ANY major disaster, natural or man-made, is invariably followed by reports of massive donations of medicines, usually from the US, made by “charitable” institutions. There have been reports of a large number of US charity organisations rushing medicines to Kosovo, Macedonia, Turkey, and now Orissa. But these “donations” are often a cover for a major fraud being perpetrated by some of these organisations. The New York Times (June ’99), for example, reported that Project Hope, an American medical charity, shipped 1.5 million dollars worth of “emergency” supplies to Kosovo refugees. But relief workers, starved of essential drugs like antibiotics and insulin, found Chap-sticks (cosmetic to treat cracked lips) and anti-smoking inhalers — donated by American companies that got a generous tax break for the donations. The shipment included thousands of tubes of lip balm, hemorrhoid (piles) ointment, anti-smoking inhalers, childrens fruit flavoured remedy for sinus pain — all contributed by Johnson & Johnson. A major part of the consignment had expiry dates within the next few months.
PROBLEM OF DONATED DRUGS
Major concerns have been raised regarding the usefulness of such donations. Gilles Forte, a World Health Organisation (WHO) advisor in Copenhagen, said that large quantities of donated medicines are not usable and wasted. He commented that as much as 30 to 50 per cent of drugs sent may be eventually worthless. According to the New England Journal of Medicine (1997), 50-60 per cent of the 27,800-34,800 metric tonnes of medical supplies donated to Bosnia and Herzegovina between 1992 and mid-1996 were considered to be inappropriate, and by mid-1996 there were an estimated 17,000 metric tonnes of unusable drug stockpiled in warehouses and clinics throughout the country. Destroying those drugs was estimated to cost over three million dollars at an estimated 2,000 dollars per tonne.
Discarded drugs pose a serious problem. In Croatia, the estimated 700 tonnes of medical waste, including packaging and needles, donated during the war and afterwards is expected to cost roughly three million dollars to destroy, and the World Bank is considering helping to finance the same cost. The WHO in a recent report commented that “Quotations for disposing of pharmaceutical waste in Croatia and Bosnia and Herzegovina range from 2.2 US dollars per kg to 4.1 US dollars per kg. To incinerate the current stockpile of waste pharmaceuticals in Croatia would therefore cost between 4.4 million US dollars and 8.2 million US dollars.”
The WHO has cited similar problems in a number of other countries in the past. Guatemala, In the first week after the earthquake in Guatemala in 1976, 700 cartons of assorted drugs were sent. These were sorted by a group of 40 pharmacy students at the rate of 25-50 boxes per day (it took about six months to finish the job!). Only ten per cent of the drugs were sorted and labelled correctly and relevant to the countrys needs.
In 1978, a 170 kg consignment was airlifted to a rural clinic in Burkina Faso. It contained 90 kg of drugs, of which half had expired before arrival. Of the rest, ten kg were useless or dangerous, 15 kg were usable but were not needed and only 20 kg were of clear value. Even of this, half were for relevant for use in a hospital setting and not needed for a rural clinic.
After the devastating earthquake in Armenia in 1988, 5,00 tons of drugs and medical supplies worth 55 million dollars were sent to Armenia. It took 50 people six months to gain a clear picture of the drugs. It turned out that eight per cent of the drugs had expired on arrival, and four per cent were destroyed by frost. Of the remaining 88 per cent, 70 per cent were finally sorted out. Of these only 30 per cent were easy to identify and only 42 per cent were relevant for an emergency situation.
From the consignments sent to war and famine-stricken Eritrea in 1993 seven truckloads of expired aspirin tablets took six months to burn and 3,000 half litre bottles of expired amino acid preparations could not be disposed of anywhere near a settlement because of the pungent smell.
DRUG DONATION TO INDIA
India had a first hand experience of this kind of inappropriate drug donation in 1996. In 1995 it was informed that the Heart to Heart International (HHI), an US based charity organisation, in collaboration with Rotary International would be donating a very large amount of drugs for West Bengal. For this purpose, a survey was conducted to find the pattern of drug requirements. The hurriedly designed survey was conducted in just three days, that too in a very few selected private organisations. The structured survey format supplied was mostly based on the scope of receiving and distribution of medical supply. At that time concern were expressed regarding the appropriateness of the “donation” given the fact that drugs worth ten million dollars would be donated by the HHI, which was several times more than the drug budget of the government of West Bengal. A local voluntary organisation wrote to the HHI suggesting that, instead it should consider donating a similar amount of money to procure drugs from the Indian market, where drugs are much cheaper and the quantity of drugs thus procured would be several times higher. This would also help the Indian companies in producing considerable amount of drugs. HHI did not bother to reply to this suggestion as they had an entirely different agenda. The same voluntary organisation wrote about its concern to the WHO. In response, in a letter to the HHI, the WHO said “it is true that some drug donations create more problem than they solve, especially if the donated drugs, the dosage form or strength are different from those already used by the health workers concerned; and most definitely if they are different from those on the national list of essential drugs or local formulary. For your information, please find enclosed a copy of the latest version of the WHO Guidelines for Drug Donations, which will be published in the near future. If you can ensure that this planned donation of drugs will follow these guidelines, its impact will be more beneficial to the recipients.” However, the HHI did not respond to this letter.
