Bikhal, a young Kurdish woman, knows she may not live to see another spring. The leukemia that has ravaged her body since she was treated with defective chemotherapy drugs at a hospital in Iraqi Kurdistan has reduced her to a ghost of her former self.
The 25-year-old gazes at the leaves falling from the plum tree in the courtyard of her home as her father, Hajj Saleh, relates her experience with the bogus medication that wrecked her chance of being cured of this deadly illness. A few days after it was administered at a government hospital, doctors informed her that recovery in Kurdistan had become “impossible.”
Bikhal’s father did his best to seek redress, even going to the courts to bring the wrongdoers to justice. But he concluded it was futile trying to fight “the dinosaurs”, the powerful political and financial interests that protect the trade in counterfeit pharmaceuticals in Iraqi Kurdistan. He is now planning to sell his small house so he can accompany Bikhal to India at the end of the year in search of a last chance to save the life of his only daughter.
Nawrouz Saleh’s face and throat have been severely disfigured since she was given a “bad injection” last autumn. She recalls that she previously only suffered from a mild bronchial inflammation, yet overnight became critically ill.
It was the same for Ayah Salim. She remains house-bound two years after she, too, was administered a “bad injection” that lost her the ability to move her right leg, and nearly killed her. She spent seven days “almost dead” in intensive care.
Suzanne Jamal, 32, also escaped death by a miracle after doctors managed to treat the side-effects of a “bad injection” she was given to treat “a simple tooth inflammation.”
Sarbast Jaafar, was not so fortunate. He died on June 15 after being injected with the antibiotic ceftriaxone, aged 18. Kazaw Abdul-Baqi, 40, was killed by an injection of the same substance on June 30. Masouma Piro died on August 3 due to an injection of cefotaxil.
The bitter truth is that these injections had been banned by the Iraqi health ministry in Baghdad at the beginning of June, says Dr. Salam Tayyeb, an oncologist at Erbil public hospital. They were on a list of prohibited pharmaceutical products it circulated to all health institutions in Iraq. But they continued quietly killing people in Kurdistan. The Health Ministry in the Kurdistan Regional Government (KRG) whose annual budget exceeds US $446 million, can do nothing to prevent the use of these banned injections or the import of counterfeit medicine.
Defective or counterfeit medicine is thought to account for 18% of the pharmaceutical drugs used in Iraqi Kurdistan in recent years, according to former health minister Taher Hawrami. He describes the phenomenon as having turned into a “monster” ravaging the bodies of thousands of Kurdistan residents.
Hawraz Sheikh Ahmad, deputy head of the Kurdistan Regional Parliament’s Health and Environment Committee , agrees. Defective and counterfeit medicines “are distributed everywhere in Kurdistan,” she says. “They are brought into the region through all the border crossings, and the business is monopolized by traders who no-one can stop, because, in short, they are backed by powerful politicians in Iraqi Kurdistan.”
This is supported by a case in March when the KRG Health Ministry announced that an unlicensed pharmaceuticals factory had been discovered in Erbil. Three tons of dangerous chemical substances were found inside it. They had been smuggled into Kurdistan for the manufacture of counterfeit medicines unfit for use. They would be placed in Syrian or Indian medical packaging and sold to pharmacies as genuine medicine imported from international suppliers, at prices sometimes reaching $50 dollars per box.
Although thousands of boxes of fake medicine were made at this factory, and these were taken by thousands of citizens in Kurdistan, the case was later shrouded in silence. Nobody dared press for a probe into it – nor into the distribution of 2,500 boxes of insulin injections to hospitals and clinics on official KRG health ministry instructions, before tests found them to be defective.
According to a member of the Kurdistan regional parliament, who requested anonymity due to the sensitivity of the case, an investigation was held, involving 27 people believed to be connected to the affair including health ministry officials. It resulted in the culprits being given a “reprimand”.
The director of the Pashmag border crossing, Sirwan Abdallah, concurs that counterfeit and expired medicines continue to be smuggled into Iraqi Kurdistan despite efforts to halt the influx.
The normal procedure used by border officials involves cross-checking the importers’ documents, verifying they were issued by the Health Ministry, and taking samples of the medicines and sending them to the KRG standards directorate for testing. The importing companies are then allowed to store the goods until the tests are complete, Abdallah explains.
If officials have doubts about certain shipment of medicines, they sometimes impound them until the test results are issued.
