Feature

Lessons in Disaster

Why is the Obama administration reading up on its Vietnam history?

There's an unofficial book club in the White House these days, George Stephanopoulos reported late last month, and the manuscript in question could not be more pertinent. As the Obama administration rethinks its strategy in Afghanistan, officials are turning to Gordon M. Goldstein's Lessons in Disaster -- an account of analogous moments of decision in the Vietnam War. And though most historical comparisons are approximations at best, the resemblance between those crucial Vietnam inflection points and today are uncanny: Casualties are rising, public opposition is growing, the host government's legitimacy and effectiveness is in doubt, and the U.S. commander in the field is calling for more troops to stave off defeat. Surely, if Obama has a Vietnam moment, it will come in Afghanistan. And that's precisely what Goldstein's White House readers might be trying to avoid. Below follows an excerpt of one lesson they might learn, which Goldstein calls "Never Deploy Military Means in Pursuit of Indeterminate Ends":

In the spring of 1995, McGeorge Bundy asked me to collaborate with him on a retrospective analysis of the American presidency and the Vietnam War during his tenure as national security advisor to presidents John F. Kennedy and Lyndon B. Johnson. We envisioned the book to be both a memoir of Bundy's experience with Kennedy and Johnson as well as a reconstruction of the pivotal presidential decisions about American strategy in Vietnam between 1961 and 1965. But the project was fatefully interrupted. Bundy died of a heart attack a year and half into our collaboration. A front-page obituary in the New York Times called Bundy "the very personification of what the journalist David Halberstam ... labeled 'The Best and the Brightest': the well-born, confident intellectuals who led the nation into the quagmire of Vietnam."

Although the McGeorge Bundy who reigned as a legend of the establishment was reputed to be brisk, quick, calculating, and overconfident, the retrospective Bundy of 30 years later -- the one with whom I spoke so many times -- was in many ways the opposite: patient, reflective, curious, and humble. In fact, on the question of Vietnam Bundy appeared tentative and unsure -- maybe on some level even mystified. Although he never said so explicitly, he seemed to be as perplexed by the disaster of Vietnam as any of the historians who studied the decisions in which he had been a central participant.

Three decades after his own role in the war ended -- he left the White House in 1966 to head the Ford Foundation -- he was still asking himself questions about its lessons. "What can we say is the most surprising?" Bundy wondered in a fragment he composed on February 3, 1996, as he and his wife Mary returned from a holiday in the Caribbean. His answer: "The endurance of the enemy." It was a dynamic of the war that fascinated him. Bundy marveled at the leadership of the insurgency, its political strength inside South Vietnam, the stamina of the armed forces of the Vietnamese communists, and the social cohesion that bound these variables together into an equation that allowed a small power, among the poorest countries in the world, to triumph over the United States.

When I began working with him on our book project, Bundy was still struggling to understand how the Johnson administration had committed itself to a strategy that would devolve into a contest of endurance Americans were destined to lose. Beginning in 1965 the United States deployed considerable and escalating numbers of ground combat forces in a protracted effort to grind down the enemy -- depleting its numbers, breaking its will, and compelling its surrender or negotiated settlement on terms favorable to the United States. That strategy was, of course, a great failure. And Bundy later asked himself, "Do we discuss whether we are in fact well-equipped to conduct a war of attrition? I don't think that question is ever presented to Lyndon Johnson in the whole of the year in which that strategy is adopted."

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It was June 14, 1965, and Johnson reached out to former President Eisenhower for his counsel on the Vietnam War. A decision was looming over whether to expand the U.S. troop commitment to the conflict. Eisenhower advised not only supporting South Vietnamese forces in action but also urged direct offensive action by American troops. "We have got to win," he said.

Meanwhile, the debate among Johnson's advisors was growing. "In raising our commitment from 50,000 to 100,000 or more men and deploying most of the increment in combat roles we are beginning a new war -- the United States directly against the Viet Cong," Under Secretary of State George Ball warned President Johnson. "Perhaps the large-scale introduction of American forces with their concentrated fire power will force Hanoi and the Viet Cong to the decision we are seeking. On the other hand," he presciently cautioned, "we may not be able to fight the war successfully enough -- even with 500,000 Americans in South Vietnam -- to achieve this purpose." Ball confronted President Johnson with lessons from recent history. "The French fought a war in Viet-Nam, and were finally defeated -- after seven years of bloody struggle and when they still had 250,000 combat-hardened veterans in the field, supported by an army of 205,000 Vietnamese."

