He would come into the pharmacy once a week and ask for Ultradol (a narcotic-like painkiller). When I asked for his prescription and he didn’t have one, I told him I could not give him the medicine. He began to cry and told me how his father was dying of cancer and the pain of the treatment was killing him faster. He claimed to be an officer, to prove his credibility. I gave in to my emotions, and out of compassion I gave him a strip of Ultradol.”

At the time, Ola (last name withheld at her request) had been a practicing pharmacist for only a few months. Three years later, the lesson from that encounter has stayed with her.

“I knew how wrong my choice had been when he returned week after week with the same story. But now, I could see in his eyes that he had been taking drugs. Eventually, I had him thrown out of the pharmacy and regretted my decision for months. I have never made that mistake again.”

“We want to put a system in place which would put us on par with developed countries. Meaning, if a patient has a prescription—he gets the drug. If not, he doesn’t.”

Ola’s experience is a common one in pharmacies across the nation, as pharmacists are faced with requests from the sick, the self-prescribing and sometimes, the substance abusers. Students want stimulants so they can stay awake to study longer; someone with a cold wants an antibiotic recommended by their cousin; another insists he needs a sleeping pill or something even stronger. It is easy to walk into the pharmacy, give the pharmacist a list of symptoms and trust them to give you the right medication. It’s almost too easy. Where do pharmacies draw the line between over-the-counter (OTC) drugs and those that require a written prescription from a doctor?

They often don’t. Even with the memory of the Ultradol abuser behind her, Ola admits, “My general rule is: As long as the patient isn’t requesting a toxic [narcotic] drug, I don’t ask.” Many will tell you that Ola’s rule is the general rule in local pharmacies.

“A good pharmacist thinks of their job as a trade in people’s health,” says Noha Hamama, the manager at the Downtown Cairo branch of Seif Pharmacy, “And it’s a dangerous trade because we are dealing with people’s lives — trying to make them better. But unfortunately in Egypt, it is easy for a pharmacist to be influenced by their relationship with a patient, for instance, a family member or a familiar-looking neighbor or customer.”

Vahid Salemi Too many easily abused drugs are available without prescription.

According to the Ministry of Health and Population, there are 33,000 pharmacies in Egypt, all of which by law must be owned and run by certified pharmacists. It’s hard to quantify how often prescription drugs are sold over the counter, but those in the industry say it’s prevalent. “It is a huge percentage, though we don’t have any statistics on it because we don’t keep statistics on which drugs are being prescribed,” says Dr. Mahmoud Abdel Maksoud, general secretary of the Syndicate of Pharmacists.

Pharmacists hand over drugs without prescriptions because they can: It’s not actually illegal. “Until today, there is no law that prohibits buying medication without a prescription — this is in principle — except for a select group of medicines classified as having a sedative effect or as being stimulants or sleeping pills,” says Dr. Abdel Rahman Shahin, spokesman for the Ministry of Health and Population. He points to medications with codeine in them and Ritalin as examples of this select group. “But the majority of drugs — about 6,000 medications — in Egypt are bought without prescription.”

For those drugs that do require prescriptions by law, called “narcotic jewels” by Shahin, there is no one single standard for keeping track of them. “Some have to have a prescription which the pharmacist is obliged to keep along with the patient’s data. In cases of certain narcotics like morphine, the pharmacist must keep track of how much the patient took and photocopy his personal ID.

“These narcotics [] have a unique prescription form on which the doctor is also supposed to keep track of whom he / she has prescribed them to. In other cases, he can keep the prescription without logging the patient’s data in the “jewel narcotics” log; or he can get rid of the prescription form but record the patient’s data [in the log].”

Ola notes however that morphine is not even allowed to be sold in local pharmacies.

Kim Piper Buying only with a prescription: Your responsibility or your pharmacist’s?

Legal issues aside, taking prescription drugs over the counter could be harmful to your health. Shahin uses antibiotics as an example. “There are a huge number of antibiotics circulating in Egypt, in a manner we can call random. What I mean by random is that a patient, for instance, has a cold and is coughing and sneezing and his friend tells him to go take Flumox, so he takes Flumox. Or he goes to the pharmacist and asks for an antibiotic so the pharmacist gives him one. Or he used an antibiotic six months ago and it works for him so he goes back and buys it.”

