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!