The Disappearance of Lifesaving Drugs
On Vali Asr Street, in a lower-income district of southwest Tehran, a 30-year-old man storms out of a pharmacy. Arash, a bachelor with long hair and a substantial mustache, lives with his father, for whose heart medicine he has been searching fruitlessly.
International sanctions, intended to compel Iran into reversing the development of its nuclear program, have brought not only straitened economic conditions for ordinary Iranians, they have made access to a host of vital pharmaceuticals difficult or impossible.
Arash says that his father had a heart attack a year ago. “His doctor prescribed Carnitine for him when he was released [from the hospital]. The doctor said that it is very beneficial for his heart muscles.”
He says Italy produces the kind of heart medicine his father needs. “It comes as pills and in liquid form. But neither exist [here] these days.” He says his father has tried domestically produced versions, “but they are not useful. They don’t have the effect of imported drugs.”
Arash believes sanctions are to blame for his inability to locate the Italian-produced drug. “Clearly, this is the result of the sanctions,” he says. “When three or four months ago I could purchase this medicine easily, and since I can’t buy them now, then what could be the reason? What happened during this period? We got sanctions imposed!”
He describes three different ways the government could make the medicine available. “First, develop the ability to produce effective drugs itself, or import the required expertise from the West, or third, import the medicine directly.”
“Of these three things, none is about to happen,” he concludes.
The European Union and the United States have both declared that they have not prohibited the export of medical goods to Iran in their sanctions protocols. Last month, when the E.U. ratified a new package of sanctions that effectively prohibits most financial transactions between Iranian and European banks, it explicitly excluded humanitarian assistance and medicine. Last month, the U.S. Treasury Department’s Office of Foreign Assets Control altered its licensing regulations to ease the export of medicine and medical supplies to Iran. Even so, many Iranians say the ban on financial transactions and a prohibitive exchange rate keep the situation from improving for them.
Mahmoud, a pharmacologist in his 50s, works at a 24-hour pharmacy. He requests that neither his real name nor even the approximate location of his pharmacy be revealed.
“The shortage of medicine started slowly about a year ago,” he says. “Imported drugs became rare, and then distributed in rations. Though not as abundant as before, they would show up, and if a person was patient, he would get some.”
He adds, “But in the last few months the shortage has become a crisis.” In July, he says, “medicine supplies diminished dramatically, and patients had to have medicine held aside for them through connections.”
It is 11 in the evening and the pharmacy is quiet, though every once in a while Mahmoud has to tend to a client. I ask him if pharmacies are hoarding scarce medicines. “No, they don’t hoard. They get three or four packages of each medicine, and they hold them for their regular customers. It is the distributors that offer limited quantities to pharmacies.”
In Mashhad, the country’s second-largest city, Elham, a 60-year-old physician who also works at a pharmacy, confirms her colleague’s description. “By way of an example, a distributor allocates 400 packages of a medicine for the whole city of Mashhad and divides that between all the pharmacies,” she explains. “We have between 20 and 30 distributors, who are all private.”
I ask her about domestically made medicines.
“Domestic production, too, started to decline by early September. Usually there would be periodic shortages of one or two drugs. That had become normal since the economic crisis started three years back. It happened all the time. The supply of a few drugs, fewer than the number of fingers on a hand, would now and then decline. It wasn’t like now, when all medicines have become rare.”
She says that among the most important domestic medicines to become scarce are female contraceptives. But is the shortage related to Supreme Leader Ayatollah Ali Khamenei’s statement this past summer that if the state’s population control policy continues, Iran will face an increasingly aging and ultimately declining population?
“Of course many thought that the shortage was due to Khamenei’s warning. But it wasn’t related,” Elham says. She says that the morning-after pill — popularly known as Oorjancie, urgency — has almost entirely disappeared from pharmacy shelves. “It’s impossible to find any.”
Elham mocks Marzieh Vahid Dastjerdi, President Mahmoud Ahmadinejad’s health minister and the first female cabinet member since the 1979 Revolution.
“A few days ago, Mrs. Vahid Dastjerdi asked, ‘Why do they baselessly claim that [contraceptive] medicine has been prohibited? Was Oorjancie prohibited? This is the pharmacies’ ploy to create a black market.'” Elham states emphatically, “This, while those of us who work in pharmacies know that this medicine is in fact unavailable. Really, no medicine reaches any of the pharmacists for them to start a black market!”
