&ldquo;Of all forms of inequality, injustice in health is the most shocking or most inhuman, because it often results in physical death.&rdquo; - Martin Luther King.&nbsp;
Babies are born equal, and they all get equal compulsory vaccines soon after birth (World Health Organization [WHO], 2020b). But from then onwards, paths diverge along the wealth divide and poverty carries a high mortality and a lower quality of life (Wagstaff, 2000). Such inequalities in healthcare like unaffordable medicines or expensive private hospitals are not this article's area of concern; instead, this article will discuss the inequities that emerge due to the proliferation of unnecessary medical interventions, enabled by conflicts of interest in the medical profession.&nbsp;
To illustrate my point, considering the following hypothetical, indicative of the burdensome and unnecessary health measures foisted upon many: Maha is a young 25-year-old mother of a healthy baby. She and her husband are low-paid employees who struggle to make ends meet. They are literate and use social media. Maha did not use the free government provided antenatal care, as it was of poor quality, badly organized and far from her area. She sought instead a reasonably priced female obstetrician close to where she lives. At the time of labor, the obstetrician advised a Caesarean section. Maha and her husband feared for her safety in poor quality public hospitals, so they opted for private care, which they could not afford, so they borrowed money via a neighbors&rsquo; saving scheme. It would seem that the inequity here between Maha and rich women who can have their C section in private expensive hospitals is striking, but in reality, they are both victims of an uncontrolled medical industry, which promotes unnecessary Caesarean sections for its own financial gains, burdening the poor more than the rich and increasing existing health inequities. Maha was then prescribed unnecessary expensive antibiotics. Her obstetrician insisted she buys the imported original brand, telling her that the Egyptian generic does not work as well. Consequently, she is in double jeopardy, losing time and money to find an unnecessary medication more than three times the price of an adequate Egyptian generic.
Five weeks later, Maha, like most new mothers, became worried that she did not have enough milk for breastfeeding. She again went to a private pediatrician, close to where she lives, who confirmed her fears and prescribed expensive imported formula milk; little did Maha know that she did not have any real problem. The doctor was recently invited to a congress in Dubai by the formula milk company for being a top prescriber of artificial feeding in one of Giza&rsquo;s poorest neighborhoods. Again, Maha and her husband were burdened by health inequity and had to resort to a local charity for help, and they were told the imported formula milk was far superior to locally produced formula. Any onlooker at their story would be very critical of the inequality in healthcare, which although it truly exists (Rashad &amp; Sharaf, 2015), is exaggerated in this case by the fact that this couple did not need either a Caesarean section nor expensive imported antibiotics, nor formula milk, all prescribed based on the interest of the prescriber not the patient. This scenario can also be found in rich countries, Ornstein et al. (2019) found that more than 2,500 physicians in the U.S. have received at least half a million dollars from drug and/or medical device companies. This phenomenon stems from the lack of free and adequate government-provided healthcare and the presence of unregulated private healthcare, whose actions are based on its own interests, not that of the patients. By default, those private medical facilities and healthcare workers have undeclared financial conflicts of interest with the patients&rsquo; proper management. They earn less money with natural labor, with breastfeeding and with prescribing less or cheaper medications.
These problems are all real, especially in the case of childbirth. Egypt has one of the highest C section rates in the MENA region and the world (Jadoon et al., 2019; Elnakib et al., 2019). A study revealed that there has been an alarming increase of C section rates from 2000 to 2014, where in the latter year, C sections accounted for 67% of hospital-based deliveries, and that key informants unanimously agreed that there had been an increase in C section overuse or misuse (Abdel-Tawab et al., 2018). This represents a significant cost to both the mothers and the healthcare system, as the study revealed that the cost of a C section is on average 60% higher than that of a vaginal delivery in public hospitals, and such overuse of C sections costed the healthcare system over EGP929 million in 2014 (Abdel-Tawab et al., 2018).&nbsp;
Another example of extreme inequality in healthcare is in diabetes care in Egypt, and other low- and middle-income countries (LMICs). It is worth mentioning that Egypt has a high rate of type 2 diabetes, especially among women due to obesity, poor diet and lack of exercise (Herman et al., 1997). The world has seen an incredible scientific development with the discovery of advanced diabetes medications by Big Pharma which offer cardiovascular benefits to diabetic patients with heart disease (Harvard Women&rsquo;s Health Watch, 2019). Big Pharma has set a multimillion-dollar budget for promoting its drugs everywhere, including Egypt (Ellen Foley, 2019). Egypt does not have its own diabetes guidelines for managing patients and wholly relies on diabetes guidelines published in the USA and Europe by large scientific associations like the American Diabetes Association (ADA), where the majority of Egyptian diabetologists get their knowledge from. The recently published American guidelines promote best or best available science and emphasize using newly released expensive medicines (ADA, 2021).&nbsp;
In Egypt, Big Pharma has organized tens of seminars to promote prescribing their newly released, guideline-based, expensive medicines, and immediately a new domain of health inequity loomed on the horizon in Egypt. Millions of Egyptian diabetic patients faced the threat of being unable to buy the new diabetic medicines to be prescribed en masse by Egyptian doctors. These doctors acquired their know-how from Pharma-organized seminars, in which the key opinion leaders &ndash; &ldquo;senior doctors who help drug companies sell drugs (Moynihan, 2008) &ndash; tell them the latest American guidelines, an issue criticized in other countries, in which these relationships between the pharmaceutical industry and the medical profession are recognized as &ldquo;not consistent with the interests of the larger society or necessarily with the patients served by these physicians&rdquo; (Blumenthal, quoted in Moynihan, 2008) and resulting in &ldquo;irrational prescribing, omission of safety issues [...] and increased costs&rdquo; (Fava, 2008).
