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Briefing and Opinion
November 12, 2004

Granny As Cross-Border Drug Trafficker
Julia Morrison

Julia Morrison listens at a press conference in New York, October 12, 2004. Morrison planned to join a group senior citizens traveling by train from Florida to Canada to buy lower-cost prescription drugs. (AP Photo/Bebeto Matthews)

Buying drugs from Canada has become an increasingly popular strategy for older Americans facing pharmacy bills that are growing faster than their fixed incomes. The following excerpt, "Granny as Cross-Border Drug Trafficker," is taken from "POWERFUL MEDICINES: THE BENEFITS, RISKS, AND COSTS OF PRESCRIPTION DRUGS," by Jerry Avorn, M.D., recently published by Knopf.

Powerful Medicines

While some governments influence drug prices by keeping them down, ours has used its regulatory authority to keep them high. A new staple of the morning paper and evening news is the photogenic spectacle of groups of elderly people in Maine, Texas and other border states climbing onto buses to fill their prescriptions in Canada or Mexico. This geriatric hajj called attention to the remarkable discrepancy in the price of the same medicine for American patients versus our neighbors to the north and south. Outside the United States, the prices of prescription drugs are regulated by national governments (as in Canada), or kept low because that's all the market can pay (as in Mexico). These are often the very same products, made by the same major drug companies in the same factories that supply American drugstores.

This new kind of drug trafficking hasn't been limited to retirees. Since the mid-1990s and even more frantically in the new century, state governments have seen their Medicaid expenses grow much faster than the rest of their budgets, with medications driving a substantial portion of that increase. These officials have begun coming together to consider joint purchasing arrangements to take advantage of cross-national price differentials. And individual Americans are logging onto the internet to fill their prescriptions at pharmacy sites based in Canada exactly as they would for mail-order pharmacy services based in the United States. They have read the headlines about the benefits of the new global economy and are acting accordingly.

In response to this growing trend and to demands that something be done to make drugs more affordable, several years ago Congress passed legislation called the Medicine Equity and Drug Safety Act of 2000, which had been quietly inserted into an agricultural appropriations bill. The law would have made it legal for Americans to buy drugs from sources outside the United States, such as Canada, as long as those drugs were manufactured in the United States. That seemed innocuous enough, as did the requirement that before the new law could take effect, the U.S. secretary of health and human services would have to certify that use of such products would be safe and would save money for Americans, pretty plausible assumptions. But in the last weeks of the Clinton administration, HHS secretary Donna Shalala ruled that she could not certify either of these conditions, and the law was never implemented.

The pharmaceutical industry, although it benefits from many aspects of globalization, including the right to buy its supplies wherever on earth it can get the best deal, has not been as eager for American consumers or health care purchasers to be able to do the same thing. It raised fears about "foreign drugs" by casting xenophobic doubts on their safety and quality. In 2002, Congress again debated a bill that would make it legal for Americans to fill their prescriptions in Canada. Virtually all of these drugs were to be products manufactured by U.S. companies or their Canadian subsidiaries.

Facing the threat of Americans importing drugs directly from those sources at lower prices, the drug industry mounted a response that might have come right out of Dr. Strangelove. It warned that "foreign handling" of these prescriptions would result in "loss of potency" and "adulteration." It ran an advertisement depicting two identical-looking pills over the caption "QUICK. PICK THE CAPSULE THAT HASN'T BEEN TAMPERED WITH." (Implication: it's the one that didn't pass through un-American hands.) The industry ad cited the support not just of FDA and HHS, but also of the U.S. Customs Service and the federal Drug Enforcement Agency, arms of government that usually worry about protecting us from very different kinds of drugs. The ad warned that allowing Americans to fill prescriptions in Canada "could open American's medicine cabinets to an influx of dangerous drugs," and closed with an exhortation to "KEEP BLACK MARKET DRUGS OUT OF AMERICA." In a further response to what might be called the Maple Peril, several large drug companies threatened to stop supplying their products to any Canadian wholesaler or retailer that knowingly sold them to American customers.

Recognition for the best commingling of fearful themes must go to HHS secretary Tommy Thompson. In arguing against the bill, he warned that "opening our borders to reimported drugs potentially could increase the flow of counterfeit drugs, cheap foreign copies of FDA-approved drugs [what the rest of us call generics], expired and contaminated drugs, and drugs stored under inappropriate and unsafe conditions." Granted, the unavailability of refrigeration in remote areas is a problem for vaccine programs in the Third World, but ... Canada? Thompson's argument in 2002 climaxed with a strange conclusion: "In light of the anthrax attacks of last fall, that's a risk we simply cannot take."

One might have expected FDA to intervene on behalf of the public and establish a means of certifying which imported drugs pass U.S. standards, exactly as it presently does for products manufactured abroad by large multinational pharmaceutical companies. Instead, it responded to the Maple Peril by aligning itself firmly on the side of the drug industry, stating that imported drugs could pose a major threat to the health of the nation, and that is was powerless to do anything about it. In the face of all the legitimate concerns of doctors and patients about real drug side effects, FDA's most visible public pronouncements about risk in recent years dealt instead with the supposed hazards of drugs from Canada -- despite the near-total absence of any scientific evidence substantiating this risk.

Copyright 2004 by Jerry Avorn, reproduced with permission. Further information is available at