Abdallah reveals that 47 tons of drugs are currently being held at the crossing and will not be allowed into Kurdistan until they have been legally cleared. A further six tons of drugs are being held which were found to have expired, along with 40 boxes containing what tests proved to be counterfeit medicines.
The impounded drugs are only a small proportion of the massive amount of counterfeit medicine that has increasingly been flooding into Iraqi Kurdistan, as acknowledged by the Reforms Committee set up by the KRG presidency in the aftermath of the Arab Spring of 2011.
The Committee reported in March 2012, after nearly a year of continual work, that large quantities of defective and counterfeit medicines were entering Kurdistan. It estimated that 90% of the drugs in use in the province had never been tested.
This called to mind a scandal in the winter of 2010 when 400 tons of counterfeit medicines were brought in through one of the border crossing from Turkey. According to a government official who worked at the crossing at the time, a senior official colluded with the owners of the two companies involved to let in the 20 trucks carrying the killer drugs. The affair was only uncovered when one of the trucks was stopped at a checkpoint in the town of Dogan and found to be carrying fake medicine. The other 19 disappeared inside the city without a trace.
To this day nobody knows where those drugs went or how many victims they claimed. But the matter was brought to a close, as many in Kurdistan know, with the official concerned being transferred to a different job, after the intervention of a former KRG prime minister who was related to him.
Although the health ministry takes issue with the Reforms Committee’s estimate, it has no figures or estimates of its own to offer on the amount of medicine that comes into Kurdistan uninspected.
Health Ministry Spokesman Khales Qader concedes that counterfeit and defective drugs have long been coming into Iraqi Kurdistan, but attributes the persistence of the problem to “lack of experience and personnel, and also of the equipment needed to test drugs.”
Dr Rozgar Hamid, head of the drugs department on the Directorate of Quality Control in Erbil concurs, saying the shortage of skilled personnel means importers have to wait a long time – up to three months on average – for their test results to come through. “Traders are not allowed to sell the medicines until the final test results have been obtained,” he explains.
But nobody can wait that long, neither the sick among Iraqi Kurdistan’s population of 5 million, nor the pharmaceuticals traders who went into the business seeking guaranteed and quick profits.
Trader Abu Ayyub invested all his savings in a deal involving medicine for treating heart disease and high blood pressure. He has been waiting over two months for the test result. He worries that the delay may result in the drugs expiring while still waiting to be tested.
“Most of the traders who share their profits with powerful partners do not have to wait for official approval,” he protests. “They have backing if they get into legal trouble, and they usually rush to sell their goods as soon as they have come across the border and samples have been taken to be tested by Quality Control.”
He says that for traders like himself who lack “backing” the long hold-ups for testing can be ruinous. Traders are forced to spend money on refrigerating and storing their stocks for months at a time to prevent them from spoiling. They are prevented from competing properly in the market, while the expiry dates of the medicines draw closer — lowering the price — and sometimes lapse.
Hamid says there are only 14 pharmacists working on testing imported medicines at the Quality Control Department, and their experience is “limited to a few years”, though they have a massive backlog of drugs to test.
There is also a shortage of equipment for testing certain medicines such as insulin. Samples have to be sent to the capital Baghdad to be tested by specialists there, who return the results in a few days, he says.
Because of this, he believes it is possible that some traders market their stocks before the samples have been tested. Given the long waiting time for tests, and in the absence of strict penalties, nobody can be sure traders don’t market their stocks of imported medicine as soon as they have taken delivery of them.
Control of the importation of counterfeit medicines through Erbil International Airport also suffers from the same constraints as at the overland border crossings, according to Goran Said, who is in charge of checking medical imports at the airport. The procedures are the same. Incoming medicines are only examined physically, as there is no equipment at the airport to conduct chemical tests. Samples are retained, and shipments are released to importers pending the results of tests.
By the time results come through, many of these drugs will have already been administered to patients, for better or worse, notes Dr. Amir Sheet, former head of the Kurdistan Region Pharmacists Union. Those samples that fail the tests are included on lists that are circulated monthly by the Health Ministry and the quality control department in Kurdistan to all pharmacies in Iraq, with orders to destroy any stocks of the batch concerned.
For civic activist Ahmad Pireh, the shortage of staff and equipment to test medicines is unjustifiable, given the enormous annual budget the KRG gets from Baghdad (some $12 billion in 2012) in addition to its proceeds from oil contracts and foreign investments.
