Fake medicines—illegal and substandard pharmaceuticals—have until now largely been a problem in low and middle-income countries. Ranging from lifestyle products to lifesaving medicines, such products are now also on the rise in the Western world. The spread is concerning, as fake medicines can be completely ineffective or extremely toxic.
Part of the problem is that many people are unaware of the risks of such drugs—and they often don’t know they are taking them in the first place. Our recent survey of doctors in Sweden, for example, shows that 36.5% had met patients who they suspected had taken fake medications. The numbers may be similar in other European countries.
As fake medicines are made in several different places worldwide, it is hard to trace their production. What’s more, such pharmaceuticals are usually so well faked—they may look, taste and smell exactly like the original drug—that only lab tests can determine their content.
According to a WHO report published in 2017, about 1-10% of all medicines in low and middle-income countries are estimated to be falsified. A study in Africa showed that up to 70% of medicines against infection in the region were fake. Today, such drugs are increasingly present in high-income countries too, according to the WHO. But exactly how prevalent the phenomenon is becoming is extremely difficult to quantify.
There are increasing reports of fake drugs in Western countries though. A falsified cancer drug, Avastin, was recently discovered by a wholesaler in the Netherlands. And in Germany, both falsified cancer and HIV medicines have ended up in the legitimate supply chain in recent years.
Not all Western countries have been affected by fake medical products in formal healthcare, though, Sweden being one exception. Although regulation of the pharmaceutical market in Sweden and many other European countries is effective, illicit products are increasing in the legal market so it may just be a matter of time before they do if no effective measures are taken.
This is clear from a recent Interpol operation, which included 123 different countries. During one week in 2018, Interpol confiscated over 10m fake medications that had spread via post with equivalent value of US$14m. As a result, 3,671 illegal websites selling such drugs were closed—including 175 sites in Sweden.
Convenience and privacy
So how do we best tackle this problem? The first thing we need is knowledge. Researchers from medicine, law and public health focus on the supply side and advocating international legal frameworks. Information about the demand side is lacking, however, as shown in our review of the literature .
People can get exposed to fake drugs unknowingly in many different ways. Our pilot study on the Swedish public’s attitudes towards the purchase of medicines that is soon to be published suggests that this includes through sharing medicines, such as prescribed antibiotics, or buying drugs online. Others may take the opportunity of buying cheap medicines on holiday abroad. Some said they would even consider planning their medical trips “if I had a sickness and for some reason could not get drugs for it in Sweden.” The same factors are likely to be at play in many other Western countries.
We also discovered that the awareness of risk appears to be low. This applies not least to the consumption of medicines on the internet. The majority of people we asked did not know that the EU requires all legally authorised internet pharmacies to display a common logo certifying the legal status of stores for the sale of prescription medicines. Instead some people who buy drugs online get it from the first seemingly best website without doing much research into it.
It’s important to understand that, while people obviously do not want to expose themselves to the risk of buying illegitimate medicines, online purchases are convenient. That’s why online sales of medicines are nevertheless rising in countries including Sweden, the UK and the Neherlands, becoming a common alternative to a prescription from the doctor.
Understanding the demand side means that it is crucial to map social conditions and health-seeking behaviours of consumers. Why does, as a British study reports, a young man prefer buying potency medicines such as Viagra at an obviously illegal internet pharmacy instead of going to a high street pharmacy? And what leads a young woman to act in a similar way to get slimming pills rather than go to a doctor?
Clearly, this could be down to people feeling ashamed to openly admit sexual dysfunction or problems with losing weight. But there is more to take into account. In Sweden, as in many other countries, we are seeing a shift of identity from care-seeking patients to care-competent consumers. As suggested in our survey, many people read up on what drugs they want before they go to a doctor and ask for it. If the doctor obliges, he or she may end up buying it from an illicit place.
There are great efforts to tackle the problem though. Europe put in place a new regulatory directive to prevent falsified medicines from entering the pharmaceutical distribution chain in February 2019. The Falsified Medicines Directive, among other things, requires that each package must have a unique barcode to trace the products and check its contents. This is an important political intervention to regulate the EU pharmaceutical supply chain.
But the global spread of fake medical products does not happen in a vacuum. We think it coincides with a reorientation of a person’s relationship with the formal healthcare system and medical professionals. This shift has eroded trust in the system and led to a rise of self-diagnosis and self-prescription that has boosted the market for unregulated websites with access to fake medical products.
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