Inappropriate Drug-Donation Practices in Bosnia and Herzegovina, 1992 to 1996

Implications

Given the difficulties of humanitarian-relief operations in Bosnia and Herzegovina, the relatively low proportion of inappropriate medicines among the medical supplies delivered in accordance with WHO guidelines is encouraging. Since we did not have access to all the warehouses in which drugs were stored, we have been conservative in estimating the amounts of inappropriate medical donations. Our investigations nonetheless underscore that inappropriate medical donations to Bosnia and Herzegovina were common, as they were to Armenia and Mexico after their earthquakes, (1,2) or to Africa during its food crisis, (8,9) and to the former Soviet Union. (10) Individuals and organizations have many reasons for sending medical supplies to a disaster area. Charitable gifts may lead to tax deductions and represent a convenient way to dispose of waste medical supplies without having to pay for their destruction. Publicity about humanitarian aid usually promotes the image of the people or organizations involved.

Because medical supplies with short expiration dates (one year or less) have little chance of being sold, a charitable gift of such supplies may permit the donor to avoid the costs of destruction. Such medicines can even be sold to donors eagerly searching for opportunities to spend money reserved for an emergency. Shortdated medical supplies might be valuable if used soon after arrival, but it is the responsibility of the donor to verify whether such supplies will be used while they are still valid. If a donor does not have that information, then it is better to refrain from delivering the supplies.

The former Yugoslavia was a signatory to the 1989 Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Disposal. (11) Unused drugs were considered wastes to be controlled. The Basel Convention states that "any transboundary movement of hazardous wastes or other wastes that results in deliberate disposal (e.g., dumping) of hazardous wastes... in contravention of this Convention and of general principles of international law, shall be deemed to be illegal traffic." (11) In France, there are 22,500 metric tons of unused medicines each year -- approximately 40 percent of the drugs marketed annually; 80 percent of the unused drugs returned by individual consumers must be destroyed. (12) The temptation is great to send these medicines elsewhere. In most industrialized nations, legislation is very strict regarding the internal production, sale, and distribution of medicines. Yet there are no established international or national regulations concerning the re-use of surplus medical supplies for humanitarian purposes. (12,13,14,15)

During war, the coordination of emergency aid is particularly challenging, but it is necessary to ensure the best response. In Bosnia and Herzegovina, effective coordination of drug donations was absent; dozens of organizations with disparate agendas provided medical supplies. Moreover, many local leaders were reluctant to cooperate with any kind of central health authority. During a period of four and a half years, no effective system of drug-supply management, monitoring, or reporting was established, in sharp contrast to the substantial funds dedicated to drug donations. This problem has also been discussed by others. (7) Effective coordination could have limited some excesses or deficits of medications and prevented the period of usefulness of valuable drugs from expiring.

The mandate of the WHO Regional Office for Europe in Bosnia and Herzegovina was to lead and centralize the coordination of health-related relief activities. (16,17) However, initiatives taken under its auspices to improve the coordination of medical-supply distribution remained limited. (18) It could be argued that financial constraints were the reason, but the WHO European office received $16 million from various sources to deliver medical supplies to Bosnia and Herzegovina. WHO should work to improve its ability to coordinate relief activities. (19)

Dumping medications and making well-intentioned donations of inappropriate miscellaneous drugs are unacceptable practices. The WHO interagency guidelines for drug donations outline basic principles for providing medical supplies in disasters. (5) There is also a consensus about drug-donation guidelines among numerous organizations often engaged in humanitarian-relief operations. (5,6) We see two principal mechanisms by which these recommendations could be enforced.

In the short term, there is an urgent need for better coordination of the provision of medical supplies. At the onset of a disaster, a permanent coordinating entity should be established. It should act like the conductor of an orchestra, inquiring about needs and adapting demands for medical supplies accordingly, directing appropriate donations to organizations that can use them, responding to offers of humanitarian aid, ordering supplies in the best time sequence, and promptly denouncing inappropriate donations. The coordinating group should delegate to others such logistics as transportation and handling of medical supplies and should neither manage nor be the source of funds donated for relief operations. Procedures could be defined and prepared in advance by experienced organizations and regularly updated. Indeed, such a system would require some willingness to truly coordinate such efforts and to allocate to their coordination a fraction of the funds usually dedicated to medical aid.

In the long term, regulations specifically addressing drug donations for humanitarian purposes should be devised by governments, using the above-mentioned guidelines and the Basel Convention as source documents. The primary goal of these regulations should be to determine the criteria that enable a medical donation to be labeled as "acceptable for humanitarian assistance." Permission to use this label could be granted by health ministries. Donations would have to carry the label before tax deductions could be taken or trucks full of charitable medical supplies could cross borders.

Punitive fines and other sanctions should be directed at companies or institutions that dump drugs. Among other things, the financial burden of destroying unusable donated drugs or eventually returning them to their country of origin should be placed on the donor. These fines and sanctions should be levied and enforced by the governments of the countries in which the donors of inappropriate drugs and medical supplies are located. Such procedures would discourage ill-devised humanitarian initiatives. The Dutch government took such steps in 1994 when it opposed a project to collect unused drugs for humanitarian purposes. (20) We hope that other nations and humanitarian organizations will mobilize to avert the delivery of inappropriate medicines and will resolutely fight the dumping of medications and medical supplies.

Supported by a grant from Medecins sans Frontieres-Belgium.

Patrick Berckmans, M.D.
Veronique Dawans
Gerard Schmets, M.A.E.
Daniel Vandenbergh
European Association for Health and Development
1000 Brussels, Belgium

Philippe Autier, M.D.
European Institute of Oncology
20141 Milan, Italy

We are indebted to Dr. Francine Matthys and to all the people and organizations we met with in Bosnia and Herzegovina, other parts of Europe, and North America for their advice and assistance.

Introduction Quantitative and Qualitative Assessment

Managing the Costs of Inappropriate Drugs Implications

Source Information References