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Dire shortage of drugs and doctors reflects catastrophic effect of war and corruption on the country's healthcare system. Muhammed Ali Hussein, 55, has had diabetes for more than 15 years and says finding insulin has been difficult for the last seven months. The shortage 'has become life-threatening for me daily. It drives me crazy'. Karbala's shortages of drugs and qualified medical professionals are undermining the provision of healthcare in the province. The problems in Karbala, the Shia holy city located kilometres southwest of Baghdad, reflect the catastrophic effects of the war and corruption on Iraq's healthcare system as a whole. The country has a centralised system in which drugs and other medical supplies are distributed to the provinces from warehouses in Baghdad, but distribution is often sabotaged by graft and violence. Many times, Hussein ends up buying his insulin on the black market. That is where much of the drugs and other medical supplies sent to state clinics and hospitals end up, while public facilities suffer shortages of medicines to treat heart disease, high blood pressure, asthma and sedatives, according to Dr Mohammed al-Fartusi, who works in Karbala. He attributed some of the shortages to corruption in government warehouses in Baghdad, where some employees allegedly steal medicine and sell it on the black market. Another problem is that drugs have sometimes expired by the time they reach the hospitals from the warehouses, he said. Violence in Baghdad has exacerbated the situation. The ministry's central warehouses in Baghdad are located in Dabbash, and employees of the Shia-run ministry have to cross through the Sunni insurgent stronghold neighbourhoods of Adil and Jamia. Many of them fear going to the warehouses, particularly after two were killed. Employees 'are afraid of being kidnapped or killed by extremist groups', said Salim Kadhim, a ministry of health civil servant. In a report issued in July, the international medical organisation Oxfam and the NGO Coordination Committee in Iraq called health services across the country 'catastrophic'. Oxfam stopped working in Iraq in but supports healthcare organisations inside the country. The two groups noted that Iraq's state-owned medical supply company, Kemadia, is not providing sufficient supplies for 90 per cent of the public hospitals in Iraq. They maintained that 'Kemadia has been crippled by bureaucratic, centralised management and a lack of distribution capacity, while accusations of corruption and sectarian influence have eroded people's confidence in its ability to deliver'. Oxfam and the Coordination Committee in Iraq recommended that Iraq decentralise many of its services, including distribution of medical supplies, particularly because much of the violence is in Baghdad where the central warehouses are located. They argued that to provide better services, local authorities should have power - and larger budgets - to warehouse and distribute medical and emergency supplies. The current supply of drugs and medical equipment to Karbala is so dire that a report earlier this year by Paul Foreman, former head of the Doctors Without Borders' mission in Iraq, noted that medics at state hospitals frequently 'ask the relative of injured patients to search local pharmacies for blood bags, sutures and infusions before they could start emergency surgery'. Baqir Ali, a year-old teacher, saw cats wandering around the corridors when he took his wife to give birth at one of Karbala's public hospitals. He was equally shocked when the doctor delivering their child asked him to go out to the market to purchase gauze and stitches to prepare for the birth. Shortages of doctors are also a major problem. IRIN, the United Nations' humanitarian news agency, has reported that 50 per cent of Iraqi doctors have fled to neighbouring countries. The province has not tracked how many healthcare professionals have left Karbala, but medical personnel here say that shortages are acute - stemming from not enough doctors being trained locally and the loss of many Sunni Arab doctors who have left the majority Shia province as the sectarian conflict has escalated.

