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Essential medicines keep flowing to Russia, but sanctions could severely effect health

BMJ 2022; 376 doi: (Published 21 March 2022) Cite this as: BMJ 2022;376:o745
  1. Owen Dyer
  1. Montreal

Boycotts, a brain drain, and the collapse of the rouble are among the factors undermining a healthcare system that was already under strain before the Ukraine invasion, Owen Dyer reports

Dozens of drug companies have promised to keep sending essential medicines to Russia, despite announcing varying degrees of withdrawal from the Russian market, amid unprecedented sanctions being imposed on the country in response to the invasion of Ukraine.

“We cannot stop the flow of our medicines to Russia,” Pfizer’s chief executive, Albert Bourla, told Yahoo Finance. “Always with sanctions, medicines are excluded. Ending delivery of medicines, including cancer or cardiovascular therapies, would cause significant patient suffering and potential loss of life.”

Like many companies Pfizer has chosen other ways to disengage from Russia. It will stop conducting new clinical trials there, although existing studies will continue. And the company announced “effective immediately Pfizer will donate all profits of our Russian subsidiary to causes that provide direct humanitarian support to the people of Ukraine.”

Stopping essential medicines would not be ethically justifiable, said Bayer AG in a statement. “People will die or have severe consequences,” Johnson & Johnson’s chief financial officer, Joseph Wolk, told investors.

Abbott, Johnson & Johnson, Novartis, and Pfizer all have manufacturing plants in Russia, a government requirement for access to the market under its “Pharma-2020” and “Pharma-2030” plans, which aimed to increase Russian self-sufficiency in medicines. Closing such plants could expose them to seizure by the Russian government under a new law, which has already seen abandoned McDonalds restaurants reopened by the state as Uncle Vanya’s.

GlaxoSmithKline announced four measures that are fast becoming an industry standard: stopping enrolment in new studies in Russia, ceasing marketing activities there, donating Russian profits to humanitarian causes, and “prioritising” the delivery of medicines “essential for people’s health.”

AbbVie, maker of Botox, said it would discontinue Russian sales of its “aesthetics” products, and Lilly said it would exclude “non-essential” drugs, citing the erectile dysfunction drug Cialis (tadalafil) as one whose delivery would be stopped.

Threat to health systems

The continued importation of essential medicines may not be enough to stave off profound effects on healthcare. Other heavily sanctioned nations, most notably Iraq in the 1990s, have seen their health systems collapse. Russia’s public system was already buckling under the effect of the far lighter sanctions introduced after its 2014 annexation of Crimea.

After a decade of steady improvement, the 2014 financial crisis and subsequent restructuring saw many hospitals close, with particularly severe losses in underserved rural regions. Waiting times have risen, patient copayments have been introduced, and 40% of medical facilities lack their normal complement of staff.

Drug companies’ obligation to provide essential drugs to sanctioned nations extends only as far as those nations’ ability to pay for them, and the collapse of the Russian rouble will immediately be reflected in the price of imported drugs. Russia’s exclusion from the Swift payments system will also complicate bulk purchases.

Other sanctions and boycotts could also affect the availability of medicines. The shipping giant Maersk, one of several carriers that has suspended all deliveries to Russia, warned this week that pharmaceuticals were likely to be affected. Novo Nordisk, the world’s largest maker of diabetes medicines, said that “we will do whatever we can to ensure the citizens of Russia receive their life-saving medication,” but it anticipates difficulties in maintaining supplies.

Of the drugs made within Russia, as many as 85% include imported ingredients, which in many cases are not exempt from sanctions.

But it is the continuing decline of medical services and infrastructure, rather than shortages of drugs, that poses the main threat to health in a heavily sanctioned Russia. Many doctors are among the estimated 200 000 Russians who have fled the country as it clamps down on free speech. Iraq under sanctions eventually lost more than half of its doctors to a medical brain drain abroad.

Although Russia’s health system is ostensibly funded by deductions from workers’ salaries, in practice times of budgetary contraction have brought swingeing health cuts. With military spending likely to take priority, and the European hydrocarbon sales on which the government depends set to decline sharply, the prognosis for Russia’s battered hospitals and clinics looks grim.

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