The interlinked crisis: pharmaceutical pollution as a driver of antimicrobial resistance in East Africa: an urgent call for ecopharmacovigilance and one health approach.

Pharmaceutical pollution is a growing environmental and public health issue in East Africa. It is fueled by rapid population growth, increased pharmaceutical consumption, insufficient wastewater treatment, and pharmaceutical uses. Leftover pharmaceuticals enter into water and land ecosystems through human and animal waste, hospital and industry discharges, and inadequate waste management practices. These pollutants present ecological dangers and significantly contribute to the rise and spread of antimicrobial resistance (AMR), posing a threat to both the environment and public health. This narrative review takes a One Health approach to explore pharmaceutical pollution, AMR, and regulatory responses in East Africa. The literature search was conducted between January 04, 2025, and July 25, 2025, using PubMed, Google Scholar, and grey literature. Evidence shows widespread contamination of water bodies, sediments, wastewater, and food products with antibiotics such as ciprofloxacin, sulfamethoxazole, and tetracyclines, often surpassing safety thresholds. Risk Quotient (RQ) analysis revealed significant environmental risks in Ethiopia (ciprofloxacin RQ = 8.58), Kenya (ciprofloxacin RQ = 3.5–40.6; sulfamethoxazole RQ = 0.1–3.53), and Uganda (RQ > 1). However, no RQ data is available in Tanzania, Sudan, South Sudan, Eritrea, Djibouti, Somalia, Rwanda, and Burundi. Furthermore, environmental samples through the regions consistently show the presence of AMR resistance genes, strongly linked through pharmaceutical contamination to the emergence of resistance. The review underlines the importance of ecopharmacovigilance (EVP), a developing field that focuses on monitoring and mitigating the environmental impacts of pharmaceuticals. Despite the development of national action plans on AMR and environmental protection policies in East African countries, implementation remains weak due to enforcement limitations, fragmented surveillance systems, inadequate wastewater treatment infrastructure, and low public awareness. This review emphasizes the immediate necessity of executing EVP within a One Health framework via augmented environmental surveillance, stringent regulatory enforcement, enhancements in wastewater treatment, green pharmacy initiatives, and geospatial monitoring. Furthermore, establishing a regionally harmonized EVP system supported by evidence is critical for addressing pharmaceutical pollution, combating AMR, safeguarding ecosystems, and promoting public health in East Africa.