Romania's Underground Cancer Drug Networks

When the market keeps chemotherapy out reach, sick people turn to friends and the Internet to import medications from countries where they are still available.

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Bucharest [Vadim Ghirda / AP]

Gabriela Stratulat lost both her breasts after she was diagnosed with breast cancer last year. Just when she thought it couldn't get any worse, her oncologist at the Sfanta Maria Hospital in Bucharest said they didn't have all the cancer drugs she needed to fight the disease. She had to start radiation therapy anyway.

"When I started the treatment, the hospital gave me all the drugs I need except for 5-Fluorouracil, because they didn't have it," she says. Ms. Stratulat, 57, checked with dozens of pharmacies in Bucharest but could only find the drug twice. "I was feeling helpless and became desperate. I was saved by one of my son's friends, who bought the drug from Belgium and sent it to me. It's frustrating. I have been paying taxes and contributing to the state budget all my life," she explains. "I don't think it is fair to be treated in such a miserable way."

Fluouracil, also known as 5-FU, is one of the most frequently used components in chemotherapy for breast and bowel cancer around the world. Around 20 other cancer drugs (such as Asparaginasum, Decarbazinum, Vinblastinum, Methotrexatum, Etoposid, Vindesine) have also been very difficult to obtain, or could not be found at all, in Romania in the last two years.

Cezar Irimia, who runs the Romanian Federation of Cancer Patients Associations, says Romania's lack of coherent strategy created a major cytostatic crisis. "The health-care system is severely underfunded, and those in power are not taking responsibility," he said.

Cancer patients have the right to receive free medication, according to Romanian law. In reality, though, many of them must find other ways to purchase the drugs they need, many times through friends or relatives who are travelling abroad. There is even a website called "Missing Drugs" where Romanian patients can find volunteers to send them the drugs they need. Anyone can register and give a hand. Most of the volunteers are Romanians who frequently travel to Western Europe or are already based there. However, this is a solution only for patients who can afford to pay for the drugs, because the state cannot cover the expenses when they are purchased this way. Very poor patients have no choice but to hope the shortage will end as soon as possible.

At the Institute of Oncology in Bucharest, for example, cancer patients who should be treated with 5-FU, Bleomycin, or Cisplatin must find a way to purchase the drugs on their own because the hospital doesn't have them. The shortage is even worse at the Regional Institute of Oncology in Iasi, a city 400 km away from Bucharest. The hospital reports constant difficulties purchasing seven cancer drugs.

When asked about the drug shortage last week, Romania's Prime Minister Victor Ponta admitted the country has to deal with a lot of bureaucracy and bad legislation. "I saw a case of a person who needed [cancer] drugs and went to Fundeni [a hospital in Bucharest] where he didn't receive the cancer medicines, although it was revealed that the doctor just didn't want to give him the drugs. I immediately asked: Can we do something about it? No, because the law does not allow such thing," he explained.

His statement comes two days after the government announced its budget for 2013, which didn't include any particular fund to solve the shortage crisis.

After 48 hours of subsequent incessant public pressure, Ponta said he found a solution: The country's Treasury will lend 800,000 Euros to Unifarm, the state company in charge of purchasing and distributing the drugs to hospitals around the country. This measure was necessary to help the state distributor purchase from the external market the drugs that are currently missing in Romania.

"In March, the ministry will start rethinking the national health programs and will elaborate health policies and strategies that could meet the current needs," explained Eugen Nicolăescu, Romania's health minister. "We are taking into consideration the possibility of introducing a centralized acquisition process for some products, in order to manage the situation not only from an economic level," he added.

Offering Unifarm a supplementary fund is only a temporary measure -- it doesn't address all the systemic problems, which, apart from underfunding, involve a need for drug regulation. When a hospital holds an auction to find a drug distributor, some of these private companies offer a very small price in order to win the contract. After a few months, though, some of them are incapable of providing the drugs, usually for financial reasons, and they block the supply. The lack of regulation makes it difficult for authorities to hold such companies accountable.

As an oncologist in Bucharest (who preferred not to be named) also explained to me, "There is another problem, in that the pharmaceutical companies need to pay a license fee before importing their products to Romania. For cheap drugs that make small profits, if the manufacturer has to pay a high fee, he will not be tempted to come. This is a problem in many European countries, not just Romania."

Current pricing arrangements in Romania create incentives for parallel exports, and it may account for diversion of as much as 20 percent of product volumes. Clara Popescu, the vice-president of the Romanian College of Pharmacists, says the number of exports has been increasing since 2009, when Romania became the EU country with the cheapest drugs. "The fact that drugs here are cheaper than in other European countries is an advantage for patients who can afford them, but this was also speculated by other jackals in the system who used this great opportunity to export the drugs in other countries where the prices are higher," she explains.

Romania has the lowest prices for drugs in the EU, which also chases away pharmaceutical companies. Accused by some of being morally responsible for the drug shortage, they face pressures to continue the drug production. Many cancer drugs involve small profit margins to begin with, leading many drug makers stop producing them. And for the drug industry, like any other type of industry in a free market, profit comes first.