Ball's dissent was aggressively countered by the administration's hawks. Secretary of State Dean Rusk and Secretary of Defense Robert McNamara strenuously argued that if South Vietnam fell, Thailand would be lost, too. Rusk envisioned a wave of falling dominoes -- even India would collapse under the control of the Chinese communists.

The top U.S. commander in Vietnam, Gen. William Westmoreland, delivered a bleak report from the front. "The struggle has become a war of attrition," he declared on June 24. "Short of decision to introduce nuclear weapons against sources and channels of enemy power, I see no likelihood of achieving a quick, favorable end to the war. ... I am becoming more convinced every day that U.S. forces in appropriate numbers must be deployed to permit the Vietnamese with our help to carry the war to the enemy." The next day, guerrilla fighters launched one of their most spectacular terrorist acts yet, exploding a bomb in the My Canh floating restaurant and killing 44.

Against this backdrop of gathering anxiety, McNamara circulated a draft memorandum that would set the terms of debate over further escalation. He formally joined the Joint Chiefs in urging the president to approve General Westmoreland's proposed expansion to a 44-battalion force in South Vietnam -- 34 U.S. maneuver battalions and 10 third-country maneuver battalions totaling approximately 175,000 men. A major escalation of U.S. forces, he argued, would force the insurgents "to accept a situation in the war in the South which offers them no prospect of an early victory and no grounds for hope they can simply outlast the US."

Gen. Earle Wheeler, the chairman of the Joint Chiefs of Staff, asked General Westmoreland directly if the escalation would be sufficient to break the insurgency. The "direct answer to your basic question is 'no,' " he replied, admitting that the 44 battalions would not "provide reasonable assurance of attaining the objective." Thus on the eve of the largest and most fateful expansion of the U.S. ground force commitment to Vietnam, the architect of that troop surge told the chairman of the Joint Chiefs of Staff that it simply would not be sufficient to achieve the stated American goal of persuading the insurgency that its victory was impossible.

The stage was set for what should have been the seminal debate of the Vietnam War. Ball seized on the inherent uncertainty surrounding the 44-battalion deployment and its implicit strategic assumptions. McNamara had thrown his support behind an enormous expansion of the American commitment. And General Westmoreland, the principal advocate of the 44-battalion strategy, clearly conceded that the new American combat commitment could not assure the achievement of its stated objective.

Where was Bundy positioned at this juncture? Frustrated by a deteriorating relationship with President Johnson, he was on the precipice of resigning as national security advisor. Ironically, the national security adviser's differences with Johnson had little to do with the substance of Vietnam policy.

For Bundy, icon of the establishment and the administration's fiercest debater, silence in response to criticism of the White House policy in Vietnam and Southeast Asia was untenable. The critics of the war, Bundy recalled, "were feeling deliberately cut off from and rejected by an administration with whom they were trying to communicate in good faith." So although he knew that Johnson would be infuriated, Bundy agreed to appear on a one-hour primetime television debate to be broadcast without commercial interruption by CBS News on the evening of June 21. "I informed him after the decision had been made and told him I just couldn't live with myself if I didn't do it," Bundy explained in a 1969 oral history.

What Bundy never said but should have retrospectively acknowledged was that his decision to go around Johnson's back to appear on the CBS Vietnam debate was tantamount to submitting his letter of resignation. When he read in the press that Bundy had agreed to the CBS debate, Johnson was enraged. LBJ told his aide, Bill Moyers, that he should inform Bundy that the president would be "pleased -- mighty pleased," to accept his resignation. Moyers did not act on the president's instruction.

Johnson's resistance to explaining and defending the administration's policy exasperated Bundy. If the new offensive were not "more quickly decisive than we had any clear reason to expect," Bundy said, there would be disturbing consequences when the public "looked back and asked themselves if they had been led openly into this war or somehow bamboozled into it." Bundy acknowledged that every president, including giants like Lincoln and Roosevelt, sought to communicate in a way that achieved the greatest political impact. Yet Johnson aspired for more. The president had "this really quite funny internal belief " that he could reshape facts to serve his interests. Johnson believed that "if he could get it stated his way in the papers it would be that way."

Although the national security advisor had reached the breaking point in his relationship with President Johnson, neither man could afford a public dustup, particularly as a major escalation decision loomed. Just six days after appearing on CBS, Bundy was back advising the president. "The commitment" to Saigon, Bundy explained on June 27, "is primarily political and any decision to enlarge or reduce it will be political. My own further view is that if and when we wish to shift our course and cut our losses in Vietnam we should do so because of a finding that the Vietnamese themselves are not meeting their obligations to themselves or to us."

