No cure for war

Valeria Romashova stopped being able to breathe without an inhaler nine years ago. “I’d use the whole thing in one go just to say a single word.” She had been using an Italian Foster inhaler on a daily basis since becoming asthmatic, receiving the medicine from the state on a subsidised basis. That prescription was denied her for the first time this year and replaced with the Russian-made Respicomb Air. Medical institutions only began to purchase the Russian alternative last year. Respicomb costs just as much as the imported version, but, Valeria says, it doesn’t work nearly as well.

News stories about the dearth of imported medicines in Russia are now commonplace: in May, the progestogen Norcolut disappeared from the shelves. In September, the antidepressant Prozac also vanished. Even Russian President Vladimir Putin has commented on the shortage of medicines, while noting the growth in domestic production.

How bad is it really?

This is due to disruption in supplies from overseas producers, the volume of which fell by a quarter. Whereas imported medicines accounted for 15% of all purchases last year, that figure is now just 9%.

By 2023, Russian hospitals were no longer receiving some 200 medicines used to treat skin diseases. Many cancer medicines had disappeared too, chiefly those treating lung and prostate cancer, leukaemia, and 17 medicines used to treat breast cancer.

Our figures show that barely any medicines have been purchased from Ukraine, the Netherlands and Israel in the last two years. Deliveries from so-called “friendly” countries — China, India, and Kazakhstan — have fallen by more than half. Of Russia’s 10 largest partners, only Belarus has managed to increase exports.

Pharmacies without medicine

In January, the Health Ministry warned of pending shortages of 86 medicines, including human immunoglobulin, ibuprofen and even iodine. In August, the list extended to almost 200 items.

According to data from Russian medical market research company RNC Pharma, Russia stopped importing medicines containing 99 active substances last year, equivalent to 8% of all imported items.

This year, a report by the market research DSM Group found that the range of foreign medicines available had decreased by a further 20%.

A report published in January by Russian newspaper Izvestia found that 99% of pharmacists admitted to shortages of medicines in 2022. We estimate that 20% of life-saving medicines are unavailable in pharmacies in regional capitals and almost 40% are difficult to access, i.e. available in under 100 pharmacies.

Some medicines have been unavailable in Russia for years, though most of the unavailable life-saving drugs disappeared from pharmacies in the past two years.

This covers 30% of cancer medicines, and 20% of medicines used to treat blood diseases and congenital abnormalities.

Whereas in Moscow you can still find 75% of brand name medicines, in more remote locations, such as the southern Russian cities of Rostov-on-Don or Pyatigorsk, pharmacies have under half of all subsidised medicines available. In Vladivostok, in the Russian Far East, that shortfall is 64%.

Cancer patients worst affected

Screenwriter Ulyana Mikulyonok has had bowel cancer for more than seven years. It is now stage 4 cancer and the only medicine that can help extend her life is the French-produced Lonsurf. Last year, the Moscow Health Department refused to purchase the drug for Mikulyonok, even though it had been prescribed.

Her story was picked up by independent media last month and the Health Department revised its decision a year later. “I don’t know what’s been more difficult: cancer, cancer treatment or fighting to get cancer treatment,” Mikulyonok told Novaya Europe.

In March last year, the Health Ministry provided a list of 39 anti-tumour drugs that may become unavailable. This, while the number of patients has increased: according to the Audit Chamber, the parliamentary financial control body, last year saw 1 million Russians diagnosed with cancer for the first time. Of those, one in five has stage four cancer. Despite this, public procurement of 25% of cancer drugs has decreased over the past two years.

‘I’m selling placebos or chalk’

“We need to get used to what we’re seeing as nothing will change in the foreseeable future,” says Viktoria Presnyakova, director of the self-regulatory Association of Independent Pharmacies and head of the Alliance of Pharmaceutical Associations.

The main reason, she says, is supply problems, both of imported and Russian-made medicines. Sergey Shulyak, general director at DSM Group, agrees.

