Indonesian doctor sends her message via radio and TV

When Sasha Jusuf's six-month-old baby developed a fever she took her to the emergency department. "Zea had a temperature of 40[degrees]C, and was coughing," Sasha remembers. A doctor at the hospital in Jakarta diagnosed a common cold and prescribed paracetamol and a cough syrup. But, seeing little improvement in Zea's condition, 27-year-old Sasha went to a paediatrician the following day. He took a quick look at the baby, "diagnosed" throat inflammation--needless to say, not a disease but a symptom--and prescribed amoxycillin. After two days on the antibiotic, Zea became extremely lethargic. Alarmed, Sasha returned to the emergency department in the middle of the night where the doctor she had seen on the first visit now discovered hives behind Zea's ears. This time he diagnosed measles and scribbled out a list of powerful medications that included an antibiotic, an antihistamine, an anti-asthma drug and, to top it all off, an anticonvulsant. These were to be ground up into a powder by a pharmacist and given to the baby in fifteen "paediatric" packets. Such concoctions, known as puyers--derived from "powder" in Dutch--are a typical response to commonplace paediatric ailments in Indonesia. According to studies carried out in the Indonesian provinces of Bali in 2000 and West Sumatra in 2006, puyers contain on average around four active ingredients, while a national study carried out by the Indonesian Ministry of Health in 1997 reported an average number of medications per prescription of 3.49. But the reality may be even more alarming according to a preliminary study of prescribing patterns for common paediatric ailments carried out in 2006-2007 by paediatrician Purnamawati S Pujiarto, founder of a nongovernmental organization (NGO) Yayasan Orang Tua Peduli, in collaboration with her colleague Dr Arifianto. This limited study, based on e-mail testimony from mothers aged between 26 and 30 years, found that in every case the women's children had been prescribed mixtures of up to 11 medications for ailments that were both mild and self limiting. The most commonly prescribed drugs were antibiotics. According to Purnamawati, more than 50% of the medicines consumed in Indonesia are prescribed, dispensed, or sold irrationally, often as a result of the grinding and compounding that is a key aspect of puyer production. "Medicines are prescribed for children when they are not needed, when they are inappropriate, when they are ineffective and when they are unsafe," she says. The practice also leads to overuse of antibiotics and steroids, which can lead to drug resistance. Meanwhile, effective and affordable medicines that are available, including many generic medicines, are underused or not used correctly. [ILLUSTRATION OMITTED] For Dr Sri Suryawati, a leading proponent of rational drug use in Indonesia, where she runs the International Network for Rational Use of Drugs (INRUD), polypharmacy--the prescription of many drugs at one time--is one of the biggest risks associated with the use of puyers, notably where there are adverse drug-to-drug interactions. Meanwhile, where side-effects occur, the fact that the drugs have been taken together makes it difficult to pinpoint which medicine is causing the problem. Other concerns include the likelihood of human error in mixing, contamination and lack of information for the consumer. "Puyer packets have no information on them," says Suryawati, pointing out that this means that puyers are not in compliance with a 1992 law on complete and accurate labelling. Children are put at particular risk when the doctor grinds adult solid dosages to a powder, which is then divided into assumed paediatric doses. This was one of many problems underlined by a meeting in March in Geneva of the World Health Organization's Expert Committee on the Selection and Use of Essential Medicines. …