When she heard that Plaquenil is being used to treat the new coronavirus, Heba al-Zahed, who lives in Cairo and works as a project manager, was alarmed. She immediately called all the pharmacies that she had frequented over the past four years to buy her daughter’s medication. Her daughter is 16 years old and has an autoimmune disease. Zahed must always keep a stock of the drug for her daughter, whose condition can have severe complications.
Zahed’s daughter must also take an imported brand of cortisone because the local version has grave side effects, according to her doctor. “I’ve stocked up on the imported cortisone since the drug shortage crisis two years ago. But the problem now is that my daughter needs thyroid medication because her autoimmune condition that attacks the thyroid gland. I can’t find NeoMercazole, the imported drug, nor Carbimazole, the Egyptian drug,” she tells Mada Masr.
Zahed is not alone in this predicament. Last week, Emad Mostafa, a 21-year-old student at a technical industrial institute in Giza, was looking for medications for his sick grandmother, but he could not find them in pharmacies. He tells Mada Masr that his grandmother needs Ocusol eye drops to treat a cataract in one of her eyes and Farcopril Plus for hypertension. But he could not find either of the drugs in pharmacies.
And Laila Labib, a 61-year-old retired assistant school principal in Mahalla, spent all of last week looking for Unitrexate, a drug for rheumatoid arthritis, which she was diagnosed with two years ago. Labib’s arthritis worsened as she struggled to find the drug.
The current crisis in the pharmaceutical market is not unprecedented. Egypt’s pharmaceutical market has long suffered from recurrent shortages, with the most recent one having come in December 2017, when penicillin G injections disappeared from pharmacies. The market is beset by problems that range from monopolistic practices, smuggling and counterfeiting to a heavy dependence on imported medication. Pharmacists that Mada Masr spoke to in recent weeks have pointed to how these factors have exacerbated public panic, resulting in a shortage of everything from over-the-counter flu pills to psychiatric drugs and vital autoimmune medication.
Mohamed Ibrahim, a pharmacist who lives in Monufiya, tells Mada Masr that the current drug shortages can be explained by the fact that manufacturers do not have control over distribution representatives. Distributors started hoarding drugs to sell them on the black market at higher prices or to distribute them to pharmacies without the usual discounts that guarantee a profit margin to pharmacies, which in turn have to sell the drugs at a fixed price.
Ibrahim explains that there has been a state of collective hysteria for the last few weeks, which has pushed consumers, manufacturers, and even some pharmacies to hoard drugs after information was leaked about a potential shortage.
“People have started hoarding popular drugs, like the one for hypertension. A person who used to buy one pack has now bought enough to last for months. I’ve been running between different companies to procure it. There is also a shortage in some drugs because distributors did not resupply them, like vitamin C, even though they have a stockpile. But now they have a minimum quota of 20 boxes. If I only want five, the distributors will tell me that I need to buy at least 20 boxes. People are sensing that there is a crisis, so they are also buying more,” says Ibrahim.
A pharmacist in the Giza neighborhood of Haram, who spoke to Mada Masr on condition of anonymity, also believes that this crisis was instigated by consumers who stockpiled drugs. “People took way more than they needed, just like they did with food, in order to protect themselves,” he says. “When the decision to suspend flights was enacted, everyone panicked about imported drugs. Companies sealed the stockpile they had, and pharmacists and patients started hoarding medicines.”
Big pharmacies exacerbated the problem, he explains, by buying up huge quantities of medication for fear that their reputations would be damaged and they’d lose customers in the event of supply shortfalls.
This has furthered the shortage of various drugs in the market. “Drugs that have hydroxychloroquine, like Plaquenil for instance, which are used to treat autoimmune diseases, malaria and rheumatoid arthritis, are nowhere to be found now in the market. Originally, this was not a drug in heavy demand. In normal times, I sell five packs per month. But lately, I’ve been asked about it a lot, and I cannot find it,” says Ibrahim, adding there is also a shortage of commonly used medications, such as Paracetamol, Congestal and Comtrex, not to mention insulin drugs.
Hydroxychloroquine has been promoted by the Health Ministry as an experimental treatment for COVID-19. This recommendation follows the publication of a laboratory study that found that chloroquine could block the coronavirus from invading cells. Doctors in China and France have reported that hydroxychloroquine, sometimes combined with the antibiotic azithromycin, seemed to help patients. But those studies were small and did not use proper control groups, and the French report was later discredited. On March 22, the Egyptian Drug Authority issued a statement warning against the use of medications with hydroxychloroquine, which can cause myocardial inflammation and fibrosis.
Ali Ouf, the chairman of the Drug Division in the Federation of Egyptian Chambers of Commerce, confirms that there is a shortage of Plaquenil on the market, a drug he agrees is vital. There are six factories that manufacture Plaquenil, according to Ouf, who adds that the Health Ministry has now intervened in the production process. These are exceptional circumstances,” he says. “The factories are still manufacturing, but under the supervision of the ministry because, if left to the market, the drug will vanish. And the ministry cannot afford to run out of medication for a COVID-19 patient.”
