Unease growing in US over medicines made in India

The WHO estimated that one in five drugs made in India are fake.

Unease growing in US over medicines made in India

India, the second largest exporter of over-the-counter and prescription drugs to the United States, is coming under increased scrutiny by US regulators for safety lapses, falsified drug test results and selling fake medicines. 

Dr Margaret A Hamburg, the commissioner of the US Food and Drug Administration, arrived in India this week to express her growing unease with the safety of Indian medicines because of “recent lapses in quality at a handful of pharmaceutical firms.” India’s pharmaceutical industry supplies 40 per cent of over-the-counter and generic prescription drugs consumed in the United States, so the increased scrutiny could have profound implications for US consumers. 

FDA investigators are blitzing Indian drug plants, financing the inspections with some of the roughly $300 million in annual fees from generic drug makers collected as part of a 2012 law requiring increased scrutiny of overseas plants. The agency inspected 160 Indian drug plants last year, three times as many as in 2009. The increased scrutiny has led to a flood of new penalties, including half of the warning letters the agency issued last year to drug makers. 

Hamburg was met by Indian officials and executives who, shocked by recent FDA export bans of adulterated generic versions of popular medicines - such as the acne drug Accutane, the pain drug Neurontin and the antibiotic Cipro - suspect that she is just protecting a domestic industry from cheaper imports. The FDA’s increased enforcement has cost Indian companies dearly – Ranbaxy - one of India’s biggest drug manufacturers, pleaded guilty to felony charges and paid a $500 million fine last year, the largest ever levied against a generic company. And many worry that worse is in store. 

“If I have to follow US standards in inspecting facilities supplying to the Indian market,” G N Singh, India’s top drug regulator, said in a recent interview with an Indian newspaper, “we will have to shut almost all of those.” The unease culminated Tuesday when a top executive at Ranbaxy - which has repeatedly been caught lying to the FDA and found to have conditions such as flies “too numerous to count” in critical plant areas - pleaded with Hamburg at a private meeting with other drug executives to allow his products into the US so that the company could more easily pay for fixes. She declined. 

India’s drug industry is one of the country’s most important economic engines, exporting $15 billion in products annually, and some of its factories are world-class, virtually undistinguishable from their counterparts in the West. But others suffer from serious quality control problems. The World Health Organisation estimated that 1 in 5 drugs made in India are fakes. A 2010 survey of Delhi pharmacies found that 12 per cent of sampled drugs were spurious. 

In one recent example, counterfeit medicines at a paediatric hospital in Kashmir are now suspected of playing a role in hundreds of infant deaths there in recent years. One widely used antibiotic was found to contain no active ingredient after being randomly tested in a government lab. The test was kept secret for nearly a year while some 1,00,000 useless pills continued to be dispensed. 

Sub-standard drugs

More tests of hospital medicines found dozens more that were substandard, including a crucial intravenous antibiotic used in sick infants. “Some of the fake tablets were used by pregnant women in the post-surgical prevention of infections,” said Dr M. Ishaq Geer, senior assistant professor of pharmacology at Kashmir University. Investigations of the deaths are continuing, but convictions of drug counterfeiters in India are extremely rare. Satish Reddy, president of the Indian Pharmaceutical Alliance, said Indian drug manufacturers are better than the FDA now contends. 

Many of India’s drug manufacturing facilities are of top quality. Cipla, one of the industry’s giants, has 40 plants across the country that together can produce more than 21 billion tablets and capsules annually, and one of its plants in Goa appeared just as sterile, automated and high-tech on a recent tour as those in the United States. Cipla follows FDA guidelines at every plant and on every manufacturing line, and the company exports more than 55 per cent of its production, said Yusuf Hamied, the company chairman.
 But Benjamin Mwesige, a pharmacist at the Uganda Cancer Institute in Kampala, said in an interview in July that the institute had stopped buying cancer drugs from India in 2011 because it had received shipments of drugs that turned out to be counterfeit and inactive, with Cipla labels that Mwesige believed were forged. 

He became suspicious when doctors began seeing chemotherapy patients whose cancer showed none of the expected responses to the drugs - and who also had none of the usual side effects. Laboratory tests confirmed that the drugs were bogus, and Mwesige estimated that in 2011 about 20 per cent of the drugs that the institute bought were counterfeit. 

Enforcement of regulations overall is very weak, analysts say, and India’s government does a poor job policing many of its industries. Last month, the US Federal Aviation Administration downgraded India’s aviation safety ranking because the country’s air safety regulator is understaffed, and a global safety group found that many of India’s best-selling small cars are unsafe. 

Absence of oversight

India’s Central Drugs Standard Control Organisation has a staff of 323, about 2 per cent the size of the FDA’s, and its authority is limited to new drugs. The making of medicines that have been on the market at least four years is overseen by state health departments, many of which lack the expertise to oversee a sophisticated industry.

 Despite the flood of counterfeit drugs, Singh, India’s top drug regulator, warned in meetings with the FDA of the risk of overregulation. This absence of oversight, however, is a key reason India’s pharmaceutical industry has been so profitable. Drug manufacturers estimate that routine FDA inspections add about 25 per cent to overall costs. In the wake of the 2012 law that requires the FDA to equalise oversight of domestic and foreign plants, India’s cost advantage could shrink. 

Some top manufacturers are already warning that they may leave, tough medicine for an already slowing economy. “I’m a great nationalist, an Indian first and last,” Hamied said. “But companies like Cipla are looking to expand their businesses abroad and not in India.” 

US businesses and FDA officials are just as concerned about the quality of drugs coming out of China, but the FDA’s efforts to increase inspections there have so far been frustrated by the Chinese govt. Using its new revenues, the FDA tried to bolster its staff in China in February 2012. But the Chinese government has so far failed to provide the necessary visas despite an announced agreement in December 2013, said Erica Jefferson, an FDA spokeswoman. 

The United States has become so dependent on Chinese imports. The crucial ingredients for nearly all antibiotics, steroids and many other lifesaving drugs are now made exclusively in China. 

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