See. Sci. Med. Vol. 28, No. 9, pp. 905-915. 1989 0277-9536189 53.00 + 0.

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Printed in Great Britain. All rights reserved Copyright 0 1989Pergamon Press plc

IN THE SHADOW OF BIOMEDICINE:

SELF MEDICATION IN TWO ECUADORIAN PHARMACIES
LAURIE J. PRICE
Department of Anthropology, Alumni Building, Campus Box 3115, University of North Carolina at
Chapel Hill, Chapel Hill, NC 27599, U.S.A.

Abstract-In Ecuador, as in most Third World nations, thousands of different prescription-only

pharmaceuticals can be bought without a doctor’s prescription. But how often does self medication
actually occur? This study documents 619 prescription drug sales in two Ecuadorian pharmacies. In 51%
of these sales, customers in fact present no prescription. Many of the drugs sold this way have serious
side effects and must be used with care. Ecuadorian law greatly restricts information on drug packaging
about side effects, indications, contraindications, schedule and dosage. Although the pharmacies differ
with respect to self medication rates, drug choices, and clerk-customer interactions, both show the
existence of a ‘shadow system of biomedicine’ in which prescription drugs are used without physician
consultation. In view of the dominant role that transnational corporations play in Third World
pharmaceuticals usage, this analysis incorporates a political economic perspective.

