In Battambang, Cambodia, a western province full of poor farmers barely managing to grow enough rice to live on, the top government official charged with fighting malaria is Ouk Vichea. His job—contending with as many as 10,000 malaria cases a year in an area twice as large as Delaware—is made even more challenging by ruthless, increasingly sophisticated criminals, whose handiwork Ouk Vichea was about to demonstrate.
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Standing in his cluttered lab only a few paces wide in the provincial capital, also called Battambang, he held up a small plastic bag containing two identical blister packs labeled artesunate, a powerful antimalarial. One was authentic. The other? "It's 100 percent flour," he said. "Before, I could tell with my eyes if they were good or bad. Now, it's impossible."
The problem that Ouk Vichea was illustrating is itself a scourge threatening hundreds of thousands of people, a plague that seems all the more cruel because it is brought on by cold, calculated greed. Southeast Asia is awash in counterfeit medications, none more insidious than those for malaria, a deadly infectious disease that is usually curable if treated early with appropriate drugs. Pharmacies throughout the region are stocked with the fake malaria medicine, which is generally cheaper than the real thing.
Artesunate, developed by Chinese scientists in the 1970s, is a leading antimalaria drug. Its active ingredient, artemisinin, comes from the wormwood plant, which ancient Chinese herbalists prized for its fever-reducing properties. Between 1999 and 2003, medical researchers conducted two surveys in which they randomly purchased artesunate from pharmacies in Cambodia, Myanmar (formerly Burma), Laos, Thailand and Vietnam. The volume of fake pills rose from 38 percent to 53 percent.
"This is a very, very serious criminal act," Nicholas White, a malaria expert at Mahidol University in Bangkok, Thailand, says of the counterfeiting. "You're killing people. It's premeditated, coldblooded murder. And yet we don't think of it like that."
Nobody knows the full scope of the crime, although the World Health Organization (WHO) estimates that counterfeit drugs are associated with up to 20 percent of the one million malaria deaths worldwide each year. Reliable statistics in Southeast Asia are hard to come by, partly because the damage seldom arouses suspicion and because victims tend to be poor people who receive inadequate medical treatment to begin with.
That dimension of the problem was made clear to me by Chem Srey Mao, a 30-year-old farm laborer in Pailin, Cambodia. She said she had been sick with malaria for two weeks before she finally visited the district's main health clinic, a one-story building with a handful of rooms. She had been dosing herself with painkillers so she could work in the fields, sometimes collapsing in the afternoon with fevers and chills. "I needed the money for medicine and food," she said. "I had to work."
The most afflicted populations live in remote, rural areas and have limited access to health facilities. An estimated 70 percent of malaria patients in Cambodia seek treatment at local village vendors, who don't have the expertise or resources to distinguish real pills from counterfeits.
"The first time they get sick they go to a private clinic or small pharmacy," Ouk Vichea says. "Only when it's severe do they go to the hospital." And then it's often too late.
Compared with what Americans typically pay for drugs, genuine artesunate is cheap in Southeast Asian countries—around $2 for the standard treatment of a dozen pills. But that's still 20 times more expensive than an earlier antimalarial, chloroquine, now seldom used because the malaria parasite has evolved resistance to it. And in Cambodia, where the average per capita income is just $300 a year, the nickels or dimes people save buying counterfeit artesunate pills represent significant savings. "It's the number one fake," says Ouk Vichea.