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Dear Editor
We would like to draw your attention to the practice of disease mongering in the developing world.
Disease mongering has been defined as widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments. Disease mongering can turn ordinary ailments into medical problems, can convert mild problems into severe ones and can treat personal problems as medical1.
In South Asia and in urban areas of Nepal, drug companies aggressively promote their medicines. The pharmaceutical industry is one of the key players in disease mongering. In Nepal there is a lack of understanding of the body and disease. Education about psychosomatic symptoms and rational interpretation of mental disturbances is absent. There is already in place a system of traditional beliefs which hold supernatural forces responsible for illness and misfortune. There is fear in the minds of the people which may be a factor pushing them into the hands of both allopathic and traditional disease mongers. Education and improved socioeconomic conditions may be of help in removing this fear.
Allopathic doctors are reluctant to serve in rural Nepal. This gap is met by traditional medicine practitioners and faith healers. Some complementary medicine practitioners, especially faith healers, may also be guilty of disease mongering. Shamans may be guilty of disease mongering on a small scale. We have named this 'minimongering'. In South Asia, evil spirits, adverse planetary positions, and black magic and witchcraft have been regarded as responsible for disease, ill health and misfortune. Priests, astrologers and shamans often warn their devotees and clients about forthcoming misfortune. They then suggest a pre-emptive ritual or puja to ward off the misfortune. The rituals are expensive and the family has to offer something (usually rice, a goat, cock or money etc) to 'pacify' the spirit. Such rituals are commonly conducted in villages, but pre-emptive rituals to ward off illness and misfortune are a part of life even among urban educated families. The practitioners define the misfortune in vague, metaphysical terms and subtly hint at disease and suffering for personal profit.
However, disease mongering by traditional practitioners may play a much smaller role compared with the role played by allopathic practitioners and the pharmaceutical industry. With the rapid urbanization of Nepal, its decade-long conflict and migration in search of employment, psychiatric and psychosomatic disorders are becoming more common. A recent review concluded that although allopathic medicines can address the symptoms of disease, only traditional medicine can heal conditions which can be traced to social or spiritual disorders2.
In remote areas of Nepal, complementary and alternative medicine (CAM) practitioners can be trained to provide medical care through the existing health network and can improve acceptance of immunization and other modern healthcare practices. Community volunteers trained both in CAM and modern medicine can be a major force for change in the village community3; in some cases traditional healers have been trained to identify and refer patients with eye problems4.
Studies on the prevalence of faith healing practices in Nepal are urgently required. The cost of rituals (pre-emptive and curative) and of 'treatment failures' should be scientifically evaluated. Studies at a national level are required. Studying whether 'faith healing' and CAM may in some instances meet the criteria for disease mongering will require in depth analysis of individual cases. The cost, although less when compared with pharmaceutical disease mongering, may be substantial to rural communities in economically poor countries.
BR Giri
PR Shankar, MD
Manipal College of Medical Sciences
Pokhara, Nepal
References
1. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002; 324: 886-890.
2. Iwu MM, Gbodossou E. The role of traditional medicine. Lancet 2000; 356(Suppl): S3.
3. Curtale F, Siwakoti B, Lagrosa C, LaRaja M, Guerra R. Improving skills and utilization of community health volunteers in Nepal. Social Sciences and Medicine 1995; 40: 1117-1125.
4. Poudyal B. Traditional healers as eye team members in Nepal. Community Eye Health1997; 10: 4-5.