Better access to drugs in developing countries is accelerating resistance
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3234 (Published 17 June 2010) Cite this as: BMJ 2010;340:c3234
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Singh DK, Tuli L, Singh L, Tuli D.
E mail: deepakbhu@gmail.com, tuli_lekha@rediffmail.com
The authors [1] have raised a very important question about the
numerous problems due to rampant and unjustified use of drugs. This matter
is of grave concern as the discovery of new antibiotics hasn’t kept pace
with the rising resistance against them.
The three governing factors are the health care provider, the patient
and the drug manufacturing and distribution. A lot has been said about the
role of health care personnel in prescribing an empirical therapy, lack of
proper guidelines for developing countries etc. The role of patients in
the form poor compliance, premature cessation of therapy due to temporary
relief in symptoms, self medication and absence of health awareness cannot
be undermined too. These patterns cause high failure rates and increasing
drug resistance.
However, we overlook the role of manufacturing companies in spreading
the drug resistance. Introduction of generic drugs has drastically reduced
the costs borne by the patients but it introduced in the market
innumerable alternatives for a drug. In a developing country it is very
difficult for the governing body to keep a regular check and maintain
uniform quality standards in drug manufacturing due to several small scale
pharmaceutical industries. At times in clinical practice one sees the
improvement in patient’s condition after changing the brand of the drug
for the same compound prescribed. This raises a question on the
manufacturing efficacy of the pharmaceutical companies. Unpublished
speculations about supplements containing just sugar and nothing more are
very rife in the developing countries. So, the antibiotics too cannot be
an exception. These medicines are fraught with under dosage, low quality
and improper drug release in the body.
There are other untouched factors, responsible for drug resistance
too. Firstly, developing countries have a very high prevalence of the
infectious diseases, so naturally they tend to have more resistant micro
organisms as compared to the developed nations. Secondly, they have low
doctor-patient ratio and high disease prevalence. Thirdly, the private
practitioners avoid taking chances with the empirical therapy and losing
their clientele (patients). As a result, they prescribe newer drugs, which
have no documented resistance against them. This in turn increases
resistance to the newer drugs too. Fourthly, the lack of any recent
knowledge disables the primary health care practitioners for healthy drug
prescription. Fifthly, their knowledge of local drug resistance is
obfuscated by marketing policies and advertisements of the drug companies,
without any solid scientific evidence.
The only way to reduce this discrepant drug use is to practice strict
manufacturing guidelines, stringent licensing and drug distribution by the
governing bodies. A continuous scrutiny and regular inspection of the
manufacturing standards is a must. Finally, educating the peripheral and
primary health care physicians and Contining Medical Education (CMEs)
should be advocated to fill the knowledge gap. After all, appropriate
prescription and drug therapy amidst so much of prejudices and advances is
a Herculean task for a medical practitioner.
References:
1. Mayor S, Better access to drugs in developing countries is accelerating
resistance.
BMJ 2010; 340: c3234.
Competing interests:
None declared
Competing interests: No competing interests
There is an urgent need for improvement in access to unbiased drug
information for patients, prescribers and dispensers worldwide. All these
groups must have ready access to appropriate, unbiased information about
medicines. Without such access, there is no opportunity to learn, no
opportunity to use medicines appropriately, and no opportunity to reduce
harm from medication error. Irrational prescribing will continue, causing
patient harm, wasting resources, promoting drug resistance, and
threatening public health at national and global level.
Patients, prescribers and dispensers need to work with providers of
drug information and others to find ways to achieve universal access to
information and to promote its use. Ultimately, this is the responsibility
of national governments, supported by international agencies, as part of
their obligation to progressively realise the right to health of their
people. Universal access is readily achievable and should be highlighted
as an urgent objective to reduce and prevent unnecessary death and
suffering, now and in the future.
Best wishes,
Neil
Dr Neil Pakenham-Walsh MB,BS
Coordinator, HIFA2015
Co-director, Global Healthcare Information Network
16 Woodfield Drive
Charlbury, Oxfordshire OX7 3SE, UK
Email: neil.pakenham-walsh@ghi-net.org
HIFA2015: http://www.hifa2015.org
Join HIFA2015 and CHILD2015 - send your name, organisation and brief
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walsh@ghi-net.org )
"Healthcare Information For All by 2015: By 2015, every person
worldwide will have access to an informed healthcare provider"
With thanks to our 2010 financial supporters: British Medical
Association, International Child Health Group (Royal College of
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Royal College of Midwives, Royal College of Nursing, and TRIP Database
HIFA2015 profile: Neil Pakenham-Walsh is the coordinator of the
HIFA2015 campaign and co-director of the Global Healthcare Information
Network. He started his career as a hospital doctor in the UK, and has
clinical experience in rural Ecuador and Peru. For the last 20 years he
has been committed to improving the availability of healthcare information
for health workers in developing countries. He has worked with the World
Health Organization, the Wellcome Trust, Medicine Digest and INASP
(International Network for the Availability of Scientific Publications).
www.hifa2015.org neil.pakenham-walsh AT ghi-net.org
Competing interests:
I work as Coordinator of the Healthcare Information For All by 2015 campaign
Competing interests: No competing interests
In South Asian countries like India one does not require a
prescription to get virtually any drug from a pharmacy. You
can walk into any pharmacy, ask for a drug and nine times
out of ten there is no objection from the pharmacist as
sending away such 'customers' cuts into his income. As a
result, the prevalence of resistant strains of E.coli
causing urinary infections and S.pneumoniae, H. influenza
and M.catarrhalis causing sinusitis and bronchitis has
increased astronomically in recent years, as these diseases
are often self treated by patients with the advice of
pharmacists. Fever of unknown origin are treated empirically
in rural settings for typhoid leading to emergence of
nalidixic acid-resistant strains in Asia. Patients often
stop the antibiotic as soon as they feel better before
attaining microbiological cure, more often due to lack of
proper guidance but sometimes also for economic reasons,
which also contributes to resistance.
