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TheView Health

The worldwide

threat of

generic drugs

By Katherine Eban

For The 16 years ThaT Dr. Brian
Westerberg, a Canadian surgeon, worked
volunteer missions at the Mulago Na-
tional Referral Hospital in Kampala,
Uganda, scarcity was the norm. The pa-
tients usually exceeded the 1,500 allot-
ted beds. Running water was once cut
off when the hospital was unable to pay
its bills. Patients often couldn’t access
the medication they needed, so on some
early trips, Westerberg brought drugs
over from Canada. But as low-cost ge-
nerics made in India and China became
widely available through Uganda’s gov-
ernment and international aid agencies
in the early 2000s, it seemed at first like
the supply issue had been solved.
Then on Feb. 7, 2013, Westerberg ex- drug companies in countries like India manufactured in China, contained a
amined a feverish 13-year-old boy who and China can produce low-cost, high- probable carcinogen once used in the
had fluid oozing from an ear infection. quality drugs for markets around the production of liquid rocket fuel. But the
He suspected bacterial meningitis but world. These companies have been patients who suffer most are those in
couldn’t confirm because the CT scan- hailed as public-health heroes for giv- so-called R.O.W. markets—the generic-
ner was broken. The boy was given in- ing the impoverished access to the same drug industry’s shorthand for “rest of
travenous ceftriaxone, an antibiotic that cures as the wealthy. world.” In swaths of Africa, Southeast
Westerberg thought would cure him. But many of the generic-drug compa- Asia and other areas with developing
But after four days, the ear was worse. As nies that Americans and Africans alike markets, some companies have made
Westerberg prepared to operate, the boy depend on, which I spent a decade in- a cold calculation: they can sell their
had a seizure. With the CT scanner work- vestigating, hold a dark secret: they ad- lowest-quality drugs where they will be
ing again, Westerberg ordered a scan, just their manufacturing least likely to get caught.
which revealed abscesses in the boy’s standards depending on They can sell In much of Africa, for in-
skull, likely caused by the infection. the country buying their their lowest- stance, pharmaceuticals used
When a neurosurgeon looked at the drugs, a practice that quality drugs to come from more developed
images and declared that surgery was could endanger not just countries, through donations
unnecessary and the swelling and ab- those who take the lower- where they will and small purchases. So when
scesses would abate with effective anti- quality medicine but the be least likely Indian drug reps offering
biotic treatment, Westerberg was con- population at large. to get caught cheap generics started arriv-
fused. They had already treated the boy These companies send ing, the initial feeling was pos-
with ceftriaxone, which hadn’t worked. their highest-quality drugs to markets itive. But Africa soon became an avenue
His confusion deepened when his col- with the most vigilant regulators, like the “to send anything at all,” said Kwabena
league suggested they switch to a more U.S. and the E.U. They send their worst Ofori-Kwakye, an associate professor
expensive version of the drug. Why swap drugs—made with lower-quality ingre- in the pharmaceutics department at the
one ceftriaxone for another? dients and less scrupulous testing—to Kwame Nkrumah University of Science
Most people assume that a drug is countries with the weakest review. and Technology in Kumasi, Ghana. The
a drug—that the brand-name or a ge- poor quality has affected every type of
neric version of it is the same anywhere The U.S. drUg SUpply is not im- medication, and the adverse impact on
in the world, so long as it’s made by a mune to quality crises. Over the past 10 health has been “astronomical,” he said.
reputable drug company that has been months, dozens of versions of the ge- Multiple doctors I spoke to through- Z ACHARY Z AVISL AK FOR TIME
inspected and approved by regulators. neric blood-pressure drugs valsartan, out the continent said they have adjusted
That, at least, is the logic that has driven losartan and irbesartan have been re- their treatment in response, sometimes
the global generic-drug revolution: that called. The active ingredients in some, tripling recommended doses. Dr. Gordon

26 Time June 3–10, 2019