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Guest Editorial: Don't fake it!

January 26, 2012 - 13:22 -- Bart G.J. Knols

This guest editorial was written by Dr. Lotte Van Dijk in The Netherlands.


Many of you will have come across counterfeit or substandard drugs in your careers and I’m sure many of you will understand my frustration. Therefore, I was really happy to see that the study on poor-quality anti-malarials by Dr Paul Newton and his team got the attention of the media. Even though their study was not large-scale and even though it cannot provide an accurate estimation of the prevalence of the fake anti-malarials all over Africa, it does provide an insight into the seriousness of the problem: it is severe!

Newton et al. show us that indeed counterfeit ACTs are present in Africa. This in itself is highly alarming. It means that poor people who seek care, which happens usually already with a certain delay, and who get diagnosed with malaria, spend their little money on drugs that do not cure them. The drugs might alleviate symptoms, but will not cure the patient. In fact, the other drugs that have been added to the ACTs, might cause unexpected, serious side-effects and drug-interactions. At community level this leads to more delay in treatment seeking, less faith in health care, more loss of income due to prolonged illness and, sadly, to a higher death rate. Counterfeit drugs have the ability to kill thousands of innocent trusting customers. But in the case of counterfeit ACTs there is also the problem of resistance. Widespread ACT resistance can potentially kill millions.


Since the turn of the millennium there have been reports of artimisinin counterfeits in SE Asia. Only two years later the first reports from the Thai-Cambodian border came in, announcing decreased efficacy of ACTs in this area. From the pre-ACT era we know that resistance to antimalarials rose in that same region. Poor-quality chloroquine and sulphadoxine-pyrimethamine (SP) has most likely sparked the spreading of resistance from this area to the rest of the world. Although the correlation between poor-quality anti-malarials and artimisinin resistance has not been proven yet, there is a strong suggestion that by underdosing anti-malarials P. falciparum drug resistance is facilitated. 


Currently ACTs provide the most effective treatment of falciparum malaria, and we have no promising good alternative treatment in the pipeline. The resistance development in SE Asia is worrying enough; we don’t need to pave the way for the rest of the world. We should not wait for a large-scale study, because this would be wasting precious time. We don’t have the luxury of time, we have to act now. But how can we act?


Most of the counterfeit drugs in Newtons research originated from China and India. It is not clear whether they are produced by pharmaceutical companies committing fraud or by organised crime labs. But lets be clear about it, it is a criminal act of the highest rank. It is homicide on a global scale. These people are knowingly killing thousands and thousands of people. They don’t care about the implications for public health care. They are only in this business for the money.


So that is probably the best way we can halt this harmful trade: we can subsidise the genuine products and ask drug companies to make the genuine products more affordable, making the fake drugs market less profitable. Besides taking away the incentive to produce the fake products, a multifactorial approach is needed to protect the consumers. African and Asian governments, WHO and Interpol have to work together to enhance effective regulation of drugs manufacture and of drugs trade. Within those countries there is a need for national quality-assured medicine laboratories to ensure that the drugs being dispatched are safe and good. Technological inventions to distinguish the real products from the fake ones are needed and they need to become available and affordable for countries facing this problem. The international community should help to make those inventions and adaptations possible, but it should also make an effort to catch and roll up these criminal organizations. For this, large-scale research is needed in order to quantify and map the problem, but we should not wait for the results to start acting.


We now have the attention of the public, let us use it well and let’s raise awareness about this problem among those who make and implement policies.


ACTs are our best treatment option, let’s give it all we’ve got!



Submitted by Bert Nanninga on

Dear Lotte,

it is indeed a shocking reality! How we all wish we could control a little bit more sometimes. Newton et al. suggest that the international boards need to be more pro-active on this, but the underlying issues are very complicated indeed. Such supervision and control can only be achieved effectively when all parties concerned are voluntarily supporting mutual accountability. The big well known and trust worthy pharmaceuticals may support it, the manufacturers of the fake drugs may not. Are not both sides motivated by mere greed nowadays? Mutual trust is lacking, let's face it.
Many large development agencies face similar dilemma's. On one side we have to admit that we are frustrated about our outcomes in reaching MDG's or economic development in general and we try to regain grip on how to move on... while on the other hand we see the Chinese bulldozing and reshaping the (African) continent beyond recognition without limitations (in many cases, not necessarily wrong development, don't get me wrong here). Why? Our values differ.
It's difficult to re-assure African counterparts that we're not governed by greed as we may suspect the 'fake' business does. We're all human and history is speaking against us.
So what next. Well to rebuild trust the first thing in any relationship is simply admit that we're (equally) wrong. I hope you can take 13 minutes of your time to see this video on TED:
To me, the message comes 15 years out of date, but alas it has come. Let's admit mistakes and learn from past blunders.
Secondly, let's be accountable and transparent about our aid-motives as well as our actual investments and outcomes with our counterparts.
This will re-create a platform where we can support health and pharmacy boards of developing countries: they were established to protect citizens and they are much more credible than any international health board: times have changed!
So I would rather focus on building relationships and strengthening the respective country's pharmacy and poison's boards; approaching it from an international level is still needed, but such can easily be interpreted as top-down (neo-colonial) control and raise suspicion that we just want to protect our own markets. It would give the fake businesses yet another alibi.

Lotte van Dijk's picture
Submitted by Lotte van Dijk on

Dear Bert,

First of all, thank you for your comment. And thanks for advising to watch the video by David Damberger. I found it really inspiring and honest. I think everybody working in or for the "Aid Industry" should watch it, as should donors.
I totally agree with you that the problem of counterfeit drugs is very complicated and that a solution would be if people got less greedy.... But I'm afraid that's not happening any time soon. Therefore I think that strenghtening (or starting!) pharmacy boards in developing countries is the best option to halt this crime. There are very few WHO certified pharmacy board in africa (only 3!). Most governments are still denying the existence of fake drugs on the market, that doesn't make it easier to fight the problem. So creating awareness, together with sharing knowledge should be our first action I think. But I do see a role for the international community in this as well. Since the problem is so multifactorial in origin, let's tackle it with multifactorial approach.

Regards, Lotte van Dijk

Submitted by Guest (not verified) on

The last paragraph brings the point home. That policymakers and desicion makers who also include governments should be at the forefront in the fight against counterfeit ACT's.

We visited Mwea(one of the districts with the highest malaria prevalence in Kenya) early last year and the main problem according to pharmacists and doctors was self prescription. The patients would come to the hospitals and get diagnosed with malaria, they seldom bought ACT's from the pharmacy at the health centers, they often visit hospitals for diagnosis purposes and go on to purchase medicine from local chemists. Unfortunately majority of chemists in Kenya especially rural areas are manned by untrained staff, they therefore sell what the buyers asks for. In Mwea's case, "nipe dawa ya malaria ya bei ndogo kabisa" which is swahili for "give me the cheapest malaria drugs you have"

The buck therefore stops with the agencies that are charged with ensuring that only quality medicine gets to the public. For as long as poverty lurks around, people people will always go for the "cheapest" option.