Pharmacies don’t have their own warehouses and are therefore dependent on supply chains. This means that shortages are a particular problem in the Russian exclave of Kaliningrad, where even life-saving medicines are in short supply.

The second contributing factor is the withdrawal of many pharmaceutical companies from the Russian market following the full-scale Russian invasion of Ukraine last year.

The third reason is the Russian policy of phasing out imports. Since 2015, Russia’s public procurement policy has stipulated that if two or more companies from the Eurasian Economic Union (EAEU), an economic union of five post-Soviet states, submit a tender to supply life-saving and essential medicines to the Russian market, a supplier from another country cannot be chosen.

In February 2020, 160 oncologists and haematologists signed a joint letter where they laid out the side effects of Russian-made generics in cancer patients. A further 27 charities and patient organisations criticised the law.

Russia has alternatives for 40–60% of foreign medicines. That includes insulin — a vital drug for patients with diabetes.

Geropharm, and other Russian companies, produce biosimilars, almost identical copies of foreign-made insulin. But, unlike generics, which are chemically synthesised alternatives, a biosimilar is not totally identical to the original, and its producer isn’t required to conduct full clinical trials before putting their product on the market — they simply have to prove the presence of the main active substance.

“With original insulin, we always know the composition and are sure it has been through at least two years of clinical trials,” says Dina Dominova, an activist and diabetic patient of 26 years’ standing. “But biosimilars are on the market in three to four months, and when I asked Geropharm to provide the full composition of their insulin, they replied that they weren’t obliged to by law, so wouldn’t.”

Since 2020, the Russian pharmaceutical market has grown by 30%, and the war in Ukraine has provided many companies with an opportunity to increase production. Last March, for example, one large domestic producer, Ozon, increased capacity at its plants from 1.1 million packs per day the previous year to 1.5 million packs per day. Since 2017, their products have featured in the Industry and Trade Ministry’s plan to phase out imports and their plants now produce alternatives to 350 imported medicines.

“In many cases, you can replace the foreign original with a Russian generic,” a pharmacist by the name of Alina explains. “But only one company — Ozon — is producing the alternatives for many imported medicines. Their pills are cheap, but don’t work at all. Customers complain that I’m selling placebos or chalk.”

The emergence of domestic alternatives means there is no room for foreign-made medicines in the tendering process. By law, the tender committee is obliged to favour Russian biosimilars and generics, even if the original medicine is among the competitors. As a result, many foreign medicines are forced to abandon the Russian market due to its unprofitability.

Next September, an even stricter law will come into force, giving absolute priority to medicines produced in the EAEU. The Russian Patients Association worries the new law will decrease the public procurement of medicines against HIV, cancer, diabetes and tuberculosis, leading to shortages and depriving patients of access to treatment.

Treatment in Donetsk

Back in 2011, HIV activists chained themselves to the Presidential Administration building opposite the Health Ministry in Moscow. Due to disruptions in supply, even pregnant women were being denied treatment.

Yelena (not her real name) already had AIDS at that time. Few people knew about treatment in the 2000s and coverage was low. She also went to a protest rally in Irkutsk, where she is from, chained to a wheelchair and carrying a banner saying “I don’t want to die”. The Siberian city and regional capital remains a statistical hotspot for HIV infection.

She survived and now runs an NGO which helps other patients access treatment.

“At the beginning of the year, they started switching all more or less healthy patients from top-of-the-line Tivicay to Russian-made Elpida. Hardly any research has been done into it and it causes a whole host of side effects. And Elpida isn’t cheap. It’s just produced in Russia in sufficient quantities,” she says.

This year, patients have already reported 400 incidents of drug shortages to the Disruptions website, which monitors the availability of HIV and hepatitis treatment in Russia. That is more than the whole of last year.

This is the third major disruption in ten years. The Health Ministry took over medicine procurement in 2017. Until then, it had been organised at regional level. But the department couldn’t deliver quickly and the medicines only began reaching the regions in June. It happened again two years later: the Health Ministry had failed to anticipate demand and procured insufficient supplies.

