By Amelia Earnest
If two cars have a fender bender in the United States, a cascade of formalities commences—numbers exchanged, police called, insurance notified, documentation filled out. I have noticed, however, that in all of the congested traffic, street venders, performers, and seemingly kamikaze pedestrians of Peru, the protocol for handling minor accidents like this is quite a bit more autonomous—and certainly more efficient. In fact, it seems to only involve two steps—general assignment of blame and hurried transfer of crumpled bills, with both cars still blocking traffic in the right lane.
This unregulated interaction is a general trend I have noticed in Lima—the desire to handle commonplace issues between individuals, in the street instead of at the police station, with apologies instead of lawsuits, with an en route haggle instead of a taximeter.
The origin of this attitude might be attributed to several factors—increased flexibility with a sparser authority presence; a desire to evade police and other higher-ups who are often seen as inefficient or corrupt; and a general greater expectation of personal responsibility towards individuals, something well exhibited in the five year olds entrusted to sell food and cigarettes from a cart, or small schoolgirls crossing busy streets alone, walking home from school.
It is really no wonder then, that this cultural norm of increased personal freedom from regulating forces is also reflected in health practices, most visibly in the small pharmacy-like stores known in Peru as “Boticas.”
Under the law, there is no real difference between a “farmacia” and a “botica.” Both require a licensed pharmacist and are subject to a host of governmental rules and regulations. In practice, however, the two differ drastically. Pharmacies are chains of spotless, fluorescently lit stores selling only prescription medications and basic, but overpriced, health essentials like toothpaste. Boticas, on the other hand, are a much more hodgepodge, exotic affair. They are generally a more mom-and-pop style establishment, and as such, vary hugely from one to the next. Some greatly resemble the typical western idea of a pharmacy, but the majority fall outside of this category—selling not only a sporadic collection of popular prescription medications, but also heaps of clothing, dusty knickknacks, and folk-medicine plant cures, as well as occasionally offering random services like document-copying or hair styling.
Boticas are notorious for their own breed of DIY healthcare, in which any person can walk in off of the street and buy himself a regulated medication without the corresponding prescription from a medical doctor. This bypasses the intermediary—and often expensive—step of seeing a doctor, and allows the person to go straight to a quick fix. This practice does have some positive effects: by removing disincentives that often impede the treatment of contagious diseases, such as losing time from work, power imbalances experienced in interactions with medical professionals, or high expense, Boticas make medicine a more accessible commodity to the poor.
On the whole, however, boticas create more problems than they alleviate. Because there is no doctor involved, the diagnosis is either self-determined, or, more commonly, is “diagnosed” by the pharmacist behind the counter—if there is, in fact, even a pharmacist actually involved. Although some Peruvians do realize that they are receiving substandard advice at a price to match, many consumers of Boticas do not grasp that the person behind the counter in uniform is not a doctor.
In April alone, five Boticas were closed down by the Peruvian health officials. With charges like sale of expired, illegal, or adultrated drugs; administration of vaccines of illegal origin; sale medical samples; functioning without a pharmacist on staff; or not counting pills given to consumers, it is easy to see just how harmful the loose practices of Boticas can be on the health of an individual.
A more surreptitious, although equally real, threat from Boticas is posed to population-wide health. Many Peruvian doctors point to Boticas as a contributing factor to the high prevalence Multidrug-resistant Tuberculosis in the poor of Peru, which is in fact the highest prevalence of any nation in of South America. The lackadaisical doling out of antibiotics at the whim of the general population has turned the common sore throat, stuffy nose, and head cold into breeding grounds for super bacteria.
Boticas have worsened TB through other avenues as well—the willy-nilly offer of diagnoses from non-medically trained personal can delay a tuberculosis diagnosis by months. A person from a TB endemic area who enters a real doctor’s office with a persistent productive cough is likely to be tested for tuberculosis. A person with the same symptoms in a Botica is likely to get shoddy advice and a medicine to suppress the cough until it gets better—which is won’t if it is TB—staving off medical intervention until a much more serious phase of the disease.
I admire the increased sense of personal independence present in Peruvian people, their desire to function quickly and fairly without some kind of agency or intervention looming overhead, babysitting. That being said, Boticas are the worst product of this lack of regulation, and epitomize the fundamental reasons why other infrastructures channel incredible quantities of money into vast and tangled networks of hungry-budgeted regulators and ministries, why they bother to lug the good ol’ red tape into every situation.
Recently, I decided to take a long weekend and fly to the Peruvian jungle. It was a last minute plan, and I had less than three days to get to get some kind of malaria prophylaxis medication, and had been trying, to no avail, to hunt down a doctor with an open appointment time. My anxiety at not being able to get an appointment seemed to genuinely perplex a Peruvian nurse. “Why don’t you just go to a Botica?” she asked.
I ended up wearing DEET head to toe.
Amelia Earnest is a junior in Pierson College. Contact her at firstname.lastname@example.org