Bundy's support for the war was balanced with nuanced skepticism. On the one hand, he dismissed critics who believed the United States was now emulating the disastrous course France followed in Vietnam. Still, on June 30, Bundy confided his concerns about the Westmoreland plan to Secretary of Defense McNamara. Bundy challenged the assumption that conventional combat forces would be effective in containing the insurgency. "I see no reason to suppose that the Viet Cong will accommodate us by fighting the kind of war we desire." Moving to "a 200 thousand-man level" of support, Bundy warned, was "a slippery slope toward total US responsibility and corresponding fecklessness on the Vietnamese side."

The impact of Bundy's critique, however, was largely vitiated by the fact that it was directed toward McNamara rather than the president or the broader team of advisors responsible for strategy in Vietnam.

So as the two stark choices confronting Lyndon Johnson in Vietnam crystallized -- the 44-battalion plan advocated by Westmoreland and McNamara or the withdrawal option espoused by Ball -- a third course was proposed. It was the so-called middle way envisioned by Bill Bundy, the assistant secretary of state for East Asian and Pacific affairs and McGeorge's brother, who proposed a force level of 18 battalions and 85,000 men. "In essence," he explained, "this is a program to hold on for the next two months, and to test the military effectiveness of US combat forces and the reaction of the Vietnamese Army and people to the increasing US role."

Anticipating Johnson's response to the three options, McGeorge Bundy wrote to the president, advising him to choose between the two levels of escalation, rejecting Ball's suggested pullout. Bundy had a reputation for skillfully aborting dissent when he deemed it necessary, and he was a practiced expert at maneuvering for advantage among competing bureaucracies. Bundy had, for example, previously undermined the secretary of state. "He is not a manager," Bundy advised the president about Rusk in early 1965. "He has never been a good judge of men. His instincts are cautious and negative. ... the Secretary has little sense of effective operation."

Johnson, meanwhile, continued to reach out to key constituencies, probing where the balance of opinion could be found. Just minutes before meeting with his senior Vietnam advisors on July 2, the president consulted Eisenhower. "Do you really think we can beat the Vietcong?" Johnson asked. Eisenhower advised Johnson to proceed with a troop buildup as soon as possible. "We are not going to be run out of a free country we helped to establish," Eisenhower declared.

By July 14, with a decision yet to be made, McNamara departed for South Vietnam. His mission, Bundy retrospectively concluded, was to negotiate a deal with the U.S. military commander in Saigon on the minimum size of the forthcoming escalation. Johnson's overarching priority was to achieve agreement, absent a fractious debate, on a course of action that would sustain South Vietnam from collapse but not disrupt his legislative agenda in Congress.

Political stagecraft -- creating the appearance of deliberation when a decision had already been made -- was the presumptive purpose of a White House meeting Johnson convened on the morning of July 21. Addressing the administration's war council, McNamara concluded that the United States had only three strategic options, two of which would leave the United States in a deplorable geopolitical position. President Johnson could choose to "cut our losses and withdraw under the best conditions that can be arranged -- almost certainly conditions humiliating the United States and very damaging to our future effectiveness on the world scene." Alternatively, Johnson could hold steady at roughly the current level of 75,000 troops, but that would leave the United States terminally weakened and "almost certainly would confront us later with a choice between withdrawal and an emergency expansion of forces, perhaps too late to do any good." The only viable choice, McNamara argued, was a substantial expansion of offensive U.S. military pressure against the Vietcong and Hanoi -- supplemented by vigorous diplomacy. Such an approach, he predicted, "would stave off defeat in the short run and offer a good chance of producing a favorable settlement in the longer run," although it would also render "any later decision to withdraw even more difficult and even more costly than would be the case today."

McNamara was vague, however, in delineating the causal logic of his proposed strategy, positing the escalation not as the military means to a military objective but simply as an end in itself. Preliminary discussion among the president's advisors seemed to anticipate that McNamara's recommendation would be accepted.

President Johnson, eager to project a ruminative state of mind, arrived after 40 minutes of discussion and unleashed a wave of questions ranging from the existential to the logistical. Then he asked, "Is anyone of the opinion we should not do what the memo says?"

This was Ball's cue to register his dissent. "I can foresee a perilous voyage," he said, "very dangerous -- great apprehensions that we can win under these circumstances. But let me be clear, if the decision is to go ahead, I'm committed."

