Small plastic packets filled with a mix of pills of various sizes, shapes and colours sit piled on the counter of a pharmacy in Phnom Penh’s Meanchey district, home to several large garment factories.
At 2,000 riel a pop, about 50 cents, these packs are sold as a cheap remedy for fevers, coughs or any number of ailments from which the young and mostly female workers living nearby suffer. They’re designed to get them back on their feet as quickly as possible.
“I always mix these together and give these to customers [to take three times a day]. My husband is a doctor and he taught me,” says Pheap, a kindly 67-year-old who dispenses the medicine at the pharmacy licensed under her husband’s name.
Customers buy as many packets as they need, or can afford, and often stockpile them at home to start using again the next time they get sick, she says.
But among the jumble of six pills in each packet, cobbled together from various unlabelled plastic tubs, one large blue and yellow pill stands out from the assortment of aspirins, vitamins and other over-the-counter medicines.
It is cloxacillin, a penicillin-class antibiotic for bacterial infections that should be prescribed by a doctor and is wholly ineffective for treating viral infections like the common cold or flu. When used, a prescribed course is meant to be followed – and completed.
But Yu Manith, a 25-year-old factory worker, says she buys such mixed-medicine packets directly from pharmacies whenever she gets ill, and simply takes as many as are needed to make her feel better.
“Oh, I don’t know what antibiotics are, and I don’t care. I just follow the instructions to take whatever the pharmacy gives me until I get better. It works so fast. I don’t want to go to the doctor, because I don’t want to spend money.”
Whenever antibiotics are used – especially if improperly or unnecessarily – there are risks that some bacteria, due to a genetic mutation, won’t be killed by the medicine.
These “resistant” bacteria can quickly replicate and spread, creating a vicious cycle where different, stronger and more expensive antibiotics might be needed for effective treatment, possibly inducing further resistance.
The World Health Organization has warned that antimicrobial resistance (AMR), which encompasses antibiotic, antiviral and anti-malarial resistance, puts “the achievements of modern medicine” at risk and requires urgent global action.
An estimated 25,000 people die each year in Europe from antibiotic-resistant bacteria, according to medical journal The Lancet.
Though a lack of data exists for poorer nations, it is expected that the costs are greater in developing countries like Cambodia due to a higher burden of infectious disease and less access to new antibiotics.
“A crisis looms. In the very near and rapidly approaching future, the wonder drugs of the 20th century, antibiotics, may cease to be useful,” the journal warned in an editorial last year.
‘Everything starts with using antibiotics’
‘Everything starts with using antibiotics’
Easy, unrestricted access to antibiotics over the counter is fuelling AMR in Cambodia, health experts say.
“Everything starts with using antibiotics. Over the past decade, people have become a little bit richer, access to drugs has become more easy … the idea has grown that when you are sick you need an antibiotic,” says Erika Vlieghe, a researcher from the Institute of Tropical Medicine (ITM) in Antwerp, Belgium.
A particular problem is that people “buy only as much as they can afford instead of what they need”, she says, with low doses of just a few pills creating the ideal circumstances for resistant bacteria to flourish.
Pheap, who prepares the packets that each hold one tablet of cloxacillin, agrees, saying that how much customers take depends on “how serious or not serious their illness is and whether they have money or no money”.
Appropriate antibiotic treatment must account for the presence of resistant bacteria, public health researchers say, but little is known about patterns of resistance in poorer countries like Cambodia, which lack well-functioning laboratories.
As part of her PhD research, Vlieghe studied blood samples from all patients who checked in to the Sihanouk Hospital Center of Hope between 2007 and 2010 with fever – the first time such large-scale blood sampling had occurred in Cambodia, according to ITM.
Roughly 500 patients had bloodstream infections, most of which were caused by E. coli and other intestinal bacterium, but many could not be treated with commonly used antibiotics.
“Sixty to 70 per cent of patients who attended with a serial bacterial infection could not be treated anymore with a general, broad-spectrum antibiotic, which was pretty shocking,” Vlieghe says.
Such resistant bacteria, which render first-line treatments ineffective and increase the financial burden on families and societies – can quickly spread in densely populated areas, including crowded hospital rooms and family homes, she adds.
The customer’s always right
According to the Ministry of Health, there were 1,795 licensed pharmacies operating in Cambodia last year, with no illegal pharmacies operating since 2011.
According to the Ministry of Health, there were 1,795 licensed pharmacies operating in Cambodia last year, with no illegal pharmacies operating since 2011.
Several pharmacists around Phnom Penh the Post spoke to said they were well aware that it was dangerous to give out antibiotics without a prescription or in incomplete doses, and that they tried to avoid doing so when possible.
According to one Tonle Bassac commune pharmacist, “It’s up to the customer ordering, if they ask for one they know works, we give it to them. [But] without the customer asking specifically or without a doctor’s prescription, I do not dare to give it to them.
“This is the culture. So if the customers want to buy it, I have to sell it. Most pharmacies do like this; it’s OK under the law,” she said.
According to Dr Chou Monidarin, vice-dean of the faculty of pharmacy at the University of Health Sciences, 400 students were admitted to pharmacy training courses in Cambodia this academic year, 160 of those at UHS.
Although his university is confident that its graduating students fully understand the risks of dispensing antibiotics without a prescription, he admits he cannot be sure that those who go on to open private pharmacies will follow what they have learned.
“When they finish pharmacy school and open private pharmacies, they really respect and abide by what they have learned. But unfortunately, if they respect everything, they will lose a lot [financially], because they must not sell any antibiotics without a prescription, and almost no customers come in with a prescription.”
Government policy states that “all levels of pharmacies will sell medicines only with prescriptions, except over-the-counter medicines as specified by the Ministry of Health”.
But according to Dr Or Oudam Roath, head of the Essential Drug Bureau at the Department of Drugs and Food, this policy has yet to be fully implemented at private pharmacies.
“In the policy, it is already mentioned like this. But now we cannot do this yet [at all privately owned pharmacies],” she says.
“The role of the pharmacy in the private sector cannot continue to be [directly] treating people.… In the future, step-by-step, this should change when people understand they should see the doctor first before going to buy medicine.
“But in the public sector, we have guidelines [already], and they are respected.”
source:http://www.phnompenhpost.com/national/recipe-disaster