Iraq: Karbala mirrors countrywide crisis

Buying MDMA pills Karbala

Metrics details. The improper disposal of pharmaceutical preparations substantially threatens human health and environmental safety. Pharmacists are responsible for properly disposing of unwanted medications and educating patients about how to do so themselves. A descriptive cross-sectional study was conducted between December and April among practicing pharmacists who were chosen to participate by random cluster sampling. Of pharmacists, stated that they did not participate in courses on the safe disposal of unwanted medications. Disposal of drugs in the garbage, an unsafe method, was very frequently recommended by pharmacists to patients, especially regarding inhalers, antibiotics, hormonal drugs, and solid and semisolid drugs. However, many pharmacists advised patients to return their hormonal, category B, and category C drugs to the pharmacy. A total of Most pharmacists in our study returned drugs to manufacturing companies and stores, and few followed the correct methods of incineration and return of drugs to the Ministry of Health. Current data emphasize the issue of improper disposal of medicine in Palestine and the need for improved education among healthcare workers. Peer Review reports. The appropriate disposal of unused drugs is crucial for the safety of humans and the environment and to prevent potentially hazardous consequences. In addition, different drugs in the environment through improper disposal can adversely affect humans and animals. For example, the United States Food and Drug Administration reported fatal cases among children due to unintended exposure to fentanyl transdermal patches \[ 1 , 2 , 3 \]. Pharmacists play an important role in safe medication disposal, as they are considered one of the ways to provide patients with the best care. Many countries have established programs to collect drugs and safely dispose of unused medications \[ 4 , 5 \]. The United States FDA developed guidelines providing advice on appropriate disposal practices that also support the urgent need for instructions of safe disposal instructions on the medication label. In addition, the United States FDA developed a program to collect and appropriately dispose of unwanted pharmaceutical preparations \[ 3 \]. In the United Kingdom, policies have been formulated asking community pharmacies to collect unwanted drugs from the public where other health agencies will be responsible for the appropriate disposal process \[ 6 \]. The Australian government conducted a similar approach, necessitating community pharmacies to collect unwanted medications \[ 7 \]. In contrast, in Palestine, there are no policy guidelines for incineration for the disposal of unwanted pharmaceutical preparations. To establish such a program for collecting drugs back by community pharmacists, data about practices and awareness regarding the disposal of unused pharmaceutical products among pharmacists are needed. This cross-sectional study sheds light on awareness and practices of unwanted pharmaceutical products among community pharmacists in Palestine. Unwanted medications are those that have gone unused or have expired, spilled, and contaminated pharmaceuticals and drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately \[ 8 \]. Sources of these unwanted medications include both households and healthcare facilities. Regarding households, unwanted medications can accumulate due to excessive prescription by physicians, poor adherence to medications, or over-the-counter medications that they buy and then expire \[ 9 \]. Hospitals and healthcare facilities are also prominent sources of unwanted medications, with waste generated from partially used or unused drugs, outdated drugs, and personal patient medications \[ 10 \]. Absent medications must be disposed of properly from households or health facilities. However, when unwanted medications accumulate, they are typically improperly disposed of in the trash or the sewage system, thus entering the environment and posing a risk to the well-being of wildlife and people \[ 5 \]. Several reports have provided evidence of the presence of drugs and their metabolites in the environment, contaminating soil and water \[ 11 , 12 \]. Chronic exposure to these chemicals threatens the health of humans and animals. It has been shown that ethinylestradiol contributes to feminization of male fish in certain rivers \[ 14 \]. Antidepressants in surface water have been shown to alter animal behaviors that are known to have evolutionary and ecological consequences \[ 15 \]. Furthermore, the disposal of antibiotics in the sewage system may contribute to the development of antibiotic resistance among bacteria by selective pressure \[ 16 \]. This highlights the need to minimize the quantity of pharmaceuticals in the environment with all available strategies. In many countries, there is much confusion about the proper methods to dispose of unwanted medications, especially where local guidelines are lacking or nonexistent \[ 17 \]. In general, the most common method for household disposal is disposal in the garbage, while flushing some drugs down the toilet still takes place in countries such as the United States and New Zealand \[ 18 \]. Otherwise, they provide instructions on safely discarding drugs in the household trash. Drug take-back programs provide a safe, legal, and environmentally friendly avenue to dispose of medications from homes \[ 20 , 22 \]. The public is encouraged to return unwanted medications to community pharmacies, where approved agents collect and properly dispose of these drugs. Take-back programs are implemented in