Perspectives on Global Health from Pharmacists Around the World, Part 3

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patient’s needs are met in countless regions across the earth. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This third segment focuses on local and global pharmacist roles in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Healthcare systems across the globe are unceasingly identifying novel approaches for health professionals to fulfill. The traditional roles that physicians, nurses, and other allied health workers performed in the past have metamorphosed as patient-care management is altered to effectively accompany patients. A few illustrations include: one of the most prominent international non-governmental organizations (INGO), Partners In Health, has a nurse – Sheila Davis – as it’s CEO contrasting a physician fulfilling this position; physician assistants and nurse practitioners being heavily utilized as primary care providers; and the introduction of community health outreach specialists as vital patient resources. The vocation of a pharmacist, in particular, has been altered significantly depending on the area of the world one inhabits. The majority of humanity believe that pharmacists are those who solely dispense medications, but several regions on the earth have realized the benefit of incorporating pharmacists in direct patient management, treatment guideline development, and even directors of ministries of health. Regardless of the development of pharmacy in a country, this healthcare profession is a key to kind, compassionate patient-centered care. The following commentaries from the United States of America, India, United Arab Emirates, and Cambodia explore the profession of pharmacy both locally and internationally while exposing initiatives to improve global health through pharmacists.  

 Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In Cambodia, a large proportion of pharmacists work in community pharmacy, pharmaceutical enterprises and hospital pharmacy. However, there is still an insufficient presence of pharmacists in each area. In community pharmacy in particular, the inadequate presence of pharmacists is due to the current system of “name renting”, a legacy of post-war public health policy in response to the shortage of healthcare professionals. In such a system, any person having minimum knowledge in medicine dispensing and having been trained by the Ministry of Health for a specific period of time can “rent” a pharmacist’s name to apply for a pharmacy permit. Nevertheless, despite the growing number of pharmacists owning a pharmacy in recent years, the pharmacists’ role remains the traditional product-oriented functions of dispensing and distributing medicines and health supplies. In other words, pharmacists are still viewed as “simple medicine sellers” by the public. As the country develops and medicine consumption has increased, the pharmacist’s services in community as well as in hospital pharmacy must shift from medication dispensing to a focus on safe and effective medication use to achieve optimal patient outcomes. Pharmacists must assert themselves as medication experts and play a more active role in patient counseling and promoting the rational use of medicine. In addition, pharmacists must also be actively involved in public health. The functions of public health that can benefit from pharmacists’ expertise may include disaster preparedness, immunizations, preventive health measures and educating other healthcare providers about various techniques of prescribing medications and issues related to the drug use process.

Transitioning the discussion to global health, pharmacists have unique skill sets and assets that put them in a prime position to collaborate with members of the health care team to address global health issues and challenges. However, there is limited information on the role of the pharmacist in this field. There are 3 areas pharmacists can play in global health in the future: global health practice and program delivery, global health research, and global health policy. In the area of global health practice and program delivery, pharmacists can serve an important role on the health care team in under-served countries by helping address barriers to the delivery of care due to their knowledge of drug products, storage requirements, dispensing requirements, and logistics of pharmacy operations. They can improve clinical outcomes through patient-centered services such as glucose monitoring and blood pressure management, and also potentially work with local and national health organizations to help develop global health programs based on successful interventions made locally in the community. In the area of global health research, pharmacists who are affiliated with a university that has a focus on this area can assess global health projects and research initiatives to determine if opportunities exist for pharmacy to get involved and to add new dimensions to existing global health research. Finally, the outcomes of global health research often stimulate the need for proposing and evaluating global health policy at both the governmental and national level at which pharmacists can lend their expertise. As medication experts, pharmacists routinely exercise their knowledge of the rational use of medications, their cost-effectiveness, and the safety and efficacy of therapeutic regimens. These concepts can be applied domestically toward the development of policies that have global implications.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

The role of the pharmacist varies from region to region and differs in several aspects. While there are areas of this world in which Pharmacists have vital roles in health sectors, there are other parts where pharmacists are given underutilized roles. Pharmacists are scattered throughout the community allowing them to be the most approachable healthcare professional – needing no appointment, no time restrictions and often being available 24 hours. Due to their aforementioned accessibility, their roles should be thoroughly revised, and the public should be made more adequately aware of their significance in communities.

Regarding the regional role of pharmacists in the United Arab Emirates, there was little utilization of pharmacists 10 to 20 years ago. Even now, some locations lack proper utilization due to their role being more product-based selling and dispensing any medication prescribed by the physicians. This occurs even though pharmacists in UAE are available in hospitals, health clinics, community and in retail stores allowing them significant access to patients.

To elaborate on the under-utilization of pharmacists, the current healthcare system typically does not promote pharmacist’s interventions in patient-management. This could include managing the dose of a hypertension agent, discussing change of therapy to more efficiently achieve patient outcomes, and a larger role in discharges from hospitals where pharmacists can provide counseling and follow-up.