Key w&s-pharmacy, political economy of health, self medication, Ecuador

INTRODUCITON billion dollars in 1983 (171. The Pharmaceutical

Biomedical technology, practitioners, and beliefs
have radiated around the globe during the past half
century. In surveying this spread, more than a few
observers have raised concerns about the negative
effects biomedicine may have on health, whatever its
benefits. While Illich describes an iatrogenesis that
results from increasing dependency on physicians (I],
Ferguson notes that in the Third World, the growing
dependency centers more on pharmaceutical drugs
than on clinical practitioners:
“In this fThird World] context the Western style health care
delivery system has undergone a process of disarticulation
and uneven penetration. Products are frequently available in
the absence of physicians or other Western trained prac-
titioners” [2].
Ferguson calls this growing dependency on phatma-
ceuticals commerciogenesis, to highlight the role of
commercial enterprises in the problem of inap-
propriate pharmaceutical use. The present study
furthers our understanding of commerciogenesis
through observation of 619 prescription drug sales
transactions at two urban pharmacies in Ecuador. To
what extent do urban Ecuadorians rely on a ‘shadow
system of biomedicine’ to guide their use of ethical
(prescription-only) drugs, rather than on physicians
[3]? Although it is exploratory in scope, this study
provides much-needed quantitative data concerning
the apparently very high rates of self medication in
Third World countries [4-g].
Why do people engage in self medication with
ethical drugs? They do so for a variety of economic,
social, and cultural reasons (2,4-14,221. But to be
compelling, the study of health practices such as self
medication must be located within a political eco-
nomic framework [15, 161. Developed nations pro-
duced 95% of total world exports of pharmaceutical
products in 1980 [4, p. 31. The United States is the
world’s largest exporter of pharmaceutical products,
with total annual exports valued at more than 10
Manufacturers Association states; “Relative to its
size, no other &l.S.] manufacturing industry is as
active in foreign trade and investment as the U.S.
pharmaceutical industry” [17, pp. 4-81. European
pharmaceutical brands are also sold widely in foreign
markets.
Two distinctly different ways to view commer-
ciogenesis are suggested by modernization theory and
political economic analysis. Modernization theory
argues that knowledge of modem drugs and their
correct usage eventually will disseminate out from
industrialized nations to Third World cities, and from
cities to rural areas [18]. Applied to self medication,
modernization theories predict that when di’ssem-
ination of information is complete and when people
are fully ‘modem’, they will use pharmaceuticals
appropriately and will enjoy maximum benefit and
minimum risk from medications. A modified mod-
ernization position is put forward by Taylor [19]. He
argues that safe drug utilization can be achieved
through provision of universal access to primary
health care, and improvement of pharmaceuticals
transport and purchasing systems in Third World
nations.
In contrast, political economic analysis questions
the extent to which modernization and education can
deliver the benefits that citizens of industrialized
nations enjoy, including more appropriate use of
pharmaceutical drugs. Education acts as a powerful
change agent at times, and there certainly is a great
need for consumer education about pharmaceuticals
in the Third World. But education is not all-powerful;
there also exist potent, and counterveiling, socio-
economic factors which buttress the misuse of
modem medicines [20-23).
From the perspective of dependency theory, Third
World nations are seen as subjugated politically and
economically to the countries and corporations that
act as their bankers [24]. A broader political eco-
nomic analysis views these outside entities as acting
906 LAURIE J. PRICE
in concert with the social and business elites of each
nation [15], whose vested interests tend to be inter-
national and commercial rather than national. The
combination of corporate and elite interests often
produces decisions that give low priority to public
welfare. The pharmaceutical trade is highly concen-
trated, since the leading 100 corporations generate
90% of world drug production [23,24J. Corporate
stakes are great with pharmaceutical commerce in the
Third World for two reasons: profit and expansion.
Companies enjoy higher profit rates in the Third
World than at home. The average profit from phar-
maceutical sales (subtracting research expenses) is
IO-15% in the United States; average profit from
foreign sales is considerably higher, at least 20%
[21; 22, p. 481. Most of the exports consist not of
medicines in finished form, but rather bulk pharma-
ceutical products. These bulk products are processed
into final form, packaged, and marketed by sub-
sidiary companies. Though physically located in
foreign nations, most subsidiary companies are
controlled by transnational corporations based in the
dev-loped world [4, 17,20,21]. Profits often are re-
turned to the base country in the guise of transfer
pricing hikes in which subsidiaries are forced to pay
extremely inflated prices for the intermediate chem-
icals being transferred. Third World nations have
had difficulty in monitoring and eliminating
this practice, although a number of different
solutions have been tried. Attempts to reduce transfer
pricing abuses include multilateral tax agreements,
anticartel laws, monitoring the prices of drugs
with large sales volume, and centralized government
procurement of high-volume essential drugs
[4, pp. 16-20; 22, p. 48; 251.
Presently, about 20% of U.S. pharmaceutical ex-
ports go to Third World areas [17, p. 4.4). However,
transnational corporations look forward to a
profitable expansion of Third World pharmaceutical
production and markets during the coming decades,
both in volume and in proportion of total sales
[4, 17,21 J. They argue that expansion is needed since
the Third World currently contains 63% of the
earth’s population, but consumes only 14% of global
drug production [4, p. 21. During the 197Os, drug sales
in the Third World grew by 20% annually [21, p. 91.
Pharmaceutical firms project that during the next 20
years, sales in Third World nations will expand
tenfold, while consumption in developed countries
will only double or treble (4, p. 31.
Because of these high stakes, it is logical that Third
World governments are under great pressure to allow
pharmaceutical companies to proceed with marketing
in a way that maximizes corporate sales volume and
profit, even if this compromises public health. Mod-
ern medications are needed, but also pose a health
risk given inadequate access to physicians and little or
no consumer education. During the height of medica-
tions misuse in the United States (the 196Os), almost
a third of all hospital admissions were due to adverse
drug reactions [26]. As recently as 1984, the chief of
the U.S. Food and Drug Administration argued
before Congress that Third World countries have to
take responsibility for setting up their own pharma-
ceutical acceptability standards, and therefore, that
pharmaceutical companies should be allowed to ex-
port drugs which have been banned in the United
States [27]. However, the problem of safety in using
pharmaceuticals cannot be assigned to Ecuador and
other Third World countries to solve on their own.
The problem is a matter for global concern, and any
complete solution must be an international one.
During the past decade, the Third World pharma-
ceuticals policies of governments and corporations
have been in a state of flux [4]. Thus, some aspects of
ethical drug production and distribution have altered
since 1980-82, when the data were collected for this
study. For instance, efforts have increased in Ecuador
and many other nations to develop a special prod-
uction system for a small number of low-cost essen-
tial drugs [4,25,28]. Other actions have been taken to
slow or stop Third World marketing of specific drugs
that are banned in the developed world [4, p. 32; 291.
Essential drug programs and the banning of specific
medications are important public health measures
and should be continued. However, self medication
with ethical drugs constitutes a largely separate prob-
lem. And, there are no indications that self medica-
tion practices or consumer information levels have
improved significantly in Latin America during the
past decade [4-9,221. Drug-induced commer-
ciogenesis will likely persist so long as uninformed
self medication is widespread.
DIMENSIONS OF THE PROBLEJI
From a utopian standpoint, prevention of illness
should have top priority. All treatments for illness
should be affordable, effective, physically safe, and
culturally appropriate. From this standpoint, the flow
of pharmaceuticals to Third World residents is seri-
ously flawed. The flaws are of four general types:
economic cost, drug type and quality, drug appropri-
ateness, and correct usage. The data reported here are
most relevant to the last two issues, drug appropri-
ateness and correct usage. As background, I will
briefly discuss the first two factors of cost and quality,
particularly in relation to Ecuador.
COST OF PHARMACEUTICALS
In developed nations, only about 7-10% of the
health care budget is spent for pharmaceuticals
[17, p. 1.1J. But medications account for a much
larger proportions of expenses in Third World
settings-it has been estimated as much as 3MO% of
the health care budget [21, p. 55; 23, p. 10; 301.
Among lower income families in these nations, the
proportion of resources spent on pharmaceuticals is
even higher. For instance, lower income households
in Ecuador may spend as much as 75% of their health
care dollar for modern drugs [3lJ. Unfortunately,
many drug expenditures in Third World nations
appear to be for treatments of questionable use-
fulness. For example, Silverman et al. report that a
third of the drug bill in Nigeria goes toward “vitamin
combinations, appetite stimulants, and other really
unneeded medicines” [23, p. 1211. A recent United
Nations report shows that vitamins and tonics consti-
tute the largest percentage of pharmaceutical
expenditures in Mexico and Malaysia, followed by
 In the shadow of biomedicine
antibiotics, analgesics, and antitussives. The authors
state:
“The lack of concurrence between the drugs marketed in
these countries and their health needs is probably due to the
high level of self medication with non-specific drugs, and the
resulting high profitability of this category, as well as the
lack of effective demand from the large numbers of people
suffering from tropical diseases” [4, p. 301.
During the past decade, a national pharmaceutical
industry has been developed in Ecuador, but medical
drugs cost considerably more now than they did 10
years ago. This is partly explained by the fact that
national pharmaceutical companies in the Third
World are owned and controlled largely by foreign
capital; for instance transnational corporations hold
78% of the pharmaceuticals trade in Brazil, and 88%
in Colombia [4, p. 91. In Ecuador, a controlling
interest in the largest national firm (LIFE) is held by
U.S.-based Dow Chemical Company. Even though
pharmaceutical firms are limited by Ecuadorian law
to a 30% profit level, some analysts claim that profits
exceed that level [32].
In the 1970s approximately three-quarters of all
primary products for pharmaceutical production
