The naive guys at the NYTimes Freakonomics blog have a short article on the cost of health care, especially medicines, in third world countries:

A new study analyzed the effects of buying four basic prescription drugs in “low- and middle-income countries,” and the results aren’t pretty. “Buying brand name amoxicillin, for example, would push an additional 34 percent of Uganda’s population into poverty levels of less than $1.25 a day,” reports FP Passport. “Even middle-income Indonesia would see an additional 39 percent of its population become poor from purchasing the drugs.”

Reality check, please.

The dirty little secret is that counterfeit medicines kill over 700,000 people every year. And how common is the problem in Africa? The IMANI Center for Policy & Education has issued a report that claims one third to one half of drugs sold in Africa are counterfeit, usually manufactured in India or China. In Asia, up to two thirds of the antimalaria medicine artesunate is substandard.

Current attempts to deal with the problem through tougher regulation and criminal penalties do not address the root causes of counterfeiting. Worse, many countries have corrupt regulatory and legal systems that are easily exploited by criminal counterfeiters, so additional rules will only increase corruption.

Governments also exacerbate the problem by making legitimate drugs more expensive through taxes and tariffs.

The reason many of us insist on good generics or brand name medicines is because we are never sure if the cheaper ones at the smaller generic drug stores work, or if they are counterfeit drugs, with little or no active ingredient inside.

Medscape has a good article on the problem, and how to fix it. I will summarize their recommendations and note the reality of third world.

1.You need the political will to stop the problem, and then someone to devise laws to regulate medicine importation and selling of medicine.

(note in the third world, often anyone can buy medicines at the recommendation of the pharmacist).

2. You need to screen imported drugs at the point of entry.

(Note: Smuggling is difficult to stop, and bribery and corruption allows one to smuggle in almost anything).

3. You need someone to test the medicines, both at entry and random testing at various outlets that sell medicine.

(Note: such expertise is rare in many countries, and of course counterfeiters often add small amounts of the real medicine, or add fake ingredients that enable the fake medicine to pass these routine tests)

4. You need to enforce the law at all levels.

(Again, bribery and corruption is a major barrier. A small gift will stop the police from removing substandard items from any store or warehouse).

In other words, in countries where a friendly gift allows one to bypass regulations, just making laws won’t stop the problem.

Yet, here in the Philippines, the government tries hard to stop counterfeit drugs from being imported and sold, while encouraging generics for the poor; and the larger pharmacy chains try to inspect and certify generics that are genuine. Yet even so, I’ve had problems when I’ve used generic medicines.

So, if having a good medicine is a life and death decision (e.g. blood pressure medicine or antibiotics) I’ll go with the brand name, or a good generic at a good pharmacy that I trust.

If it’s just a cold pill or ibuprofen, well, generic or even herbal medicine will do fine.

So the PLOS article cited in the NYTimes has an easy solution: Just supply cheap generic drugs. Sounds like the Chomsky type who go around frothing at the mouth against rich drug companies who dare to make a profit. These naive types demonize anything from the first world, while ignoring the criminals who flourish in their beloved third world countries.

Earth to ivory tower: Hello! Waving a magic wand won’t allow good and cheap generic medicines to be sold to poor people everywhere.

To paraphrase Bill Clinton: It’s the corruption, stupid.

And no, most Americans can still rely on genuine medicine, including generics. But if you buy on line, beware.

And remember: The bad news is that many American pharmaceutical factories now outsource part or all of their manufacturing to China…which is what resulted in the Heparin scam deaths two years ago.

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Nancy Reyes is a retired physician living in the rural Philippines. She blogs at Finest Kind Clinic and Fishmarket.

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