Immunization is another role of pharmacists which could make a huge impact. Currently, most of the immunizations in this region are taking place in hospitals and health centers which are handled by nurses and physicians. However, this role can be handed to pharmacists in the community who can bring awareness to communities so that people won’t miss their vaccinations . In particular, many people are not even aware about the importance of flu shots. Pharmacists should be given an equal responsibility in bringing the awareness in a community and assisting people to receive their shots on time and prevent ailments. Counseling on family planning, use of contraception, palliative care, prevention of disease, identifying high-risk patients for diabetes and cardiovascular diseases are services not offered in pharmacies. Over-the-counter advice and educating patients on dietary supplements are often performed, but pharmacists are still underutilized overall.

However, the future of pharmacists in UAE look promising as several chain pharmacies make new exceptions in implementing more significant roles for their pharmacists. For example, physicians are advised to use the generic name so that pharmacists can choose to dispense the trade name.Additionally, pharmacists are being advised to minimize the use of antibiotics by making them strictly prescription based thus avoiding unnecessary use of them. Many barriers for increased pharmacist services need to be overcome: lack of time to offer services, shortage of pharmacists, lack of patient demand and low patient acceptance, lack of knowledge and skills, and underestimation of enhanced pharmacy services by physicians. With these barriers in mind, government and health authorities are planning their best and making promising change to bring the best of the pharmacy divisions.

Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America 

Before delving into the role of the pharmacist in the United States, I would like to highlight the Oath of a Pharmacist as this serves as the model of how a pharmacist should view their role:

“I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

  • I will consider the welfare of humanity and relief of suffering my primary concerns.
  • I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.
  • I will respect and protect all personal and health information entrusted to me.
  • I will accept the lifelong obligation to improve my professional knowledge and competence.
  • I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.
  • I will embrace and advocate changes that improve patient care.
  • I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

Currently, the USA is in the midst of a great shift in the pharmacist profession. According to 2017 statistics, 60% of pharmacists in the United States were practicing in retail pharmacies – this includes drug, merchandise, and grocery stores. However, these roles are expected to decrease over the coming years. There are several contributing factors for this decrease – one being a decrease in the price margins per prescription. As pharmacies make less money for each prescription that is filled, businesses have to fill more prescriptions with less staff. This can cause a host of issues, such as having less time to counsel patients, more reliance on technology to catch errors, an increase in likelihood for medication errors, and a more difficult time fulfilling the oath of a pharmacist. Ultimately, this leads to under-utilization of the pharmacist profession by placing less of a value on their role of positively impacting patient care.

Fortunately, pharmacists have been realizing this shift and have been proactive in adapting. They have achieved this by advocating for additional venues to provide value, such as being able to bill for medication therapy management services and administering vaccines. These services are extremely beneficial for patients and also increase revenue for the businesses. While roles in the retail setting are expected to decrease, roles in the hospital and ambulatory care settings are expected to increase. Currently, 30% of pharmacists are in these settings. With an increasingly elderly population, these roles are becoming even more important.

These aforementioned pharmacist provided-services typically utilize this profession in a more productive way by rounding with physicians and helping to inform clinical decisions for specific patients. The rest of pharmacists are scattered across a variety of specialties. Two of these specialties are academia and the pharmaceutical industry. Both of these have more of a global health impact, as academia is training the next wave of professionals who will have an international presence and will impact care while the pharmaceutical industry is developing the next wave of transformative medications that will improve patient care on a global level.

Before I finish, I want to revisit the oath of a pharmacist. As the United States healthcare system is being scrutinized due to the cost, as technology is becoming more utilized, and processes are becoming more automated, pharmacists will need to “embrace and advocate changes that improve patient care.” Pharmacists are in a unique position as the medication experts to greatly impact patient care, and it’s up to this profession to ensure that the right patient gets the right drug at the right dose via the right route at the right time.

Dr. Maneesha Erraboina, PharmD.

International Business Manager – Helics Group Scientific Networks 

Hyderabad, India 

In theory, the role of Indian pharmacists is to dispense medications by adjusting the dose for patients based on their health condition, and they play a major role in the rational use of drugs especially antibiotics. However, in India, it is very difficult to find a pharmacist in clinical hospital settings and none of the medical organizations have pharmacist professionals in the healthcare team. 

According to mainstream Indian psychology, most of the population only accepts medications from physicians rather than another profession, like pharmacists. This is an ongoing trait of Indian citizens that has existed for several years with very few signs of significant change in the future. 

In my own personal experience, I had an opportunity to attend an interview for a pharmacy position; however, the role was not directly related to dispensing medications. Due to the disconnect between the doctorate level education and the available job opportunities, I ended up in another profession within the health arena that wasn’t directly related to my education. Although I feel all PharmD. graduates are in a very good position today, they may need to explore unique opportunities as the profession catches up with the education level. 

