E-DRUG: Media attention on drug donations to Kosovo
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Dear e-druggers,
In the weeks following the European expert seminar on appropriate drug
donations (June 11 and 12) in the Amsterdam region, the Netherlands
(http://www.wemos.nl/donations/seminar.html), drug donations to Kosovo
have been exposed extensively in the media. In recent e-drug postings
others and I have made references to articles in several media. In this
posting I will refer to this media coverage and specifically comment on
several articles. At the end of this text you will find an overview of
(a selection) of media references.
Since many e-druggers do not have easy access to the Web I will quote
some of the articles in the text below. This is solely for discussion
purposes, not harming copyrights.
Contents:
1 - DONATIONS OF DRUGS TO KOSOVO-REGION - DATA AND CASES
2 - EMERGING PROBLEMS AND DISCUSSIONS WITH WELL-KNOWN CHARACTERISTICS
3 - APPROPRIATE ACTIONS
1 - DONATIONS OF DRUGS TO KOSOVO-REGION - DATA AND CASES
General data on the drug donations' situation in the Kosovo-region shows
the magnitude of the problem. What is striking is that a similar
situation seems to emerge as happened during the civil war in Bosnia and
Croatia.
From BMJ's article (July 3) (Ref.nr. 7):
> Reports are emerging from the World Health Organisation
> (WHO) and pharmaciens Sans Fronti�res that quantities of
> unrequested and unusable medical drugs, sent by governments
> and others in response to the Kosovo crisis, are
> contributing to the postwar chaos.
From WHO-Euro's press release (June 30) (Ref.nr. 6):
> A WHO audit of humanitarian drug donations received in
> Albania during May 1999 reveals serious quality problems.
> The assessment of all donations received by the drug
> distribution authority owned by the Albanian state during
> May revealed that 400 000 tablets and 1200 large volume
> intravenous fluids were already expired upon receipt and
> that 2 000 000 tablets, 85 000 vials for injection and 16000
> tubes of cream for external use will expire before the
> end of 1999. Only 28% of drug donations were packed in the
> large-quantity units recommended by international
> guidelines, and 36% of donations were in small sample
> packets.
>
> [...]
>
> We estimate that 50% of the drugs coming into Albania
> donated by non-medical organizations are inappropriate or
> useless and will have to be destroyed. We are very
> concerned that some pharmaceutical companies are using
> this humanitarian crisis to get rid of unwanted
> stockpiles."
>
> An analysis of import permit documents submitted to the
> Ministry of Health by humanitarian agencies during May 1999
> showed that 65% of drugs presented an inadequate expirydate
> (either missing or expiring less than 1 year from the date
> of donation): 32% were declared with brand names only that
> are unfamiliar to Albanian health professionals and almost
> 10% of donations were not accompanied by any detailed
> packing list at all. The situation in June has not
> improved.
From The Lancet (June 19) (Ref.nr. 3):
> [...] in one donation to Macedonia more than 40 % of drugs
> were non-essential or did not comply with national
> standards; 30 % were past or near expirydate. And in Albania
> only 20 % of donated drugs were distributed through
> appropriate channeled.'
From Wemos' press release (June 11) (Ref.nr. 1):
> About 30% of drugs are donated directly by countries and not
> co-ordinated through programmes by international agencies.
> In Albania, for example, an estimated 20% of the donated
> medicines, worth $9 million, have only been channeled
> through appropriate co-ordination structures. "Tons of
> medicines to treat cholera and acute diarrhoea are
> stockpiled," he said. "Meanwhile, medicines for non-
> communicable and chronic diseases are in great need." A
> survey by WHO May 10 to 19 in FYROM highlighted the poor
> compliance of relief agencies with WHO's interagency
> Guidelines for Drug Donations. In one donation, more than
> 40% of the medicines were considered non-essential or did
> not comply with national standards. About 30% were expired
> and had less than one year remaining shelf life.
Specific case material data provides a face to the general data
presented above. Below some case-material from several sources are
presented. Some people have approached me asking why always negative or
(in-)appropriate donations are highlighted while there are much more
examples of good donations. Are highly needed good donations not
hampered by the negative news about donations? "The media works this
way" is not a sufficient answer, I realize. But inappropriate donations
still form the case-material and proof needed to convince donors
(especially those that donate inappropriately) to change. The data above
stress the utmost important to change donation practices.
This example describes quite well the complex situation donors should
take into account when donating certain drugs.
From the Philadelphia Inquirer (June 16) (Ref.nr. 2):
> A relief convoy arrived in Tirana, Albania, last month
> bringing tons of antacids, antibiotics and multivitamins,
> all donated by American drug companies. But the shipment,
> destined for Kosovar refugees, included nearly a ton of a
> drug whose side-effects could be especially dangerous under
> refugee camp conditions and amid the even greater chaos of
> refugees returning to farms, villages and cities ravaged by
> war.
