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How the illegal sale of cancer drugs works

For three months, a reporter of Armando.info followed the lead of a seller exclusively engaged in diverting oncology medicines from state institutions to the black market, where they can be sold at 300 times higher prices. Her motivation was some basic questions: Are they angels or opportunists? How do they organize their networks? Still with unresolved doubts, she finds that it is a trade that has become possible only in the aftermath of the Bolivarian revolution in Venezuela, in the midst of chronic shortages and bureaucratic controls.

25/09/2016 12:24:59

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It does not take many speculations to understand why someone would resort to the illegal market in a country with medicine shortages of around 86%, according to the Venezuelan Pharmaceutical Federation. It is already becoming a common practice in Venezuela, hand in hand with the crisis.

However, few talk about it. Fear for doing something illegal and exposing the person who gives them a small dose of life —though often at the expense of denying that same dose to another patient— predominates.

Ana (a fictitious name to protect her identity) has been an oncology patient. When facing the disease, she faced the dilemma of submerging or not in the underground medicine market. She continues today with the maintenance cycles that the doctor prescribed, but the hardest phase of treatment has ended. You could say it is out of danger. "What they do with us is not human. Nobody should resell cancer drugs," she said in a first contact. A few months ago, she ran out of Avastin, a monoclonal antibody that is used in the treatment of different types of cancer, such as breast cancer. "I needed it. It is distressing being sick and topping it with worries. When they diagnose cancer, they tell you to avoid stress," she explains, face to face, in Maracaibo, the capital of the state of Zulia (northwest of Venezuela), where she lives. It was at the clinic there where she came into contact with the illegal drug market. Her treating doctor gave her a phone number. "He told me that I could get what I needed there. He had already talked with other bachaqueros [Editor’s Note: Spanish name given in Venezuela to black market traders] but they did not fulfill. I paid good money and I was left with nothing."

The seller seemed to have everything when there was hardly anything in the country. "For example, he had filters for Taxol [Editor’s Note: a taxane that prevents the growth of cancer cells, used for breast and lung cancer and Kaposi's sarcoma] when they were scarce. He could easily have everything I asked for cancer treatment. He said that he and a girl who worked with him could get me everything." Ana made several transactions with him. She paid to his checking account and a friend picked up the merchandise in Caracas and took it to Maracaibo.

How was it possible to have such a supply of high-cost medicines? Were they stolen, brought abroad or falsified? To clear those doubts and understand how the black market of high-cost medicines works it was necessary to have, at least, some samples of the merchandise that the dealer handled.

Contact and First Encounter

In order not to raise suspicions, the author of this story pretends to be a customer. Using a pseudonym, she contacted R.L. She requested Methotrexate 2.5 mg tablets, which is used for psoriasis and rheumatic arthritis, but also in the treatment of breast, skin, head, neck, and lung cancer. The sale price per sheet or blister of ten pills is Bs. 8,000 (about eight dollars at the average exchange rate of the illegal parallel market). The payment can be made by deposit or transfer to two accounts in Mercantil and Banesco banks. The trader offers to send it by private courier, although through the MRW parcel service only, with a charge of Bs. 850, or in person, if it is in Caracas. As the latter was the case, Plaza the delivery was agreed to be in Plaza El Cónsul in La Guaira (state of Vargas, central coastal region), in front of the fishing pier popularly known as El Mosquero, on a Saturday morning.

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The encounter lasted just a few minutes in a square full of people, cars, buses, and bustle. At no time could it be determined if he was alone or if more people watched the scene. The objective of the meeting, which was covertly recorded, was to obtain a medication to prove its origin and reliability, as well as to test the dealer and his selling ability. The reporter got the blister of Methotrexate from R.L. But, to continue building trust, she also asked for a supply of a sufficient amount of Avastin for a one-year treatment.

R.L. said he has it. He took a different way to leave.

The drug name brand of Methotrexate tablets is Emthexate, imported by Laboratorios Elmor in Venezuela. The sample corresponds to lot 3A406027, with sanitary permit E.F. 30.975/09 and date of issue 06-2019. Elmor confirms that it was received at its plant in Carabobo on January 14, 2015, and that the lot was distributed to the Drug Bank (Badan) and the Venezuelan Institute of Social Security (IVSS), both State institutions with headquarters in Caracas.

