COMMENTARY

Black Market for Remdesivir Thwarts India's COVID Response

Saurabh Jha, MBBS, MRCS, MS

Disclosures

June 02, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

"Know anyone selling remdesivir?" messaged Rishi Khanna in a WhatsApp group. He was caring for a relative with COVID-19 whose oxygen saturation had fallen below 92%.

An affluent business leader in Gurgaon, a financial hub near New Delhi, India, where property prices rival London and New York, Khanna wasn't used to scarcity. He golfed and dined with Delhi's elites. He had cardiologists and surgeons on speed dial. Wealth and status had given him access to everything, except remdesivir and oxygen. 

India's COVID-19 crisis has overwhelmed resources, creating scarcity of oxygen, drugs, and ventilators. Even burial spaces have become scarce. The shortage of remdesivir, one of the few drugs shown to work in COVID-19, has been exacerbated by panic buying, like a bank run on the drug. India's affluent class are realizing that money can't buy what's not there.   

After exhausting legitimate sources such as hospitals and pharmacies, Khanna approached the shadow market. He had heard of dealers who illegally hoarded remdesivir. They weren't easily found. They had no websites. No online customer reviews verified their quality. Their information came from word of mouth: people knew of people who knew them.  

Khanna contacted a dealer from South Delhi who promised remdesivir for Rs 5000 (USD $68). Although this was still five times the mark-up, it was a bargain in the market of price gougers, where a single injection of remdesivir fetched Rs 100,000 (USD $1374, and more than most doctors in India earn in a month).

The price sounded too good to be true. Khanna became suspicious but was so desperate that when the dealer insisted he pay first, he obliged. He'd see neither the drug nor the dealer again.  

Dr Anupam Singh, an internist at Aarogya Hospital in Ghaziabad, has a new task added to his merciless clinical schedule treating sick COVID-19 patients. Every day, he verifies the authenticity of remdesivir for dozens of patients who have bought the drug in the illegal market. 

"There's a risk of getting fake remdesivir from the illegal market, which would be bad for patients — financially and medically," Singh says.

Wasn't he abetting the shadow market by verifying the quality of its product? I asked. 

"My patients tell the dealers that a doctor will verify the drug. This encourages dealers to be honest. Ideally, we'd have enough supplies and people wouldn't be relying on the illegal market. But the situation isn't ideal in India," says Singh.   

Singh is an aficionado of evidence-based medicine. He knows P values and effect sizes. He's read the trials on remdesivir in COVID-19. He knows that the drug isn't a parachute.

"I'm reluctant to prescribe remdesivir to my patients. The therapeutic effect is marginal. But the side effect, the price they pay, isn't marginal. They can get bankrupted by the price gougers," says Singh. 

Singh dares not raise the issue of cost with his patients, who aren't as wealthy as Khanna. If they got a whiff that a "life-saving" drug was being withheld because of price concerns, they'd insist on it even more. In the market of desperation, life has an infinite value for rich and poor alike. The rich pay by cash, the poor by reluctant surrender. 

"Paradoxically, the high price of remdesivir makes it appear more efficacious than it actually is," says Singh.  

Singh's patients travel far and wide seeking remdesivir. One, recounts Singh, spent several days in the holy city of Rishikesh — literally the city of sages — seeking remdesivir for his mother. By the time he found the drug from an illegal dealer, his mother was in the 12th day of the illness, by which time remdesivir, which is most effective early in COVID-19 infection, became less effective. 

Unlike the illegal market for illegal drugs, the illegal market for legal drugs retains an aura of propriety. The dealers often have families and bona fide jobs and generally don't indulge in other criminal activities. Though large hospitals contract directly with drug manufacturers, thousands of small hospitals and pharmacies in India rely on intermediaries, who ensure drugs disseminate from manufacturers to consumers seamlessly. This intricate network of agents and distributors is a boon in times of feast. Through competition they keep the drug prices low. But in times of scarcity, they can be a curse. 

"When the cases began rising, the distributors sensed demand and began hoarding remdesivir, little by little. They knew they could price-gouge desperate patients if the demand skyrocketed," explained Singh. Often, remdesivir changed multiple hands, each buyer having aspirations of being the seller of last resort, each transaction ensuring that the patient — the final consumer — would face a heftier surcharge.  

What could be done to end this inhumane practice? I asked.  

"Even if you confiscated all the hoarded remdesivir, you wouldn't meet India's clinical need. The only solution is more supply. We need drug surplus. Corruption is a sign of scarcity. It's scarcity — not people — that's evil," said Singh. 

At 2 AM, Rishi Khanna received a WhatsApp message. A dealer in Agra, a city 150 miles away, was selling remdesivir for Rs 78,000 (USD $1072) an injection. His offer seemed genuine. He might lower the price to Rs 60,000 (USD $824). Khanna was in no mood to haggle. He gulped coffee and minutes later was speeding down the Delhi-Agra expressway in the thick of the night in search of the elixir.   

Saurabh Jha, MBBS, MRCS, MS, is an associate professor in the Department of Radiology at the University of Pennsylvania in Philadelphia.

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