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Authentic Network Authentic.Network uses blockchain technology to tackle the problem of counterfeit drugs. See their pitch below, and find out more about their product here: https://authentic.network/en/home.html This is not an endorsement of this product.

PharmacideFilms This documentary film investigates tracing and identifying counterfeit medicines in rural Southeast Asia. The project was funded by USAID through the US Pharmacopeial Convention Promoting the Quality of Medicines Program, and supports novel solutions for protecting public health by ensuring good quality medicines for all.

Visit the events page to view submissions for the "Technologies to Tackle Substandard & Falsified Medical Products in Global Health" event. In the meantime, here's one from my personal collection - to shock and inspire! Storage of antiretroviral medicines in a remote clinic, observed during a medicines management audit. Photo credit: Petra Straight.

As I embark upon a large qualitative research project, I've been thinking a lot about metrics. I've been thinking about what we measure (and how sometimes reality differs from intention!), about how we measure it, about the value that this imparts onto it and about what it means to be a qualitative researcher in a quantitative world. In this post, I wanted to share some of my initial thoughts about the pros and cons of metrics in global health. There's a short bibliography at the end, but I'd really appreciate your recommendations for further reading on the subject. I'd also love to hear your thoughts and feedback on my summary so far. What do we mean by metrics? Global Health metrics seek to translate the status (and trends) of complex, shifting and multi-faceted ethnographic circumstances into a manageable, malleable and memorable quantitative format through the use of indicators. It occurs to me that the process of reducing rich and nuanced occurrences into a handful of digits is akin to a siren-like beauty: the idea is beguiling but can be treacherous if trusted without question. Keeping Count The discipline of global health has evolved in conjunction with the rise of quantitative data (i.e. inventories, statistics, metrics, indicators and numerical goal-setting). Before dissecting the relative merits and problems with this, I think it's useful to reflect upon the sheer extent to which metrics are woven into the fabric of our world’s health systems, as one can become blind to normative practices when they are familiar. So let's have a quick think about some of the myriad ways in which we use (and are used by?) numbers: Indicators and metrics guide governments in both determining and communicating priorities and resource allocation to national health providers. In a global setting, metrics are used for measuring the baseline of, and progress beyond, key health issues (and a plethora of non-health related issues such as poverty or corruption, for example). This information not only directs the policy and priority of global health organisations, it influences investments, trading, and the global economic market as a whole. Metrics are utilised by donors (institutional and philanthropic alike) to hold recipient organisations to account, frequently in combination with hefty incentives and reprisals. The Bill & Melinda Gates Foundation are a high-profile example of this: a powerful donor with a zealot-like belief that quantitative data and financial incentives are key to solving global health challenges. Metrics are a powerful tool of advocacy groups, think-tanks and researchers for influencing change. Consider the Access to Medicines Index, which has impressively shifted the behaviour of pharmaceutical behemoths in a short span, through the use of indicators, analysis, public reporting and thereby the generation of competition. Metrics are used heavily in research and academia where there is sometimes a propensity for quantitative studies to be considered more serious and scientific than qualitative ones. This is reflected in journals like the Lancet, for example: a highly-respected and widely-read journal, which is a strong proponent of metrics. Pervasive, to say the least. With this in mind then, let us explore the positive and detrimental impact of metrics. Photo by Stephen Dawson on Unsplash The benefits of Global Health metrics As pithily stated by Shiffman and Shawar, “the inherent allure of metrics [is] their ease of use and their alleged capacity to render legible complex worlds” (1). The value of this is undeniable (by all but the most ardent critics) because it enables information to be utilised and applied in a manner that is not feasible (or at least practical) with qualitative data. Through the generation of a number, our “complex world” is reified into a single reference that can be manipulated through calculation and communicated with ease. Based on my experiences, and through my initial readings, I think the benefits of metrics could be summarised and grouped as follows. So, what's all the fuss about numbers? Calculation. Firstly, they allow us to conduct processes (e.g. budgeting, or risk management) that would otherwise be less effective, or even unworkable, without numbers. Such fundamental activities are core to “business as usual” for most health organisations. Moreover, certain disciplines are entirely dependent on, or characterised by, their use of statistical analysis (epidemiology, or quantitative research, for example). Motivation. Secondly, information becomes compelling. Numbers are simple, memorable, and easy to communicate (relative to other forms of data). There is also evidence to indicate that individuals tend to be more willing to trust quantitative data, as it is more likely to be viewed as scientific (1). As a result, information shared in this manner tends to resonate with the audience and thus it is a powerful tool for those wishing to gain attention or exert change. Competition. Thirdly, it facilitates comparison. Distillation of an issue into a single, solid figure, removes extraneous factors, bypasses ambiguity, and creates a tangible and actionable output. An obvious application of this is to track