"As we agreed, I am forwarding you the email from our Quality Director, Dayana Franco, confirming that the product EMTHEXATE 2.5 mg tablets, Sanitary Permit E.F. 30.975 / 09, and Date of Issue 06-2019, actually belongs to lot 3A406027, containing 8618 Units... They were received in our Plant on 01/14/2015 and distributed to the Drug Bank (BADAN) and the IVSS Caracas. However, it is important to emphasize that since you did not acquire it in BADAN or in the IVSS, naturally, we do not know if it has suffered any type of alteration due to factors such as temperature, storage location, content manipulation, etc., which is obviously beyond our control because they were not purchased in the places authorized to sale this type of medication. Please contact us should you need any information."

The communication of the pharmaceutical company, of which a segment is transcribed, is final: the medicine is real; it is part of its importation.

On the other hand, it does not provide answers about its origin. Is it from Badan or the IVSS?

A few days after the first meeting, we sent another text message to R.L.

- How are you? Look, I have several friends who would like to know what medications you have for sale. You know that it is very difficult to find several things.

- Only oncology medicines. I do not deal with general medications...

Necessary Parentheses: How are the Medicines Distributed?

The pharmaceutical union estimates the Venezuelan Government’s debt with its affiliates in
US$ 9,000 million. They cannot produce many of the medicines that used to be made in the country due to lack of inputs, and they are not imported because they do not have the foreign currency. The solution of the Government is to import certain quantities of medicines under the promise of paying ipso facto to the laboratories in the country or to the parent companies abroad. "They buy based on the money they have, import in an epidemiological plan, not based on planning," explains a sector source, who rather be anonymous. In many cases, they buy surpluses from other countries; in others, "they sell the medicines without registration, there is no drug supervision, no support".

When it comes to high-cost medicines, such as those for cancer or the treatment of the human immunodeficiency virus (HIV), only some institutions are authorized to import: the IVSS, the Ministry of Health, the state oil company PDVSA or Military Health; also the Drug Bank, known as Badan, which retails in stores open to the public.

It is the first link where merchandise theft could occur, especially if inspections are made at night, when there is fewer staff in the warehouses.

Once the medication is purchased from the laboratory, it is sent from the country where it is under strict control. The bulk is photographed and weighed and the exact amount of merchandise is specified. To know if there was an "unwanted" alteration at any time, a device called a temptale —a temperature meter with memory that records if there are changes in storage and transport conditions— is placed in some packages. The box containing it is not revealed. If the box is opened or removed from the cold rooms in which they must be in some cases, i.e. if there is improper handling, the device registers it. When arriving by plane at Simón Bolívar International Airport in Maiquetía, which serves to the city of Caracas, they are stored in the warehouses of the airline company that transported them. If they are medicines that need a cold chain, they will be stored in refrigerators. They are also weighed there, and the packages are verified for damages. They may stay up to two days in customs, waiting for an agent of Seniat (the tax and customs office) and another of Cencoex (the foreign trade authority and foreign currency administration) to review the cargo. If they do not require the cold chain, they are opened. Here is the first link where merchandise theft could occur, especially if they are inspected at night, when there is fewer staff in the warehouses.

The next opportunity waits in the merchandise dispatch. The customs agent hires a third party who is responsible for the transfer and the high-cost drugs are taken to the IVSS warehouses in Guarenas (commuter town east of Caracas, in the state of Miranda). According to what the IVSS determines, the merchandise will go to hospitals, the warehouse or another particular destination. Theft can also occur on the way to these places.

In the last link - the health centers - there is another opportunity to divert the destination of the medicines. R.L. works precisely in a hospital, which could be verified for this report.

Second Encounter

After a few weeks of the first encounter with R.L., the contact was resumed. On this occasion, he was asked about the availability of Taxol, Doxorubicin and Tamoxifen.

-Taxol and Tamoxifen only. Doxorubicin has been out of stock for a month and a half. And there is none in Venezuela.

- And do you know when you will have it again?

- No idea, my friend. I have to wait for the early month orders to see if it arrives.

-When, more or less? Just to be aware.

-From the 5th to 10th of each month.

This dialogue would provide a first version to refute the explanation that R.L. then offered to describe how his network works. This will happen at the third encounter, when the customer revealed herself as a practicing journalist.

Taxol is ordered, an vial that requires refrigeration and for which Bs. 13,000 (equal to US$ 13 on the black market) will be paid, this time in cash and in hand. R.L. ensures that the cold chain for the medication was maintained. In fact, to do the delivery, he requires you to bring an ice box. After completing the requirement, he adds: "I have Paclitaxel of 300 mg, which is the same as Taxol". This information will also serve to clarify the origin of R.L.’s merchandise.

