Cambodian Inspectors examine suspected medicine in a crowded market along Thai-Cambodian border during an inspection July 23, 2010 in Pailin province, Cambodia. Photo: Getty Images
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Unregulated fake medicines are threatening the fight against diseases like malaria

There is currently no international law or body that can organise the detection and prevention of fake medicines - and it's a critical threat to our ability to fight deadly diseases.

In the UK, when horsemeat – which is not life threatening – turned up in a supermarket burgers that claimed to be made of beef, it was a national scandal. Imagine that a similar situation emerged, but this time instead of beef products, it was life-saving medicine that contained unlabeled, unsafe ingredients. You’d rightly expect the full weight of the law to come down on the manufacturers. And in the UK, that would likely be the case. You might be surprised, then, to find out that there is in fact no international law to prevent the trade in falsified medicines, and in many parts of the world without similar regulatory systems in place, these ‘medicines’ – packets labeled as a drug, but in fact containing none of the active ingredients - are big business.

In June 2012 a shipment of loudspeakers arrived in a container in the Luanda docks having travelled by sea from Guangzhou to Angola. Nothing unusual in that, given the burgeoning trade between China and Africa. However, all was not what it seemed.

Within the loudspeakers were 1.4 million packets of falsified medicine, mostly labeled as a key life-saving antimalarial drug: artemether-lumefantrine. Detailed analysis by scientists confirmed that the packets contained no active drug and would have had no beneficial affect for malaria – no more than listening to music through the loudspeakers.

There were also packets that claimed to contain the deworming medicine mebendazole. Not only did they not contain any of the active ingredient stated on the label, they did contain a drug called levamisole, a deworming medicine that has been withdrawn from human use in many countries due to severe side effects, including bone marrow failure. There has recently been an epidemic of severe blood vessel inflammation resulting from ‘cutting’ cocaine with levamisole, suggesting links between criminals producing cocaine and these falsified medicines.

Had the falsified malaria tablets got into the supply chain they would inevitability have increased death and sickness. Worse still, they could increase malaria parasites’ resistance to the real drugs which save millions of lives in sub Saharan Africa each year.

On their own, falsified medicines, containing no antimalarial, will not risk antimalarial resistance, as there is no drug in the patients’ blood for any resistant parasites to survive attack from and multiply. However, in the many countries with inadequate regulation of medicine both falsified medicines and substandard medicines commonly occur together. Substandard medicines result from errors in production and not fraud, and usually contain less than the stated amount of antimalarial compound. If patients develop very high concentrations of parasites in their blood through taking falsified antimalarials that have no effect, and then take substandard medicines, susceptible parasites in the blood are killed but the resistant ones multiply – and are sucked up by mosquitos to spread to the next unwitting patient.

This risks catastrophe for the spread of resistance to these front line drugs. If resistant parasites spread to Africa, as has already happened across Southeast Asia, the death toll will be enormous: potentially millions of lives and billions of dollars.

Over the last few decades there has been much high level debate about malaria, given the toll on lives, livelihoods and societies. The scandal is that there has been remarkably little action to ensure the quality of antimalarials. It is not regarded as a sexy subject in international public health and seems to be viewed as intractable. It is not intractable. The seizure in Angola illustrates some of the major problems in improving the global medicine supply but, as I and others have outlined in Lancet Global Health this week, there are solutions.

At the most basic level, we need a global system for mandatory reporting, assessment, and appropriate dissemination of information on suspicious medicines. The seizure in Angola was first brought to public attention on Facebook after five months and then in the Wall Street Journal after eleven months.

Although such reporting is commendable, it is grossly inadequate for public health. What proportion of African malaria patients and their families read Facebook and the Wall Street Journal? Until recently no nation had legislation requiring the pharmaceutical industry to inform the national medicine regulatory authority of drug falsification. It is extraordinary that, in 2014, such systems are widely in place for fake aircraft parts but not for medicines.

Medicine falsification, unlike money counterfeiting, is not currently regarded as an international crime, making extradition and prosecution of criminals, such as those trading in falsified medicines between China and Angola, extremely difficult. We need an international public health convention that enshrines the crime in international law, allowing extradition, and helping countries to combat criminal networks. It could also provide a financing mechanism for supporting the many countries with insufficient capacity for the regulation of medicines. Indeed, the WHO has estimated that 30 per cent of countries have no drug regulation or a capacity that hardly functions. Functional national medicine regulatory authorities are essential for the interventions needed, and to ensure that the benefits of increased accessibility to internationally financed medicines and inexpensive generics are translated effectively into improved public health.

The enormous investment in increasing global accessibility of essential medicines without investing in checking and ensuring their quality is profoundly illogical. We cannot expect the world’s medicine supply to improve without coordinated functional national regulatory systems.

We need much more vigorous and urgent action to promote Access to Good Quality Medicines or the promise of beating malaria and other endemic diseases will be squandered.

Professor Paul Newton is the director of the Lao-Oxford University-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Vientiane, Lao PDR

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How gendered are this year’s most popular Christmas present toys?

Meet the groups fighting back against the gendering of children’s toys over the festive season.

You’re a young girl. You go into WH Smith’s to pick out a colouring book for Christmas. You could buy the Girls’ World Doodling and Colouring Book, a "gorgeous gift for any girl". In this, the pictures range "from flowers, fans, feathers, to birds, buttons and butterflies". Or Colouring for Girls: Pretty Pictures to Colour and Complete, where you can colour in "beautiful birds, seashells, cupcakes, pretty patterns and lots more". The counterpart Boys’ Colouring Book has a range beyond buttons and feathers: "Planes, trains and automobiles – plus the odd alien spacecraft".

