Q: Before you set out on your Internet purchase project, what were your expectations in terms of the proportion of illegal on-line pharmacies and number of suspect or fake medicines that you thought you might source?
To be perfectly honest, I thought we would find around two thirds of medicines being offered online to be counterfeit or substandard. We were really careful with the criteria we applied to filter out the patently criminal sites. If we'd wanted to, we could have found 100% to be fake, but that wasn't what we set out to do. We set out to replicate the likely experience of the average patient sourcing medicines online and the harsh reality is that a patient would have a 62% chance of receiving a counterfeit or substandard medicine - with no recourse whatsoever.
Q: What were the most alarming findings you uncovered and indeed the strangest incidences that occurred?
Most of the packages that arrived were alarming in one way or another. However, a few stand-out examples come to mind. There was the package that we hadn't ordered and that contained Diazepam (a controlled substance) together with a blank prescription. Then we received a pack of Plavix (for serious cardiac conditions) with two complimentary Sildenafil Citrate (Viagra) tablets taped to the blister pack. This "cocktail" was wrapped in the cricket pages of the Mumbai Times - giving a whole new meaning to the term "patient information." To my mind, the most sinister pack was a simple envelope containing a month's supply of Propecia. Bearing in mind that we ordered these medicines in the name of a woman and that one of the side effects of that particular medicine can be to render a woman infertile, this brought home to me that we are dealing with criminals who are not in the least bit concerned with the health of their customers.
Q: The detailed report was published in June 2008. Has your subsequent research and analysis found any further details about the nature of the medicines received, their origin, or indeed the extent of the networks involved?
We passed on the information behind the report to the relevant investigative authorities and to the brand protection specialists within the companies. With regard to the routes and networks, we are working with carriers to try to tighten up their policies. Where the medicine looked as if it might be real, we asked the companies to analyse it. Indeed, I was recently briefing the in-house medics of one of the companies and a couple of their brand security people attended the briefing. I presented them with a pack of their medicine that we had bought and asked them to verify if it was real. After several minutes, they cautiously said that "Yes, it could well be real." They were fairly sheepish when I showed them the certificate showing that it was counterfeit and I'll spare their blushes by not revealing the name of the company. The purpose of the research wasn't really to track the criminal networks, but to raise awareness of the issue. In that regard, it was a spectacular success and we are still receiving significant media coverage.
Q: You rightly point out that the Internet is here to stay and that there are many personal reasons why people buy medicines on line. On reflection, how do you think the various parts of society should tackle this serious issue quickly and effectively?
Good question, and one that I have wrestled with. People buy medicines online for a number of reasons, not least a desire to circumvent the medical mainstream. Coming from a mental health background, where a diagnosis on one's medical records can have dire consequences, I have certain sympathy for people who go to such lengths to avoid a formal diagnosis. I also understand why people with embarrassing conditions might want to avoid the GP's surgery. But these are societal issues and though they need to be addressed, the fact remains that when people buy POMs (Prescription Only Medicines) online, without a prescription, they put themselves at risk. The very least that we can do is to make them fully aware of the risks. The best that we can do, in time, is remove the stigma and discrimination associated with some diagnoses.
Q: Do you plan to repeat the exercise, for example in another country or to determine if the problem is getting worse? If so, are there any other angles you would investigate?
I presented the report to the recent APEC-funded conference on counterfeit medicines in Mexico City. It was extremely well received and one of the outcomes of that conference was a proposal to mirror the research in the APEC region (countries with a Pacific Ocean border.) I am currently working with the Argentinean regulatory body to develop the project. For me, another major and increasingly urgent challenge is to convince those American politicians (rightly) concerned with controlling healthcare costs, that what they call "Importation", both personal and commercial, is a very bad idea. Legislation to approve importation has now been re-introduced. The American supply chain is simply not ready for it and, in my view, importation represents huge risks to patients - not least in those countries that would see shortages, and provides a fertile environment for counterfeits.
Q: EAASM is currently focused on Europe and has highlighted the issues of the Internet. Other contributors to No To Fakes have explained the problem of access to safe medicines in developing countries. Do you see your organization’s role expanding, and how do you work with bodies, such as the WHO, that also have a remit and responsibility for the kind of mission you are on?
Our focus is clearly European and we are working with various organizations (such as the European Commission and Council of Europe) concerned with counterfeit medicines. That said, we are acutely aware that the counterfeiter doesn't respect international borders and we will therefore work with any individual or organization concerned with patient safety. In practical terms, this normally means sharing information but in 2009 we will also be collecting and collating patient experiences from around the world, as a precursor to a major project that should emerge towards the end of the year, and which will form the backbone of our patient information going forward. We are also more than happy to work with the WHO. Indeed, at the Mexico City event, I co-moderated both plenary and workshop sessions with Valerio Reggi of WHO IMPACT. I leave it to those of your readers who may know Valerio and me to picture how anarchic that was!