were imported rather than produced locally by the 29
manufacturers operating in Ecuador [33]. In 1980,
about 5 years after a national industry was begun in
Ecuador, the legislature revoked tarrifs on pharma-
ceutical products. Since the pharmacy industry in
Third World countries is primarily a bottling and
pill-making enterprise, this elimination of tarrifs
placed transnational firms in an even better financial
position than before. They could now bring all the
primary ingredients into Ecuador without paying
high import taxes on those ingredients.
Another factor which contributes to excessive cost
of pharmaceuticals is the lack of consumer and even
physician education about drug equivalencies. The
same ingredients often sell at vastly different prices
under different names. For example, the widely used
drug ampicillin varies in price by more than 200% in
the same drugstore. Customers frequently respond to
the high cost of drugs by purchasing fewer pills, or
by purchasing them sporadically. Pharmacy custom-
ers often buy only two or three capsules of an
antibiotic which requires at least 12-20 capsules for
an adequate course of treatment. In addition to the
potential harm to the individual who takes drugs in
this manner, the practice has serious ecological
effects. When people take insufficient doses of an
antibiotic, this selects for strains of the bacteria that
are resistant to that medication. Thus, over time, that
drug becomes a much less effective treatment for
everyone [4, p. 34; 21, p. SO].
DRUG TYPE AND QUALITY
Ecuador and most Third World nations have
difficulty in maintaining truly effective agencies to
monitor pharmaceutical safety. In Ecuador, the
bureau charged with this task has only about 20
people to look after the safety and appropriateness of
newly-introduced products, in addition to the more
than 4000 different drugs already registered (321.
Even if the financial resources existed to enact a
reasonably staffed pharmaceuticals safety program,
907
there are many reasons why government bodies
might minimize this effort. A multitude of other
serious public health problems compete for attention.
Many government officials, like Ecuadorians in gen-
eral, endorse self medication and discount the risks of
modem medications. A sophisticated scientific infra-
structure is necessary to do adequate drug testing and
population-based research on the ill effects of self
medication. Finally, corporations and some sectors
of government downplay this problem in order to
promote permissive marketing policies.
Other aspects of the drug safety issue include the
problem of counterfeited drugs and environmental
threats to drug quality. Counterfeit drugs are so
common that national newspapers publish full-page
advertisements warning the public to beware of them.
The quality of counterfeit products ranges from
simply inferior to toxic. Environmental threats to
pharmaceutical quality include exposure to sensitive
medications to the deleterious effects of sunlight and
heat (particularly problematic in rural distribution
networks), and the marketing and use of drugs past
their expiration dates.
DRUG APPROPRIATENESS. CORRECT USE,
AND HEALTH RISKS
There are serious health risks associated with many
of the prescription drugs that are sold so casually in
Third World countries. Many drugs that have been
banned or severely restricted for use in developed
nations have been available or still are available in
these countries. Drugs such as dipyrone and cli-
oquinol, which were very popular in Ecuador at the
time of this study, are associated with severe and
sometimes fatal side effects [4, 21, p. 41; 231. Clio-
quinol recently has been taken off the world market
voluntarily by drug companies [4]; however dipyrone
continues to be popular [28,29). For the widely-used
fixed-combination antibiotics, there seem to be no
reasonable clinical indications, while the drugs chlo-
ramphenicol, phenacetin, and clofibrate are overused
and misused (4, p. 311. To attain even a modicum of
safety, most of these drugs require periodic blood
counts or other lab tests to monitor for development
of life-threatening disorders. These disorders can
occur with extended use or with very limited use;
symptoms can appear during administration of the
drug, or not until months afterward. As just one
instance, it is estimated that chloramphenicol causes
fatal aplastic anemia in one person out of 24,000 (341.
However, that rate characterizes a situation in which
people consume the drug with adequate biomedical
advice and laboratory monitoring. How much higher
might the rate be among individuals who take the
medication without knowing the correct dose, with-
out understanding the contraindications (such as
pregnancy, lactation, impaired liver function, concur-
rent administration of other drugs), without recog-
nizing symptoms of an adverse reaction, and without
having blood studies done every 2 days as advised?
CULTURAL CONTEXT OF SELF MEDICATION
WITH PRESCRIPTION DRUGS
Ecuador is a highly economically stratified society,
in which the majority of the population have very low
908 LAURIEJ.
income and very high morbidity rates. The same
economic and health profile applies to most other
Third World populations. Contaminated water sup-
plies and other environmental deficits cause much of
the illness, in urban as well as rural areas. Working
class residents of Quito are frequent consumers of
health care, although they often cannot afford to
consult higher-priced practitioners such as phvsi-
cians. For most illness episodes, access to bio-
medicine comes in the form of access to biomedical
drugs, and sometimes access to a pharmacist.
Although most physicians and government officials
use the term ‘self medication’ (au~omedicacion) to
refer to use of prescription drugs without physician
consultation, it has been widely documented that
such self medication in Latin America is typically a
very social process, and involves any number of
relatives, friends, and nonphysician health specialists
[2,5-9, 31, 35,361. Physicians and health officials in
Ecuador recognize that self medication is very com-
mon; they typically regard it as an irritating but
unavoidable problem. Compounding the problem of
uninformed drug use, Ecuadorian law mandates that
prescription drugs are to be packaged with no or very
restricted information about side effects, dose, indi-
cations and contraindications. Physicians were
among those who lobbied to limit customer access
to such information, arguing that more complete
labeling encourages self medication [37].
In Ecuador, pharmaceuticals are sold in notion
stores, in food shops, and in street markets and
stands, although the greatest volume of sales is in
pharmacy settings. Ferguson showed in El Salvador
[2], that commercial pharmaceutical practitioners are
the primary source of health care outside the home
for people in the economically lower half of the
population. Community-based fieldwork in Ecuador
reveals that the pharmacist is usually discussed by
Ecuadorians as though he were in fact a physician;
even drugstore clerks may be thought of in this way
[31]. Although the biomedical world considers the
pharmacist’s training inadequate to carry out physi-
cian responsibilities, it appears that many Ec-
uadorians operate with a different cognitive model of
professional credentials than that held by profession-
als themselves. Thus, the type of ‘self medication’
which is based on consultation with pharmacy per-
sonnel may not be intended as such. Included among
the findings reported below is a description of inter-
actions I observed between pharmacy clerks and
customers.
In Quito, as in El Salvador, nonbiomedical healers
of various types have incorporated ethical drugs into
their recommended treatments. Folk ‘prescriptions’
have evolved which also incorporate these drugs. For
example, in the barrio where my community
fieldwork took place, a common folk formula for
treating children’s diarrhea consists of one capsule of
terramycina and herbal tea. Terramycina is an anti-
biotic in the tetracycline family, which is con-
traindicated for children under 8 years of age [34].
The barrio does not have a drugstore, but ter-
ramycina capsules are sold at the local notions store.
While all settings in which pharmaceuticals trans-
actions occur deserve study [9], the pharmacy is the
primary setting for such distribution. The aim of this
PRICE
paper is to illuminate ethical drug use from the angle
of the pharmacy as an institution with its own
ecology and its own modes of interaction with the
health care consumer.
DATA COLLECTION IN TWO PHARMACIES
Although many social scientists, tourists, and pub-
lic health officials have commented that in the Third
World, “you can walk into any drugstore and get
almost anything you want”, the purpose of this study
was to measure the actual extent of self medication.
In addition to its quantitative contribution, the re-
search extends our understanding of self medication
by focusing specifically on pharmacies in an urban
setting. The urban pharmacy does a high volume of
business and can be a relatively anonymous situation
for customers, compared with the more widely stud-
ied village pharmacy. Finally, this analysis examines
differences in pharmacy ecology and raises the possi-
bility that such differences may be associated with
varying levels of commerciogenesis.
The two pharmacies in which this study took place
serve very different populations of people. One is
located in the wealthiest sector of Quito, and will be
referred to here as North Pharmacy. The other sits
downtown in the centro, where historically preserved
buildings belie the marked poverty within. This sec-
ond research site will be called Center Pharmacy. The
first enterprise is family-owned and run; the second is
part of a large chain of pharmacies. North Pharmacy
has only a few employees and turnover is very low;
much of the clerking is done by family members.
Center Pharmacy employs between 4 and 8 clerks at
a time to keep up with the higher customer volume.
To begin the research, I approached drugstores at
random and explained that I was a student in anthro-
pology and public health, and that I wanted to
observe what kinds of drugs were sold to whom, and
in what quantities. North Pharmacy was the second
store I visited in this way, and its owner agreed to let
me carry out a period of observation. Since Center
Pharmacy is part of a chain, the entry problems were
somewhat more complicated. However, I had con-
tacted some Americans working in the health field in
Quito who were enthusiastic about this project. They
had connections with one of the owners of the Center
drugstore chain, who gave his permission for the
study.
With drugstore clerks, I had excellent re-
lationships, particularly considering that I frequently
needed their help to record the amount and names of
the drugs sold. Communication was much more
relaxed in North Pharmacy, partly because the vol-
ume of sales was much lower. In Center Pharmacy,
there were many more clerks and they tended to be
much busier. Thus it was difficult to achieve good
rapport with all the clerks in this chain drugstore.
Although I explained that I was there to carry out a
study of the drugs people buy in Ecuador, I think
many clerks assumed that I also was a pharmacy
student, or a clerk-in-training. Perhaps they got the
clearest notion of my aims when I conducted semi-
structured interviews with them midway through the
observation period. Only one or two of the 15 people
I interacted with in these settings seemed at all
 In the shadow of biomedicine 909

