Issues Magazine

Pharmaceutical Supply and Storage in Remote Indigenous Communities

By Chris Thompson and Kym Thomas

There is a stark contrast between a visit to the doctor by a person of European descent and by an indigenous Australian from a remote community.

You are a person of European descent living in the city and are feeling unwell. You decide that you need to visit your general practitioner (GP). The following events take place:

  1. You ring your GP’s surgery, and are told that an appointment can be made for you that afternoon.
  2. You drive to the GP’s surgery, report to the receptionist and sit down to wait with all of the other patients.
  3. Your GP calls your name and takes you to the consulting room.
  4. You discuss your symptoms. Based on the information you give, the GP will ask you further questions and may need to conduct a physical examination.
  5. The GP arrives at a diagnosis and decides that medication is warranted.
  6. You are asked about any possible allergies to the drug product being considered. Your GP hands you the prescription and advises when you are to take the medication, in what quantity and for how long.
  7. You take the prescription to your pharmacy, which is nearby, and have it dispensed within 20 minutes or so.
  8. Your pharmacist repeats the doctor’s instructions regarding dose and advises that you will need to store the product in your refrigerator and to avoid excessive sunlight exposure while you are taking it.
  9. You pay for the medication, go home and store the product in your fridge.
  10. At the appropriate time you begin taking the medication but, unfortunately, it makes you very ill. You report to your GP who is so concerned that a home visit is arranged.
  11. The GP visits, provides measures to relieve your distress and writes a prescription for an alternative medicine, which is taken to the local pharmacy by a family member.
  12. The new medication is dispensed and paid for, and this time you take it without further problems.

All of the above probably sounds quite familiar and straightforward. However, every one of the listed events can represent a significant barrier to indigenous Australians obtaining their medication, with the result that the original problem may go undiagnosed and untreated. In combination, the problem can be seen as nearly insurmountable.

Now imagine you are an indigenous Australian living in a remote community. This is what happens to you as you try to follow the previously listed steps:

  1. Your nearest doctor is likely to be over 100 km (or more) away, so phoning for an appointment that day is out of the question, even if you did have access to a telephone. The local indigenous health service is staffed by indigenous health workers and perhaps a registered nurse, but a doctor may only visit once a week, if you are lucky, and more likely less often than that.
  2. If you are an indigenous Australian from a remote community who just happens to be in a large city, then the thought of attending a “mainstream” GP’s surgery for attention is simply too daunting to contemplate. There may be all sorts of complications and mis­understandings while speaking to the receptionist, and then sitting down among many non-indigenous people may be too threatening, and you will feel extremely uncomfortable and stressed. (It was for these very reasons that indigenous health services were begun in the first place, beginning in the early 1970s in Redfern, NSW. The idea was to have indigenous Australians run the clinics, thereby presenting a less intimidating environment.)
  3. If you have courageously waited to be called by the doctor, you may be attended by someone of the opposite sex. For certain conditions this is culturally inappropriate, and will cause you shame and embarrassment and almost certainly result in an unsatisfactory encounter.
  4. The doctor begins asking you questions, but English is not your first language. It isn’t even your second language, and there are no words or meanings in your mother tongue for you to convey what is wrong, and the terms the doctor is using are equally difficult for you to understand.
  5. Indigenous Australians have lived in Australia for more than 40,000 years. That means that they must have learned a thing or two about survival in a harsh environment and how to look after themselves. In remote South Australia, traditional healers known as Ngankari continue to tend the health of their communities. Traditional medicines are derived from bush flora and fauna and are widely used, but it is interesting to note that few traditional remedies involve oral ingestion of medicines. Most involve topical application or inhalation, so to you the idea of taking a tablet by mouth to cure a headache simply may not make sense. Thus, you may not have a great deal of confidence in Western medication even before it is prescribed. (An illness may be viewed in a cultural sense as a form of punishment for having done something wrong. Thus, even though the doctor and other health professionals believe they are providing the finest treatment possible, it may be in vain.)
  6. The doctor asks if you have any allergies to the newly prescribed product, but there are so many drugs on the market these days that even so-called well-educated people struggle with names, benefits and side-effects. While handing you the prescription, the doctor tells you to take one tablet twice per day. What does this mean? OK, you have to take two tablets every day, but when? The easiest thing to do is to take both tablets at once, and then you don’t have to worry about the next dose until tomorrow. (This may be a quite inappropriate way to take the medication. Some drugs have an inherently long life within the body and others are quite short. The latter drugs require more frequent daily dosing [i.e. shorter intervals between ingestion] for optimal effect. The terms “compliance” and “adherence” have been coined to provide some sort of measure as to how well clients take their medication compared with the instructions provided by the doctor, or as agreed upon by the doctor and the client. It is extremely unusual for anyone to have a 100% adherence rate, but the lower the figure, the less likely the product is to achieve the desired therapeutic outcome. One common practice is to take a prescribed course of antibiotics for only 2–3 days, about the time it takes to start feeling better. With fewer symptoms to remind clients of the need to take their tablets, the tendency is to forget. It is believed by many, but not all, that failure to take a complete course of antibiotics contributes to the occurrence of bacterial resistance.)
  7. Your nearest pharmacy may be hundreds of kilometres away. The local indigenous health service may have a limited supply of medications and may have to send away to a contracted pharmacy to obtain the product. Depending upon distance, it may take up to a week to arrive. On the other hand, in the wet season in the tropical north, roads may be cut for weeks and the only possible way in might be by aeroplane or boat.
  8. It is suggested that your medications need to be stored in a refrigerator, which is very easy, isn’t it? All you need is a refrigerator and a reliable supply of electricity to run it. Neither may be available in a remote community. Summer temperatures, and median temperatures, are higher over prolonged periods of time and refrigeration is essential to preserve the potency of the drug product and to prevent wastage. One possibility is to store the medication at the indigenous health service, but this places demands on the facility to provide additional refrigeration capacity beyond their own requirements, and with limited budgets this is almost impossible. If you are on medication for a chronic illness, the daily trip to the health service may be an inconvenience, and the result is less than regular taking of tablets.