the progress of an issue over time. Another benefit is that it creates scope for rankings and competition. This benefit is readily used by employers, campaigners, regulators and numerous global actors to, often publicly, urge change or alignment with a cause. Liberation. Fourthly, it is emancipatory. Impartial measurement can map issues and shine a light on problems that may otherwise be marginalised, in a manner that may be challenging to deny (1). Communication. Fifthly, it enables engagement with a non-technical audience. While an individual may lack the competence or time to engage with a subject, complex ideas, issues and circumstances can be rapidly communicated and discussed. In my experience, this is often of particular value when dealing with the public or when liaising with senior management. Obligation. Finally, it creates accountability. Numbers allow a systematic and objective consideration of an activity or outcome that provides a dispassionate and apparently unbiased picture of performance. "When counting, try not to mix chickens with blessings." Leonardo da Vinci The problem with Global Health metrics However, and rather obviously, there are drawbacks to metrics that not only undermine all of these benefits, but also that may have an actively detrimental impact on global health. These could be described as follows: Abstraction. Similarly to Plato’s Allegory of the Cave, metrics are a shadow of reality, dancing on the cave wall of our understanding. The methods of data collection, and of imputation, are often opaque. In addition, as discussed, the numbers (and indicators) themselves are “products of social processes heavily reliant on interpretation” (1). However, through ignorance or inability, there is a risk that these abstracted figures are confidently used and applied as if they are complete and specific. Over-Simplification. Metrics are reductive by intention. However, it strikes me that quantifying human experience – particularly human suffering – is a somewhat grotesque and heartless activity. It, according to Fukuda-Parr, “redefines [the concept] to a utilitarian perspective” (2) and in so doing, it undermines an individual’s lived experience. She exemplifies this statement by considering poverty: metrics may describe it in terms of income, but this is wholly unsuited to conveying the dehumanisation experienced by begging or prostitution (2). Generalisation. Metrics involves gathering data from an array of cases and analysing them as a cohort. The results are used to make generalised observations, declarations and decisions and, in so doing, ignore nuance, quirks and specificities. Tichenor and Sridhar question “the larger ramifications of practices of standardization, data correction, and imputation… particularly with the goal of making local contexts readable from a satellite’s view of the world” (3). They point to the problem of universalising experience and applying the results to national or district health services without local adaptation. This issue is particularly problematic for the Global South and may result in the presumptive implementation of inappropriate interventions (3). Individualisation. Counterintuitively, metrics can both be generalised and individualised. Since the 1960s there has, broadly, been a reframing of metrics and global goals into person-centred measurements and targets. Although this humanisation of data is not entirely regrettable, some birds-eye analysis of (and interest in) global issues has been lost (2). For example, moving the narrative from economic development to an impact on livelihoods can mean that a macroeconomic understanding of the issue is neglected. Information. Global data sets have the potential to subvert the establishment of national information systems (1). Over the last three decades, as globilisation, humanitarianism and economic development have matured, metrics have shifted from an organisational tool to a world-wide industry. Massive data sets are gathered, analysed and communicated on a global stage and, whilst this data may not be intended for national decision-making, it is predictable that it has disincentivised the creation of individual governmental health information systems in some lower income countries (1). As a result, effected countries may lack the national or local knowledge required to make suitably adapted decisions (regarding intervention, priority, or resource allocation, for example) (1). In addition, this contributes to a lack of local data analysis skills, due to a lack of opportunity and investment to build this capacity (3). Finally, it also means that the open-source data sets used by a country are not actually owned by it, which can have implications for the interpretation and analysis of it (as full knowledge of collection, imputation and calculation methods are unlikely to be available). Domination. Whilst considering large data sets (used to measure and track global burden of disease, international development goals, or country comparators, for example) we should question who determines the indicators that are used. These are, inevitably, large organisations (such as a UN agency or the World Bank), wealthy organisations (such as donors or private firms), or High-Income Countries situated in the Northern hemisphere. Even if we assume that indicators are selected by these parties for purely altruistic purposes, the outcome is a shift of power: from designated to designator, from low-income to high-income entity. This results in global attention being focussed on those conditions and causes that the privileged consider to be worthy – and, similarly, to be measured by indicators that they believe to be representative. This paternalistic exclusion of relevant actors creates, according to Shiffman and Shawar, an “uneven playing field” (1). It is this same “uneven playing field” that prevents these metrics being corrected and optimised through scrutiny and iteration. Not only will differing perspectives have a smaller platform and be less likely to be heard, but alignment around them is driven via financial incentives or social pressure. Public ratings and comparisons create the potential for reputational damage, which in turn