with the actual percentage of poor-quality drugs (Björkman-Nyqvist et al., 2012).

As well as having accurate doubts about individual pharmacies, consumers in places where fake drugs circulate have reason to lose faith in the public health system. A recent systematic review suggests that patients across a range of developing countries already have poor perceptions of the health system, especially the technical competence and clinical skills of the staff and the availability of medicines (Berendes et al., 2011). Poor-quality medicines stand to damage the perception of the health system even more. Qualitative research in China suggests that patients view the loosely regulated private health care system poorly, seeing it as rife with “fake doctors” and “fake drugs” (Lim et al., 2004, p. 227).

During a site visit to Brazil, the IOM delegation heard that, although the Brazilian drugs regulatory authority is strong, the public still doubts the quality of many medicines. Participants consistently attributed this poor confidence to unplanned pregnancies following a 1998 lapse in the quality of oral contraceptives (Associated Press, 1998; Goering, 1998). Anvisa, the Brazilian drugs regulatory authority, was created in response to this and other medicine quality problems (Csillag, 1998). Rumors about contraceptive quality linger in Brazil, a kind of urban folklore. They are evidence, however, that fake medicine can do long-term damage to the reputation of the health system.

Social and Developmental Costs

In a larger sense, trade in falsified and substandard medicines undermines not just the health system but all public institutions. Corruption in the health system can cause patients to assume the drug supply is substandard (BBC, 2012). Falsified medicines are often the business of criminal cartels, including the Camorra crime group in Naples, the Russian mafia, and Latin American drug cartels, and terrorist organizations, such as Al-Qaeda and Hezbollah (Findlay, 2011). These organizations run profitable and untaxed businesses. Organized crime flourishes under authoritarian governments and weak rule of law, both common in developing countries (UNODC, 2009). Criminals grow wealthy under either system, eventually wealthy enough that tacit (or active) collaboration becomes necessary for private citizens and politicians to survive (UNODC, 2009). When criminals control politicians, governments cannot be trusted. Donors are then obliged to withhold development aid, as several countries have done in response to corruption in the Zambian health ministry (BBC, 2010; WHO, 2009).

The sale in falsified medicines funds other criminal activities, buys weapons and ammunition, and conveys power and influence to corrupt officials (Findlay, 2011; UNODC, 2009). The United Nations Office on



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