KATHMANDU, NEPAL – Away from the central bus park in Kathmandu, Nepal’s capital, and the hustle and bustle of the Balaju area, life has stopped some two kilometers away in Goldhunga, another village in the district.
Inside a one-story house there, Purna Patuwar lies in bed. His eyes are moist as he holds a photograph of his wife close to his chest. They were married in April 2011, but she died before the year ended.
His mother, Sami Patuwar, tries to console her grief-stricken son.
“I think it was your destiny,” she says to her son.
She says her daughter-in-law died from taking expired medicine.
“Expired medicines killed my daughter-in-law, and I haven’t been able to comfort my son,” she says.
Patuwar says he hasn’t been able to overcome the loss.
“I only have her thoughts on my mind,” he says with tears in his eyes.
He says he met his wife, Soniya Tamang, when she was 17 and instantly fell in love. He went to Qatar for foreign employment soon after they met, but upon Tamang’s insistence, he returned after 22 months abroad so they could get married.
Among the reasons for her haste, Tamang was already pregnant before the couple married. But the couple decided not to have a baby so soon, so they decided to abort the child. Eight days after their wedding, Patuwar says they went to a nearby pharmacy for the abortion.
At Miteri Pharmacy, Patuwar says there was a line of women waiting for their turns to receive abortions. Patuwar agreed to pay Bhim Bahadur KC, the man who ran the pharmacy, 2,500 rupees ($30) to perform the abortion.
As his wife went inside with KC, Patuwar waited outside. Seven minutes later, he heard KC yelling for him to call a cab.
They rode in the cab for only a couple of minutes to a hospital located half a kilometer from the pharmacy. But Tamang was already unconscious, and the doctor pronounced her dead at the hospital.
Tamang’s postmortem report and the police record attribute her death to an expired muscle relaxant drug that KC gave to her before the abortion.
“It is because the pharmacist used the expired medicine that my wife died,” Patuwar says.
The pharmacy was a registered facility. But Bijaya Laxmi Shrestha, a senior pharmacist in the industry, says that what KC was doing – performing abortions and dispensing expired medicine – was against the law.
Neon Laboratories Ltd. manufactured the muscle relaxant that killed Tamang in 2009 in India, according to research by the Department of Drug Administration under the Ministry of Health and Population. Called Necocuron, the muscle relaxant had expired in February 2011.
Minutes after Tamang received the injection, she was unconscious, says Dinesh Lohani, deputy superintendent of the Balaju Police Office. Fifteen minutes later, Tamang was dead.
“This is sheer negligence,” Lohani says. “Incidents like these occur frequently.”
Although Nepalis frequent pharmacies to obtain medicine to ease a variety of symptoms and ailments, they often end up feeling worse thanks to expired and fake products that have flooded the market. Expired and fake drugs have been linked to countless deaths, injuries and ailments here. Authorities attribute victims’ susceptibility to illiteracy and lack of awareness. Although the government has various regulatory measures and bodies in place to monitor the industry, officials admit that implementation is weak. As many accuse pharmacists of caring more about profits than customers’ health, pharmacists say it’s difficult to meet government standards. Meanwhile, the government is striving to strengthen monitoring and to increase consumer awareness.
Statistics on the number of people affected by expired or fake medicine in Nepal are unavailable. But lawyer Jyoti Baniya, chairman of the Forum of Protection of Consumer Rights, a nongovernmental organization that advocates for consumer rights, estimates that more than half of Nepal’s population may be using and affected by expired and/or fake medicine.
“This is not unusual because the market is flooded with fake products,” he says.
Doctors and other employees at local hospitals say that many people are dying because of expired medicine and unlicensed practitioners at pharmacies.
“It’s unfortunate that standardized procedures that should be done in hospitals are being carried out in pharmacies,” says a hospital employee, who declined to be named for fear of losing his job.
Many say that pharmacies are also distributing fake and expired medicine.
Indra Chapagain says that when he started vomiting and having diarrhea last year, he attributed it to food poisoning. So he walked to a pharmacy near Bir Hospital in central Kathmandu and purchased medicine for diarrhea.
Chapagain took the medicine in doses as the pharmacist instructed, but it didn’t work. Twenty-four hours later, his condition worsened, and he had to be rushed to Sukraraj Tropical and Infectious Disease Hospital in Kathmandu.
At the hospital, doctors immediately gave him saline water and the same medicine that he had taken the day before. Chapagain says he felt better.
When Chapagain showed the doctor the medicine he had taken from the pharmacy, the doctor told him that it was eight months past its expiration date.
Chapagain says that he was at least lucky to have been in the nation’s capital to receive care.
“Otherwise I probably wouldn’t have survived,” he says.
While the medicine that Tamang and Chapagain received from pharmacies was expired, Reema Sharma, who came to the capital two months ago for an eye operation, says the medicine she received was fake.
After her eye operation at Tribhuvan University Teaching Hospital in Kathmandu, the doctor prescribed a fluid and asked her to follow up in a week. But when she returned the following week, the doctor said her condition had not improved. She showed him the medicine she had obtained at a pharmacy. The doctor examined it and told her it was fake.
“Due to that fake medicine, my eyes could have suffered badly,” she says. “Thank God nothing happened.”
Sanjib Acharya, office assistant at the Nepal Pharmacy Council, the autonomous professional and regulatory body for pharmacists created by Parliament in 2001, attributes the victims’ susceptibility to fake and expired medicine to illiteracy and lack of awareness.