coerces a State or organisation to align with these designated priorities. Trust. According to Shiffman and Shawar, critics of metrics feel that they “present a scientific veneer to a contingent undertaking, and thus acquire an authoritativeness [that] they do not deserve” (1). While their compelling and motivating nature is acknowledged as a benefit in this paper, the flip side is a skewing effect that it holds on the sector (as is manifest in several of the points already mentioned). While anyone can digest metrics and graphs at face value, the critical thinking and interrogative scepticism needed to interpret and act upon them are learned skills. This, inevitably, leads to the politicisation of metrics. Numbers can be presented and manipulated to great effect to mobilise support and resources for a campaign, to undermine a competitor’s reputation, or to disingenuously present results, for example. The scale of this unearned legitimacy is perhaps most simply summarised by the adage: “Lies, damn lies, and statistics”. Force. Finally, and as is evident across all of these points, metrics possess a force (for influence seems too weak a term). The aforementioned negative aspects result in a host of negative consequences and – as forceful as they are – not only measure global health, but shape it in their own right. First, as stated, metrics can create alignment around, and have a substantial influence on, strategy, prioritisation and the allocation of resource. This has the effect of supplanting national/organisational strategic processes of prioritisation and therefore interfering with internal structures, mechanisms, and outputs. Secondly, and equally significantly, metrics impact things that are not measured. As only a limited number of indicators can be tracked, this effectively both narrows and silos global focus (thereby further influencing the global agenda). Furthermore, regarding what is not measured, it sends a tacit message in respect of its worth(lessness) – and therefore of the issues and experiences that it seeks to represent. For example, when the Millennium Development Goals (MDGs) chose not to include access to reproductive health as a measure (believing that that this was sufficiently covered by poverty reduction and maternal mortality) they failed to recognise the struggle and significance that this has on the rights and capabilities of women (2). Given the influence of global targets in setting national agendas, it is easy to see how such an omission can (negatively) impact initiatives and subsequently alter their course. Thirdly, the existence of data (or the potential for it) is influential. Where it exists, it begs to be researched. This has an impact on the popularity of quantifiable issues, which in all likelihood leads to their increased discussion, readership and scientific progress. Furthermore, where an intervention can be measured, it may be preferentially implemented. For example, Cognitive Behavioural Therapy is a cornerstone of NHS mental health intervention. Its measurability has undoubtedly contributed to this status – a trait that more traditional (yet potentially more effective) forms of talking therapy do not share. This creates a “technocratic agenda” and can medicalise issues that should instead be progressed via social, educational or alternative interventions (1). Fourthly, there is a general human (and organisational) preference for metrics over other forms of data. This privileges that “form of knowledge…[over] those that cannot be quantified” (1). This has a directing effect on interventions, research, publications and public support. Fifthly, finally, and most profoundly, metrics have the potential to shape our perspective on reality. They categorise the world and in doing so they define and shape it, by delineating how it should be categorised, considered and valued. Final thought Given the pervasiveness of metrics in Global Health, it is not a stretch to assert that they (and the indicators from which they are derived) have the potential to shape every facet of healthcare, in every corner of the world. However, how this potential is realised is, of course, dependent upon how the numbers are interpreted and applied. References & Bibliography (1) Shiffman J, Shawar YR. Strengthening accountability of the global health metrics enterprise. The Lancet (British edition) 2020;395(10234):1452-56. doi: 10.1016/S0140-6736(20)30416-5 (2) Fukuda-Parr S. Global Goals as a Policy Tool: Intended and Unintended Consequences. Journal of Human Development and Capabilities 2014;15(2-3):118-31. doi: 10.1080/19452829.2014.910180 (3) Tichenor M, Sridhar D. Metric partnerships: global burden of disease estimates within the World Bank, the World Health Organisation and the Institute for Health Metrics and Evaluation. Wellcome Open Research 2020;4(35) doi: 10.12688/wellcomeopenres.15011.2 Adams V. Metrics : what counts in global health. Durham, [North Carolina] ; London, [England]: Duke University Press 2016. Whittemore R, Chase SK, Mandle CL. Validity in Qualitative Research. Qualitative Health Research 2001;11(4):522-37. doi: 10.1177/104973201129119299 Thanks for reading. I'm currently researching these issues at the Ethox Centre of the University of Oxford, with the kind support of the Wellcome Trust. If you'd like to stay in the loop, please get in touch or join the community on this site. Cover photo by Jon Tyson on Unsplash - with thanks.

Just a little announcement to share that I've had my first academic paper published! The full text of Elusive Quality: the Challenges and Ethical Dilemmas faced by international Non-Governmental Organisations in Sourcing Quality Assured Medical Products is available in a Special Issue (Social and ethical issues of poor quality and poor use of medical products) in BMJ Global Health. Please have a read and get in touch with me or leave a comment with your thoughts. Thanks for reading. I'm currently researching these issues at the Ethox Centre of the University of Oxford, with the kind support of the Wellcome Trust. If you'd like to stay in the loop, please get in touch or join the community on this site. Many thanks to Jan Kopřiva on Unsplash for the cover photo.

