History doesn’t repeat itself, it rhymes

The Economic Times reported today of my petition to the Prime Minister to hold the Ministry of Health and Family Welfare to account for all the promises it made to the Parliament of India over several years regarding its opaque and unscientific decisions regarding several drugs that continue to be on the market today. A copy of the petition is here.

I was asked why I decided to petition the Prime Minister now, almost after two years since the highest court in the land refused to listen to plea calling it academic. For the sake of context, I am reproducing my responses to the questions I was asked below:

Why have you petitioned the PMO now, when it has been years since these developments took place and also two years since you were told by court that you could petition the government?
 
After I withdrew my PIL from the Indian Supreme Court, I did prepare an extensive report backed by substantial data and submit it to the Ministry of Health (MoH). Thereafter, the administration did take some small steps toward improving quality of our supply chain, including an effort at making BE and Stability testing compulsory. These were two key recommendations that I had made in my report to the MoH. While K L Sharma was the Health  Secretary, it appeared that he was trying to address the concerns I raised in my report, including defending the decision to ban irrational FDCs in the Indian Supreme Court.
While these efforts address how we do things going forward, it is important to understand how these four drugs got on the market in the first place. In our report, we had documented to the extent which statutory bodies like DTAB had dragged their feet when it came to issues of BE and Stability. Unfortunately, despite many attempts, we couldn’t get any data substantiating the reasons why the DCGI approved these drugs in the first place. While the observations in the Parliamentary Standing Committee Reports are scathing; none of the Action Taken Reports actually tell us how these approvals came about. In fact, despite representations to the Parliament, the MoH seems to conveniently forget its commitments to the people of India. In order for us to fix this problem, we need to understand what happened to get us to this place so that such mistakes do not happen going forward. We need to invest in correcting our processes and building our institutions so that they are not held hostage or unduly influenced by special interests as has been pointed out by the Standing Committee.
The administration has not yet taken any action on these 4 drugs despite the fact that I had flagged these in my report in 2016. Over the last year, even the 2011 ban on using Letrozole for infertility treatment has been revoked in the most opaque manner.  Deanxit is back on the market after the MoHFW lost its case not once but twice now in the court.  Since the MoHFW clearly lacks political will, it is time now to petition the Prime Minister – if no positive action is forthcoming from the PMO, I have been advised to approach the judiciary once again; this time with conclusive evidence that the government is not acting despite a visible threat to public health. After the recent Supreme Court judgment that Parliamentary Reports can be considered as evidence, my lawyers are confident that a second petition will be successful.
I hope it doesn’t have to come to that and that the PMO orders the MoHFW to follow up on its promises to the Standing Committee to conduct an inquiry. I am not asking for anything new – I am only asking for the Ministry to fulfill its own written committment to the Parliament.
 
Has the PMO responded to your petition? If yes, what have they said? If no, what follow up action are you planning to take?
 
Its been just two weeks – I think we should give the PMO a little more time to respond.
 
Have you also reached out to the health ministry and the Drug Controller General of India about this issue this year? If not, why not?
 
As mentioned above, the report summarizing my findings was sent to the MoH – there has been little action by the Ministry – the one officer who was doing some good work has been transferred to a punishment posting. I don’t see any point of reaching out to the Ministry when no action has been taken on my earlier extensive report. More importantly, it has been five years now since Ranbaxy pled guilty to seven counts of criminal felony in my case in the US. This has led to discovery of numerous instances of data integrity violations and outright fraud among Indian pharmaceutical companies that has been documented by regulators from the USA, France, Germany and the European Union. While these foreign regulators work to protect their drug supply, precious little has been done by the MoH to protect ours. The MoH doesn’t seem to be interested in talking to me about how to stem this behavior. What confidence do you think I ought to have given their track record to reach out to them again this time?
 
If you have approached the health ministry and DCGI, what response have you received?
 
I was asked to meet K L Sharma two years ago, subsequent to me sending my report to the MoH. The meeting was promising, but there has been no follow through – there are powerful interests at play here and unless we have a Minister with political will, nothing will change. I’m told the PMO has that political will to effect some positive change regarding our drug supply and hence the petition to the PMO.