There are a number of problems with taking an antibiotic without the advice of a physician. Shahin notes that you could be taking the wrong antibiotic or the wrong dosage, and the microbe you’re trying to kill gradually becomes resistant to the drug. “Second of all, some antibiotics have side effects,” he continues, “they might have an effect on the kidney or the liver or blood or any organ, and the patient wouldn’t know.” Another problem is that the antibiotic may have a negative interaction with other drugs the patient is taking.

“The other thing that happens, which is really a violation, is when someone goes and asks for ampicillin [an antibiotic] and the pharmacist says, ‘I’ll give you this on your responsibility,’ Shahin adds. “But he doesn’t check to see what the complaint is. What we want to do is create a culture where a patient does not ask for a drug except if the doctor specifies it.”

This is one of the first areas the Ministry of Health wants to reform in the administration of pharmaceuticals. “We are currently looking into creating a program that would allow antibiotics to be dispensed [only] with a prescription. There is a great chance that this project will be approved by early 2008,” Shahin says. “In the future, a small number of antibiotics will be dispensed freely, those which are not so sophisticated. The rest can only be dispensed from the pharmacy with a prescription.”

A potentially harmful drug that is often self-prescribed is the popular antidepressant Prozac. Dokki pharmacist Fareedah, (who spoke with et on the condition her last name be withheld) says that sometimes a person will come in feeling nervous or depressed, looking to shake the bad mood. They ask for alam tazbeet for “maarad il ‘asr” — something to help them get ‘up’ for the “sickness of our time.”

Both Fareedah and Ola are quick to point out that this occurs mainly in the poorer neighborhoods; the upper class tends to get written prescriptions to help them with maarad il ‘asr.

“Any pharmacy that cares about its reputation must have a prescription signed by a doctor before filling a request for antidepressants,” says Seif Pharmacy’s Hamama. “They are like any drug, the human body builds up a tolerance to it and if the patient and the dose are not monitored it can have the complete opposite effect, in some cases leading to suicide.”

Shahin is concerned about people misusing medications. “These drugs originally have other purposes. Most of them are used for psychiatric disorders,” the Ministry of Health representative says. “There are drugs used for asthma that have a stimulating effect. So the drug is used in areas other than what it is originally meant for. In such cases it is legally prohibited to dispense the drug. Some addicts drink entire bottles of cough medicine at once, when one tablespoon is meant to be taken every six hours.”

This is not to say that pharmacies are completely without monitoring. Shahin points out that pharmacies are inspected periodically, and inspectors “have the authority to close down a pharmacy if they find the pharmacy dispensing narcotics without keeping a log. If the drug count of narcotics does not match the pharmacies’ records, this is a serious offence.

“Inspectors narrow down the pharmacies they suspect to a few, and they keep a close watch on them. These are things an inspector can sense by instinct from his experience. They pay regular visits to the pharmacies in their area. They check that the people who work there are licensed, that their logs match their sales and the drug count in the pharmacy and that they have no offences. There are people who have cases filed against them for such offences, but those are a minority of course. The great majority of Egyptian pharmacists are honorable people. But like any society or any profession, you’ll find outlaws.”

Ola has been through a number of those inspections, and she’s not impressed. “I don’t think they’re very effective,” she says. “For example, if they find that the person attending the counter is not a licensed pharmacist, what do you think the penalty is?” She answers her own question with surprise: “Five Egyptian pounds. That’s it.”

Inspections take place about once a month, a consistency that Ola says has drawbacks. “The pharmacists are familiar with the personalities of each of the inspectors in each district — there’s the guy who just wants to do his job, the guy who wants to look like he’s doing his job, the guy you know to bribe, and then there’s the guy who has been working for so long he has established relationships and built-in trust with the pharmacists.”

In short, she says, “When it’s easy to bribe inspectors, we’re left with no watchdog on the pharmaceutical practice.”

According to officials in the Pharmacists Syndicate and the Ministry of Health, flaws in the system have as much to do with the patients as with pharmacists and doctors.

“We cannot do anything about [the sale of prescription drugs over the counter] because we have economic circumstances that force pharmacists to want to sell things that require a prescription as over-the-counter drugs,” Abdel Maksoud asserts. “The patient is also influenced by these same circumstances. When a patient doesn’t have health insurance or can’t afford a doctor who will write [] a prescription, then [the patient] is in a position where he goes to the pharmacy to request medication over the counter.”