Imagine that, as you're reading this, you're doing so from a low income country. (Indeed, perhaps you are!) Now imagine that we are joined by a family with a very young daughter, who has been diagnosed with pneumonia. The situation is grave and the family are concerned because the last two courses of antibiotics have failed to work. The doctors are unable to explain why, as the medicines have been Quality Assured by the government. Perhaps it's antimicrobial resistance? Perhaps the medicines have been stored incorrectly and have degraded? Perhaps they've expired and the vendor altered the label? Perhaps they're fake? Perhaps... well there are a host of possible reasons. For now let's focus on the real problem: a dying child, without access to basic, effective treatments, because of where she lives. It is estimated that 10.5% of medicines in low- and middle- income countries are fake or substandard (1). This is unsurprising, and possibly an underestimate, given that nearly 75% of governments are not considered to have a “stable, well-functioning and integrated regulatory system” (2). Let's return to our story. There's hope: the family are informed of a nearby clinic that can provide treatment. However, the clinic operates outside of the State-sponsored health system and, it is whispered, smuggles in its medicines from a neighbouring country. These medicines are real yet illegitimate: Quality Assured by one country, but not approved by this one. Who is right? What should the family do...? This scenario highlights how concepts like "quality" can be subjective and how authenticity is not necessarily binary. It also provides a small snapshot into the kind of dilemmas that uncertainty can cause in global health - for patients, doctors and regulators alike. I explore these ideas, and the notion of the "Genuine Fake", in this podcast with Assoc Prof Patricia Kingori - please have a listen (it's about 15 mins long) and leave a comment below. I'd love to hear your thoughts and your own stories. References 1. A Study on the Public Health and Socioeconomic Impact of Substandard and Falsified Medical Products. Geneva: World Health Organization (2017). {Available at: https://www.who.int/medicines/regulation/ssffc/publications/se-study-sf/en/ } 2. Khadem Broojerdi A, Baran Sillo H, Ostad Ali Dehaghi R, et al. The World Health Organization Global Benchmarking Tool an Instrument to Strengthen Medical Products Regulation and Promote Universal Health Coverage. Frontiers in Medicine 2020;7(457) doi: 10.3389/fmed.2020.00457 {Available at: https://www.frontiersin.org/articles/10.3389/fmed.2020.00457/full } {For information about the WHO's Global Benchmarking Assessment Tool, head to: https://www.who.int/medicines/regulation/benchmarking_tool/en/ } Thanks for reading. I'm currently researching these issues at the Ethox Centre of the University of Oxford, with the kind support of the Wellcome Trust. If you'd like to stay in the loop, please get in touch or join the community on this site.

FIP (the International Pharmaceutical Federation) have published a competency framework for pharmacy professionals who work in the humanitarian sector (and support health programs in emergency, fragile, and humanitarian contexts). "The aim of this work was as to provide an international competency framework for pharmacists working in the humanitarian arena, that would be used to guide education and training programmes in this increasingly important field of practice." After years of discussion and hard work, it's finally out! I'm very happy to have had the opportunity to be a part of this wonderful initiative. But... Even though this framework offers a huge first step towards guiding education, training, and professionalisation for those working in pharmacy in the humanitarian sector, much remains to be done. With such an enormous, diverse, and undefined field, there will certainly be errors, omissions, ambiguities, and controversies in this document that need to be worked through. (Indeed, during development we even needed to define what we meant by humanitarian pharmacy!) So, whilst I am pragmatic about the completeness of this work, I also believe that there is huge cause to celebrate. The first step is often the hardest - and now we have a focus for debate! Therefore, I hope that you and your organisation will benefit from this work. However, I also hope that rather than using it as an authoritative document, you will offer constructive feedback and criticism, so that future versions will benefit from healthy debate and broad input.

I've recently become more involved with an "Emergency Medical Team" (a World Health Organisation (WHO) initiative) and am struck by the central - but underrepresented - role of pharmacists and medical supply chain experts. What's the EMT initiative? Essentially the WHO aims to validate any team that proposes to deliver international medical care during a Sudden Onset Disaster e.g. an earthquake. It's worth pausing for a moment here to reflect on the importance of this or, to put it another way, to consider what could happen without this kind of global governance. Imagine the unintentional harm that could happen - has happened - by teams of unregistered, ungoverned, unaccountable healthcare professionals, who arrive at a disaster zone without suitable supplies, language, infrastructure, coordination ... and then start conducting invasive surgery, before going home a few days later. Harrowing. So the WHO EMT initiative aims to end this poor practice and to capacity build those wishing to become registered members. What does an Emergency Medical Team do? There are several types, all of which are self-contained and designed to be responsive to the needs of the population. A "Type 1" is like a primary care facility, providing emergency care for outpatients. A "Type 2" is like a hospital, providing acute and surgical care for major trauma cases. A "Type 3" is like a large, specialist hospital, able to deal with complex surgical and medical cases, as well as providing intensive care. A "Specialist Cell" is able to bolt on to a Type 2 or 3, to deliver a tertiary service like spinal care or dialysis. No matter the EMT type it's a self-sufficient unit, able to be rapidly deployed and provide