Rusk regretted the failure to act earlier. "We should have probably committed ourselves heavier in 1961," he said.

Henry Cabot Lodge, who would return as the U.S. ambassador to South Vietnam at the end of the summer, bemoaned the dysfunctional nature of the regime. "There is no tradition of a national government in Saigon," he said. "I don't think we ought to take this government seriously."

When discussion resumed that afternoon, Ball was given the floor to present his challenge to the Pentagon escalation plan. "We can't win," he contended. "The most we can hope for is a messy conclusion." Continuing to prop up the Saigon regime, he also warned, was tantamount to "giving cobalt treatment to a terminal cancer case." Ball proposed that the United States devise a political strategy to stimulate a withdrawal of its military forces from South Vietnam. "The worst blow," Ball replied, "would be that the mightiest power in the world is unable to defeat guerrillas."

Bundy refused to engage Ball's counterargument, once more invoking the credibility imperative. "The world, the country, and the Vietnamese would have alarming reactions if we got out," he said. Achieving victory was apparently less important than the perception of pursuing it. "There will be time to decide our policy won't work after we have given it a good try," Bundy insisted.

"We won't get out," Ball retorted. "We'll double our bet and get lost in the rice paddies." Reviewing Ball's prediction three decades later, Bundy conceded: "He's right."

What struck Bundy most in looking back on the discussion of July 21, 1965, he told me, was a quality of unreality to the deliberations, because Johnson had already communicated his approval of Westmoreland's 44-battalion strategy to McNamara on July 17. The essential decision had already been sealed. Johnson "wants to be seen having careful discussions," said Bundy.

One of the consistent themes of Bundy's Vietnam counsel as national security advisor was his support for deploying military means in pursuit of indeterminate and primarily political ends. Bundy wanted a military commitment that evinced U.S. credibility even if it did not hold real promise of winning the war.

The adoption of attrition as the de facto U.S. military strategy was determined, in part, by the absence of other viable options. And by that metric, U.S. forces did in fact succeed in imposing severe losses on the insurgency. The United States presumed that a crossover point would be reached, when the accumulated pain of war would compel the insurgents to relent. But in practice this coercion strategy simply created an endurance contest. In that competition it was not the will of the Vietnamese communists that was broken. For each year of combat from 1965 to 1973, Bundy observed, the United States inflicted far greater casualties on the enemy than it absorbed. Yet despite this dramatic disparity, it was the United States that withdrew its forces "home without victory." As Bundy starkly confessed, "We had followed a losing strategy -- one that led us not to success but to the acceptance of failure. Attrition is a brutal measuring stick," he affirmed. "Its use is not advertised and its authorship not eagerly claimed."

How far would Bundy have gone in holding himself accountable for the lack of rigor that characterized the evaluation of military strategy? Bundy was often bluntly critical of himself, and he was equally critical of Johnson for authorizing a muddled military mission. He proclaimed his "deep conviction" that in the pursuit of a flawed strategy in Vietnam, "the decisive errors were those made or approved by the president as commander-in-chief."

When in 1995 he finally decided to address the unresolved questions of the Vietnam War, Bundy registered a starkly different point of view from his years in power. He called Vietnam "a war we should not have fought" and conceded that "on the overall issue -- are you for the war or against it, in 1965 and after, the doves were right." Bundy would therefore try to explain "the ways in which the executive branch continuously got that great choice wrong -- not because it wanted the long, hard war it got, but because it would repeatedly reject the hard alternative of 'losing to the Reds.'" Bundy in retrospect had embraced a quality he had lacked when in high office three decades earlier. He had finally learned humility.

AFP/Getty Images

Feature

The Deadly World of Fake Drugs

Whether it's phony Viagra or knockoff cancer meds, fake drugs kill thousands of people each day, thanks to counterfeiters in China and India who mix chalk, dust, and dirty water into pills sold around the world. With the Internet becoming the world's dispensary, these poison pills could be coming to a pharmacy near you.

Suresh Sati, a large and cheerful man from a small city in northeastern India, has been hunting down counterfeit goods for more than half his 49 years. From the moment I meet him at my hotel in Delhi, I can tell that he enjoys his work. Most days, Sati makes the rounds visiting his undercover agents, who live near the main wholesale markets in Delhi, where most fakes are traded. They pass on news and rumors about new dealers and crooked police. As we set off down the road toward one of the city's sprawling markets, Sati smiles nostalgically as he recalls his first anticounterfeit raid, back in 1981, on a small-scale outfit manufacturing knockoff TV antennas. His work has changed a great deal since then; his targets today are far better financed, organized, and dangerous. These days, Sati runs a company called "The Protector," which leads raids for multinational corporate clients. His bread-and-butter work: hunting for fake drugs.

