Paktribune.com, January 15, 2007
Sale of expired, spurious drugs on rise in Afghanistan
Afghanistan has about 5,640 doctors for about 28 million people. Even though there is one doctor for roughly 4,964 people
KABUL: Seeking treatment for her grandmother is an experience Nilab will never forget. The 20-year-old from the central Logar province had brought her grandmother to Kabul for treating a fever in late July. The 70-year-old passed away after she began medication.
"She was fine until the night before," said Nilab. "We took her to a doctor and after she began taking medicines, her nails and lips turned blue, she died as we tried to get her to a doctor again," she added.
The doctor had prescribed treatment for malaria (Quinine Sulfate, Paracetamol tablets and glucose drip) which they bought for 150 Afs at a pharmacy at Karta-i-Naw, Kabul. After the death, the family discovered that the medicines were expired. When they tried to confront the pharmacy, the owner shrugged responsibility saying he did not sell the type of medicines.
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Doctors say Nilab's grandmother could have died of complications of malaria or other causes but the family is convinced that it was the medicines that caused the death.
Nilab's grandmother is one of about 18 people killed by the fake expired medicines between March and May last year. Health Ministry officials say the number of deaths could be higher because all cases are not reported.
Amir Muhamad Farahi, director of the Evaluation Department at the Health Ministry said the government data reported only deaths that had occurred at the hospitals.
The registration of births and especially death is new to Afghanistan. And in cases such as those described above, people are unaware that poor quality medicines could have caused death. Or they believe all death to be "natural" or an act of fate.
Health officials said that certain medicines could be equivalent to "poison" upon expiry, and these could cause complications, and even death. The misuse of medicines or use of spurious or fake medicines is another major problem.
Farahi said all of these problems result from poor awareness, ignorance, lack of specific laws and inadequate enforcement of the rules that exist.
Ahmad Shah dispenses medicines in Deh Afghanan locality, a major street of Kabul. His supplies comprise common over-the-counter medicines and even antibiotics and medicines that are "controlled" - according to the Afghanistan Licensed Drug List. He sells his wares out of a plastic bucket. His stock had Aspirin, Paracetamol, Diazepam (a controlled medicine), Resochin, Metodine and Erythromycin when visited by reporters from the Centre for International Journalism (CIJ).
"I don't know the difference between different medicines, they have the same stamps and we buy those which are the cheapest and resell them," said Shah. "Generally the poor people buy medicines here, but some come, look at them and walk away saying the pills are fake," he added.
According to Dr Saeed Ibrahim Kamel, director of Health Regulations and Control at the Health Ministry, Kabul province has around 4,000 registered pharmacies. This number does not include the bucket-pharmacists who vend drugs at prices lower than the market rates and serve a clientele that is not educated and often very poor.
Chera Gul, 42, from Deh Sabz district about 15km northeast of Kabul, says the medicine vendors with buckets sell a strip of paracetamol for five afghanis. The same medicine costs 10 Afs at a registered drug store.
The bucket-pharmacists are not as ubiquitous as the telephone card sellers cum money changers on the streets of Kabul. But their numbers on certain streets like Deh Afghanan, Pul-i-Khishti and Kabul Mandi is high.
The medicine business is more obvious in Farah City, provincial capital of the western Farah province, situated about 1,000 kilometres from Kabul. "You come across a pharmacy after almost every five steps," said Mahtab, a resident. "Many medicine sellers don't even know how to read a prescription."
According to official statistics, Afghanistan has about 5,640 doctors for about 28 million people. Even though there is one doctor for roughly 4,964 people, most of them are based in the cities, and typically it is the untrained health workers who dispenses medicines in the villages.
Afghanistan imports all the medicines it needs. Most of the poor quality medicines originate in Pakistan, Iran, China and India are imported by companies that don't have import permits.
Since 2005 the government has a list of 1,270 approved medicines, including essential drugs, dispensary items and dental preparations. It lists 27 over-the-counter medicines and 42 controlled drugs (narcotic and psychotropic substances). It has another seven medicines which have been deleted from the list because of their high risk or availability of safer alternatives.
The Health Ministry officials said that they had test about 80 per cent of all medicines legally imported in the country. "With so many non-registered imports around, it is difficult for ordinary people to differentiate between good and bad medicines," said Dr Sayed Mohammad Ibrahim Kamil, head of the department of Health Law and Evaluation.
Mohammad Jafar Husaini, head of the Pharmaceutical Department in Kabul, describes the situation as "pathetic." This is largely because the government has almost no control on the medicines being smuggled and sold. He added that the concerned ministry checked the quality and prices of medicines that are legally imported.
Another official of the ministry, however, said only 30 per cent of the medicines in the market were legally imported. The smuggled medicines also include good quality drugs - which are smuggled to avoid government taxes.