The situation is no better in government hospitals where the
huge number of patients and lack of adequate resources
mandate empirical therapy for most in-hospital infections.
Research into local resistance patterns has given variable
results and future research should be directed at developing
treatment guidelines tailored for South Asian countries. The
current practice is to follow empirical therapy guidelines
from developed countries, which although based on sound
evidence and large scale randomized clinical trials may not
be applicable with the rampant resistance patterns to
commonly used beta-lactams, quinolones and macrolides. An
allowance for more empirical therapy must be accounted for by
the guidelines, as culture to identify the offending
pathogen is not realistically possible in many rural
community centers.
Competing interests:
None declared
Competing interests: No competing interests
Editor, I agree that the note by Mayor might be an important but
forgotten issue in infectious medicine [1]. Due to urbanization in many
developing countries, better life of local population and increased
accessibility to drug can be expected. This can be a dilemma. People might
get better medical care but it might lead to the problem if there is no
good control of drug usage. Control must cover production, distribution,
usage and post usage surveillance.
References
1. Mayor S. Better access to drugs in developing countries is accelerating
resistance. BMJ 2010; 340: c3234
Competing interests:
None declared
Competing interests: No competing interests
Drug resistance in developing countries: Who is responsible?
Improving access to drugs to treat serious diseases common in
developing countries as mentioned by author [1] is not the only factor
which is responsible for microbial resistance to drugs. Factors that are
responsible for antimicrobial resistance can be broadly classified in to
patient related and prescriber related. To an extent even a few
pharmaceutical companies and hospitals contribute to microbial resistance
menace.
Patient related factor include self medication. Many patients in
developing countries opt for self medication when they feel they are ill.
Self medication by patients started with pain killers and extended to the
drugs which have to be taken strictly according to physician's
instructions. Due to poor implementation of legislations, most frequently,
antibiotics are dispensed with out prescription by pharmacists in
developing countries. Drugs having low dose of active ingredient may
considerably contribute to microbial resistance. Less educated patients
fail to differentiate between substandard, spurious, fake drugs to that of
genuine drugs. Income level of patients also to a lesser extent may be a
factor, when patients settle down to low priced substandard drugs.
Prescriber related factor like lack of prescriber knowledge about the
organism causing infection, lack of patient followup and fear of
litigation to a lesser extent may all contribute to the drug resistance.
Now increasingly physicians are under pressure to prescribe the latest
generation antibiotics to keep up their good practice and to satisfy the
expectations of patients [2]. Hence, most of the physicians are
prescribing the latest broad spectrum antibiotics although there are
narrow spectrum antibiotics very well available for treating specific
infections. Also many physicians tend to prescribe injectable broad
spectrum antibiotics as many patients feel injectable agents are superior
over their oral counterparts.
A few pharmaceutical companies also contribute to the resistance by
manufacturing substandard, spurious and drugs of low quality which usually
contain low dose of active ingredient or the bioavailability of
formulation is compromised. Recently some pharmaceutical companies were
blamed of manufacturing irrational combinations. These irrational
combinations are said to contain antibiotics, antifungal agents and
painkillers in combination where no rationale of combining such drugs were
mentioned in standard pharmacology textbooks and also such combinations
were not suggested by the experts. Ciprofloxacin and Tinidazole
combination although considered to be broad spectrum, combining a
fluoroquinolone antibacterial and antiprotozoal is irrational because
patient suffers from only one type of diarrhea. Also Amoxycillin and
Cloxacillin is said to be irrational as Amoxycilin is inactive against
Staphylococcus and Cloxacillin is not so active against Streptococci. For
any given infection, one of the components is useless but adds to cost and
adverse effect. Since amount of each drug is halved, efficacy is reduced
and chances of selecting resistant strains are increased [3]. Many
pharmaceutical companies are advertising their drugs both prescription
only and over the counter drugs in mass media. This direct to consumer
advertising is slowly encouraging self medication among patients.
A few unhygienic hospitals may also contribute to the problem by
spreading the resistant microorganisms. Resistant nosocomial infections
are extremely dangerous and difficult to eradicate.
There is an urgent need to tackle these factors inorder to reduce the
ever increasing bacterial resistance to drugs. It is only possible by
coordinated effort of all the stakeholders of health care namely
physicians, nurses, pharmaceutical manufacturers, pharmacists and
patients.
References
1. Mayor S, Better access to drugs in developing countries is
accelerating resistance. BMJ 2010; 340: c3234.
2. Alexandre S. Are We Killing the Cures? Perspectives in health
2002; 7:1.
3. Gautam C S and Aditya S. Irrational drug combinations: need to
sensitise the undergraduates. Indian J Pharmacol 2006; 38:169-70.
Competing interests:
None declared
Competing interests: No competing interests