suspicious of my motives or intent. Self medication is
so much a part of the cultural fabric that Ecuadorians
do not regard it as a practice to conceal.
In both pharmacies, ethical and over-the-counter
medications are stored on open shelves behind the
sales counter. The inventories of drugs, numbering in
the thousands, are organized by alphabetical and/or
brand criteria. Separate sections contain drugs with
expiration dates, those needing refrigeration, and
the very frequently requested analgesics, including
dipyrone. This high volume section also contains
the most common antidiarrheal agents (such as
clioquinol, at the time of the study). There are no
spatial or other organizational markers to separate
ethical from over-the-counter medications. However,
ethical drugs are easily distinguishable because pack-
aging always includes the standard phrase, ‘only with
a physician’s prescription’ (solo por recetu media).
FINDINGS
My data collection in North and Center Pharma-
cies was carried out in 21 separate observation peri-
ods, for a total of 34 hr. In order to correct for
possible bias from temporal patterns in self medica-
tion, I observed equal numbers of hours in the first
and second halves of the shop day; observation
periods also were carried out on different days of the
week. During these periods, I recorded more than a
hundred types of ‘prescription only’ drugs being sold
without the customer presenting any evidence of a
physician’s prescription. The majority of the medica-
tions fell into a few categories; analgesics/narcotics,
vitamins, antitussives, antibiotics, antidepressants,
nonsteroidal anti-inflamatories. Figure 1 shows some
of the sales transactions that were recorded during a
typical 2-hr observation period at Center Pharmacy.
Each of the drugs on the list was sold without a
prescription. Table 1 presents rates of prescription
drug sales for the entire observation time of the study.
Remarkably, 51% of the customers who bought
prescription medications did so without showing any
kind of a prescription. Such transactions are assumed
to involve the use of prescription drugs without
biomedical supervision, and thereafter will be called
‘no-dot’ sales. After a few comments on these general
findings, the figures will be further broken down into
specific types of medication.
Like all unobtrusive measures, these observations
of pharmaceutical sales have some limitations. From
time to time, customers give clerks ragged scraps of
paper bearing the names of prescription drugs they
want to buy. While these written requests are usually
scraps of notebook paper or paper bags, they never-
theless present a concern in calculating rates of
no-doctor sales. To be on the safe side, these ambig-
uous transactions are counted separately, and are
reported in the category called ‘Transactions Uncer-
tain’. Also included there are sales of any medications
whose status as a prescription-required drug is in
question. Very likely, many or most of the trans-
actions in this uncertain category actually belong in
the no-dot column of the table. Their inclusion with
other no-dot sales would expand the no-dot per-
centage to 66% of all sales. Along the same lines, the
possibility should be considered that some of the
verbal requests for particular medications originated
with physician exam and recommendation. However,