approximately 30 countries, and pharmacies play a central role in these programs \[ 5 \]. When properly implemented and on a wide scale, these programs have the potential to significantly reduce the negative environmental impact caused by improper medication disposal \[ 23 \]. This study focuses on Palestine, a developing nation without a drug take-back program and with no clear guidelines regarding the disposal of unwanted medications. Another study conducted at hospitals and homes in the Gaza Strip showed inadequate handling of unwanted medicines \[ 25 \]. This emphasizes the need to educate healthcare workers and pharmacists on proper medication disposal. Pharmacists interact a great deal with patients and influence not only how they use their medications but also how they dispose of them. Therefore, accessible healthcare providers are in a prime position not only to dispose of unwanted drugs in their pharmacies but also to advise patients about the proper disposal of medications within the household. This study aimed to evaluate the methods community pharmacists use to dispose of unwanted drugs, the methods they recommend to patients, and their awareness of the environmental hazards of improper drug disposal. We also aimed to evaluate their views on recommendations to improve safe drug disposal practices, including funding for drug-disposal programs and perceived challenges facing drug disposal processes. A descriptive cross-sectional survey of community pharmacists was conducted in Palestine between December and April The study included licensed professionals and registered pharmacists who worked in community pharmacies throughout the West Bank. According to the last report by the Palestinian Ministry of Health, the number of registered pharmacists in Palestine is The sample size was calculated using an online Raosoft sample size calculator. The data were collected by five pharmacy students who were in their final year of study through face-to-face interviews. This study included practicing pharmacists of all academic degrees who worked in community pharmacies in the West Bank, aged 23 years and older. The questionnaire was adopted from several previous studies and consisted of 36 questions divided into six sections \[ 27 , 28 , 29 , 30 , 31 , 32 \]. The first section was concerned with demographic data, and participants were asked if they had participated in educational courses or workshops on this topic. The second section evaluated the practice of pharmacists on how to dispose of unwanted medicines including expired medications in the pharmacy, providing them with several options to answer, with the possibility of choosing more than one answer. The third section evaluated whether pharmacists could provide sound advice and direct patients to the safest way to dispose of a variety of drugs, including solid, semisolid, liquid, expired class B controlled drugs i. Their feelings of responsibility towards the environment and other living creatures were assessed, in addition to what they perceived as the sources of unwanted medications. This section was evaluated through six questions on the 5-Linkert scale, with a higher score indicating good awareness. The questionnaire was offered in Arabic. They evaluated the organization, clinical terminology, completeness, appropriateness, logical sequence, and accuracy of the statements and modified some questions as needed. The questionnaire was piloted among 10 patients to test its readability and reliability. However, the results of the pilot testing were not included in the final data analysis. The survey instrument was improved based on the feedback received during the pilot review. Furthermore, the pharmacists obtained informed consent verbally before participating in the survey. Finally, we described the study goals to the pharmacists and asked them to participate in the study. Categorical variables are expressed as frequencies and percentages, while continuous variables are described as medians and IQRs interquartile ranges. A P value of less than 0. Four hundred pharmacists completed the questionnaire, women The median age IQR of the participants was 27 24—30 years, and the majority lived in cities , The majority of the participants were from Jenin , Sixty-five Most pharmacists in our study , Approximately half of the pharmacists and one-fifth disposed of pharmaceutical products via environmentally unfriendly routes, such as the trash and sink, respectively. Other commonly used methods were drug disposal in a drug take-back box , Table 2. Regarding class-B drugs, most participants , Regarding class C drugs, most participants , Regarding antibiotic disposal, the vast majority of study participants , Most participants recommended that inhaler drugs be disposed of in the trash , However, 66 Most pharmacists agreed , Additionally, most agreed , Similarly, most participants agreed , Most participants believed that community pharmacists should ensure that expired drugs are properly sorted and separated, with Most also agreed , Regarding the sources of these unwanted medications, most pharmacists , Other perceived sources with fewer contributions included those returned from hospitals 17, 4. The vast majority of participants in our study , Most , Meanwhile, 77 Providing proper training to healthcare workers on managing expired medications was the most favored recommendation among participants in our study to improve drug disposal practices, with pharmacists Organizing events and scientific forums around proper drug disposal was the second most preferable recommendation. The least common proposal was the passage of strict laws on the safe disposal of all forms of drugs