>
> The drug, Voltaren, is a powerful arthritis painkiller made
> by Novartis Pharmaceuticals Corp. of East Hanover, N.J., Its
> journey to Albania illustrates how well-intended U.S. tax
> laws encourage drug companies to make charitable donations
> that offer relief to their own bottom lines but can endanger
> patients, create surpluses of unneeded or outdated
> medicines, and undermine local drug makers and doctors.
>
> Albania's health ministry approved the Voltaren donation,
> and a trusted U.S. pharmacist in Albania asked for the drug
> by name. But the pills Novartis donated are three times
> stronger than what Albanian doctors usually prescribe, and
> the drug must be taken twice daily with meals - a diet
> regimen hardly guaranteed in refugee camps.
>
> Even when it is taken by the book, the English-language
> label warns, Voltaren can cause sudden and fatal bleeding
> ulcers, particularly among "elderly and debilitated
> patients." In the United States, cautious doctors monitor
> blood and kidney functions closely when Voitaren is
> prescribed and may prescribe a second drug to reduce the
> gastrointestinal side effects.
>
> At the time Novartis donated the Voltaren, worth $2 million
> wholesale, the drug's sales were slumping, in part because
> of the success of Monsanto's Celebrex, a newer, less-
> expensive competitor that advertises fewer side effects.
> Regardless of the circumstances, under US tax law the gift
> qualifies for double the normal charitable tax deducation
> because it is humanitarian, intended for the "ill, the
> needy, or minior children".
>
> [...]
>
> Often what is donated is just a giant-sized version of an
> American medicine cabinet. The shipment that included
> Voltaren, for example, also contained Tylenol, sanitary
> napkins, iron supplements and three tons of shampoo. That
> was welcome, camp doctors resorted, but what refugees really
> needed was anti-lice shampoo.
>
> [...]
>
> lvar Bjarnason, a professor of gastroenterology at King's
> college Hospital in London, predicted that Voltaren's side
> effects would be more likely with this higher dosage - 75-
> milligram tablets vs. the 25-milligram dosages of generic
> Voltaren that are standard in Albania. For Balkan patients
> accustomed to taking an extra tablet or two for added
> relief, Bjarnason warned, the effects could be fatal.
>
> "A lot of people will have discomfort," predicted Loren
> Laine, a gastroenterologist at the University of Southern
> California, "but the benefits outweigh the small risks." The
> medical corps' Hayes said camp doctors could cope.
>
> The size of the donation - 14.320 bottles of 100 tablets
> each, due to expire by the summer of 2006 - may be
> excessive, said Serge Male, senior epidemiologist for the
> U.N. High Commissioner for Refugees in Geneva. Hayes
> responded that any surplus would be given to Albanian
> hospitals.
From the New York Times (June 29) (ref.nr.5):
This article delves more deeply into US donations, identifies areas
where there is a conflict of interest.
> The shipment from Project Hope, the Milwood, Va., charity
> best known for health education, for example, included lip
> balm, hemorrhoid ointment and bottles of Robitussin cough
> syrup, courtesy of American Home Products, according to an
> inventory of the items. Other boxes contained Nicotrol anti-
> smoking inhalers and endless varieties of Tylenol, including
> a children's fruit-flavored remedy for sinus pain, all
> contributed by Johnson & Johnson.
>
> "I can tell you from being in refugee situations in the last
> eight years, refugees need Chap Stick, Preparation H and
> Robitussin," said Jack Bode, the vice president of
> development and communications for Project HOPE.
>
> Items like Chap Stick and Robitussin represent only a tiny
> fraction of the nearly $5 million worth of shipments that
> Project Hope said it is sending to Macedonia. Of that, most
> drugs are either antibiotics or gastrointestinal drugs. The
> charity also said that all of its donations were reviewed by
> the Ministry of Health in Macedonia, which requested the
> items -- including the Nicotrol inhalers for use in a pilot
> anti-smoking program.
>
> [...]
>
> American companies, for instance, are eligible for twice the
> normal tax deductions 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 form of sampling
> that can introduce new markets to their products.
>
> The charities, which are under intense pressure to prove to
> their donors how much good they are doing, are also at the
> heart of the problem. They serve as middlemen between the
> drug companies and the hospitals and clinics receiving
> drugs.
>
> And some companies turn the pressure up by insisting that
> charities take unwanted donations as a condition for getting
> the things they really need. A relief worker in Macedonia
> for CARE said his group was offered what seemed like a
> ackage deal: baby food, which was welcome, and infant
> formula, which was not.