Vahid Dastjerdi is an associate professor and a member of the Scientific Commission on Women’s Health and Reproduction at the University of Tehran. In October, according to the semiofficial Fars News Agency, she announced, “The production of conception prevention drugs…has not been restricted. The pharmacies who say those things may be intending to start a black market, or have a special agenda….. We have no shortages of pregnancy prevention drugs, and they are all at the public’s disposal. They are among the most inexpensive pills and can be procured easily.”
But Elham’s description seems to better reflect the reality of the situation. Ali, 20, a waiter in a café on Enghelab Avenue says, mischievously, “Really? There are no Oorjancies? This can’t happen!” He breaks into a wide, sarcastic smile.
All of the anti-pregnancy medicines that have been available in Iran are domestically produced, so why the shortage? I raise the question with Nasser, a pharmacology student in his final semester of graduate school. He does his research for his dissertation in the morning and then works a shift in a pharmacy.
“The fact is that even domestic medicine can’t be produced from heavenly ingredients,” he says. “Usually, their basic ingredients have to be imported. Therefore, the sanctions have not only made imported drugs scarce, they have also made it impossible to produce domestic ones.”
Nasser says that the main ingredient of emergency contraceptive pills is levonorgestrel. “Iran doesn’t produce this,” he explains. “Iran doesn’t produce ingredients for any standard drugs. Even something like ranitidine [the generic name for Zantac], is not produced in Iran, nor is omeprazole [used to treat gastroesophageal reflux disease] and many others.”
Referring to the government, he says, “It claims that it produces the main ingredients of a series of specific drugs, I don’t know what, and that it is producing anti-cancer drugs with domestically made ingredients, and also medicines against M.S. It claims too, that it has decoded the secrets of synthesizing azithromycin.”
I ask him to tell me more about it. “Azithromycin is an antibiotic,” he says. “A couple of months ago they trumpeted that they have decoded its production secret. That’s just one drug, while we see 300 standard drugs [missing].”
Nasser introduces me to his dissertation adviser, Mohammad, who studied in Great Britain. I ask him about what drugs he knows have become impossible to find in recent months. He says Clidinium-C, which is used against gastric cramps, is not available. Worse than that, he adds, is the disappearance of vital blood pressure medicines such as Triamterene-H.
Where do Iran pharmaceutical companies import their main ingredients from?
“Respectable companies, generally procured from Germany — companies such as Sobhan and Bakhtar. But since Germany imposed sanctions, their business has deteriorated. Bakhtar Pharmaceuticals is practically out of business.” He says that according to one of his closest friends, who works at Sobhan Pharmaceuticals, the company recently had to furlough their entire staff for a month due to lack of ingredients and income.
Mohammad says, “I don’t know why Germany and other countries do not supply Iran with medicines and basic ingredients. Perhaps they [are willing to] do so, but Iranian companies don’t have access to enough foreign currency to purchase them.”
With September oil exports dropping to 860,000 million barrels per day, a 60 percent falloff from last year’s average of 2.2 million, the Iranian Treasury’s foreign reserves have been severely depleted. In addition, in the month leading up to October 3, “Black Wednesday,” the Iranian rial crashed in open-market trading from 18,000 to 40,000 to the dollar.
The government has announced that it will provide importers of medicine, as an essential good, hard currency at the official exchange rate of 12,600 rials to the dollar. Yet even the health minister has criticized the Central Bank for not making available an adequate amount of foreign currency for healthcare-related imports. “We have not been able, in any way, to obtain the amount of international currencies that medicine importers need to offer necessary drugs,” Vahid Dastjerdi said a few months ago.
She had previously declared that the Central Bank had exchanged only one seventh of the foreign currency — around 300 million dollars — needed for the country’s foreign medicine requirements. In recent years, Iran has imported roughly two billion dollars worth of medicine annually.
“Basic ingredients from India and China…,” Mohammad begins, then interrupts himself. “I just thought of something. I believe we have foreign currency issues, because if we didn’t, we could procure all the basic ingredients from India and China. But we see all medicines becoming scarce,” he says. “Thus, our problem is not directly a problem of importing medicines due to the sanctions; our problems are due to the economic sanctions pushing the Iranian currency into crisis. We have financial problems. We don’t have foreign currency to pay China to give us basic ingredients.”
Why don’t importers use international monetary exchanges to meet their currency needs? “With a dollar above 35,000 rials, they can’t avoid losing,” Mohammad replies. “They can buy the ingredients, but they would have to sell their products at new [higher] prices, because medicine is under price control. Ahmdinejad’s government can’t provide foreign currency, nor will it allow drug prices to be raised.” He qualifies his remarks. “Of course, there have been some price increases, but few. Amoxycilin was raised from 6,500 rials to 8,000 rials, and gelophen from 5,000 rials to 8,000.”
