APHA opposes Trump move to cut essential WHO funding

Washington, D.C., April 14, 2020 – The American Public Health Association stands in solidarity with the World Health Organization and denounces the Trump administration’s decision to halt U.S. funding. Ending U.S. contributions to WHO will cripple the world’s response to COVID-19 and could harm the health and lives of thousands of Americans.

“WHO is in a race to treat, test and protect people from the devastation of COVID-19. Its leadership in combatting COVID-19 has been indispensable, irreplaceable and decisive,” said Georges C. Benjamin, MD, APHA’s executive director.

“Getting ahead of this virus requires a rapid global response and the coordination of multiple countries,” Benjamin said. “It is only with this coordination that we can accelerate the pace of research and generate the critical science-based evidence that is needed to save the lives of people in the U.S. and around the world.

“We must be singularly focused on using all of our assets, including WHO, to get in front of this insidious virus.”

WHO’s work is critical for:

  • Creating a comprehensive research and development agenda to get safe vaccines and effective therapeutics in play. A WHO-led approach allows multiple countries to work together to accelerate the pace of research and development and increase the amount of what can get done.
  • Addressing the next frontier of the pandemic, which will devastate low-resource countries and humanitarian settings. While more than 70% of the world remains underprepared to prevent, detect and respond to such public health threats, WHO has been working with low-income countries for to help them prepare. Strong, effective and functional public health systems within countries are crucial for reducing risks.
  • Leading the U.N. development system’s public health work at the country level. WHO works with vital operational arms of the United Nations, including UNICEF, the World Food Program and UNHCR. Though U.S. assistances is essential to aiding these countries, funding is still insufficient.
  • Supporting and coordinating supply chains for critical public health commodities, such as personal protective equipment and lab kits. WHO is the lead of the U.N. COVID-19 Supply Chain Task Force for the global procurement of pandemic commodities. The U.S. is purchasing its own supplies, but if all countries did so on their own, prices would skyrocket everywhere. Bulk purchasing will help everyone.

“Now is not the time to undermine WHO’s vital work,” Benjamin said. “There will be a time for lessons learned once this pandemic is over. WHO has expressed a full willingness to participate in a thorough review of what has worked and what has not as we have raced to stop this disease, and we support their inclusion.

“Any effort to remove funding from WHO, particularly in this time of crisis, would be a crime against humanity and endanger the health of Americans and people around the world.”

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The American Public Health Association champions the health of all people and all communities. We are the only organization that combines a nearly 150-year perspective, a broad-based member community and the ability to influence federal policy to improve the public’s health. Learn more at www.apha.org.

Rising to the Emerging Global Health Challenges in 2020

By: Dr Yara Asi

Dr Asi was featured in the most recent Section Connection newsletter. To learn more about Dr. Asi please click here.

An interview with Dr. Aisha Jumaan, founder and president of the Yemen Relief and Reconstruction Foundation, and Dr. Samer Jabbour, professor at the American University of Beirut, co-chair and convener of the ‘Lancet-AUB Commission on Syria: Health in Conflict’, and founding Chair of the Global Alliance on War, Conflict, and Health.

Earlier this year, the World Health Organization released their predictions for the urgent health challenges of this new decade. To any public health professional, many of these challenges aren’t new: climate change, conflict, health equity, consumer protections, and infectious disease and epidemics, to name a few. At the most recent APHA Annual Meeting in Philadelphia, dozens of panels and presentations covered these very issues. However, because of the interlinkages between all these health threats at the local, national, and global levels, it is not enough to simply be able to name these threats. The real challenge is building the global coalitions with the resources to tackle these complex problems. While the membership of APHA certainly can’t accomplish this alone, the level of expertise within the organization on dealing with these issues, including within the International Health section, provides an excellent foundation for the research, advocacy, and practice that is necessary to tackle these complex risks.

