Across Africa, cancer medications have been found to be substandard or counterfeit. That means people are being given medicine that may not work, or that could even cause them harm.

An alarming number of people across Africa may be taking cancer drugs that don’t contain the vital ingredients needed to contain or reduce their disease.

It’s a concerning finding with roots in a complex problem: how to regulate a range of therapeutics across the continent.

A US and pan-African research group published the findings this week in The Lancet Global Health . The researchers had collected dosage information, sometimes covertly, from a dozen hospitals and 25 pharmacies across Ethiopia, Kenya, Malawi and Cameroon.

They tested nearly 200 unique products across several brands. Around 17% — roughly one in six — were found to have incorrect active ingredient levels, including products used in major hospitals.

Patients who receive insufficient dosages of these ingredients could see their tumors keep growing, and possibly even spread.

Similar numbers of substandard antibiotics, antimalarial and tuberculosis drugs have been reported in the past, but this is the first time that such a study has found high levels of falsified or defective anticancer drugs in circulation.

“I was not surprised by these results,” said Lutz Heide, a pharmacist at the University of Tübingen in Germany who has previously worked for the Somali Health Ministry and has spent the past decade researching substandard and falsified medicines.

Heide was not part of the investigative group, but said the report shed light on a problem not previously measured.

“I was delighted that, finally, someone published such a systemic report,” he said. “That is a first, really significant systematic study of this area.”

Causes need addressing, but it’s not straightforward

“There are many possible causes for bad-quality products,” Marya Lieberman of the University of Notre Dame in the US, the investigation’s senior researcher, told DW.

Those causes can include faults in the manufacturing process or product decay due to poor storage conditions. But some drugs are also counterfeit, and that increases the risk of discrepancies between what’s on the product label and the actual medicine within.

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Spotting substandard and falsified products can be difficult. Usually, a medical professional or patient is only able to perform a visual inspection — literally checking a label for discrepancies or pills and syringes for color differences — to spot falsified products.

But that’s not a reliable method. In the study, barely a quarter of the substandard products were identified through visual inspection. Laboratory testing identified the rest.

Fixing the problem, Lieberman said, will require improving regulation and providing screening technologies and training where they’re needed.

“If you can’t test it, you can’t regulate it,” she said. “The cancer medications are difficult to handle and analyze because they’re very toxic, and so many labs don’t want to do that. And that’s a core problem for the sub-Saharan countries where we worked. Even though several of those countries have quite good labs, they don’t have the facilities that are needed for safe handling of the chemo drugs established.”

Not only cancer treatments are affected

Nearly a decade ago, the World Health Organization found around one in 10 medicines used in low and middle-income countries were substandard or falsified. Independent research conducted since has backed those figures up, sometimes finding rates that are potentially twice as high.

“This could lead to treatment failure, adverse reactions, disease progression,” health economist Sachiko Ozawa told DW. Ozawa contributed to the investigation on anticancer drugs and has separately researched other cases of defective medicines.

“For the community, there’s also economic losses in terms of wasted resources,” she said. “So countries may be spending a lot of money on medications that are not going to be effective.”

While high-income countries can monitor supply chains and have stringent regulatory systems in place to identify and withdraw suspect products, the infrastructure to do that is far from common in other regions.

The WHO has long called for greater local regulations to take fake medicines out of circulation Image: Denis Balibouse/REUTERS

In those places, poor access to affordable medication often drives patients to less-regulated marketplaces. Inadequate governance and regulation, as well as a scarcity of surveillance and diagnostic equipment to test pharmaceuticals, are all contributing to the problem in Africa.

“In high-income countries, I think there’s a much more secure supply chain where you know the manufacturers are vetted, it has to go through very stringent regulatory processes to get approval…it gets tested more frequently,” said Ozawa.

The WHO told DW that following the report’s findings, it was working with the four affected countries to address the problem.

“We are concerned with the findings the article has highlighted. WHO is in contact with national authorities of four impacted countries and obtaining relevant data,” it said in a statement. “We expect to assess full information to evaluate the situation, which often takes time and capacity. But we’re committed to address these issues working with the relevant countries and partners.”