In the future, I feel pharmacists could play an active role in the healthcare system as they are meant for patient care. I believe this feeds into having a primary role in clinical hospital settings. In addition, Pharm.D graduates will have other opportunities in clinical and medical research, pharmacovigilance, teaching, and scientific journal publishing companies in India.

In India pharmacists are underutilized in professional pharmacy roles such as a clinical pharmacist. However, in exploring other areas of the health field, Indian pharmacy graduates have taken advantage of their education to influence the global health society. As a personal example, my current role as an international business manager allows me to organize health conferences around the world to advance healthcare. As the pharmacy profession continues to grow and adapt across the globe, I believe one role for pharmacists will be ubiquitous: avoiding the irrational use of drugs to protect patients and improve health outcomes.

Perspectives on Global Health from Pharmacists Around the World, Part Two

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This second installment focuses on medication quality in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

The onset of the biomedical and synthetic medication era brought with it a formerly unknown hope for the betterment of humanity’s health. The introduction of antibiotics like the beta-lactam class, vaccinations to completely eradicate diseases like smallpox, medications with unique mechanisms of action to regulate hypertension and diabetes, and more recently, targeted oncology medications to successfully attack cancer cells have all contributed to vastly improving patient care across the globe. However, with this tremendous advancement, novel complications have arisen that have plagued health care professionals in devastating arenas. For the pharmacy profession, specifically, the quality of medications has emerged as an additional concern in the treatment and dispensing process. Although a majority of nation states have regulatory bodies to monitor the quality of medications, low quality medications frequently find themselves in the hands of patients. This often leads to substandard care, furthers health inequalities, creates distrust in healthcare workers, promotes drug resistance, and damages the solemn promise every health care professional strives to follow – to properly care for those afflicted with various ailments. The perspectives and ideas that are shared in the following text explores medication quality throughout various parts of the world and initiatives that aim at addressing this determintental issue. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

Access to high-quality medicines in many countries is largely hindered by the rampant circulation of counterfeit and substandard medicines. The use of counterfeit and substandard medicines represents a worldwide public health concern, and its prevalence is particularly high in developing countries. In Cambodia, the Ministry of Health reported in 2001 that 13% of medicines were spurious/falsely labeled/falsified/counterfeit, with 21% being substandard and 50% unregistered.

This crisis affects commonly used lifesaving medicines such as antibiotics, analgesics and anti-parasitics. The impact of poor-quality medicines is enormous ranging from increased adverse effects to increased morbidity and mortality. Poor-quality antimicrobials in particular has led to multi-drug-resistant malaria and bacterial infections which result in a huge burden for the country’s health sector. The high prevalence of poor-quality medicines has possibly contributed to the loss of confidence in health systems and health workers due to repeated treatment failure.

Among the reasons for the high rate of fake drugs in Cambodia are corruption, weak law enforcement, poverty and high sales taxes with self-medicating being often the driving force behind counterfeit drug markets. Counterfeit drugs mostly enter Cambodia through illegal drug outlets. The counterfeiting of drugs in Cambodia usually appears in the form of finished pharmaceuticals imported from neighboring countries, rather than the counterfeiting of bulk drug ingredients. This is due to the country’s lack of manufacturing capacity. Substandard drugs on the other hand are the result of limited implementation of good pharmacy practice regarding the distribution and the storage of pharmaceuticals which results in the deterioration in medicine quality.

Efforts have been made by the Cambodian government to tackle this problem. In 2015, the Cambodia Counter Counterfeit Committee (CCCC) was established and has been in charge of tracking counterfeit and substandard medicines circulating in the country. In 2018, the CCCC confiscated 138 types of illegal goods and substandard medication in 10465 packages from a pharmaceutical company in the capital city, Phnom Penh. The government is also working with its neighbors to decrease the number of fake drugs smuggled across the borders of Southeast Asia. Non-licensed drug outlets have been gradually disappearing, especially in the capital, either due to closure or accreditation, resulting from a strengthening of regulatory efforts. These initiatives are supported by pharmacists in communities by creating a front line against the distribution of counterfeits in the Kingdom through educating the public about the dangers of fake pharmaceuticals. 

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Maintaining a healthy environment, reducing the healthcare cost, and using effective treatment options are all linked to medication quality. In any community, city, or region there are countless investments undertaken to improve the quality of healthcare overall. The Institute of Medicine defines health care quality as “ The degree to which healthcare services for individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge.”

More specifically, medicine quality has two major roles: patient safety and effectiveness of treatment. Consuming a poor quality medicine will not only increase the risk to patient safety, but will hinder the proper treatment of patient. This can cause a patient to suffer more and increase the cost of treatment. Being a pharmacist and dispensing a low quality medication will also result in losing a patient’s trust. Since pharmacists have the role of dispensing medications, it is vital to ensure the medicine is in highest quality.