This summer, activists appealed to Mikhail Murashko, the Health Minister. The federal budget for the year for HIV treatment had already been used up, and the medicines procured only covered 30% of patients.

According to our data, medical facilities have reduced procurement of almost half of all HIV medicines available. They have stopped supplying 13 medicines altogether. Some doctors compare the current shortages with those of 2011. The worst affected areas are the occupied regions of Ukraine, where patients will, at best, receive out-of-date medicines.

Ksenia from the occupied city of Makiivka in eastern Ukraine’s Donetsk region has been living with HIV for 16 years. After becoming a Russian citizen she moved to Rostov-on-Don in southern Russia, but continues to visit her mother in the self-proclaimed Donetsk People’s Republic. The centre for AIDS treatment in Makiivka has been giving her out-of-date drugs for six months now.

“To get medicine in Rostov, you need to make an appointment three months in advance. There’s also a risk they’ll change your treatment. So I keep going to Makiivka, where at least they give me Tivicay, even if it is out-of-date,” says Ksenia.

Yulia Vereshchagina, an activist with the Patient Control pressure group explains that until last spring, patients were provided with medicines by the Global Fund to Fight HIV via the International Red Cross. Now it is Russia’s job. Ukrainian citizens in the occupied territories also receive treatment, but in regional centres, not where they live.

“Ukraine had a completely different dispensing system, and now you can only get the medicine in Donetsk. People in Makiivka don’t understand why they have to go to Donetsk, under fire, along mined and ruined roads,” says a Patient Control activist, who asked to remain anonymous.

The occupied territories receive their medical supplies from annexed Crimea and the Rostov and Krasnodar regions of southern Russia. The highest number of complaints on the Disruptions website comes from the same three regions: patients are largely being given Russian medicines, even if they are not appropriate.

“A lot of people get some kind of rash, suffer from indigestion. Taking foreign pills is like taking vitamins, but these are like having chemo,” says another Patient Control activist from the Black Sea city of Sochi, who also asked to remain anonymous. 

Last year, the UN ranked Russia among the five countries with the highest rates of new HIV infections. The fight against the epidemic has now been going for 35 years. The latest strategy to combat the disease in Russia aims to have 95% of HIV patients on top-of-the-line antiretroviral therapy by 2030. Doctors think that forecast is fanciful.

“The HIV treatment situation in Russia is difficult. In order to defeat the epidemic, 95% of people with HIV need to know their status, 95% of them need to start therapy and 95% of them need to have a suppressed viral load,” according to Yekaterina Stepanova, a Moscow-based infectious diseases physician. “However, according to the AIDS Centre [Foundation], we only have treatment for 58% of people living with HIV, and their viral load is only 80% suppressed.”

The situation around the treatment of hepatitis, which is often associated with HIV, is even worse. According to the doctor, many overseas medicines are still not available in Russia, and even the ones that are are on the way out. Take Swiss medications Pegasys and Russian-made Algeron, for example. They are the two most effective medicines for hepatitis D, but are not now available in any pharmacy. According to Nikita Kovalenko, president of the patients’ association Together Against Hepatitis, their removal from the market has made treatment for people with hepatitis D even more inaccessible. “You can literally count the number of people getting it now.”

You can’t replace everything

While the Health Ministry continues to deny that there is a shortage of medicines, one in five patients has encountered issues filling prescriptions.

Domestic producers cannot fully substitute overseas pharmaceutical companies. There could be shortages of all medicines, Professor Vasily Vlasov from Moscow’s Higher School of Economics told Novaya Europe.

“There has been insecurity in medicine provision in the country for more than a year now due to large-scale logistical and financial difficulties. It’s impossible to say which group of medicines will be most affected. Problems can occur anywhere. … There are many medicines Russia cannot replace. We are able to meet most of the demand, but Russian production is weak when it comes to complex and technologically advanced medicines.”