•Doctors, other health practitioners make revelations, advise government
By Enyeribe Ejiogu, Christy Anyanwu, Olakunle Olafioye and Agatha Emeadi
Health authorities in Nigeria, just like in all other countries, have consistently cautioned against self-medication. In well-organised societies overseas with strict and effective regulation of the drug distribution system, licensed pharmacists are in firm control of the dispensing of drugs, either in private pharmacies or in the hospitals.
Before the civil war, the drug distribution system in the country was organised because only very few pharmaceutical firms, less than five, were responsible for the importation of drugs, mainly from the United Kingdom, United States and a few other European nations.
Towards the late 70s the introduction of the import licence policy under the military regime, and which continued under the first civilian administration that took off in 1979, regulatory oversight and control of the drug distribution system became somewhat driven by corruption as a growing population of non-pharmacists, essentially deep pocket businessmen, who saw pharmaceutical drugs as just another article of trade, got into the importation and storage of medicinal drugs, which were distributed through the large army of patent and proprietary medicine dealers and vendors dispersed across the country.
This happened about the time that experienced medical doctors began to withdraw from the public hospitals to relocate overseas for greener pastures in the United Kingdom and USA, thus triggering the first wave of brain drain in the healthcare system.
Many others went into private practice. For most ordinary Nigerians, getting attention at public hospitals, which in most cases are faced with drugs out-of-stock syndrome, was difficult.
On the other hand, the cost of treatment in private hospitals was not easily affordable by most people in the lower income group just like many families in the lower class.
Increasingly, ordinary people began to patronise the operators of the patent and proprietary medicine shops, known in local parlance as chemists.
It was common to see copies of the book, Where There Is No Doctor, given a prominent place on the table of the owners of the patent medicine shops.
The more literate ones read the book like it is the Bible, and learnt just enough to “diagnose” some of the illnesses being suffered by the “patients” and then “prescribe” drugs for them.
They also went ahead to “dispense” drugs from the stock in their chemist shop. Boom, as it were, Nigeria’s era of self-medication was born and it has grown in leaps and bounds since then, manifesting different dimensions of the malady.
“In simple terms, self-medication is the selection and use of medicines by individuals to treat self-recognised symptoms or illness,” Dr Andrew Ukegbu, a fellow of the National Postgraduate Medical College of Nigeria and a consultant Public Health Physician at the Federal Medical Centre, Umuahia, Abia State, said.
He pointed out: “In this case, there is no recourse to a medical expert. The most worrisome is the inappropriate or irresponsible act of self-medication, where someone takes drugs when not needed or takes wrong drug or takes inappropriate dose or for duration resulting in negative outcomes.”
For Dr Olubusola Oladeinde, a medical practitioner, “self-medication refers to the use of drugs to treat self-diagnosed disorders or symptoms, or the intermittent or continued use of a prescribed drug for chronic or recurrent disease or symptoms,” adding that “while self-care and self-medication can sometimes be beneficial, it can also be harmful if not done responsibly.”
There are certain reasons for the practice of self-medication. The common ones are poor health-seeking bbehaviour among the people. Usually, some people when they are sick don’t go for appropriate treatment in recognized healthcare facilities. Another reason is the cost of healthcare and poverty. Nowadays, healthcare costs are very exorbitant. The majority of the people do not have the money to buy drugs.
Healthcare service related reasons include long waiting time at public health facilities. Another reason is the distance of the facilities from where people live as well as time constraints suffered by individuals to even go and wait for a long period at health facilities. So, they resort to buying drugs over the counter at pharmacy and patent medicine shops. Again, for convenience, some people do not want to go the health facility to seek services.
It is understandable why Associate Professor of Neurology, Department of Internal Medicine, University of Uyo Teaching Hospital, Dr Bertha Ekeh, and other doctors like Oladeinde often advise against self-medication. The main reasons doctors advise against self-medication include the following:
Misdiagnosis: There is a need to Google one’s symptoms either because going to the hospital is stressful or expensive. Without proper training, individuals may misdiagnose their condition, leading to ineffective or even harmful treatment.
Inappropriate treatment: People may use the wrong medication or treatment approach for their condition, which can worsen symptoms or lead to complications. In Nigeria, for instance, any sign of fever calls for the treatment of Malaria and Typhoid, with the result that most times, people abuse anti-malarials and anti-biotics.
Drug interactions: Self-medicating with multiple substances can lead to dangerous drug interactions, especially when combining prescription medications with over-the-counter drugs or supplements.
