Volunteers and Donations

Offering help to people in need is a basic human instinct. During the war in Yugoslavia (1999), thousands of people were able to survive because of donations from foreign governments and private individuals or organizations. Donations and volunteerism can be a help or hindrance, though, depending on whether the right amount of goods, people, and materials are sent to the disaster region. There is a common misperception that when a disaster occurs, people should send everything they have as rapidly as possible. Misperceptions such as this can result in large amounts of wasted human and nonhuman resources. There are two types of donations: in cash and in kind. Cash donations are often ideal because of flexibility, ease of coordination, and because cash allows materials to be purchased through normal channels while supporting the local economy.

The Internet and social media have become efficient methods for obtaining cash donations. During the South Asia Tsunami disaster (2004-2005), large amounts of money were donated rapidly through the Internet, with sites such as Amazon.com collecting upward of $3 million within days of the event. Lobb et al. examined the relationship between media coverage during the 2010 Haiti Earthquake disaster and charitable donations during 4 weeks after the event. Traditional media coverage quickly spiked after the earthquake and then waned over the next 3 weeks, with charitable contributions following this trend. Social media outlets such as Twitter also followed this trend, although they tended to dissipate more quickly. The authors found that Facebook could provide a medium for longer-term engagement. There was a positive correlation with media coverage and donations: “every 10% increase in Twitter messages relative to the peak percentage was associated with an additional US $236,540 in contributions, whereas each additional ABC News story was associated with an additional US $963,800 in contributions.” Finally, text messages also were found to be a useful way to gather donations.

The downside to cash donations is that they are susceptible to misuse. Nonetheless, the importance of cash donations cannot be underestimated. Multiple recent disasters show that donors are responding. Médecins Sans Frontières reported that donors gave $150 million for emergency aid after the 2004 Indian Ocean earthquake and tsunami. Within 2 weeks of the tsunami, MSF instructed donors that they had received enough money for tsunami relief and redirected donations to other global emergencies. ^,

Donations in kind are less standardized, but while often being immensely helpful, they can cause problems unknown to the donor. In this chapter disaster volunteerism and in-kind drug and blood donations will be examined. It is interesting to note that in-kind donations of materials other than drugs and blood can be important in certain situations. Dzwonczyk and Riha looked at medical equipment donations after the 2010 Haiti earthquake. They inventoried and assessed 951 pieces of clinical medical equipment at seven public Port-au-Prince area hospitals (of which 86% had been donated to these hospitals before the earthquake). They found 28% of the equipment was working and being used; 28% was working and not in use (because of lack of parts and supplies or lack of a location in which to use them, such as an operating room); 30% was not working, but repairable; and 14% was neither working nor repairable. The authors concluded that failure to follow the 2000 World Health Organization (WHO) guidelines for equipment donation lead to these equipment issues.

Overall, coordination of in-cash and in-kind donations remains a challenge. Donations after the 2004 Indian Ocean Earthquake and Tsunami are a good example of these challenges. The worldwide response was estimated at $13 billion, the largest relief effort in history. The United Nations raised $2.5 billion (much of which came from individuals), whereas American companies raised $273 million in-cash and $140 million in-kind donations. However, some companies wanted to do more than just send money or supplies; there was a desire to send communications, managerial, logistical, and IT support. No coordination enabled this to occur. On the ground, the local authorities were already swamped with unsolicited donations. For example, “Sri Lanka’s Colombo airport reported that within two weeks of the tsunami, 288 freighter flights had arrived without airway bills to drop off humanitarian cargo … a large number brought unsolicited and inappropriate items (such as used Western clothes, baked beans, and carbonated beverages), which piled up at the airport, clogged warehouses, and remained unclaimed for months. Worse yet, these prepaid flights refueled and then returned empty, when they could have carried commercial cargo. As a result, the airport ran out of fuel for the scheduled flights.” What did work, though, was using corporate partnerships that had already existed in that region. “Coca-Cola, for example, has for years maintained relationships with the Red Cross and other aid agencies in many countries. Working with local subsidiaries, Coca-Cola converted its soft-drink production lines to bottle huge quantities of drinking water and used its own distribution network to deliver it to relief sites.”

Drug donations

During times of crisis, many different entities provide drug donations, including private individuals or companies, nongovernmental organizations (NGO), international agencies such as the UN, and foreign governments. The literature on this subject, which focuses on disasters, as well as complex humanitarian emergencies such as refugee situations, indicates that many disaster-stricken regions become dependent on foreign medical aid for both acute emergencies and long-term aid. ^,Drug donation is a complex issue, however, and even though such donations can help disaster-stricken countries retain their treatment quality and meet health care needs, there are numerous negative outcomes that can occur as well. For example, the common misperception that it is better to send any drug than none at all results in often-inappropriate medical materials arriving in the recipient country. Despite the donors’ good intentions, donated drugs and goods are often inappropriate to treat local diseases (e.g., Zaire 1994, commercial soft drinks were sent to treat cholera). In addition, a practice known as “drug dumping” often results in large quantities of useless drugs arriving in the disaster-struck region. Drug dumping , a term meaning the donation of defective products, has been studied both in terms of quantity and quality (e.g., amount, appropriateness, and usability).

