Prescribing drugs here in New Zealand has been an interesting experience, especially with all the debate in the U.S. last year about the Medicare drug benefits bill. This is sure to be an issue in the upcoming election, especially since the current administration is running huge deficits due to the Bush tax cuts plus the war spending. Time magazine recently (Feb 2nd) had a cover story "Why Your Drugs Cost So Much", about the situation in the United States. In a nutshell, they said the pharmaceutical companies, the largest lobbyists in Washington, are ripping off the American people by ensuring that government regulations protect their oligopoly. The article states that these massive profits are NOT used for research and development, but for shareholder profits and direct advertising. Furthermore, protections for the industry have grown tremendously via the fine print that was snuck into the recent Medical benefit bill. New Zealanders who have read the Time article here are very surprised when I tell them that NZ$ 30 is a great deal for the same Cipro that would cost US$130 at home.

The system in New Zealand is both simple and complex, and I can only really speak to it as a prescriber, as I'm not really sure I understand all the in's and out's of how it works for the consumer. The country has a national pharmaceutical schedule administered by Pharmac, a "a Crown entity established by the New Zealand Public Health and Disability Act 2000". Their goal is "to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonably achievable from pharmaceutical treatment and from within the funding provided." They also have a mission to encourage responsible prescribing. Their main activity is to manage the drug schedule and to negotiate reasonable and lower prices for drugs for the entire population of the country. The entire mission statement and details are available at their web site if you want to know more.

For me, what is means is that as a "GP" here, I can only prescribe out of the book. Not only that, I can only prescribe "non-restricted" medicines in the book. For example, I can prescribe baby formula, but only milk-based products. If a child is having feeding problems and needs a soy-based formula, they have to go to the hospital outpatient department and see a pediatric registrar (i.e. Resident), or I have to fax one of my consultant pediatricians with the details and hope he or she will be nice enough to sign off on the form. This particular example has only happened once in the last 5 weeks, and is an unusual one, because for the most part, all the patients here breast feed (and are delivered by midwives). Well child care occurs at Plunket, but that's another story too. Another GP example: I can prescribe any SSRI I want as long as its fluoxetine, and it will be fully subsidized. Citalpram, Nafazodone, and Paroxetine can be prescribed, but the patients will have to pay the difference between the subsidized price (NZ$5.25 for 90 days of generic fluoxetine capsules versus NZ$35.02 for 30 days of paroxetine) [See, I TOLD you drugs were cheaper here!]. Most of the older tricyclic antidepressants that I used when I was a country doctor in the 1980's are on the GP schedule however, so I am thankful I have had a lot of experience using them in the past.

What this means for me, is that if I want to prescribe a class of drug like an antidepressant, the first thing I do is pull out my little Pharmac handbook and look at what is available. Because New Zealand has this program, some pharmaceuticals are not even available in the country. Thus some of the antidepressants I used in the U.S. cannot even be purchased out of pocket. They just aren't marketed here. The flip side of this, is that some European drugs that we cannot use in the States ARE available here, so I have to look them up in the Compendium or on the internet if the patient is already taking them or if I am considering using them. The issue of unfamiliar drugs was especially acute for me the first two weeks here, particularly for hypertensive drugs, as there are ACE inhibitors and thiazide diuretics I had never heard of before. If you'd like to see the list of drugs, I've made a little Excel spreadsheet out of the data that Pharmac kindly emailed me.

Every day there is at least one patient with a drug need that I makes me scramble about. Some things I've recommened a lot in the past, like triple antibiotic cream (Neosporin) are not on the formulary here, so it is a challenge to find a substitute in the book to do the same job. Sometimes there is no substitute, and on several occaisions I've called the local "chemist" (pharmacist) for advice and discussion and he has been very helpful.

I've read and heard from other locums doctors that have worked here that figuring out the drug system was their major difficulty, and that the biggest frustration was the limited prescribing powers. However, I have tried to look at the whole big picture if I can, and it has led me to wonder about a lot of things.

Certainly, with the push to use evidence-based medicine and limiting such things as overuse of antibiotics, this system seems to have a lot of potential to eliminate poor prescribing and encourage good medicine. Most patients here have respect for antibiotics as "powerful drugs that should only be used when the immune systems fails" as one patient told me. I am not allowed to prescribe the macrolides Biaxin or Zithromax (except in a gonorrhea/chlamydia treatment regimen) as a GP, so these drugs are preserved for hospital use. If I have a patient who needs a macrolide, I may use erythromycin, or decide that I want a hospital physician to see them. This can usually be arranged, but is a barrier to both me and the patient that must be overcome. Does this prevent overuse and ultimate drug resistance to the newer macrolides? I'm not sure, but it is a very interesting experiment that I hope is monitored and evaluated.

The other side effect of the government negotiating directly with pharmaceutical companies is on TV. Or rather, is NOT on TV. We noticed the first few days that we were here- there are virtually NO drug ads in the media. No patients coming in asking for the latest antihistamine, antidepressant, etc. by brand name. In fact, when I prescibed fluoxetine to an elderly man recently, I gently explained that this drug had become rather famous and controversial under the brand name "Prozac". I was about to discuss any questions or concerns he had about that, when he cut me off with "well, I never heard of it before!". That was a bit of a shock, I'll tell you!

Finally, one of the first things I noticed about a New Zealand pharmacy is that 4/5's of the floor and counter space is taken up by cosmetics. There is usually only 1-2 small shelving racks for drugs, and usually over half of those OTC drugs are common herbals, like ginseng, ginko, black cohosh, etc. However, the herbals here are most often at homeopathic strengths, so I don't worry much about drug interactions or effects as the strength is so low.

