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Pharmaceutical chaos: e-mails from an academic pharmacist in Iraq

Pam Mason is a pharmacist and a freelance pharmaceutical journalist based in Monmouthshire, Wales

There is no pharmaceutical care in Iraq, only pharmaceutical chaos, said Ayad Ali in a recent e-mail. “We are suffering from a complete breakdown in the pharmaceutical distribution system, with limited access to essential drugs, counterfeit medicines flooding the market and an escalation in the number of unlicensed street vendors. Pharmacists and academic staff are subject to terrorist attacks. Some have been murdered; others, kidnapped. Community pharmacies have been destroyed, looting of drugs and equipment is rife. The recent war, on top of a decade and a half of economic sanctions, has had a disastrous effect on pharmaceutical care and public health. What a sorry state for a country which is the cradle of pharmaceutical civilisation.”

Tomorrow’s Pharmacist

Tomorrow’s Pharmacist, our annual guide for students and preregistration trainees, is published next week.The guide is sent to all preregistration trainees and schools of pharmacy.

In an article in this year’s issue, Muna, a third-year student, together with Ayad Ali, interviewed here, both from the school of pharmacy in Tikrit, tell Pamela Mason about pharmacy studies in Iraq and the impact of the war on pharmacy.

Other articles include advice on student finances, a day in the life of a supplementary prescriber, a guide to who offers what in the job market and a look at what pharmacy will be like in five years’ time.

According to Dr Ali, the first apothecary shops in the world were established in Baghdad in 766, and the world’s oldest written prescription — dating from the third millennium BC — was found in the form of a Sumerian clay tablet. This prescription included the name of the patient with the names and amounts of the herbs to be mixed and used. The first medieval school of pharmacy was founded in Baghdad and pharmacists in Iraq were among the forerunners in developing standards for preparing and storing drugs.

Dr Ali is an academic pharmacist at the University of Tikrit. Tikrit is situated about 100 miles north-west of Baghdad on the River Tigris, with an estimated population in 2002 of about 28,900. It is home to one of seven schools of pharmacy in Iraq. The others are in Baghdad, Basrah, Qufa, and also Mosul, from which Dr Ali graduated in 2002.

Pharmacy training

The BSc degree programme in Iraq is five years long. This is followed by a preregistration year, which must include eight months’ experience in a state hospital pharmacy and four months in the pharmaceutical industry. Dr Ali completed his internship in Kirkuk at the Saddam General Hospital and a community pharmacy and at the Nineveh Drug Industries in Mosul.

In common with the majority of new pharmacy graduates in Iraq he most enjoyed the clinical experience he gained at the hospital. However, the popularity of hospital pharmacy tends to exacerbate the woeful shortages of pharmacists in other areas of the profession. Although some pharmacists work part-time in both hospital and community, many community pharmacies have had to close due to lack of pharmacists.

Shortage of academics

The schools of pharmacy are facing a lack of teaching staff, particularly of those with higher degrees in pharmaceutical specialties, including pharmaceutical chemistry, pharmaceutics and toxicology. Academics have been the targets of terrorism. According to Iraqi Ministry of Education statistics, more than 40 academics have been assassinated during the past eight months.

Shortages of pharmacy academics have been compounded by the opening of five schools of pharmacy during the past six years. “I am the only qualified pharmacist working in the University of Tikrit,” said Dr Ali. “Most of the others I work with are either veterinarians or chemists. Teaching is therefore not well oriented to pharmacy practice and this is contributing to the stagnation of the profession.”

Laboratory equipment is also in short supply and has been since United Nations sanctions were imposed on Iraq after the Gulf War in the early 1990s. “During my undergraduate years, I remember washing and drying filter papers and reusing them. It is the same today with six or more students sharing glassware, such as pipettes, burettes and measuring cylinders.”

Access to books, journals and other pharmaceutical information is a severe problem. The UN sanctions provided no exemption for the transmission of medical and scientific literature. Iraq has therefore been isolated from the international academic community for the past 15 years. “Our university library has a large number of books, but all are copies of the original and most are of poor quality with missing pages. The British National Formulary is an essential source of information for all pharmacists in Iraq, but at the beginning of the war, the most recent edition we had was from March 1998. Since the war we have seen many more recent BNFs, particularly the March 2004 edition, but again they are all copies. However, Betty Falconbridge of the Commonwealth Pharmaceutical Association, has sent me three BNFs, which I am delighted to be able to share with colleagues and students.”