However, Ouf warns against the unsupervised use of Plaquenil, which can have negative side effects on the retina, liver and kidneys. Children and pregnant women are also not allowed to take it. And the prescription dose has to be determined by a doctor. Ouf stresses that overuse of the drug can also worsen the complications of the virus and push it to mutate.
Beyond hydroxychloroquine, the list of drugs missing from the Egyptian market runs the gamut. Consumers can’t find Clopixol, a medication that is used to treat schizophrenia and addiction. Nor can they find Philozac, the cheaper Egyptian alternative to Prozac, according to the pharmacist in Haram, who added that he usually buys 10 packs of Philozac, but that he could barely find two packs as it is now in demand. Panadol, a brand of acetaminophen, is also not easily available. “I used to buy 1,000 packs at a time, and now I have to run around just to find two or three packs,” the pharmacist in Haram says.
In some cases, counterfeit and smuggled products have filled the gap left by shortages. This is the case with isopropyl alcohol — specifically, the 70-percent alcohol solution, according to the pharmacist in Haram. And even after a factory announced that it would provide one-liter bottles of ethyl alcohol, there was a shortage in containers, the price of which jumped from LE0.50 to LE5 per container.
On March 23, the Ministry of Military Production announced that it would sell ethyl alcohol solutions in its retail outlets, but the Haram pharmacist said that he could not find them in two of the ministry’s retail stores in his neighborhood.
According to Ouf, Carbimazole, the medication Zahed needs to treat her daughter’s thyroid condition, has been subject to smuggling and black market sales due to a drop in its price. However, he says that 500,000 packs of Carbimazole are currently being manufactured and will be distributed on the market soon.
Ibrahim is also worried about the rise of counterfeit drugs. “We pharmacists always say that 30 percent of drugs in the pharmaceutical market are counterfeit. And under the current circumstances, there is more space for producing counterfeit medicines. This can happen by refilling used and registered medicine packs. There have been some violations by private pharmacies. The pharmaceutical market needs better policies and stronger oversight,” he says.
In the face of the myriad problems, Ouf and Ibrahim note that there have been initiatives from individual pharmacists. Ouf has called on pharmacies not to sell any drugs — with the exception of flu medication — without medical prescriptions. And Ibrahim says that some pharmacies have put a cap on selling certain drugs, a measure that pharmacists do not see as the most effective, given that a patient can send all of their family members to buy up a large quantity of the same drug.
Oversight and drug policy falls under the purview of the Egyptian Drug Authority, which organizes the activities of pharmacies, including the registration, distribution, and monitoring of pharmacological products and supplies as well as guaranteeing their availability, quality, and safety. A law was passed in August 2019 to establish the EDA. It was enacted in January by presidential decree. The EDA is now under the direct supervision of the prime minister, whereas its older version, the Central Administration for Pharmaceutical Affairs, was under the supervision of the Health Ministry.
The main purpose behind the establishment of the Egyptian Drug Authority was to address drug shortages, counterfeit drugs, smuggling, weak oversight of monopolistic practices and the obstacles facing local drug manufacturers in Egypt.
Mada Masr tried to reach the chairman of the Egyptian Drug Authority for comment, but he did not respond to our questions by the time of publication. On April 1, however, reports from the Health Ministry asserted that there are enough vital drugs and raw materials to last six months. This includes insulin drugs, Epoetin, which is used for chronic kidney disease, as well as other medications for chronic diseases. The reports added that all of these drugs are available in ministry and universal health insurance hospitals.
On March 17, sources told Al-Mal newspaper that the EDA is coordinating with local pharmaceutical companies to find ways to procure raw materials from countries other than China.
Ouf explains that all the unavailable drugs are available in ministry-affiliated pharmacies. There are roughly 18-20 of them across the country. According to Ouf, those pharmacies do not dispense drugs without a medical prescription.
Despite officials’ insistence, patients who Mada Masr spoke to say that they have faced difficulty in finding medications at government hospitals and that there remain hurdles in obtaining prescriptions amid the pandemic.
Laila Labib, who has rheumatoid arthritis and has health insurance, tells Mada Masr that she went to her doctor at the beginning of April, who wrote her a prescription that she took to two of the universal health insurance pharmacies. But she could not find the Unitrexate injections she needed, so she was forced to buy them from a private pharmacy. After much searching, she was able to buy enough for an additional month, as the ampule only contains enough for one injection per week over the course of one month.
Mostafa highlights a different problem, which is the difficulty to go to a doctor to prescribe a new, available medicine at the present moment, not to mention the difficulty of convincing his 80-year-old grandmother to change her medication after relying on it for years.
As for Zahed, who has become an expert on the black market due to the recurring shortage of her daughter’s drugs, she tells Mada Masr that she has never found the medications she needs in the ministry’s pharmacies in times of crisis. “The Health Ministry pharmacies are all about personal connections,” she says. “If they don’t know me, they won’t give me the medicine.”