Mexico’s Doctors, Druggists in Tug of War

It is an open secret in Mexico that often ill-trained pharmacy clerks illegally diagnose and prescribe medications for millions of Mexicans every year, sometimes without mentioning potentially fatal side effects.

“It is very probable that [pharmacies] are selling 3 or 4 million prescription drugs a day without prescriptions,” said Dr. Luis Zavaleta, president of the Mexican Doctors Assn. “We as a population have to change our culture. The rules exist; however, they are not applied as they should be.”

The pharmacy industry and the national Health Ministry, tacitly acknowledging problems in the medication system, have launched pharmacy training programs and public awareness campaigns in the past year. The government also recently put limits on drugstores that don’t have full-time registered pharmacists.

And Antonio Pascual Feria, president of the National Assn. of Mexican Pharmacies, said the organization last year adopted a code of good practices for selling medicines, including a strict ban on sales of controlled drugs without a prescription.

Yet a Los Angeles Times researcher was able to buy prescription antibiotics and painkillers at 10 different pharmacies in Mexico City without a prescription. Although the drugs included dipyrone and other medications that could have serious side effects, none of the pharmacy clerks mentioned any possible dangers.

“This is incorrect. This sale was illegal,” Pascual said when shown bottles of the medicines. “These pharmacies could face a fine of 90,000 pesos [$9,300].”

“We are trying to get pharmacies to take responsibility,” Pascual added. “We understand that our survival depends on ethical practices, not fraudulent practices.”

In Mexico, the absence of consumer information in drug packaging is intentional. Under Mexican policy, people are meant to use prescription drugs only under a doctor’s direction, not to decide for themselves what to take. Information is limited to prevent inappropriate self-medication.

“We are absolutely against self-medication,” said Dr. Luis Fernando Hernandez Lezama, chief advisor on regulatory issues in the Ministry of Health.

Yet Dr. Raul Enrique Ojeda Silva, a medical forensic specialist, calls it “one of the most serious problems we have.”

“In Mexico, medicines are available that are contraindicated or not allowed in other countries,” Ojeda said.

He cited the antibiotic chloramphenicol, which is frequently found in raids on back-room clinics in Southern California. It has not been used by pediatricians in Mexico since 1975 because of potentially harmful side effects, but is often sold by pharmacies.

“They say, ‘You have diarrhea and fever? Take chloramphenicol.’ And it doesn’t matter if the patient is a child or an elderly person; what interests them is to sell the product,” Ojeda said.

Ojeda works with the Foundation for the Improvement of Health Services, tracking complaints of improper care and negligence. The association is unprecedented in a country where malpractice suits are rare and doctors are treated reverently.

The foundation was created in 1995 by Luz del Carmen Giese, after her 6-year-old niece was admitted to a hospital for sinusitis and vomiting, and died within days. Giese suspected negligence and hunted for similar cases. The foundation has received 2,000 complaints, she said.

In many Third World countries in Latin America and Africa where private health care is too expensive for most people, it is common for pharmacists to guide patients in choosing treatments for lesser ailments. Indeed, in the United States, pharmacists also guide patients in the use of over-the-counter drugs.

Mexico also wants to increase the availability of drugs for minor ailments, the Health Ministry’s Hernandez said, while increasing control over prescription drugs. To this end, Mexico has shifted a number of previously prescription-only drugs to the over-the-counter category in recent years.

“Our principal competitor is the pharmacist,” said Zavaleta of the doctors association. “He is the medical consultant, he is the one prescribing.”

Maximiliano Leonardo Asturias, director of the major Farmacias del Ahorro chain, said that throughout his 50 years in the business, selling many medicines without prescription “has always been the custom, and the custom becomes the law.”

He said he bars his staff from recommending specific medications. “This has not constituted a health problem because it is the experience of many years, and it helps the sick save money.”

Mexico’s 20,000 pharmacies, many of them tiny street-front shops, are undergoing traumatic changes as chains expand and push corner pharmacies out of business. By 2004, Pascual estimated, there will be just 7,000 pharmacies.

The pharmacy association opposes the Health Ministry’s plan to require all first-class pharmacies--those that can sell the most-restricted drugs--to have a licensed pharmacist on duty at all times. Pascual said the association instead supports intensive training to upgrade employees’ knowledge and commitment to sell controlled drugs only with prescriptions.

He acknowledged that “professional pharmacists, in nearly all Latin American countries, have very little presence. It is a mere formality.”

The association argues it would be impossible to put the country’s 40,000 pharmacy employees through university pharmacy degree programs, and therefore training existing staff is more feasible.

“We believe our work is to train pharmacists to treat simple illnesses, but when in presence of a serious illness to channel that person to a doctor,” he said.

But medical association chief Zavaleta said physicians and pharmacists traditionally have failed to establish working links for issues such as side-effects reporting and prescription problems.

“We have to open channels between the pharmacies and the doctors in Mexico,” he said. “Without having this information, they don’t understand the damage they could cause at any given moment. There’s a saying here: He who knows nothing fears nothing.”

Times Mexico City bureau researcher Greg Brosnan contributed to this story.