Murder by Proxy: The Story of Fake Artesunate

_{By: Sai Awn Murng}

 
    Saw James was barely conscious, mumbling incoherently, his eyes semi-shut.  Medics immediately diagnosed him with a common, deadly complication of malaria: cerebral malaria.  Saw James was quickly given artesunate, the only medication to reliably treat malaria along the Thai-Burma border.  Two days later, he felt weak but was awake and without fever.  Saw James was lucky and would survive, this time.

            Like other social services in the country, Burma’s health system has collapsed, another consequence of military misgovernance.  The current regime, the State Peace and Development Council (SPDC), devotes 40 cents per person per year on health, amongst the lowest in the world; neighboring Thailand’s equivalent is $61.  Concurrently, erratic policies, including purchases of military hardware and a nuclear reactor, in addition to relocating to the new capital of Naypyidaw, estimated by the International Monetary Fund (IMF) to cost 122-244 million dollars per year, continue to divert scarce resources away from essential social services.  Notes The Gathering Storm, a report published in July 2007 by the Johns Hopkins University and University of California, Berkeley, “Decades of neglect by Burma’s military government have turned the country into an incubator of infectious diseases.” Malaria, particularly the most dangerous type, Plasmodium falciparum, is a top cause of sickness and death, and Burma accounted for over half of Asia’s deaths from malaria in 2005, including India, with her vastly larger population.  70% of the peoples of Burma live in malaria-endemic areas, especially along the frontiers of the country, overwhelmingly populated by non-Burman ethnic groups and where lack of health services and poverty is especially pronounced.  According to Chronic Emergency, a report published by the Backpack Health Worker Team, working in eastern Burma, malaria was the cause of almost half of all deaths and, at any point in time, over 12% in the community had Plasmodium falciparum malaria. 

            The problem is now compounded by the widespread availability of fake drugs, including artesunate, the mainstay of malaria treatment in the region, a practice which has been appropriately termed “murder by proxy.”  In one analysis, over a fifth of artesunate obtained in Burma were fake, a problem that has continued to grow.  For the first time, two different batches of artesunate purchased in Kengtung, the capital of eastern Shan State, have been confirmed by the Division of Parasitic Disease of the United States Centers for Disease Control and Prevention, tasked with testing for malaria drug quality, to be fake.  The report of the analysis performed in January, 2008, noted, “They [the pills] contained no measurable amounts of the active ingredient, artesunate.  The tablets weighed much more than the comparable genuine Guilin [Pharmaceutical] tablets… [and were] much harder to manually split in two.”  Concluded the report, “these samples are definite fakes.  It is almost impossible to distinguish fakes from genuine based on package appearance.” 

            Lack of governmental regulatory control and widespread corruption contribute to the burgeoning black market trade, including in pharmaceutical products, both authentic and fake.  “There is no control of medicines… pharmacy shops sell them but sometimes even betel nut stalls sell medicines,” noted a Burmese physician, previously working in Mon State and Tavoy.  “There is a lot of indiscriminate use.”

  The problem is exacerbated by worsening poverty and runaway inflation, estimated to run over 35% per year, the worst in Asia, which have made healthcare, paid for almost entirely out-of-pocket, an unaffordable luxury for many of the peoples of Burma, especially given that 70% of the average Burmese household income is spent on food alone.  The result is the growing, unwitting, demand for fake drugs, sold more cheaply than the genuine product and packaged almost identically, compounding the health tragedy that continues to unfold in the country.   

_{Malaria risk areas in Burma.  Source: World Health Organization, Regional Office for South-east Asia.}