Quality of pharmaceutical products, mainly medicines, poses a serious challenge to the entire healthcare sector including drug manufacturers, distributors and dispensing pharmacists. According to the World Health Organization (WHO), the influx of fake or counterfeit medicine is a major concern in the market over all the globe.

Medicine in the United Arab Emirates (UAE) is manufactured so that medications go through systematic quality checks which are checked and re-checked several times while maintaining records in order to avoid any health hazard, Quality assurance teams then conduct self inspection or hire a third party to undertake inspections. The health regulations make sure that medicine distributed meet the standards of the listed quality and accepted internationally. On the other hand, imported medicines have similar criteria for safety and quality management. 

In order to further address low quality medications, the UAE Ministry of Health unveiled a new machine to detect imported drugs and inspect fake or counterfeit drugs. This machine is known as the TruScan RM Analyzer. It’s high tech detector is used to identify low quality drugs that pose health threats to the community. The device is helpful for chronic disease medicines such as diabetes, heart problems or even cancer drugs. The TruScan RM Analyzer also helps inspection regulators in the country to make informed and timely decisions for the release of drug shipments which are entering the country. In addition, UAE has been fighting the spread of low quality medicines in the country by taking many measures like high quality control labs and research on medicines and healthcare products.

Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

In the United States, the quality of medications isn’t commonly considered in the process of treating a patient. This is because of laws and regulations that are in place to ensure the quality of the medication. However, this wasn’t always the case. Up until 1906, there was no law requiring medications to be pure. That changed in 1906 with the passage of the Pure Food and Drug Act. This required medications to be labeled correctly and to meet purity standards put forth by the United States Pharmacopeia. 

This act greatly improved the quality of medications produced in the United States as manufacturers were required to list the ingredients that are used in the creation of medicine, and the ingredients and manufacturing process must meet certain standards. However, there is still a market for counterfeit medications as patients search for ways to reduce the cost of medications. It is estimated that 19 million US citizens purchase medicine outside of the current regulated system (e.g. from unlicensed sources such as foreign online pharmacies).  One recent example is with counterfeit Avastin, an anticancer drug, that was found to have no active ingredient. Another example is the recent opioid epidemic. Street drugs are being laced with fentanyl leading to increased overdoses and mortality. 

Recently, there have been discussions to allow for greater importation of medications into the United States. While this could potentially reduce the cost of medications, it could also increase the risk of counterfeit medications. Medications originating from outside of the United States makes it harder for the Food and Drug Administration (FDA) to regulate the quality and purity of medications. 

Patients in the United States can reduce the risk of receiving counterfeit medications by picking up their medications from their local pharmacy and can feel comfortable knowing those medications are of high quality. If cost is an issue, a patient can discuss their options with the pharmacist. There may be a cheaper alternative or an assistance program that can help offset the cost of the medication.

Perspectives on Global Health from Pharmacists Around the World

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, these roles accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. This initial segment focuses on medication access in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Throughout both developed and developing healthcare systems, access to medications is consistently a top priority for pharmacists and health care systems. As this health care profession attempts to provide services that meet the needs of their communities, access deficiencies habitually impede the ability to follow through with individualized and compassionate care. The lack of access to life altering chemical entities can affect anyone anywhere, from an affluent metropolitan city like Washington D.C. to a small rural Cambodian village in the province of Kampot. Despite the differences in these locations, each of these instances cause significant harm, breed mistrust in healthcare professionals, and create despair among those that seek healing. These frustrating situations are due to intensify because of the increased strain on medical resources who take a “do-what-has-always-been-done” approach. These following four pharmacists, all from various corners of this vast planet, will describe the barriers they consistently face regarding medication access and initiatives that are being undergone to ensure that a novel approach is commenced to address this looming medical tragedy.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Before discussing medication access in the United Arab Emirates, I would like to give a brief introduction about the United Arab Emirates (UAE). It is a middle eastern country with a population of 9.68 million. The country is comprised of seven emirates and healthcare in UAE is regulated both federally & at the Emirate level. 

Now, starting with the topic on hand about medication access in UAE, there are several factors that have an impact on it and I will touch on them individually and in detail. 

First and foremost, I think the most important factor is the number of medications available in UAE. The majority of medications available in UAE are imported drugs. UAE imports pharmaceutical products from 72 different countries. Of those, 10 countries constitute approximately 80% of the entire country’s supply. The domestic sector is rather small; however the UAE Ministry of Health (MOH) plans to increase the number of pharmaceutical manufacturing facilities to 30 by 2020 up from 16 in 2017. Availability of different medication combinations or different strengths are difficult to find due to the limited number of industries in UAE. One such example is oral prednisolone, which in UAE is available in strengths of 1mg, 5mg, 10mg & 20mg. In the USA, there are more strengths available including 1mg, 2.5mg, 5mg, 10mg, 20mg and 50mg. Tourists or expats coming from overseas that need a particular medicine or medicine combination or a particular strength may not find it available.

