Twenty-five-year-old Ahmad Faraj suffered from chronic gastroesophageal reflux disease (GERD) as a child. He did not imagine that taking antibiotics would one day – nearly seven years ago - cause him a stomach infection. The bacteria causing this illness it seems had gained resistance against many antibiotics due to excessive doses administered along the years.

Ahmad was prescribed antibiotics for years by his supervising doctor to deal with ‘germ in the stomach’, but the medicines did not achieve the desired results. He did a blood sample analysis to determine which antibiotics the bacteria would respond to.

Recently, Ahmad Faraj’s doctor prescribed him some imported antibiotics with a price tag of around 3,500 and 4,000 Egyptian pounds ($183 and $209). Ahmad said, “The doctor informed me that it was the last medical option (available), since I had used most of the antibiotics available in the market but to no avail. After this, I will have to adapt with the stomach germs, and avoid certain foods.”

The case of Ahmad Faraj is one of 560 people whose experiences and issues with antibiotics were documented in Egypt through a survey we conducted in preparation for this report. In 2019, the United Nations Interagency Coordination Group on Antimicrobial Resistance warned that drug-resistant diseases could cause 10 million deaths per year by 2050 if no action is taken. According to the World Health Organization report, currently, there are at least 700,000 deaths annually.

The World Health Organization says that if we do not take urgent action to reduce the purchase of antibiotics without prescriptions for human or animal use, we would embark on a post-antibiotic era in which common and minor infections can become fatal once again.

Doctor Alaa Abu Al-Fotouh, professor of microbiology and immunology at the faculty of pharmacy at Alexandria University says that the problem of antibiotic resistance in bacteria becomes worse with the increase in the consumption of antibiotics, and this makes the human body develop resistance to these antibiotics. When these bacteria are transmitted from one person to another, they are also resistant to the same antibiotics in the new patient.

Abu Al-Fotouh believes that the more significant problem is that inventing or composing new antibiotics is not as fast a process as it used to be fifty years ago; therefore, there is no fast replacement for bacteria resistant antibiotics.

Patients are not tested for allergies

Majdi Fahmi received a double shot of antibiotics, which turned his family’s life upside down for about a month, since the injection he was given, has been administered without carrying out an allergy test at the clinic of a famous internal medicine doctor.

Fahmi’s son Mohamed explains that his “father was literally no longer able to swallow food or water within four days of getting that injection. He lost more than twenty kilograms in weight, and developed a rash. We thought he was infected with the Coronavirus.”

Mohammad took his father to a hospital close to his house in El-Marg area in Cairo, where he was put on a drip to try to stabilise his condition, and that was followed by some medical tests the next day. The doctor discovered that he developed an allergy as a result of the antibiotic injection and said that if it had not been for his father’s strong physical built due to the nature of his work in the construction sector, his situation could have become worse.

The sixty-five-year-old man began to gradually recover after few weeks, and this episode taught him a lesson about how to use medications in the future compared to his old way of relying on familiar repeated prescriptions the minute he developed familiar symptoms.

560 people participated in the questionnaire conducted by the author of this report, 78.9% of them said that the doctor or pharmacist did not ask them to do a bacterial or allergy tests before taking the antibiotic course.

Doctor Mohammad Izz Al-Arab, medical advisor to the Egyptian Centre for the Right to Medicine, says that antibiotic injections must be done in a place equipped with an “emergency unit” to treat any nervous shock side effects that may occur due to allergies to some types of antibiotics. Delaying medical help leads to complications that may cause death.

More than a year ago, antibiotics has helped twenty-two-year-old May Majdi when she had a cold. Her mother used to buy what is locally known in Egypt as a “cold kit” (which is usually made up of cough medicine, painkillers and antibiotic) from the pharmacy. Her daughter would consume few tablets until she starts feeling better partially for a day or two, before the same original symptoms return.

For May, the defining moment in using antibiotics was when one of her relatives who is a pharmacist advised her to avoid taking them unless prescribed by a doctor after he had examined her condition, reminding her that usually the full prescribed dose must be taken every time.

May, who lives in a village in Qalyubiyya Governorate describes her experience to us through a social media application, “Like everyone, when I feel tired or have a cold when such situation does not require me seeing a doctor, I go to the pharmacy. Whoever is there gives me some antibiotics or a so called “cold kit.” The person may not be even a doctor to begin with, so he would not know that this is wrong.”

Upon hearing the golden piece of advice, May stopped using antibiotics. She says, “If someone is sick at home, I tell them not to take anything on their own. People underestimate the matter either because they are lazy, or because the symptoms are light and people elect that there was no need to see a doctor. Some people even cannot afford the costs for a doctor examination, so they make do with whatever they can.”