Antibiotics
Acromaxiclina, 4 capsules (tetracycline)
Ambrasinto, 3 capsules (tetracycline and chloramphenicol combination)
Ambrasinto, 4 capsules (tetracycline and chloramphenicol combination)
Ampibex (ampicillin)
Chloromycetin, 2 capsules (Chlorampenicol)
Mexaformo (clioquinol)
Pantomicina (erythromycin)
Tetrabroncol, 2 capsules (tetracycline and dipyrone combination)
Urobiotico, 3 capsules (tetracycline and sulfa combination)
Uropol, 3 capsules (tetracycline and sulfa combination)

Analgesics/Narcotics
Baralgina (dipyrone)
Beserona (dipyrone)
Cheracol (chlorpheniramine)
Novalgina (dipyrone)
Sistalgina (dipyrone)
Tonopan (butalbital-barbiturate)

Nonsteroidal Anti-Mamatories
Dolo-tanderil, 3 pills (oxyphenbutarone)
Tanderil (oxyphenbutazone)

Other
Antabus (antialcohol)
Bonadoxina (meclizin-otion drug)
Pancreatina (pancreatin)
Plasil (metoclopramide)
Scherisolona (hydrocortisone)

Fig. 1. Partial Listing, prescription drugs sold without prescription Center Pharmacy, 26 June, 1980,
1I a.m. to 11 p.m.
910 LAURIE J. PRICE