The WHO also reiterated its ongoing call for countries to improve their regulatory frameworks to “prevent incidents of substandard and falsified medicines, including in settings of cancer programs.”

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Prevention, detection and response

In 2017, the WHO’s review of substandard and falsified medicines offered three solutions based around prevention, detection and response.

Stopping the manufacture and sale of those medicines is the primary preventative measure, but where defective products make it to market, surveillance and response programs can prevent poor quality medicines from reaching patients.

But regulatory reform sought by experts and authorities takes time. More immediate solutions are being developed in the form of better screening technologies.

Lieberman is working on a “paper lab” — a type of test that can be used by trained professionals to chemically test the quality of a product before it’s administered to a patient. Other laboratory technologies are also under development.

One comforting point is that while a significant proportion of the medication circulating in medical facilities in the four African countries was defective, the majority of the products tested met required standards.

“[With] two-thirds of the suppliers, all the products [were] good quality, so there are good quality suppliers,” said Heide. “But a few of them really have a suspiciously high number of failing samples.”

Edited by: Derrick Williams

Most of Africa’s 1.3 billion people have little advance knowledge of the weather. But on a continent often hit by extreme weather events, knowing the forecast could save lives.

African nations are particularly vulnerable to severe weather events. These not only cripple economies and people’s livelihoods but also cost lives across the continent.

In West Africa, for instance, more than 70% of the population is affected at least once every two years by flood, drought or sandstorms.

But like other less-developed regions, many parts of Africa have gaps in the ability to warn people of both imminent natural disasters, such as flash flooding, or future hazards, such as drought.

This has dramatic consequences. Over the last two decades, the average number of deaths caused by a flooding event in Africa is four times higher than in Europe or North America, according to a 2024 article in Nature, a science journal.

The continent, where the vast majority of people are dependent on rain-fed agriculture, also suffers the most deaths from droughts. From 2006 to 2015, 99% of deaths from all droughts worldwide were in Africa, even though it only experienced half of globally reported droughts in that time.

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Push to improve Africa’s forecasting

With climate change predicted to increase the intensity and frequency of such extreme events, said Victor Ongoma, an assistant professor of climate change adaptation at Morocco’s Mohammed VI Polytechnic University, “there’s pressure on weather providers in Africa to provide more reliable, accurate and timely weather forecasts.”

They’ve made great strides in terms of quality and timing, he told DW. “It’s still below average, but there is still lots of effort going on and I’m hopeful things will get better with time.”

Weather forecasting is complex. In the best case scenario, it needs millions of data points — measurements of things like temperature, rainfall, humidity, solar radiation and wind intensity and direction.

These observations are collected on land, lakes and oceans, in the atmosphere and by satellites, and then crunched by powerful computers using complex mathematical models to predict weather patterns.

Data observation still poor in Africa

But weather forecasting still has a way to go on the continent, which has the world’s least developed land-based weather observation network. And, according to a 2019 report by the World Meteorological Organization (WMO), this aging network is deteriorating due to lack of maintenance.

Angola, for example, went from more than 150 working weather meteorological stations before independence from Portugal in 1975 to 20 in 2022 .

In West Africa, more than 60% of weather data is still collected manually by non-professional and voluntary staff, leading to poor quality data that can’t be used for real-time monitoring.

According to a WMO database, Africa only has 37 radar facilities, which are vital for tracking weather fluctuations and rainfall and for forewarning of floods and other hazards. In comparison, 345 radars cover Europe and Russia, which together have a smaller land mass than Africa.

Moreover, more than half of Africa’s radar stations are unable to produce accurate enough data to predict weather patterns for the coming days or even hours, the 2024 Nature article noted.

Weather models weak for Africa

On top of this, the global models used to predict the weather perform poorly in Africa.

“The main disadvantage is that most of these models were developed for the global North,” said climate scientist Benjamin Lamptey, explaining that these models work well in the mid-latitudes (about 30 to 60 degrees north or south of the equator), where much of Europe and the USA fall.

But African weather patterns, such as monsoons, haven’t been incorporated into the models, said Lamptey, a visiting professor of meteorology at the UK’s University of Leeds, which is why “we’re seeing shortcomings in the forecasting.”