 

Our primary responsibility in holding the elected and bureaucracy accountable is to demand that the promises made to us are fulfilled. More often than not, these promises are conveniently swept under the rug, and we go on with business as usual. Unless we learn from history, and find out what was done wrong, how do we expect those who govern to correct the processes and do the right thing going forward?

Buclizine: A reminder of lack of accountability at the Ministry of Health

According to a recent report in the Mint, the Drugs Technical Advisory Board (DTAB), a statutory authority under the Drugs and Cosmetics Act, 1940 was to meet this week to deliberate amongst other things, the possibility of a ban on a drug called Buclizine. This drug, which was initially introduced in India by a Belgian company called UCB Pharma, was then sold to an Indian company named Mankind Pharma.

Buclizine is the most potent reminder of the absolute lack of accountability at the Ministry of Health. Originally approved as an antihistamine (treating motion sickness and allergies), the government in 2006 mysteriously approved the drug for an additional indication – as an ‘appetite stimulant’ for children. In order to approve the drug for an additional indication, the drug regulator is required to review data from additional clinical trials to establish the efficacy of the drug for the new indication. Except, the allegation against Buclizine has been that there were never any clinical trials or studies to establish the drug’s efficacy as an appetite stimulant. Apparently, even Belgium, the country of origin of this drug, has not approved Buclizine as an appetite stimulant. In other countries like the US, the drug has been entirely discontinued for all indications.

The controversy surrounding Buclizine’s approval in India as an appetite stimulant is no secret. Some vocal sections of the medical community have been voicing their criticism against the use of the drug as an appetite stimulant since 2011. Then in 2012, the Parliamentary Standing Committee on Health & Family Welfare, in its 59th report, slammed the regulator for approving the drug. The committee reviewed the status of this drug in other countries, the lack of clinical trials needed to demonstrate safety and efficacy and demanded an inquiry into how an approval was granted; it also recommended punishment for those who approved the drug. The committee concluded with the following recommendation to the government:

“The Committee is of the view that responsibility needs to be fixed for unlawfully approving Buclizine, a drug of hardly any consequence to public health in India, more so since it is being administered to babies/children. At the same time the approval granted should be reviewed in the light of latest scientific evidence, regulatory status in developed countries, particularly in Belgium, the country of its origin.”

The government promised an inquiry, which never took place even though in 2013 the Standing Committee “took serious umbrage” in its 66th report to the Ministry’s dilatory tactics.

Finally, in 2016, almost 4 years after the Standing Committee red-flagged the approval, an expert committee called the SEC met on February 19, 2016 and held deliberations over the use of Buclizine as an appetite stimulant. Since the company marketing the drug was unable to present any clinical data to justify the use of the drug as an appetite stimulant, the committee recommended that the drug be discontinued as a therapy for this indication. A few months later, the DTAB met on June 27, 2016 and after considering the SEC’s report “endorsed the proposal for prohibiting the manufacture, sale and distribution of Buclizine for the indication “as appetite stimulant”. DTAB also set up another expert committee to examine the continued use of Buclizine for other indications.

These recommendations from the SEC and DTAB were more than sufficient for the Ministry of Health to issue an order under Section 26A of the Drugs & Cosmetics Act, 1940 prohibiting the use of the drug as an appetite stimulant. Yet, no such order was passed by the Ministry of Health.

Now in 2018, we are back to square one with the DTAB reportedly meeting once again to deliberate the issue of Buclizine. In the meantime, the company selling Buclizine has claimed a turnover of Rs. 14 crores from this product, selling 42 lakh tablets every year to unsuspecting patients.

If you think that courts will hold the government accountable, think again. I tried filing a PIL before the Supreme Court in 2016 raising a number of issues including the approval granted to Buclizine. I was told by the court that I was raising academic issues after which my lawyers withdrew the petition.

The case of Buclizine is open and shut – if there is no clinical data demonstrating the efficacy of the drug as an appetite stimulant, the drug should never have been approved in the first place. The fact that the drug continues to be available on the Indian market 6 years after a bipartisan Parliamentary Standing Committee rapped the Ministry on its knuckles is a sign of a deep-rooted rot in the Ministry of Health. Merely changing secretaries in the Ministry will not cure this rot. Repealing and replacing the Drugs & Cosmetics Act, 1940 to put in place a more transparent and accountable mechanism is the only solution.