Table I. Sales transactions in two pharmacies showing % ‘pre- Table 2. Drug-specific rates for chloramphenicol no-dot sales at
scription only’ drugs sold without prescription (total for 34 hr of North and Center Pharmacies
observation)
Observed no-dot sales of chloramphenicol
Bought with Bought with no Transactions
prescriprion prescription uncertain Total
Volume-
adjusted
North IO1 163 Real rate rate
Pharmacy (2:;) (62%) (&,
North Pharmacy O.l/hr 0.4/hr
Center 174 217 456 (2 sales in 21.5 hr)
Pharmacy (38%) (48%) (I$
Center Pharmacv O.S/hr O.S/hr
Total 208 318 619 (IO sales in 12.Shr)
(34%) (51%) (&,
Rate at lower-volume drugstore is multiplied by 4.5 to adjust for an
overall rate of prescription drug sales at Center Pharmacy with
is 4.5 times greater than the overall rate at North Pharmacy.
Drugs containing chloromphenicol: Acromaxicela, Ambrasinro,
the nature of the sales transactions make this seem Chloromycetina, Cloranfenicol, Quemicetina, Sintomicetina. h-
improbable in the majority of these cases. Customers dicorions: Rare, except for typhoid or Rocky Mountain Spotted
typically buy drugs in small quantities, e.g. three Fever. Side e&?crs: Serious, even fatal blood damage may occur
after short-term or long-teqn therapy. The Grey Syndrome
capsules of ampicillin, two tranquilizers. At the least,
brings vomiting, abdominal distension, falling body tern-
it appears that customers are exercising self medica- perature, irregular breathing, ashen color and shock; primarily
tion regarding the amount of medicine they buy in occurs in newborn. Physicians Desk Reference says: “[Chlo-
such transactions, if not in regard to the type of ramphenicol] must not be used in the treatment of trivial
infections or where it is not indicated, as in colds, influenza,
medicine [38].
infections of the throat, or as a prophylactic agent to prevent
According to the data in Table 1, Center and bacterial infections.” With aplastic anemia, death rate may be
North Pharmacies have distinctly different rates of 40% or more. Frequent blood counts are advised during admin-
no-dot sales. North Pharmacy has the higher rate. istration. up to every 48hr [23, pp. l4-151. Manuficrurers:
Lepetit/Dow. McKesson, Parke-Davis.
The rates were compared, omitting all the Trans-
actions Uncertain cases. The difference proved to be
significant at the P -c0.005level, employing the At Center Pharmacy, the downtown high-volume
chi-square test of significance. The higher rate of store, chloramphenicol and tetracycline are sold with-
no-doe sales at North Pharmacy suggests that pov- out prescription at about 10 times the crude rate at
erty is not the only cause of self medication. North North Pharmacy. Correcting for the higher volume of
Pharmacy has primarily a middle to upper-class prescription drug sales at Center Pharmacy, we still
clientele, judged from customer appearance and lan- see a difference in the rate at which the downtown
guage, and from the store’s location in a wealthy customers are self medicating with these two anti-
neighborhood. But this is the pharmacy with the biotics. Much of the difference can be traced to sales
higher rate of self medication. of one drug in particular, Ambrasinto (manufactured
Included among the 319 no-dot sales transactions by Lepitit/Dow). This drug contains both tetracycline
are a number of pharmaceuticals that put people at and chloramphenicol, a combination which is of
risk of serious adverse reactions, even death. The data dubious therapeutic value, and which multiplies the
analyzed in detail here concern five specific medica- separate dangers of each of these ingredients.
tions; three kinds of antibiotics which demand great Kanamycin, manufactured by Bristol and McKes-
care and close monitoring to minimize risk (chlo- son, can often lead to auditory nerve damage. The
ramphenicol, tetracycline, and kanamycine); clio- Physicians Desk Reference recommends close super-
quinol, a drug which was prohibited in most of the vision of patients, and discontinuation of the drug if
developed world at the time of this study and which signs of damage occur [34]. Whereas Center Phar-
has now been taken off the market worldwide; and, macy sold none of this drug to people without
dipyrone, an analgesic which is banned in most of the prescriptions during the 13 hr of observation, North
developed world but still distributed elsewhere. These
substances are sold under a large number of different
names, which complicates the picture for pharmacy Table 3. Drug-specific rates for tetracycline no-dot sales at North
and Center Pharmacies
clerks, drug consumers, and anyone who wants to
study pharmaceutical use. Observed no-dot sales of tetracycline