He notes that 1.35 million of Iraqi Kurdistan’s 5 million people are on the public payroll — over 30% of the workforce, the highest proportion in the region – as either government employees or security personnel. Thousands are employed as guards for the politicians and other prominent figures. For the KRG to hire only 14 pharmacists to vet the deadly influx of thousands of tons of dubious drugs is nothing short of a “crime,” he says.
Regional MP Burhan Rashid agrees. He describes the testing process as a “failure” and the work of the quality control directorate as “very bad”, adding that Kurdistan “has now become a place to sell anything that is bad quality or past its expiry date.” He faults the KRG for failing to regulate the trade in pharmaceuticals “despite acknowledging how big the problem is. As a result, importers seek to maximize their profits by procuring the cheapest drugs they can procure, even if that means the worst quality and most dangerous.
KRG officials and parliamentarians, doctors and pharmacists, heads of pharmaceutical firms and civic activists alike acknowledge that there are scandalous shortcomings in the control of imported medicines in Iraqi Kurdistan. This is not only due to the absence of a coherent system for testing medicines before they are distributed to pharmacies and hospitals, but also to the fact that powerful politicians and political forces have moved into the pharmaceutical business in Kurdistan along with all other commercial sectors.
Dr. Baran Rasoul, who heads the Awamedica pharmaceuticals firm in Erbil, says the resultant state of affairs is “catastrophic”. Some of the traders “don’t care about anything except making quick profits, even at the expense of thousands of peoples’ lives,” he says. “It’s a new Anfal,” he says in reference to the Saddam Hussein’s regime’s murderous campaign against the Kurds in the late 1980s, “carried out by the counterfeit medicine mafia on behalf of some powerful figures and decision-makers.”
Another “catastrophe” cited by Rasoul is that there are only 320 pharmacies and 57 dispensaries in Iraqi Kurdistan with official licenses, alongside 4,000 unlicensed pharmacies, dispensaries and clinics where much of the imported medicine is supplied. That means only 9% are licensed, and the unlicensed 91 % do not receive the Health Ministry’s monthly lists of counterfeit medicines.
Drugs on Demand
Pharmacists Union chief Sheet argues that the single most effective step the authorities could take would be to restrict the importation of pharmaceutical drugs to specific specialist companies, as many of the traders currently in the business know nothing about the field.
But trader Gharib Saadeddin disagrees, maintaining that the problem is with the system used for testing imported medicines, not the people who import them. Whether the latter are pharmacists or not, in the final analysis the judge of the drugs’ quality will be the tests conducted by the relevant authority, not “the trader’s conscience,” he remarks.
Saadeddin says any trader can travel to India, China or Iran and chose whatever drugs secure them the best profits. Pharmaceutical companies in these countries offer traders a variety of options for drugs with different proportions of active ingredients. The lower the proportion the cheaper the drug. Whether they are pharmacists or not, dealers can arrange to buy medicines with a very low percentage of active ingredient, sometimes as little as 1%. “It’s here where the traders can make the kind of profits they drool over,” he says.
Most traders assume they will be able to get their supplies through unhindered, and will have arranged the sale of their entire shipment in advance, so the drugs are distributed as soon as they have arrived. They therefore tend to opt for the cheapest and lowest quality products.
Leila Fattah, a customer at an Erbil pharmacy, says that a relative of hers in the pharmaceuticals business advised her to buy any medicine she needs for herself and her family abroad, as the drugs coming into Kurdistan from China, India and Iran are “lethal.” She retorts that on her $350 monthly wage she can barely afford the cheapest brands on sale let alone get them from outside Iraq.
Her friend Nadia carefully examines some boxes of heart medicine, trying to determine the quality before deciding whether to buy any. “We don’t trust anyone. The region is full of killer medicines. The pharmacist told me they were genuine, but I don’t trust anyone anymore.” Like most people in Kurdistan, Nadia has heard of fatalities after taking defective medicines, and has heard reports of counterfeit drugs being sold. So she agonizes over whether to buy Indian-made heart pills for her Dad for 2000 dinars (around $1.5) or the French-made equivalent for $75.
“Everyone in Kurdistan knows the pharmacies are full of fake and spoiled medicines, but nobody can do anything to change it,“ mutters Fateh Mulla Muhammad as he pays the equivalent of some $65 for two boxes of arthritis medicine. “The merchants import the worst varieties of medicine and nobody holds them to account, because they are partners with powerful officials. They sell us death here, and send their own families to be treated at the best hospitals abroad.”