Most people treat a cold at home, with home remedies like tea, hot and cold packs, and for children, nasal suction and saline drops. You can sometimes find Dimetapp or Benadryl cold products on the shelves of the pharmacies, but the chemist will get them for you and discuss their use. You never find OTC cough and cold products in grocery stores, or in the "dairy" store (New Zealand's answer to "7/11"). So I don't worry a lot about patients taking OTC meds. The most commonly sold medicine here is Panadol (paracetamol or as we would know it, acetominophen [Tylenol]). By and large a lot of folks don't even take that when they should, as in the sheep farmer I saw who walked around on a fractured fibula for 3 days with no pain meds or treatment, and only came in when the swelling interfered with getting his boots on.

All this makes me think that for a lot of things, more expensive, newer drugs are not the answer. Pharmac's system certainly attempts to balance evidence, cost and public health with the needs of patients. I don't feel I can conclude how well it works, but I can say that it is a great example to look at closely when we consider the 44+ million uninsured patients in our own country who have NO access to affordable medicines. And I really enjoy not having to listen to patients tell me how their drug costs are forcing them to choose between food and medicines. It gives me time to really work on the compliance issues of how and when they are taking their medicine, instead of wasting time talking about why they can't even buy it.

It's been a nice weekend here in Winton. Yesterday was cold and rainy in the morning; so much so that we had to start up the stove to warm the house. I never expected to see coal mines in New Zealand, but there are quite a few small strip mines in the Hokonui hills around here. Mostly they are places where a trench has been dug, or a hillside dug into and the coal is taken out with a backhoe. You can buy it by the gunney sack here, and I must say it does heat the house wonderfully well- lasting lots longer than wood would! [sorry, I could't resist]. At first I felt bad about all that greenhouse gas going up the flue, but when you think about it, its probably more energy efficient that burning coal in a huge powerplant, converting the heat to electricity, transmitting it over power lines and then converting it back into heat. These stoves seem to burn pretty well, although occaisionally we'll get an acrid smell while on a walk around town, and I wonder if it isn't somebody's coal burning stove. Or then again, maybe somebody is just burning a tyre, as they spell it here.



















In the afternoon the girls were busy cooking or knitting or doing things, so I took the car and drove over to Browns and the Hokonui hills to walk at Dunsdale. The road takes you up into the hills, on 8 km of gravel through half-grown pine forests that are being farmed for eventual logging some day. The rain held off as I drove into the carpark. I was the only one there. I put on my goretex raincoat and hat and took a walk in the forest. This is a very easy level walk along both banks of a stream, that comes out in a grassy flat up above. Just as I got to the open area, it began to pour- so I stopped under the trees and just waited it out for about 20 minutes. I was rewarded for standing still by having a bellbird come look me over, about 4 feet away, and start singing his song. It was great, because mostly you hear them but never see them. The rain let up for a bit, and I walked through the meadow, over and back down the stream. Halfway down it began to pour again- but in the dense bush you hardly notice it. I got back to the car after an hour's pleasant walk with just sounds of birdsong, wind and falling water for company.

On the way back down, a lone sheep was in the road, having jumped the fence and being too dumb to find the way back in. (One of my Quincy patients told me once that "sheep were her proof of the existence of God, as no animal so dumb could survive without God watching over it.") The rain was pouring again, but as I came down the road further a young farmer was coming up on his 4-wheeler, typical "Southern Man" type, as they call it here, with rain slicker, hat and 2 very wet sheep dogs balancing on the back. I waved him over.
"There's a sheep loose on the road back up there- I don't know if it matters much" I yelled at him.
"Hmm," he said. "Could be one of mine, how far back was it?"
"About 1/2 a kilometer, just after the hill that's being mined."
"Hmm...... Lovely day out here, isn't it?" he said, looking around at the pounding rain, "I'm sure it will find its way home eventually".
"Yeah, I guess. Its beautiful out here though in the rain." I said, "I was up walking in the hills, and there was no one else up there".
[Looking out at the rain.] "Well there wouldn't be now, would there?. But when you're alone up there you're either the King or Mad I guess."
"Well, Mad probably fits me best", I said.
He grinned, waved goodbye, and gunned his 4-wheeler off, in a direction away from the sheep.

Contrast yesterday's walk with today's trip to Queenstown. This was a lovely drive, up the Oreti river valley, 150 km. We went mostly to explore the area. Liz wanted to shop a bit, as she's realized that she has no warm clothes. Her dream is to find a cheap sheepskin coat. I wanted to get the lay of the land, see the place, and maybe do a short walk. We spent most of the afternoon there. It is a very pretty resort town, in a beautiful setting. The sky and lake really ARE that blue color, and the rain cleared off on our drive up, so we had perfect weather. The mountains are beyond human scale. However, I just am not excited about drinking cappucino and watching the lake and the people jet-boating and paragliding over it. And you won't catch me bungy-jumping this trip. I visited the DOC office and looked in a few shops with the girls. Prices were as-expected for a high end resort town. Liz wanted to shop some more, so Vicki and I drove up the lake and did an hour's hike up the terrace to Lake Dispute and back. Beautiful day, but not nearly as peaceful as the trees, alone in the rain. My opinion of Queenstown: resort not really my cup of tea, great place to make plans to go somewhere else (like the backcountry or Fiordland, etc.). But with lots of fresh air, sunshine and blue lake and clouds, certainly one of the world's most stunning places for scenery and setting.