Historical perspective: drug dontations

Standardization and management of medical donations has been an issue for years. It was the domain of the Red Cross Movement until 1957. Following World War II, national and international organizations focused on this issue. It was not until after the Gulf War, however, that emergency relief deficiency came under the scrutiny of the UN.

Starting in 1976, reports began appearing about the deleterious effects large amounts of inappropriate donated drugs can have on a recipient country. In 1996 the UN designated WHO the coordinator of health-related international agency work. WHO took several actions to facilitate this mission in Bosnia, including establishing interagency coordination committees, assessing needs, coordinating drug supplies, disseminating drug lists and guidelines, and promoting the use of essential drug kits. Despite WHO’s efforts, drug donations to Bosnia and Herzegovina were criticized for being of low quality. Frequently the donated drugs had expired, adding to the postwar chaos; drugs were unequally distributed, because NGO were allowed to deliver materials to an area that had recently received similar materials from a different NGO. The influence of the media was often inappropriate, and it could sway what donors gave and how much. ^,^,Some authors felt these criticisms were “elitist,” and noted that, for example, drug expiration dates are extremely conservative and that a possible solution to the problem of expired drugs could be to “perhaps double the usual dose.” These authors also noted that human suffering would be worsened by not using donated drugs. Nevertheless, using expired drugs has generally not been acceptable because of problems related to toxic metabolites and unknown efficacy, for example, which opens the door to bad donation practices and may lead to a loss of credibility for the donors. Moreover, the practice violates the Basel Convention, which regulates the transnational movement of hazardous waste (including unused drugs) and its disposal, and requires the owner, receiver, and transporter of any chemical that could be toxic, poisonous, or eco-toxic to get clearance from the relevant authority in charge of the Basel Convention). ^,^,^,

Examples of inappropriate donation practices are shown in Table 45-1 . During the war in Sudan, in 1985, inappropriate pharmaceutical donations included contact lens solution, appetite stimulants, cholesterol lowering drugs, and expired antibiotics. In Lithuania (1993), 11 women were temporarily blinded after taking a drug donated by Cartias (closantel, a veterinary anthelmintic) that was mistakenly given to treat endometriosis because of poor labeling. ^,In Georgia (1995) 20 tons of expired silver sulphadiazine were received, and Eritrea (1994) received seven truckloads of expired aspirin, a container of unsolicited cardiovascular drugs with 2 months to expire, and 30,000 bottles of expired amino acid infusion (that could not be disposed of because of the smell). ^,Other examples of completely nonsensical donations—although not drug donations per se—include bikinis sent to Gujarat (after the earthquake), crates of Double-D bras sent to Kobe (after the earthquake), breast implants sent to a hospital in Malawi, and ski jackets sent to Sri Lanka. ^,

Table 45-1

Examples of Drug Dumping

Year	Location	Amount Donated (Metric Tons * )	Inappropriate Amount	Notes
1976	Guatemala (earthquake)	100 (7000 cartons)	90% unsorted	1120 hours of sorting time
1984-1985	Ethiopia (famine)	Not listed	Not listed	US $500,000 worth of inappropriate drugs were destroyed
1985	Mexico (earthquake)	1088 Drugs: 31% Food: 14% Supplies, clothes, and blankets: 24%		Heavy machinery 6%-14% (most needed)
1985-1987	Sudan (famine)	Not listed	8 million chloroquine and 500,000 piperazine were expired	380,000 Citramon tablets were banned. Vitamins and baby food were not registered
1989 ^,	Armenia (earthquake)	5000 Drugs: 65% IV: 20% Consumables:15%	70% Expired: 8% Frozen: 4% Unsorted: 18% Useless: 11% Unidentifiable: 12%	Poorly labeled antibiotics (238 names in 21 languages) Sorting time was 6 mo with 50 people
1992-1996	Bosnia and Herzegovina	27,800-34,800	50%-60%
1994-1997	Armenia, Haiti, and United Republic of Tanzania	16,500 shipments (no weight listed)	10%-42%	6% expired
2000	Venezuela (floods)	Not listed	70%	$16,000 spent to sort drugs

* 1 metric ton = 2204.6 pounds; 1 ton is approximately 40 cubic feet.

