The pharmacist’s role in fighting antimicrobial resistance

Every day, people walk into Stella Nanyonga’s pharmacy in Kampala and tell her exactly what they need. Carrying old medicine boxes and handwritten notes scribbled with advice from neighbors, they point at her shelf of medicine, instructing her: “I want the red and black capsules.”

It’s antibiotics they are looking for — but often, they don’t actually need them.

Uganda has a law that dictates antibiotics should only be sold with a prescription. It aims to curb the misuse and abuse of antibiotics which is fueling the silent pandemic of antimicrobial resistance. At least 700,000 people each year die globally from drug-resistant disease. Without action, this could spiral to 10 million deaths each year by 2050, with 4.1 million people likely to be from Africa. In the next 10 years, it could push another 24 million people into extreme poverty.

But the law is not well enforced in Uganda, Nanyonga said, and many pharmacies dole out antibiotics to patients without prescriptions. At its root is a flawed profit model for the distribution of drugs — many pharmacy owners are more interested in increasing sales than withholding antibiotics from a patient that doesn’t actually need them. And many people would rather go straight to the pharmacy than spend additional money and time at a health clinic to get a proper diagnosis, Nanyonga said.

This problem is true in many African nations, health experts say, where weak regulatory systems, porous borders, and a lack of incentives to improve distribution practices are increasing drug resistance.

“Imagine if all the babies who come into the hospital with childhood pneumonia end up dead because we don't have an antibiotic to treat them? It would be a catastrophe,” Nanyonga said. “But I don't know why no one sees that.”

A looming catastrophe

The problem became personal for Nanyonga when she worked as a hospital pharmacist.

“Everyone who would walk into our outpatient department, walked out with an antibiotic. It was so gross,” she said. “I knew: This is a ticking time bomb — just waiting to go off.”

One patient she encountered had a drug-resistant infected wound on his leg. He died after he was referred to Nairobi for more intensive treatment.

She is now the chair of the antimicrobial resistance committee at the Pharmaceutical Society of Uganda. The committee, which is eight months old, is providing training on antimicrobial resistance for pharmacists. It is also working with medical students at three universities and supports pharmacy students who are conducting research on antimicrobial resistance.

When a person comes into her pharmacy, maybe to pick up medicine for their child’s cough, Nanyonga will probe them on symptoms. She then might offer a cough syrup, which often they refuse, instead asking for antibiotics. People in Kampala have learned it’s easier to go to the pharmacy with their own self-diagnosis, as opposed to the health clinic, she said, adding that if she doesn’t give them antibiotics, they will just walk to the next pharmacy.

It’s because of this that some pharmacy owners prefer their pharmacists don’t come in for work. They notice that sales go down during the shifts where the pharmacist is counseling the customer, she said.

“Are you going to turn away people who come in without a prescription, if those people are your loyal customers, and there is a likelihood that turning away those customers cuts into your sales and ultimately, your profit?” asked Dr. Walter Fuller, antimicrobial resistance stewardship and awareness lead at the World Health Organization’s Regional Office for Africa.

The demand for antibiotics is so high, Nanyonga said, because many people don’t know how to differentiate between a viral infection — which can’t be treated with antibiotics — and a bacterial infection. And often when people come into the pharmacy and get antibiotics, they do end up feeling better in a few days.

“But viral infections clear within three days, so it doesn't mean the antibiotics are actually working,” she said.

People might also come into a pharmacy and only purchase a portion of pills, instead of the full course of several days worth of antibiotics. Not finishing the full treatment can lead to resistance.

“They will tell you: ‘I'll come tomorrow when I get more money.’ But two days later, when they are better, they won’t come and buy the rest of the doses,” Nanyonga said.

Or a person who feels better might save the rest of the doses for the next time they are sick or share them with someone else, she said.

Nanyonga estimates that about 20% of the pharmacists in Kampala actually follow the prescription-only law, and the rest hand out antibiotics without prescriptions.

Improving enforcement and enhancing awareness

Antibiotics are sold at roadside markets or hawked by merchants wandering the streets because of the weakly regulated pharmaceutical supply chains in some African countries that allow medicines to move, untracked through porous borders and into the wrong hands, said Joachim Osur, public health specialist at Amref Health Africa. Some markets are also flush with fake drugs — including antibiotics with watered-down ingredients.

“Sometimes resistance happens because a person is under-dosing. The medicine does not contain the active ingredients that it purports to contain,” he said.

And, in some countries, there is limited oversight over everything. In low resource settings, governments juggle a lot of issues — and the enforcement of laws surrounding antimicrobial resistance might not be a priority, WHO’s Fuller said.

“It is not a question of if countries have laws or not. Most countries have laws. The question is the problem of enforcement,” he said.

The Africa Medicines Agency, which is now ratified, plans to unify regulatory efforts across the continent, with expectations the body will help reduce the infiltration of fake drugs into the supply chain. But the creation of the agency is still in very early stages.

For Nanyonga, the heart of the issue is awareness. She’s found many people are willing to change behaviors after she sits down and explains to them how improper use of antibiotics might limit future treatment options. She wrote a column in a local newspaper a few years ago and was flooded with feedback from people wanting to know more.

“When you look at awareness, I believe this is where we're letting everyone down,” she said. “Because we're not telling them about it, they just go to the pharmacy and demand antibiotics.”

WHO’s regional office for Africa is working on raising awareness across the continent, including providing messaging tailored to different practitioners, such as doctors, pharmacists, policymakers, and communities. There is a need for “a holistic approach where the policy, the regulations, the incentive to pharmacists and the society are coming together to address this problem,” Fuller said.

Pharmacists also need continuous education on the management of antibiotics, he said. This should be supplemented further with business training to help pharmacy owners leverage other parts of their businesses, such as how to sell alternative therapies to antimicrobials.

“Then their bottom line at the end of the day is not affected,” he said “We want partners. We want people who are willing to do the job and not feel as if they are suffering because they are doing it.”

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