As dusk draws in on the humid Lagos evening, the policemen check their machineguns one last time and scramble across the dusty courtyard into unmarked cars. A guard briskly opens the metal gates and the convoy lurches out on to the main road: two Peugeots, two pick-up trucks and a minivan, each as dented and battered as the surrounding Nigerian traffic. Mindful of quotas they have to fill, the teams swerve impatiently to avoid ever-present motorcycles and pedlars, using horns, indicators and an occasional flash of weaponry to carve out an implausible third lane between two slow-moving rows of vehicles.
As the bustling Apapa district draws near, the drivers adopt a lower profile. The lead car slows to a halt by an elevated junction, its prey in sight. Two plain-clothes enforcement officers slip out and half-run to their unsuspecting target as the other vehicles pull to the edge of the road. While one agent grabs the suspect, and the other seizes his pink plastic basket piled high with packets of brightly coloured medicines, three of the uniformed police dismount and take up positions nearby, cocking their weapons in a pre-emptive show of force.
It is their first haul in an operation carried out twice a week in Lagos, an essential part of the ”Other War on Drugs”: the fight against a trade in illegal medicines that is proving almost as lucrative and sometimes as lethal as that in narcotics. The woman behind the strategy is Dora Akunyili, a charismatic pharmacist whose high-profile actions since becoming director-general of Nigeria’s food and drug agency in 2001 have sparked threats, arson and assassination attempts, and have been slowed by political opposition, corruption, vested interest and every other obstacle that those behind the international fake medicines business can throw up.
As we move off in our convoy to hunt the next drug hawker, I ask the man next to me if the show of force is really necessary. ”Sometimes they use daggers, and two years ago they shot a policeman,” says Dioka Ejionueme, Akunyili’s hand-picked director of enforcement, shaking his head. ”They warn each other by phones, and because we stepped up our morning activities, they have shifted to selling in the evening.”
Two hours later, our convoy returns to the darkened compound, unscathed by its productive foray. Seven men - from mere boys to stooped pensioners - are hauled from the minivan. They squat next to the vehicles, heads down, and wait silently to be transferred to a police station. ”They will stay for two or three days in the cells, sign a statement undertaking not to sell again and raise the money for their release,” says Ejionueme.
He surveys the rest of the haul. In front of us sit 13 heavily laden baskets: one for each hawker, and another six abandoned by salesmen who got away. Ejionueme runs his finger across the packets of drugs decorating the baskets’ sides, expertly identifying Viagra, multivitamins and a dozen antibiotics from a quick glance at their distinctive shapes and sun-faded colours. ”Drugs should be stored at a particular temperature and be sold by people who know what they are doing. Most of these hawkers are illiterate. Imagine giving headache tablets to someone with malaria.”
It was a modest victory in the fierce struggle against a trade for which Nigeria became notorious around the world. Whether such a vast underground industry can be brought down by a thousand small cuts is another question.
By the turn of the millennium, Nigerians had become among the world’s most frequent victims of fake drugs. The country’s reputation was so bad that its west African neighbours were refusing to import the medicines that came across its borders. An analysis in 2001 of 2,060 drug samples taken from the large wholesale markets where most medicines are easily bought showed that 62 per cent were not registered with the country’s National Agency for Food and Drug Administration and Control (Nafdac).
Dr George Okpagu, a past president of the Nigeria Medical Association, is no naive patient, yet Nigeria’s fake drugs trade nearly took his life. An imposing figure, draped in a white robe and presiding over a desk piled with papers and packs of medicines, ”Dr George” explains how in 2003 he moved for some months to his home state of Anambra, in the south of the country, to run for governor. While campaigning (he eventually lost the election), Okpagu switched his source for routine hypertension drugs from a well-established pharmacy in Lagos to a local shop.
”I had been taking a 20mg tablet a day of Zestril for more than 15 years and was always okay,” he explains. ”But when I came back after the campaign, I continued taking the tablets I had bought in the local pharmacy.
