In 2010, I was invited to Bangladesh for an event relating to antimicrobial resistance organized by ReACT and the INDEPTH Network. There was a field trip to a village that I vividly recalled.

We took a several-hour drive to the village in four wheel drives provided by the icddr,b (formerly International Centre for Diarrhoeal Disease Research, Bangladesh) team, during which the vehicles were stuck in the mud and required the help of friendly locals to extricate.

The village itself was rural and rustic, and had several hundred villagers, most of whom were farmers.

The village pharmacy, however, was well stocked and typical of pharmacies in bigger cities. Much to my naive astonishment then, we were able to find all sorts of antibiotics in the pharmacy, including amoxicillin/clavulanate and levofloxacin (there were also IV paraphernalia and packs of saline).

Even more inaccessible towns and villages in lower-middle and low income countries are similarly provisioned. We are often concerned about the impact of inappropriate use of antibiotics on antimicrobial resistance rates, and in most high income countries, antibiotics are available only with a doctor’s prescription (even then, we worry about inappropriate prescribing). I stopped by a Guardian pharmacy at Changi Airport and noted that there were no antibiotics displayed on the pharmacist’s counter shelves. The duty pharmacist explained to me that this was in order to reduce over-the-counter (OTC) requests for antibiotics by travelers.

In countries like Singapore, we perceive the problem as “excess” antibiotics, but it is good to see that the complementary problem in many parts of countries like Bangladesh is one of “access” to antibiotics. This role is served by OTC antibiotics, and is unlikely to disappear in the short- and middle term, given the lack (or uneven geographic distribution) of doctors.

What can be done to resolve the twinned problems of antibiotic “access” and “excess”?

There is no clear answer now, although it is quite clear that the impact of antimicrobial resistance will fall highest on the poor and the people of such villages where access to hospital care is a problem. One suggestion is to expand the role of pharmacists and educate pharmacists/dispensers in lower-middle and low income countries (although the paper focused more on the formal healthcare system). Public education is similarly important, as part of the inappropriate use of antibiotics also comes from those who bought them. Both of these – while important – ultimately seem like partial solutions to the problem.

There is a huge ongoing study – Project ABACUS – of antibiotic provision in Asia and Africa that will hopefully provide more insights when it completes next year. This study, led by Prof Heiman Wertheim of Radbound Medical Centre and supported by INDEPTH Network, had its genesis in that Bangladesh trip 8 years ago.