When Counterfeits Kill

By Deborah Sanborn

The toxic truth about the cheap alternative and underground market for fake medicines abroad  

A new epidemic is galvanizing public health experts—the proliferation of counterfeit medicines. And it’s one with serious implications for adventure travellers, since the meds for malaria are at the top of the counterfeiting list. Over the past decade, several tragic incidents have shown how fake medicines are now wreaking havoc on innocent lives, especially those in the poorest of places.

In 1995, during a devastating meningitis epidemic in Africa, more than 50,000 people were given a counterfeit vaccine and 2,500 died as a result. (Alarmingly, the vaccine had been donated from a reputable source.) Fake cough syrup containing a chemical used in antifreeze killed hundreds of children in Asia, Africa and South America, and in Cambodia several people died after they were treated with a falsified version of an antimalarial drug.

How extensive is the problem? Let’s just say it’s redefining what’s meant by the illegal drug trade.

In 2006, Dr. Paul N. Newton, a worldwide expert on the issue, reported that 38 to 53 percent of all artesunate—the most up-to-date and effective drug to treat malaria—being sold in Southeast Asia was counterfeit. And since then, he tells Outpost, fake artesunate has shown up in at least four sub-Saharan African countries.

And the fakes are popping up everywhere.

The Angolan government reported in 2004 that possibly 70 percent of  all medicines used in that country were “forgeries”—an extraordinary admission. In 2006, the Peruvian government estimated that 1,800 illegal pharmacies were operating in Lima alone (though it’s cracking down on them). In Russia, where organized crime is booming, the government has said about 10 percent of all drugs on its market are fake (the WHO calls this a conservative estimate). Just a few months ago, raids in the Philippines (where an anti-counterfeiting task force is hard at work) and port inspections in Nigeria (where Dora Akunyili, a global crusader on the issue, heads the country’s drug administration) netted scores of counterfeit medicines—including ones for high blood pressure.

While the WHO is now working to have all such incidents reported to it, tracking the scope of the problem worldwide remains elusive, even for the best experts.

There just isn’t enough reliable data, states Newton, who as director of an infectious disease centre run by Oxford University and Mahosot hospital in Laos, has investigated the problem extensively. Moreover, though it’s now known many come from China and India—which have robust pharmaceutical industries—fakes can be easily made in any backroom kitchen. And counterfeiters are the craftiest of criminals, finding ever more clever ways to produce, distribute or sell their wares.

The WHO defines a drug as counterfeit if it has been “deliberately or fraudulently mislabelled” in any way, and/or if it has an incorrect, inactive or insufficient amount of the appropriate medical ingredient. (So are drugs of substandard quality including knock-offs), and ones with altered expiration dates, or no reference to a manufacturer. The important thing to know, Newton states, is that at some level deception—no matter how minor it may seem—has been involved.

Obviously, countries with poor or no governmental monitoring—and no policing bodies to monitor the flow of illegal drugs—are where counterfeits tend to flourish, as they do in regions where there’s little access to medicines (smaller towns, villages, remote areas), and in places where prices are so high consumers are susceptible to low-cost alternatives. The redirecting and repackaging of drugs from legitimate sources (like pharmaceutical companies) to illegitimate ones—where medicines can be broken up, remade or diluted with fillers and contaminants, some of which are toxic—is a link in the counterfeiting chain.

In 2005, spurred on by previous findings, Newton, the WHO, Interpol and a range of experts began a widespread investigation into the trade of illegal artesunate in Southeast Asia. (The following year saw the creation of IMPACT, the International Medical Products Anti-Counterfeiting Taskforce, now a global leader on the issue.) The findings, published in PLoS Medicine, were revealing: while it was less surprising that half the samples tested contained little or no artesunate (other studies had shown this), analysis of the ingredients told investigators at least some of the fakes had come specifically from southern China (The Chinese government found and arrested the culprits). The samples also had some dubious ingredients—antibiotics, acetaminophen, a chemical used in ecstasy, even carcinogens.

Moreover, 16 fake holograms were identified—disturbing, given that holograms are put on packages to assure consumers that drugs are legitimate.

“Travellers cannot realistically tell if a fake is professionally packaged,” Newton states, adding that five out of six professors of medicine couldn’t distinguish between genuine and fake artesunate when given packaged samples. (Security measures are also ever-evolving; one company in Europe has created a faux-DNA coding system for products.) Experts are extremely concerned that fakes with small amounts of real medical agents, especially the ones that treat malaria, tuberculosis and HIV, will compromise their long-term effectiveness, as the microbes that cause these diseases learn to resist them.

For travellers, all of this is yet another reason to get all the meds you need long before you board the plane. If you do buy abroad, don’t ever do so from travelling drug sellers, or at market stalls, small stores, unlicensed sellers and kiosks. Like a good fake Fendi, sophistication makes spotting imitations near impossible. Stick to buying in capital or large cities, and from professional pharmacies with qualified staff. (Don’t buy from grocers!) Newton says travellers need to be most wary when buying anti-infective drugs like anti-malarials or antibiotics—as untreated infections can kill—and goes so far as to warn that it’s wise to be “almost always suspicious” of any drug you get in a foreign country. In malaria-risk countries, find out if there’s a national malaria program, or if antimalarials can be purchased through a government health service. And here’s a tidbit in a nutshell: any drug that’s “surprisingly inexpensive,” states Newton, “should always ring alarm bells.”

Spot a Fake

  •  Misspellings, uneven type, poor quality print, ink blots or thick letters on packaging.
  •  Poorly reproduced holograms that look faint in appearance, or have uneven circles and ink spill-through.
  •  Drugs that smell or taste strange, look unusual (especially in shape or colour), are chipped, crumble or break easily, and cause new or unfamiliar reactions or side effects.
  •  Drugs that don't cost what you would normally expect to pay in general.

Safe Medicine Practices While Travelling

  • If buying antimalarials in-country: go to local/national government websites, look for "malaria"; some countries post warnings on websites about counterfeits circulating locally.
  • Ask foreign and tourism industry staff (at embassies, hotels, etc.) where it's safe to buy medicine locally.
  • Avoid drugs not sold in original packages or with original labels; if not possible, only buy from a reputable, recommended or known pharmacist or seller.
  • Don't be shy: question pharmacists about their products to show you're aware of counterfeiting; always ask if the medical agent in the drug you're buying is the same (and not a facsimile) as in the drug you need.
  • If you take medicine for a pre-existing condition; take a list of the brand and generic names of all meds, as well as the name of the manufacturer.
  • Keep all meds in their  original package with original labelling- not pill drawers; keep meds in purse or carry-on in case luggage is lost.
  • Only buy from certified Internet websites. Check the Verified Internet Pharmacy Practice Sites (VIPPS) run by The National Association of Boards of Pharmacy (www.nabp.net) for safe american sites.

For more info, see www.safemedicine.orgIMPACTWHO and CDC; see also Dr. Paul N. Newton in PLoS Medicine.

NOTE: This is a guidance only. Always get individualized advice from a qualified professional or travel health clinic.


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