The next encounter for the delivery is scheduled at three in the afternoon at the food fair of Expreso Chacaíto mall, in the geographic center of Caracas, on the border between the Libertador and Chacao municipalities. Once again, he seems to be a cordial and good-looking young man, with a neat cut beard, soft manners, and clothing intended to be trending. The novelty is that this time, he does not come alone. He is flanked by a group of five men. All wait seated, many of them with ice boxes. R.L. said that they are friends and denied that they work together or that they even know what he is doing. In the exchange, he looks calmed, does not hide when he takes the Paclitaxel out of his ice box or when he takes the envelope with 130 bills of Bs. 100 that the reporter gives to him, neither when he offers and shows the filter that is needed to apply the medication.

The exchange concludes in less time than in La Guaira. One of those accompanying R.L. stands up from the table "to watch" something that the reporter cannot understand. He returns after a while. He is big, the most corpulent of the group. After receiving the Paclitaxel and leaving the place, the group remained a while longer, moved around the fair, returned to the site and left again. Later, it was verified that some of them watch out the area, like the watchmen of the organized crime.

For several days, the reporter went back to the mall to check if the group was delivering merchandise there, but they were not seen, at least in those days.

Paclitaxel 300 mg is a medicine obtained in Venezuela through Lapreven S.A. The product is imported from Argentina, "legally, with all the permits," as the responsible of the laboratory emphasized to the reporter. The sample belonged to Lot 6207/D with delivery date 03.2017. LaPreven informed by email that this lot was sold to the IVSS Main Warehouse only, but did not indicate date of arrival to the country or delivery.

The sample was taken to their offices in Torre Financiera in Bello Monte, Caracas, but they did not accept the medication and suggested taking it to the Instituto Nacional de Higiene Rafael Rangel (National Institute of Hygiene - INHH) to do the relevant analyzes or to the IVSS itself to file the pertinent complaint "so that the hold Lapreven harmless".

The next step was to take the vial to the INHH inside the ice box, with ice. There, the sample was delivered with a form for analysis and to determine whether the sample was adulterated or falsified. It was reported that the results would take from 15 days to a month. However, long after, at the time of writing this note, the results were not yet available.

Third Encounter: Revelations

Without any purchase in between and with the excuse of clarifying some doubts about several medications, a new appointment with R.L. was agreed, alone, at the same food fair where Paclitaxel was delivered a few weeks before. He appears nervous, repeatedly checks the phone, send text messages to someone. He is informed that he has been negotiating with a journalist. The reporter asks him, as he is in the open, to guide her on how his network works. Are there other partnerships? His eyes, hidden under the visor of a cap, hide even more when he bends his head and says with a gesture of resignation: "I knew that this was something like that, I knew you were journalists, I do not want trouble." He agrees to tell his story, but the next day he dodges by cell phone: "I need to think".

He does not appear again, neither the next day nor the day after that. Finally, after much insistence, he agreed to one last conversation over the phone.

“I am like an intermediary. Four nurses from four different clinics, who are in charge of managing these medicines, call me."

“I am like an intermediary. Four nurses from four different clinics, who are in charge of managing these medicines, call me. They call me to let me know that someone will call me asking for a product and when I get the phone call, they have already told me what is there, how many are there, and how much is it. They are from La Trinidad, La Floresta, El Ávila clinics, and I do not remember the name of the other one. The ones that I use most are these three. I do not know where the medicines come from, Badan or IVSS. I do not know what is behind them. I take 15% of each thing I sell," he says to end the trance.

He has been engaged in the business for two years. He says that he used to have more customers. It was a weekly flow, where he could earn up to Bs. 250,000 (US$ 250) a month. Now, he has around three customers per week, "I do not know if it is because there are more people engaged in this," and confirms that he has a branch network in Maracaibo, where more people resort to their services "because there is trust, because we do not sell expensive". But he has customers all over the country: Bolívar, Valencia, Portuguesa, "from everywhere, because they do not even have food there". When they are not from the capital city, Caracas, they go there. "I tell them to come, especially if it is something refrigerated, because it is delicate and must keep the cold chain... I am not an unconscious, I am aware of the oncology part and I know how the thing".

He also has a large customer portfolio at Fuerte Tiuna, the country's main military barracks, southwest of Caracas, to where he goes to ship his merchandise. "These are higher rank people. They pay me the taxi back and forth because they have many meetings and they need the medicine immediately. They get me into their offices; we talk; they offer me a drink, tell me that the medicine could not be found anywhere... And at the end they say 'what else can we do?'"