Antibiotics are a much-needed medication in the Volume-

Third World and can have positive impact on mor- adjusted
Real rate rate
tality rates. But some are safer than others. Chlo-
ramphenicol, tetracycline, and kanamicin are three North Pharmacy O.OS/hr 0.2/hr
(I sale in 21.5 hr)
that call for caution and restraint in use [4,21,23,34].
These drugs are never to be employed if ampicillin Center Pharmacy I .b/br I .6/hr
(20 sales in 12.5 hr)
will effect a cure. In addition to comparing pharma-
cies with regard to overall no-dot sales, data from Rate at lower-volume drugstore is multiplied by 4.5 10 adjust for an
overall rate of prescription drug sales at Center Pharmacy which
this study can be used to look at differences in no-dot
is 4.5 times greater than the overall rate a( North Pharmacy.
sales rates of particular drugs. This gives us a way to Drugs conraining lerracycline: Acromicida, Acromaxiclina, De-
quantitatively assess pharmacy ecology and self med- mebronc. Meflacilina, Reverin, Tetrecu, Tetrex, Tetranax. Tet-
ication preferences in different regions. As can be raciclina, Urocyclar. Uropol. Side effecrs: Can cause defects in
teeth and bones of fetuses and children so ic should not be used
seen in Tables 2-4, the rates of sales of chlo- by pregnant women or children under 8 years; cautious mon-
ramphenicol, tetracycline, and kanamicin differ itoring called for in presence of liver or kidney disease. Menu-
considerably at North and Center Pharmacies. ficwcrs: Acromax. Italmex. Lederle, LcpitiVDow, McKesson.
 In the shadow of biomedicine
Table 4. Drug-specific rates for kanamicin no-dot sales at North
and Center Pharmacies
Observed no-dot sales of kanamicin
Volumc-
adjusted
Real rate rate
North Pharmacy 0.2S/hr I.l/hr
(5 sales in 21.5 hr)
Center Pharmacy O/h? O/hr
(0 sales in 12.5 hr)
‘Center Pharmacy does carry this drug, but did not sell it to anyone
without a prescription during the observation period. Drugs
conraining konamicin: Kanamicina. Kanfotrex, Kantrex, Kan-
trexil. Side efecrs: Can lead to deafness; requires close mon-
itoring; should not be used if other antibiotics will be effective
[34]. Manu/ocrurers: Bristol,McKesson.
Pharmacy sold it to someone once every 4 hr on the
average.
If data like these are collected from a representative
sample of the 1274 legal drugstores in Ecuador [20],
they could be used to estimate no-dot sales of ethical
pharmaceuticals for the nation as a whole. With this
information, we could estimate the size of the popu-
lation most at risk of suffering serious side effects
from uninformed use of prescription drugs [39].
Clioquinol is another medication which has been
associated with very damaging side effects. Ciba-
Geigy, leading manufacturer of this drug, was or-
dered by the courts to pay more than 490 million
dollars in damages to thousands of people who
suffered paralysis or blindness from using this drug
[21, pp. 38-40; 23, pp. 44-581. The medication was
subsequently withdrawn from the market worldwide.
When this drug was still marketed, medical experts
considered it critically important to limit course of
treatment to the fewest possible days (231. In an
average day at North Pharmacy, three people bought
the drug without access to that fact or any other
information about clioquinol; in an average day at
Center Pharmacy, six people did so. Table 5 shows
real and adjusted rates for no-dot sales of clioquinol
Table 5. Drug-specific rates for clioquinol, no-dot sales at North
and Center Pharmacies
Observed no-dot sales of clioquinol
Volume-
adjusted
Real rate rate
North Pharmacy O.ZS/hr I.ljhr
(5 sales in 21.5 hr)
Center Pharmacy 0.6fir 0.6/hr
(8 sales in 12.5 hr)
Ram at lower-volume drugstore is multiplied by 4.5 to adjust for and
overall rate of prescription drug sales at Center Pharmacy which
is 4.5 times greater than the overall rate at North Pharmacy.
Drugs containing clioquinol: Entero-Sediv, Entero-vioformo,
Mexaformo. fndicarions jar use in rhc Unired States: drug not
used internally. Now ofl rhe marker. but was used in brin
America to trew: diarrhea, bacillary dysentery, tnveller’s diar-
rhea, enteritis. amebic dysentery. There is no evidence that is
useful for any condition other than amebic dysentery, which is
the least common kind of intestinal infections (21. p. 38; 23,
p. 541. Side egPcrs: Can cause severeabdominal pain, optic nerve
atrophy and blindness, foot/leg paralysis; subacutc-myelo-
optico-neuropathy and death. In rare caseswhen use is appropri-
ate, should not exceed IO days. Monufacrurers: Ciba-Geigy.
Gruenthall-Hoechst.
911
Table 6. Drug-specific rates for dipyrone no-dot sales at North and
Center Pharmacies
Observed no-dot sales of dipyrone
Volume-
adjusted
Real rate rate
North Pharmacy O.S/hr 2.25ihr
(IO sales in 21.5 hr)
Center Pharmacy Z.S/hr 2S/hr
(31 sales in 12.5hr)
Rate at lower-volume drugstore is multiplied by 4.5 to adjust for an
overall rate of prescription drug sales at Center Pharmacy which
is 4.5 times greater than the overall rate at North Pharmacy.
Drugs conmining dipyrone: Antineurol, Beserol. Buscapina. Con-
mel, Doloneurobion, Espasmo-Cibalgina, Novalgina, Coricidin
(SA), Dipirona, Stegalgina, Valpironc. Tetrabroncol, Vis-
ccralgina. Indicafiomfor use in the United Sores: According to
a 1973 statement by the American Medical Association, “be-
cause dipyrone may produce fatal agranulocytosis and other
blood dyscrasias. its use as a general analgesic. antiarthritic, or
routine antipyretic cannot be condoned.” This drug was not even
listed in 1980 because it is considered obsolete in the U.S. [23,
p. 641. Munu/acrurers: Ciba-Geigy, Hoechst, Merck, Sterling,
Winthrop.
at the two pharmacies. Adjusted rates indicate that
North Pharmacy distributed clioquinol in no-dot
sales at twice the rate of Center Pharmacy.
Dipyrone is an antipyretic that has been phased
out of use in the U.S. and most other developed
nations, because it can lead to fatal blood disease,
and because there are safer drugs that serve the same
purposes. Dipyrone is being manufactured in Ec-
uador by Winthrop Laboratories and Ciba-Geigy
among others. Table 6 shows that the rate of no-dot
dipyrone distribution at Center Pharmacy is 2.5
sales/hr; the rate of no-dot sales of this drug at North
Pharmacy is about O.S/hr. After correcting for overall
prescription drug sales volume, it appears that the
two drugstores differ little with respect to no-dot
dipyrone sales rates.
Although the difference in no-dot sales is negligible
for dipyrone, we see clear differences in rates of
no-dot sales rates for the other four high-risk medi-
cations described above. Tables 2-6 show that phar-
macies can differ greatly in the extent to which they
distribute certain prescription drugs to customers
without prescriptions. For instance, North Pharmacy
distributes much more kanamycin in no-dot sales
than does Center Pharmacy, while Center Pharmacy
distributes tetracycline in no-dot sales at eight times
the (adjusted) rate of North Pharmacy. Although the
figures will not be presented here, the same sort of
pharmacy-level differences in self medication rates
show up in sales of tranquilizers, nonsteroidal anti-
arthritics, and anti-inflamatory drugs.
What accounts for these differences between phar-
macies? Some of the difference in sales rates can be
attributed to factors outside the pharmacy. The rep-
utation of particular medications may vary from
neighborhood to neighborhood of the city. Local
preferences and lore about desirable treatments are
probably considerably influenced by what biomedical
and other practitioners have prescribed over the years
for different maladies in each locale.
Some differences in self medication rates for a
particular drug may be traceable to recommendations
by pharmacy clerks. For example, Center Pharmacy
912 LAURIE
personnel may recommend Ambrasinto more fre-
quently, while North Pharmacy clerks recommend
Kanamycin. If such patterns of recommendation do
exist among clerks, these may in turn be traceable to
marketing strategies of pharmaceutical company rep-
resentatives. More research is necessary to determine
what factors are the most important ones in patterns
of self medication. One reason why such local
differences should be taken seriously is the possibility
of educational interventions on the pharmacy level.
Such intervention might decrease distribution of the
drugs with more serious side effects, and increase
awareness among clerks and consumers of safer
alternatives.
CLERK-CUSTOMER INTERACTIONS
Therapeutic consultations between clerks and cus-
tomers have been reported in observation of many
Third World pharmacies [2,40,41]. But the fre-
quency of such interactions may be low relative to the
frequency of self medication with ethical drugs
[5,30,31]. Such consultations are not common in
either pharmacy I observed. However, they appear to
be more frequent in North Pharmacy-serving the
wealthy sector of Quito-than in Center Pharmacy
which serves the poor central area of the city. In
North Pharmacy I saw only 15 therapeutic consul-
tations in 21 hr. Due to the high volume of business
in Center Pharmacy, it was not possible to closely
monitor every clerk for such consultations, but obser-
vation of a sample of personnel suggests that clerks
are too busy coping with the flood of customers to
give advice very often.
Personnel in North Pharmacy are more atti-
tudinally predisposed to give therapeutic recommen-
dations to customers than are those in Center
Pharmacy. North Pharmacy is a family business with
low employee turnover. Clerks feel they have had a
great deal of experience and are therefore competent
to give advice. In North Pharmacy, clerks also feel
more able to make recommendations because they
have become personally acquainted with many of
their customers through repeated business over the
years. When asked about selling prescription drugs to
people without prescriptions, one clerk in North
Pharmacy stated:
“To the general public, no-only to people who we are
familiar with.. . We don’t consult with people about high
blood pressure, heart disease, bronchitis, or TB. but only
diarrhea, rheumatic pain, colds, headache, and upset stom-
ach. Those are the sicknesses that we consult about-little
things [cosar suuues].”
The same clerk feels that only a physician should
inform people about dosage and side effects of med-
ications. He also states that the biggest problem
people have with self medication is from sedatives,
and from other drugs that ‘cause intoxication’.
None of the clerk-customer interactions I observed
in either pharmacy (about 40 total) lasted more than
a couple of minutes, nor did they involve any sort of
physical examination. The most common type of
interactions was a recommendation for the substi-
tution of one medicine for another, usually on the
J. &ICE
grounds that the drugs were equivalent. The second
most cbmmon interaction was a brief report of
symptoms by the customer, which resulted in a
recommendation for medications to purchase. I never
heard any clerk mention possible side effects, nor did
I see them write down any information about dose or
counterindications. Only rarely did clerks give verbal
information about dose or administration schedule.
Interviews I conducted with clerks showed that they
had many misconceptions about the nature of certain
drugs and indications for using them. For instance,