Marwan Karim, the owner of a pharmaceuticals firm, says the growing power of politically well-connected owners of drugs companies has made him seriously reconsider the pharmaceuticals business for some time.
The “powerful” companies sell their goods as soon they arrive, while those without political backing have to wait months, or perhaps a year, for theirs to be tested and approved and then start the process of marketing them. He believes the hold-ups are deliberate, aimed at forcing the firms not connected to senior officials to hold on to their stocks and keep them out of the market.
The Reforms Committee report seemed to uphold this charge. It referred to three unnamed officials who it said were behind the importation of counterfeit and expired drugs.
MP Rashid concurs, and holds the main Kurdish political parties responsible for the abuses, as “they control most of the commercial activity in Kurdistan, including the pharmaceuticals trade.”
Dr. Muath Sheet, a former member of the pharmacists’ union and currently a health ministry official, is also convinced that “the hidden hands of some officials control the medications trade in Kurdistan.” He sees no other explanation for why the testing process is so protracted in the province whereas it takes only a few days in Baghdad.
He also questions the shadowy nature of some of the companies that import drugs into Kurdistan. In Baghdad, he says, the importers are well-known experienced specialist firms with agencies from major international pharmaceuticals corporations. But it is the complete opposite in Kurdistan, where out of 65 companies in the trade, the activities of only 25 are known, while the operations and imports of the remainder are a mystery.
Article 50 of the pharmacists’ law in Kurdistan provides for a sentence of up to three years in jail as punishment for endangering someone life due to pharmaceutical negligence.
Penalties for pharmacies selling counterfeit or expired medicine range from being issued a caution, to being closed down for a few days or weeks or permanently. But the existence of 4000 unlicensed pharmacies makes it impossible to monitor drugs sales fully or catch offenders.
Samir al-Jaff, whose father died after buying diabetes medicine from an unlicensed pharmacy in Erbil, has still not been able to find out the name of the pharmacy’s owner, who he wants to prosecute for causing his father’s death.
Most patients who suffer serious and sometimes fatal, side-effects from being given counterfeit medicines are unable to obtain compensation from the pharmacists or companies involved. Ultimately, it is very hard to prove a drug was counterfeit if the authorities were unable to determine that previously. Attempted prosecutions are also hindered by lengthy and time-consuming legal procedures, and by political, or even tribal, interventions, which invariably mean they get nowhere.
But the owners of unlicensed pharmacies and clinics bear only a small part of the blame, says activist Hakar Mohammad. The real culprits are what he refers to as “the big pharmaceuticals whales”, while the pharmacies are “mostly victims of the dysfunctional health system in Kurdistan.”
Investigations were held into some major violations, such as the smuggling of doctored medicine or the unlicensed manufacture of counterfeit drugs, but no real measures were taken to prevent their recurrence, he says.
The same goes for the recommendations of the Reforms Committee report. “It spoke at length about the need for measures to be taken — including the sacking of officials in the health sector from their posts, putting those complicit in importing counterfeit drugs on trial, and blacklisting some pharmaceutical firms – to stop yet more billions of dollars being wasted, “ says Mohammad. “But nothing changed.” None of the culprits were punished, nobody was sacked, and meanwhile the list of drugs whose destruction is requested by the health ministry in Baghdad grows by the moth.
Says one official at the Quality Control Department of the free hand enjoyed by the dubious drug importers: “I have authority, but only officially. In reality I have no authority at all. The real authority is held by people much more powerful than us and we cannot confront them.”
MP Sheikh Ahmad also affirms that none of the people responsible for the many deaths caused by counterfeit medicines has ever stood trial or been held to account. She says there are even efforts been made to allow the unlicensed factory in Erbil that was closed down for making counterfeit drugs to reopen, albeit under a different name. She repeats her earlier remark about the impunity enjoyed by the big pharmaceuticals traders, “Nobody can stop them because they are backed by powerful politicians in Kurdistan.”
While MPs and health and industry professionals warn of the scale of damage inflicted by counterfeit drugs in Kurdistan, the victims whose lives have been devastated, and the relatives of those killed, look forward to the day when the culprits face justice in court rather than mere letters of reprimand
Bikhal, meanwhile, only hopes that an Indian hospital will be able to prolong her life, if only for one more final spring, because Kurdistan’s hospitals and its government’s multi-billion dollar budget, cannot save her.