Among U.S. Donations, Tons of Worthless Drugs
By Reed Abelson
Last month, Project Hope, the American medical charity, shipped $1.5 million worth of emergency supplies to the Kosovo refugees. But relief workers desperate for syringes, penicillin and insulin found many of the hundreds of boxes instead contained Chap Stick, Preparation H and anti-smoking inhalers -- given by U.S. companies that got a tax break for the donations.
The outpouring of aid from corporate America and elsewhere for the roughly 700,000 refugees that flooded Albania and Macedonia during the war between NATO and Yugoslavia was indeed massive and included many badly needed medicines. But the World Health Organization said about a third to half of all of the shipments were essentially useless and are likely to just gather dust in warehouses or be destroyed at government expense.
Some shipments contained medicine not suited to the needs of the refugees or drugs that would expire before they could be given out, according to the World Health Organization and some of the relief agencies on the ground responsible for overseeing medical care.
The problem arises, critics say, as there remain far too many incentives for companies to empty out their warehouses, regardless of need, and for charities to ferry the supplies along. What particularly upsets the critics is the belief, especially prevalent among American donors, that any gift is better than none.
The shipment from Project Hope, the Milwood, Va., charity best known for health education, for example, included lip balm, hemorrhoid ointment and bottles of Robitussin cough syrup, courtesy of American Home Products, according to an inventory of the items. Other boxes contained Nicotrol anti-smoking inhalers and endless varieties of Tylenol, including a children's fruit-flavored remedy for sinus pain, all contributed by Johnson & Johnson.
"I can tell you from being in refugee situations in the last eight years, refugees need Chap Stick, Preparation H and Robitussin," said Jack Bode, the vice president of development and communications for Project HOPE.
Items like Chap Stick and Robitussin represent only a tiny fraction of the nearly $5 million worth of shipments that Project Hope said it is sending to Macedonia. Of that, most drugs are either antibiotics or gastrointestinal drugs. The charity also said that all of its donations were reviewed by the Ministry of Health in Macedonia, which requested the items -- including the Nicotrol inhalers for use in a pilot anti-smoking program.
Like many of the drug companies that make donations, American Home and J&J spokesmen say they rely on the charity collecting the donation to make sure the drugs are needed. In addition, American Home's spokesman said the company has provided a "significant amount" of penicillin to the refugees.
Indeed, in the world of corporate giving, relief workers have learned to take the good with the bad. Another recent shipment to Macedonia contained drugs that expire within a few months, according to a relief worker. While some of the drugs are exactly what the doctor ordered, some were given in such tiny amounts as to be virtually worthless.
Mixed bags like these are not unusual, according to some relief workers who are responsible for dispensing donated drugs or, if they cannot be used, destroying them. Despite the efforts of governments and major relief agencies to oversee the quality of the drugs, "large quantities of donated medicines are not usable and wasted," said Gilles Forte, a World Health Organization adviser in Copenhagen, Denmark.
While hard numbers are impossible to come by, Forte estimates that as much as 30 percent to 50 percent of the drugs being sent may be essentially worthless.
The problem is expected to worsen as the refugees stream back into Kosovo. With no central authority in place to provide much in the way of oversight, relief workers say that they fear widespread dumping, worse even than what they saw in Macedonia and Albania.
"Kosovo is going to be the big one," predicted Sebastian Fouquet, who has been heading the relief work in the region for Pharmacists Without Borders, a French group that oversees the delivery of medicine.
If Fouquet is right, Kosovo will be only the latest area to be besieged with inappropriate donations. In Bosnia-Herzegovina, for example, possibly as much as half of the roughly 30,000 tons of donated medical supplies were of little or no use, according to an article that appeared in late 1997 in the New England Journal of Medicine. The cost of destroying those drugs is estimated to be upward of $30 million -- $2,000 per ton.
Charities like Pharmacists Without Borders do not want these useless donations, said Sophie Logez, who has been working for the group in Macedonia. "We worked in Bosnia for two years, and we have spent a lot of money destroying drugs," she said. "That is what we want to avoid."
The situation in Bosnia, as well as examples of useless and potentially harmful donations in Armenia, Sudan and Lithuania, helped solidify support for the voluntary guidelines issued by the World Health Organization and other agencies in 1996, which were revised earlier this year.