”I was here in my clinic one evening when I started feeling dizzy. I called in the other doctor, who measured my blood pressure at 200/120 - that’s incompatible with life. Soon after, I collapsed. The rest was told to me afterwards, because I was unconscious for eight days, and in Lagos university teaching hospital for three months.”
Okpagu’s story is far from unique. He cites a patient he treated for a urinary tract infection. The man had been taking antibiotics for eight days without improvement. ”I tasted the drug he had bought: it should be bitter, but it was tasteless. I gave him my own supply for five days and he was fine.”
Even when produced with the best intentions, many such drugs prove ineffective because they do not meet any consistent manufacturing standards and rarely contain the right mix of ingredients. One study showed 48 per cent of drugs from Nigerian pharmacies failed to meet these norms.
Add in criminals deliberately doctoring medicines to make money by substituting less costly chemicals, and the results are still more troubling. At best, patients are put at risk because they are not being treated properly, while their disease continues to flourish and resistance develops. At worst, the consequences can be deadly. In 2003, four children who underwent surgery in a hospital in Enugu, a city in the south, died after being given adrenaline. Doctors suspect the drug was heavily diluted with water.
Ejionueme, the enforcer, wants to show me the scale of the problem in a way more vivid than statistics can. We drive an hour out of Lagos before pulling off the busy highway on to a potholed dirt track. A few hundred metres in, we stop in an area of scrubland, where men armed with machetes are guarding a three-metre-high pile of medicines confiscated at ports, in factories and from hawkers.
Immaculate in his black jacket and blue shirt, despite the humidity, Ejionueme pulls out some samples at random. There is injectable ketamine, an anaesthetic, with the expiry date ”07/05”; a box of phenylbutazone, a painkiller banned in Nigeria because of severe side effects; and Gynotab vaginal tablets that failed laboratory quality tests. ”We can inspect shipments of medicines when they arrive in Nigeria, but many arrive labelled as something else, like shoes,” Ejionueme says. ”Drugs yield more money faster than other products for criminals and don’t occupy much space. And some are made locally, in factories that operate a secret second shift at night.”
We are interrupted by a coach containing 20 local journalists invited to get a look at the stash - and to witness Ejionueme’s plans for it. As they gather round, he squares up to the microphones and cameras, and begins touting the recent investigations and raids that have yielded the 168 batches of medicines behind him - medicines with a retail value of N427m (₤1.753m). ”We are removing from circulation these poisons that would have incapacitated, maimed and possibly killed citizens,” he announces to his audience.
He puts a match to a rag attached to a long stick and pushes it gingerly towards the haul of medicines his staff had doused in petrol. The flames quickly spread, bottles exploding and shedding their pills; a thick, black cloud of smoke begins trailing upwards as the cameras turn. ”We are saving lives,” declares Ejionueme, ”and sending out a message to other violators that if we catch them, we will deal with them in the same way.”
I had read about the admiration Nigerians have for ”Professor Dora”, whom her devoted staff call ”madame” or even ”mummy”. But my first impression of Akunyili is not so much of a maternal character as a woman in whom striking efficiency meets a shrewd eye for publicity.
I spoke to her assistant by phone from London to arrange an interview. I expected a bureaucratic fob-off, a half-hearted promise to call back, or a polite agreement in principle that would need to be pinned down against the odds on arrival. Instead, Akunyili rang me back herself within hours, quickly grasped what I wanted, and quizzed me on how long I could stay. Within three days, she had e-mailed me a full itinerary of meetings and travel logistics.
A few weeks later, I passed an armed guard at Nafdac’s headquarters in Abuja, Nigeria’s soulless modern capital, mounted two flights of stairs, passed through a metal detector and was ushered to a couch at one end of a long office that looked more like a shrine. Dozens of cups, shields and rows of diplomas, awards and photographs crowded the walls.
”Ah, you are here,” said a voice, and I turned to see Akunyili looking up from a pile of documents from across the room, her beaming face almost lost against the backdrop of gleaming trophies. She stood up, resplendent in a bright blue dress and gele (headscarf), and led me to a seat by her desk. Her awards - 416 to date, according to a thick CV her staff handed me - may suggest a little egoism, but are modest recompense for her achievements in the face of considerable danger. ”When you have such a big challenge, success is easier,” she says. ”It gives you courage.”
