Correspondence
Inappropriate Drug-Donation Practices in Bosnia and Herzegovina
N Engl J Med 1998; 338:1472-1474May 14, 1998
- Article
To the Editor:
As a pediatrician who worked in Bosnia on four occasions from December 1993 to March 1997, I agree with the description and criticism of drug-donation practices in Bosnia and Herzegovina presented by Berckmans et al. (Dec. 18 issue).1 I wasted many hours in my organization's freezing warehouse, sorting and discarding outdated and inappropriate medical supplies that somehow made their way through the 17 various checkpoints to us in central Bosnia. Although I occasionally discovered wonderful caches of cephalosporins, I usually cursed the idiots whose “altruism” confined me to our cold warehouse with no benefit to any of our patients.
Unfortunately, the “altruism” of Western medical-supply donors has a Bosnian counterpart. Expatriate and local entrepreneurs sell medical supplies on the black market for substantial tax-exempt profits. My most troubling memory is of a middle-aged man whose elderly mother we treated for a stroke in Zenica Hospital. This poor man traded 50 kg of flour for five bottles of mannitol, which his physicians, who supplied the mannitol, assured him would cure his mother. Although 50 kg of flour has little street value in America, it was worth some 1250 German marks, well over two years' salary for a senior physician. More important, 50 kg of flour can feed a family of four for one month. I will never forget the look of despair on the man's face when we told him that the mannitol was useless.
I very much hope that the recommendations by Berckmans et al. will be adopted by the World Health Organization (WHO), nongovernmental organizations, and the medical industry in general. However, I know, as the authors do, that the logical and equitable distribution of medical supplies will not come easily. Too many people, both in the West and in Bosnia, stand to gain too much financially from abusing the victims of war.
1 ReferencesRichard Aplenc, M.D.
Children's Hospital of Philadelphia, Philadelphia, PA 191041
Berckmans P ,Dawans V ,Schmets G ,Vandenbergh D ,Autier P . Inappropriate drug-donation practices in Bosnia and Herzegovina, 1992 to 1996. N Engl J Med 1997;337:1842-1845
Full Text | Web of Science | Medline
To the Editor:
The brief experience of one of us, who directed the distribution of medical supplies in Central Bosnia for Médecins sans Frontières, confirms the findings of critical problems in the provision of medical aid to Bosnia reported by Berckmans et al. With the destruction of the economy by the war, the system of distribution that emerged had neither the virtues of central planning nor those of a market in which individual agents (pharmacies and hospitals) signal their medical-supply needs to the distributing agencies. The result was chaos. Hospitals had ludicrous stockpiles of some medicines but critical shortages of others; the attention of the media and, in particular, camera crews were important determinants of supply; nongovernmental organizations would at times follow on each other's heels, needlessly duplicating deliveries. Despite the proliferation of medical-supply programs by WHO, the International Committee of the Red Cross, Médecins sans Frontières, Médecins du Monde, Pharmaciens sans Frontières, and other organizations, the lack of supplies in hospitals and clinics was the single most frequently cited factor limiting health services during the war.1
For a more efficient and equitable system, we suggest either the introduction of a quasi-market system, perhaps a token economy that could allow the supply mix to meet specific local needs more closely (although this is probably not feasible during a war, given unreliable delivery schedules and perverse incentives to horde) or the reinforcement of a centrally planned system with more reliable instruments and training to assess public health needs, as well as stronger interagency coordination under the leadership of WHO.
1 ReferencesDavid Kent, M.D.
University of Michigan, Ann Arbor, MI 48109-0604Miguel Glatzer
Harvard University, Cambridge, MA 021381
Michael M . Medical supplies donated to hospitals in Bosnia and Croatia, 1994-1995: report of a survey evaluating humanitarian aid in war. JAMA 1996;276:364-368
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To the Editor:
Berckmans et al. describe a response to donated medicines and supplies that I can only call elitist. Perhaps in a European country used to first-class medications and having everything done according to expiration dates, receiving plaster tapes dated 1961 may seem like “dumping.” In other countries and other situations, a truckload of adhesive tape dated 1961 that still stuck would be considered a godsend, not dumping.
The donation of “outdated” medications is presented as another donor sin. The truth is that the expiration dates on many medications are extremely conservative. There is only a very short list of substances for which toxicity is involved when the medication is used after its date of expiration (tetracycline comes to mind). The luxury of having freshly dated medications means nothing to a rural health center when an “outdated” antibiotic used in doses that are perhaps double the usual doses will certainly provide lifesaving efficacy.
This all-or-nothing approach, coupled with penalties for donors trying to do some good with less-than-perfect supplies, will result in increased human suffering.
John B. Hoehn, M.D.
Blue Mountain Medical Group, Walla Walla, WA 99362To the Editor:
Donations of drugs during the war in Bosnia and Herzegovina were essential to meet the health care needs of the population. Coordination and control of donated drugs, as Berckmans et al. point out, pose a difficult task. Although the vast majority of donations resulted from a great impulse of generosity,1-3 many charities often did not have information about the medical needs in Bosnia and Herzegovina and had little experience in health relief work. Donations were often unannounced, inappropriate, and unsorted, and the medicines unknown or expired. In times of war, medicines represent valuable goods. Lack of regulations and control made it possible for any shipment to enter war zones and led to random deliveries to health care institutions ill prepared to receive the aid.