healthcare within hours or days of a disaster. What role can Pharmacy & Medical Supply Chain play in an EMT? In summary, it's vast. It's probably only a slight exaggeration to think of an EMT as an enormous medical logistics operation with a cluster of highly committed clinicians at the "frontline". The success of the deployment - the ability for those clinicians to save lives - is contingent on having a high-functioning and agile Medical Supply Chain. I recently thought through the considerations for building this high-functioning, agile Pharmacy & Medical Supply Chain for an EMT. Here's the "mind map" overview of what I came up with: I say "overview", as each of the categories can be exploded into greater detail, like this example: You'll probably be relieved to hear that I'm not going to summarise each of these sections here! (Although if there's enough interest I'd be happy to do so and toshare my thoughts on each - just leave a comment.) What I find amazing is the sheer scale and breadth of activities that demand specialist pharmacy knowledge... and therefore the pivotal role that pharmacy and medical logistics professionals can have in the Emergency Medical Team - for the World Health Organisation, as well as for health providers enrolled in the project. ...but where is the humanitarian pharmacy workforce? In my experience, there's a substantial skill gap in the Humanitarian Pharmacy Workforce - and yet the significance of this is wildly underappreciated by the Global Health community. How many humanitarian pharmacists do you work with? I'm willing to bet that you could count them on one hand! How about Humanitarian Pharmacy Technicians or Assistants...? Rarer still. Humanitarian Medical Logisticians are more common, but then this is a self-certified title (and many who claim it are pharmacists). It seems that Humanitarian Pharmacy is facing something of an identity crisis. We struggle to properly define the roles and therefore the competencies needed to excel at them. As a result, we're confused about the skills and qualifications that a pharmacy professional should possess. This makes recruitment bewildering for employers, career progression a mystery for employees, and advocacy a much greater challenge for people like me! "Emergency" pharmacy staff. It's not only EMTs that stand to benefit from a larger, stronger, more empowered Humanitarian Pharmacy workforce - it's a central component to Global Public Health and to achieving Universal Health Coverage. Arguably however, disaster response is an easier context to define and therefore the roles involved with it are more clear cut. Perhaps then, this is a good place to start when tackling this Humanitarian Pharmacy identity crisis?! Over the coming months I'll be documenting the roles, responsibilities and competencies of various EMT pharmacy staff, before developing a training programme for them. Hopefully this work will also provide a foundation for future advocacy on the role of pharmacy and medical supply chain experts in EMTs. I'd be delighted to hear from others working in this space - to collaborate, share perspectives and, I'm sure, to hear what I've missed in the Mind Map above! #GlobalPharmacy #NotJustAPillCounter #Health #Humanitarian #Disaster #EMT #UHC Kate Enright is a humanitarian pharmacist (whatever that means) and the founder of GlobalPharmacyExchange.org - a place for Global Pharm-ers to connect, collaborate and create change.

Happy Antibiotic Awareness Week (13th - 19th November 2017)! "A whole WEEK?" Well if that sounds excessive, perhaps you didn't realise that Antimicrobial Resistance (AMR) is one of the greatest threats to your health, safety and livelihood? Concerned? You should be... What are antibiotics and antimicrobials? An antibiotic is a medicine designed to "fight" bacteria. Antimicrobial describes any medicine that "fights" a microbe (aka a microorganism). Microorganisms are invisible to the naked eye and include bacteria, viruses, fungi and protozoa. So "antimicrobial" is a collective term for the drugs that help us to overcome these infections i.e. antibiotics, antivirals, antifungals, antiprotozoals etc. Man vs Microbe Our bodies provide a potentially warm, comfortable and nutritious environment for microorganisms, so we're a prime target for them. Although we live in peaceful harmony with trillions of them, problems arise if they are pathogenic (cause harm) or if they become overwhelming in number. Our immune system wages a brutal and daily war against pathogens, keeping us safe from infection. But sometimes a pathogen may outwit our immune system - perhaps because it's particularly virulent, or because we're more vulnerable due to injury, poor health, malnutrition, age, stress and so on. At these times, we're dependent on antimicrobials to fight the war that we can't - to protect us from disease and to allow us to recover. But this infers that there is, and always will be, an antimicrobial to save the day. Increasingly, this is not the case. The rise and rise of Antimicrobial Resistance (AMR)? Our war against germs is not a static one. Microorganisms may rapidly adapt methods to undermine or resist our medicines. Common mechanisms for this include: pumping the antimicrobial back out of the bacterial cell. creating proteins that degrade the antimicrobial. changing or protecting the target site of the antimicrobial. ...all of which renders the antimicrobial ineffective. As a result, clinicians must turn to another medicine for treatment: one that is sufficiently different in its chemical structure to be unaffected by the type of AMR, but one that is still active against the type of pathogen. In several infectious diseases "multidrug resistance" is becoming increasingly common and a prescriber's options for treating disease are dwindling. The impact. Unsurprisingly AMR increases the likelihood of treatment failure and of mortality. But there are a host of associated hospital costs that further drain the health system: Increased length of hospital stay... and in more expensive beds (e.g. isolation or intensive care). Increased use of medical devices and equipment (e.g. ventilators, imaging, laboratory tests, blood screens). Increased demand for staff, in terms of their number, seniority