In response to a letter asking for a list of drugs planned to be donated, HHI said, “Because we depend on the goodwill of pharmaceutical donors, the value of this airlift range from two million US dollars to five million US dollars. At this time, we have no idea about the value of this particular airlift We will not know about the final figure about a month prior to the airlift.”
WHAT THE CASE STUDY HIGHLIGHTS
The Department of Health and Family Welfare, government of West Bengal, asked the donors and the government of India for the detail nature of the proposed donation and requested that these drugs should be distributed through government institutions. The government of West Bengal constituted a committee in February 1996 to oversee this operation. This committee requested the HHI to provide a list of drugs they would donate, but the request received no response. At the end of March 1996 the Govt. of India sent a list of drugs that were being donated to the West Bengal government, but by then it was too late to make a proper analysis of the list.
On April 1, 1996 a DC-10 aircraft loaded with the “donations” landed at Calcutta. Among the 44 passengers in the aircraft, there were a large number of executives of American corporate houses. The material contained in this donation was as follows:
|Total number of airlifted packs||708|
|No. of packs containing drugs||304|
|Packs containing non-drugs and appliances||404|
|Total number of drug items||57|
|Number of essential drugs||9|
|Number of alternative/borderline drugs||7|
Thus in this table very little of the contents was made up of by essential drugs. Many other items like batteries, water purifier, pillow cover, dolls, screw drivers, sand papers, hair shampoo, etc, were sent in the name of drugs. As per the HHI’s list, 10.5 million dollars worth of medicines and 1.5 million dollars worth of appliances were received. Out of the 57 drugs that constituted the consignment of medicines, the number of essential drugs was just nine. The cost of non-essential drugs in the consignment constituted about 95 per cent of the total cost of the drugs in the consignment. The whole lot of anti-allergics, painkillers and cough remedies were not worthy of donation as per the shelf-life criteria in the WHO guidelines. Out of the total value of 10,532,910 dollars worth of drugs received, drugs worth 7,434,125 dollars had either expired before arrival or would expire within one year.
Further, three drugs — Terfenadrin, Sucralfate and Glybenclamide — constituted 84 per cent of the total cost of drugs. Of these, Terfenadrin was banned in the world market and in India within a year from the day the donation reached. The whole drug consignment, valued at 10.5 million dollars (Rs 370 million) would have cost not more than Rs five million if they had been procured locally. Ironically, the government of India had waived duties and taxes worth Rs 250 million to receive a donation costing just Rs five million in the Indian market!
The HHI announced to the press that the donations were made to serve Mother Teresa’s institutions. Strangely though, none of the donated medicines were meant to treat leprosy or TB — the two main categories of diseases treated at Mother Teresa’s institutions.
NOVEL METHOD TO EARN DOUBLE BENEFITS
In contrast to this the HHI, in a press release stated that “more than 30 of these companies are literally saving hundreds of lives at no benefit to them except for the very great reward of doing good and meeting needs… they give us their very best products — top quality pharmaceuticals — never expired, out dated, or experimental medicines.” What the release did not say is that drug companies in the US receive very high tax reliefs if they donate drugs. The New York Times reports that, “American companies are eligible for twice the normal tax deduction when they participate in a humanitarian effort. They also are able to shed old or slow-moving products, and save the cost of disposal. In some cases, companies may view giveaways as a way to introduce their products to new markets.”
Recipient countries, in distress situations, are in no position to take a position against such donations. They may feel that faulty donation is better than no donation. As a consequence US drug companies enjoy benefits from both ends. They get added tax benefits and are able to dispose off expired and banned medicines at no extra cost. It is time that recipient countries demand that all drug donations strictly follow the WHO Guidelines for Donation of Drugs adopted in the World Health Assembly in 1998.