Table 5. Participants in our study viewed the greatest challenge facing drug disposal processes as poor education and awareness about the management of expired or unwanted drugs, and Other notable challenges perceived by study participants included poor law enforcement , The median \[Q1-Q3\] awareness score was The univariate analysis results showed that pharmacists with higher education degrees were more aware of the disposal of unwanted pharmaceutical products. Furthermore, participants who previously participated in courses on proper drug disposal methods had higher scores than others Table 7. In this study, out of community pharmacists, Similar results were found in a study conducted in Saudi Arabia, where between The disposal of drugs in the trash was used as a second method of drug disposal This practice of disposing of unused medications in the trash or through the sink caused The current study showed that Furthermore, most of them agreed or strongly agreed and considered themselves responsible for protecting the environment Community pharmacists in Palestine showed a good level of awareness regarding inappropriate practices of medication disposal, and the median \[Q1-Q3\] awareness score was The awareness level was positively correlated with the education level of pharmacists, which is expected, as the higher the level of education, the more courses covered safe disposal the pharmacist received. This is also shown in a study conducted in Iraq, where the majority of pharmacists Furthermore, participants who previously participated in courses on proper drug disposal methods had higher awareness scores than others. In these courses, pharmacists received education on the proper disposal practices, which eventually positively affected their level of awareness. These findings are similarly supported by studies conducted in New Zealand, Kuwait and Saudi Arabia that strongly encouraged conducting education courses and training programs for pharmacists and other healthcare professionals as the best way to increase their level of awareness \[ 27 , 30 , 32 \]. All the results and reasons mentioned above support the need to establish policy guidelines for the safe disposal of medications within community pharmacies in Palestine. However, to achieve efficient and effective results using safe disposal, barriers and challenges facing community pharmacists in Palestine reported in this study must be solved, such as the lack of education and awareness on the issue of removing unused drugs and weak law enforcement. Most participants agreed that good training for health care professionals through organizing workshops to develop knowledge and awareness of this subject would be an important step in improving practices. Although some countries may have legal restrictions on such practices, there are no restrictions or guidance about this practice in Palestine. The questionnaire included these choices because some pharmacists may recommend these practices under certain circumstances. For example, it could be cost-effective and environmentally friendly to donate unwanted medications instead of disposing of them \[ 33 \]. The reason beyond that is to ensure the safe and proper disposal of certain drugs, such as controlled substances. This study was carried out on the West Bank in Palestine, and most of the sample was from the North Regions, which is considered a limitation of our study. Furthermore, the current study focuses on community pharmacists, although the problem of unwanted medication disposal affects other healthcare professionals, households, and healthcare institutions. In addition, our study was generalized, assessing awareness and practices of unwanted pharmaceutical products and does not specify dangerous or controlled drugs or quantities. However, environmental or human harm could occur from any type or quantity of drug if disposed of improperly. Most pharmacists in our study returned drugs to manufacturing companies and stores, approximately half of them disposed of drugs in the trash, and few followed the correct incineration and return of drugs to the Ministry of Health. Current data emphasize the improper disposal of medicine in Palestine and the need for improved education among healthcare workers. Further research is needed to answer the question about the quantities of pharmaceuticals discarded by different sectors and their relation to the total amount of drugs discharged in Palestine. Specifically, we recommend using the simulated client technique that gives a better picture of practice assessment as well as decreases bias in results. Data collected and analysed for this study are available from the corresponding author upon reasonable request. Water-borne diclofenac affects kidney and gill integrity and selected immune parameters in brown trout Salmo trutta f. Aquat Toxicol. Disposal practices for unused medications in New Zealand community pharmacies. J Prim Health Care. Article PubMed Google Scholar. Disposal practices for unwanted residential medications in the United States. Environ Int. Return Unwanted Medicines. Pharmaceutical waste reduction in the NHS. The prevalence of unused Medications in Homes. Pharm Basel Switzerland , 7 2. Pore SM. Pharmaceutical waste from hospitals and homes: need for better strategies. Indian J Pharmacol. Pharmaceutical Residues in Municipal Wastewater. Fate and uptake of pharmaceuticals in soil-plant systems. J Agric Food Chem. Pharmaceuticals in the environment: scientific evidence of risks and its regulation. Widespread sexual disruption in wild fish. Environ Sci Technol. Dilute concentrations of a psychiatric drug alter behavior of fish from natural populations. Genomics