>
> Most relief organizations see formula as undermining breast-
> feeding and rightly worry about whether refugee camps or
> poor regions have the proper sanitation to make sure bottles
> and other supplies are sterile. The deal was refused.
Recent cases are not only from the Kosovo-region ...
From the Philadelphia Inquirer (June 16) (ref.nr. 2):
> Taxpayers rarely learn of the inefficiencies they subsidize.
> After Hurricane Mitch,-for example, U.S. -agencies airlifted
> to Central America thousands of liters of Pedialyte, a drink
> that rehydrates children with diarrhea. It is a water-based
> solution of oral rehydration salts that costs $5.84 a Alter
> wholesale. The value of the.tax deduction is roughly $1.50 a
> liter.
>
> But a packet of oral rehydration salts, a water-purification
> tablet, and water can also rehydrate children with diarrhea
> for about 15 cents. The bottom line: If Americans really
> want.to treat infant diarrhea, buying.the salts and tablets
> would do 10 times as much good as a tax break for donated
> Pedialyte.
2 - EMERGING PROBLEMS AND DISCUSSIONS WITH WELL-KNOWN CHARACTERISTICS
An emerging problem in the Kosovo-region is how to dispose of the
unwanted pharmaceuticals (*). These quotings from the different articles
give an idea ...
From The New York Times (June 29) (Ref.nr. 5):
> [...] If Fouquet is right, Kosovo will be only the latest
> area to be besieged with inappropriate donations. In Bosnia-
> Herzegovina, for example, possibly as much as half of the
> roughly 30,000 tons of donated medical supplies were of
> little or no use, according to an article that appeared in
> late 1997 in the New England Journal of Medicine. The cost
> of destroying those drugs is estimated to be upward of $30
> million -- $2,000 per ton.
>
> Charities like Pharmacists Without Borders do not want these
> useless donations, said Sophie Logez, who has been working
> for the group in Macedonia. "We worked in Bosnia for two
> years, and we have spent a lot of money destroying drugs,"
> she said. "That is what we want to avoid."
>
> [...]
>
> Discarded drugs are a particular problem, as they are
> considered chemical waste and their disposal is strictly
> regulated. In Croatia, for example, the estimated 700 tons
> of medical waste, including packaging and needles, donated
> during the war and afterward is expected to cost roughly $3
> million to destroy, and the World Bank is considering
> helping to finance some of the cost.
Some parts from the New York Times article I would like to repeat here.
The purpose is to highlight the conflict of interests of different
parties involved at the donor side.
From the New York Times (June 29) (Ref.nr. 5):
> American companies, for instance, are eligible for twice the
> normal tax deductions 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 form of sampling
> that can introduce new markets to their products.
>
> The charities, which are under intense pressure to prove to
> their donors how much good they are doing, are also at the
> heart of the problem. They serve as middlemen between the
> drug companies and the hospitals and clinics receiving
> drugs.
>
> And some companies turn the pressure up by insisting that
> charities take unwanted donations as a condition for getting
> the things they really need. [...]
When we talk about donations we talk about ethics. It is the ethical
discussion that should not be avoided. Some perspectives offered in the
quotes below are interesting ...
From the BMJ (July 3) (Ref.nr. 7):
> It seems that in every humanitarian disaster drug donations
> take on a life of their own; a cyclical pattern emerges
> which is resistant to disciplined procedures and defies
> common sense. As soon as any disaster reaches our television
> screens, drugs that fail to meet the most urgent, or any,
> real health needs are dispatched. They arrive in small and
> large boxes, often without any indication of the contents;
> some are even half used. They may lack labelling, or be
> labelled in a language that cannot be read in the region.
> Some are out of date or nearing their expiry date.
From The New York Times (June 29) (Ref.nr. 5):
> Many recipients of the donations -- those small hospitals or
> clinics -- are also reluctant to speak up. "Donations, as a
> rule, are not refused," explained one recipient who
> participated anonymously in a recent survey conducted by the
> World Health Organization. "Health professionals believe
> that if they refuse to receive some drugs, they get nothing
> in the future. Their stance is: Be content with 5 to 10
> percent of all that is offered."
>
> Those who balk risk being cut off from future gifts. "This
> is a kind of dilemma for our units," said Sister Nympha Que,
> a Medical Mission Sister in Malawi, one of the poorest
> nations in southern Africa. "If they say something to our
> donors, there is a fear that the donations would stop."
>
> [...]
>
> No one seriously expects governments in every case to speak
> up against the practice, either. Many rubber-stamp the
> shipments lest they set off diplomatic waves and offend
> donors at a time when they may be desperate for foreign aid.
