Invading the Commonwealth

I’m in Ghana at the Commonwealth Pharmacists Association (CPA) Annual Conference to talk about drug resistance. Ghanaians are famously friendly, and everyone here has been so welcoming that I think they’re ready to invite us to join the Commonwealth: an option the U.S. chose not to exercise once before. All in all, the right decision because otherwise, I’d have to remember the words to God Save the Queen, and I do badly enough with the Star Spangled Banner. The Commonwealth Pharmacy meeting attracts about 2000 pharmacists from all over the world. This year’s meeting has a strong representation of Nigerians -- so much so that one speaker in the opening plenary slipped up and introduced the local host of the meeting, Professor Alex Dodoo, as the president of the Ghana Pharmaceutical Society of Nigeria! Alex, a member of the CGD Drug Resistance Working Group, is thankfully, also very good-natured, and the invasion of the Nigerians became a running joke at the conference. It’s a good thing the Nigerians are here in force, because they and others in Africa need to get serious about drug resistance. If there is a front line against drug resistance, its advance team is the pharmacy profession, and Nigeria is where the battle is being waged. Pharmacists – and less formal dispensers of drugs – interact more with patients seeking drugs and the pharmaceutical companies seeking to sell drugs than anyone else in the health system. They also see the results of ineffective and counterfeit drugs, in the faces of the patients who keep returning because the few pills they first bought didn’t work, or in the jumble of expired and useless medicines handed out by well-meaning charities, or in the almost-perfect holograms affixed to the boxes of anti-malarials made in China that don’t have any active pharmaceutical ingredients (API) in them. Each of these is the starting point for drug resistance, and the end of effective health care. Nigeria has seen more than its share of all these, and until she was promoted to Minister of Information under the new government, Dora Akunyili was a famously aggressive National Drug regulator in Nigeria. In her first 5 years (2001-2006) as head of the National Agency of Food and Drug Administration (NAFDAC), the proportion of fake drugs sold in Nigeria dropped from 70% to about 10%.¹CGD’s Drug Resistance Working Group came to Ghana to share draft recommendations about how global policies and actions can contain and prevent the spread of drug resistance. There are pharmacists from 40 countries represented in the CPA, from Antigua to Zambia. Next month, I will be in Istanbul at the invitation of the International Pharmacists Association (FIP) to share our recommendations at their global conference. We’re spending the time and money to meet with approximately 5000 pharmacists and pharmacy educators from around the world, because drug resistance can’t be slowed without their help.The DRWG has plenty to talk with pharmacists about. We will be releasing our consultation draft report later this month on our website, and disseminating it widely. Almost half of our recommendations relate to pharmacists in some way, because appropriate drug use is where the rubber meets the road on drug resistance.But there’s a big distance between good ideas – even those carefully based in evidence and endorsed by international players – and the reality. Here’s what we hear around these halls: parents can’t always read drug labels to give correct dosages to their children, full courses of medicines may be prescribed but are often not purchased, there is virtually no training in pharmacy schools about drug resistance, central medical stores often contain less than 50 percent of essential medicines on their shelves, and on and on. Here’s what we see around these halls: the conference room is filled with serious discussion of improving drug quality and appropriate dispensing and the hallways are filled with exhibits from manufacturers that are well-known here for not meeting quality manufacturing standards (one exhibit stall displays bottles of olive oil in many sizes that are almost appetizing until you notice that it is recommended for deworming!). Meanwhile, just a few hours down the road from Accra, members of the DRWG visited the coastal community of Apam, which has no running water and no sanitation. What it does have is frequent outbreaks of ciprofloxacin-resistant typhoid and cholera, so much that people dose themselves almost continuously with antibiotics, making such resistant strains rampant.There is no scarcity of ideas about how to reduce the spread of drug resistance in African communities. The DRWG has worked hard to select from among the good ideas those with evidence to back them up (such as drug dispenser certification and professional education with real incentives) and to devise feasible ideas for those aspects of resistance that need new attention (such as global industry standards for post-marketing quality assurance). But the real challenge lies ahead in getting global stakeholders to take responsibility for this problem – and it is not just the pharmacists who need to put their olive oil on their pasta and take medicines more seriously.---------------------¹ Ann Harding, “Dora Akunyili: scourge of Nigerian drug counterfeiters.” The Lancet, Volume 367, Issue 9521, Page 1479, 6 May 2006.