Born in a village in southern Nigeria in 1954, Akunyili won top marks at school and began a successful career as an academic pharmacologist. She published her first papers in the early 1980s on anti-snake venom derived from local plants, received a PhD in Nigeria and then a post-doctoral fellowship in London in 1988. In that same year, she witnessed first hand the impact of counterfeit medicines when her diabetic sister, Vivian, died after taking fake insulin. Akunyili became active in her community, first opening a local medical clinic, and then, in 1997, taking a job at Nigeria’s Petroleum Trust Fund, co-ordinating social projects funded by government oil revenues.
It was during her time at the fund that she caught the eye of President Olusegun Obasanjo, elected in 1999 with a reformist agenda. He heard how she had flown to London with ₤17,000 from her employer for expensive surgery, but when told by specialists in the UK that it was unnecessary, returned the balance of the cash. Impressed by such honesty, as well as her credentials, Obasanjo named her to run Nafdac in 2001. The appointment was controversial for a number of reasons: she was not affiliated with Obasanjo’s party, she was a woman, and she was an ethnic Igbo from the Enugu region, which has a reputation for trading in counterfeits.
Yet Akunyili swiftly proved her doubters wrong, clamping down on hawkers and wholesale drug markets, and pursuing dodgy manufacturers and importers alike. Nor did she flinch from angering powerful people, reprimanding Nestle for importing out-of-date baby milk, closing the bakery of the wife of the former president Ibrahim Babangida for using a carcinogenic bread-enhancing chemical, and even fining one of the current president’s farms for importing chemicals without a permit. But the worst abusers were far more difficult to target. ”The drug people were like gods here,” she says. ”Since 1960, with independence, they became progressively entrenched and terrorised everyone unchallenged. Outside oil, there’s no business as lucrative as drugs.”
Still she persisted, restricting the import of medicines to two ports and two airports - allowing easier scrutiny - and drawing up a blacklist of 31 manufacturers of poor-quality drugs in India, China and Pakistan. As well as lobbying those countries for greater controls, her agency placed their own staff abroad, to authorise drugs before they could even be sent to Nigeria. She also strived for reform within the organisation. ”One of my directors - a man - suggested we should stop posting men to the ports and the drug registration department because they were too tempted. They could make hundreds of thousands of dollars a month there,” she says. ”Women are less corrupt.”
When I ask how many corrupt Nafdac staff she had to fire, she replies breezily: ”Oh, I don’t think more than 300 out of 3,000.” The dismissals included her husband’s younger brother. ”I don’t know if my husband forgives me today,” she confesses. ”I can still see the pain in his eyes. But if I didn’t do it, it would have destroyed the system. All the staff were watching.”
Such progress did not go unchallenged. The first attempts to co-opt Akunyili were swift. ”Someone came to me and said ’Madame, don’t kill yourself. Why don’t you just tell me where you want money - even $1m. It can be done, just as other people have done,’” she recalls.
”When they could not succeed with bribing, they fought back with harassment and threats. They left fetishes in my office: blood-stained feathers, beads and tortoises.” And when that failed, they took to still more violent steps. Nafdac’s Lagos office and its main laboratory were burnt down. On at least two occasions, assassination plots against Akunyili were thwarted only because her heavy workload meant she changed her travel plans unexpectedly. But at Christmas 2003, she was less lucky. As her convoy approached the family house, a gunman’s bullet smashed the rear windscreen and grazed her scalp. A bus driver caught in the crossfire died. ”I didn’t sleep for months afterwards, and was taking sedatives every night,” Akunyili says.
She is now followed everywhere by 10 armed guards, and two follow her husband, a doctor. She sent the last of her six children to the US after two men tried to grab the boy from his school; sensing danger, he survived by telling them Akunyili was not his mother, but an aunt.
No matter the number of poor quality drugs going up in flames under Ejionueme’s watch, many more remain in circulation. Akunyili has therefore focused on ”enlightenment” campaigns to curtail demand, and a serious crackdown on the unregulated street medicine markets.