The guidelines generally call for donations to be based on what is needed -- a list of priority drugs generated by the country, if possible -- and given only with the consent of those distributing the drugs. The guidelines also suggest that drugs have a shelf life of at least one year. While expired drugs may still be effective for a while, critics worry that outdated medicines add to the confusion and look like an ungenerous way for drug companies to get rid of medicines that they cannot sell.
But critics say that some groups are ignoring these standards. When Heart to Heart International, a Kansas charity founded by a doctor, was given a draft of the guidelines by the WHO just as they were being formulated, it chose to ignore them, according to the Community Development Medicinal Unit, a not-for-profit organization in Calcutta, India, which said it contacted the charity about an incoming shipment.
In April 1996, what the charity claimed was $12 million worth of drugs arrived. But the Calcutta unit said that it determined that nearly all the drugs were nonessential. None of the medicine could be used to treat its most pressing cases of leprosy and tuberculosis, and some of the drugs were already past the expiration date.
Certain drugs "are very, very hard to procure," said Barbi Moore, the senior vice president of international programs for Heart to Heart. She said that the group does not send drugs with a shelf life of less than six months, although records of the shipment indicate drugs were sent that expired in less time. The donations were approved by the proper officials, she said, and she noted that Heart to Heart has worked hard since then to improve its system.
Discarded drugs are a particular problem, as they are considered chemical waste and their disposal is strictly regulated. In Croatia, for example, the estimated 700 tons of medical waste, including packaging and needles, donated during the war and afterward is expected to cost roughly $3 million to destroy, and the World Bank is considering helping to finance some of the cost.
In the meantime, companies have every incentive to keep giving and recipients have every incentive to take what comes. "This is not a single-cause problem," said Michael Reich, a professor at the Harvard School of Public Health, who expects to publish a detailed study of drug donations in late August.
American companies, for instance, are eligible for twice the normal tax deductions when they participate in a humanitarian effort. They also are able to shed old or slow-moving products, and save the cost of disposal. In some cases, companies may view giveaways as a form of sampling that can introduce new markets to their products.
The charities, which are under intense pressure to prove to their donors how much good they are doing, are also at the heart of the problem. They serve as middlemen between the drug companies and the hospitals and clinics receiving drugs.
Some may be too eager to accept donations regardless of their actual value, because the donations help inflate both the amount they claim to be raising and the amount that they claim to be spending on the needy. This, in turn, makes them look more efficient than they are, by turning their overhead into a smaller fraction of their revenues.
Many recipients of the donations -- those small hospitals or clinics -- are also reluctant to speak up. "Donations, as a rule, are not refused," explained one recipient who participated anonymously in a recent survey conducted by the World Health Organization. "Health professionals believe that if they refuse to receive some drugs, they get nothing in the future. Their stance is: Be content with 5 to 10 percent of all that is offered."
Those who balk risk being cut off from future gifts. "This is a kind of dilemma for our units," said Sister Nympha Que, a Medical Mission Sister in Malawi, one of the poorest nations in southern Africa. "If they say something to our donors, there is a fear that the donations would stop."
No one seriously expects governments in every case to speak up against the practice, either. Many rubber-stamp the shipments lest they set off diplomatic waves and offend donors at a time when they may be desperate for foreign aid.
And some companies turn the pressure up by insisting that charities take unwanted donations as a condition for getting the things they really need. A relief worker in Macedonia for CARE said his group was offered what seemed like a package deal: baby food, which was welcome, and infant formula, which was not.
Most relief organizations see formula as undermining breast-feeding and rightly worry about whether refugee camps or poor regions have the proper sanitation to make sure bottles and other supplies are sterile. The deal was refused.
But even the critics say that most of the charities and corporations work together in ways that clearly save lives. During the current Kosovo refugee crisis, the Albania Ministry of Health singled out a donation from Glaxo Wellcome, valued at more than $1 million, as including "a good quantity of medicines with a very good quality."
And then there is also one solution to the problem, which happens when some companies actually part with cold cash -- allowing the relief agencies to buy whatever they need.
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Carl Remick