PRISTINA -- In Kosovo's capital, for around 8 euros ($9), you can treat both yourself and your child to a full course of antibiotics. No doctors. No prescriptions. No questions asked.
And while it doesn't take a medical degree to know that handing those and other prescription drugs out like candy is unwise -- it's also illegal.
However, despite potential fines for pharmacists and years of expert warnings about creeping drug resistance around the world, efforts to put a lid on the runaway distribution of antibiotics in this Balkan state appear to be failing.
"Yes, we provide antibiotics even without a prescription," a dispensing technician told a correspondent for RFE/RL's Balkan Service from behind the counter of a pharmacy in Pristina's Dardania neighborhood recently. "Why is there anything wrong with that?" She then explained how to use the amoxicillin-based medicine she had just sold prescription-free, guidance usually given by a trained pharmacist.
Such no-questions-asked dispersals at pharmacies in and outside the capital are more the norm than the exception, say Kosovars. Experts are concerned about the improper use of antibiotics as it contributes to the global issue of antimicrobial resistance (AMR), an accelerating trend whereby bacteria, viruses, and parasites adapt to evade even the most powerful drugs.
The European Center for Disease And Control (ECDC) says more than 35,000 people die each year from drug-resistant infections in the European Union, Iceland, and Norway alone. The United Nations Environment Program (UNEP) predicted last year that AMR-related deaths could reach 10 million annually by 2050, matching cancer fatalities. The World Health Organization (WHO) says it's already a "top 10 threat to global health" that kills 4.9 million people a year and pushes millions more into poverty.
There is a mad scramble to develop new ways to kill those hyper-resistant superbugs. In the meantime, medical experts around the world are saying that often in the case of antibiotics, less is more.
Lack Of Safeguards
Europe has woken up to the problem, with antibiotic consumption leveling off or falling "significantly" on average on the continent.
But local researchers and pharmaceutical experts caution that Kosovo has yet to institute serious safeguards to tackle the problem. They blame a casual reliance on antibiotics compounded by disregard for the law and lax enforcement, an outsized role for dispensing technicians instead of qualified pharmacists, and a general lack of trust in the health-care system of Europe's youngest state, which declared independence from Serbia in 2008.
Kosovo has legislation and administrative guidelines that prohibit the sale of most antibiotics without a prescription. Pharmacists are restricted by health-care guidelines to "providing only the drug that is described in the prescription," for a maximum of three days after it is issued by a physician.
Valdet Hashani, head of family medicine at a Pristina clinic, said an absence of electronic prescriptions and the lack of a national Health Information System (SISH) can discourage even the most responsible pharmacist from insisting on the proper documentation.
He said there have been cases of doctors being coerced into prescribing antibiotics by asymptomatic patients, although it is difficult to say how widespread such threats have become. "We have many cases when doctors and nurses have been beaten in the workplace," Hashani said. Most people, though, just ask.
Reliable figures on the current pattern of antibiotics use in Kosovo are hard to find, a fact that was highlighted in 2019 at the U.S. National Library of Medicine. But the same researchers said data from seven hospitals suggested that "antibiotic use in Kosovo's hospitals is very high," and expressed the hope that their study could encourage "the prudent use of antibiotics."
Some of those same scientists helped examine Kosovo's ongoing "national action plans for antimicrobial resistance" in an article for The Lancet medical journal around the same time. They concluded, that while Kosovar authorities' planned activities were "in line with" WHO and other international recommendations, one of its "cornerstones" lay in "antimicrobial stewardship."
Antibiotics consumption was falling "substantially" in Europe as a whole, they noted, by almost one-quarter.
"[But] the main challenges regarding antimicrobial resistance in Kosovo are limited financial and human resources, over-the-counter sale of antibiotics, and scarcity of clinical guidelines authorized by the Health Ministry," they concluded in The Lancet. "The prevalence of antimicrobial resistance in Kosovo is two to five times higher for the majority of bacteria and corresponding antibiotic groups compared with the means in EU countries."
Microbiologist Lul Raka, an associate professor at the University of Pristina who co-authored both of the milestone Kosovo papers in 2019, said that one in three doctor's visits at the time resulted in the prescription of antibiotics.
Too Many Pharmacies, Too Few Pharmacists
Kosovo has 1,022 registered pharmacies, including 166 in the capital and 856 throughout the rest of the country, for a population of around 1.8 million people. That's double the average rate for the 38 member countries of the Organization for Economic Cooperation and Development.
But quantity doesn't equal quality, and who's behind the counter might be just as important a contributor to the ongoing problem. Shkumbin Jusufi, a member of the Kosovo Chamber of Pharmacists, argued that a lack of pharmacists is one of the biggest factors in the rampant use of antibiotics.
Pharmacists are more highly trained than pharmaceutical technicians, also known as dispensing technicians, with years more mandatory education and specialized knowledge on the effects of drugs on the body, potential side effects, and interactions with other medications. Regulations vary by jurisdiction, but as a rule of thumb, pharmaceutical technicians simply fill or deliver prescriptions while pharmacists are also expected to help ensure that patients are being prescribed the right medicines; or, if technicians prepare prescription medication, it is under the supervision of a pharmacist.
"I think they [are responsible for] the most abuse," Jusufi said of dispensing technicians. "They don't know the pros and cons of the antibiotic, they're not competent to provide what they're providing." He said that pharmacists often knock off early, so by early afternoon, many of Kosovo's pharmacies are left in the hands of technicians or others without the authority to hand out prescription medications.
Laws in Kosovo on drugs and health care call for a fine of 1,000 euros ($1,089) for selling prescription medicines without a prescription.
The Health Ministry's pharmaceutical inspectorate carried out 932 inspections in all of last year, and officials say they acted where appropriate. They handed out fines in 249 cases, they told RFE/RL's Balkan Service, including for "illegal products, lack of a responsible pharmacist or substitute, or for providing products without a doctor's prescription," among other irregularities.
One of the dispensing technicians who provided a broad-spectrum children's antibiotic to an RFE/RL correspondent expressed surprise when asked whether they had the authority to distribute them or whether such drugs even required a prescription. "It's not a problem to give out this antibiotic because it's prepared," the technician said, meaning it doesn't need to be mixed on the premises.
Raka, the microbiologist, sees problems all around. "Antibiotics must not be provided without a doctor's prescription," Raka told RFE/RL's Balkan Service.
"If there are laws, they must be enforced, [and] the inspectorate must also act. On the other hand, the citizens of Kosovo themselves should know that, if they buy antibiotics without consulting a doctor, they are wrong," he said.