The second hindrance to medication access is the cost of medications. There are many reasons for the high cost medication. The aforementioned fact that about 80% of medications in UAE are being imported rather than locally manufactured is one reason. Another reason is an insignificant availability of generic medicines as the majority of medicines available are brand name. The final reason is the national health insurance model. Because all national citizens do not have to pay for their own medications, there is no incentive to keep the medicine prices low. As a result, individuals who are not insured under the public national insurance system, for example expats and tourists, face a huge barrier to obtaining medicines. 

With these barriers in mind, initiatives have started to take place in UAE to find a solution. The government reduced 24% of the prices for 8732 medicines over the course of 6 years. Another initiative which took place is increasing the number of generic medicines while also advising physicians and pharmacists to dispense the generic rather than the branded medicines. Through this initiative, generic medicines now account for 30% of the overall pharmaceutical market which has increased from 12% of the market two years ago. If the UAE can bump these numbers up to 70-80% of the overall market in UAE, the UAE will be seen in better position in terms of generic medicines. 

I am glad to be a part of a region where these issues are actively tackled, not just by the government but by private sectors as well. We are also seeing that pharmacists are playing a larger role, providing information on availability of cheaper alternatives on medicines. Pharmacists are the most accessible healthcare professional and it should be part of their responsibility to help make medicines as accessible as possible to their clients.

 Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

Although there are a host of issues surrounding access to medications, I will be focusing on oncology medications as oncology is my current specialty as a medical science liaison in the USA. 

To begin, I would like to highlight encouraging statistics that show the accessibility of oncology medications in the USA. A recent 2019 study found that 96% of new cancer medications were available within the United States, the next highest nation was at 71%. Furthermore, the average delay in the availability of cancer medications within the United States was 3 months, with the next closest nation being at 9 months.

In terms of novel and innovative treatment options, oncology drugs have been increasingly approved by the Food and Drug Administration (FDA) throughout the last few years. The FDA has enacted policy changes to attempt to increase the efficiency of drug reviews. The results have been significant – in 2017 alone, 46 new oncology drugs were approved. Moreover, from 1991 to 2016 there was a 27% decrease in cancer related deaths in large part to the expanded and more targeted-based therapy. The chance that a patient will live for 5 or more years has increased by 41% since 1975.

Outside of regular treatment options of those living with cancer, patients have the ability to participate in a clinical trial. Currently, there are 24,351 clinical trials listed as active (defined as not yet recruiting, recruiting, enrolling by invitation, or active) – 11,813 of those trials are active in the United States. However, even with the surplus of ongoing clinical trials, it still seems there is a lack of patient enrollment. It is estimated that roughly 70% of patients are interested in clinical trials, and yet <5% of patients actually enroll in clinical trials. Some of these barriers to enrollment include: lack of availability at a specific clinic, lack of a specific trial available, patient ineligibility, physician is unaware of trials/not offering them to patients, and a patient deciding not to enroll in a clinical trial (perhaps due to a fear of receiving the placebo).

An aforementioned barrier to cancer treatment that needs to be emphasized is the locations of specialized cancer clinics. Studies have shown that patients who are diagnosed with advanced staged cancer are likely required to drive an hour or more to the nearest cancer clinic for the appropriate care they need. Additionally, travel distance may affect treatment decisions. A patient may select a slightly less efficacious therapy if that means they have to travel less often. 

Two initiatives have recently been instituted to further increase the accessibility of medications. First, in an effort to go towards value-based contracting, some companies are beginning to only charge patients if their medications are effective. While this is a rarity, it will be interesting to follow the impacts of this on other more costly treatments and to determine the impact on patients. Secondly, in 2018, the right to try act was passed. This essentially gives terminally ill patients who are unable to enroll in a clinical trial and have no other remaining FDA approved options, access to other treatments. While this is a relatively new policy and there are some restrictions, hopefully it will give patients hope and additional treatment options. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In rural Cambodia, access to medication is especially limited when compared to urban areas. Access is limited by two main factors in these communities. Firstly, many people living in rural areas have low incomes which means it is difficult for poor rural individuals to buy medicines for serious illnesses. Secondly, community drug outlets and public health facilities are generally concentrated in the provincial capitals/cities, making it difficult for people from rural, remote areas to get access to those places. 

Usually, medicines imported from other Asian countries such as India, China, Vietnam, Thailand, or Malaysia are cheaper and therefore, more accessible. These cheaper medications, however, tend to be held toward a lower quality standard which can lead to disease state progression, antibiotic resistance, and other situations that can inflict harm onto patients. However, western brand medicines, which are usually held to a higher standard of quality, are less accessible because their prices are higher. Locally, they are generally considered “medicines for the rich.”

The lack of access due to  these aforementioned barriers makes diseases difficult or impossible to treat in cases where medication is necessary to cure it. Patients may see their disease aggravated and could die of it.