Hassan Al-Shazily, a pharmacist, explains that antibiotics are made to treat bacterial infections, but colds and influenzas are viral infections.

In their response to a question in our informal questionnaire about how people obtain antibiotics, 60% of the participants said that they got it from a pharmacy without a prescription or doctor consultation. In the questionnaire some respondents ticked more than one answer. 30.7% of the respondents said they use antibiotics as a treatment for colds and flu.

Medical advisor to the Egyptian Centre for the Right to Medicine Doctor Mohammad Izz Al-Arab says that most cases of microbial resistance are due to the fact that pharmacies dispense medicines without a prescription.

The results of the questionnaire also revealed that in 62.9% of the cases, the doctor or pharmacist did not discuss the harm of overusing antibiotics needlessly, or the gravity of not adhering to dosage instructions. 21.6% of the respondents had never heard of “antibiotic resistance.”

The study explained that patients have chosen to go down the road of obtaining antibiotics without prescription due to their limited awareness of the risks of using antibiotics without a doctor’s guidance. Also they maybe pushed to do that to avoid the high cost of visiting a doctor for diagnosis, especially if they are familiar with the symptoms and have previously improved upon taking the antibiotics.

80% of the pharmacies participating in the study have said also that when they try to advise patients customers to visit health care institutions, their advice is usually refused. Additionally, those pharmacists believe that if they stop dispensing antibiotics without prescriptions, customers will easily get them from other pharmacies.

Doctor Ahmad Abu Doumah, a member of the General Syndicate of Pharmacists, calls for the amendment of the ‘Pharmacist Practice’ Law No. (127) of 1955, which does not prohibit the sale of antibiotics to citizens without a prescription. This amendment would make the law align with the current changes; when it was issued nearly seven decades ago, it addressed a society with a different population size and fewer pharmacies.

Executive Director of the Egyptian Centre for the Right to Medicine Mahmoud Fouad says that introducing the electronic medical prescription is the best way to eliminate the problem of selling antibiotics in pharmacies without a prescription. In his opinion this will make the pharmacist dispense only the prescribed medicines issued by the doctor and stamped by the clinic.

A member of the Health Affairs Committee at the House of Representatives Doctor Enas Abdel Halim says that she had submitted a briefing request to the House of Parliament months ago, in which she demanded that medicines, including antibiotics should not be dispensed by pharmacies without a doctor’s prescription. She says, “The Egyptian Drug Authority responded to the committee’s recommendations stating that they are seeking to issue a decision to prevent dispensing any medicines without a prescription. The National Committee to ration the consumption of antibiotics will also be launched.”

Doctor Ashraf Hatim, chairman of the Health Affairs Committee of the Egyptian parliament says that the Drug Authority formed the committee six months ago to discuss the application of the mechanisms by which pharmacies can dispense antibiotics with a prescription.

Doctor Mohammad Izz Al-Arab, medical advisor to the Egyptian Centre for the Right to Medicine says that some citizens even resort to buying only one strip of the antibiotic dose, and not the full package because it is too expensive. In this way, they do not complete the dose, which leads to bacterial resistance to the antibiotic, even if it is prescribed by a specialized doctor and targets the specific bacteria causing the illness.

37% of those who participated in the questionnaire say that they usually stop taking antibiotic doses as soon as their health improves.

Professor of microbiology and immunology at the faculty of pharmacy at Alexandria University Doctor Alaa Abu Al-Fotouh describes the harm caused by not completing antibiotic doses saying that “It is like a boxing match, the antibiotic knocks the bacteria to the ground and turns its back thinking it won the match when the bacteria did not really die but took advantage of the opportunity to recover and respond with another attack to win the match; the blow did not really kill it but made it stronger.”

Pharmacist, Mohammad Rifai, kept trying to persuade the owner of the pharmacy where he was training when he was a student in 2014 not to sell antibiotic “tablets” within the so called Egyptian “cold kits” and managed to convince him after two years.

He adds that since he started working in the field, he has been fighting in the market with patients, pharmacists and doctors themselves to raise awareness of the dangers of misusing antibiotics.

Another recent graduate of pharmacy who participated in the questionnaire says, “The first thing people ask for is antibiotics, and I often tell them that is wrong. But sometimes I feel like I am wasting my time and energy. They listen to my words and then say, ‘Okay, give us the antibiotics this time, and we’ll continue this conversation later.’”

It seems that the wishes of Al-Rifai and the recently qualified pharmacist are hard to attain, at least in the near future. One of the participants in the questionnaire says, “The idea is to have an ‘understanding’ pharmacist who would give us a suitable medicine when we ask him for some. We don’t have money to see a doctor. It is bad enough that we have to pay for the medicine to begin with, when we are about to collapse completely.”