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Counterfeit Drugs in Lower-Income Countries

Authored by Simra Yousaf

Art by Nava Lippman

Imagine this: you are a diabetes patient living in Pakistan, and you have been suffering for weeks from an eye condition caused by diabetes. Seeking relief, you go to a doctor, who recommends the cancer drug ‘Avastin,’ which is commonly used in Pakistan to treat diabetes-related eye conditions [1]. You are referred to an intermediator to obtain Avastin, receive an injection of the drug, and then go to sleep. The next morning, you wake up to a world that is pitch black - you have become blind.


This scenario is a reality for Mumtaz Akhter, one of 68 other diabetic patients in Punjab, Pakistan that fell victim to the spread of counterfeit drugs [2].


Counterfeit and substandard drugs deliberately conceal their real composition, identity, or source. They may fail to meet quality standards or specifications, skip an evaluation or approval process, lack an active ingredient, or contain the wrong inactive ingredient (or wrong amounts of a correct one). Antimalarials and antibiotics are typically more susceptible to being counterfeited. Counterfeit drugs commonly contain corn starch, potato starch, or chalk [3]. Some fake medicines have even been found to contain “mercury, arsenic, rat poison, or cement,” according to Interpol [4].


The counterfeit drug epidemic is not limited to Pakistan; it is a global health crisis affecting all nations. However, it has been found to be more prevalent in lower-income countries, where 9% to 41% of all distributed medicines are counterfeit, compared to less than 1% of distributed medicines in higher income countries [5]. Why does this drastic disparity, seemingly based on a country’s income class, in proportion to counterfeit drugs exist?  


This occurrence is attributed to a lack of effective regulation and a weak enforcement capacity, as well as the expensive nature and/or lack of availability of many medicines, which incentivizes consumers to seek out inexpensive alternatives. For patients in these countries, the most significant risk factor is that the demand for drugs (as medicine) exceeds the supply. Furthermore, there may be a decrease in the supply of pharmaceutical drugs due to poverty, illiteracy (resulting in a lack of understanding about counterfeit drugs), and location (where the rural market means less opportunity for profit) [6]. The shortage in the pharmaceutical drug market appeals to fraudulent people who see this as an opportunity for financial gain. Taking advantage of their less fortunate audience, these scammers may advertise the counterfeit drugs at a lower price than the genuine product. Additionally, in recent years, pharmaceutical production has become increasingly globalized, meaning that different drugs are manufactured in different countries and move through the international market through various modes of distribution. Regulatory authorities in lower-income countries simply lack the resources to efficiently regulate the medicines in their respective countries [7].


The proliferation of counterfeit drugs poses a significant threat to countries of all socioeconomic levels. Drugs with insufficient active compounds fail to carry out their designed function as a treatment, and high concentrations of certain compounds can cause unfavorable reactions. Families end up bearing the large economic burden of these unfavorable reactions, and society loses confidence in genuine pharmaceuticals and healthcare systems as a whole. Additionally, incorrect doses of particular antibiotics can also lead to drug-resistant diseases such as HIV and malaria, creating another societal problem [8].


While the ideal solution is to improve quality standards and regulations, this is currently unachievable for many lower-income countries. As these countries tend to have lower levels of education and literacy rates, adequate and easy-to-understand communication tools should be developed for policymakers that lack a technical background in quality assurance of medicines [7]. At the individual level, it is recommended to only buy medicines from licensed suppliers who are able to display an authenticity certificate. It is also best to avoid drugs that are substantially cheaper than those sold by reputable providers as they are likely to be fake [4]. A counterfeit drug can be identified if it contains too much or too little of an ingredient, includes alternative ingredients, claims to have different properties or side-effects, has different physical properties, or is not correctly labeled or not labeled at all. Additional identifiable properties for a counterfeit product include an out-of-date or missing expiry date, poorly constructed or manipulated packaging, or instructions and/or packaging with grammatical errors [4].


The presence of counterfeit drugs is a global health issue that transcends socioeconomic status. However, it is evident that lower-income countries have a disproportionately higher quantity of counterfeit drugs than higher-income countries due to a lack of effective regulation, weak enforcement capacity, high costs, and lack of availability of medicines [6]. As a consumer, it is vital to be wary of what medicine you are buying and where you are buying it from in order to avoid serious repercussions. Pharmaceutical companies need to do more, especially for people like Mumtaz Akhter. 


Works Cited

  1. American Academy of Ophthalmology. (2023, April 19). What is Avastin? American Academy of Ophthalmology.

  2. Janjua, B. (2023, September 29). Warning over “counterfeit” drugs that blinded diabetes patients in Pakistan. The Telegraph.

  3. World Health Organization. (2018, January 31). Substandard and falsified medical products. World Health Organization.

  4. CDC. (2022). Counterfeit medicines. Centers for Disease Control and Prevention.

  5. Glass, B. (2014). Counterfeit drugs and medical devices in developing countries. Research and Reports in Tropical Medicine, 11–11.

  6. Raffaella Ravinetto, Vandenbergh, D., Cécile Macé, Pouget, C., Renchon, B., Rigal, J.-F., … Caudron, J.-M. (2016). Fighting poor-quality medicines in low- and middle-income countries: the importance of advocacy and pedagogy. Journal of Pharmaceutical Policy and Practice, 9(1).

  7. Counterfeit and Substandard Drugs in Low Income Countries. (2010, January 15). Issuu.

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