Back in his basement office the next day, in an unremarkable building in residential Delhi, Sati offers me a glimpse of what he is up against. He lays out the samples of phony drugs he has collected from recent clandestine purchases and the previous week's raid. He places two vials of liquid erythromycin, an antibiotic used to treat bacterial infections, on the table in front of me. One vial is the real thing; the other contains water from a Delhi tap. "Which one is the fake?" Sati quizzes. I can't say. They look absolutely identical.

During the past decade, trafficking in counterfeit drugs has become one of the world's fastest-growing criminal enterprises. The World Health Organization (WHO) estimates that more than 30 percent of medicines on sale in parts of Africa, Asia, and Latin America are fakes. By 2010, the global turnover for phony pharmaceuticals is projected to be $75 billion, a 90 percent increase since 2005. A sharp increase in drug seizures also points to a mounting crisis. In 2006, the European Commission reported that customs agents intercepted 2.7 million counterfeit drugs at EU borders -- an increase of 384 percent from a year earlier.

The fake drug industry works in much the same way as the counterfeiting of designer handbags or DVDs of the latest Hollywood blockbuster. It provides a superficially reasonable imitation of the real product, manufactures fakes in vast amounts, and relies on economies of scale to make profits. Products are often distributed by the same criminal middlemen who deal in other knockoff goods. The difference is that fake drugs can carry a human price tag.

For much of the past decade, lifestyle drugs -- erectile dysfunction medicines, painkillers, and anti-anxiety medicines like Valium -- were the most common knockoffs, particularly in rich countries. But in the past few years, counterfeiters have moved into far more life-threatening fake pharmacology, manufacturing drugs used to treat cancer, HIV/AIDS, and serious heart conditions. As many as 1 million people a year die as a result of taking these fakes, most of them in the developing world, but an increasing number in wealthy countries, too. In the past year, at least 95 Americans died from allergic reactions linked to Chinese-manufactured heparin, a medicine used to prevent blood clots. Sources at the U.S. Food and Drug Administration tell me that the contaminated heparin was almost certainly counterfeit.

Some counterfeit drugs are simply good copies of brand-name pharmaceuticals -- hygienically made with the correct ingredients in the correct proportions. They breach intellectual property rights, to be sure, but they are not inherently dangerous, so long as they are perfect copies. Unfortunately, the motivation for most counterfeiters is profits, not reliable products. So, they are more inclined to perfect the packaging, not the contents, and then pass off their dangerous wares as the real thing.

A lack of quality oversight and enforcement makes poorer countries the most lucrative potential markets for these counterfeiters. A market like the United States is more difficult to crack, but the anonymity and breadth of the Internet now offers counterfeiters an attractive route around controls. Many so-called Canadian generics bought over the Internet are actually made in China and India, transported by traders via Dubai, Egypt, or Russia, and then shipped into Europe and North America for sale. In the fall of 2007, British customs officers uncovered a scheme in which millions of dollars' worth of fake Viagra was shipped from India, Pakistan, and China to Britain, where it was repackaged, and then sold online to customers in 35 countries -- including the United States and Canada. According to the WHO, half of all drugs purchased over the Internet fail simple tests for active ingredients.

But the greatest cause for concern may be just how little is being done to combat the counterfeit drug trade, especially in developing countries. Hampered by a lack of resources, most countries find the problem overwhelming. On the day I spent with Sati, his rounds started at 7 a.m. and finished just before midnight. He may not work that hard every day, but he hardly ever stops. That's because he's fighting a losing battle. "I’ve been busy," he says. "For every faker we shut down, another two or three start up."

OVER-THE-COUNTER COUNTERFEIT

It's hardly surprising that a product like pharmaceuticals might be a target for massive counterfeiting. The price of genuine drugs is high, which pushes the profit margin on fakes even higher, and the global market of potential customers is enormous. What's more, fakes can be difficult to detect. A patient will likely attribute ineffective drugs to the severity of an illness, not to the quality of the medicine. Policies designed to promote domestic generic-drug producers may also permit lower quality controls on exported drugs, creating an opportunity for counterfeiters to sneak their supply into the market.