3 - APPROPRIATE ACTIONS
From WHO-Euro's press release (June 30) (Ref.nr. 6):
> "The audit identifies several ways to improve the
> situation," notes Regine Seer, pharmacist, Keele University
> (United Kingdom), the second member of the WHO audit team.
> "Don't send drugs that have not been requested. Don't send
> returned-to-pharmacy drugs or free samples issued to health
> professionals because their quality cannot be assured and
> such use is forbidden in many European countries. Send drugs
> only according to assessed needs, and all donated drugs
> should expire more than 1 year from the date of donation."
From Scrip pharmaceuticals news (June 23) (Ref. nr.4):
> The NGOs point out that the guidelines have not yet been
> adopted by the US or in the EU. Although several EU member
> states have been addressing the quality of drug donations,
> there has been no consolidated efforts at European level to
> share knowledge or implement the guidelines. The NGOs used
> the seminar to launch a Europe-wide awareness raising
> campaign designed to inform national governments and donors
> of the "urgent need" for implementation. Following on from
> the meeting, they plan to issue information booklets in five
> European languages, summaries of which will be published on
> the Internet in the coming months.
From Wemos' press release (June 11) (Ref.nr. 1):
> The recent events in the Balkans and Central America
> highlight the need for implementation of the WHO inter-
> agency guidelines, according to conference organisers.
> Developed three years ago and revised in March 1999, they
> have not yet been adopted by the United States nor by the EU
> member states and have been the subject of much controversy
> within the aid community and pharmaceutical industry.
>
> "Drug donations in emergency situations are essential, but
> they can cause as much harm as they can do good," according
> to Mark Raijmakers of WEMOS, a Dutch based NGO concerned
> with international health issues. "With the Kosovo crisis,
> we have the opportunity to bring the problems to light and
> underscore the need for appropriate donations. We simply
> cannot risk repeating the mistakes that were made in the
> past."
>
> Another issue is how to dispose of inappropriate drugs in
> recipient countries. As one participant pointed out, expired
> pharmaceuticals turn into chemical waste, with all of the
> associated costs and potential health threats to the area.
> WEMOS, DIF�M and PIMED used the seminar to launch a Europe-
> wide awareness campaign, designed to inform national
> governments and donors of the urgent need to implement the
> WHO Guidelines.
MEDIA ATTENTION FOR THE ISSUE OF DRUG DONATIONS - JUNE 1999
1 - June 11, Wemos press release on behalf of NGO consortium of DIFAM,
PIMED, Prosalus (new member) and Wemos - APPROPRIATE DRUG DONATIONS -
THE TIME TO ACT IS NOW!
Internet:Get
2 - June 16, Philadelphia Inquirer: DRUG DONATIONS: A BITTER PILL?
Internet:
http://www.phillynews.com/inquirer/99/Jun/16/front_page/DONATE16.htm
3 - June 19, The Lancet: CALL MADE FOR APPLICATION OF DRUG DONATION
GUIDELINES.
Ref.: The Lancet, Vol. 353, June 19, 1999: 2131
4 - June 23, Scrip Pharmaceutical News: DRUG DONATIONS NEED TO BE
IMPROVED.
Ref.: Scrip pharmaceuticals news, No. 2448, June 23rd, 1999, p. 13.
5 - June 29, New York Times: AMONG U.S. DONATIONS, TONS OF WORTHLESS
DRUGS.
Internet:
http://www.nytimes.com/library/world/europe/062999kosovo-drugs.html
6 - June 30, WHO-Euro Press release: WHO DRUG DONATION AUDIT IN ALBANIA
REVEALS MANY EXPIRED AND UNUSABLE "GIFTS". Ref.: Press release
EURO/15/99.
Internet: WHO/Europe | Home.
7 - July 3, British Medical Journal: DONATIONS OF USELESS MEDICINES TO
KOSOVO CONTRIBUTES TO CHAOS.
Ref.: BMJ 1999; 319: 11(3 July).
Internet: http://www.bmj.com/cgi/content/full/319/7201/11
(*) The WHO has recently issues guidelines for the disposal of unwanted
pharmaceuticals, these can be found on the Internet, on two addresses:
http://www.who.int/dap/edmguidelines.html (Word-document online) and on
http://www.drugdonations.org/eng/richtlijnen/eng_richtlijnenvernietiginggene
esmiddelen.html
(frame-version http://www.drugdonations.org).
E-drug posting by Mark Raijmakers, Wemos Foundation Amsterdam.
Reply per e-mail to: mark.raijmakers@wemos.nl
* Address
Wemos Foundation
P.O. Box 1693
1000 BR Amsterdam - The Netherlands
Tel.+31-20-4.688.388 / fax 4.686.008
* NEW Web-site on drug donations
http://www.drugdonations.org (under construction)
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