With few pharmaceutical producing companies of its own, Afghanistan relies heavily on imports of medicines from Pakistan, Iran, China and India. While the government says it monitors quality, consumers and doctors
Unlucky dip? A makeshift medicine stall in Jalalabad (Photos: Sharifi)
A man clutching a prescription rushes into a drug store in Jalalabad, slaps the paper onto the counter and implores two teenagers running the store, “Doctor, please give me good medicine.”
He explains that he bought medicine from another pharmacy the previous day which proved to be out of date, and the patient was now suffering even more. “I beg you, I am very poor, please give me high quality medicine, so our patient recovers.”
It has become a regular spectacle in pharmacies in the eastern provinces in particular, where smuggled low-grade, fake or expired medicine is on broad sale, and the phrase “Please give me good medicine” can be heard everywhere.
Skirting the issue
While rigorous customs checks and state quality control mechanisms exist, they are easily circumvented here in Nangarhar Province and elsewhere down the more than 2,000-kilometre border with Pakistan, either allegedly by bribing officials or bringing in loads using remote mountain trails. And tragic stories abound as a result.
“I have a small daughter who has been sick for three months, and no medicine I get from any doctor or clinic helps,” says 34-year-old Ghazi as he leaves the gate of the Nangarhar Medical University. “I do not know what to do, when I ask the doctors why she is not improving, they tell me that the medicine is the problem and I must buy better quality.”
State procedures exist to screen imports by road and regulate their subsequent sale. According to regulations, legally imported medicines are first held by the provincial customs service while a sample is sent to Kabul for laboratory testing, says Dr Najeb Saheb Zada, head of the Nangarhar government’s pharmacies unit. But the procedure can take weeks, and this has produced evasion and corruption.
“Then there’s the other way, where traders and customs staff help each other to get medicine out of customs and onto the market without any sampling or checking,” Zada said. The problem is lack of technical expertise in the province to shorten the procedure, he added, stressing that, “Unless the medicine is checked in a laboratory, eyes alone cannot judge its better or worse quality.”
Meanwhile, Khan Mohammad, a salesman for the Jalalabad-based Afghan Pharma, one of the few domestic pharmaceutical companies, said that despite his company’s efforts to work within the law, the black market was harming its business: “I will not name the factories, but these companies bring in poor quality medicine without consulting with wholesalers and sell it to retailers directly.”
Pharmacies employ illiterate staff
To make matters worse, youths or young boys employed at many drug stores often have little or no knowledge of the medicines they sell, despite regulations that only a qualified pharmacist can sell them.
Some of the 87 tons of sub-standard or contraband medicine seized by authorities in 2011.
Jalalabad resident Mohammad Fahim cites numerous drug stores employing boys who cannot even read the prescriptions and often sell the wrong medicine.
“My nephew was sick some days back, I bought some medicine for him at a specialised pharmacy for children, they give me the wrong pills and when I gave it to him he got worse. I went back to the same doctor and when he looked at the medicine he told me that I had the wrong one and had to buy another.”
Unscrupulous owners of pharmacies bear much of the blame and the problem is driving people abroad to seek good treatment, causing great economic hardship for families, said Dr Ahmad Zia, director of Jalalabad’s Arianna Hospital.
“Poor quality medicine causes different kind of diseases and sicknesses,” he said. “As long as small boys work in drug stores, the Department of Public Health has to take action, because people are needy and have to buy medicine anyway.”
Bonanza for the smugglers
At a press conference in late 2011, acting health minister Suraya Dalil said lack of border controls was the main problem. But just as Afghan and NATO forces cannot seal off the frontier against insurgent forces, those who must combat smuggling also say it is impossible.
General Aminullah Amarkhail, commander of the eastern border police, said his forces were making progress in controlling illegal imports of medicine, but that smugglers were taking near inaccessible routes in response.
The mountainous areas that constitute the border can barely be controlled, Amarkhail said, because, “there are no roads there and they are many hours away by foot, and they cannot be accessed at night because we don’t have any air forces to hand.”
Nesar Ahmad Naseri, head of customs inspections at the Torkham border crossing, is equally insistent that it is a near impossible task: “Our border with Pakistan is around 2,300 kilometers long, and apart from Torkham there are trails near Kandaow, Groko and Goshta which smugglers use to bring in a variety of goods beside low quality medicine,” said Naseri.
Efforts were being made to better coordinate the work of the army, police and customs service, said the officer, rejecting claims that his force took bribes to let medicines through unchecked.
What’s to be done?
At the retail end of the process, numerous companies have had their licence revoked for stocking and selling low quality medicines, said Ghulam Sakhi Kargar, spokesman for the Public Health Ministry. “We are trying to obstruct and prevent it, but we need the assistance of our security departments.”
"When I ask the doctors why my daughter is not improving, they tell me that the medicine is the problem and I must buy better quality.”
For the time being, the advice of the authorities is simple, said Baz Mohammad Sherzad, director of Nangarhar’s Public Health Department: Do not buy medicine from pharmacies tended by boys and never buy medicine unless prescribed by a doctor.
Mohammad Qasem Yousofi, head of the provincial chamber of commerce, said the system needs to be adjusted to market realities. “The medicine currently imported to Afghanistan is first stopped for days and sometimes for weeks in Torkham customs, and samples are sent to Kabul for quality control. Any trader who pays can get any kind of medicine through without being checked. And if he does not pay, his medicine will not leave Torkham customs for months.”
Since, according to Yousoufi, only Kabul has laboratory testing facilities, the quality of medicine will not be improved in Afghanistan until quality control laboratories are established in the frontier provinces and customs departments.
It's not just Nangarhar. Asadullah Fazli, head of public health in Kunar, said contraband medicine enters that province and neighbouring Nurestan across mountain trails from Pakistan. “Not all the smuggled medicine is low quality but there is still a lack of quality control laboratories,” he echoed.
Licencing process also under fire
“Holding a license or charter for import of medicine in Afghanistan means nothing, a license is merely a piece of paper,” said Nangarhar Chamber of Commerce head Yousoufi. Most traders took illegal methods of importing, he said, and “no one can restrict them.”
Last journey of a box of impounded medications - into the furness.
According to the Ministry of Public Health, 110 companies currently have licenses to import medicine, issued after screening by the Ministry for Commerce and Industry and the health ministry’s own pharmacy department. The licencing process was adequately thorough, said Ayesha Nourzai, the department's head, but acknowledging that the amount of poor quality medicine in the country still increased over the past two years.
On the basis of 348 samples recently sent for analysis in India and Germany, the amount of low grade products was estimated at only 6.5 per cent, and the remainder was good quality, Nourzai said.
According to health authorities, almost 87 tons of poor quality medicine was collected in Kabul and other provinces and destroyed last year, while the amount in 2010 was almost 340 tons.
Desperate patients and their families in places like Nangarhar would likely argue that far more needs to be destroyed, and also contest the ministry’s low estimates of the amount of poor-grade medicine in circulation.
Twenty-five-year-old Abdul Majid blames bad medicine for the worsening condition of his daughter, who he holds in his arms outside the Nangarhar Public Health Care Hospital, having spent his last money trying to cure her. “I bought and administered all the medicine prescribed, but it didn’t help my child.”