My next stop is a pharmacy near Vanak Circle. I ask a young pharmacy assistant, Maral, how many times a day someone comes in for medication only to find it unavailable.
“Quite a few,” she replies. “Half of the clients. If not half, then at least one third go back empty-handed.”
Which medicines in particular have become scarce? “Foreign drugs are unavailable for diabetes — truly nonexistent,” says Maral. “Most patients are dissatisfied with domestically made diabetes medicines. Diabetes medicine is a day-after-day matter, which the diabetic patient must use constantly. Three to five times a day.”
What happens if a patient doesn’t? “His blood sugar will rise and he will pass away!” she says with a smile. Shaken, I ask, “What do you mean? He’ll die?”
“Yes, it means that his blood sugar will not be regulated. It will increase and he will die. It’s that simple.” Maral adds, “Domestically produced versions are plentiful, but they are not controlled properly. In fact, patient’s lives get shortened…. I see that the vital foreign drugs we’re missing are metformin and glibenclamide, which, as I said, are for diabetes, causing patients to live only ten years instead of 20 more years.”
She takes care of a customer and then looks over to see if I have any more questions. I ask if there are other lifesaving drugs that have also disappeared.
She names the blood pressure medicine that Mohammad previously mentioned to me. “Triamterene-H is totally nonexistent. But luckily, it can be temporarily substituted for with another one. Foreign psychoactive drugs no longer exist. Especially those who have epilepsy, their conditions can only be controlled by drugs we import, such as Liskantin [one of several Western brands of the anticonvulsant primidone]. If the patient doesn’t take the proper drug, he will have an epileptic seizure.”
And what are the effects of that?
“An attack can occur all of a sudden,” Maral explains. “You might fall, hit your head somewhere, and have a concussion and die. You might be sitting behind a desk and suddenly you’ll fall. Aside from that, a significant number of brains cells are destroyed with each epileptic attack. Your IQ and memory will decline. If you take this foreign-made medicine, your epilepsy will be managed, but if you don’t, you will definitely have a seizure.”
Can Iranian drugs manage epilepsy?
Maral replies, referring to Western-produced primidone, “See, patients would take two doses per day and their conditions were under control. Now that pill doesn’t exist, so they go and take two Iranian-made ones and still have attacks.”
Why is that?
“Because they lack quality. A patient would have to take four now in order to not have an attack. When he takes four, firstly, the drug’s side effects increase, and furthermore, the patient is anxious that he may have another attack, and this stress is very harmful to an epileptic patient.”
A Looming Catastrophe
“For anyone or any group to say sanctions don’t target the people of Iran is childish.”
So said Fatemeh Hashemi of the Foundation for Special Diseases in an interview with Al Jazeera last month. The head of the major Iranian charity group continued, “They’re well aware that sanctions put people under pressure, not the government…. If a drug can’t be imported at all, or only in insufficient quantities, it is the people who will be traumatized.” She said that the constriction on imports of medicine and medical equipment is imperiling the health of up to six million patients.
In a letter sent to U.N. Secretary-General Ban Ki-moon in mid-September, Hashemi, daughter of former President Akbar Hashemi Rafsanjani, wrote, “The importation of medicines that can’t be produced in Iran and certain basic ingredients have become impeded, and it will lead not only to the scarcity or complete absence of certain medicines, but also to the halt of production at several drug manufacturing plants in Iran within a month or two.” She called on Ban to act to prevent further harm to the ill in Iran.
In a U.N. report made public in October, the secretary-general observed, “Even companies that have obtained the requisite license to import food and medicine are facing difficulties in finding third-country banks to process the transactions.”
Patients with cancer, muscular dystrophy, and amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease) are among those most at risk, according to Mojtaba, the proprietor of a 24-hour pharmacy in east Tehran. He talks to me in particular about ALS, a neural system disease that damages the brain and spinal cord. It leads to a slow loss of muscle control and eventually near-total paralysis. Most of those stricken with it don’t survive for very long — British physicist Stephen Hawking is a renowned exception. ALS medication, whose production requires advanced technological processes, has never been manufactured in Iran, which relies entirely on its importation.
I ask Mojtaba what happens if an ALS patient loses access to the medication. “Paralysis sets in,” he replies. “Suddenly your legs lose strength, and eventually your body weakens to the point that you can’t inhale or exhale.”
He adds, “You also have to include hemophiliac patients. If they miss their drugs, they will have unstoppable bleeding. There is an enzyme in the blood that helps it coagulate. People with hemophilia don’t have this enzyme — drugs make it up for them. Imagine what would happen if there was no drug available?”