Masking underlying conditions: Self-medication can mask underlying conditions, delaying proper diagnosis and treatment. Children are not little adults. Parents tend to give paracetamol whenever they notice a rise in their children’s temperature. This sometimes brings down the body temperature, but hides the underlying conditions that need urgent care. These underlying conditions, if caught early, could lead to a better outcome, but delayed intervention worsens prognosis in the long run.
Dependence and addiction: Self-medicating with substances like painkillers, benzodiazepines, or alcohol can lead to dependence and addiction. There is an upward trend in substance addiction due to availability and increased awareness. Due to the high level of stress and workload, people tend to abuse various substances to numb the pain and pressure, like alcohol, sleeping tablets, opioids. Over time, this can lead to dependence, a state that can make one to neglect other sources of pleasurable activity and, at times, induce psychotic symptoms.
On overdose/under dose: Some people may guess the correct medication, but take the wrong dose. Overdose causes toxicity with terrible consequences including death. Under-dose leads to resistance. This is the main problem with anti-biotic usage in Nigeria. Lots of people take a small dose indiscriminately thereby sensitizing the organisms. The organism adjusts itself and builds up resistance against that medication. The anti-biotic, therefore, is no more effective for that infection.
Worsening other conditions: Medications have other effects which may be beneficial or detrimental depending on whom it was administered. Some special considerations before certain drugs administered include pregnancy, children, the elderly and those with some medical conditions like hypertension, asthma and peptic ulcer disease. Others include kidney disease. Certain everyday common medications may have detrimental effects in these conditions.
Drug interactions: In Nigeria, there is the alarming practice of mixing drugs in the chemist. All medications are chemicals. Hence there are interactions between these chemicals. Some may be positive (beneficial) and some may be negative (detrimental). In order to prescribe a medication, the pattern of interaction is put into consideration.
Allergic reactions: Allergic reactions occur when the person’s immune system over-reacts to a substance that is generally harmless to most other people. These substances can be food, pollen, dust mites, pets, leather, insect bites and drugs. Certain of these medications can cause severe allergic reactions.
These problems noted above may lead to worsening of the ailment or provoke another sickness, teratogenicity (disfigurement of an unborn baby), organ damage, disability and even death. Others are drug addiction, prolonged suffering and wastage of resources.
Forms of self-medication
Some common examples of self-medication practices that doctors advise against include: taking medications without a prescription or medical supervision; using alcohol or drugs to cope with mental health issues; using herbal concoctions or alternative therapies without consulting a healthcare professional; ignoring medical advice or delaying seeking professional help; and taking excessive doses of over-the-counter medications
Oladeinde offered this time-honoured advice: “It’s essential to prioritize your health by seeking professional medical advice and treatment when needed. If you’re struggling with physical or mental health issues, please consult a qualified healthcare professional for proper guidance and care. Also, regular medical fitness checks will go a long way in maintaining good health. Health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity. Self-medication is an irresponsible way of caring for one’s health.”
When you watch the normal day hospital scenes depicted in some American and European films, you will see the organised and smooth way patients are given attention, even for the mundane things.
But when you compare this with what some patients pass through in some Nigerian public hospitals, you begin to appreciate why there have been instances where individuals simply chose the risky option of self-medication in handling some health challenges.
This was the experience of Mr Taiwo Ahmed, whose fear of being diagnosed with other ailments apart from the medical reason behind his visit to the hospital became a major reason to adopt self-medication.
Ahmed had returned home dejected after visiting a hospital with the intention of donating blood.
“Some years ago when my wife was pregnant with our first son, she registered for antenatal at a government hospital and I was requested to donate blood in case she might need blood transfusion during delivery. On getting to the hospital for the exercise, I was subjected to a series of medical tests. By the time the results of the tests came out, I was declared unfit to donate blood and recommended for more comprehensive and elaborate medical tests and treatments,” he said.
Ahmed said that he became dejected because of the outcome of the results, but after some weeks he decided to take his mind off the issue.
“My son is over 15 years old now, but I am yet to repeat those tests and I have never experienced any major health problems. So, occasionally when I have signs of sickness, all I do is to visit a pharmacy and buy some regular drugs and that’s all,” he said, explaining why he opted for self-medication rather than go to the doctors for proper medical diagnosis, treatment and advice.
For Mrs Joy Ekezie, just going close to medical facilities makes her very uncomfortable and as such she has developed a serious phobia for hospitals.
