W HILE the public sector health industry - government hospitals and clinics present in every commune - dispense a total of $8 million worth of drugs every year, the private sector has burgeoned in the last three years into a $40 million-a-year moneyspinner, according to Ministry of Health.
The World Bank Pharmaceutical Assessment of Cambodia, the first survey of the country's private retail sector, will take place in October. Its terms of reference state that "the country's private sector pharmaceutical industry is very large and is almost completely unregulated."
Dr Dy Narong Rith, Under Secretary for Health said: "There are 150 legal pharmacies and 450 illegal ones [in Phnom Penh]. The city also has 74 legal depots, or smaller pharmacies.
"In the provinces, there are 45 legal pharmacies and 256 depots. But we have no idea how many more illegal medical shops there are," said Rith.
Similarly, there are 28 agencies legally allowed to import about 600 medicines into the country. Ministry officials say illegally-imported retail drugs have been seized by customs in the last year, but admit there is little follow up and are not even sure of quantities.
A lack of law enforcement machinery has meant that illegal imports continue to thrive, with no account of how much they are worth, according to Narong Rith.
"The legal imports fall far short of the $40 million worth of drugs required. Also, legal importers may not be importing the drugs the pharmacies really want. This means an ideal environment for illegal drugs," says Andrew Morris, Unicef's Project Officer for Health.
Before 1989, there were 17 factories manufacturing drugs in the country, according to Dam Sovanny, assistant to the head of the department of pharmacy at the Ministry of Health. When supplies of drugs and raw materials from Eastern Bloc countries ceased after 1989, all but one of them closed down. Now the country is almost totally dependent on imports.
The World Bank-funded assessment will determine the annual sales and the number and types of drugs sold from both legal and illegal pharmacies in the city. Ministry of Health officials say they will use the information to move legislation to register importers, drugs and pharmacies.
The present laws, dating from 1991, require that all pharmacies be registered and be supervised by a qualified pharmacist. Depots, which are allowed to sell only a small range of drugs, are to be supervised by pharmaceutical assistants or retired doctors.
But pharmacists and Ministry of Health officials admit the law is often flouted. "Though the name of a pharmacist is displayed outside the shop, the person often does not actually supervise the shop, he is only paid a sum every month to lend his name," says Mao Makara, head of the Pharmacists' Association of Cambodia (PAC).
This means that those dispensing medicines are often ignorant about how medicines should be stored. "Most pharmacies store their medicines at room temperature, there are no refrigerators or dark cabinets," said Rith. "That can be dangerous sometimes, but usually the drug becomes ineffective.
"Patients often go to pharmacies and ask the sellers themselves to prescribe drugs for them, and that can be equally dangerous because most of the sellers are not qualified to do the job," he adds.
Health officials, pharmacists and doctors say that open sales of drugs which are often fake or past their official expiry dates is not new. "Medicine during the SOC. period was illegally imported through Thai and Vietnamese borders, and some of it was fake," said Makara.
"Smugglers just imported materials like capsules and filled them up with flour. The local illegal producers now use chemicals to manufacture medicines, but sometimes in dangerous or ineffective quantities," he says.
A doctor at the PMI hospital on Monivong Boulevard says patients, including children, are often brought in with severe stomach aches after swallowing large quantities of common painkillers like Poppy and Jetse.
"They are usually very poor, they try to avoid going to hospital. They ask shopkeepers in Orasei or Russian markets, who know nothing about drugs, to give them medicines," she said. "We never prescribe these medicines ourselves."
Rith says the Ministry does not know how much illegal production is going on. No detailed tests have been conducted on medicines because the Ministry's laboratory is not equipped for them, he said.
Some popular brands of fake medicine, according to Rith and Makara, are Tiffy, Kofu, Poppy and Roxican Fort, which they say are produced near the Thailand-Cambodia border and smuggled in. The medicines, which are heavily advertised almost daily on IBC television, are used for headaches and stomach pains.
Rith says he has received complaints from people who bleed in the stomach after using Roxican Fort. "I have requested the Minister and Secretary of State for Information to ban the advertisements, but they want them to stay because they earn revenue.
"I think we spend more on treating people who fall ill after using these medicines than we earn from their advertisements," he says.
Manufacturers of spurious traditional medicine are also having a field day. Herbal medicinal wines (Sra Thnam) are widely advertised on television and radio and can be manufactured legally in the city with the permission of the Municipality. But again, there is no account of how much the illegal trade is worth. The wines are consumed to 'treat' a wide variety of diseases, including sexuallly-transmitted diseases.
Makara says the alcohol is not well distilled and often contains methyl alcohol which causes severe headaches or loss of eyesight. "Herbalists put in plant extracts to flavor the wine, very often that means addictive substances like ganja or opium," he says.
Though pharmaceutical drug smuggling has never been officially investigated, both pharmacists and Ministry officials say there is strong resistance to change because it is a lucrative money spinner for people within the governing establishment.
"Inspectors from the Ministry of Health have already warned illegal pharmacy owners to close their shops down but they just refuse, they ignore the warnings," Rith says.
He quotes the example of one shop where he says the Ministry's inspector was threatened by a two-star general who owned an illegal pharmacy. "He said: 'If the ministry dares to do anything we will shoot you.'
"I met the Co-Prime Ministers and asked them to help solve this problem. But they pointed out that people who close their pharmacies should be given some other job. They said we should repeatedly warn the shops to close down," he says.
Pharmacists complain the Ministry itself is to blame for most of the mess. "If the ministry really wants to close down these shops, they can, they simply don't want to," said Nget Monino, a pharmacist from Kampot.
"They [the ministry] say the problem cannot be solved because smugglers have the support of high ranking-officials and soldiers. That is a pretext to prolong the present situation so that they themselves can profit from the business," said Makara .
Narong Rith himself admits that several Ministry officials have their own pharmacies to supplement their meager salaries. "We need that to avoid corruption," he says in defense.
Pharmacists are also incensed at the present law which makes it mandatory for students at the Faculty of Pharmacy to serve at least one year with the Ministry of Health before being allowed to open pharmacies.
The requirement has meant that several qualified pharmacists who do not want to work on low salaries with the ministry are doing other jobs, Makara says.