A Game of Russian Roulette
For a second, the uniformed officer looked threatening. He followed me. When I reached the stairs leading to my Transavia flight to Paris, he stepped in front of me, asking, “Sir, may I talk to you for a second?” Did he suspect I was smuggling precious Islamic art or some cannabis, the popular Kif? “When are you returning to Marrakech,” the customs officer inquired. “In four days”, I replied. “Perfect,” was his reaction. “May I ask you to buy in a French pharmacy the drugs mentioned on this prescription for my mother?” Before I could react, he handed me the medical paper and added, “Mama, Allah protect her, believes those rumors that some of the pharmaceutical products sold in our pharmacies are fake, substandard or outdated.”
The officer’s mother certainly is not the only citizen on the African continent questioning the quality of medical supplies, and not just since the outbreak of deadly Coronavirus. Illness, hospital care, and, in particular, the pharmaceutical industry, are part of an unending, partly imaginary, but nevertheless intense African debate. The invisible coronavirus is suddenly bringing back fear, posing the question of whether the continent is up to the dramatic challenges the global community faces. Will the necessary medical supplies be available, and are they up to international standards? Africa, according to the World Health Organization (WHO), accounts for as much as 42 percent of globally detected substandard and fake medicine products.
In May 2013, African Renewal, a quarterly magazine financed by the United Nations, published a front page story headlined ‘Counterfeit drugs raise Africa’s temperature’. It stated that the counterfeit medicines trade, a billion dollar industry, is thriving in Africa: “The markets are flooded with fake and poor quality drugs, making the trip to the pharmacy seem like a game of Russian roulette. If you pick the wrong box, it could literally mean your death,” the article said. The problems of fragile healthcare systems and questionable pharmaceutical products are still not under control, and buying medical products can be a Las Vegas-style gamble. The “proliferation of fake medicine in Africa,” reported the BBC in January of this year, citing a health report by the London based think tank the Brazzaville Foundation, “is a public health crisis that can no longer be ignored.” Counterfeiting, argued professor Pierre Ambroisé-Thomas, a WHO expert on malaria and tropical parasitic diseases, in the Mediterranean Journal of Haemotology and Infectious Diseases, is more than a criminal act. Manslaughter is perfectly justified to describe such an act, although some prefer calling it simply murder.”
“Not far from the Hotel 2 Fevrier in downtown Lomé, middle-aged men and women hawk medical disposables and assorted drugs outside in the humid, hot weather, not far from the pharmacy store,” reported Amindeh Blaise Atabong in Quartz Africa magazine in January 2020. “The packaging of the medicine looked visibly battered by the scorching sun and the cardboard was peeling, leaving the expiring dates and batch numbers barely visible. But even more troubling than the appearance is that closer inspection revealed some of the well known brands hawked are fake versions.” Ironically, the journalist revealed, less than a mile away, some of Africa’s leaders were meeting to try to end the scourge of fake medicine, which claims the lives of hundreds of thousand African children every year. Presidents Faure Gnassingbé of Togo, Macky Sall of Senegal, Yoweri Museveni of Uganda, and representatives of the heads of state of Ghana, Congo, Niger, and The Gambia, signed in January a political declaration and framework agreements, named the Lomé Initiative, to work together and stop the counterfeit drug problem. One of the proposals: a minimum 10-year jail term for offenders for fake drug-related crimes. No reliable data measures the scale of this vast, sophisticated, and lucrative business, but “we are talking about big quantities seized and sophisticated criminal networks,” confirmed one of Interpol’s leaders of the International Medical Products AntiCounterfeiting Task Force (IMPACT). The range of counterfeit products reaching outdoor vendors and pharmacies on the continent, has been broadened with the increased commercial use of the internet, providing, as the World Health Organization has observed “a dizzying array of both branded and generic drugs.” In more than half of cases, medicine purchased over the internet from illegal sites has been found to be counterfeit.
FIGURES FORESHADOWING THE CORONA CRISIS
According to U.S. magazine Forbes (2018), counterfeiting is the largest criminal enterprise in the world, estimated at $1.7 trillion. About $200 billion of this sum can be attributed to counterfeited pharmaceuticals, estimates the WHO. The World Health Organization believes that about 30 percent of pharmaceutical products sold in developing countries are fake, making it likely that “anyone, anywhere in the world can come across medicines seemingly packaged in the right way, but which do not contain the correct ingredients and, in the worst-case scenario may be filled with highly toxic substances.” In other words: there may even be the danger that criminal enterprises will hawk COVID-19 vaccines before pharmaceutical giants succeed in developing genuine products to halt the global pandemic. Each year, malaria causes an estimated 207 million clinical cases worldwide (a figure which foreshadows the number of COVID-19 victims as of now), resulting in an estimated 627,000 to 1,238,000 deaths, the majority in sub-Saharan Africa (reported in 2015 by the American Society of Tropical Medicine and Hygiene). Many antimalarials sold in this part of the world are of poor quality, falsified, substandard, or degraded. Results aggregated from surveys of antimalarial quality, carried out between 2001 and 2010, from 21 sub-Saharan African countries, show that 35 percent of samples failed chemical analysis, reported the scientists.
