Let the buyer beware

The Roxy market in the Adjamé district of Abidjan in Côte d'Ivoire is well known among the city's poor people. With hundreds of vendors, it is a vast expanse of shelters and parasols under which all kinds of drugs in all sorts of forms—pills, syrups, powder, suppositories, injectables, ointments—are displayed in a jumble on tables or in baskets. The drugs are constantly exposed to dust, sun, and changes in weather that can affect their quality. It is common to find drugs sold without their original packaging and repackaged in plastic bags with no mention of the drug's name, active ingredients, or expiry date. Nearly all the vendors are women, and more than a third are illiterate. None has knowledge of drugs or any medical training—but this does not mean they aren't ready to quickly diagnose an illness or try to decipher a prescription so they can provide a drug, though their choice is more likely to be determined by what they have in stock than the actual cause of the illness.

The substandard drugs are often those in high demand for AIDS and malaria

The drugs in the market can be divided into two broad categories. The first is drugs that can also be found in legal pharmacies and street markets. They find their way to Roxy from legal wholesalers and pharmacists. Indeed, the legal pharmaceutical sector supplies about 48% of the stocks of drugs in the country's illegal street markets (www.remed.org/fichiers/ReMeD22.pdf). Some wholesalers have set up a supply system to the illegal outlets so that all the groups of drugs present in the legal pharmacies can also be found at cheaper prices in the illegal market. This new business line is helped by the fact that the street sellers buy on a cash on delivery basis, while the legal pharmacists negotiate payments by credit. The delivery cars operate at night or early in the morning. Some drugs are stolen from pharmacies by employees and sold in the street market at a cheaper price. It is often possible to see drugs labelled “free sample, not for sale,” provided by medical representatives who sell the samples intended for doctors.

Many visit the street vendors to avoid doctors' consultation fees

Drugs donated to charities are also often found in the street market. These drugs are often not suited to the needs of the receiving population and so will be sold by the organisations. In addition, some drugs made in Europe are in the street market—probably sold on by unscrupulous Europeans—even though domestic manufacturers are licensed to make the same drugs.

The second category is the drugs found only in the illegal street markets. These are drugs that have escaped government regulation and are essentially those smuggled into the country past customs agents (or with their connivance). They are usually not registered in Côte d'Ivoire and mostly come from Ghana, Nigeria, and India. Also in this category are the illicit Chinese traditional medicines, a burgeoning market throughout the country. They are distributed by young jobless Ivorians, under the guidance of a Chinese boss. The vendors, unable to read the Chinese characters, give the medicines their own designations to identify the product. Of course the accompanying leaflets, if any, are likewise illegible to the consumers.

Figure 1.

Pile them high, sell them cheap

Credit: ISSOUF SANOGO/AFP/GETTY

The few studies that have looked into the problems caused by the spread of illegitimate channels of drug distribution in less developed countries have all found that a large proportion of the drugs are of low quality. This is partly because the drugs are sold after the expiry date or stored in bad conditions but mostly because the active ingredients are lacking or even wrong, owing to irregularities in the manufacturing process, whether intentional (in the case of counterfeit drugs) or not (substandard drugs). Up to 25% of the drugs consumed in poor countries are counterfeit or substandard (Journal of Advanced Nursing 2004;46: 338-9).

Because of the absence of controls in markets like Roxy, the proportion of poor products sold there must surely be higher, but we do not have any reliable data. The substandard drugs are often those in high demand for life threatening conditions such as AIDS and malaria. Inevitability, their ineffectiveness leads to clinical aggravations and even death. The situation is made worse by the encouragement of prompt self treatment for diseases such as malaria.

Although the market's customers may sometimes need a prescription, many visit the street vendors to avoid doctors' consultation fees. Less than 10% of Côte d'Ivoire's population has health insurance. The exact proportion of people buying medicines from the illicit outlets is unknown, but estimates are that in some African countries as many as 85% of patients may visit these ignorant and dangerous bogus “doctor-pharmacists.” Occasionally the authorities publicise the dangers, but nothing concrete is being done to eradicate the problem, by either the authorities or the pharmaceutical sector. The paradox is that these illegal vendors pay daily fees to the city council to occupy space on the pavement or the street. Sporadically the police mount raids and arrest the vendors and confiscate their merchandise, but usually the owners can get their goods back by paying the police.

The country needs a much stronger political will and enforcement of drug regulation to beat this rapidly expanding problem. However, the country's current political and economic crisis makes this unlikely. Instead it is up to those in Côte d'Ivoire's pharmaceutical sector to face up to their responsibilities and fight this dishonouring of their profession.