“I don’t like going to the hospital because the environment makes me sick. I have been to hospitals on a few occasions, not as a patient, just as a visitor to family members or friends on admission, but the experience is not what I like to have.
“Seeing people with serious health challenges always makes me sick. There was a time I visited a church member who was on admission in a hospital. I was already sick with the whole environment to the point of bidding the person hasty goodbye when an accident patient was rushed in.
“His condition was so bad that the sight haunted me for weeks. Even till date, anytime I remember that particular scene, it makes me queasy and sick. So, going to hospital is always out of the equation even when I feel unwell,” she said.
Several other people blame the high cost of accessing medical care in the country for their resort to self-medication. One of such persons is Mrs Mutiat Azeez. Though she admitted that self-medication was dangerous and could prove much costlier than expected, Mrs Azeez said: “I prefer going to hospital when I or any member of my family is sick, but on a number of times we have had to take to the option of self-medication due to lack of money. I am aware that self-medication is very risky and could lead to a much bigger issue that could cost much more than one could imagine.”
A clearing agent, Amina Ezeigwe, is one of the country’s huge population of citizens, who have sworn to maintain a wide gap between them and hospitals and the doctors who work in them.
“I hardly go to hospitals. Once I have a health challenge I go to Google and find out what it is and look for the natural means of healing. With the difficult and harsh economy things are really expensive. Going to see a doctor means that he will prescribe medication after the consultation and those things don’t come cheap or easy nowadays.
“Aside from that the doctors would also ask you to go for laboratory investigation and they have their own laboratories that they direct that patients should go. If you don’t oblige and use another laboratory, they will utterly reject your test result, no matter the level of credibility or reputation of the facility. That tells you that they are interested in the money they will earn as commission from sending patients to such medical laboratories.
“So, after my Google search, I swing into action, go to the market, to buy materials for preparing my agbo (local herbal therapeutic preparation). Otherwise, I use natural spices like garlic, ginger, turmeric, moringa and soursop. All these things work wonders in the body.
“After all, these doctors also go to Google to check the symptoms you are telling them during consultation. I can’t remember the last time I visited hospitals. I take my natural medicines,” Ezeigwe said with a tone of dismissive finality.
Bose Clarke, who works as a secretary in a firm, told Sunday Sun: “I don’t usually fall sick. But anytime I have malaria symptoms I just walk into a pharmacy and get some malaria tablets. I already know the ones that are okay for my body and I use them.”
Incidentally, Ekaette Brown is in the same camp with Ezeigwe: “I am not a fan of hospitals except when the case is getting out of hand. I prefer taking agbo stuff. Those things work. I just buy the agbo from the hawkers, cook it, drink and I’m fine.”
Going by the definition of self-medication, Dr Bertha Ekeh, asserted that most Nigerians are guilty of the practice of resorting to self-medication.
“Medications are supposed to be prescribed by medical doctors who have been trained to evaluate patients and make a diagnosis before treatment,” she said, noting that “studies in Nigeria have shown that self-medication is common in Nigeria. The rates range from 52.1 per cent to 92.3 per cent. This is a far cry from the Western world where the practice ranges from 8-14 per cent and is even reducing because of better control.”
The most common illnesses people take self-medication for are headaches (21.10%), fever (9.15%), Cough/Upper respiratory tract infections (11.64%) and body pains (6.05%). Some of these are generally referred to as over-the-counter (OTC drugs). OTC drugs are drugs that can be purchased without a doctor’s prescription. One Nigerian study found that the most common self-medicated drugs are analgesics (95.2%), vitamin supplements (84.7%) and antibiotics (83.1%).
Again, common sources of self-medication include family members, friends, colleagues, neighbours, other health workers, newspapers, and social media more recently. “In the Nigerian context, other sources include faith-based healers, herbalists, itinerant medication hawkers in the bus, market, and even on the road.”
Ekeh narrated that a typical case of dangerous self-medication induced by family or friends was the case of a man, James (surname concealed), who was urinating frequently and confided in his friend, Matthew (real name concealed), who had been properly diagnosed with diabetes and was placed on medication.
Matthew told James that he must also have diabetes since excessive urination is one of the symptoms. He convinced him to commence taking diabetes medication. Meanwhile, the blood sugar of James fell so low that he was rushed to the hospital in unconscious state.
It took emergency resuscitation and the mercy of God to save his life. He almost died because he was treating the wrong disease. There are other causes of frequent urination; he was eventually treated for the correct condition by the doctor and he became well.
