This is a detailed ethnographic investigation into the social and economic realities of pharmacies in urban India, with a specific focus on Mumbai. Kamat and Nichter explain how pharmacies do not exist in a vacuum, but rather the practices of staffing, stocking antibiotics, and giving advice on antibiotic use are all highly influenced by the economic and social context of the retail medicine business.  Most studies on pharmacies and pharmacists in the global south have focused on pharmacist and pharmacy attendant interactions with patients and how these interactions increase or decrease antibiotic use, self-medication and experimentation. What has been missing is the economic and social context of these interactions. Here, Kamat and Nichter explain how pharmacies are deeply entangled within local economic systems and global pharmaceutical economic systems and supply chains: Pharmacies are increasingly lucrative business ventures, and ‘setting up shop’ in under-regulated informal communities has become an easy way to avoid intensive start-up costs. But this abundance of pharmacies has led to competitive pricing between pharmacies, the use of ‘agents’ to lure people to their shops, and a model of ensuring client satisfaction to guarantee return customers, which includes ensuring clients have access to drugs without a prescription, discounts, and extending credit to clients in need.

On the other side, pharmacy owners are targeted by aggressive marketing strategies by pharmaceutical companies, who offer appealing incentive schemes, including rebates, ‘buy some get some free’ schemes, stock bonuses, gifts, and cash discounts. These economic systems extend beyond the pharmacy, the authors explain: “Medreps who represent pharmaceutical companies encourage doctors to prescribe their products and pharmacies to stock them. To accomplish the latter, medreps act as intermediaries assisting pharmacies to liquidate unsold and slow moving stocks. A complex chain of symbiotic relationships between all parties involved in medicine dispensing and sales influences pharmaceutical practice” (792, emphasis added).

This study suggests that more attention need to be paid to the social and economic context within which antibiotics are sold and used. Treating the encounter between pharmacist (or pharmacy attendant) and client as if in a vacuum will obscure important insights relevant antibiotic use and AMR policy.

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