In order to address these medication access complications, a specialized team should be created that assists patients or their relatives to get medication which is far from their home and provide a specific loan with very low or no interest rate for villagers who cannot afford to buy medicines. This approach has been initiated in Cambodia through the increased access of health equity funds (HEF). These funds, allocated to individuals unable to afford the out-of-pocket expenses for public services, are pooled from a variety of sources like the national health budget and various donors. These patients are then given a specialized card to receive these funds when public services are used. The HEF focuses on addressing low medication access through the initial financing as aforementioned, community support, quality assurance, and finally policy dialogue. The results of this project have been promising – there was a 28% increase of patients utilizing public services with HEF than before without the HEF. In addition, the patients were not perceived to be more stigmatized within their communities.  

Veda Peddisetti, B. Pharm.

Clinical Pharmacist – Satya Sree Clinic & Diagnostics 

Hyderabad, India 

India is the largest country in South Asia and the second most populous country (1.35 billion) in the world. In addition, India is said to be in the third stage of demographic transition with birth rates declining and death rates decreasing. In the past few decades, India has experienced monumental population growth. This has led to many problems in healthcare management throughout the country, in particular, medication access. The direct cause seems to be the over-demand of medications. However, various indirect causes include poverty, varying per-capita incomes, unemployment, and out of pocket expenditures (India doesn’t have an established federal healthcare insurance system like Medicare in the USA, National Health Service in the United Kingdom, etc.).

In addition to the aforementioned causes, the literacy level in villages and rural areas are quite low. Many of the farmers and laborers from rural India are uneducated. As a result, many don’t know how medication can help them get better and how important it is to take medication every day to keep chronic conditions like hypertension and diabetes in control. In urban areas, all income classes are more educated and are given awareness more frequently about healthcare when compared to individuals in rural areas. So, they tend to use medication and other healthcare facilities more frequently. Accessibility is not a huge issue in cities but this creates competition among providers and results in high costs which turns into a problem for low and average income communities of the urban population.

Usually, regular medications like anti-diabetics, anti-hypertensives, common antibiotics, analgesics, vitamins are available throughout the country except in some deeply located tribal areas. Medications which are used for some cancer chemotherapies, auto-immune diseases, and some orphan drugs are not widely available. People have to go to highly rated hospitals in developed metropolitan cities to get these medications, and I believe this scenario is the same anywhere in the world. This kind of accessibility shouldn’t affect any patient or healthcare provider unless there is any medical emergency. And thanks to the continuous efforts of the Government of India, India is improving the accessibility of medication. Recently, various health benefit schemes were implemented like free supply of in-patient medications in civil hospitals and sale of reasonably priced generic medications in rural and urban communities.

It is a well-established fact that India is a potential supplier of medications to many countries in the world. India is a manufacturing and research hub for many reputed pharmaceutical companies. However, this often leads to pharmaceutical companies who are exporting their products in large quantities rather than supplying them domestically. These medications range from certain medications for chronic diseases like diabetes drugs to life saving medical devices like the Epi-Pen. These pharmaceutical companies more interested in profit are preventing the Indian population from getting the best medications.

With the lack of proper medications, healthcare professionals cannot take the proper steps in patient care that they could actually do if they had adequate access to medications. So, it is vital to educate people of India, especially the rural population, while simultaneously framing and implementing some regulations and limits on the export of medications by pharmaceutical companies in order to improve healthcare in India.

1000 Deaths and Rising: The Complexity of DR Congo’s Ebola Outbreak

The Ebola epidemic in the Democratic Republic of Congo (DRC) has officially taken the lives of over 1000 individuals, according to the country’s Ministry of Health. These statistics, which were released at the end of last week, have been accumulating since the outbreak’s onslaught in August 2018. This occurrence is considered the second deadliest in the history of this Filoviridae Virus in the world and the deadliest in the DRC. This specific incidence afflicting humanity is often referred to as the Kivu outbreak due to the initial emergence in this northeastern DRC province; however, the identified virulent strain is the Zaire Ebola Virus which happens to carry the highest rate of mortality of all strains.

The following is an up-to-date timeline of the current Ebola outbreak’s transition to an epidemic:

  • August 1st, 2018: The DRC’s Ministry of Health declares an Ebola outbreak in Mangina, North Kivu
  • August 7th, 2018: Laboratory findings confirm this outbreak is caused by Zaire Ebola
  • October 17th, 2018: World Health Organization (WHO) convenes a meeting about the Kivu outbreak. WHO declares this situation does not constitute the classification of a “Public Health Emergency of International Concern”
  • October 20th, 2018: An armed attack occurs in Beni, Kivu at a health care facility leaving 12 people dead
  • November 9th, 2018: The number of cases in DRC reaches 319 which marks the largest outbreak in the country’s history
  • November 29th, 2018: The Kivu epidemic becomes the second largest recorded outbreak of the Ebola virus in the history of the disease on this planet.
  • December 27th, 2018: There is an announcement of postponement of elections in Benin & Butembo which are two largest cities in Kivu.
  • February 24th, 2019: An MSF health care facility is partially burned down and MSF suspends activities in North Kivu by unknown militants
  • February 27th, 2019: A second MSF health care facility is attacked also by unknown militants and the NGO is forced to evacuate staff and suspend all operations in the province of Kivu
  • March 20th, 2019: The outbreak reaches the 1,000 confirmed cases mark of the Ebola Virus
  • April 12th, 2019: WHO holds an additional meeting but finds the Kivu outbreak still doesn’t qualify as a “Public Health Emergency of International Concern”
  • May 3rd, 2019: The number of deaths secondary to the Ebola virus reaches 1000