The complexity of the drug supply chain and the pains forgers take to conceal their origins make it extremely difficult to pinpoint the hubs of international drug counterfeiting. That said, nearly every observer and researcher on the hunt for these dangerous fakes will point to two primary culprits: China and India. My own research on antimalarial drugs suggests that 60 to 80 percent of those fake drugs come from these two countries alone. "The overwhelming volume of counterfeit pharmaceuticals originate in Asia," says Peter Pitts, president of the Center for Medicine in the Public Interest. "Fifty percent is probably a conservative estimate."

Chinese and Indian counterfeiters come in all shapes and sizes. Some counterfeiters work for legitimate pharmaceutical firms; rogue employees stay after hours to substitute substandard ingredients and then sell the drugs to criminal networks. Other counterfeiting rings are based in slums, with ingredients shoveled into concrete mixers and blended to produce medicines sold on the street. Some producers market chalk as aspirin or lactose as Viagra, putting extreme care into faking a medicine's packaging so that the drugs can be sold in stores or exported to foreign markets. More sophisticated counterfeiters add small amounts of the right ingredients so their drugs pass simple chemical tests, fooling authorities trying to prevent fakes from entering the distribution chain. "Indians copy everything," says Vijay Karan, the former chief of Delhi police. "There is more Black Label whiskey sold in India than made in Scotland."

But when it comes to fake drugs, the Indian government strongly denies that it has a problem. Indian government figures claim, somewhat preposterously, that counterfeit medicines account for just 0.4 percent of all legal drugs on the market there. The WHO says the rate is closer to 20 percent, and other experts place it as high as 30 percent. But the Indian government may not know how bad the problem is because it isn't looking very hard. Even when drug authorities in other countries do the necessary detective work, banning Indian firms producing counterfeits from shipping drugs to their countries, the Indian government often allows those firms to continue operating.

In January, Sati and I drove for more than an hour down rutted roads in the state of Uttar Pradesh to visit a "drug factory" where some of India's fake medicines are made. The factory turned out to be nothing more than a small house in a remote village outside of Aligarh, a city of a million people about 90 miles south of Delhi. An industrial cement mixer was blending dust and chalk, which would be compressed into pills and passed off as a local painkiller. The eight or nine people working in the factory were too poor to venture outside the village. They probably had no idea they were doing illegal work or that their product would be shipped to pharmaceutical wholesale markets in nearby cities.

One such city is Agra, best known as the home of the Taj Mahal, and it has become the center of India's counterfeit drug trade in recent years. Of the three main wholesale markets where fake drugs are traded in Agra, the largest is Mubarak Mahal, which spans three floors and houses about 500 small drugstores. According to Uday Shankar, a pharmacist with Agra Government Hospital, fake drugs comprise 20 percent of store sales, which are easily in excess of $5 million a day. In the nearby Fountain market, at least 50 stores trade in generics, but they offer illegal copies as well. But, according to Shankar, it's the market in and around the S.N. Medical College, where at least 180 drugstores operate, that has the highest percentage of fake drugs. "Many doctors at the college will tell patients to buy drugs from particular vendors within the market," he says. "Some [do it] to ensure that these patients buy drugs of decent quality, but others to intentionally direct them to pharmacists supplying fakes." Shankar believes the doctors are probably receiving kickbacks for the referrals.

Some of the markets' supply of fakes will come from big manufacturers such as Rajesh Sharma, who is believed to be an increasingly important counterfeiter from the state of Haryana, just outside Delhi. Sharma allegedly specializes in producing fake drugs to order, allowing the buyer to set the percentage of active ingredients. Some drugs will be chemically similar to brand-name antibiotics and painkillers, but other versions will be little more than placebos with excellent packaging. It all depends on what the buyer wants and what he is willing to spend.

Sharma, who is believed to move millions of dollars' worth of merchandise a year, has a business that is growing and mobile, with production facilities in several locations outside Delhi. But he does not yet operate at the level of the infamous counterfeiter Pavel Garg, whose operation produces millions of fake pills each day. Garg once notoriously told an undercover BBC crew that to keep his operations alive, he had bribed the chief minister of Haryana with a Bentley. (It's worth noting that despite such an admission, Garg's counterfeit drug business continues to flourish.)