The International Health Section Luncheon at the 2019 Annual Meeting featured two speakers who are working on the leading edge of some of these threats to public health. Dr. Aisha Jumaan, founder and president of the Yemen Relief and Reconstruction Foundation, and Dr. Samer Jabbour, professor at the American University of Beirut, co-chair and convener of the ‘Lancet-AUB Commission on Syria: Health in Conflict’, and founding Chair of the Global Alliance on War, Conflict, and Health, spoke of the challenging conditions that the world’s most vulnerable people face in accessing their most basic health needs. I talked with both of them after the meeting to get their thoughts on international health and what the members of APHA can do to support health practices, advocacy, and research that responds to the needs of fragile populations.

Due to their combined decades of experience, I first asked them what they have learned about international health in their work. Dr. Jabbour first reminds us of the difference in one’s approach to international health depending on their country of origin. As someone living and working in Beirut, to him international health “is not an ‘external’ subject or a field.” He emphasized, however, that the overall goodwill, commitment, and meaningful work happening in international health is vital in reducing global health equities and that this is an important support to count on for the countries that need to make the greatest progress. The importance of the local approach was supported by Dr. Jumaan. “Training 10 professionals outside Yemen and then having them conduct training in Yemen to a higher number of beneficiaries with a small budget have resulted in a multiplicative impact for our work…these local professionals have a better access to the countries we work in and are trusted by the local communities.”

Dr. Jumaan reiterated this perspective when I asked about the largest challenges to international health. She cited the lack of connection between the agencies that provide funding as well as the recipients of much of the funding with the environments where they are actually implementing projects. “We need to engage the beneficiary communities in every step of the way in planning and implementing international health projects.” Of course, many practitioners and researchers in this field agree with this sentiment and have for decades, but without fundamental change in how the major international health organizations operate, it is difficult to imagine these various interests coalescing around the types of widespread solutions needed to deal with the challenges presented by the WHO. Dr. Jumaan found localization efforts to be the most significant change that the international community could make going forward, with powerful institutions and associations doing the work of empowering local professionals to care for their own populations and supplying technical support when necessary.

Dr. Jabbour was clear in his response to what the largest priorities of the international health community must be going forward: “Pay more attention to political determinants of health, particularly war and conflict, contribute more meaningfully to climate change, including through engaging with the younger generations who are now leading the fight, and work towards more equitable economic systems, everywhere.”

What can we do, as members of one of the largest public health associations in the world? Aside from research and advocacy, Dr. Jumaan emphasized the need to provide technical assistance and mentoring to professionals within countries we want to support. The skills of the IH section of APHA could help “develop the skills of these professionals to implement public health projects that address the local needs in a cost-effective way.” Dr. Jabbour saw the strong potential of APHA to serve as a “beacon for public health,” but in terms of tackling the hardest public health problems, he found it vital to “take a hard decision, make the commitment, start talking with partners, draw up plans, and get seriously engaged.”

As the world’s eyes are freshly poised on global public health, we can remember Dr. Jabbour’s directive in our own work. What is the question that no one is asking? Where is the population that needs representation and outreach? How can APHA leverage its considerable institutional and scholarly resources to show solidarity with our fellow public health professionals around the world? We will need these global alliances to tackle the public health threats that are known, like war, climate change, and poverty, and those yet to come, as our global vulnerability to infectious disease is once again being made apparent with the coronavirus. Especially for practitioners and researchers in stable or more developed nations, our colleagues like Dr. Jabbour and Dr. Jumaan that are working on the frontlines of global health emergencies are counting on us for our time, energy, and engagement. As this new decade begins, let us ensure that we rise to these impending challenges and preserve health and well-being for all.

Repealing the ACA will be catastrophic for America’s mental health

On December 18, 2019, a big piece of healthcare news went relatively unnoticed amidst the impeachment vote in the United States House of Representatives. A federal court based in New Orleans ruled that the “individual mandate” within the Patient Protection and Affordable Care Act (ACA), the provision that imposes a tax penalty on those in the US who do not have health insurance, was not constitutional. The court failed to make decisions on the rest of the law, asking a lower court to decide if the ACA could hold up with the individual mandate removed. Democrats in favor of the healthcare bill have vowed to fight for its longevity, and it’s expected that it will eventually be heard before the US Supreme Court. 