of IncP-1 antibiotic resistance plasmids isolated from wastewater treatment plants provides evidence for a widely accessible drug resistance gene pool. Disposal practices for unused medications around the world. Disposal of unused drugs: knowledge and behavior among people around the World. Rev Environ Contam Toxicol. Household medical waste disposal policy in Israel. Isr J health policy Res. Disposal of Unused Medicines. Drug Disposal. Fass JA. Prescription drug take-back programs. Article Google Scholar. Medication disposal practices: increasing patient and clinician education on safe methods. J Int Med Res. Safe disposal of medicines in Palestine. J Pharm Pharmacol Plestina. Google Scholar. Management of unused pharmaceuticals waste at governmental hospitals and homes in Gaza, Palestine: empirical insights for further actions. Int J Environ Waste Manag. Educational campaign for proper medication disposal. Disposal practices for unused medications in New Zealand. Safe disposal of prescribed medicines. Australian prescriber. Albaroodi KAI. Practice, awareness and opinion of pharmacists toward disposal of unwanted medications in Kuwait. Assessment of disposal practices of expired and unused medications among community pharmacies in Anambra State southeast Nigeria: a mixed study design. J Pharm Policy Pract. Healthc Basel Switzerland , 9 7. Pharm Basel Switzerland , 6 3. Download references. Lamees L. Nairat, Noor A. Abahri, Yosr A. Hamdan, Razan T. Abdel-khaliq, Sawsan M. Odeh, Samah W. Al-Jabi, Amer A. Koni, Amani S. You can also search for this author in PubMed Google Scholar. SA and ASA reviewed the literature and wrote the manuscript. AAK designed the study, analyzed the data, and participated in the manuscript writing. SHZ and SWA conceptualized the study, critically reviewed the manuscript to improve its intellectual content, and assisted with the final writing of the manuscript. Correspondence to Amani S. We described the study goals to the pharmacists and asked them to participate in the study. The reason for verbal informed consent is that participants were only required for the interview and were not subjected to any harm as long as their privacy was kept confidential. The authors confirmed that all methods followed the relevant guidelines and regulations. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and permissions. Nairat, L. Assessment of practices and awareness regarding the disposal of unwanted pharmaceutical products among community pharmacies: a cross-sectional study in Palestine. Download citation. Received : 06 November Accepted : 08 August Published : 27 September Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Research Open access Published: 27 September Assessment of practices and awareness regarding the disposal of unwanted pharmaceutical products among community pharmacies: a cross-sectional study in Palestine Lamees L. Nairat 1 , Noor A. Abahri 1 , Yosr A. Hamdan 1 , Razan T. Abdel-khaliq 1 , Sawsan M. Odeh 1 , Shatha Abutaha 2 , Samah W. Al-Jabi 1 , Amer A. Koni 1 , 3 , Amani S. Abstract Background The improper disposal of pharmaceutical preparations substantially threatens human health and environmental safety. Methods A descriptive cross-sectional study was conducted between December and April among practicing pharmacists who were chosen to participate by random cluster sampling. Results Of pharmacists, stated that they did not participate in courses on the safe disposal of unwanted medications. Conclusions Most pharmacists in our study returned drugs to manufacturing companies and stores, and few followed the correct methods of incineration and return of drugs to the Ministry of Health. Background The appropriate disposal of unused drugs is crucial for the safety of humans and the environment and to prevent potentially hazardous consequences. Methods Study design A descriptive cross-sectional survey of community pharmacists was conducted in Palestine between December and April Study area and study population The study included licensed professionals and registered pharmacists who worked in community pharmacies throughout the West Bank. Sample size and sampling technique According to the last report by the Palestinian Ministry of Health, the number of registered pharmacists in Palestine is Inclusion and exclusion criteria This study included practicing pharmacists of all academic degrees who worked in community pharmacies in the West Bank, aged 23 years and older. Data collection instrument The questionnaire was adopted from several previous studies and consisted of 36 questions divided into six sections \[ 27 , 28 , 29 , 30 , 31 , 32 \]. Results Demographic data of pharmacists who participated in the study Four hundred pharmacists completed the questionnaire, women Table 1 Characteristics of pharmacists Full size table. Discussion In this study, out of community pharmacists, Conclusions Most pharmacists in our study returned drugs to manufacturing companies and stores, approximately half of them disposed of drugs in the trash, and few followed the correct incineration and return of drugs to the Ministry of Health. Data Availability Data collected and analysed for this study are available from the corresponding author upon reasonable request. Acknowledgements Not applicable. Funding No funding was received for this study. Zyoud Authors Lamees L. Nairat View author publications. View author publications. Consent for publication Not applicable. Competing interests The authors declare no competing interests. About this article. Cite this article Nairat, L. Copy to clipboard. Contact us General enquiries: journalsubmissions springernature.

Buying MDMA pills Karbala