Lebanese patients dice with death on the medicinal black market

Pharmaceutical shortages are driving many with life-threatening illnesses to resort to the dangerous world of smuggled drugs

Fadia, a cancer survivor, with a photograph of a black market medicine that would have killed her had the nurse not realised it was fake just before injecting it. Matt Kynaston / The National

Fadia's journey as a breast cancer survivor from Lebanon almost came to a tragic end at the age of 29.

The threat was not from her illness, but the dangerous counterfeit medication she bought on the black market.

“People can hurt you more than cancer,” she says.

As Fadia tells her story to The National, her soft smile slowly fades and tears well up in her hazel eyes.

“I was mere seconds away from death; it's not something I can put into words.”

Fadia's battle with stage 4 cancer began in 2021. But in crisis-hit Lebanon, plagued with acute shortages of medicine, she was forced to fight another battle: to secure treatment for the cancer.

After months of trying to obtain the drugs she needed at a discounted price from the Ministry of Health, she was left with no choice but to resort to unregulated channels.

Testimonies from doctors, dealers and patients suggest that the medical black market is a vast and multi-layered network, with sellers primarily based in Turkey and Syria. It serves as a crucial source for essential treatments often unavailable through legal channels in Lebanon, as the cash-strapped country struggles to finance its medication imports.

Fadia bought her medicine from Turkey after finding an intermediary on Facebook who travelled between Turkey and Lebanon. She never spoke directly to the seller. She paid $600 for the medicine — about 50 times the price at which it is provided by the government.

Little did she know that this decision would almost cost her life. As the nurse was blending the powder to administer intravenously, the mixture started to get cloudy as crystals formed, Fadia recalls.

These would have clogged her veins and killed her had the nurse not stopped the procedure at the very last moment, when she realised something was wrong.

“How could I have known the treatment was fake? It looked exactly the same as the legitimate one,” Fadia says.

'No other option'

Fadia's experience is not an isolated one. The true scale of Lebanon's black market in medicines is hard to assess, but based on interviews, it appears to have become widespread since the country sank into economic crisis in 2019.

Medicines subsidised by the government are often scarce, as the country struggles to pay suppliers on time due to shrinking foreign exchange reserves. This is further exacerbated by the smuggling of these medicines to neighbouring Syria, where they are sold at prices that generate significant profits for the smugglers.

The subsidies have been reduced dramatically since 2021, but the government continues to provide treatments for cancer and chronic diseases at reduced cost, although it cannot provide enough to meet demand.

As a result, patients are often forced to take matters into their own hands — if they can afford to do so.

“During the worst of times, almost half of our patients had to secure their medications before bringing it to the hospital,” says Hady Ghanem, head of haematology and oncology at LAU Medical Centre-Rizk Hospital, a leading private healthcare facility that treats more than 400 cancer patients a month.

“People are desperate; these are life-saving medications. They may have no other option than to resort to alternative routes. But we cannot compromise on safety,” he says.

The hospital has implemented a specific protocol to prevent situations such as Fadia's from happening.

“We have our pharmacists examine each of the medications brought in by patients, in collaboration with the manufacturers, verifying their authenticity through barcode scanning. If we find out that they are counterfeit — and it happens very often — we refuse to administer them.”

But this is not the case at all medical facilities, Dr Ghanem says.

“This is a heavy process, smaller institutions do not have the necessary resources to conduct thorough checks.”

While some black market medications may be genuine, the lack of controls makes their consumption a gamble, akin to playing Russian roulette. Dr Ghanem says there have been reports of high toxicity and even deaths caused by fake or contaminated medicines outside his hospital.

Hospitals report counterfeit medications to the Ministry of Health, but there is no comprehensive effort to fight the black market through a “co-ordination between medical centres”, says Sami Rizk, chief executive of the LAU Medical Centre-Rizk Hospital.

Cartel-like networks

To conceal the origin of the drugs and remain anonymous, sellers often use a complex web of intermediaries, including dealers responsible for connecting with patients locally and, in some cases, local pharmacies.

Ali, who did not want to disclose his last name, used to be one such middleman.

Every month he would sell about 250 boxes smuggled across the border with Syria to patients in Tripoli in north Lebanon, one of the country's poorest cities.

He explained to the National how the system worked.

Ali's phone number was spread throughout the neighbourhood as the go-to person for desperately needed medication. “Patients or their relatives would contact me on Telegram with their requests,” he says.

Although Ali never had direct contact with the seller in Syria, he worked with the smuggler responsible for transport. Ali would share the patients' requests with him and make sure that the required medication was available.

“I took a commission from both ends, 1 per cent from the patient and 2 per cent from the supplier,” he says.

While some sellers provide smuggled medication directly to pharmacies, Ali preferred to deal with his patients directly. “If the pharmacies were caught, they could have revealed my identity, and I could have been arrested.”

Ali's best friend has been in prison for more than a year for dealing in smuggled medicines. This was a wake-up call for Ali, who immediately decided to abandon the business. But it did not change his views on medicine smuggling.

“I did profit from this, but I also wanted to help those around me who were in dire need of these medications,” he says.

He says he did not doubt the quality of the products he provided since they were sourced from reliable Syrian pharmacies and offered clients affordable alternatives.

Ali says a lack of job opportunities is pushing many young people in Lebanon into the black market, which is thriving with the country in a state of collapse.

“It’s like El Chapo in Mexico,” he says, referring to the former Mexican drug lord and cartel leader. “You have a black market for almost everything, with different families overseeing specific types of businesses in each region.

“At least smuggling medication is better than many other kinds of black market.”

Tracking medication

Caretaker health minister Firas Abiad has acknowledged the prevalence of counterfeit medicines but views it as a trend affecting several countries with “loose regulations”, rather than a problem specific to Lebanon.

He told the The National his ministry had taken measures to tackle the issue, including a “robust pharmacovigilance programme” and “holding medication institutions accountable” for administering counterfeit medication.

“This has limited life-threatening cases,” he says.

To improve the availability of medicines, Mr Abiad says his ministry is providing free medication in primary healthcare centres, especially for chronic illness, and empowered local pharmaceutical production. Another key tool is the Meditrack platform introduced last year that tracks imports on a per-patient basis, helping to rationalise medicine use and prevent smuggling.

But drug shortages are a harsh reality.

Fadia, who is now free of cancer, still cannot find her medication in pharmacies, which she is supposed to take to maintain her remission.

She has been helped so far by an NGO, and dreads the thought of having to resort to the black market once again.

“I'm terrified by the idea … you never know if the medication can kill you or not until you take it: it's all about luck.”