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Counterfeit medicine: the silent epidemic

Up to 400,000 deaths in China since 2001, 30 in Cambodia in 1999 and 2,500 in Niger in 1995... These are the rare figures that are known, the visible part of the iceberg consisting of the victims of counterfeit medicine! Every year in the world, hundreds of men, women and children are victims of this market based on deceit. A deadly industry that affects developing countries in particular. But the rich world is not spared, either. In 2004, almost 900,000 counterfeit pharmaceutical products were seized in the European Union! The WHO defines counterfeit medicine as a “product whose composition and active ingredients do not meet scientific standards. As a result, it is ineffective and often dangerous for patients”. Counterfeiting is found in very diverse forms. It may concern both branded and generic products. The main forms of counterfeit products can be summarised as follows: they may include products containing the authentic active ingredients of the original product, but with fake packaging or no packaging at all. Bulk storage of medical products is a widespread but dangerous practice. Quality packaging is in fact essential to protect the medical product against heat, humidity and sunshine… The counterfeit product may sometimes contain the required active ingredients, but in an insufficient amount compared with the original version. Or it may contain different active ingredients from those in the real product. The way is clear for all kinds of abuses. The counterfeit product may not contain any active ingredients at all. A kind of placebo that uses the name of a real medicine. This can lead to terrible damage, if it is used to treat potentially fatal diseases such as malaria, tuberculosis or HIV-AIDS infections. A murderous industry that is expanding rapidly! One in every ten medical products sold in the world is fake. According to a study by the American Food and Drug Administration (the FDA), counterfeit medicine accounts for over 10% of the world market. In other words, 32 billion dollars’ profit per year! And there is no sign of this stopping. According to the International Federation of Medical Industries, the traffic in medical products is 25 times more profitable than the heroin industry and five times more profitable than the cigarette industry! Creams, eye lotions, syrups, tablets – nothing is spared. A study recently published by The Lancet reveals that up to 40% of products in the world supposed to contain artesunate did not contain any active ingredient and therefore had no therapeutic effect at all! Artesunate is in fact the best medicine available at the moment to combat chemio-resistant malaria. A really essential medicine. Counterfeiting is a very lucrative industry, which does not require major logistics. No need for large facilities. Fake medicine can be produced at a low cost. It is often enough just to have a simple unused warehouse or even a back shop to embark on making copies of medical products at home. According to the WHO, counterfeiters have even been discovered at work in the shade of a tree in Africa! The products are sold in markets and peddled on the roadside. This very fruitful market is expanding rapidly with globalisation. Even in rich countries where the Internet has enabled counterfeiters to progress rapidly. Corticoids, anti-inflammatory drugs and even Viagra are most often sold on the Web, without any medical control. Idem for the many plant-based products imported from Asia. The WHO also considers that 40% of counterfeit medicine comes from developed countries. Forty percent, that means that the remaining 60% concern poor countries! Which have no reliable checks at borders that are capable of stemming this traffic. The specialists consider that up to 50% - or even more – of medical products consumed in some developing countries are counterfeit. Above all in Asia and Africa. In Nigeria, for instance, six out of every ten products sold are not authorised. The same applies to Guinea where over 60% of medical products sold are counterfeit. This indicates the extent of the problem in countries where pharmaceutical regulations are not strict enough and the supply of basic medicine is insufficient. And above all too expensive for a large section of the population. The fact that medical products have to be paid for even in hospitals encourages the black market. Why is Africa so badly affected by this phenomenon? Because it has been severely afflicted by a series of economic and social disasters. The HIV-AIDS pandemic has decimated the continent’s population. Civil and cross-border wars have devastated several countries. The devaluation of the CFA franc has made imports more expensive. Fraud has prospered on this fragile terrain. The African continent has become the choice location, so to speak, for counterfeiters from all over the world. From South-East Asia, Latin America, India and certain Eastern European republics. But other regions of the world are