and speciality. For the individual, antimicrobial resistance may cause: Impoverishment, due to loss of earnings and out-of-pocket healthcare costs. Impaired livelihood or standard of living for self and dependents. Morbidity (transient or permanent disability) through prolonged ill-health and use of medicines with a poor toxicity profile. Death. Are those in developing countries at the greatest risk? The quality and availability of healthcare is not evenly distributed across the globe. Although AMR is a global threat, surely those in low income or "resource poor" countries are at the greatest risk and may be disproportionately affected? Here's why: Falsified medicines. A "falsified" medicine is a fake - a spurious substance created by criminals for financial gain. It may contain a small amount of drug in order to fool Quality Control checks, but a falsified medicine will have no therapeutic benefit. Its threat to health is obvious but, in the case of antimicrobials, it can also have a broader public health impact e.g. by undermining "herd immunity", enabling the spread of the pathogen and by encouraging antimicrobial resistance due to sub-therapeutic dosing. National drug regulation, which is designed to protect the population from falsified medicines, is an expensive and highly skilled business. Low income countries lack the resources to regulate their national pharmaceutical markets effectively - and are therefore actively targeted by counterfeiters. Cost. New drugs, or drug formulations, are protected by a patent for up to 20 years. Whilst patented, the drug company has the exclusive right to market the product - and ordinarily does so at a cost that is prohibitive to most buyers. Many countries have insufficient budget to afford patented "brand" medicines. Equally those living in or near poverty will be unable to purchase medicines privately. These individuals will therefore have fewer therapeutic options - and those that remain are likely to be restricted to older medicines with a greater likelihood of AMR. Drug development. Pharmaceutical R&D (research and development) is normally focussed on discovering drugs with the potential to generate high revenues, rather than the potential to address the world's greatest health needs. Infectious diseases - particularly those uncommon in the West - do not offer much return and so gain relatively little investment. Did you know that there hasn't been a new class of antibiotic on the market for over 30 years? Access to effective healthcare. Lack of resources and vulnerability to conflict, disaster or corruption will erode the effectiveness of the health system. Lack of laboratory and diagnostic equipment will make infections harder to identify and treat. Lack of supportive or critical care options, especially for infants, may negate options for intensive therapy or aggressive disease management. Weak prescribing culture and Clinical Governance will result in inappropriate and unrestrained antimicrobial use. Finally, obviously, lack of access to essential medicines will make treatment an altogether a futile endeavour. Undernutrition. "Undernutrition" is a deficiency of calories and micronutrients in the diet, which impacts health and growth. It's a vicious circle: undernutrition makes an individual more susceptible to disease and, during that infection, their nutritional requirements will increase. Not only this, but chronic undernutrition during childhood may have a permanent effect on the individual. So the undernourished are at greater risk of infection and will have a greater reliance on antimicrobial therapy. Immunosuppression. HIV, AIDS and TB have a far greater prevalence in developing countries and are less likely to be well-controlled. These illnesses may make a patient more susceptible to concomitant and opportunistic infectious diseases, which - for all of the reasons listed - will be more challenging to treat in developing countries. What can you do... as a patient? Only use antimicrobials if prescribed by a healthcare professional. Don't share your antimicrobials with someone else, even if you think it's the same infection. Complete the prescribed course of antimicrobials, even when you start to feel better. Take the antimicrobial as prescribed - following the directions for the right dose, frequency and timing in relation to meals. Educate your friends and family about being more #AntibioticAware - and remind them that don't treat viral infections. What can you do... as a healthcare provider? Don't prescribe antimicrobials unnecessarily - even if your patient pressurises you to do so! Always follow your antibiotic or antimicrobial treatment protocols - seek advice from your pharmacist or laboratory if you are unsure. Educate your patient about how to take their antimicrobials safely and effectively. Become a champion for the appropriate use of antibiotics - help to raise awareness about AMR and good antimicrobial stewardship. Support the World Health Organisation's "Global Antimicrobial Resistance Surveillance System" (GLASS). Be especially sparing of parenteral or second and third line antimicrobials - they may be our last line of defence. So Happy Antibiotic Awareness week... "A whole WEEK?" I agree - it's not enough, let's try to make it last all year. Photo credits: World Health Organisation, available here: http://www.who.int/campaigns/world-antibiotic-awareness-week/en/ Further reading: World Health Organisation website > Antimicrobial Resistance Centres for Disease Control and Prevention website > Global Health About the author: Kate's the founder of Global Pharmacy Exchange where she strives to connect and empower the Global Pharmacy Workforce for the sake of #UniversalHealthCoverage ... and because she's a bit of a pharmacy geek. #AMR #AntibioticAwareness #FighttheSuperBugs #GlobalHealth #GlobalPharmacy #AccesstoMedicines

