The Blurb On The Back:

Long the scourge of developing countries, fake pills are now increasingly common in the United States.  The explosion of Internet commerce, coupled with globalisation and increased pharmaceutical use has led to an unprecedented vulnerability in the U.S. drug supply.  Today, an estimated 80% of our drugs are manufactured overseas, mostly in India and China.  Every link along this supply chain offers an opportunity for counterfeiters, and increasingly, they are breaking in.  In 2008, fake doses of the blood thinner Heparin killed 81 people worldwide and resulted in hundreds of severe allergic reactions in the United States.  In 2012, a counterfeit version of the cancer drug Avastin, containing no active chemotherapy ingredient, was widely distributed in the United States.  In early 2013, a drug trafficker named Francis Ortiz Gonzalez was sentenced to prison for distributing an assortment of counterfeit, Chinese-made pharmaceuticals across America.  By the time he was arrested, he had already sold over 140,000 fake pills to customers.

Even when the U.S. system works, as it mostly does, consumers are increasingly circumventing the safeguards.  Skyrocketing health care costs in the U.S. have forced more Americans to become “medical tourists” seeking drugs, life-saving treatments and transplants abroad, sometimes in countries with rampant counterfeit drug problems and no FDA.  Bitter Pills will heighten the public’s awareness about counterfeit and substandard drugs, critically examine the historical context of the problem and discuss possible technical solutions, and help people protect themselves.  Author Muhammad H. Zaman pays special attention to the science and engineering behind both poor quality and good quality drugs, and the role of a “technological fix” for the fake drug problem.  Increasingly, fake drugs affect us all.  

You can order Bitter Pills: The Global War On Counterfeit Drugs by Muhammad H. Zaman from Amazon USA, Amazon UK, Waterstone’s or Bookshop.org UK.  I earn commission on any purchases made through these links.

The Review (Cut For Spoilers):

Muhammad H. Zaman is Professor of Biomedical Engineering and International Health at Boston University and in this timely book he examines the problems in tackling drug counterfeiting from science and technology, political, regulatory, and business viewpoints but while he does well at highlighting the complexity of the issues involved, there’s a lot of repetition, the writing is quite dry and the last chapter on ivory left me bewildered.

What this book does well is go through the different issues that contribute to the counterfeiting problem in a way that’s easy to understand.  I thought Zaman was particularly good at highlighting issues specific to developing nations such as Ghana and Kenya – not just corruption (although that does play a part) but also cultural matters (e.g. suspicion of authorities), politics and poverty.  He also touches on the lack of cross-border regulatory bodies, which creates a vacuum when it comes to tackling cross-border trade in counterfeits and is quietly damning of the failures of the World Health Organisation while developing nations are suspicious about attempts to impose western manufacturing standards on them as potentially a means of restricting competition.  

What becomes clear is how lack of resources and infrastructure within developing countries hampers them even when the will was there – an opening chapter setting out the issues of storing drugs in Ghana (and the devastation wrought by the destruction of the central pharmaceutical store really opened my eyes to basic logistics issues that I hadn’t considered before.  Zaman expands on this by detailing the costs and difficulties in putting in place testing equipment, which are expensive to buy and then require on-going, expensive maintenance to keep in use, not to mention the training required for those needed to use it (and his points about deficits in pharmaceutical and medical training was a big revelation to me).  

Zaman is also good on the business and competition pressures on generic pharmaceutical manufacturers, explaining how they are wary of big Pharma companies trying to stifle them in the name of quality control and use intellectual property rights to shut them down or restrict them but he also points out the lack of regulation when it comes to maintaining quality control within generic producers and the power they exercise in countries such as India and China, which prevents better regulation.  I found him to be fairly even-handed in his take on the efforts of Big Pharma, pointing out the impact that their high pricing has on driving customers towards seeking cheaper alternatives, which helps the counterfeiters but also showing how Big Pharma can assist in tackling counterfeiting through technological innovations (although he does not do this uncritically).

I certainly came away from the book with more appreciation for the complexity of the problem and Zaman includes some horrifying examples of what happens when counterfeit drugs get into the system, e.g. the contamination of a hypertension drug in Pakistan, which was believed to cause dozens of deaths (the precise nature being open to debate because of the difficulties in diagnosing and reporting).  However, for me, there wasn’t enough colour within the writing – Zaman has quite an academic style and while he wins points for not being too full of jargon, he does get bogged down in areas such as the history of pharmaceutical regulation (which, while interesting didn’t have the immediate connection to the current problem) and there’s a lot of repetition of his points, which I found a little frustrating.  Also, I was a bit confused by the final chapter, which purports to be about the ivory trade but turns out to be a thin attempt to suggest that shaming may play a role in encouraging action against counterfeiting based on the fact that the shaming of Chinese diplomats for taking ivory from Tanzania led China ending the ivory trade (although research suggests that in practice it persists).

I think that if you want an introduction to this topic, then this is certainly a good place to start as Zaman does cover the breadth of it while bringing it together.  However, while it’s an interesting reading it isn’t an easy one and there were times when I found it a bit of an effort to keep going (although it is worth while persisting with it).

BITTER PILLS: THE GLOBAL WAR ON COUNTERFEIT DRUGS was released in the United Kingdom on 26th April 2019.  Thanks to the Amazon Vine Programme for the review copy of this book.