High prices cause city residents to run the risk of street drugs

The young woman lying in a hospital bed in Libreville, Gabon’s capital, complained of pains caused by poor blood circulation in her swollen legs. She could hardly walk, she said, because of the cramps which started after she took slimming pills her sister had bought on a city street. She could be considered lucky. Others have suffered much more from drugs bought from informal vendors, according to Isabelle Mboumba, head nurse in the emergency wing of a public hospital in Libreville. The nurse told IRIN she had seen many people die from poisoning, develop severe stomach and kidney ailments or run mad after taking “dubious medicines” purchased on the streets or in markets without a doctor’s prescription. In September, the Association of Gabonese Pharmacists ran a one-week awareness campaign on unlicensed drugs to alert the authorities and the public to the threat the medicines posed to public health. Two months later, Libreville’s mayor, Andre Dieudonne Berre, banned their sale from the streets of his city. Since the ban, announced on 9 November, cigarette vendors and other street hawkers no longer openly peddle painkillers, tranquillizers, cough syrups, rheumatism medication and the host of other drugs they used to offer. However, the products are still being sold discreetly in markets in the Gabonese capital. Unlicensed medicinal drugs first started appearing on Libreville’s streets about 20 years ago. The first tablets made in Nigeria appeared in corner shops, before they spread to Libreville’s main markets, of Mont-Bouet and Nkembo, medical sources said. Most of the drugs now sold on the street are smuggled in from Benin, Cote d’Ivoire, Ghana, Nigeria and India. However, some legally imported ones have also found their way into the informal sector. Employees of the National Pharmaceutical Bureau caught stealing drugs from their workplace during a routine check in early 2003 admitted that they sold them at low prices to street vendors. Whatever the origins of the street drugs, their prices are much lower that those of medicines purchased from pharmacies. Price matters when money is tight For example, a box of Dolko painkillers costs 1,050 CFA francs (just over $2) in the average pharmacy, compared to 600 CFA francs (about $1.20) on the street. A 20-ml bottle of valium, a tranquillizer, goes for 900 CFA francs ($1.80) in the street but 1,700 CFA francs ($3.70) in pharmacies. Such prices might seem low to the external observer, but many of Gabon’s roughly 1.2 million people have to make do with much less than the $150 a month the state pays its most junior civil servants, so both the medication cost and the price differences represent significant amounts for them. Medical practitioners cite a number of reasons for the price differences. For one, the customs duty on imported drugs is 30 percent, whereas the bulk of the street drugs bypass customs. Consumers also pay an 18-percent value-added tax on all goods, including medication. What also keeps pharmacy prices high, medical practitioners say, is that brand-name rather than generic drugs are imported into Gabon. A first step towards improving access to affordable drugs was made in 1987 when a list of basic medicines was drawn up by the Ministry of Health with the assistance of the local office of the World Health Organisation in Libreville. “Its adoption was to have led to a reduction of the purchasing prices of medicines through the promotion of generic drugs whose prices are on average four times cheaper than those of the products currently used,” said Dr Emile Mboutsou of the Centre Hospitalier de Libreville (CHL), the biggest hospital in Gabon. However, the list was not adopted by the government, according to a document called ‘Following Up the 20-20 Initiative in Gabon’ that was produced in 1999 by the UN Children’s Fund. The main reasons included budget restrictions and the fact that the government was unable to reach a compromise with certain foreign pharmaceutical firms to obtain lower prices for medicinal drugs. Other factors include the low priority given to the health sector and the absence of a national policy on drugs. Public hospitals sometimes provide some of the drugs needed by their patients and these are generally cheaper than those found in pharmacies. However, state hospitals sometimes run out of given drugs so patients have to buy them elsewhere. Even emergency patients are sometimes forced to buy medicines needed for their treatment off the streets, nurse Mboumba told IRIN. Old, damaged or fakes Some of the medicines found in the informal sector are fakes and have no curative properties. Others are bona fide generics, but sometimes they are sold beyond their expiry dates. Generally, street drugs are substandard because they are kept in poor conditions and are exposed to the elements, said pharmacist Paul Mercier. Buying drugs off the street can have repercussions not just for the individual but for society as a whole. Last year the government advised pharmacies to stop selling Nivaquine 100 after a study conducted in mother-and-care centres showed that it was no longer effective against malaria. According to the study, the misuse of anti-malaria tablets sold by street vendors had caused the malaria bacteria to become more resistant to the drug. Despite the health risks unprescribed or unlicensed drugs represent, Mayor Berre’s ban alone is unlikely to be enough to stop Libreville residents from using them. It needs to be accompanied by other measures, medical practitioners say. These could include lowering the prices of licensed medicinal drugs and having physicians provide needy families with free medication, according to Dr Michel Ibouily, an adviser to the Ministry of Health. Doctors who participated in a televised debate on health issues in October said the state could go a long way towards improving access to drugs by making them free for people registered at the National Social Security Fund, as was the case up until the 1970s. During the 1960s and 1970s, workers and pensioners who were members of the fund received free medical drugs for themselves and their families. However, the system broke down because insured workers used it to provide free drugs to distant relatives and even neighbours, exhausting the stocks.