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.
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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.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
Screenshots of the conversations between the journalist and R.L. prior to the first encounter.
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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.
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. 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.
Vial of Paclitaxel acquired from R.L.
The journalist going the second encounter with R.L. in Chacaíto (an area of Caracas)
The journalist going the second encounter with R.L. in Chacaíto (an area of Caracas)
Emthexate acquired from R.L.
Emthexate acquired from R.L.
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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.