    (Clients of indigenous health services are informed not to leave their drugs at a friend’s or relative’s home, but often this is the only option available. There may be children at the other person’s home who may be tempted, on seeing something new and perhaps colourful in the refrigerator, to try it for themselves, give it to their younger brothers or sisters or even to the family pet.)

  9. Payment for medication may be beyond your means. Unemployment in remote communities is very high, so government allowances may be your only source of income. The cost of food is very high, due in part to the cost of transportation and the previously discussed lack of refrigeration equipment. Fresh fruit and vegetables in particular are hard to obtain and to store for reasonable lengths of time. Reliance on packaged food, with its excessive carbohydrate and salt content, is therefore unsurprising. Use of tobacco and alcohol are additional expenses and so there is rarely enough left over to pay for medications. (Even the Pharmaceutical Benefits Scheme [PBS] does not help remote indigenous Australians because the co-payment alone for the medications is often unaffordable and to obtain the concession prices both a current Medicare card and health care card must be presented to the pharmacy. Remote indigenous Australians rarely carry their Medicare cards, if they have ever been given one in the first place. It should not be surprising to learn, therefore, that PBS expenditure on a per capita basis is about one-third as much on indigenous Australians as it is on the remainder of the population. This is ironic, as the much poorer state of indigenous Australians’ health means that they should be consuming more medications than the average. To help alleviate this problem the Commonwealth government used a regulation in the National Health Act to make medications available to remote indigenous communities by relaxing, to a certain extent, the requirements associated with the provision of medications. Pharma­cists are contracted to provide medications to indigenous health services which can then be distributed by trained health workers or nurses. Funding is also available to the pharma­cists to enable them to travel to the health service at regular intervals during the year to maintain the service to prescribed standards and to provide educational services to health service staff. They may also consult with individual clients but this will be at the request of the health service workers and will always occur in circumstances that provide maximum cultural safety for those clients. To that end, pharmacists undertaking these services must make themselves aware of the cultural practices of the community they serve. Regrettably, not all pharmacists are able to visit the health services as often as they would like. It has to be appreciated that a pharmacist cannot leave his or her pharmacy without a registered replacement, and obtaining the services of these locum pharmacists is very difficult to achieve in rural, let alone remote, areas.)
  10. You decide to begin taking your medication, but even then there may be complications. (It is known that some indigenous Australians are greatly influenced either by the colour or the shape of the product that has been prescribed. It is a highly individual thing, and may be due to a bad experience the person had in the past with a product of a similar colour. The decision may then be taken to simply throw the product away, but this may be done in an unsafe manner and again children may find the discarded medications and believe them to be lollies.)
  11. The home GP visit simply isn’t going to happen in the remote setting, so the most likely outcome of this bad experience is that you will not take any more of the medication (which is very sensible) and to await for recovery to occur and not to follow up with a visit to the health service to report on events (a decision that may not be quite so wise). The original complaint therefore goes untreated and may in fact get much worse and be more difficult to treat later on.
  12. The second prescription won’t be written and in any event is most unlikely to be dispensed owing to the previously mentioned financial pressures. No refund is payable on the first product, even if only one tablet has been taken from the packaging, because it is unsellable.

The above scenarios imply that only one drug product is being taken. However, indigenous Australians are far more likely to have chronic conditions, such as diabetes or kidney failure, which require multiple drug products and are extremely difficult to obtain reliably or to store and take correctly. Prescribers experienced with remote communities will very often utilise products that need to be taken only once a day.

Pharmacists can provide compartmentalised containers of medications, the aim of which is to make the taking of multiple drug products more straightforward. These containers can be either single-use-only or reusable. The latter are gradually falling from favour for a number of reasons, including provision of dosage information and hygiene. The single-use-only containers were developed for use in urban settings with good storage facilities. It was discovered that the adhesives used to seal the packages simply gave way when exposed to the high temperatures and/or high humidity of some remote communities.

There is little doubt that indigenous health workers represent the best solution to the overall problem of medication provision in remote settings. The question that needs to be asked is whether they are sufficiently trained and supported in their role of distribution of medications. Proper training in the preparation of dosage containers is only a partial solution because current legislation requires the involvement of a qualified professional in the final checking of the product.

If the health worker is insufficiently trained, mistakes may be made in the assembly process, which necessitates corrective steps. If this happens too often, the task of the preparation may be taken away from the health worker, which is a short-sighted step. If meaningful tasks are taken away from workers, they adopt an attitude that their employment is “sit down money” (i.e. they are not valued in the service but just get paid for turning up and hanging around for a while). This must be avoided, because it does not promote self-determination and can even promote an atmosphere of animosity.

Courses are becoming more widely available both at TAFE and within the tertiary education system to provide training for indigenous health workers, not only in medications but in all other aspects of health service provision. The number of indigenous doctors is increasing, owing to the availability of specific funding, and a number of indigenous pharmacists are becoming qualified.

This description of the provision of medications to remote indigenous communities has included indigenous history, traditional health belief systems and treatments, transport, finance, employment, education and dietary intake. As such, it is characteristic of every problem associated with indigenous health and well-being. Solving this problem requires understanding and cooperation across all health professions, and it is also dependent on the resolution of much larger issues, from human rights to housing, employment and equal opportunities.