Apothecary Apathy

How much is your life worth? How much would you do to save it, or your child’s life? Any amount, most likely. Look at the concept and practices of selling medicine around and one feels to be in an uncomfortable position. Those who are responsible for making drugs available in market are not doing enough. That becomes clear after visiting some medical stores, also called pharmacies or apothecaries.

Pharmacies in Pakistan are not meeting licensing requirements. Local reconnaissance reveals that the drugs are not stored properly. Qualified pharmacists are not available. Drug sellers have fragmentary knowledge regarding drug storage. And consumers do not have much choice when anyone has to buy medicine.

In 2001, World Health Organization in collaboration with Pacific Health and Development Sciences Canada, Islamabad Social Mobilization Cell and other local stakeholders carried out a survey to estimate the conditions drug storage in pharmacies in urban Rawalpindi during July–September 2001.

Results: “The proportion of pharmacies meeting licensing requirements was 19.3 percent, with few qualified persons (22 percent). Only 10 percent had a temperature monitoring device and 4 percent an alternative power supply for refrigerators (present in 76 percent of pharmacies). Personal market scouting reveals that not much is different anywhere in Pakistan even now.

Major problem is that of shelf temperature inside the medical stores. The recommended maximum storage and transit temperatures for most drugs is 25 degrees centigrade and are set (and written on the packages) by the pharmaceutical manufacturers. Exceptions apart, most medical stores are keeping drugs at much higher temperatures. Others, who seem to be temperature sensitive, keep a refrigerator and or a deep freezer for special medicines only.

Storage of medicines in medical stores without controlled temperature is a health hazard. “The risk is that the efficacy of drugs will be adversely affected in higher temperature,” says Dr. Najma Khan. She argues, “The quality of drugs deteriorates fast because chemical compounds get decomposed due to exposures to high temperature even for a short period.” On the other hand, we can not afford air conditioning of the store,” says owner manager of a successful medical store at Zarrar Shaheed Road in Sadar Lahore. Academically, the issue of drug efficacy and stability is being studied more closely in the developed world.

Dr. Rubab Shah says, “Research studies have shown that many drugs, including cefalexin, ampicillin and erythromycin have reduction in efficacy when exposed to high temperatures. This is especially true for tablets and capsules. Unnecessary exposure to heat and moisture can cause them to lose their potency prior to their dates of expiration. For example, a warm, muggy environment can cause most commonly used aspirin tablets to break down into acetic acid (vinegar) and salicyclic acid, both of which are potential stomach irritants. Constant exposure to temperatures above 30 degree centigrade for a few days can substantially degrade the antibiotics and vitamins. In rare cases, improperly stored drugs can actually become toxic.

The need for proper storage of drugs starts from the manufacturing units where stockrooms of pharmaceutical companies are located. Very few pharma companies maintain refrigerated godowns for most of their pharma products. Moreover, the quality of drugs gets seriously affected during the transportation from the factory to sale points usually through the open trucks. During course of the journey, drugs get exposed to extreme heat conditions particularly during summer.

Hardly any pharma company insists on transportation of drugs in refrigerated vehicles just to cut costs. The story continues at the retail level too. Some of them, located in rural areas, do not even have a working refrigerator to keep essential vaccines and injections safe. By remaining in the shelves of retail chemists for weeks and months with varying high temperatures, the drugs become further degraded.

Medical stores situated in Cavalry Ground, one of the posh localities of Lahore, that I visited has a notice pasted on the door that reads, “Salesmen boys required.” I asked the owner of the store, who is a retired nursing assistant and is known as “doctor sahib,” about qualification required for appointment. He replied, “No qualification is required. They just have to help me and nothing else” When I pointed out to need of special training for selling medicine, he became conscious and said, “I am trained and have a license.” I counted three other young boys dealing with customers in the store. Even “medical stores situated inside big hospitals are worst,” says Habib Khan, patients pay for degraded products. It is a matter of serious concern that authorities concerned have not been looking at such an important issue like this for years.”

Another practice that has been noted during local exploration is that medical storeowners are selling counterfeit, non registered or even prohibited medicines. Zulifkar Chatta, the district administration and executive district officer said that government has set up a comprehensive monitoring system to check quality of drugs across the country. But nothing seems happening on ground.

Representative of the World Health Organization, Dr Khalif Bille has been quoted as saying at a seminar organized by the Network for Consumers’ Protection in Karachi, “About 70 per cent of the allocated budget for the health sector can be saved and health services and facilities extended to majority of the people if facilities for storing and transporting medicines are improved.”

Enforcement of rules by the regulatory authorities is hardly ever done in our country. There is a need to implement existing legislation with training programmes directed towards drug sellers and to involve the pharmaceutical industry, which plays an important role in influencing pharmacy knowledge and practices.

Consumers must show informed reactions and government should arrange to bring the medicine selling practices to an internationally accepted standards. If pharmacies are air conditioned in other parts of the world, why don’t we set the same standards in Pakistan? (This appeared in daily the Nation)