Still, the future of the ACA is once again in question, and the countless Americans who have accessed healthcare in the last decade with the help of Medicaid expansion and marketplace subsidies now face uncertainty. So far, the bill is estimated to have saved the country about $2 trillion in health costs. But with the repeal of the individual mandate, 13 million Americans are expected to choose to go without coverage by 2027, leading to an expected 10% increase in annual premiums on average for plans in the individual marketplace. For many, this translates to even higher costs in a country that is already spending disproportionately more on healthcare. Those of us that live with a mental health concern have particular cause for concern. 

How the ACA Changed Mental Health Care in the US

  • The ACA required that a number of preventive care services, including certain screenings, be available to patients at no cost. One of these screenings was the inclusion of a yearly screener for depression, alcohol misuse, and cognitive impairment. 
  • Insurance companies could no longer deny plans to individuals based on their pre-existing conditions. This was a big win for the mental health advocacy community, as serious mental health concerns (major depression, anxiety, etc.) were the second most common reason cited for health coverage denials. Even mental health counseling for situational or acute concerns (grief, trauma, etc.) could count as a “pre-existing condition” prior to the ACA.
  • The legislation also expanded the existing mental health parity laws in the US (Mental Health Parity and Addiction Equity Act of 2008). The former parity laws required that mental health services had to be covered in a way that was equal to physical health services but only IF mental health services were offered by the plan. Many plans got around these laws by simply not offering coverage for mental health and substance use services. The ACA closed this loophole by listing mental health services as one of the ten “essential health benefits” for individual and employer-provided health plans (different parity laws apply to plans offered by Medicaid and Medicare). 
  • The Community Health Center Fund, established by the ACA, generated over $11 billion in grants for community health centers, the primary care clinics seeing a huge portion of the country’s under- and uninsured population, to expand services in their communities. Behavioral health services were one of my qualifying service targets eligible for funds. 

As a result of these provisions, million uninsured Americans were able to obtain coverage. The number of patients with mental health concerns that were uninsured or could not afford treatment dropped post-ACA implementation. The ACA has allowed providers and health networks to find innovative ways to integrate physical and behavioral health. As a result, patient satisfaction with providers and treatment has, not surprisingly, increased. Nearly one-third of Medicaid dollars are now spent on mental health or substance use disorders. Those living at 138% of the Federal Poverty Line, those who may have previously had to delay seeking care for mental health concerns, are now able to receive earlier intervention and more consistent care. 

Image Source: https://twitter.com/ObamaWhiteHouse/status/819607805552394241/photo/1

Having a mental illness isn’t cheap, and healthcare reforms have been instrumental in improving access to care for countless Americans. A 12-month prescription for antidepressants costs approximately $800. An in-patient hospital stay costs more than  ten times that. Individuals with depression have more than twice the number of outpatient visits per year than those without and more than three times as many prescriptions. Repealing the Affordable Care Act or dismantling its’ individual provisions could mean that the United States returns to a not-so-distant past where nearly 20% of individual plans offered no coverage for mental health services. With Medicaid expansion removed, 3 million low-income Americans with with serious mental health concerns could find themselves with nowhere to turn for care. Repealing the essential health benefits would allow insurers to go back to side-stepping parity laws. And should states be allowed to reduce Medicaid eligibility again, individuals living with a mental health concern will be disproportionately impacted. 

There’s still time for major portions, if not all, of the ACA to be saved. Due to the lengthy court proceedings, the case would not make it in front of the Supreme Court until after the 2020 elections, lending hope that a new wave of elected officials might hinder attempts to dismantle the legislation. But whatever the next year of divisive American politics brings, those living with mental health concerns should not be punished. At a time when illness attributed to mental health or substance use are on the rise in the United States, and at a time when more economic productivity is lost to mental health concerns than any other non-communicable disease, weakening the current mental health delivery system is more than irresponsible: it’s dangerous. 

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.