Security

The ongoing security situation has resulted in the closure of several colleges, including the University of Mosul and the University of Anbar. “We have been fortunate in Tikrit because our city has not faced conflict until recently, but we had to delay the start of the present academic year by two weeks because of the lack of security. Three first-year students — all from Fallujah — and six second-year students have stopped attending college. Two students were accidentally shot on their way to college. Immediately after the war we suffered looting. Hardly anything in the college was left. Even the electricity switches were stolen. Had the walls been removable, they too would have been taken away.”

Availability of medicines

The conflict has had a huge impact on the availability and usage of medicines in Iraq. The essential drugs list exists, but according to Dr Ali, that is all it is — “a list without real application because of acute shortages”. There is a particular lack of antibiotics and also drugs for long-term medical conditions, such as diabetes, cardiovascular disease and thyroid problems. Cancer drugs are almost non-existent.

In the pharmacy, prescriptions are returned to the patient after dispensing, which means they can have as many repeats as they want. Apparently, the most common question patients ask about their prescriptions is not “how do I use my medicine?” but “is my prescription in the bag?”.

Opening of the borders has led to widespread availability of counterfeit medicines and substandard pharmaceutical products. Before the conflict, two major national drug manufacturers were responsible for most of the drug supplies. Since the war many unlicensed pharmaceutical manufacturers have appeared. This has led to a lack of good manufacturing practice and 97 per cent of medicines are now of unknown origin.

Unlicensed drug street vendors have mushroomed as a result of the breakdown in law and order. Medicines were looted from hospitals and primary health care centres then sold on the street. Piperacillin, for instance, is no longer found in hospitals, but there is a surplus on the pavements and this anti-pseudomonal antibiotic is increasingly being used for conditions such as minor tooth swelling. Fewer than a quarter of patients with diabetes have access to insulin, yet it is not uncommon to see vials of it baking in the sun on market stalls. Pharmacy inspectors exist, but if they were to challenge an unlicensed drug seller, they would almost certainly be assassinated or threatened within 24 hours, said Dr Ali.

Indiscriminate use of medicines is all too common. Quinolones are used to treat minor fevers and metronidazole for acute diarrhoea in children. Ironically, oral rehydration salts are left unsold on pharmacy shelves then destroyed because they have gone out of date. Addicts request drugs such as diazepam, benzhexol, procyclidine and codeine, which they can buy over the counter. Potent corticosteroids are sold frequently for conditions such as nappy rash.

Rofecoxib is still on the market. Dr Ali maintains that the Ministry of Health took no action to ensure the withdrawal of this drug. “Even the national pharmaceutical association (the Syndicate of Iraqi Pharmacists) did not warn its members to take the drug off their shelves.”

Public health

The health of the Iraqi people continues to decline. According to a report issued in October 2004 by the Iraqi interim government’s ministry of health, the burden of infectious disease increased last year. From January to June, 8,253 cases of measles were reported, up from 454 cases in the whole of 2003. The ministry reported 11,821 cases of mumps in the first four months of last year, nearly double the figure for 2003. TB is still endemic, malaria has re-emerged in northern Iraq and hospital-acquired infections are increasing. One in three children under five years of age is suffering from chronic malnutrition and life expectancy has fallen below 60 years for both men and women.

In addition to a lack of essential drugs and vaccines alongside ready availability of sub-standard and counterfeit pharmaceuticals, lack of clean water and of basic foodstuffs is taking its toll on health. “For the past three months, the Iraqi people have not received their shares of flour and sugar,” Dr Ali commented.

The future

“The situation here is not improving,” he concluded. “Today is worse than yesterday and this day is better than tomorrow. But we must have hope. The longest day must have an end and the darkest hour is the one before dawn. Let us keep our fingers crossed to the post-elections era.”

Further information

Further information about Ayad Ali and the pharmaceutical situation in Iraq can be found at www.psnc.org.uk/weblogs or e-mail pharmayad@yahoo.com

Citation: The Pharmaceutical Journal URI: 10018290

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