Global Trends by Martin Khor

Monday 6 June 2005

Medicines becoming useless due to overuse 

Blurb:  The recent World Health Assembly highlighted a major global health problem:  that many medicines are becoming ineffective because their overuse or wrong use have enabled life-threatening microbes to become resistant to antibiotics and other drugs.  Action to curb irrational drug use is now urgent, yet not much has been done until now.

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The wrong prescribing and use of medicines is contributing to increasing resistance by bacteria and viruses that cause infectious diseases to antimicrobial medicines such as antibiotics.

Both the irrational use of drugs, and the anti-microbial resistance have reached alarming proportions.

These interrelated problems was one of the more interesting issues brought up at the World Health Assembly (WHA), attended by Health Ministers and officials in Geneva a fortnight ago.

The World Health Organisation says that antimicrobial resistance is one of the world’s most serious public health problems. A major cause is the wrong use of medicines.

Though the WHA debated these inter-related issues, measures to control irrational drug use were downplayed because some major developed countries did not want the spotlight to be placed on the marketing tactics of drug companies.

Proposals to control the sales of drugs as growth-promoting agents in animals were dropped in a draft resolution at the insistence of these countries.  

Worldwide, more than 50% of all medicines are prescribed, dispensed or sold inappropriately, and 50% of patients fail to take them correctly.  These startling facts were presented by WHO officials at a briefing for WHA participants on “Irrational use of medicines damages health and wastes resources.” 

“Only two thirds of the world’s population have regular access to medicines, and of the people who do receive medicines, more than half of those people are prescribed medicines incorrectly,”  said Dr. Kathleen Holloway of the WHO’s Department of Medicines Policy.  “And of the people that are prescribed medicines, more than half of those people fail to take them correctly.”

Arithmetically, that would mean that less than a quarter of medicines prescribed are used appropriately.

Holloway also gave some data on adverse consequences of irrational drug use:

• 2.3 to 4.7 million new cases of hepatitis B and C and 160,000 new cases of HIV per year, resulting from 15 billion injections per year, half of which are non-sterile.

• 4 to 10 percent of hospital inpatients suffer an adverse drug reaction in developed countries.  This is the fourth to sixth leading cause of death in the US and costs $130 billion in the US and 466 million pounds sterling in the UK yearly.

• There is increasing antimicrobial resistance, with resistance of up to 70-90 percent to original  first-line antibiotics for dysentery (shigella), pneumonia (pneumococcal), gonorrhoea, and hospital infections (staph. Aureus).

“Irrational drug use is a very serious global public health problem and much more action is needed at national level,” she concluded. 

During question time, a member of an Asian consumer organization remarked that a major cause of irrational medicines use in developing countries was the unethical promotion of drugs by drug companies, which practiced double standards in marketing and labeling (in developed and developing countries) and gave incentives to doctors to induce them to use more medicines.

He added that a large portion of antibiotics produced were sold as inputs in animal feed to fatten the animals, and as there was little control of this in developing countries, this had contributed to resistance in the bacteria and viruses in the animals which were then passed on to resistance in microbes that affect humans.

He expressed concern that part of a draft WHA resolution on antimicrobial resistance, that dealt with the need to regulate drugs in animal feed had been removed.

A senior WHO official replied that sales promotion by companies is effective in influencing the decisions of doctors on their use of drugs.  On what can be done towards more responsible sales promotion, he said regulation seems to be the measure that works as it was shown to prevent the worst aspects of promotion.

On the use of drugs in animals, Hogerzeil said that the drafting group for the WHA resolution had decided that the resolution should only deal with the medical problem as there are other international agencies that deal with drug use in animals. 

In his response, Prof. Otto Cars, Director of the Swedish Programme for Rational Use of Antimicrobial Agents, agreed that the ethical standards of drug companies is a very important issue, and that there needs to be regulation on sales promotion.  

On drugs in animal feedstuff, he agreed it was a major issue, and that the European Union was going to prohibit the use of drugs as growth promoters in animals in 2006. 

As the discussion showed, there were differences behind the scenes on how the WHO should deal with irrational drug use.

Some developed countries objected to a focus on irrational drug use and narrowed the issue to antimicrobial resistance. They did not want the marketing tactics of drug companies to become a focus of attention.

During the discussions on antimicrobial resistance, some countries proposed that governments should control the use of antibiotics used to promote growth in animals that are for human consumption, as this practice has been considered hazardous since the 1970s.  However, the proposal was removed at the insistence of a major developed country.

A WHO policy paper on “Containing antimicrobial resistance” says that many of the microbes that cause infectious disease no longer respond to common antimicrobial drugs such as antibiotics, antiviral and antiprotozoal drugs.

“The problem is so serious that unless concerted action is taken worldwide, we run the risk of returning to the pre-antibiotic era when many more children than now died of infectious diseases and major surgery was impossible due to the risk of infection.”

WHO’s 2002-03 data show the following antimicrobial resistance global prevalence rates:  malaria (chloroquine resistance in 81 out of 92 countries);  tuberculosis (0-17% primary multi-drug resistance);  HIV/AIDS (0-25% primary resistance to at least one antiretroviral drug);  gonorrhoea (5-98% penicillin resistance); pneumonia and bacterial meningitis (0-70% penincillin resistance in streptococcus pneumonia); diarrhoea: shigellosis (10-90% ampicillin resistance, 5-95% cotrimoxazole resistance);  hospital infections (0-70% resistance of staphylococcus aureus to all penicillins and cephalosporins).

Another WHO paper says that irrational medicines use includes use of more medicines than are clinically necessary, inappropriate use of antimicrobial agents for non-bacterial infections; inappropriate selection or dosing of antibiotics for bacterial infections; over-use of injections when oral formulations are more appropriate; failure to prescribe in accordance with clinical guidelines; and inappropriate self medication often of prescriptions-only medicines.

“The extensive misuse of antimicrobial agents leads to bacterial pathogens becoming resistant, thereby rendering treatment ineffective,” says the paper.  “The rapid and alarming spread of antimicrobial resistance around the world has not been matched by a concerted and powerful public health response.”   

The WHO paper lists measures that governments can take, including regarding drug sales promotion.  “Pharmaceutical promotion often has negative effects on prescribing and consumer choice,” says the WHO.

“Countries should consider regulating and monitoring the quality of drug advertising and of the pharmaceutical industry’s promotional practices, and enforcing sanctions for violations.”