In the run-up to Christmas, this kind of gendered marketing is rife, particularly finding its way into the predominantly pink colour scheme of girls’ toys.

Take Amazon’s page "2016 Toys for Girls": a pink icecream trolly set, a pink light-up tablet, pink building blocks, pink and purple friendship bracelets and so on.

There are several groups taking action against the "pinkification" of children’s toys. One of these is Let Toys Be Toys, a group that targets large supermarkets with the aim of reducing the gendered marketing used on children’s goods.

The Let Toys Be Toys blog focuses on specific examples of targeted gendering within shops, catalgoues and online. A particularly revealing example of how prevalent this has become in recent years is in two pictures published from the Argos catalogue, one from the Seventies, and one from nowadays. The eye-wateringly pink page from now makes the 1970s page look dour by comparison. The lack of change over four decades of what kind of products are marketed at girls is equally striking:

Despite the efforts of campaign groups such as Let Toys Be Toys, the prevalence of gendering within the highest-rated children's gifts for 2016 is staggering.

Look no further than the Ultimate Christmas Gifts Guide from Toys R Us. One of the most immediately obvious examples is the way in which the pink/blue colour schemes are used to market identical products. This is repeated again and again:

This identical drawing board is uniquely packaged to the binary colour codes that are so common within children's toys stores.

The same applies with this keyboard, where the young girl and boy are pictured almost identically, save for the coordination of their clothes to the colour of their toys.

The message is a hugely limiting one: one that allows little movement away from the binary of pink/blue. The effects of this are longstanding. A recent poll from YouGov shows that "only a third of parents approve of boys playing with Barbies". The data goes on to explain that "while most parents approve of girls playing with toys marketed to boys, a minority of adults approve of the opposite".

Images like this were the inspiration behind Let Toys Be Toys, back in 2012. The campaign began on Mumsnet, the forum for parents, on a section called "AIBU", which stands for "Am I Being Unreasonable?". One parent posted the question: "Am I being unreasonable to think that the gendered way that children’s toys are marketed has got completely out of hand?" The heated discussion that followed led to a sub-section with the founding memebers of Let Toys Be Toys.

This aside, Let Toys Be Toys has made signifcant progess since it began. It targets large stores, focusing on gendered signage both in store and online. In their four years, they have campaigned for signs like "girls' toys" and "boys' toys" to be removed from retailers such as Boots, Debenhams, Morrisons, Toys R Us and TK Maxx. It is the go-to hashtag on Twitter for examples of the often shocking gendering of children’s toys.

"This is ostensibly about toys, but what we’re really talking about is gender stereotypes that shape our children’s worlds in an apparently very unassuming way," says Jess Day, a Let Toys Be Toys campaigner. "It seems very innocent, but actually what we’re doing is giving children very clear instructions about how to be a man and how to be a woman."

These clear instructions work beyond colour coordination: where girls are sold the image of the pink "girly girl", for instance. This is evident in children’s fancy dress costumes. Early Learning Centre’s (ELC) children’s fancy dress range imposes very rigid gender roles. To give examples from the current christmas range:


Credit: ELC

Again, the predominant colour sceme is pink. The roles offered are mainly fairies and princessess: generally make-believe.

“I found it really interesting that there were almost no ads showing girls doing anything," comments Day. "Physically they were very passive. The only physical activity we saw girls doing was dancing. They weren't really moving around much."


Image: ELC

By contrast, young boys are offered the possibility of pretending to be a firefighter, a policeman or a doctor, among other practical, professional roles.

This year's Toys R Us Christmas advert follows on from this, with girls mainly dressed as princesses, and boys dressed as knights and kings. Much like the pink/blue colour scheme that we see all over children's shops, these fancy dress costumes create an unnatural binary. They send out a message that restricts any kind of subversion of these two supposedly polar opposites.

What's more, the subtext is one that is deeply rooted in expectations, building up a picture where careers such as that of a policeman and fireman come more naturally to boys, who have been socialised into these roles from childhood through fancy dress costumes of this type. Instead, girls are later forced to learn that most of us aren't going to become princessess, and none of us fairies – and so the slow process begins to unlearn these expectations.

There are certainly groups who try to counteract this. Manufacturers such as the toy brand IamElemental aims to break down the gendered distinctions between boys' toys and girls' toys, by creating female action figures.

“We always say that we are not anti-doll or anti-princess, but that if you give a girl a different toy, she will tell a different story," says Julie Kershaw, a member of the organisation. "As the mom of two boys, I always say that it’s just as important to put a strong healthy female action figure in a boy’s hand as it is a girl’s”.

Like the campaigners behind Let Toys Be Toys, IamElemental sees children’s toys as the starting point.

“We want kids – both girls and boys  – to internalise these messages early and often,” says Kershaw. “While there are certainly biological differences between girls and boys, gender-specific toys are not a biologically dictated truth. Toys are not “for girls” or “for boys”  – toys are for play; for exploration and creative expression.”

This attitude is ingrained in a child’s early years. Only through reconfiguring the gender sterotypes of the toys we buy for our children can we begin to break down their expectations of how to behave in age. We challenge you this Christmas to avoid these highly gendered products. Below are our three favourite Christmas presents for children this year, for girls AND boys, as approved by Let Toys Be Toys:

Mini Table Tennis (£7.99)


From: The Little Toy Box

Djeco Intro to Origami - Animals (£3.99)

From: Rachel's Toy Shop

Seedling Make Your Own Dino Softie! - Dino(sew)or Kit (£5)


From: Gifts For Little Ones