When Dr Paul Yonga was called to save the life of a 76-year-old patient, who had a severe urinary tract infection (UTI), his biggest challenge was to find medicines that could treat the common disease.
The patient, having taken a buffet of antibiotics for many months, had developed resistance to most of the medicines available in the Kenyan market.
The patient was resistant to 14 antibiotics, five drugs showed promise of clearing the infection and were to be administered into the vein, and three had a 50-50 chance of curing the UTI.
“We did a drug resistance profile (which shows which medicines can work or not), and found that she was resistant to all the affordable and most commonly-used medicines. I ended up using an antibiotic that cost Sh1,000 a day for two weeks. Being a drug that affects the kidneys and hearing, I had to continuously do tests that weren’t cheap. Treating the UTI cost the family a lot of money, which included doctor’s fees, hiring a home nurse, yet this is a common disease that would ideally cost Sh500 to cure,” says the infectious disease specialist.
Antibiotics resistance is increasingly worrying Kenyan doctors as they struggle to select effective medicines to treat diseases that were easy to cure years ago. Kenyans are heavy consumers of antibiotics and the magnitude of the abuse has begun to emerge.
Research from Kenyatta National Hospital shows that quite a number of antibiotics are no longer effectively curing simple illnesses such as UTIs and upper respiratory diseases.
“There is an overwhelming resistance noted to commonly used antibiotics such as penicillin,” says Dr Frederick Wangai, the lead researcher in the Kenyatta National Hospital study “Bridging antimicrobial resistance knowledge gaps: The East African perspective on a global problem” published last February.
Particularly alarming among the drugs losing efficacy are those mostly prescribed in hospitals. Some, such as carbapenems, which are highly-effective antibiotics used in severe infections, in most cases as last resort in intensive care units (ICU), are not working yet they are crucial as doctors’ medicinal arsenal.
The overselling of over-the-counter antibiotics by unscrupulous drug store owners and over-consumption of the medicines by uninformed patients is to blame for the drug resistance.
In most chemists, especially those located in low-income areas, any patient who walks in, with or without a doctor’s prescription, is likely to walk out with an antibiotic, whether he has a flu, headache or stomach pain. An antibiotic is like a gift. But in Kenya, it is dished out like sweets. The more Kenyans misuse antibiotics, the more these drugs become ineffective. Most of these drugs now have a more than 50 percent resistance level. Drugs such as Amoxilicin and Ampicillin are almost reaching a resistant level of 90 percent, meaning that Amoxicillin cannot be used to effectively treat UTIs. We have already lost Septrin,” points out Dr Yonga, who is also the founder of Fountain Health Care Hospital in Eldoret.
Dr Daniella Munene, the chief executive of Pharmaceutical Society of Kenya says the most affected areas, where sellers illegally dispense antibiotics without a doctor’s prescription, are urban slums.
In Nairobi’s Kibera slums, Joseph Ouma, runs a small chemist-cum-laboratory, which he plans to expand to house a one-bed ward. “I treat typhoid, H Pylori, malaria, syphilis, UTIs and others,” says Mr Ouma, who studied for a certificate course as a medical laboratory technician.
“I have a lab where I mostly do malaria tests. But when a patient has no money for the diagnostic tests, I weigh which antibiotics to give. For instance, I will ask a patient if she has travelled upcountry. If yes, then my wild guess will be she has malaria. Therefore, I will give her anti-malaria drugs plus antibiotics. I must give them antibiotics in addition to the anti-malaria tablets because if they don’t have malaria, then it must be an infection,” he adds.
In some cases, Mr Ouma says, he prescribes two types of antibiotics and painkillers to speed up the healing process.
“If someone complains of chest pains, I know it is a cold so I give him two types of antibiotics and anti-cough syrup. For UTI, I first inquire (verbally) if the infection has spread to the kidney,” he adds.
Mr Ouma, who previously worked in a laboratory as a technician and later in a clinic, says he has always wanted to start his own business.
“My job is to do lab tests but after some time, I learned how to treat different types of diseases. Even if I don’t test for infections, I know what diseases most patients have. I also have doctor friends who have taught me and I sometimes consult them if in doubt,” says the 28-year-old who also lives in Kibera.
Together with tens of other drug traders in Kibera and other slums, Mr Ouma says, they buy their medicines from Kawangware, a low-income area, and Nairobi’s downtown.
“Initially, we used to go to the suppliers who sell to us in smaller quantities, but now they know us so they bring the drugs here,” says Mr Ouma, who has been selling medicines for three years now.
Buying fakes, dispensing antibiotics without prescriptions and patients abandoning the medicines are some of the factors fuelling antimicrobial resistance (AMR), which occurs when a bacteria, virus or parasite stops an antibiotic, antiviral and antimalarial drug from working against it.
According to the World Health Organisation (WHO), one in 10 medicines in low and middle-income countries like Kenya is either substandard or falsified, and these drugs find their way into unregistered chemists.
Dr Serufusa Sekidde who works at GlaxoSmithKline as the Director Policy and Partnerships (AMR) Global Corporate Government Affairs and Policy/ GSK China Institute of Infectious Diseases and Public Health says falsified patented and generic medicines are a public health threat.
“GSK recognises that we have an important role to play in helping to minimise the falsifying of our products, including exercising our trademark rights. We are committed to combat this, including packaging features designed to help detection,” he said.
“However, GSK cannot tackle this issue alone. The prevention and detection of falsified products is primarily a matter for national governments,” he adds.