‘FOUR FULLY-LOADED JUMBO JETS CRASHING EVERY DAY’
Counterfeit medicines have dramatic consequences. An additional 72,000 to 169,000 children die each year from pneumonia due to fake or substandard antibiotics, according to scientists at the University of Edinburgh in Scotland. The British think tank the International Policy Network has estimated that globally 700,000 deaths a year are caused by fake malaria and tuberculosis drugs, comparing the death toll to the equivalent of “four fully-loaded jumbo jets crashing every day.” Five years ago, 30 percent of Africa’s nations lacked any capacity to oversee medicine manufacturing, importation, and distribution, and only South Africa, Kenya, and Tanzania were, for example, malaria-endemic countries with WHO-qualified laboratories for drug-quality testing. A study published by The Lancet in 2012 found an even more complicated turn—counterfeiters are adding active ingredients to their fakes, enabling them to pass quality controls, but the fakes still provide no benefits to users.
India and China, where most legal pharmaceutical products are manufactured, are often cited as major sources of counterfeit products, while Nigeria is said to be key entry point for fakes into Africa. The cost of medicine is “a determining factor” for Africa’s consumers, argues a WHO report, since most pay for their medication out of pocket. Products sold in licensed pharmacies “remain out of reach for many”. The result: unlicensed drug vendors, most of them selling on the street, from kiosk, or in open markets. Fighting the trafficking of fake medicine, reported Quartz Africa, “is a thorn in the flesh of Africa’s governments and health systems”, because the continent provides almost perfect conditions for a thriving illegal market.” In sub-Saharan Africa, “all risk factors come together”, confirms Dr Innocent Koundé Kpeto, president of Togo’s Pharmacists Association. “Governance is weak, provision of healthcare insufficient, the network of pharmacies too thin, a parallel market is practically tolerated and the people are poor.”
‘CRIMES AGAINST HUMANITY’
The global consulting giant McKinsey predicted that Africa’s pharmaceutical industry would reach between $40 billion and $65 billion by this year. This makes the sector attractive to pharmaceutical industry players but also tempts criminals. Unfortunately, the penalties for the crime are not strong enough to act as a deterrent, researchers Gaurvika Nayyar and Joel Breman emphasized in a June 2012 report on poor quality drugs in The Lancet Infectious Diseases publication. Nayyar and Breman strongly advocated for the production and distribution of counterfeit antimalarial products to be treated as crimes against humanity.
Since 2008, Interpol and IMPACT have mounted operations to tackle counterfeiting in Asia and Africa, cooperating with local governments. One example: in a major sweep of 16 seaports in the east and west of Africa, the World Customs Organization seized more than 82 million doses of illicit medicines, estimated to be worth over $40 million. The fake drugs found during the raid included cough syrup, anti-parasitic and antimalarial drugs, antibiotics, and even contraceptives. “However, the raid also exposed the Achilles heel of African government agencies in charge of licensing and regulating drugs,” wrote the UN supported African Renewal magazine. “Lack of training, insufficient manpower and corruption often plague national regulatory agencies.” Furthermore, “government inspectors frequently accept bribes and kickbacks and allow the fake drugs to pass borders.”
THE COUNTERFEIT INDUSTRY FOUGHT BACK VICIOUSLY
Dora Akunyili, former director of the National Agency for Food and Drug Administration and Control, spent eight years trying to cripple the counterfeit industry in Nigeria. Having lost her sister to fake insulin, she saw her task as more than just a job. She fired corrupt officials, blacklisted over 30 manufacturers and led raids against open-air drug markets. Between 2001 and 2005 the proportion of drugs for sale that were illegal went from 40% to 16.7%. But then the counterfeit industry fought back, viciously, burning the agency’s labs, attempting to kidnap Mrs Akunyili’s son and nearly killing her. The fight goes on. In March 2019, the WHO’s Global Surveillance and Monitoring System for Substandard and Falsified Medical Products issued an alert over the circulation of fake meningitis vaccines in Niger, and at the same time, warnings were issued that in Cameroon fake hypertension drugs had been found. The alert came at a time when the Cameroon customs had just seized thousands of drugs of questionable quality.
The European Union has backed, for some time now, an African project, Enhancing Africa’s Ability to Counter Transnational Crime (ENACT), which is tackling the fake-drug crisis. Start-ups such as the mPedigree network have designed systems that allow legitimate drug manufacturers to label their packages with an encrypted code. Consumers simply scratch off the label on the package and text the code for free to the company that maintains the system. The response, sent by text, is instant, informing the consumer whether the drug is real. Franck Verzefé, a Cameroonian pharmacist developed TrueSpec, a portable device that uses artificial intelligence and enables hospitals, pharmacies, and pharmaceutical laboratories to verify if certain drugs are genuine. Verzefé’s innovation was listed among the TOP 30 in the WHO Innovation Challenge 2019, which rewards health-oriented innovations.
When I returned to Marrakech from my Paris trip (I did not face any problems with the Morrocan prescription in a pharmacy near the Champs-Élysées), my new friend, the uniformed officer, was waiting for me. He handed me the money for mama’s drugs and accompanied me through passport and custom controls more smoothly and rapidly than ever before.
The opinion expressed in this article belongs to the author.