia out of the blue,” the doctor said.  “The symptoms I see here are pointing me towards suspecting that your daughter may have sickle cell anaemia.  Some symptoms include joint pains and stomach pains that could lead to the fever and diarrhoea she has now.  And then of course, the low red blood cell count.”

My husband and I were speechless.  It is not easy to hear that your child has a chronic illness.  The only thing that kept us from falling apart is that we are both educated human beings and though we are not in any scientific fields, we know that we both have to be carriers of the condition for our daughter to get it.  Neither of us had a history of sickle cell in our families.

I reached out and silently held my husband’s hand, staying him from an angry reaction.  His eye caught mine and I nodded, silently urging him to calm down.

The doctor did not notice this silent exchange between us and continued, “There is a screening test which is only done on Thursdays.  We will have to admit her until then as she awaits the screening.”

It was a Sunday evening.  Admission until Thursday would be costly!

“But isn’t routine screening for sickle cell anaemia done at birth?” I asked, remembering our neonatal paediatrician explaining this to me.  Actually, she had come with a nurse who took a blood sample from my daughter’s foot.

“It is supposed to be so but some hospitals are negligent and do not do it,” explained the doctor.

“But my daughter was born in this very hospital and she comes for her post-natal clinics here,” argued my husband.

“Well, I’ll have to confirm then because I did not see it in her clinic book,” explained the doctor seeming unsure.  “Further, sometimes the symptoms may be missed at the initial screening but present later in the baby’s life.”

We were not convinced.

“So what do we do about her dehydration right now and her diarrhoea and vomiting as we wait for those tests?” I asked worried that we were forgetting why we came here in the first place.

“We cannot carry out any medical interventions before screening and diagnosis,” said the doctor.  “My advice is we admit mother and baby until Thursday as we observe how the symptoms develop until the screening is done.”

“Are you being serious right now!” my husband shouted angrily, shooting out of his chair.  “You can refuse to rehydrate a dehydrated baby because of some disease and test that you have conjured up?”

“Calm down sir,” said the doctor also standing up.  “I know the news I have just given you is difficult to digest but if you don’t calm down I will have to call security.”

I could see my husband getting even angrier and I stepped in quickly.

“Why don’t we then come tomorrow when her regular paediatrician is here,” I said.  “I will call her to make an appointment and she will make an assessment and decide whether or not this screening is necessary.  In the meantime, I demand to see another doctor for an opinion on the rehydration or better yet, we should just go to another hospital.”

“If you think that what I am saying is not credible then you might as well go to another hospital,” said the doctor.

We gathered our things ready to go and on my way out, I called my daughter’s regular paediatrician to book an appointment for the next day.  The paediatrician asked why the paediatrician on duty could not handle a simple matter like dehydration and I had to explain to her our encounter from beginning to end.  She informed me that she was out of town and said that if I felt that my baby needed to be rehydrated then it should be done.  She directed me to P.D. Patel Hospital where our daughter was to be seen by one of her colleagues Dr Nigosi as a matter of urgency.

We drove to P.D. Patel Hospital.  Baby was now asleep but was still dehydrated, as she was not breastfeeding well.  On arrival, we found that Dr Nigosi was occupied with another patient.  However, she had left instructions that the baby’s vitals be checked and blood and stool samples be taken for tests to confirm what she was actually suffering from.

The nurses were very kind when doing the tests.  One of the nurses determined that the baby was very dehydrated and needed to be rehydrated as a matter of urgency as we awaited the test results.  They expertly found a vein and inserted a line and then set up the intravenous drip in the day care room.

After a while Dr. Nigosi came in and introduced herself.  She was a very pleasant old lady and told us stories of how our daughter’s paediatrician had been her intern and the escapades they undertook together.

“Do you have your clinic book?” she asked.

“Yes,” I responded, taking it out of the diaper bag and giving it to her to peruse.

“So tell me the whole story of how baby fell sick and how you find yourself here with me today,” she said flipping through the clinic book.

I narrated to her baby’s symptoms, all the hospital visits and what the various doctors said.  Finally, I produced Exhibit A, which was the huge bag of drugs we had been given.  It was too late for her to hide her shock at the quantity of medicines we had.

“This is not good,” she said.

She took out the medicines one after another.  After reading the labels, she threw each one of them into the trash can.

“This is why I have thrown away you ‘money’ so to speak,” she explained.  “Our retesting of baby shows that whatever bacterial infection she had has now completely cleared from her system as our lab could not find any traces of it.  Comparing with the laboratory results from Lowervalley Clinic, I have no doubt she had a bacterial infection and that it has now cleared.”

“The antibiotics you were given at Lowervalley Clinic were very okay and were to be taken for three days, right?” she asked.

“Correct,” I confirmed.

“Well, the good news is that three days ended today and they have done their work effectively.  The infection has cleared! So you don’t need that bottle anymore.  It is a poisoning hazard for baby.  That is why I have thrown it out,” she said.

“I have thrown out the rest of the medicine because it is unnecessary.  You definitely did not need a stronger antibiotic for a baby of this age.  She has just recently got out of exclusive breastfeeding.  Her immune system is stronger than yours or mine, if you ask me,” she said smiling.

“The paracetamol is not necessary anymore because end of infection means end of fevers.  A fever is just a way of showing you that your body is fighting an infection.”

“You do not need the probiotic given.  I have found many babies to get nauseated when given probiotics.  This makes them vomit and become even more dehydrated.  My suggestion is, give yoghurt as it is a good natural probiotic.  It is true that the antibiotics kill even the good bacteria and a probiotic is important.  If you have not yet introduced yoghurt to baby’s diet, start with plain natural yoghurt.  Baby will get the probiotics she needs from that.”

“As for her red blood cell count, our test shows that they are the same as when she was tested at Lowervalley clinic.  I guess this is because she has been vomiting her medication as you said.  The iron supplement you were given is okay but I would not recommend it at this stage.  You see, for her age, her red blood cell count is not too low.  During the last month of gestation, baby stores as many important nutrients as possible for use during the first few months outside the womb before she is introduced to solid food.  I note from the clinic book that your baby was born preterm.  She therefore did not get the chance to store enough iron to last her until iron rich foods were introduced.”

“Iron deficiency is actually common in most babies after six months,” she explained.  “Only that it resolves itself when baby is introduced to solid foods that are rich in iron.  In fact, if your daughter had not fallen sick and had not taken a blood test, we would never have known of this iron deficiency.  It would have resolved itself as you continue introducing iron rich foods.”

“My advice therefore is to continue with the iron rich diet the nutritionist prescribed.  Also, give infant formula in addition to breastmilk but only if you can afford it.  The reason I am advising you to give infant formula is that it is usually fortified with iron.”

“As for the sickle cell anaemia, all I can say is that her clinic book indicates that the routine neonatal screening was done and she is clear of the condition,” said the doctor smiling.

My husband and I gave a collective sigh of relief.

“Now, the only thing I will prescribe is a zinc supplement.  The World Health Organisation recommends zinc supplementation to reduce the duration and severity of diarrhoea.  I can attest to its effectiveness in doing this.  Further, I will give you some low concentration oral rehydration salts, commonly known as ORS.  Administer these for the next four days.  It will help her regain the fluids and electrolytes that she lost from diarrhoea or vomiting.”

“Thank you doctor,” we chorused.

“Your little girl will be okay,” said the doctor reassuringly.  “However, in case she develops any sudden fevers or the diarrhoea persists, you can take her to see her regular paediatrician.”