The case of Marcel Nnakwe illustrates both battles. Sitting at her desk, Akunyili picks up a plastic egg timer and twists it, triggering a shrill ring that brings one of her female assistants scurrying into the room. ”Fetch me the Nnakwe letter,” she says.
The typewritten document on letterhead reads: ”I, Chief Marcel Nnakwe, and my family hereby apologise to Nafdac and the good people of this Nigeria for importing fake, counterfeit and expired drugs. I promise that I will never again involve myself in this nefarious activity.” Underneath the letter, written in 2001, lies a paper pledging formal consent for the forfeiture and destruction of 15 batches of expired and sub-standard drugs from Nnakwe’s warehouse. ”We had to get that because he had a court order forbidding Nafdac from ’harassing’ him,” Akunyili explains.
Nnakwe’s pledges were worth little. He is accused by prosecutors of plotting Akunyili’s murder in 2003 - a charge to which he pleaded not guilty. But the lengthy court case - which has heard testimony from dozens of witnesses and examined evidence including Akunyili’s bullet-ridden gele - remains unresolved. In late 2005, the judge said he had no jurisdiction and called for a retrial - in Nnakwe’s home base in the southern city of Onitsha. That decision is currently on appeal in Abuja.
Meanwhile, the wholesale drug market in Onitsha continues to thrive. When Ejionueme led a raid there last July, the nine local policemen protecting them fled, and he and his staff had to turn back as chanting youths chased them and smashed their six vehicles. ”I was in shock,” says Akunyili. ”They were openly telling me I had lost control. It was a very bad signal.”
Her head-on approach at the markets has worked elsewhere. Tony Osimiri, who remembers selling medicines 35 years ago from a makeshift zinc lean-to, smiles ruefully when the subject comes up. Squeezed behind a tiny desk in a brick-built cubicle, lined with shelves piled high with drugs, he recalls a painful period nearly three years ago when Akunyili put his livelihood under severe threat in one of her boldest challenges to fake drugs. One Wednesday in August 2004, Nafdac launched a raid inside the Sabon Gari market in Kano, a historic and volatile Muslim city in northern Nigeria. Nafdac seized medicines and demanded the identities of the vendors, who sit alongside merchants of all sorts in tight alleyways bustling with customers. Two days later, officials told Osimiri - then president of the Kano chapter of the Nigerian Association of Patent And Proprietary Medicine Dealers (slogan: ”health is wealth”) - that they would close the market.
”I was asked to come to Lagos for a dialogue on Sunday,” he says. ”When I arrived, they told me to relax because the discussion would be on Monday. Then they took us to a ’five-star hotel’ with no light or water.” Eight of the medicine dealers were locked up in a police cell for 17 days.
Eventually, they brokered a peace deal with Nafdac. The Kano salesmen agreed to self-regulation, kicking out a handful of their colleagues who refused to agree to sell only over-the-counter non-prescription medicines registered with the agency. They had to apologise publicly, making announcements on television and radio, and publishing statements in three national newspapers. Only when all these conditions had been met did the market reopen for business in October 2004.
”You can make a lot of money selling fake drugs, but it’s a matter of conscience,” concedes Valentine Aguocha, the association’s vice-president. He claims the market is now compliant - a view largely shared by local Nafdac officials.
On my flight from Kano to Lagos, I flick through a sheaf of Nafdac publications. Nothing in Nigeria, it soon becomes clear, is free of the threat of counterfeiting. Nafdac’s own official registration numbers were faked, as were the hologrammed ”good manufacturing practice” certificates it awards to quality producers. Its website was cloned, and imposters have been arrested, shaking down businesses with fake Nafdac identity papers.
To test Akunyili’s progress, I conducted my own clandestine operation in Lagos’s Idumota market. Walking down Enu Owa Street, an alley less than two metres wide, I saw tiny ”patent medicine stores” on all sides. They offered antibiotics, anti-malarial drugs, painkillers and asthma treatments without prescriptions. Around the corner, on Igan Idugaran Street, still more potent medicines were on sale. On a shelf in one humid shop stood a stack of green and white boxes of Tamoxifen, a powerful treatment for breast cancer. I wiped a thick layer of brown dust off the packet, and looked at the expiry date. It said simply ”November” - an almost certain sign that it was a fake.