also affected by this plague. In Lebanon, for instance, it is not rare for counterfeit pharmaceutical products to be seized that come from Egypt, Iraq and Pakistan. In particular insulin and contraceptive pills which sometimes contain only talcum powder. Or even entire containers filled with fake Viagra containing at the most 10% of the normal dose of sildenafil (the active ingredient), but more often than not, none at all. Fake Viagra is found also in North Africa. In Algeria and Morocco, the famous “souk al fellah” (literally “peasants’ markets”) are inundated with it. Everything is sold in these souks, from car wings, fuel and household products to counterfeit or contraband medicine. According to Faouzi Mohamed, President of the Pharmacists Union in Oujda, in the north-east of Morocco, on the border with Algeria, “these markets sell a selection of products that come from Spain, Eastern European countries, Libya and Egypt. For instance, Viagra which is known all over the world. Here you find Vegra, not Viagra. They play on the name. Also for certain neuroleptic medicines such as Klonopin, antiseptic products and a few anti-inflammatory products”. Fake products kill! According to the WHO, the expansion of counterfeit medicine can be explained by the immense poverty of a large part of the world’s population, who do not hesitate to obtain supplies outside the official distribution system. Dr Yves Juillet is an adviser to the President of Leem (Medical Industry Enterprises) in France. Within this organisation, he also chairs the anti-counterfeiting group. He explains that “the research carried out has shown that in over half the cases counterfeit products did not contain any active ingredient. And in the other cases, they either contained less or contained other products or impurities. The risk, first, is not to get the treatment you need. In an infectious disease, this can be very serious. It is also thought that resistance to anti-parasite products, in particular anti-malaria drugs, is largely related to the fact that people are taking products that contain high doses or that are not properly prepared”. Treating oneself with a counterfeit or lower quality medicine leads, in the best of cases, to the failure of the treatment, or worse, to the emergence of resistance. All too often, death is the consequence. The WHO considers that every year 200,000 people affected with malaria die because of poor quality medicine. In other words, one-tenth of the fatalities caused by malaria! This is because a number of fake anti-malaria drugs are circulating on the world market. A study carried out in South-East Asia in 2001 revealed that 38% of anti-malaria drugs sold in pharmacies contained no active ingredient and were therefore causing many deaths. The same happened in Cambodia in 1999. Over 30 people died there after having taken counterfeit anti-malaria drugs containing sulfadoxine-pyrimethamine (an old malaria drug that is less effective) sold under the name artesunate. Another well-known case is the consumption of cough syrup containing paracetamol, prepared with diethylene glycol (a toxic chemical product used as antifreeze). It killed 89 people in Haiti in 1995 and 30 infants in India in 1998. Pale copies of anti-retroviral agents were also discovered in central Africa, a region that is already severely affected by the HIV-AIDS pandemic. Other products such as adulterated contraceptive pills and non-impermeable condoms were also seized. This gives rise to fears of a considerable delay in combating the disease in this region where problems of access to medical products already represented a major barrier in fighting the spread of the virus. To combat this counterfeiting, industrialists, distributors and the authorities have an interest in putting up a united front. According to Yves Juillet, the role of the pharmacist is vital on the field. “The pharmacist plays a very important role as he is one of the essential links in the pharmaceutical chain. The only way to combat this plague is to safeguard and guarantee the pharmaceutical chain from the producer to the pharmacist, including the distributor. The pharmacist must therefore be very, very careful about his chain of supply and only buy products in circuits that he knows very well and where quality is guaranteed”. Of course, it is not enough for pharmacists to be vigilant. This must be supported and accompanied by publicity campaigns and information on the risks of the illegal trade in medical products. If there is no prevention, people will always turn to the black market because they believe, unfortunately, that medical products are cheaper when bought in the streets. This is quite wrong, of course. Financial calculations show that a medical product peddled in the street is dearer. But as it is sold by the unit, by the tablet, it is of course easier for people to buy… but extremely dangerous! So be careful. Medicine is not like sweets. It must be bought in purchases and not elsewhere. Especially not on the Internet! Your life is at stake.