not work. Poor-quality medicines cause treatment failure, but doctors do not generally suspect medicines as a cause of disease progression. Lifesaving medicines can be of poor quality, which may be an uncounted root cause of high mortality in low- and middle-income countries.

No class of drug is immune to being compromised. Medications for chronic and infectious diseases alike have been found falsified and substandard. A considerable body of research indicates that inexpensive anti-microbial drugs in low- and middle-income countries are frequently of poor quality. Such drugs not only put patients at risk but also encourage drug resistance, thereby threatening population health for future generations.

Substandard antimicrobials often contain low and erratic drug doses, while falsified ones can be diluted. In either case, exposing pathogens to subtherapeutic doses of medicines selectively allows the growth of resistant organisms. Poor-quality drugs have contributed to the rise of drug-resistant tuberculosis. Drug-resistant staphylococcus infections are an emerging problem, especially in India, Latin America, and sub-Saharan Africa. Antimalarial resistance threatens to undo the good that artemisinin therapies have done, threatening global malarial control programs.

THE ECONOMIC AND SOCIAL EFFECTS OF
SUBSTANDARD AND FALSIFIED MEDICINES

Falsified and substandard drugs increase costs to patients and health systems. Medicines are expensive; patients and governments waste money on ineffective ones. Lingering illnesses decrease productivity, causing workers to forgo pay and spend more on treatment. Through encouraging antimicrobial resistance, illegitimate medicines reduce the effective life of a drug. Society must bear the cost of drug development, an expense that increases as drugs become more complex.

Substandard and falsified medicines undermine confidence in the health system and in all public institutions. Fake5 drugs are often the business of criminal cartels. Their sale finances other crimes, buys weapons and ammunition, and conveys power to corrupt officials. Victims of falsified and substandard drugs usually do not even know they are victims and are therefore deprived of their right to redress. In many ways, the trade in illegitimate pharmaceuticals further erodes the already weak political infrastructure that allows them to circulate, part of a vicious cycle of poverty and crime.

THE MAGNITUDE OF THE PROBLEM

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5 As the report explains later, fake is a commonly used synonym for falsified.



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