Yesterday I had the pleasure of advising on content for an international pharmacy conference. It got me thinking... what would you do if confronted with the amazing opportunity of debating with the great and the good of the international pharmacy community? What agenda would you set if given a stage, and a room-full of the world's chief pharmacists? As you know, at Global Pharmacy Exchange we're passionate about empowering the pharmacy workforce, because we believe that in doing so we will address inequalities in healthcare and improve Access to Medicines. So you'll be unsurprised about my ideas for this global meeting. I've summarised them below - I'd love to hear your thoughts! So, I picked four broad topics... ... and then proposed four key areas within each... Emergency Health Response The rapid deployment of staff and commodities to support an overwhelmed healthcare system following a Sudden Onset Disaster or conflict. •Introduce the WHO Emergency Medical Team initiative •Coordination during an emergency and activities of the MoH / NDRA (DoH / MHRA) etc Resilience & Preparedness Planning and preparing for emergencies that have the potential to impact a local area or the entire country. •Education, training, stockpiling, coordination, transport, clearance… •Dealing with Cat 3 & 4 emergencies i.e. without international intervention The role of pharmacy professionals In humanitarian aid, pharmacists and pharmacy technicians are under-represented and funded – a vicious cycle. The impact on the effectiveness and quality of health programming is shocking. •Active promotion of the pharmacy skill set in humanitarian organisations, at all levels. •Empowering national pharmacists to influence and support strengthening of national health systems. Immunization Campaigns A cross-cutting theme with challenges routed in fair-pricing and R&D as well as logistics – that affects OECD nations as well as LMICs. •Addressing patient education and acceptance •Challenging the barriers to an effective vaccination campaign (see also Access to Medicines) Research & Development A huge disease burden exists in LMICs for which novel health products are urgently needed. •A collaborative effort to fund/incentivise R&D in neglected areas •“Open labs” and non-competitive initiatives Pricing Current models for the pricing of medicines are determined by the temporary, legal monopolies created by patents – thereby causing rationing or non-availability of novel essential medicines for most of the world’s population. •The idea of delinkage as a business model to drive fair pricing. •Current campaigns for fair pricing and opportunities for government lobbying. Patents & Licensing As above, but different discussion points. •Current initiatives to improve access to patented medicines – Medicines Patent Pool, compulsory and voluntary licensing, TRIPs and the newly re-named CPTPP. •Dealing with Investor-State Dispute Settlements (ISDS) – experiences and advice. Supply Chain Strengthening The work of pharmacy professionals in the development sector is frequently focussed on strengthening the pharmaceutical supply chain… because it is the primary obstacle. •Policies, tools, training •Current technologies, innovation and (open-source) software. Registration Some countries are “unattractive” to drug companies, or are unable to effectively consider registration requests, therefore compounding in Access to Medicine challenges. •Harmonisation initiatives and the promotion of regulatory convergence •Technical assistance and the opportunities for work-sharing arrangements. Falsified Products The threat to health represented by the counterfeit “industry” is unquantifiable, but extreme. •Global intelligence sharing and cooperative opportunities. •The application of pharmacovigilance and detection measures in tackling the challenge. Substandard Products & Regulatory System Strengthening Assuring the safety and efficacy of products on the national market is impossible for many countries, based on the competence and capacity of many regulatory authorities. •International cooperative technical assistance to build GMP and GDP capacity. •Incentivising investment in GMP and GDP, the implementation of minimum standards, cooperative agreements to hold multi-nationals to account. •International prequalification schemes and information sharing. AMR The global threat of AMR is widely acknowledged, however the disproportionate impact on LMICs is less-well explored. •Monitoring, reporting and information sharing initiatives (e.g. GLASS by the WHO). •Joined up approaches to tackling the challenge e.g. rational use, addressing the use in livestock etc Education Building the competence of the pharmacy workforce to address global challenges – and improving awareness of “pharmacy” issues amongst other professional communities – requires an educational foundation. •Introduction of global pharmacy issues into MPharm programmes. •Increasing the awareness of global challenges relating to medicines amongst non-pharmacy professions. Research & Funding There are paltry opportunities for academic research in the humanitarian pharmacy space, which further undermines progress and innovation in the sector. •Incentivising research into “non-R&D” pharmaceutical arenas. •Enabling resources, collaboration and information sharing amongst research institutions. Peer Support Connecting pharmacy professionals, particularly those in clinical settings, to educate, empower and advance professional growth. •Global Medicines Information scheme – particularly important due to the challenge of obtaining up-to-date and reliable reference sources. •Global mentorship and buddying. I've been very brief in my descriptions (which was a struggle!) but these are the things I'd like to debate with the world's most influential pharmacists. Given the opportunity, what would you do? #GlobalPharmacy #NotJustAPillCounter #AccesstoMedicines