U.S. pharmaceutical companies often are saddled with a negative image for their poor donation practices, which may be somewhat justified. For example, Eli Lilly donated six million poorly labeled Ceclor CD tablets, even though the tablets were nearing expiration and had not received Food and Drug Administration (FDA) approval for sale in the United States. There are worthwhile long-term sustainable U.S. pharmaceutical programs, however, including the Merck Mectizan Donation Program (providing free drugs to treat river blindness since 1988), Aventis’s partnership with WHO, Roche’s policy to make HIV protease inhibitors (nelfinavir and saquinavir) available to the developing countries at much reduced costs, and the medical NGO Médecins Sans Frontières that distributes medicines for African sleeping sickness. ^,

In 1999 WHO identified six specific problems associated with drug donations, leading to the development of “good practice” guidelines. ^,^,The problems identified by WHO were: the donation of drugs irrelevant to the recipient country’s situation, unsorted and poorly labeled drugs, low-quality drugs (e.g., expired drugs and returns), ignorance of local administrative procedures, high custom charges to the recipient (because of high declared drug value), and donation of incorrect quantities (too much of some drugs and too little of others). ^,^,Many authors agree with the assessment by WHO and add other factors to consider. For instance, Berckmans noted three categories of donations that were sent to Bosnia and Herzegovina: those that conformed to WHO’s interagency guidelines for drug donations, miscellaneous medicines (e.g., unsorted drugs and free samples), and large quantities of donated drugs that were useless or unusable (e.g., plaster tape from 1961 and World War II supplies). During the 1985 war in Sudan, the country received drugs that were in small packets and in partly used open blister packets. Another problem with donations to Sudan was that local doctors often were unfamiliar with newly introduced drugs. Further, once the stock of new drugs ran out, patients wished to continue the often more expensive drug, which led to treatment interruptions. In Croatia (1990-1994), it was found that drug donations led to “changes in therapeutic principles,” as well as changes in prescribing patterns and organized drug acquisition at the University Hospital Center of Rijeka (e.g., decreased use of cotrimoxazole, ampicillin, and cephalexin and increased use of amoxicillin + clavulanic acid, gentamicin, and cefuroxime). Médecins Sans Frontières also notes that the practice and culture of corporate drug donations does not encourage local production of generic drugs and may hinder the recipient countries’ attempts at a sustainable cost-recovery program. Finally, Hogerzeil points out that donation of excessive quantities leads to stockpiling, pilfering, and black market sales. ^,

There are many reasons to donate medical materials to a disaster-stricken region, and most donations are well intentioned. ^,However, there are several nonaltruistic reasons for donating drugs, such as avoiding drug destruction costs, seeking publicity, disposing of surplus or wasted medicines, political pressure to take action (drug donations “film well”), tax benefits for donor companies and private voluntary organizations (PVO), and stimulating the market for certain products (brand recognition in a potential new market). ^,^,^,^,Whether these motivations are viewed as morally corrupt and self-serving or as well intentioned but gone awry depends on perspective, and it constitutes a debate beyond the scope of this chapter.

Whatever the reasons behind it, there are definite consequences to drug dumping, and the resource-strapped recipient country usually suffers them. It is difficult to store, sort, organize, and handle large quantities of donated medical supplies. Researchers studying the situation in Bosnia and Herzegovina had difficulty locating unused medical supplies because the warehouses were subject to restricted access, and their whereabouts were often unknown. There can also be high destruction costs associated with donated unusable drugs: 1 ton of drugs in Bosnia and Herzegovina cost $2000 U.S. dollars to destroy, costing the recipient country a total of $34 million dollars and requiring the construction of incinerator plants—a situation that occurred in Macedonia and Armenia as well. ^,^,^,In cases where the drugs are inappropriate to the situation but are usable, the drugs could be shipped to another country rather than be destroyed; however, shipment can cost $2 to $4 million per 1000 metric ton. Other less-tangible destruction costs include health and environmental hazards, as well as storage, handling, and transportation costs, which are often greater than the donated drugs. ^,In the wake of the South Asia Tsunami disaster (2004-2005), there were concerns about empty water bottles littering the environment, as well as medicines no longer needed (morphine) being loose and uncontrolled in Sri Lanka. WHO has developed guidelines for the safe disposal of drugs, including the use of sanitary landfills, encapsulation, inertization, discharge to a sewer, high temperature (1200 °C) incinerators, and chemical waste treatment centers. ^,^,^,

The Armenian earthquake situation vividly demonstrates the local costs associated with poor donation practices. In December 1988, Armenia was rocked by an earthquake (6.9 M) in an area populated by 700,000 people. Deaths were estimated between 24,000 and 60,000 people. Three days after the earthquake, international relief from 74 countries arrived, including 5000 tons of medical materials (valued at $55 million U.S.), money, and human resources. Local resources in the ill-prepared region were depleted, and disorganization reigned. The Armenian airport handled 150 landings a day, where unaccompanied shipments were dropped onto the airstrip and left behind. Armenian personnel were quickly overwhelmed as they attempted to locate specific supplies amid the sea of donations and deliver medical materials to the field. It took a month to set up an efficient donation management strategy. Pharmacists spent two thirds of their time searching for appropriate drugs, and it took 50 people 6 months to sort the donations (mostly nonmedical personnel using pharmaceutical textbooks and cross-indexes to decipher the donated drugs). ^,There were also problems handling large heavy packages, finding adequate storage space (32 new storage buildings were constructed holding 70% of donations, while the rest were shipped to Moscow), and disposing of drugs destroyed by cold temperatures (4%).