But little did these diabetologists know that the WHO has noted, with alarm, that the lack of affordability of new drugs will result in poor control of diabetes, and therefore responded to this looming crisis by publishing its own guidelines for diabetes treatment in LMICs (WHO, 2018). In these guidelines, the WHO emphasized the need for diabetes prevention, recommending &ldquo;initial management with lifestyle modifications (dietary changes and weight loss)&rdquo; (p. 45), and then describing in detail diabetes treatment through affordable drugs in settings where the use of expensive modern drugs is not possible, illustrating how it is feasible to treat diabetes efficiently at a low cost.&nbsp;
The WHO&rsquo;s recent guidelines are rarely promoted or taught to Egyptian physicians, who are hammered daily by Pharma-sponsored seminars promoting expensive new drugs, either by international pharmaceutical conglomerates or by local pharmaceutical companies, promoting their own versions of expensive drugs produced locally at about half price. These are still quite expensive for many patients, yet better priced at least. The question is, are they really needed? How can we protect the Egyptian patient from the vested interests of the medical industry? The answer should be answered, at least partially, following the full implementation of the Universal Health Insurance Law 2/2018, which will cover 100% of the population, and prescriptions will be provided free of the charge. Medicines provided will include locally produced (and approved) high quality drugs and/or government-priced imported drugs as done recently in several scenarios (Ministry of Trade and Industry, 2020).&nbsp;&nbsp;
In addition to unregulated healthcare, there is also unregulated access to medications. This was recently seen in the blatant example of COVID-19 management in Egypt, where the original Ministry of Health protocol &ndash; which included medications proven later to be not only ineffective but outright harmful to some, like hydroxychloroquine &ndash; was not updated. It instead was promoted by local pharmaceutical companies, and chain emails were sent to doctors and pharmacists to promote those dangerous and faulty protocols. Likewise, the medical industry promoted unnecessary and expensive lab tests, and unnecessary X ray scans, which eventually got promoted on social media from patient to patient in a dangerous farce on a scale not seen before &ndash; a fatal farce for some &ndash; and a clear example of the exploitation of both the poor and the rich by a wild uncontrolled medical industry. These unregulated practices have actually led to the spread of COVID-19 in the community by encouraging infected individuals to mingle in clinics, labs and pharmacies instead of isolation as recommended by the WHO (2020a).
While there exist significant health inequalities between rich and poor within countries, in many instances helping bridge those gaps through increased prescriptions and medical procedures will benefit healthcare industries and/or providers more than low-income patients themselves, who are used as proxies by many service providers for their own financial interests. Medical interventions and prescriptions need to be conducted in an appropriate manner which prioritizes patients over profits. This can only be prevented by establishing good governance and regulatory systems regulating financial conflicts of interest in healthcare.