This month I have the pleasure of introducing salbutamol: it’s inspirational. Class Salbutamol is a “selective beta 2 (β2) adrenoreceptor agonist”. That's quite a mouthful, but hopefully it will make more sense by the end of this blog! Mechanism of Action Your lungs resemble a tree. The trunk is akin to your trachea (or windpipe), while the branches are like the bronchi, which gradually reduce in size as each branch bifurcates. Let’s say our tree is a Cherry Blossom, where every fine branch is adorned with a delicate flower. Well, our bronchi are adorned with delicate gas-filled sacs known as alveoli, which are situated adjacent to capillaries (slender blood vessels). Each alveolus is responsible for exchanging blood gases with the atmosphere i.e. excreting waste gases and drawing in oxygen. Wow! But how do the lungs work? You’ll be well aware that, in a healthy adult, the rhythmic rise and fall of your chest coincides with the inspiration and expiration of air, respectively. That’s because when you expand your chest, you contract your diaphragm and the intercostal muscles located between your ribs. This forces your lungs to inflate due to the negative pressure created. Conversely, by relaxing your intercostals and diaphragm, you allow your ribcage to return to its original position under its own weight, thereby forcing air from the lungs. So my breathing is controlled by these muscles? Not quite. Your breathing is controlled by the “respiratory centre” in your brain and is under the command of the “sympathetic nervous system” (SNS). (“Sympathetic” may sound like a bit of an unusual title – it is actually a reflection of the fact that the SNS is sympathetic to your basic survival needs, because it manages your “fight or flight” responses.) When you are placed in a stressful situation, your body releases chemicals known as catecholamines (these include hormones like adrenaline aka epinephrine). These catecholamines get your body ready to act to the urgent situation: to fight, or to flee for your life. The catecholamines "stimulate" your SNS, which has a variety of effects, including: pupil dilation, faster and harder heartbeat, sweating, blood vessel dilation, urinary retention and bronchiole dilation. These are basically the sort of things that you’re thankful for if you have to run or fight effectively, but which are a nightmare if you’re public speaking! Where does salbutamol come into all this? As you can see, catecholamines cause a number of different effects, which is partly because they act upon a number of different receptors. In this blog, we’re just going to concentrate on the β2 adrenoreceptor. Salbutamol is an agonist of this receptor i.e. it activates it. The β2 adrenoreceptor is predominantly located in the lungs - more specifically on the smooth muscle tissue of the bronchi. When activated, these receptors cause the bronchi smooth muscle to relax, which in turn causes them to expand (or to "dilate"). In addition – and very usefully for respiration – activation of the β2 adrenoreceptor also reduces the lung’s hypersensitivity to allergens, thereby inhibiting the release of certain physiological hormones e.g. histamine. Indication As you will have guessed, salbutamol is used in respiratory conditions that are characterised by a shortness of breath: asthma and COPD (chronic obstructive pulmonary disease), which includes bronchitis and emphysema. Random fact Unusually, salbutamol is sometimes used therapeutically for of one of its side effects rather than to induce bronchodilation. Hyperkalaemia (high potassium levels in the blood) is potentially fatal and unfortunately, your body can not tolerate much margin for error in your blood serum potassium concentration. Therefore severe hyperkalaemia is rapidly and aggressively managed in hospital and sometimes salbutamol is used to “buy more time” while other agents work, because it “pushes” potassium back into cells for a short period. Thanks for reading. Have a marvellous weekend, wherever you are!

This month I have the pleasure of introducing you to benzylpenicillin – it’s cracking! Class Benzylpenicillin is an antibiotic that belongs to a class of medicines known as – you guessed it – penicillins. Mechanism of Action Penicillins (and a few other related antibiotics) kill bacteria by disrupting the production of the bacterial cell wall. Mammalian and bacterial cell walls are entirely different - which is fantastic news, as otherwise penicillins would be lethal for us too! So how do mammalian and bacterial cell walls differ? Good question. Well, as you may know, a mammal’s cell is composed of lipids (fats). However, a bacterial one is made from a substance called murein - aka peptidoglycan. Peptidoglycan is a sugar with a chain of five amino acids bolted on to it. That's probably a little difficult to imagine, so instead, think of a yo-yo... The sugar of peptidoglycan is the body of the yo-yo, while the amino acid chain is the flailing string. As you would expect, on their own, a cluster of yo-yos do not form a particularly effective wall. However, with the help of an enzyme known as DD-transpeptidase, they get organised: the amino acids chains (the yo-yo strings) knot and matt themselves together. OK... but what does this have to do with penicillin? Penicillin mimics the spacial and chemical characteristics of a portion of the amino acid chain, the yo-yo string, and is highly unstable and reactive to boot. The DD-transpeptidase is tricked into binding to it and, when it does, the penicillin powerfully and irreversibly locks it in place. This means that DD-transpeptidase, the "organisation enzyme", is unavailable to bind other peptidoglycan chains together. As a result, the bacterium is unable to produce a stable cell wall and is unable to maintain its own integrity. Essentially the cell wall breaks and so the bacterium dies. Indication Broadly, there are two different types of bacteria: gram positive and gram negative, which are characterised by the differences in their cell wall. Gram positive bacteria have a larger and more predominant peptidoglycan cell wall, therefore penicillins are generally more effective against them. Responsive infections for benzylpenicillin include: skin infections (e.g. caused by staphylococcus), ear/nose/throat infections (e.g. caused by streptococcus), respiratory infections (e.g. caused by pneumococcus), syphilis (caused by spirochetes), gonorrhoea (caused by gonococcus). As benzylpenicillin is unstable in acid it can not be taken orally (as it would be destroyed in the stomach) and therefore it is always administered via an injection. Random fact Penicillin was the first antibiotic ever used – it was discovered in 1929 and, strangely, not used as a chemotherapeutic agent until 1945. Although today penicillins can be found in every country in the world and are relatively cheap, back in 1945 they were unable to produce it on a large scale and therefore they were rare and exceptionally expensive. Have a marvellous weekend!