Unlike smaller village operations, Sharma and Garg sell a lot of their drugs overseas. When a colleague approached Sharma's network, posing as a buyer for a southern African pharmacy chain, he was offered rifampin, a critical tuberculosis drug, at 15 percent strength. Fifteen percent is "enough to pass color dye tests and much cheaper than 100 percent," Sharma told him. From the point of view of the sophisticated faker, this may make sense. But at that strength, the pill will do little to help the patient and is likely just enough to allow the bug to become resistant to future drug treatments. 

THE MISSING INGREDIENT

If the international community thinks that going after men like Rajesh Sharma or Pavel Garg is a priority, it seems to be biding its time, too afraid to engage a politically sensitive issue. The WHO has been vocal about combating fakes, but even it hesitates to embarrass member countries who allow fake drugs to enter the market. Unfortunately, many observers believe it may take large-scale casualties for real action to occur. As one British drug-security expert put it to me in April, "Action against al Qaeda really only took off after September 11."

Making matters more complicated, the governments of some countries where faking is big business, notably China, India, North Korea, Thailand, and Vietnam, often do their best to throw up roadblocks. Although India's counterfeit drug problem appears to be driven by willful government ignorance and illicit distribution networks, China's is rumored to involve a more official channel: the military. Shanghai- and Hong Kong-based insiders, fearful of retribution if they speak on the record, tell me that a small fake-drug factory in northern China is even housed inside a military base. African health experts tell me that their complaints about fakes to the Chinese government fall on deaf ears, alleging that corrupt Chinese politicians are paid off to not inspect manufacturing facilities. And though Beijing executed the former head of its drug authority last year for accepting bribes, such retribution has not been followed by enforcement of tough penalties against counterfeiters themselves. In nearby Thailand, the Government Pharmaceutical Organization for years produced drugs of suspect quality and dictated that hospitals purchase their more-expensive domestic drugs over better-quality imports. And in North Korea, where much of the foreign currency comes from counterfeit operations, fake drugs are a sizeable chunk of the revenue stream, British security sources tell me.

It might seem logical that Western pharmaceutical companies would be at the forefront of anticounterfeiting efforts, eager as they are to protect their brands. Pfizer, for example, spends a lot of time and effort trying to stamp out illegal copies of its drug Viagra. But going after counterfeiters too hard -- or too publicly -- can be a double-edged sword. Ultimately, if the public believes a drug is being widely faked, sales of the genuine drug may suffer. As a result, many large pharmaceutical companies have been reluctant to pursue fakes, particularly imitations being distributed in developing countries. In 2005, Oxford University health professor Nicholas White, one of the world's top malaria experts, lambasted British pharmaceutical giant GlaxoSmithKline for failing to warn patients in Ghana of fake Halfan, the company's pediatric antimalarial drug. Thousands of children were potentially exposed to and harmed by the phony medicines. GlaxoSmithKline denied it had hidden information, but Nigerian and Ghanaian health experts I spoke with confirmed the company's silence. Like governments protecting substandard businesses, pharmaceutical giants often have reason to remain quiet.

Well-intentioned nongovernmental organizations distributing drugs in developing countries may also contribute to the problem. To save money and treat more patients, the groups often purchase copy drugs from China and India that have not been tested properly. Many of those drugs might indeed be of reasonable quality. But those countries' overall record for quality enforcement is poor, and too many substandard medications are allowed to slip into the supply chain, even alongside genuine ones. Desperate to get lifesaving medicines to the world’s poor, humanitarian groups are left with a difficult choice: expensive, safe drugs that treat fewer patients, or cheaper drugs that might not work.

With so many standing by doing so little, the counterfeit drug trade has been given time to grow larger and more complex. With free-trade zones and Internet sales offering counterfeiters more options for moving and selling their wares, the fight against fake drugs becomes all the more difficult without concerted and coordinated international efforts. Luckily, that hasn’t stopped a few brave individuals from taking on the challenge alone. But their hard-won progress could easily be undone.

THE OTHER DRUG WAR

Dora Akunyili, a 54-year-old pharmacy professor, knew she had her work cut out for her when she took the helm of Nigeria's drug-watchdog agency seven years ago. Back then, in 2001, the WHO estimated that 70 percent of the drugs on sale in Nigeria were counterfeit or substandard. But little was being done; government corruption was rampant. Akunyili only got the job when she impressed the former president with her honesty, returning leftover funds from a medical operation paid for by the state. But Akunyili always had a more personal reason for fighting drug counterfeiters: Her sister died from taking fake diabetes medicine in 1988. Since taking office, Akunyili has collected volumes of shocking tales about phony drugs and government complicity. "People have been dying in this country from fake drugs since the early 1970s," she says.

