ISLAMABAD: A countrywide shortage of cancer, heart failure and other drugs is putting patients’ lives at risk, doctors have warned. Cheaper medicines for leukaemia, diabetes, thyroid problems and thalassaemia have either disappeared from pharmacies or are in dangerously short supply because of pricing and regulation problems in the pharmaceutical industry.

Common drugs for the treatment of conditions like migraine, indigestion, sleep disorders and eye infections have also disappeared in recent weeks. Campaigners believe that drug regulation, registration, pricing and non-enforcement of drug law have resulted in a crisis in Pakistan’s healthcare system.

Patients with low incomes are particularly vulnerable. Seven-year-old Isra Ghazal from Rawat – who was diagnosed with leukaemia, a form of blood cancer, two months ago – was lucky to get her chemotherapy drug, L Asparaginase. She was admitted to Pakistan Institute of Medical Sciences (PIMS) last week but her treatment was delayed for three days because the medicine was unavailable. Her father, Adeeb Iqbal, said he had visited “almost each medical store of the twin cities in his search for the drug but could not find it anywhere.”

Her doctor, who asked not to be named, said her colleagues are forced to use their personal connections to source affordable chemotherapy drugs because their patients cannot afford more expensive alternatives. “We don’t recommend the alternate injection because it costs over Rs170,000 and most of the patients from poor backgrounds can’t afford it,” she said. Isra’s father, who owns a small grocery shop in Rawat, said his daughter had no choice but to wait for the cheaper, more affordable drug. “It costs over Rs4,000 per injection and even that is an extra financial burden for me,” he said.

He spoke of his relief that this time the drug was found and his daughter was able to start her chemotherapy treatment but he fears for the future. “We don’t know what will happen when we come the next time for treatment,” he said. According to oncologists, drugs to treat blood, skin and kidney cancers etc. are in short supply and there are some extremely important drugs that are not registered in Pakistan yet. Some new drugs are available in limited supply but they are out of reach of middle-income families.

“Cancer kills patients but shortage of medicines accelerates their deaths,” said Dr Qasim Mahmood Butter, Oncologist at PIMS. “During chemotherapy patients are administered various drugs in combination and delay in administration of any drug affects the quality of the treatment course.” These shortages mean patients either wait or face exploitation at the hands of unscrupulous suppliers who import cheap drugs from India and then offer them at exorbitant prices to the desperately ill.

Dr Saqib Ansari from National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, said expensive drugs are replacing the cheaper ones gradually in the market and putting treatment beyond the reach of the poor patients. A two months course of L Asparginase leukaemia injections used to cost Rs60,000, but now the cheaper version has almost disappeared and patients are forced to buy the new L Asparginase (paegelatede) which costs Rs370,000. A few can afford it, he said.

Some 500 to 1,000 patients are diagnosed with cancer every year, according to oncologists. Those suffering from other debilitating and potentially fatal conditions are facing the same shortages. Folic Acid is widely-used for preventing and treating low blood levels of those with thalassaemia, expecting and lactating mothers and anaemia patients. The drug has been unavailable for months because local manufacturers have stopped making it and the imported version is too expensive.

Aisha, 23, suffers from thalassaemia, a hereditary blood disorder which causes anaemia, and requires regular blood transfusions, medications and nutritional supplements. Folic acid, which reduces anaemia and boosts the patient’s immune system, is essential but Aisha has not taken it for three months. She had been taking cheap, locally-made versions which cost around Rs30 for a pack of 100 tablets but they are no longer available and even the more expensive brands which cost up to Rs900 are hard to find, she said.

Without her daily dose of folic acid, Aisha feels lethargic all the time, she has to undergo more frequent blood transfusions, and the future will bring yet more suffering. “My organs will start deteriorating if I don’t take medicines properly,” she said. Thalassaemia patients always face issues in getting prescribed medicines, said Dr Naila Yaqub, head of the department of Thalassaemia Centre, PIMS. “Then we try to contact manufacturers through our Cure 2 Children Foundation to provide medicines at affordable rates.”
There are about 30,000 registered patients with the condition in Pakistan but many more who have not been officially diagnosed, and all of them need folic acid every day for life, according to Thalassaemia Federation of Pakistan.

“Poor families all over the country who have one or more thalassaemia children can’t afford imported tablets throughout their life. They have been complaining and demanding the local and cheaper tablets,” says Dr Jawaria Manan, chairperson of medical advisory board of Thalassaemia Federation of Pakistan.

Nutritionists say micronutrients like folic acid are essential when 61.9 percent of Pakistan’s children are anaemic – according to National Nutrition Survey of 2011 – and malnutrition is responsible for 35 percent of under-five death. Dr Irshad Danish, coordinator of Scaling Up Nutrition Civil Society Alliance Pakistan – a coalition of over 100 nongovernmental organisations – said the government must step in and address the medicines crisis.

Manufacturers blame the government too. Many have stopped making the medicines because a price cap introduced by the government has made their production unprofitable. Folic acid is one of those medicines that are no longer produced in Pakistan and others will follow, said Saeed Allawala, Chairman of Pakistan Pharmaceutical Manufacturers Association (PPMA). “It’s better to raise some prices of local medicines to ensure continuing availability instead of allowing imported and smuggled medicines to flood the market that further financially burden already suffering patients,” he said.

Oncologists suggest Pakistan should allow the import of Indian generic medicines which are up to 10 times cheaper than those imported from western countries. Drug regulators insist medicines are being imported from India but doctors in Pakistan say they are hard to find. Aslam Afghani, CEO of Drug Regulatory Authority of Pakistan (DRAP), said the makers of 57 ‘unviable’ drugs who stopped their production will now be allowed to increase prices as an incentive to maintain their availability.

Amid the shortages some desperate families are turning to spurious smuggled drugs from grey markets, said Professor Azhar Hussain, head of pharmacy department at Hamdard University. Some manufacturers are deliberately keeping supply short to inflate prices, he claimed. “The regulator should register new and less expensive drugs to discourage the black market and then force the companies to ensure their availability as per drug act of 1976,” he said. Little Isra and Aisha, however, may not be able to wait that long.