Although each explicit manifestation of this deadly communicable disease carries with it seemingly insurmountable barriers in the form of human resources, supply logistics, social tendencies, and global support, the Kivu is particularly devastating due to political uncertainty, lack of trust in the health care system, and civil unrest.

Despite the increase in novel innovations for treating Ebola and even a promising vaccine that can prevent the virus virology, the Kivu outbreak continues to surge ahead and torture the human species in large part to a break down of trust in the medical system. The surge has lead to identifying 126 confirmed cases over a seven day stretch at the end of April 2019 in addition to the aforementioned data confirming this outbreak to be the second largest in the history of Ebola. Despite this, the mistrust has amassed in a disbelief that the outbreak even exists. A study conducted by the Lancet in March 2019 revealed that 32% of the respondents believed that the outbreak did not exist in the DRC, it only served as a way serve the elite’s financial interests. Another 36% stated that the Ebola outbreak was fabricated to further destabilize the surrounding areas. With these sentiments, the responders marked that fewer than two-thirds would actually want to receive the vaccine for Ebola. These perceptions of fellow humans provides an additional barrier to overcome for health care professionals in addition to treating a high mortality rate disease in resource limited settings.

While the mistrust in the healthcare system provides a tremendous intrinsic challenge for the DRC, the civil conflict that has targeted Ebola treatment centers delivers a physical and emotional component of the devastatingly uniqueness of this outbreak. With over 100 armed groups thought to be estimated within Kivu province, this has led to widespread violence causing this area to be difficult to maintain access. Due to the high rate of armed groups and the political unrest, there has been 119 incidents of Ebola treatment centers and/or health workers that have been attacked since the start of this outbreak. A few shocking examples include the murder of Dr. Richard Mouzoko who was a Cameroonian WHO physician and the two torched MSF facilities in the northern part of Kivu that were mentioned in the timeline.

The Kivu Ebola outbreak has been unanimously christened one of the most complex humanitarian crises that faces this fragile planet today – the global health community is attempting to treat a disease with a 50% mortality rate, with inadequate but effective evidence-based treatment options in a resource-limited setting, all while in a treacherous war zone. Although these are insurmountable odds, health care professionals across Africa and other parts of the world are addressing the needs of their patients and communities to defeat this ailment. These physicians, nurses, pharmacists, and so many others are generating trust in the health care system at a grass-roots level in the DRC to combat the negative perceptions and the actual outbreak. This example, that the global health community can learn from, highlights the role each person dedicated to global health needs to undertake before an outbreak batters a part of this fragile planet. The vitality of trust can start to be built through having individual/group conversations truly listen to health beliefs, coming in with an open mind to acknowledge local health treatments to complement evidence-based treatment, providing patient centered care that encompasses their culture and values, supporting capacity-building initiatives that allow humanity to act accordingly, investing both time and resources in local public health care infrastructure, and expressing empathy ubiquitously socially and professionally.

Being part of the global health community, it is imperative that this outbreak is adequately supported by humanity. As fellow humans striving towards a healthier society, health care professionals and public health experts must accompany those tormented by the social factors associated with Ebola and the actual virus through global awareness of the situation, an un-stigmatized compassion for those who contract the disease, and a pragmatic solidarity to address this humanitarian crisis.  

Repurposing Medications: Reimagining Treatment Options

Last month around the Chinese New Year holiday, a prominent Chinese scientist from Guangzhou Medical University made an announcement that stirred controversy both domestically and internationally while also highlighting a route to combat ailments that global academia and pharmaceutical industries have been attracted to for years. The scientist revealed that his team had been injecting patients with a malaria-causing parasite in order to cure a range of cancers – with two patients seeming to have no cancer cells remaining at the site of tumor and five additional patients having no disease progression out of ten total patients receiving this malarial therapy for at least a year. Although this type of treatment has been attempted in the past in an attempt to combat HIV in the 1990s, the Centers for Disease Control (CDC) and other health governing bodies determined that there was insufficient pre-clinical data to justify human trials during this time period. The controversy revolving around this announcement encompasses the aforementioned determination by CDC, the release of trial results before being published in a peer-reviewed journal, and, most importantly, the possibility of creating a malaria public health emergency for a country due to eradicate the communicable disease by 2020. Although the scientist who underwent this study clearly abdicated internationally conferred health principles, this avenue of repurposing – repositioning, re-profiling, re-tasking, etc – medications and therapy is becoming more appealing to those invested in novel treatment options for both established and emerging diseases.