While he acknowledges that it happens, Shahin counters, “That’s not an excuse. It is true that the pharmacist is more easily accessible; he’s on the street, he has no schedule, and the patient doesn’t need an appointment to see him. But the price is not an excuse because some doctors charge five pounds, while some governmental hospitals are for free. But we take the easy way out by going to the pharmacist instead and the pharmacist wants to sell. If a patient is complaining of stomach pains, he has to find out what the root causes of the pain are, not just take something for it.

“We need to teach people that medication is a double-edged sword. We need to teach them that they’re not saving five pounds by not going to the doctor — those five pounds will give you special care in the form of advice that the pharmacist cannot give you,” he says. “The pharmacist’s job is to make sure the patient really does need the drug he asks for by checking the prescription and the patient’s history.”

Therein lies another shortcoming in the system: the patient’s history is not always available. According to Shahin, “There is no law that obliges the doctor to [keep a record of patient history]. But the patient’s data has to be available; when he came to the clinic, his name, age and address, his diagnosis and treatment. Doctors are obliged to record this much by law.”

But what happens in practice is sometimes very different. “Some do, and some don’t keep records,” Shahin admits. “I know some doctors who take the patient’s data before the checkup and then make notes throughout the examination. They make files and keep them. Some do it electronically. Some do neither.”

Even if the patient has spoken to a doctor, he may not have a written script. Sometimes the patient telephones the physician, who tells the patient to go to the pharmacy and ask for a certain medicine.

“If there is a major issue, the pharmacist is responsible for it, but he is not responsible for asking every single patient,” Shahin says. “The doctor’s job is to sit with the patient, talk to him, give him a physical exam, and conduct lab tests, but the pharmacist doesn’t have this authority.”

The proper distribution of medication is “a shared responsibility between the doctor and the pharmacist,” Shahin says. “However, what happens in reality is different from what is written in books. Pharmacists get a prescription and they just dispense it. If there’s a major problem, sometimes they might call the doctor and notify them. But in reality the pharmacist has no record of the patient, and they don’t take the time to ask the patient about their history.”

The current system of dispensing medications also leads to a significant waste of drugs. Abroad, the pharmacist prepares the exact amount indicated by the doctor on the prescription. “In Egypt, a patient may need treatment for 10 days, two tablets daily — so 20 total. And they buy a box with 30 tablets,” Shahin notes. “All Egyptian households — with no exception — have redundant drugs. There’s so many and they just sit there until their expiration date. [] If we can solve [this] through dispensing drugs using generic names and their specific doses that would be very good. This has started in some pharmacies.”

It’s an issue with enormous economic impact. “About LE 2 billion are spent annually on drugs. We have a huge market,” Shahin says. “The drug market grows by about 20 percent annually, while the population grows by [1.7] percent. This is an unjustifiable growth. It’s mainly because of people who buy drugs without being advised to do so by a doctor, and by doctors who over-prescribe.”

According to Ola, the business of pharmaceuticals is exactly that: a business. “Most of the time I feel like I’m moving the drugs from the shelves to the patient — like a salesperson rather than a pharmacist,” she says. “I spent five years studying how drugs interact with each other, memorizing the names of active constituents, and so on, and in the end all I’m doing is selling drugs with brand names on them. I’ve started to forget all that I studied.

“Unfortunately, at the end of the day, a pharmacy is a business like any other. Over the past few years, I’ve seen an increase in the advertising of discounts for patients — a way of keeping customers loyal. It has come to the point where a patient will come in and ask for the discount before requesting the medication itself.”

The road to pharmaceutical reform must be paved with changes not just in laws and health care practices but in how we as a society seek medical care. “The cycle starts with the doctor,” Shahin says. “When a patient starts to feel sick, he shouldn’t listen to his friend or teacher or mother. He should go to a doctor. Most cases only require a general physician, they don’t need a specialist; general physicians are everywhere in Egypt. The pharmacist in turn has to check that the drug in the prescription presents no danger to the patient. If it does, he should call the doctor. The first and final call is the doctor’s.”

Ultimately, the ministry spokesperson says, “We want to put a system in place which would put us on par with developed countries. Meaning, if a patient has a prescription — he gets the drug. If not, he doesn’t.” et  et