All I can do is shrug in resignation.
“A cut on a hemophiliac’s hand will not stop bleeding, not tomorrow, never. He will bleed until he dies,” says Mojtaba.
I ask him how things currently stand in terms of access to medicine, especially for those with such critical illnesses. “Fortunately we have not reached the condition where the ill have to be turned away from hospitals, being told, ‘Go away and die, there are no drugs available for you.’ But drugs with the quality of foreign-made ones don’t exist any longer. At least I don’t see any. High-quality domestic drugs have become rare too. Now they are being replaced by mediocre drugs. Thus, patients’ response to the drugs diminishes and the probability of death rises.”
In his estimation, if the current sanction regime continues, at what point will drug shortages yield a human catastrophe?
“In a year!”
He pauses and then offers an even more dire assessment. “If the rate of importation and production of drug remains as is, between six months to a year.
“It is impossible for me to think this government cares about the people. The solution is to barter oil for medicine with India. At least the catastrophe would be prevented. Indian drugs are of higher quality than domestic ones.”
Payman, a young man waiting for his medicine at an adjacent window, joins our conversation. “Yes, the government is ineffectual, but we didn’t have to struggle with such a catastrophe between 2005 and 2011. The E.U. and the U.S. say we have not been forbidden medicine. We are not children. When they block all financial transactions and there is no possibility of trade,” he says, the truth of the matter is apparent.
“It’s an insult to human intelligence,” he continues. “They try to justify themselves ethically. ‘We haven’t prohibited medicine, we only imposed sanctions on banks.'”
Mojtaba laughs in agreement and offers an analogy. “It’s like going to a pharmacy to buy medicine and the pharmacist says that he will sell it to you and you have to pay, except that he won’t accept your payment! You have to pay, somehow, but he will not accept your payment in any form.”
A commotion breaks out at another of the pick-up windows. A spectacled woman in her 50s is arguing with the pharmacy assistant about her order. I approach them to hear better.
The woman begs in a haunting voice, “This is a medicine for the nerves. I need it for my child in high school.” The assistant responds, apparently repeating herself, “This drug has not been around for a long while.”
The mother utters a plaintive Persian expression, “What kind of dirt should I pile on my head?”
Mojtaba advises her, “You should visit a few other 24-hour pharmacies. You may find a few doses.”
Tears well in her eyes. “My son responds only to this drug. Other drugs don’t affect him. He has been taking this medicine for many years.” She adds with a sob, “What am I to do now?”
She leaves the pharmacy crying. Mojtaba turns to me. “There are a dozen of such cases each day,” he says. “My job has become torturous.”
I ask him what illness was involved in this case. “Epilepsy,” he responds. There are “four or five different types of epilepsy, and each type requires a specific drug, but now, medicine for two types are nonexistent and they have to take drugs for other kinds. Its like using one type of antibiotic for all infections.”
The incident has affected others around us. A middle-aged man says, “So, this is the land of the Imam Mahdi.” Devout Shiites believe that the Mahdi, the last of the 12 Imams, will one day reemerge from centuries of occultation as a savior. To rouse popular support, conservative leaders in the Islamic Republic’s ruling apparatus have often promoted veneration of the Mahdi.
Another lady adds sarcastically, “All thanks to Ahmadinejad for his handiwork. We have truly reached independence.” She turns to Mojtaba and asks, “Doctor, isn’t nuclear energy helpful for our sick?” Laughter erupts across the pharmacy.
Later, a conversation I strike up with a car salesman who is smoking outside his showroom in Shahrak-e Gharb, an upper-middle-class neighborhood in northwest Tehran, turns to conspiracy, as most topics with Iranians tend to do. Could President Mahmoud Ahmadinejad, by not allocating foreign reserves to the purchase of drug purchases, be trying to incite a humanitarian backlash against the international sanctions?
“I think they are playing a vicious game, because a year’s medicine needs can be met with a couple of billion dollars. Iran’s foreign currency reserves have declined, no doubt of that, but saying that it is unmanageable, this is doubtful. It is possible that they have intentionally created circumstances that cause drug shortages.”
I ask him if he thinks that the United States would ease economic sanctions in response to international pressure over the issue.
“Improbable,” he says. “The U.S. has embarked down a road which it will follow to its end. It has realized that there are two options: either wipe out Iran’s nuclear program with a military attack, or through economic pressure on food and medicine. And there are no other choices on America’s desk. It has chosen the latter.”
* This article first appeared on The Tehran Bureau. The views expressed in this article are those of the individual who expressed them and may not necessarily reflect the Green Voice of Freedom’s editorial policy.