I asked the shopkeeper if he would sell me some insulin. He turned, opened the door of an old, broken refrigerator in the rear room, and brought out a box of Humulin at room temperature. The packet looked genuine, but insulin is a fragile protein that should be kept chilled all the way from factory to user. I bought it without a prescription for N1,400 (₤5.70), and sent it to Nafdac’s laboratory for analysis. When the report came back a few days later, it was judged ”unsatisfactory”. The ”potency test” showed 91.8mg/ml, below the specification of 95-100. Injecting it could have played havoc with a diabetic’s blood sugar.
Akunyili and her team have proposed a national wholesale drug distribution system to replace the current ramshackle facilities in which vendors operate unsupervised, but the idea has so far been blocked. She has called for tougher legislation to raise the maximum penalty of just N500,000 (₤2,050) on those who make or sell fake drugs, but got nowhere with the parliament. The biggest violators are still avoiding prosecution entirely.
But her efforts are beginning to pay off. Recent studies suggest that the proportion of fake and unregistered medicines in Nigeria has dropped to less than 20 per cent over the past six years. Foudeh Darwish, the Lebanese managing director of Afrab-Chem, a manufacturer of antibiotics and other drugs based in Lagos, tells me Akunyili’s efforts have changed life for the better. As we drive to his factory, he recalls speaking out against Akunyili in 2001, but says he quickly changed his views. ”When she was appointed, we called to propose that we pay her a courtesy call. She said she would come to us instead. She gave a speech laying out everything that needed to be done.”
After the assassination attempt on Akunyili in 2003, Darwish joined forces with others to pay for the one gift that she has accepted from drugs companies: a bullet-proof BMW. ”I would never do her job,” he says. ”It’s too difficult and dangerous.” When we reach his office, Darwish shows me the plans for his new ₤2m factory set to open later this year in compliance with international quality manufacturing standards. ”Two years ago, this would not have been possible,” he says. The investment is a sign both of new demand within Nigeria for high-quality medicines, and a reduced threat that genuine regulated products will be undermined by fake alternatives.
Akunyili’s official residence in Lagos sits behind a high wall topped with razor wire. Armed guards hover in the yard. I pass through a metal detector and spy her in the living room. She has just spent five days travelling to the north of the country in her new part-time role as director of mobilisation and operations for Obasanjo’s PDP party, ahead of elections this month. She returned via Abuja, where she met the president, and finally won his backing to use the army to support another raid to close down the Onitsha market. It is scheduled for the following Thursday, although she has been warned that the local traders have heard about the plans. She picks up one of her four mobile phones and reads me a text message she has just sent to the army chief of staff. ”My big brother: I cannot thank you enough for helping fight these criminals feeding on the people.”
While her popularity has clearly given her a taste for politics, I can’t help thinking that she agreed to take the PDP post mainly to win presidential backing for the assault on Onitsha. When I ask whether her new-found partisanship risks jeopardising her work at Nafdac, she shrugs: ”My faith and hope in God is very strong. Onitsha makes my heart bleed. I want to clean it up or I will never stop feeling regret.”
Akunyili calls me two weeks later. The raid had been delayed at first, but when it finally happened, Ejionueme and his team shut down the market with support from 700 police and army troops. ”I feel very fulfilled,” she says. ”They have long been behaving as if they were above the law. Right now we are smiling.” I suggest it could be time to leave her stressful job. But she is still awaiting the appeal court judgment against Nnakwe. ”I’m not desperate to do another job. Whatever happens is the will of God. But if he [Nnakwe] was convicted, it would be the end of an era.”
Akunyili’s future in politics, and her continued leadership at Nafdac, may be uncertain. Victory in her campaign is far from complete. But with Onitsha’s closure, she has at least won a decisive battle in the Other War on Drugs.
Andrew Jack is the FT’s pharmaceuticals correspondent.