The weight of the scheme, according to his version, seems to fall on the nurses, who are, as he emphasized, who got him into the business. Here begin the inconsistencies. According to R.L., they manage the customers; however, during the negotiations with the reporter, no person other than him ever participated. He explains that he does not have medicines at home, that the nurses manage them, "they tell me they have weekly stock, and they manage what is left over from what the clinics buy," and that he does not know when the medicines arrive. But when he was asked for a supply of Doxorubicin, he knew how to anticipate delivery dates, just as he did with Ana, the patient from Maracaibo. "I have to wait for the early month orders," he said on those occasions.

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He also alleges that the nurses set the prices based on the sale prices in Badan. But this information does not fit either. Methotrexate of 23.5 mg is sold in Badan at Bs. 309.04 the 100 tablet box; but R.L. sells the 10 tablet blister at Bs. 8,000. Paclitaxel of 300 mg costs in Badan
Bs. 18,852.75 the vial, while he sells it at Bs. 13,000.

The second medication purchased, Paclitaxel, is also the clue that can close the circle of the origin of the medicines. Lapreven confirmed that the purchased lot was sold to the Social Security only. Badan confirmed that this brand of this item has not been purchased for over a year, but that is the brand that R.L. resells.

The Clinics

Visits were made to each of the pharmacies of the oncology unit of the three clinics mentioned by R.L., i.e. El Ávila, La Floresta, and Centro Médico La Trinidad, all in the East of Caracas. According to him, the nurses get the drugs there, from what the clinics buy or what the patients bring.

In the first pharmacy, they said that they only have one or two chemotherapy patients per week; that the stock they usually have is minimal and that they have patients who have died and their relatives decide to donate. In the second one, they explained that they do not buy oncology medicines; that the patients purchase their own treatment t in the IVSS or Badan and bring them. The third pharmacy, the one that claims to have a larger volume of patients, said the same thing, that they manage the treatment for each patient, which is labeled with the patient’s name and stored. Can there be stock? Yes, but minimal. Hence, the offer in La Guaira to get the one-year treatment of Avastin seems difficult to achieve through the stock of these three clinics. "It can be done with all the nurses. I can ask one, the other... And thus they take out all the doses they ask for," he defends himself.

Until now, there had been no reference to R.L's workplace, Hospital Luis Razzetti, a place of reference for cancer treatment in Caracas. He denies that he takes the drugs from there. "The surveillance is strong," he says.

-Exactly, what do you do?

-I work in Pharmacy. But I do not control it, because I am not in charge of that. I work there, I see everything and I know all the movements. And there I inquire, I ask and they tell me that they have seen odd things at pharmacy level because many medicines come from donations and in the same place, which is unusual.

Razzetti

At the entrance of Hospital Luis Razzetti, a military man demands the visitor to show an ID and indicate where you are going. The only way to know if there is a medication for cancer treatment is by having a card that identifies you as a patient of that medical center and appearing in person. It is an order, apparently, followed by all the drug distribution personnel, because when three employees of the hospital - two women and one man – were asked about it, they answered that this information could not be given to anyone.

There are several posters stuck on the wall in the drug delivery department: "Prednisone 5 mg [sic] tablets will be given to patients with prostate or lymphoma diagnosis only." And one that draws special attention: "There are no filters for Paclitaxel," the same that R.L. offered at the first encounter at the Expreso Chacaíto mall.

A patient says that she has not obtained all the medicines there, but that it is one of the best places to find them in the case of oncology treatment. She did not want to give more statements. A woman waiting at the pharmacy door accompanies her daughter, a patient of uterine cancer. She did not want to give her name either, but confirmed that she receives almost all the treatment there.

R.L. denies taking something from the hospital. "I have helped a lot of people in a certain way, because sometimes they do not get anything and they tell me that they have it thanks to me. This really started with the problem of scarcity. As far as I know, this had never happened before. I had not seen it before."

- Are you afraid of doing this?

-No, no fear, really. I would like it to end, because it might be a relative of mine who needs it and I am the one who would have to look for a medication. This is really not quality of life for any Venezuelan. Do not think this is easy. I think about myself and I hope that this will eventually end.

The head of the Razzetti's Pharmacy, Dr. Lisde González, says that every day they write down what comes in and what comes out of the Pharmacy. "We have a rigorous record; it is very difficult to take anything from here." But when mentioning R.L., she thinks, sighs, and says: "He is in charge of the administrative part. He usually stays overtime. He can change the records." The control method is an Excel table.

(*)The entire Armando.Info team supported this work.

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