WHO was designated by the United Nations High Commissioner for Refugees as the coordinator of the health-related work of international agencies in Bosnia and Herzegovina. We established a network of eight interagency coordination committees in the mission area to assess needs and coordinate drug supplies.2 As evidence of inappropriate drug donations emerged, we developed and disseminated guidelines and monthly lists of priority needs.4 These guidelines were most effective when systematic control of shipments was possible, such as during the airlift to Sarajevo. Donations that did not comply with our guidelines were rejected.
WHO promoted the supply of essential drugs in the form of prepackaged kits that were designed for specific types of disease and for a defined patient population over a set period. WHO also developed a project for the Mostar area (implemented by Pharmaciens sans Frontières) to improve the management of drug supplies. Appropriate structures and systems were established, the necessary equipment was provided, and staff members were trained.2 Today, this model is operational in Zenica, Tuzla, and Goražde.
Together with local authorities in Bosnia and Herzegovina, WHO estimated that there were about 800 tons of unused drugs in Bosnia and Herzegovina in 1996. WHO never supported the building of incinerators purely for drug disposal. Guidelines for the safe disposal of pharmaceuticals were developed. As an interim solution, the repackaging of unused drugs by making them inert and encapsulating them has been completed in Mostar and Bihac, and the opening of a new sanitary landfill in Mostar is awaited.
WHO has repeatedly addressed the problem of inappropriate drug donations and the coordination and control of donations.3-5 We strongly believe it is best to prevent the problem at the source: donor countries such as Australia, the Netherlands, and Norway have developed guidelines. Consumer organizations and nongovernmental organizations also campaign regularly to sensitize the public to the problems generated by inappropriate drug donations and to promote good donation practices.
5 ReferencesGilles-Bernard Forte, Ph.D.
Richard Alderslade, M.D.
World Health Organization Regional Office for Europe, DK-2100 Copenhagen, Denmark1
Stritof M, Vrhovac B. Report on the receipt and storage of donations and evaluation of drug distribution during and after Croatian Patriotic War from August 12, 1991 to August 12, 1996. Zagreb: Croatian Ministry of Health and State Institute of Health Insurance, 1997.
2
Access, quality and use of essential drugs in the Federation of Bosnia and Herzegovina: report of a situation analysis. Copenhagen: World Health Organization Regional Office for Europe, July 1996.
3
Forte GB. Private donations: an ounce of prevention is worth a pound of cure. Presented at the International Conference of Drug Regulatory Authorities, Amsterdam, the Netherlands, April 18–22, 1994.
4
Guidelines for drug donations: WHO humanitarian assistance, former Yugoslavia. Zagreb, Croatia (Zagreb Area Office): WHO Regional Office for Europe, January 1995.
5
Hogerzeil HV ,Couper MR ,Gray R . Guidelines for drug donations. BMJ 1997;314:737-740
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Author/Editor Response
The authors reply:
To the Editor: Both Aplenc and Kent and Glatzer describe situations frequently encountered during disasters. Inappropriate drug donations during the warfare in the former Yugoslavia were not confined to Bosnia and Herzegovina. The health authorities in Croatia recently issued a report describing an identical problem of massive arrivals of unsolicited and inappropriate medical donations.1 Some sources of inappropriate drug donations have become known. For instance, the Swedish Ministry of Defense has recognized that they sent outdated military medical supplies to Bosnia and Herzegovina.2
We stressed the need for effective coordination of medical relief efforts in disasters, as well as the need for regulations in donor countries to ensure that humanitarian medical supplies comply with internationally accepted recommendations.3 The experiences in Armenia4 and now in Bosnia and Herzegovina have shown that the development of guidelines is not sufficient for effective coordination. Coordination can be implemented only by small teams of experts acquainted with such situations and able to audit health problems and needs continually. Organizations with minimal bureaucracy are best suited to this task. Coordination also suggests the willingness of organizations involved in relief operations to cooperate and to devote to coordination a small fraction of the money used to purchase medical supplies. The lessons of past disasters have been taken into account by some groups, notably the Pan American Health Organization.5
Hoehn defends the view that a donation of expired drugs is acceptable, since expired drugs may retain some of their biologic activity. That is an open invitation to send drugs nearing their expiration date to any area in the world where humanitarian assistance seems necessary. Also, the expiration date has legal importance: in Australia and most other countries, deliberately giving an expired drug to a patient because it is thought to be (probably) still active and without danger may result in a criminal investigation. Why should a potential criminal act in one country be seen as virtuous when other populations are concerned?
5 ReferencesPhilippe Autier, M.D.
European Institute of Oncology, 20141 Milan, ItalyPatrick Berckmans, M.D.
Gérard Schmets, Ph.D.
European Association for Health and Development, 1000 Brussels, Belgium1
Stritof M, Vrhovac B. Report on the receipt and storage of donations and evaluation of drug distribution during and after Croatian Patriotic War from August 12, 1991 to August 12, 1996. Zagreb: Croatian Ministry of Health and State Institute of Health Insurance, 1997.
2
Helberg A. Svenk medicin var för gammal — Bosnier Fick Dålig Medicin (The Swedish medicines were outdated. Bosnia has received bad medicines). Stockholm, Sweden: Dagens Nyheter, December 31, 1997:1, 5.
3
Hogerzeil HV ,Couper MR ,Gray R . Guidelines for drug donations. BMJ 1997;314:737-740
CrossRef | Web of Science | Medline4
Autier P ,Ferir M-C ,Hairapetien A , et al. Drug supply in the aftermath of the 1988 Armenian earthquake. Lancet 1990;335:1388-1390
CrossRef | Web of Science | Medline5
The SUMA Project. A disaster relief supply management system. Washington, D.C.: Pan Amercian Health Organization, 1996.
