Resistance, delivered

Antimicrobial resistance remains one of the gravest public health challenges of our time


Muhammad Hamid Zaman January 24, 2023
The writer is a Howard Hughes Medical Institute professor of Biomedical Engineering, International Health and Medicine at Boston University. He tweets @mhzaman

"Everything can be delivered,” claimed one relative as I was on my way to Pakistan. For them, apps and home delivery services had been a life-changing experience. While home delivery of food items from restaurants had started well before Covid-19, the pandemic had made it a lot easier for customers to get pretty much anything they desired. It had not occurred to me, until last week, that everything included medicines. Apparently, several drug stores have their own delivery people (or partners) who would conveniently fill that gap in case a particular app was not an option.

Over the weekend in Lahore, three years since I had been last here, I decided to run a simple experiment. It was close to midnight, and some of the stores were going to close soon. I downloaded the delivery app and entered information about what I wanted. And yes, to my surprise (and dismay), I could get medicines at the doorstep. These medicines included antibiotics for serious, life-threatening infections. Just to make sure that there was no issue with the app, I called pharmacies within a few mile radius of where I had been staying. Every single one of the pharmacies said that they would be glad to send the drugs on the order made on the app or through other delivery mechanisms. No one asked me about the prescription, or the condition for which I needed the drug. When I asked if I could get a whole box (that would have several hundred tablets as opposed to five or ten that would be the normal course), I was told that it would be no problem at all.

On the app, and in my conversations with the pharmacists who were willing to send me the drugs via a delivery person, I requested azithromycin, the last line of our defence against extensively drug resistant typhoid. That particular typhoid outbreak that started in 2016 still continues to go strong as our recent work in Punjab has shown (published in the American Journal of Tropical Medicine and Hygiene in January 2023). If the pathogen that is causing typhoid becomes resistant to azithromycin (and there are some early indicators showing that it already has), we would be left with very little to save those who are infected. Abuse and overuse of the drug, and the convenience of doorstep delivery of boxes within minutes, is likely to make that a reality sooner than later.

To make sure that I was not somehow misunderstanding the grave reality, I called up a few pharmacies that were not in the immediate vicinity of where I was staying. It was the same answer. In one instance, one particular brand of azithromycin was not available, but the sales person offered me several other brands. Clearly, I had plenty of options to choose from.

In a country where few bother getting prescriptions for antibiotics, and even fewer on the other end of the counter request one, I should not have been surprised with the results of my mini-experiment. But I was. In hindsight I was perhaps more troubled than surprised. Antimicrobial resistance remains one of the gravest public health challenges of our time killing well over a million every year, but here in a large urban centre of one of the most populous countries of the world, we were not only playing with our own lives, we were endangering the lives of countless people around us, not just in Lahore but all over the world.

I wondered about not just the legal aspect but also the ethical one. There are numerous laws on the books in the country about prescription practices
— few are followed. But should the delivery service not have any obligation to protect public health? Or as long as there is a willing seller and a willing buyer, they are just happy to deliver whatever is ordered. Where do we draw the line?

Technology and privatisation are being pitched as the cure to the ills of our bankrupt economy. But without sound ethics and effective regulation, they are likely to make a lot more people very, very sick.

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