Ethics and the global trade in counterfeit drugs

A few years ago, on a market in Cape Town, I bought a knitted hat with ‘Nike’ and the famous swoosh weaved into it with gold thread. The local vendor had made these hats entirely himself. A form of innocent theft: if a man can eke out a living by using the brand of a multinational infamous for its exploitive labor practices, well, so be it.

Hats are one thing, medicines are another. The production and sales of fake medications have been booming for some time in the developing world. In many parts of Francophone Africa, they are routinely sold at pharmacies par terre (roadside drugstores) by self-proclaimed pharmacists or docteurs de rues (street doctors). Much of what they sell are counterfeit medicines made to look convincingly like drug products of major pharmaceutical companies: from the packaging to the hologram to the imprint on the pills themselves. But these fakes may contain a reduced amount of the active ingredient, none of the active ingredient or substances that may be positively toxic. An estimated 120,000 Chinese patients are reported to have died from consuming counterfeit drugs in 2001, and some 500 patients (mostly children) in Haiti, Argentina, Bangladesh, India and Nigeria died when their fake paracetamol syrup turned out to contain diethylene glycol. When you realize there is a powerful underground industry and flourishing market for ersatz drugs ‘treating’ some of the major causes of global mortality -- tuberculosis, malaria and HIV/AIDS – you get a sense for the potential public health consequences of the trade.

The scale of the problem is staggering: in a recent article, it is estimated that 15% of all medicinal drugs sold worldwide are fake, and in parts of Africa the figure exceeds 50%. And this is a truly global issue: in a recent book (Dangerous Doses: How Counterfeiters are Contaminating America’s Drug Supply), Katherine Eban describes in detail the increasing difficulties US authorities have in keeping phony drugs out of American medicine cabinets.

As far as evaluating the trade in fake drugs goes, this is an ethical no-brainer: those who produce and knowingly distribute them to unwitting patients are simply immoral and criminal. The real ethical questions concern who is responsible for the enabling conditions of the trade, and who is responsible for doing something about it. Pharmaceutical companies are not just victims here. When the price of legitimate medications essential to health lies outside the financial means of a good percentage of the world’s sick, it is hardly surprising that a market exists for cheap substitutes. Pharmaceutical companies also have typically not taken an active, public role in the investigation of counterfeits of their own products. Fearing loss of consumer confidence in their brand, loss of commercial advantage and falling stock prices, they tend to conduct secretive internal inquiries instead of notifying the public about potential dangers. The companies also are reluctant to cooperate with bodies such as the World Health Organization. Unsurprisingly, governments have historically taken the side of the pharmaceutical firms on this matter. But the only ones to profit from this atmosphere of secrecy, mutual suspicion and narrow self-interest may be the manufacturers and distributors of counterfeit medications themselves.