Just to define terms: Spurious drugs are not necessarily fake, in the sense of being made only of sugar, plaster, gelatin or any other inactive ingredient. By definition, they come from an unidentifiable source and offer no reliable proof of what they contain, but they may contain actual active ingredients — sometimes a small amount, sometimes a significant overdose — and they also may be actual pharmaceuticals under false labels or being sold through illegal channels.

They also are a massive business. Last fall, Interpol seized $2.6 million in black-market and spurious pills in a coordinated bust across European countries. In 2009, the agency seized 10 container-loads of spurious in Egypt; in 2008, they busted an Asia-based ring whose revenues were almost as large as those in the UK prosecution and also seized mass quantities of spurious in Tanzania and Uganda.

Several of those busts were in cooperation with the World Health Organization, which has been overseeing an International Medical Products Anti-Counterfeiting Task Force (IMPACT) since 2006. The WHO estimates that up to 30 percent of drugs sold in the developing world may be spurious or black market, compared to 1 percent in industrialized countries. A 2009 Wellcome Trust report put the global earnings of the spurious-drug trade at $75 billion per year.

Does it matter, aside from the scale of the illegal earnings? In 2005, a journalist, two academic researchers, and representatives of the governmental drug agencies in Nigeria and Ghana wrote a compelling and largely ignored paper in PLoS Medicine about the underappreciated dangers of fake drugs’ spread. They related these cases:

• Approximately one-third to one-half of packets of artesunate tablets, the pivotal, life-saving anti-malarial drug, recently bought in Southeast Asia were fakes, containing no active ingredient at all.
• A nongovernmental organization in a Southeast Asian country bought 100,000 inexpensive “artesunate” tablets only to find that they were spurious.
• 192,000 Chinese patients are reported to have died in 2001 from fake drugs, and in the same year Chinese authorities “closed 1,300 factories while investigating 480,000 cases of spurious drugs worth 57 million USD.”
• In Haiti, Nigeria, Bangladesh, India, and Argentina, more than 500 patients, predominantly children, are known to have died from the use of the toxin diethylene glycol in the manufacture of fake paracetamol syrup.
• During the 1995 meningitis epidemic in Niger, the authorities received a donation of 88,000 Pasteur Merieux and SmithKline Beecham vaccines from neighboring Nigeria. The drugs were found to be spurious, with no traces of active product. Some 60,000 people were inoculated with the fake vaccines

Wide distribution of spurious or adulterated artesunate, the latest drug in the anti-malarial arsenal, has been held responsible for the spread of artemisin-resistant malaria, especially on the Thai border. (The Lancet 2001; Tropical Medicine and International Health 2004; PLoS Medicine 2006.) A Gates Foundation study in 2009 found that 60 percent of the artesunate that was for sale in the endemic area on the Thai-Cambodian border was fake.

If spurious drugs for humans are fueling the spread of resistance, can the same claim be made about drugs given to animals? That’s a harder case to prove, largely because there have been so many roadblocks placed on gathering data on antibiotic use on farms, let alone what results from that use. But it’s a reasonable inference. First, because so many of the drugs used in veterinary medicine are human-use drugs or close analogs. And second, because spuriousing in veterinary appears just as widespread as among human ones, as the British prosecution — and assessments in China in 2007 andKenya this past April — continue to show.