As Dr Ekeh also explained the reasons for self-medications as practiced by Nigerians to include ignorance or poor education, poverty, high cost of hospital care and previous experience with the disease. Others include socio-cultural norms and beliefs, distrust of the health workers and poorly implemented policies.
“Ignorance and poor education generally stem from the African social cultural beliefs. Many Africans belief that diseases like epilepsy, stroke and mental illnesses are spiritual and should be handled spiritually. Hence such persons are taken to faith-based healers and herbalists. Interestingly, these spiritual healers occasionally resort to giving medications, but not correctly. Regrettably, these beliefs run across educational and socioeconomic strata,” Dr Ekeh said.
According to her, poverty is probably the commonest cause of self-medication in Nigeria and sub-Saharan Africa as a whole.
“This factor has been worsened by the recent economic crises in the country. People who have been on regular medications are unable to procure them with the current high cost of living. They have had to resort to self-medication with terrible consequences.
“Another major reason is high cost or inaccessibility of hospital care. Some others cite a high cost of proper hospital care, but in the long run people spend more money ‘supposed’ in the sense that they eventually spend more on the long run.
“Again, some people take medications for diseases that require another modality or treatment like surgery. This is commonly seen in cases of breast lump or breast cancer. Women have been known to take other medications, herbs and even the rubbing of anointing oil on the area. By the time they go to the hospital the disease would be at the late stage,” she said.
Twin ‘demons’ called malaria and typhoid
Most ordinary Nigerians, including many that are literate who have been through intermittent bouts of illness that lasted over a period of three to five months, when questioned have often claimed that they were suffering malaria and typhoid. This has been one major case associated with self-medication.
“In Nigeria, the co-diagnosis of malaria and typhoid is over-estimated and is not evidence-based in most cases. It is an employ by both medical and non-medical practitioners to economically exploit the ignorant population,” Ukegbu said, stressing that specimen culture still remains the gold standard for diagnosis of typhoid fever.
“However, in most parts of Africa, Nigeria inclusive, the Widal test is a common diagnostic test employed by healthcare professionals to make the diagnosis of typhoid fever. This is due to the fact that it is relatively cheap, easy to perform and takes minimal time for the result to come out. It is worthy of note that Widal test has its limitations. A single Widal test is not valid for the diagnosis of typhoid fever because of its low sensitivity and high false positive test results associated with it.
“Nigerians usually practice self-medication based on self recognized symptoms such as fever, body aches, headache, common cold and cough. In line with this, the most widely used drugs for self-medication are analgesics, antipyreutics, antibiotics and multivitamins.”
Malaria and typhoid fever, Dr Ekeh explained,, are acute infections that are common in the tropics. However, there is still a step-wise way to make the diagnosis. The symptoms of malaria make it a commonly recognizable disease and many Nigerians successfully treat malaria. However, typhoid fever is not very common.
“The practice of making a diagnosis of typhoid from the popular Widal test is not correct. This is because the Widal test can be influenced by some other factors. It is an anti-body test and the anti-bodies take weeks to disappear from the blood. In essence, the test can remain positive weeks after treatment of an infection. In addition, many other diseases give a ‘false positive result’. Hence a positive Widal test is not a ‘sure diagnoses of typhoid fever.
“It is noteworthy that the route of transmission of typhoid fever is faeco-oral. This means that one can only get typhoid fever when either the food or water was contaminated with faeces. In other words, if you have typhoid fever, it means that faeces entered your mouth! It is, therefore, pertinent to ensure food and water hygiene. That is the way to eliminate typhoid fever.”
Way forward
Self-medication is almost unknown in the United States of America, this is because of strong government policies that regulate medications.
Dr Ekeh, therefore, suggested thus: “In order to mitigate these issues, the Nigerian government should make policies to regulate and control the prescription and dispensing of drug. These policies should be ensured.
“One common cause of self-medication is lack of funds. To alleviate this problem to some extent, there should be better healthcare policies for the country such that individuals can get to the hospital and get proper medical evaluation and correct prescription of medications at an affordable cost. Special attention should be given to the vulnerable groups (pregnant women, children and the senior citizen).”
Again, she said that the poor access to health care facilities is another huge issue in sub-Saharan Africa. “Access to health care facilities is the essence of primary health care in Nigeria. Every community should have a health centre that is accessible to all members of the community. Equipping these health centres as well as hiring qualified health care personnel is paramount to reducing self-medications and leading to a healthier Nigeria.”