Throughout the development lifecycle of new chemical entity (NCE), the process for regulatory approval could span over ten to fifteen years with an associated cost of over 2 billion dollars. This has led to an average of only 20 to 30 NCEs being approved by the Food & Drug Administration (FDA) each year. However, through repurposing medications, the development span can be cut to five to eight years at approximately 60% of the total NCE cost – in addition to higher approval rates from regulatory agencies. This repurposing process, as shown by the statistics, is enormously appealing for pharmaceutical companies/investors, but also provides targeted therapy for patient’s disease states at a theoretically lower price than an NCE. Even for rare genetic diseases, repurposing has become common due to only 400 medications being on the market to treat over 7000 genetic conditions. Repurposing is accomplished through the theory of translational research which takes a look at basic scientific discoveries and determining how a medication can be made to match this discovery – for example, examining the molecular pathway of diabetes and then matching it with a chemical entity that has an effect within the pathway like glucagon-like peptide 1 (GLP-1). The known chemical entities are commonly stored in giant databases within academia and the industry. Through big-data analytics, advanced modeling, and high throughput screening techniques, these chemical entities can then be extracted from the databases and determined if it has a possible role in a certain molecular pathway.

This method of establishing novel treatment options ought to be utilized more frequently and effectively, though there are medications over the years that have undergone this type of approval. The following are examples of already approved medications and others undergoing clinical trials:

Approved Repurposed Medications:

  1. Thalidomide, which was originally developed as a racemic mixture of enantiomers for the treatment of morning sickness but found to be teratogenic due to the effect of the (S)-isomer, was later successfully developed by Celgene as a single (R)-isomer product for the treatment of leprosy and multiple myeloma.
  2. Viagra (Pfizer’s sildenafil) was a drug that initially failed as an angina treatment in clinical studies; however, during these trials, its effect on erectile dysfunction was noted and then later approved for this indication.
  3. Celebrex, commonly used in osteoarthritis, works by inhibiting COX-2 receptors. Recently it has been shown that for patients that previously had colon cancer, taking this agent can reduce the risk of additional polyp formation without negative gastrointestinal effects associated with existing treatments.
  4. All-trans retinoic acid (ATRA), which is an acne medication, when combined with traditional chemotherapy, results in complete remission of acute promyelocytic leukemia in 90% of treated patients.
  5. Tamoxifen, a hormone therapy medication, treats metastatic breast cancers, or those that have spread to other parts of the body, in both women and men, and it was originally approved in 1977. Thirty years later, researchers discovered that it also helps people with bipolar disorder by blocking the enzyme PKC, which goes into overdrive during the manic phase of the disorder.
  6. Raloxifene was initially developed to treat osteoporosis, but has since been shown to reduce the risk of invasive breast cancer in postmenopausal women in 2007.
  7. Zidovudine (AZT) was initially developed to treat various types of cancer, but was determined to be ineffective. However, it was repurposed into the first approved HIV/AIDs medications in 1987 and has had a tremendous impact on the progression of the autoimmune disorder.

Repurposed Medications Undergoing Clinical Trials:

  1. The lipid soluble simvastatin is currently undergoing a trial in the UK to assess the efficacy of reducing the progression of Parkinson’s disease. The statin drug class is thought to prevent this ailment through its pleiotropic effects including reducing inflammation, reducing oxidative stress, reducing the formation of sticky bundles of alpha-synuclein, and increasing the production of neurotrophic factors. The results are expected to be released in 2020.
  2. Purdue University received a grant from the National Institutes of Health (NIH) to discover the effectiveness of Ebselen, a chemical entity, against methicillin-resistant Staphylococcus aureus (MRSA), and auranofin, which is FDA-approved for the treatment of unresponsive rheumatoid arthritis, against Clostridium difficile.
  3. Metformin, a first line agent for many diabetics, has been shown to reduce the risk of breast cancer in diabetes patients and is being investigated as a treatment for cancer in many different clinical trials

Although this is certainly not an exhaustible list of the impacts repurposing has had on healthcare, the majority of this repurposing stems from serendipitous observations rather than targeted interventions. Through these unanticipated occurrences, a range of disease states can now be more effectively treated ranging from communicable diseases like HIV/AIDS to mental health ailments including bipolar disorder and Parkinson’s disease to non-communicable diseases. As the rising cost of healthcare continues to devastate humanity and lead to health inequalities, heads of governments, pharmaceutical industries, academia, and nonprofits need to commit themselves into investing their time and resources into this repurposing method. The targeted repurposing interventions are more vital and should be devoted to in order to expand options for health disorders rather than the unexpected observed effects. The financial and health outcomes will lead to novel treatment options accessible to a majority of the world which will allow health care professionals to properly accompany their patients through their disease state.