<hr>
References
<ul>
<li style="text-align: justify;">Abdel-Tawab, N., Oraby, D., Hassanein, N., El-Nakib, S. (2018). Cesarean section deliveries in Egypt: trends, practices, perceptions, and cost. Population Council. <a href="https://cutt.ly/QvnCznC">https://cutt.ly/QvnCznC</a></li>
<li style="text-align: justify;">American Diabetes Association. (2021). Standards of medical care in diabetes &ndash; 2021. Diabetes Care, 44(1). <a href="https://care.diabetesjournals.org/content/44/Supplement_1">https://care.diabetesjournals.org/content/44/Supplement_1</a></li>
<li style="text-align: justify;">Ellen Foley, K. (2019). Big pharma spent an additional $9.8 billion on marketing in the past 20 years. It worked. Quartz. <a href="https://cutt.ly/8vnXs6b">https://cutt.ly/8vnXs6b</a></li>
<li style="text-align: justify;">Elnakib, S., Abdel-Tawab, N., Orbay, D., &amp; Hassanein, N. (2019). Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study. BMC Pregnancy Childbirth, 19, 411. <a href="https://doi.org/10.1186/s12884-019-2558-2">https://doi.org/10.1186/s12884-019-2558-2</a></li>
<li style="text-align: justify;">Fava, G. A. (2008). Should the drug industry work with key opinion leaders? No. BMJ (Clinical research ed.), 336(7658), 1405. <a href="https://doi.org/10.1136/bmj.39541.731493.59">https://doi.org/10.1136/bmj.39541.731493.59</a></li>
<li style="text-align: justify;">Harvard Women&rsquo;s Health Watch. (2019). If you have diabetes, a crop of new medicines may help your heart. Harvard Health Publishing. <a href="https://www.health.harvard.edu/womens-health/if-you-have-diabetes-a-crop-of-new-medicines-may-help-your-heart">https://www.health.harvard.edu/womens-health/if-you-have-diabetes-a-crop-of-new-medicines-may-help-your-heart</a></li>
<li style="text-align: justify;">Herman, W. H., Aubert, R. E., Ali, M. A., Sous, E. S., &amp; Badran, A. (1997). Diabetes mellitus in Egypt: risk factors, prevalence and future burden. Eastern Mediterranean Health Journal, 3(1), 144-148. <a href="https://applications.emro.who.int/emhj/0301/emhj_1997_3_1_144_148.pdf?ua=1">https://applications.emro.who.int/emhj/0301/emhj_1997_3_1_144_148.pdf?ua=1</a></li>
<li style="text-align: justify;">Jadoon, B., Mahaini, R., &amp; Gholbzouri, K. (2019). Determinants of over and underuse of caesarean births in the eastern Mediterranean region: an updated review. Eastern Mediterranean Health Journal, 25(11), 837-846. <a href="https://applications.emro.who.int/emhj/v25/11/10203397-2019-2511-837-846.pdf?ua=1">https://applications.emro.who.int/emhj/v25/11/10203397-2019-2511-837-846.pdf?ua=1</a></li>
<li style="text-align: justify;">Ministry of Trade and Industry. (2020). MTI orders drug companies to provide contracted supplies to &lsquo;unified procurement authority&rsquo; for 3 months. <a href="https://cutt.ly/9vnXwWf">https://cutt.ly/9vnXwWf</a></li>
<li style="text-align: justify;">Moynihan, R. (2008). Key opinion leaders: independent experts or drug representatives in disguise?. BMJ (Clinical research ed.), 336(7658), 1402&ndash;1403. <a href="https://doi.org/10.1136/bmj.39575.675787.651">https://doi.org/10.1136/bmj.39575.675787.651</a></li>
<li style="text-align: justify;">Ornstein, C., Weber, T., &amp; Grochowski Jones, R. (2019). We found over 700 doctors who were paid more than a million dollars by drug and medical device companies. ProPublica. <a href="https://cutt.ly/SvnZC9i">https://cutt.ly/SvnZC9i</a>&nbsp;</li>
<li style="text-align: justify;">Rashad, A. S., &amp; Sharaf, M. F. (2015). Catastrophic economic consequences of healthcare payments: Effects on poverty estimates in Egypt, Jordan, and Palestine. Economies, 3, 216-234. <a href="https://www.mdpi.com/2227-7099/3/4/216/pdf-vor">https://www.mdpi.com/2227-7099/3/4/216/pdf-vor</a></li>
<li style="text-align: justify;">Wagstaff, T. (2000). Socioeconomic inequalities in child mortality: Comparisons across nine developing countries. Bulletin of the World Health Organization, 78(1), 19-29. <a href="https://www.who.int/bulletin/archives/78(1)19.pdf">https://www.who.int/bulletin/archives/78(1)19.pdf</a>&nbsp;</li>
<li style="text-align: justify;">World Health Organization. (2018). Guidelines on second-and third-line medicines and type of insulin for the control of blood glucose levels in non-pregnant adults with diabetes mellitus. Geneva: World Health Organization. <a href="https://cutt.ly/YvnX4Vp">https://cutt.ly/YvnX4Vp</a></li>
<li style="text-align: justify;">World Health Organization. (2020a). Criteria for releasing COVID-19 patients from isolation. <a href="https://cutt.ly/rvnZ0PE">https://cutt.ly/rvnZ0PE</a></li>
<li style="text-align: justify;">World Health Organization. (2020b). Vaccines and immunization: What is vaccination? <a href="https://cutt.ly/Tbwdber">https://cutt.ly/Tbwdber</a></li>
</ul>

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