In the broken antibiotics market, most drug sellers have little time and knowledge to tell patients about usage. Most poor patients buy half doses or miss doses when they begin feeling better, and return to buy more antibiotics with a recurring infection that has developed resistance.
“I tell the patients to eat well. If someone does not have money, I give them a half dosage plus painkillers and I ask them to come back when they get money. Most times they never come back because they get well,” Mr Ouma says, adding that he sells one antibiotic tablet for Sh20.
Poor patients see drug traders, whether quacks or professional pharmacists, as “cheaper and more efficient doctors.”
This perception has cut doctors from the treatment chain all together in favour of the chemists. Such is the case in Kinanie, a village in Machakos, that has only one hospital and a thriving drug selling business.
Mrs Esther Kimongo, a 40-year-old, owns a small chemist in the sleepy shopping centre, a just few kilometres from Kinanie Level 3 Hospital. Together with two other drug store operators, she serves thousands of patients who cannot access treatment in the hospital.
“Most patients by-pass doctors to avoid the long queues in the hospital. And some see no sense of going to the hospital just to be given painkillers,” says Mrs Kimongo.
Before opening her chemist about two years ago, she worked in a hospital’s procurement department.
Just like Mr Ouma in Kibera, she does not buy drugs in bulk and mostly stocks antibiotics, antimalarial, cough syrups, painkillers and pessaries, in small quantities. Her top sellers are medicines used to treat sexually transmitted diseases, malaria and coughs.
Mrs Kimongo says chemists play a big role in rural areas with few hospitals.
“A child was brought to my chemist with convulsions and a high fever. I gave her drugs, she gained consciousness as the parents rushed her to hospital. Here, children die on their way to the hospital, which is over three kilometres away,” she says.
Though she acknowledges the role chemists play in watering down the efficacy of the crucial life-saving drugs, she noted that they are still an important cog in the treatment process and adds that if rural traders were trained on how to accurately dispense drugs for common diseases, they will help save lives.
Mr Isaac Kaivi, another chemist owner in Kinanie has been in business for 10 years now. The pharmaceutical technologist by training says the highest selling drugs are antibiotics to treat upper and lower respiratory diseases and urinary tract systems.
Part of the strategy to tame antibiotics abuse is patients to buy drugs from accredited outlets.
There are about 5,500 registered pharmacies in Kenya, according to Dr Munene. So far, only 60 pharmacies countrywide are accredited “Green Cross” outlets.
In Embakasi, Kenya’s most populous neighbourhood in Nairobi, an area, which has a mix of informal settlements and gated communities, there are over 15 retail outlets located within a radius of less than two kilometres, and only one has a “Green Cross”, a mark of quality by the pharmaceutical society that shows the chemist meets patient safety standards.
Antibiotics resistance not only kills over 10 million patients per year globally, according to WHO, but it also strains the public health system.
“The real consequence is on public health, the loss of effective antibiotics for life-threatening illnesses, and the shift to more expensive antibiotics that place a heavier financial burden on both the family and the health system,” says Dr Munene, whose organisation has been fighting quacks and teaching Kenyans on better use of antibiotics.
To turn the tide, pharmas such as GSK are also investing in development of new medicines to tackle drug-resistant bacteria.
“We recently started phase three trials for a new first in class antibiotic, Gepotidacin for uncomplicated UTI and gonorrhoea-infections which are common and show increasing resistance to current antibiotics,” said Dr Sekidde, adding that vaccines also play a role in reducing AMR.
“We are studying the potential for our pneumonia vaccine to protect against gonorrhoea infections as well as earlier stage vaccines for Shigella,” he said. However, the biggest headache lies in slums. As informal drug shops are shut down and the owners penalised, more sprout overnight.
“Quacks are not our members. We encourage our members to report quacks operating in their neighbourhood to the regulatory authority- the Pharmacy and Poisons Board for action,” Dr Munene says.
In slums, it is hard to know which drug store is run by a professional or by a quack. In these areas that lack clinics, fake pharmacists thrive because infections are high due to poor sanitation.
It is 6pm in Kware, a Nairobi slum that stretches many kilometres. Raw sewage drains onto the crowded road where traders have lined up roasting liver, goat intestines, (mostly rejects from abattoirs)}, and fish on an open fire. On this road, where motorbikes rumble through leaving a trail of dust and fuel fumes, the meat is not expensive.
Four pieces of firewood-grilled liver cost Sh10. At every selling point, three or four customers mill around to buy and eat the meat without washing their hands. With a high appetite for foods sold in dirty, open-air spaces, and handled with sellers with poor hygiene, getting infections is easy.
“AMR is a complex problem. The first thing that we need is to ensure people don’t get infections. The challenge is most Kenyans live in areas with poor sanitation, already an infection basket. And when these people who cannot afford healthcare become sick, they first run to the chemists to buy antibiotics,” says Dr Yonga.
Ideally, Dr Yonga says, if a patient goes to a pharmacy to ask for drugs, the pharmacist has the responsibility of directing the patient to a doctor for proper examination, because a bacterial infection can only be detected through lab tests.
“However, that happens in few instances because owners are also looking to make money. I worry that we (doctors) will have limited options to save patients. In terms of cost, an infection that would have cost Sh500 to treat will cost Sh300,000 to Sh500,000 because the disease will be more severe, the patient will have to be admitted in ICU, will need dialysis and many specialists. And yet this patient will likely be poor,” Dr Yonga says.
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