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When the drugs don't work, but just make it worse

Substandard Chinese medicines are an increasing problem for Africa, proving expensive, ineffective and even dangerous

Across much of Africa, cheap Chinese goods are virtually unavoidable. From the bustling streets of Lagos to the busy markets of Nairobi, Chinese products abound thanks to their variety and affordability.

These cut-price goods help tight budgets stretch that little bit further. But the mark 'Made in China' does not always inspire confidence. African buyers know from experience, and are often reminded by the exaggerated rumours that circulate, that low cost can also mean low quality. That may not deter people from snapping up cheap clothes, cosmetics and electronics, but for one type of product, there is much more at stake than mere consumer satisfaction.

China is one of the world's leading manufacturers of medicines and a main source of the drugs sold in Africa. On a continent where millions die each year from treatable diseases, demand for cheap drugs is high. But like many other Chinese-made goods, these products also sometimes suffer from quality issues. Whether they contain impurities, were stored incorrectly, or lack enough of the active ingredient, the result is that those taking them may be putting their faith, and lives, in the hands of drugs that don't work. In fact, at worst, these faulty medicines may even be inadvertently strengthening the diseases they are meant to be fighting.

"Substandard drugs are a problem of great magnitude," says Lorraine Kabunga, a pharmacist in Mbarara, Uganda. "When people buy substandard drugs, there may be a delayed response or no response at all. I have seen patients take two weeks to recover when taking a particular brand from Asia, while those who bought the more expensive European drug improved after three days."

Kabunga decries the effect of low quality medicines on individual sufferers, but argues that the broader impacts are even more serious.

"Substandard drugs have increased the morbidity rate of some infections, they have meant higher management costs for certain conditions, and they have led, although rarely, to fatalities. Furthermore, they may have contributed to drug resistance."

One common shortcoming that makes drugs substandard is if they contain the correct active ingredient, but in doses too small to be fully effective. When this happens, the drug may kill off the weaker germs but leave the strongest to mutate and adapt into more resilient strains. This may eventually render even the best drugs ineffective.

Drug-resistance presents a potentially major setback in the fight to eradicate certain diseases and is already a growing problem. In Thailand and Cambodia, malarial parasites resistant to key antimalarials have recently emerged, while in South Africa, drug-resistant tuberculosis is becoming increasingly prevalent.

When policymakers and the media discuss the problem of substandard drugs, they often group it together with the issue of fake drugs. Together, these two forms of faulty medicines are estimated to contribute to hundreds of thousands of deaths globally each year, and are believed to account for around one-third of all malarial medications and 16 percent of all tuberculosis drugs in Africa.

But although there are thought to be similar numbers of each type of bad drug on the continent, fake and substandard medicines are very different problems: fake drugs are produced by criminal gangs in order to intentionally deceive consumers; whereas substandard drugs are inadvertently – or negligently – manufactured by licensed pharmaceutical companies capable of producing high quality goods.

"Substandard drugs usually come about when legitimate producers cut corners," explains Roger Bate, author of Phake: The Deadly World of Falsified and Substandard Medicines. "Most of the time these shortcuts might not matter, but sometimes they will."

The two also differ in that falsified medicines rarely contain any active ingredient whereas substandard drugs often contain the right ingredients but in the wrong proportions, leading to drug resistance. So while fake drugs are a criminal matter, substandard drugs are predominantly a regulatory issue.

"The problem is that oversight mechanisms in the likes of China are really very weak," says Aziz ur Rehman, Legal and Policy Advisor for Doctors Without Borders' (MSF) Access Campaign. "Authorities lack the personnel and the resources necessary to monitor how drugs are being manufactured, meaning systems can easily be compromised."

Bate agrees, adding that there are vested interests behind these regulatory shortcomings. "Most of the people producing substandard drugs are legal producers, and most authorities are reticent about going after such producers either because they're employing people and paying taxes or because they're politically-connected in some way," he says.

For these reasons, Bate explains, it has proven far harder to mobilise action around the problem of substandard products than falsified drugs. "The largest producer nations want to crack down on criminal counterfeiters as there's no incentive for them not to, but the substandard problem is a much thornier one," he says. "The political will in China and India is far lower."

Experts also agree that international actors and the media are taking the issue of substandard drugs less seriously than shady counterfeiting criminal networks. But with Africans paying the price, some believe the final burden of action lies with African governments.

"It's high time for Africa to have its own regional regulatory authorities," says Luiz Loures, Deputy Executive Director of Programme at UNAIDS. "China ought to act too, but the responsibility for drug regulation must come back to Africa in the end. It has the technology, the leadership and certainly the interest for regulating itself."

Furthermore, Rehman insists that there are clear measures that can be taken, whether it is Africa, China or the international community leading the efforts. "The solution is not something that is magical and beyond comprehension", he says. "If governments really want to act, tackling the issue is completely possible."

As well as being possible, the need to tackle the issue is also urgent. Building the capacity, fostering the cooperation, and acquiring the technology necessary to tighten regulations will take time. And until then, unwitting African consumers will continue to take drugs that could be strengthening rather than fighting the very diseases the world most wants to see eradicated.


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