3rd world medicines

       I routinely hear from relatives, how the medical system in my native country of Bangladesh is terrible. As a third world country, access to care, diagnostics and medications is a difficult everyday reality, especially for the millions in poverty. But even for those with money and access to the best care, my relatives often insist they don't know what they're doing. They complain to me and encourage their sick family members to find a way to get to a country with more advanced care. They tell me these things as I think about how physicians in 3rd world countries are excellent diagnosticians because they don't rely as much on imaging or even blood tests. I think about how, despite our advanced technology and monetary investment in healthcare, our mortality data lags behind many other industrialized nations. I respect my elders and their belief in our healthcare system, and graciously accept their praise of my "expertise," while secretly harboring skepticism towards their beliefs.
       Last year, I saw a 44 year old gentleman immigrant from Bangladesh who presented as a new patient. He had a fairly long list of medical problems for a young man. He had diabetes mellitus requiring insulin, he had a history of a coronary artery disease, high cholesterol, anxiety and depression. He was a pleasant gentlemen, who had been doing well without any particular chief complaint. His primary concern was getting refills on his medications. For the past 6 months, his physician in Bangladesh had been mailing them, but realized this was a dangerous proposition after 1 shipment was delayed and he missed a few doses. I looked at his medication list and didn't recognize a single name except aspirin. After doing some research online, his deciphered medication list included an Angiotensin receptor blocker (ARB), a beta blocker, a statin, an ssri for depression, and a long acting insulin. It seemed like a very sensible evidence based regimen, and by all accounts had kept him symptom free, without any recent hospitalizations.
        Despite my preconceived notions about his health care in Bangladesh, I was thrilled at how well he was doing. As we were concluding the visit and I began renewing his medications, the dreaded "I" word reared its ugly head. He was a working man but unable to afford insurance yet. Quickly, I realized he would not be able to afford the ARB. I suggested an ACE inhibitor, which he recalled getting a cough from. But he would take it. We found the same beta blocker, except it wasn't an extended release version, so he'd have to take it twice a day. He was on a brand name statin but now would have to settle for something less efficacious. The SSRI needed to be changed to something cheaper, despite its success. The insulin, despite being generically available here would be far more expensive than back home.
        In the spirit of full disclosure, I was embarrassed to tell my countryman, some of his new medications maybe inferior to what he was already on. He had a perplexed look on his face, waiting for an explanation. I have a hard enough time trying to cogently describe to a medical student or a resident, how our healthcare system operates, let alone an immigrant lay person. I couldn't give him a straight answer, except to reassure him, we would make this current regimen work. His last question for me was whether he should finish the last 10 days of these 3rd world medicines. My 1st world expert training and sensibilities suggested yes.