The trust issues

Let us start with a simple thought experiment. Imagine going to a local pharmacy and asking for a drug for a particular ailment. The worker at the counter offers you two options. One made in Pakistan, and one made abroad. Assuming that you have the means to pay, most of us will likely opt for the foreign brand. It is not because of lack of patriotism, or the fact that we want the local economy to suffer. It is most likely because we do not trust the local brand, as well as the entire ecosystem that surrounds manufacture, packaging and supply of the local brand.

Events of the last week with Avastin underscore this lack of trust. The tragic issue at hand is the use of injectable, locally made Avastin, causing vision loss and blindness in dozens of diabetic patients. I cannot even imagine the pain, anxiety and the horror the patients are going through. But I do understand why so many other patients would no longer want to buy other or any Pakistani drugs. Ending up buying local brands are often those who cannot afford anything else.

The Avastin tragedy is not an unexpected or a one-off episode. Poor quality medicines are widely available, to the extent that even pharmacists working at various shops would gladly tell the customer which brands are trustworthy, and which ones are not. Over a decade ago in 2012, the issue of poor quality medicines causing dozens of fatalities at the Punjab Institute of Cardiology (PIC) made global headlines. There were investigations and lawsuits, claims and counter-claims, but the system as a whole did not improve. In the years that followed the crisis, I spoke to dozens of people, from pharmaceutical manufacturers to regulators, from politicians to doctors. There were many who were disturbed and anxious, and wanted to bring a positive change, but by and large, this was a non-issue for the government after the headlines faded away. The incident, one of the worst public health crises in the nation’s history, is probably long lost from our collective memory. Other incidents regarding poor quality medicines are considered so routine that they do not even make the news.

The most recent Avastin incident is awfully tragic, but it is not surprising. While the specific details may vary from one situation to another, the underlying issues are the same. It is the complete absence of a robust regulatory system that is well-funded, well-run, holds the manufacturers and suppliers accountable and is held accountable itself. The national regulator, DRAP, is often in the news, but mostly for the wrong reasons. Regulation is not an ad hoc mismatch of ideas and impulsive actions, but a serious discipline with rigorous foundations. Those foundations have never been laid down in educating or training our regulators.

The government response, while praiseworthy in its speed, is also lacking the long view. The idea to stop the sales is the right one, but the conversation cannot and should not end there. It should not be just about how it happened, but how to stop this from happening ever again. That vision, however, would require asking difficult questions about the ability of the regulators, developing a system that is immune from political interference, overhauling the national drug testing strategy and providing significant resources to maintain effective technologies and hiring of well-trained personnel. I am not sure if there is interest or appetite for that.

At this particular moment in time, there is a lot of discussion about reviving the economy, and getting outside investors to fund projects in the country. There are new national institutions and initiatives that go all the way to the top of the power ladder. But we should ask, why would investors from outside trust us with their resources, if we ourselves are unable to trust the system that protect the things that are most precious to us: our health and our lives. To convince others to trust us, we should build and support systems that we ourselves can trust. Public health should be at the top of that list.

Published in The Express Tribune, September 26^th, 2023.

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