“Just developing things in the global North and transferring them to the global South does not work. We need to have ownership and things must be viewed from the African perspective,” he said.

Many African nations lack computing facilities powerful enough to run complex weather models, while power cuts and weak internet connections limit the access to global data sets.

Increasing efforts and funding

There is some good news. For climate expert Jeffrey N.A. Aryee from Ghana’s Kwame Nkrumah University of Science and Technology, weather forecasting in Ghana, and across many other sub-Saharan nations, is quickly evolving.

Ghanaians used to complain that forecasts were “way off” what the actual weather was, Aryee tells DW. But the Ghana Meteorological Agency has “undergone a revolution,” he said, where it is now able to provide a realistic short-term forecasts because of better access to satellite and radar data (although Ghana’s radar recently broke down) and prediction models.

The numbers of surface weather stations across Africa sending data to the global observing network known as GBON nearly doubled in the first half of 2023 , going from 589 to 1,045.

And thanks to the WMO and other organizations, African nations are making inroads into digitizing the millions of data points hidden in their historical weather archives.

“This will help make more data available because for you to know where you’re going [with weather predictions], you need to know where you are coming from,” said Victor Ongoma.

Both Ongoma and Lamptey also praise the development of regional climate centers .

“For example, if you take countries along the Gulf of Guinea in West Africa, they have two rainy seasons, and the rainfall originates in the east and moves towards the west,” said Lamptey.

“So, weather systems are unique to the regions,” he said, meaning the five climate centers can tailor their expertise to boost regional forecasting.

Amid the flurry of efforts to close Africa’s weather forecasting gaps, it’s important not to forget the end users, warn experts, and how they access information and in what languages.

Fishermen going out on the ocean want different weather information to pastoralists looking for water for their herd. And farmers trying to decide when to plant or harvest need a reliable seasonal forecast to help with decision making.

“You need to know what people really want to know, so you don’t just tell them, ‘OK, it’s going to rain,'” said Jeffrey N.A. Ayree. “A fisher is not just interested in whether it’s raining or not. He’s also interested in the nature of the sea.”

Edited by: Keith Walker

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While you’re here: Every weekday, we host AfricaLink, a podcast packed with news, politics, culture and more. You can listen to AfricaLink wherever you get your podcasts.

Emily was combing her baby daughter’s hair when she first felt the lumps. It was a week before Christmas, and she and her husband had taken their children to visit family. Her youngest daughter, Isadora, had been feverish and listless, unwilling to play or take a bottle. The lumps were clustered on the back of Isadora’s neck, the size of small beans. Something was very wrong.

At the emergency centre, the doctor found more lumps under Isadora’s arms and in her groin. The doctor urged Emily to take her daughter to a hospital as soon as she could.

Back home in Porto Alegre in southern Brazil, Emily watched as doctors hurried her daughter through medical tests. The lumps had grown. That night, Isadora was lying on a stretcher beside Emily when a doctor told her the news. Isadora had an aggressive type of leukaemia, a cancer that affects white blood cells.

Acute lymphoblastic leukaemia (ALL) is the most common kind of childhood cancer, and Isadora was one of roughly 3,000 children in Brazil to be diagnosed with it in 2017. Her treatment would be gruelling: a cocktail of chemotherapy drugs that would leave her skeletal, vomiting and lethargic. One cancer doctor described this process as a fine art: to almost kill a child, but not quite.

Isadora, usually a bubbly baby, began to suffer side effects. Emily took hope from the idea that, although the drugs were making her daughter sick, they were also curing her.

Key facts

Oral diseases, while largely preventable, pose a major health burden for many countries and affect people throughout their lifetime, causing pain, discomfort, disfigurement and even death.

It is estimated that oral diseases affect nearly 3.7 billion people.

Untreated dental caries (tooth decay) in permanent teeth is the most common health condition according to the Global Burden of Disease 2021.

Prevention and treatment for oral health conditions is expensive and usually not part of national universal health coverage (UHC) benefit packages.

Most low- and middle-income countries do not have sufficient services available to prevent and treat oral health conditions.

