Issue No. 816

Silent Killers: Counterfeit Drugs in Somalia

While the global trade in counterfeit, falsified, and adulterated pharmaceuticals has proven difficult to trace, it has been estimated to be worth as much as USD 200 billion annually. Produced en masse and smuggled through complex transnational criminal networks, the majority of the world's counterfeit drugs are believed to originate in China and India before dispersing across the globe. The issue is especially acute in Africa, where falsified and substandard medicines have been estimated by the UN Office on Drugs and Crime to contribute to up to 500,000 deaths in the sub-Saharan region every year. And Somalia, in particular, faces a grim confluence of problems stemming from the lack of regulation in its pharmaceutical industry, a partial legacy of the collapse of the state in the 1990s. But with the sector intimately connected to transnational smuggling, attempts to tackle the booming trade have toiled in the face of entrenched corruption, porous borders, and weak regulatory oversight.

In Somalia, pharmaceutical products now rank amongst the most commonly circulated counterfeit items. With virtually no domestic drug manufacturing capacity and a regulatory vacuum, substandard, falsified, and expired medicines dominate the market. Even many pharmacists in Somalia apparently do not know what they are selling, with one study conducted by UNICEF in 2012 revealing that most pharmacies did not cross-check their products' serial or batch numbers to confirm they were the correct drugs or of the right quality. The ubiquity of expired medicines in Somalia is, in large part, a result of international pharmaceutical companies seeking to sell off their stockpiles of lapsed drugs. These are then bought up and imported into Somalia by voracious merchants who easily navigate the country's weak customs controls, and go unchecked by pharmacies and consumers.

In turn, many everyday healthcare items are contaminated with banned pharmaceutical ingredients or have gone past their expiry date. Analysis of skin-bleaching or whitening products that have become ubiquitous across much of Africa and Asia often reveals that they contain mercury, an ingredient that can cause kidney and neurological problems. A study conducted by Somalia's Ministry of Health indicated that nearly one-third of sampled antibiotics failed basic quality tests, with some containing no active ingredients whatsoever. But for the most part, it is impossible to know what is precisely contained within imported drugs without careful and costly testing—a capacity that Somalia does not currently possess.

Patient self-administration is another often concerning element at play in Somalia's unregulated sector, with individuals taking medications whether or not there is a requirement. This self-administering, alongside the lack of prescription oversight, contributes to growing antimicrobial and antibiotic resistance in Somalia, predicted to have potentially calamitous consequences in the coming years. Still, there are some positive elements of patient-seeking behaviour, including that if a pharmacy or non-governmental organisation is known to import quality drugs, communities are more likely to use them.

It is not just everyday users of supposedly harmless medicines who are threatened by the unregulated market; it poses dangers to those with addiction issues in Somalia as well, including individuals who use Valium and Rohypnol to combat khat-induced insomnia. Large numbers of urban Somali youth have abused tranquillisers and sedatives for years, both driving and being fuelled by a mental health crisis emerging from years of societal fracture, internecine warfare, terrorism, and mass unemployment. Drug use and dealing have been further linked to the youth gangs known as ciyaal weero, or "aggressive children", that populate Mogadishu, who carry out a host of petty crimes to fund their addictions. Meanwhile, the rising import of more dangerous and addictive opioids and amphetamines, such as Captagon from the Middle East, are stoking a much-overlooked addiction crisis in Somalia, partially obscured due to the haram nature of drug-taking in Muslim society.

Spasmodic and half-hearted attempts by successive federal administrations over the years to regulate the pharmaceutical industry have achieved little. The collapse of the Somali Agency for the Import of Pharmaceutical and Allied Products (ASPIMA) after 1991 left the sector rudderless, and despite the establishment of the Interim National Medicines Regulatory Authority (NMRA) in 2023, enforcement remains negligible. The body lacks both laboratory facilities for testing medicines and the authority to enforce compliance at key entry points. In March, Somalia's federal parliament reviewed the draft 'Medicine Regulation Bill', which seeks to regulate medicines and implement guidelines on the importation and distribution of drugs. However, given the scale of profits being made from counterfeit pharmaceuticals, it is improbable that any such legislation will make a significant difference.

In turn, Somalia still hosts one of East Africa's most extensive illicit pharmaceutical distribution networks, with maritime routes into ports in Mogadishu, Kismaayo, and Bosasso serving as the primary conduits for the trade. The same infrastructure used to import legitimate products is used to smuggle counterfeit drugs and cosmetics masquerading as 'genuine'. Al-Shabaab is at the centre of this trade, wielding its highly organised transnational criminal networks to exploit the country's ungoverned coasts and compromised port facilities. It partly inherited the decades-old business of importing expired medicines, but Al-Shabaab has further cultivated ties with customs officers and embedded their own operatives into Somalia's arterial ports as a means to tax goods as well as to manipulate import processes. Every vessel's manifest that docks at Mogadishu Port can be accessed by the militants, allowing affiliated goods to pass through without inspection. Once in Somali territory, these medicines are sold in corner shops, online pages, and local pharmacies. Here too is Al-Shabaab implicated, with prominent pharmacy chains known to be owned and operated by individuals connected with the jihadists or their shadowy ideological competitor, Al-I'tisaam bil Kitaab wa Sunna. One of the largest pharmaceutical distributors in Somalia today is even owned by Ali Mohamed Rage, better known as 'Ali Dheere'—the spokesperson of Al-Shabaab. It is not Al-Shabaab alone that profits from the business, but a host of actors that reap the financial rewards of importing expired and counterfeit drugs.

The distribution and sale of counterfeit drugs should be considered a tax on the poorest in Somalia, placing further financial pressure on households with limited means who are often forced to opt for the 'cheaper option' from dodgy pharmacies. When these counterfeit medicines fail, they may pursue alternative forms of medicine that similarly fail to treat their family member's ailment. The Somali elite, on the other hand, are able to travel to Dubai, Istanbul, or Nairobi for their medical treatment. And pharmacies in Halane—the heavily fortified campus hosting Somalia's diplomatic presence in Mogadishu—are far less likely to stock fake drugs than one in Luuq in Gedo, say. The pattern of healthcare inequities and counterfeit drug use closely mirrors the broader socio-economic disparities in Somalia.

Put simply, the most significant public health issues for Somalia are the lack of prescription oversight at the pharmacy level and inadequate supervision at the importation stage. These are decade-old issues, but if Mogadishu were serious about tackling the scourge of transnational smuggling, it could employ an international import/export company that could verify imports at their point of origin. Not only would this help limit the smuggling of counterfeit drugs, explosive material, and other illicit goods through Somalia's ports, but verification can also help tackle the systematic undervaluation of goods used to avoid taxes. But it is improbable that the government-- even if it had the capacity-- would pursue such a course of action with such vested interests lying in the import of fake pharmaceuticals. And though Somalia's various conflicts may continue to grab the headlines, it is counterfeit medicines that will continue to prove the silent killer.

The Somali Wire Team