Elaborating on the trend in Nepal, Acharya says that people don’t visit hospitals here unless it’s serious because of long lines at public hospitals and high bills at private ones. Instead, they usually go to their closest pharmacy when they think they require any medication.
“They don’t even care about the pharmacists’ qualifications or if they are registered to prescribe or give medicines,” he says.
Patuwar says his wife reasoned that her mother had aborted in the same pharmacy three times, so she thought it would be fine.
“We didn’t know that other places had abortion services,” Patuwar says.
According to Nepal’s Drug Act of 1978, medicines should be effective, standardized and safe for the public to use. The legal code prohibits the import, export, manufacture, distribution and sale of substandard medicines.
Bodily damage from medicine can lead to fines and up to 10 years in prison for the seller, Baniya says. Selling potentially life-threatening expired medicines could result in life in prison. The Department of Drug Administration also has policies regarding marketing and guidelines for standards of quality.
But Baniya says pharmacies are still cheating people and making them suffer because of the government’s weak implementation of laws and policies and the strong position of manufacturers, distributors and sellers.
“Though the law is strict, its implementation is weak,” he says.
The Department of Drug Administration routinely inspects the pharmacies. But many times, the shopkeepers don’t open their shops to the inspections or are combative, Shrestha says.
“Sometimes you really have to risk your life during inspections,” Shrestha says.
The court process is also long and tedious to charge pharmacists for selling fake or expired medicine, says Shyam Adhikari, one of the drugs inspectors at the Department of Drug Administration. Therefore, he says the department has appealed to the ministry to enable the inspectors to issue penalties on the spot.
Adhikari cites the lack of manpower in the department as another barrier to stricter monitoring of pharmacies. He says that people in rural villages are dying because of a lack of basic medicines for diarrhea, so it is more important to focus resources on saving lives than inspecting pharmacies for registration and skilled workers.
But people also die as a result of weak inspection practices, says Baburam Humagain, an associate professor of pharmacy at the Central Institution of Science and Technology in Kathmandu.
“Innocent people are being affected,” says Humagain, who is also a member of the Forum of Protection of Consumer Rights. “It’s a violation of consumer rights as well as human rights.”
Humagain, who worked in the Department of Drug Administration for 25 years, says the government can’t always cite lack of manpower for the underlying problems. In the department’s inspection section, there are about seven to eight employees who can work full time if needed, he says.
Currently, there are 41 domestic and 243 foreign allopathic medical manufacturers approved by the department to supply and distribute medicine, Humagain says. But he says that, out of the 41 domestic suppliers, only eight follow and operate under the World Health Organization’s good manufacturing practice, guidelines to regulate quality in the pharmaceutical industry. He says that fake and expired medicine is also a problem among foreign suppliers.
“In order to control and curb, there should be a proper law and order in the country,” Humagain says.
Nepal Health Council, a body under Nepal government, recently partnered with WHO to monitor pharmacies in 22 of Nepal’s 75 districts. It found that most of the pharmacies didn’t have skilled professionals, says Dhana Prasad Poudel, registrar at the council.
“Usually you can find everything at the same store: from tea to lab test and even abortion services,” he says.
Although the council has forwarded some 200 people to the Department of Drug Administration for investigation, Poudel says he doubts that they’ll be punished.
“There’s big corruption in the Department of Drug Administration,” he says. “There’s no honesty.”
Baniya estimates that there are only 12,800 medical centers or pharmacies registered in the country, yet there are some 25,000 stores operating. And it’s not only these unregistered stores that cheat consumers, he says. In order to maximize profits, the registered pharmacies charge more and sell fake and expired medicine, too.
“In Nepal, people are mostly cheated in the health sector,” Baniya says.
Humagain agrees that some pharmacists here are more concerned about earning a profit than improving their customers’ health.
But pharmacists and pharmacy owners say they do their best in a difficult industry.
Gokul Dhital has been running a pharmacy for 14 years in Dhulikhel, an hour’s drive outside Kathmandu. He says it’s difficult to run a store according to the government’s standards, and there always seems to be some lapses. He says renting places, which are not always suitable, and an inability to be at his store all the time also create problems.
Another problem is a lack of qualified staff available to prescribe medicine. In order to run a pharmacy, a person must pass a three-year course to obtain a diploma in pharmacy, as well as receive a license from the Department of Drug Administration.
Adhikari admits that there has been negligence on the issue at the government level, but he also says there has been progress as well.
From 2010 to 2011, Adhikari says that authorities inspected 929 pharmacies in 36 districts. Of these, 107 were shut down, 39 were suspended for operating against the standards and 221 stores received warnings. He says the reasons varied: selling expired medicine, storing medicine at inappropriate temperatures, not having a skilled person at the pharmacy and selling the medicine for more than its cost, among others.
Since Prime Minister Baburam Bhattarai took office at the end of August 2011, inspections and monitoring have gained momentum. Most of the pharmacies that have violated regulations have been closed and asked to improve, says a source in the prime minister’s office who declined to be named.
KC is now in jail for manslaughter after Tamang’s death, and his pharmacy was shut down. His wife tried to reopen it, but locals protested. On the other hand, Sharma and Chapagain say that they haven’t filed formal complaints about the pharmacies that sold them the expired and fake medicine.
After the directive from the prime minister’s office, Nepali media has proactively covered the issue, and consumers have also become more aware about it, Adhikari says. Poudel says that as pharmacists are lured by profits and the government seems to be numb to the issue, the consumers must be aware in order to protect themselves.
Chapagain says he is now aware of the issue and the consequences and will only purchase medicine after checking the date.
“But I’m illiterate,” Sharma says. “How do I even know if the date is correct?”