Oral diseases are caused by a range of modifiable risk factors common to many noncommunicable diseases (NCDs), including sugar consumption, tobacco use, alcohol use and poor hygiene, and their underlying social and commercial determinants.

Overview

Most oral health conditions are largely preventable and can be treated in their early stages. Most cases are dental caries (tooth decay), periodontal diseases, tooth loss and oral cancers. Other oral conditions of public health importance are orofacial clefts, noma (severe gangrenous disease starting in the mouth mostly affecting children) and oro-dental trauma.

Prevalence of the main oral diseases continues to increase globally with growing urbanization and changes in living conditions. This is primarily due to inadequate exposure to fluoride (in the water supply and oral hygiene products such as toothpaste), availability and affordability of food with high sugar content and poor access to oral health care services in the community. Marketing of food and beverages high in sugar, as well as tobacco and alcohol, have led to a growing consumption of products that contribute to oral health conditions and other NCDs.

Dental caries (tooth decay)

Dental caries results when plaque forms on the surface of a tooth and converts the free sugars (all sugars added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices) contained in foods and drinks into acids that destroy the tooth over time. A continued high intake of free sugars, inadequate exposure to fluoride and a lack of removal of plaque by toothbrushing can lead to caries, pain and sometimes tooth loss and infection.

Periodontal (gum) disease

Periodontal disease affects the tissues that both surround and support the teeth. The disease is characterized by bleeding or swollen gums (gingivitis), pain and sometimes bad breath. In its more severe form, the gum can come away from the tooth and supporting bone, causing teeth to become loose and sometimes fall out. Severe periodontal diseases are estimated to affect more than 1 billion cases worldwide. The main risk factors for periodontal disease are poor oral hygiene and tobacco use.

Edentulism (total tooth loss)

Losing teeth is generally the end point of a lifelong history of oral disease, mainly advanced dental caries and severe periodontal disease, but can also be due to trauma and other causes. The estimated global average prevalence of complete tooth loss is almost 7% among people aged 20 years or older. For people aged 60 years or older, a much higher global prevalence of 23% has been estimated. Losing teeth can be psychologically traumatic, socially damaging and functionally limiting.

Oral cancer

Oral cancer includes cancers of the lip, other parts of the mouth and the oropharynx and combined rank as the 13th most common cancer worldwide. The global incidence of cancers of the lip and oral cavity is estimated to be 389 846 new cases and 188 438 deaths in 2022 (1). Oral cancer is more common in men and in older people, more deadly in men compared to women and it varies strongly by socio-economic circumstances.

Tobacco, alcohol and areca nut (betel quid) use are among the leading causes of oral cancer. In North America and Europe, human papillomavirus infections are responsible for a growing percentage of oral cancers among young people.

Oro-dental trauma

Oro-dental trauma results from injury to the teeth, mouth and oral cavity. Latest estimates show that 1 billion people are affected, with a prevalence of around 20% for children up to 12 years old. Oro-dental trauma can be caused by oral factors such as lack of alignment of teeth and environmental factors (such as unsafe playgrounds, risk-taking behaviour, road accidents and violence). Treatment is costly and lengthy and sometimes can even lead to tooth loss, resulting in complications for facial and psychological development and quality of life.

Noma

Noma is a severe gangrenous disease of the mouth and the face. It mostly affects children aged 2–6 years suffering from malnutrition, affected by infectious disease, living in extreme poverty with poor oral hygiene or with weakened immune systems.

Noma is mostly found in sub-Saharan Africa, although cases have also been reported in Latin America and Asia. Noma starts as a soft tissue lesion (a sore) of the gums. It then develops into an acute necrotizing gingivitis that progresses rapidly, destroying the soft tissues and further progressing to involve the hard tissues and skin of the face.

According to latest estimates (from 1998) there are 140 000 new cases of noma annually. Without treatment, noma is fatal in 90% of cases. Survivors suffer from severe facial disfigurement, have difficulty speaking and eating, endure social stigma, and require complex surgery and rehabilitation. Where noma is detected at an early stage, its progression can be rapidly halted through basic hygiene, antibiotics and improved nutrition.