Winstrol (an anabolic growth hormone with serious
side effects) was described as beneficial for ‘weight
problems’.
Pharmacy clerks are in a structurally ambiguous
and difficult position in Ecuador. On the one hand,
they are acutely aware of physician privilege in
matters of prescribing and providing information
about biomedical treatments. On the other hand,
clerks are confronted daily by people who need
medical help, often cannot afford a physician, and
regard the clerks as a good source of advice. Clerks
themselves are influenced by the widespread cultural
notion that one gains biomedical expertise by serving
in any capacity at all in a biomedical institution.
Public health officials in Ecuador periodically have
promoted training programs for pharmacy clerks to
improve their ability to give advice about drugs and
their proper use. However, this type of program has
met with considerable resistance among some of
Ecuador’s physicians.
SUMMARY
The great majority of the world’s pharmaceutical
drugs are produced by a handful of transnational
corporations based in developed nations. These com-
panies aim to increase their sales to the Third World
tenfold during the next two decades in pursuit of
profits and market expansion. Unfortunately, for
both cultural and economic reasons, the system is not
in place in countries like Ecuador to promote safe
and cost-effective pharmaceuticals consumption. Ob-
servation in two Ecuadorian pharmacies indicates
that 51% of prescription drug buyers in fact have no
prescription. High levels of no-dot pharmaceutical
consumption appear also to characterize other Third
World locations [5-8, 12, 131.
Rates of no-dot sales vary at the two pharmacies
observed. North Pharmacy, which serves a wealthier
clientele, shows a significantly higher rate of no-doe
sales than does Center Pharmacy, which serves the
poorer central sector of Quito. The two pharmacies
also show different rates of no-dot sales for specific
types of medication, such as chloramphenicol. Many
of the drugs with which people are self medicating
can pose very dangerous side effects. A number of
popular ones are no longer approved for sale in the
United States.
Why does a shadow system of biomedicine exist in
Ecuador and elsewhere? Why do the prescription
only regulations not function effectively? While eco-
nomic factors are important, as stressed by Ferguson
[2], cultural and social factors are also clearly at
work. It is true that low-income Ecuadorians often
 In the shadow of biomedicine
cannot afford to consult a physician and do engage
in self medication for this reason. However, eco-
nomics do not tell the whole story.
Self medication is woven into the fabric of
Ecuadorian culture, based on both Spanish and
indigenous healing traditions. Self care practices have
existed for millenia, maintained by widespread
knowledge of plant remedies and by communication
about illness within local social networks. In addi-
tion, many Ecuadorians appear to hold a cultural
model of biomedicine which does not differentiate
specialist credentials in the same way that profession-
als do. Thus, pharmacists and pharmacy clerks are
viewed as legitimate sources of advice about treat-
ment; drug consumption based on such advice proba-
bly is not regarded as ‘self’ medication by customers
themselves. The same is true of consumption based
on advice from nonbiomedical healers (e.g. midwives
or bonesetters) who recommend a particular pharma-
ceutical product. Even Ecuadorians who have ade-
quate economic resources practice self medication. In
fact, since the pharmacy with the richer clientele
shows the higher rate of no-dot sales, this study raises
the possibility that wealthier individuals self medicate
at even higher rates than the poor.
In Ecuador, there is little consciousness of the risks
associated with modern pharmaceutical drugs. The
lack of awareness may be due to a long cultural
tradition of using thousands of plant remedies with-
out major mishap. Lack of awareness is compounded
by the time-lag between drug administration and
visible adverse reactions. Inattention to risks also
arises from inadequate or misleading information
about medications.
Pharmaceuticals can be dangerous substances in
anyone’s hands, but particularly so in the hands of
those who have little awareness of potential risks and
correct administration. What is the likelihood that
individuals who buy powerful pharmaceutical drugs
on the advice of family, folk healers or pharmacy
clerks, have the necessary information to use drugs
correctly and to monitor for side effects and dosage
problems? We can begin to answer this question by
reiterating that consumers have access to few or no
sources of written information on dose, indications,
contraindications and side effects; a small amount of
information about side effects appears on some drug
packages, but not the majority. When medications
are sold in small quantities, typically no printed
information accompanies them. Nor is verbal infor-
mation about drug administration given to the great
majority of self medicating customers, if the two
pharmacies observed are typical of urban drugstore
transactions in Ecuador.
It is extremely difficult to investigate the rate at
which the misues of pharmaceuticals induces illness.
There are ethical problems in doing research of this
sort without immediately advising people of the risks
of a medication. There are problems of documenting
commerciogenesis due to the delayed effects of many
drugs. There are problems of confounding side effects
of medications with symptoms of the primary illness.
In retrospective research, people often cannot recall
even the names of the drugs they took, much less the
dosage schedule, or course of treatment. And, of
course, few political or economic motives exist to
913
document the human costs resulting from iatro-
genesis and commerciogenesis.
As treated earlier, any complete solution to the
public health threat posed by self medication must be
an international one that takes into account political
and economic forces as well as individual behavior
and motivations. Some Third World nations have
developed strong government policies and actions to
promote safe and economical pharmaceutical use;
others have not [4]. Sometimes transnational phar-
maceutical firms have shown responsibility with re-
gard to the products they market and marketing
practices; sometimes they have not. Action is needed
on both national and commercial fronts in the Third
World to promote consumer risk awareness, expand
reliable information about pharmaceuticals, upgrade
pharmacies as a drug education resource, and ensure
the safest possible inventory of products.
As noted above, the physicians association in
Ecuador has often opposed measures that might
increase access to biomedical knowledge, such as
complete information in pharmaceutical drug pack-
aging. The insistence on a physician information
monopoly, combined with typical pharmaceutical
company marketing policies and the cultural tradi-
tion of self medication, make commerciogenesis
almost unvoidable in Ecuador.
Since pharmacies appear to differ in their
ecology-in patterns of drug distribution and
customer communication-it may be possible to
intervene on the pharmacy level to decrease com-
merciogenesis. Clerk education can alleviate some
of the problem. Establishment of drug information
centers in large volume pharmacies could make
information available to consumers through books,
pictures, even videotapes. The likelihood of success
for such interventions will be increased if physicians
can be enlisted to support upgrading the pharmacy’s
role in the health care system.
Until the situation improves, it is incumbent on
government agencies and transnational pharma-
ceutical corporations to exercise great caution in
decisions about ethical drug distribution in Third
World nations. Transnational corporations should
cease marketing all pharmaceutical products that
have been banned or greatly restricted in the devel-
oped world, such as dipyrone and fixed combination
antibiotics. In these countries self medication is wide-
spread. Drug consumers have far less physician con-
tact, tend to lack awareness of side effects and
contraindications, and often do not get even basic
dosage information about the products they use. This
analysis argues that, if they differ at all, drug accept-
ability standards should be more rather than less
stringent for Third World nations; furthermore, in-
formation about the correct administration and the
risks of prescription medications should be dispersed
as widely as possible.
Acknowledgements-This research was carried out with the
support of a National Science Foundation predoctoral
fellowshio. The nawr is dedicated to the work and ideals of
Anthony’Tltom&,‘a mentor who inspired my interest in the
political economy of health, and who encouraged me to do
the research reported here. An earlier version was presented
at the 1985 Annual Meeting of the American Anthro-
911 LAURIE J. PRICE
pological Association, in a memorial session for Dr
Thomas. I would like to thank Duncan Pedersen, Kim
Hopper, John Burns, and three anonymous reviewers for
their comments during revision of the manuscript. My
appreciation goes also to Gina Rabinovich and Patricia
Murgueytio, for providing information about current avail-
ability of certain pharmaceutical products in Peru and
Ecuador.
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with medical literature, but now they don’t. Now there
 In the shadow of biomedicine
is none. They come only like this-with the chemical
ingredients and the name and nothing more. That
absence [of complete information] is by law. . . About
four or five years ago, this information [about dose,
indications] was stopped. . and it was because of the
efforts of the college of physicians, of the physicians
association.”
38. To understand the reasons for drug choices and to
assess the level of consumer safety, this study should be
followed up with a larger-scale project which incorpo-
rates brief exit interviews with self medicating custom-
ers. A systematic sample of these customers would be
asked the following; for whom they have purchased the
medication; what problem/s it will be used to treat; how
they decided to buy that drug; what side effects they
think it might have; their plans for dose and medication
schedule.
39. To work through one very hypothetical example: if we
91s
assume that the national rate of no-dot chloramphen-
icol sales is the average of the rates found in Center and
North Pharmacies (0.45 sales/hr), and that pharmacies
do business 12 hr/day on average, 350 days/year, we end
up with a tentative figure of 2407,860 no-dot sales of
chloramphenicol per year for the 1273 pharmacies that
existed in L979 [20]. Even assuming that only 481,572
individuals are involved in no-dot use of the drug
(allowing a very conservative five separate purchases
annually per buyer), this still puts thousands of people
at risk of serious adverse reactions, with a conservative
fatality rate of 30 people per year.
40. Mitchell F. M. Popular medical concepts in Jamaica
and their impact on drug use. Wesrn J. Med. 139,
841-847, 1983.
41. Logan K. The role of pharmacists and over-the-counter
medications in the health care system of a Mexican city.
Med. Anrhrop. 1, 68-89, 1983.