OTC Medications in Ecuador

Today was a rather odd day. Around midnight the water stopped working at our apartment and at 6am there was still no running water, which made bathing, cooking and flushing toilets impossible.
A few hours later we discovered our preceptor has dengue. He will be out of the clinic for the next week. This is his second case of dengue, which apparently increases his chances of having the more serious hemorrhagic type. Dengue is a HUGE issue here. There are multiple patients each day presenting with the non-specific symptoms of dengue - malaise, fever, fatigue, headache and rash. However, the lab test specific for dengue takes six days for results. Thus, the lab test is not performed. Dengue is diagnosed based on a CBC with differential and clinical presentation. Dengue is a very hot topic among the clinic staff and patients at the moment. 

Now for the real purpose of this post - OTC Medications in Ecuador.

Many of the same generic drugs are available in the Ecuadorian pharmacies as American pharmacies. However, there are two major differences: 1. Many drugs are available OTC that are prescription only in the United States, such as antibiotics 2. The person working at the pharmacy is often not a pharmacist and may only have a high school diploma. The second point is a bit scary since patients often present to the pharmacy asking for medication to treat various symptoms. The pharmacy worker is not medically trained and will simply recommend a treatment based on past experiences and limited medical knowledge. Thus, patients often receive inappropriate treatment in the pharmacy. Inappropriate treatment can have various results, including patient harm from adverse effects, no improvement in the symptoms and bacterial resistance caused by inappropriate antimicrobial treatment. Additionally, patients do not receive appropriate education on how to use the medication.

One interesting OTC drug experience we have had in Ecuador occurred over the weekend. The bus system in Ecuador is quite extensive and utilized by the vast majority of the population. It is very common for street vendors to hop on the bus and sell various items - drinks, snacks, home cooked bakery items, CDs, fruit and newspapers. It is also common for "salesmen" to stand at the front of the bus and give a lengthy sales pitch about a product.

One such product was an ointment that came in a small container that looked much like a retainer case. The salesman began by passing out ointment from his personal bag to each passenger on the bus. The salesman stated that the ointment could be used to sooth sore muscles and joints and remove varicose veins when applied topically. He also stated that the ointment could CURE pneumonia and asthma when taken orally - all for only $1. He even presented a specific dose and duration for treatment. According to the FDA, "The FD&C Act defines drugs, in part, by their intended use, as 'articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease' and 'articles (other than food) intended to affect the structure or any function of the body of man or other animals' [FD&C Act, sec. 201(g)(1)]. Thus, by American standards the ointment would indeed be considered a drug based on the presented intended use. The FDA has extensive requirements for drugs in the United States, including clinical trials which must support safety and efficacy, labeling requirements, and very stringent marketing restrictions.

After hearing that the ointment could cure pneumonia, I immediately concluded that the ointment was clearly a sham. However, much to our surprise over half of the passengers on the full bus purchased the ointment! I desperately wanted to tell the other passengers that there was no way the ointment could do all of these things and perhaps the ointment might even be dangerous. I also wanted to engage the salesman in a conversation about the pharmacology of his product, but alas I did not want to cause problems in a foreign country and my Spanish speaking ability would limit my ability to express these thoughts. Frustration.