Cleft lip and palate

Orofacial clefts, the most common of craniofacial birth defects, have a global prevalence of between 1 in 1000–1500 births, with wide variation in different studies and populations (2). Genetic predisposition is a major cause. However, poor maternal nutrition, tobacco consumption, alcohol and obesity during pregnancy also play a role. In low-income settings, there is a high mortality rate in the neonatal period. If lip and palate clefts are properly treated by surgery, complete rehabilitation is possible.

Risk factors

Most oral diseases and conditions share modifiable risk factors such as tobacco use, alcohol consumption and an unhealthy diet high in free sugars that are common to other NCDs including cardiovascular disease, cancer, chronic respiratory disease and diabetes.

In addition, diabetes has been linked in a reciprocal way with the development and progression of periodontal disease. There is also a causal link between the high consumption of sugar and diabetes, obesity and dental caries.

Oral health inequalities

Oral diseases disproportionately affect the poor and socially disadvantaged members of society. There is a very strong and consistent association between socioeconomic status (income, occupation and educational level) and the prevalence and severity of oral diseases. This association exists from early childhood to older age and across populations in high-, middle- and low-income countries.

Prevention

The burden of oral diseases and other noncommunicable diseases can be reduced through public health interventions by addressing common risk factors.

These include:

promoting a well-balanced diet low in free sugars and high in fruit and vegetables, and favouring water as the main drink;

stopping use of all forms of tobacco, including chewing of areca nuts;

reducing alcohol consumption; and

encouraging use of protective equipment when doing sports and travelling on bicycles and motorcycles (to reduce the risk of facial injuries).

Adequate exposure to fluoride is an essential factor in the prevention of dental caries.

Twice-daily tooth brushing with fluoride-containing toothpaste (1000 to 1500 ppm) should be encouraged.

Access to oral health services

Unequal distribution of oral health professionals and a lack of appropriate health facilities to meet population needs in most countries means that access to primary oral health services is often low. Out-of-pocket costs for oral health care can be major barriers to accessing care. Paying for necessary oral health care is among the leading reasons for catastrophic health expenditures, resulting in an increased risk of impoverishment and economic hardship.

WHO response

The World Health Assembly approved a Resolution on oral health in 2021 at the Seventy-fourth World Health Assembly. The Resolution recommends a shift from the traditional curative approach towards a preventive approach that includes promotion of oral health within the family, schools and workplaces, and includes timely, comprehensive and inclusive care within the primary health-care system. The Resolution affirms that oral health should be firmly embedded within the NCD agenda and that oral health-care interventions should be included in national universal health coverage benefit packages.

In response to the mandate outlined in the resolution, the Secretariat developed the Global strategy on oral health, adopted in May 2022 (decision WHA75.11), and included the Global oral health action plan 2023‒2030 (GOHAP) in the report on NCDs, noted by the Seventy-sixth World Health Assembly in 2023 (WHA76.9). The GOHAP includes a range of actions for Member States, the WHO Secretariat, international partners, civil society organizations and the private sector.

In 2024, as an outcome of the first ever WHO Global Oral Health Meeting that took place 26–29 November in Bangkok, Thailand, the Bangkok Declaration – No Health Without Oral Health was adopted. This Declaration advocates for elevating oral diseases as a global public health priority. The Bangkok Declaration reiterates Member States’ commitment to the landmark 2021 resolution on oral health, which advances the prevention and control of oral diseases as part of the NCD, UHC and environmental agendas. It emphasizes the need to strengthen health systems through primary health care approaches, ensuring that environmental sustainability and climate resilience are central components.

References

1. Ferlay J, Ervik M, Lam F, Laversanne M, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2024). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. Available from: https://gco.iarc.who.int/today

2. Salari N, Darvishi N, Heydari M, Bokaee S, Darvishi F, Mohammadi M. Global prevalence of cleft palate, cleft lip and cleft palate and lip: A comprehensive systematic review and meta-analysis. J Stomatol Oral Maxillofac Surg. 2021;S2468-7855(21)00118X. doi:10.1016/j.jormas.2021.05.008.