Current practice: drug donations

Suggested solutions to problems associated with drug donations are based primarily on basic disaster planning techniques, such as preparing for anticipated needs, recognizing that each disaster is different and priorities change, and performing realistic needs analyses. ^,Many have advocated for better communication of needs and the exchange of information that is more reliable between recipient countries and donors. ^,^,Mitigation planning should be done by countries to help strengthen legislative policies toward donors, centralize drug donations and emergency aid (using principles of good pharmacy practice), put registration and quality-assurance procedures in place, and develop a national essential drug list. ^,^,

The Pan American Health Organization (PAHO) and WHO’s Supply Management System (SUMA, 1992) is a good example of an information management tool that could help disaster-stricken countries deal with donations more effectively. To help disaster managers to sort through large amounts of donations, the SUMA system uses simple tracking software. SUMA works by prioritizing and collecting data at donation entry points (airport, seaport, or border) and categorizing these items. Other SUMA team members gather data at warehouses and distribution centers and then electronically send this information to the central area. From this area, customized reports detailing donation activity and status can be generated.

WHO has taken the lead on setting standards for good donation practices, with the guidelines promulgated in 1999. WHO started work on these guidelines in 1990 and finished them through an international consultative process involving more than 100 agencies. WHO’s guidelines provide core donation principles and contain four categories ( Box 45-1 and Table 45-2 ). ^,^,^,^,^,WHO also maintains a list of essential drugs (the Model List, revised in 2003) and encourages each country to produce its own national drug list (focusing on safety, appropriateness, efficacy, and cost-effectiveness). ^,

Box 45-1

WHO Guidelines: Core Principles for Drug Donation

•

Maximum benefit to the recipient
•

Respect for the wishes and authority of the recipient
•

No double standards in drug quality
•

Effective communication between donor and recipient

Table 45-2

WHO Donation Guidelines (1999) *

From the WHO. Guidelines for Drug Donations—Revised 1999. 2nd ed. Available at: http://www.who.int.easyaccess1.lib.cuhk.edu.hk/medicines/library/par/who-edm-par-1999-4/who-edm-par-99-4.shtml.

Selection of drugs	• All drug donations should be based on an expressed need and be relevant to the disease pattern in the recipient country. Drugs should not be sent without prior consent by the recipient. • All donated drugs or their generic equivalents should be approved for use in the recipient country and appear on the national list of essential drugs, or, if a national list is not available, on the WHO Model List of Essential Drugs, unless specifically requested otherwise by the recipient. • The presentation, strength, and formulation of donated drugs, as much as possible, should be similar to those of drugs commonly used in the recipient country.
Quality assurance and shelf life	• All donated drugs should be obtained from a reliable source and comply with quality standards in both donor and recipient country. The WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce 7 should be used. • No drugs should be donated that have been issued to patients and then returned to a pharmacy or elsewhere, or were given to health professionals as free samples. • After arrival in the recipient country, all donated drugs should have a remaining shelf life of at least 1 yr.
Presentation, packing, and labeling	• All drugs should be labeled in a language that is easily understood by health professionals in the recipient country; the label on each individual container should at least contain the INN or generic name, batch number, dosage form, strength, name of manufacturer, quantity in the container, storage conditions, and expiry date. • As much as possible, donated drugs should be presented in larger quantity units and hospital packs. • All drug donations should be packed in accordance with international shipping regulations, and be accompanied by a detailed packing list, which specifies the contents of each numbered carton by INN, dosage form, quantity, batch number, expiry date, volume, weight, and any special storage conditions. The weight per carton should not exceed 50 kg. Drugs should not be mixed with other supplies in the same carton.
Information and management	• Recipients should be informed of all drug donations that are being considered, prepared, or actually under way. • In the recipient country the declared value of a drug donation should be based upon the wholesale price of its generic equivalent in the recipient country, or, if such information is not available, on the wholesale world-market price for its generic equivalent. • Costs of international and local transport, warehousing, port clearance, and appropriate storage and handling should be paid by the donor agency, unless specifically agreed otherwise with the recipient in advance.