The pharmaceutical department carries out surprise checks on drug stores but has not been able to control the spread of fake, expired or substandard medicines.
The Health Ministry's claim that about 80 per cent of the legally imported medicines are checked for quality, is a major improvement compared to the situation five years ago when it was a free for all. The government department responsible for regulating medicine trade and use has been around always, but there was little control on imports and use.
The government says its quality control laboratory conducts the tests though its effectiveness still remains a question.
The fake medicines are different in both appearance as well as the content. Pharmacists said that the fakes come in different colors, have different smells and taste different than the good quality medicines. The good Augmentin tablets - used for treating respiratory infections like pneumonia, bronchitis, lung abscess, among others - are of white colour, while the fake ones are grayish. Likewise, a good Aspirin relieves pain while the fakes cause drowsiness.
While those in positions of responsibility hesitate to discuss the situation freely, Abdul Qadir Samay, a recent pharmacy graduate, did not mince words. "Medicines whose utility has expired are sold openly and remain a major threat to public health," he said.
The poor regulatory oversight is partly because many institutions in Afghanistan that were rendered ineffective during the more than two-decades of civil war have yet to resume normal functions. The government's drug-testing laboratory at Ibn-i-Sina Hospital is a lab in the name only. Much of the equipment there - including microscopes - was acquired during the former Soviet rule and many machines were damaged during the 1999 - 2000 war.
The five-room lab has six old tables and employs 15 pharmacists. The employees refused to disclose the situation of their stocks but said they were getting far less chemicals and other supplies than that needed for proper testing. The government of Finland and the World Health Organisation has been assisting the work of the department, which is frequently disrupted by power failures.
Iwaz Mohammad Faizy, director of Chemical Pharmacy of the Pharmacy Department of the University of Kabul, says the government does not have the capacity to control trade in poor quality medicines. He said the government tested samples sent by the customs department but there were problems with sampling itself because it was customs officers and not trained pharmacists picking them up for random checks.
It was not possible to obtain test results from the Chemical Pharmacy, but officials there said there had been instances when they had tested Aspirin tablets and discovered that they had come with 10 parts of Diazepam. A normal Aspirin tablet should not contain Diazepam, which causes one to feel drowsy and sleep.
Dr Jamahir Anwari, the trade deputy at the Directorate of Pharmacy, denies the inefficiency of the government, saying that his department has capacity for checking the quality of all legally imported medicines. "We may not have the best equipment, but we have the means to separate the good from the bad," he added.
The government rules require all medicines imported into Afghanistan to be from a list of approved companies. Also all imports have to be registered at the Pharmacy Department of the Ministry of Health. The punishment for importing unregistered medicines is stiff, including confiscation of medicines and revocation of trading licenses. But there is no specific jail term for those guilty of the malpractice.
"First we advise them to stop the trade, then warn them, then put them on a blacklist and eventually even revoke their license and close down the store," said Hafiz Qureshi, head of the generic medicines at the Pharmacy Department.
Government records show that import licenses of only 33 foreign medicine companies had been cancelled for malpractice over the past four years. Abdul Hafiz Quraishi, manager of the generic medicine section of the Pharmacy Department provided the CIJ with names of some of the 33 companies. The list includes nine Indian and three Pakistani firms.
During a visit to different pharmacies in Kabul, CIJ reporters purchased 30 different types of medicines. Among them, three medicines Metodine (used for treating amebic diarrhea), Fansider (used for treating malaria) and Fluxitine (an antidepressant) were found expired.
The 47-year-old owner of the Hossaini Pharmacy located in Karta-i-She, said he was paying for all the medicines he sells, irrespective of whether they were expired or not. He admitted removing labels with the expiry dates before selling them to customers. He said he was unaware of the harm old medicines could cause and was also unaware of the punishment he could face if caught selling fake or old medicines.
Like many developing countries, many doctors in Afghanistan have business links with pharmacies or are on their payrolls. Often doctors write down prescriptions and instruct patients where to go for buying medicines. There are no official estimates but health ministry officials said about 30 per cent doctors may own pharmacies or have some interest in stores run by friends or cousins.
Most of Afghanistan's 930-kilometre border with Iran and the 2,240-kilometre border with Pakistan are scantily patrolled and largely porous. The smuggling is also decentralised in the sense that individuals going across the borders for different reasons are given lists of medicines to bring back by the pharmacies, which they deliver upon return. The more organised and larger importers have connections with government officials, who are duly compensated for the aid they provide to businesses.
Nilab has returned to Logar. She is now fully aware about the quality of medicines, for which she had to pay very high price - her grandmother. However, there are hundreds of people all over Afghanistan who like Nilab's grandmother become victims of poor quality medicines every year. But most of these families are largely unaware of the cause of death and continue to blame fate, while trade in old, fake and poor quality medicines continues to flourish.
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