One of the major causes of death in the world is malaria, but the World Health Organization estimates that 20 percent of the one million deaths from malaria are dying because the medicines that they are taking are substandard or outright counterfeits. If you include fake antibiotics and fake drugs used to treat tuberculosis, the number has been estimated to be 700 thousand people a year.

Kenya Broadcasting Corporation estimates that half of the medicine sold in Africa are substandard or outright fakes, and last May, Nigerian authorities confiscated a large shipment of antimalaria drugs  which had been labled as originating in India but were actually counterfeit medications from China.

The main problem has been the anti malaria drug  artesunate, which is often sold over the counter. Because the medicine is expensive to make, counterfeit versions are profitable. Often the counterfeit medicine contain small amounts of the drug in order to pass unsophisticated inspections, but physicians worry, because giving too low a dose of any antibiotic can result in drug resistance.

The manufacture of such drugs is often quite sophisticated: often the criminals use  manufacturing techniques to make their products look exactly like the brand name drug.

Since those who die tend to be poor people, mainly in rural areas of Africa and Asia, the problem hasn’t gotten a lot of publicity. So I am happy that Smithsonian magazine has an excellent article on it this month.

Fake drugs kill, and those who profit from them need to be prosecuted, and alas this is often only done if it kills westerners (as in the fake heparin ingredient that killed people last year) and the western governments pressure the local governments to prosecute the criminals.

But there is another problem that we also have to face, and that is when medications are made locally, and are approved to be used by officials, but they don’t work because they are not made with proper quality controls.

This type of problem can be seen in this CDC report on a malaria outbreak in a refugee campe in Pakistan. The outbreak was fought with the usual methods: getting rid of standing water, spraying pools and ditches, mosquito nets. But the physicians noted that a lot of the patients were relapsing despite adequate treatment.

This time, it wasn’t due to fake artesunate, but involved another drug,  Fansidar.( SP or  sulfadoxine-pyrimethamine). This drug’s been around for awhile, (I took it 30 years ago when I had chloroquin resistant malaria) but because of the allergy problems with sulfonamide medicines, it is usually only used in areas where there is chloroquine resistant malaria. In a few areas of the world, such as Southeast Asia, where SPresistance occurs, the more expensive artesunate is used.

In this case, the problem was not a fake medicine: when tested, the pills contained the proper amount of the medications. The problem was that the pills did not dissolve properly, so those taking the pill essentially got only half of the medicine.

So the next time you read about the need for buying generic or  locally produced medicine to fight HIV or some other illness, just remember that  third world countries don’t always have the sophisticated testing and quality control techniques to guarantee the medicines work. The arguments of American drug companies about generic medicines are not completely to be ignored.

We docs all know of patients harmed because of generic medicines that were substituted for brand names. Such problems are rare in the US, but a major problem in places like here in the Philippines.

But the real problem is the criminal networks that  deliberately make and sell counterfeit medicines that look like the real thing. Most of these are manufactured in China or India, where corruption and bribery of officials complicate the ability of the government to regulate these criminal gangs.

In the Smithsonian article, Chinese authorities arrested three of those who arranged sale of the fake anti malarial medicines. These three got a short prison sentence, but the manufacturers were never punished.

Dante puts such criminals in the eighth circle of hell: and personally, I can’t think of a better place in eternity for those whose products kill the poor and innocent for profit.

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Nancy Reyes is a retired physician living in the rural Philippines.

Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at Hey Doc Xanga Blog.

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