According to Akunyili, corrupt Nigerian officials extort money from legitimate drug manufacturers and accept bribes from counterfeiters in exchange for access to the market. In 1995, when the Nigerian government tried to help neighboring Niger battle a meningitis epidemic, more than 60,000 vaccine doses were distributed before all of it was found to be fake. Some 2,500 patients died as a result. But most troubling for the country is the widespread counterfeiting of antimalarial medicines. Some 2.6 million people are afflicted by malaria in the country each year; roughly 5,000 succumb to the disease. My own research shows that a third of new antimalarial drugs are fakes. Thousands of Nigerian mothers have watched their children die because their meager savings bought imitation drugs.

Akunyili has made impressive strides in fighting counterfeit drug rings in the country, securing the convictions of more than 60 counterfeiters, with as many cases pending. In 2006, her office shut down a market in the southeastern city of Onitsha in a raid that netted more than 80 truckloads of counterfeit drugs with convincing labels. Public awareness campaigns have also had notable successes, with $16 million worth of fake drugs seized or voluntarily handed over in 2005. Akunyili's efforts have brought the country's proportion of fake drugs down from 70 percent in 2002 to just 16 percent last year. She recently told me that this year, it is close to 10 percent. "Not good enough, but a lot better than before," she says.

But Akunyili's work has not come without steep personal costs. In 2003, her car was ambushed; a bullet grazed her head and a member of her staff was killed. The following year, her government offices were burned down. She now has bodyguards with her around the clock. Akunyili is a target partly because she successfully pushed for harsher punishments. Prior to her taking office, drug counterfeiters faced at most an $80 fine and three months in jail. Most of the accused never saw the inside of a courtroom, let alone a jail cell, because they paid off police. Today, the penalties still do not rival those dealing in narcotics, but fines are increasing -- many exceed $1,000 -- and jail time is measured in years, not hours. Despite these successes, Akunyili thinks unscrupulous local businessmen and politicians would like her out of the way so they can go back to business as usual. And she faces a daily battle dealing with officials from India and China, the two countries that supply most of her country's fake pharmaceuticals. "Neither government is really trying to stop production and export of fakes," she says.

In India's case, the troubles stem partly from toothless laws. As far as my research shows, counterfeiting was not even successfully prosecuted as a criminal offense until last year, and today there is scant enforcement. In a small sign of progress, the Indian cabinet approved a bill in July that increases counterfeiting fines from $250 to $25,000 and jail sentences from 5 to 10 years for the worst offenders. But much more needs to be done. Cases still rarely make it to court. Police are often bribed to look the other way. Waiting in Sati's office one day, I watched the local police come by to talk about a pending prosecution; they spent 10 minutes trying to persuade Sati to drop the case.

A PRESCRIPTION FOR REFORM

As noble as the efforts of people like Dora Akunyili and Suresh Sati are, their hard work will be meaningless against global drug counterfeiting if the major sources of the product are not pursued. That will require far more effective international drug testing and oversight, and most importantly, the nerve (and necessary budgets) to see good intentions through. At the very least, the struggle against these fakes should not be left to a courageous few. After all, what is to say that Nigeria's progress against dangerous fake medicines won’t be reversed if the next bullet aimed at Akunyili hits its mark?

As the fake-drug sector continues to grow in speed and sophistication, the global situation will get worse before it gets better. China and India may be the major producers today, but several countries are hot on their heels. Russia's counterfeit drug industry is estimated to be worth $300 million a year. Small-time producers in Argentina and Brazil are growing rapidly. Egypt has become a major hub for Chinese counterfeits en route to Europe and the United States. Even terror links have become part of the equation: In March 2006, the U.S. FBI busted a counterfeit ring with associates in Brazil, Canada, China, and Lebanon. The ring was funneling money to Hezbollah.

The good news is that new technologies are making random quality testing easier and faster. Hand-held spectrometers can assess drug potency in a matter of seconds. If more of these devices are made available to customs agents, imported fakes can be found rapidly and destroyed. But technology can only be one facet of the response. Governments that protect counterfeit drug industries must be named and shamed, and aid agencies should only purchase and distribute drugs that have undergone rigorous testing. That may mean that when the moment comes to decide between untested drugs or no drugs at all, we go without -- for our own sake. That's the approach Dora Akunyili believes in. "Better to have lack of access," she says, "than access to counterfeits and substandard medicines." In the end, it may be the only sensible remedy.