Abortion Drugs Tade
Sales of abortion drug thrive in social media, even in online shops. The demand boom and ample loopholes in supervising enabled black market growth for drug used to abort fetus.
This article is a collaboration between Tempo, Change.org, and KitaBisa.com under the collaborative program of Bongkar!
THROUGHOUT 2015, the com-muni-cation and informatics ministry blocked 300,000 websites selling illegal drugs, which were mostly used for abortion, following a report from the Food and Drug Monitoring Agency (BPOM). However, the effort to shut down those websites is futile as more are sprouting. Throughout 2017-2019, the ministry had shut down 96 sites that overtly sell abortion drugs.
Law enforcement does not deter those sellers. Last October in Malang, East Java, police apprehended a network selling abortion drugs on Facebook. The kingpin is an employee of a drugs distribution company for hospitals and pharmacies in that city. The network took profits of Rp40,000 per tablet of Cytotec, the most popular abortion pill.
In Klaten, Central Java, police arrested Agung Nugroho, who allegedly was the mastermind behind Cytotec sales in social media. Agung and Annisa Puspita Sari managed Facebook and Line accounts under the name of Nindira Kurnia Wati. Agung put his phone number that could be read by 1,004 followers. “I started selling in mid-2018,” he told Tempo in Klaten Police Office in June 2019.
In running the business, Agung pretended to be a doctor, while Annisa as his assistant. He sold the drugs package at the price of Rp800,000 to Rp2 million. Each pack contained five to 10 tablets, depending on the gestation period. The price would increase to Rp11 million if buyer requested midwife assistance. Agung was helped by ‘midwife’ Ari Janti, who worked at the Ceper subdistrict office and received Rp1 million per abortion. “I am only Agung’s referral,” Ari said.
Agung admitted he received the abortion tablets online from Instagram and Twitter. Tempo traced the abortion drug suppliers’ accounts referred by him. One of them is Agus who told Tempo by phone that he could sell Cytotec at the price of Rp60,000 per tablet. In pharmacies, Cytotec is sold at the price of Rp45,000. Agung then sold the drug Rp100,000 each. Until his arrest, he confessed to have sold only three packs, each contained 10 tablets. However, police investigation found that Agung had successfully sold more than 100 packs.
Nonetheless, the crack down on illegal drug traders does not diminish the sales of abortion medicine. Based on Tempo’s two-month investigation last year, Cytotec, which is produced by the giant pharmaceutical corporation Pfizer, circulates through social media. In Indonesia, Ethica Industri Farmasi holds the distribution license for Cytotec. In addition to Cytotec, another abortion drug is Gastrul. Both contain misoprostol which function to shed the fetus.
Drug traders have a similar method. Like Agung Nugroho in Klaten, those sellers claimed to be doctors or midwives to convince customers. The targets are female students or women with unwanted pregnancies. One of them is Yulianti, 31 years old. With her partner, who lived in South Jakarta, the employee of a private company obtained abortion tablets from the Internet. “We look for the ones who are well-spoken to avoid fraud because of the sizeable amount of money,” she said.
She finally chose a seller who provided money-back-guarantee for an unsuccessful abortion. The transaction process happened like online shopping: buyer ordered through WhatsApp and transferred Rp920,000 to an account. Yulianti did not remember the exact sender address on the drug package. “If I am not mistaken, it was from East Jakarta or Bekasi,” she added.
There was no usage instruction in the package. Furthermore, several capsules and tablets came without packaging. “There were three pentagon-shaped pills, the rest were white-colored tablets which I suspected as paracetamol and one more medicine that I was certain as amoxicillin,” Yulianti explained. The pentagon-shaped pills were Cytotec.
Feeling odd, she ignored and contacted the seller’s number to ask the usage instruction. The seller only said one pentagon-shaped pill to be inserted into the vagina and the remaining two to be taken orally. Yulianti followed suit. “Only recently that I know it was a fraud,” she said. “The dosage was incorrect, the usage was wrong.”
Her fetus did not shed. Her baby kept growing in her womb. “It was only brief spotting, but without any effect,” Yulianti uttered. The seller she contacted told her to be patient because many patients only received the effect after two days. After that, Yulianti did not receive her money back, and she could not contact the seller as her calls were rejected.
Yulianti searched for another seller online. From the seller, she received instructions to buy Cytotec, but with a higher dose. And that time it worked, and her eight-week-fetus was aborted.
Tempo brought Yulianti’s story along with the revealed sales modus to the Secretary-General of Management of the Indonesian Pharmacists Association, Noffendri. He explained misoprostol in Cytotec or Gastrul was used to treat peptic ulcers. These pills were also potent to be abortion medicine as it triggered womb contraction. With a specific dose, this medicine could prepare the cervix for childbirth. Doctors, Nofferndri continued, also used the medicine in low dose to induce labor during emergency situation.
An obstetrics and gynaecologist specialist of Pondok Indah Hospital, Ni Komang Yeni Dhana Sari, said that gynaecologists rarely used misoprostol for labor induction. “The medicine (we) usually used are different due to lower complication risk,” she said. Nevertheless, these medicines were tightly controlled by doctors and could only be used in the hospital for inpatients
Yeni did not suggest the usage of medicine containing oxytocin or misoprostol with inaccurate dosage due to their harmful effects. The fatal use of stimulants is strong uterine muscle contractions that can cause torn uterus and severe bleeding resulting in death. Babies born with a high dose of this stimulant drug are generally affected by microcephalous or minor head abnormalities. “In other cases causing allergies to blocked breathing,” she said.
In November 2019, the World Health Organization (WHO) published an evidence brief on unsafe abortion prevention. According to the publication, throughout 2010-2014, there were approximately 7 million unsafe abortions annually that resulted complications. In the developing countries like Indonesia, approximately 220,000 to 100,000 unsafe abortions resulted in death. In the document, WHO provided a guideline on the procedure for doctors to solve complication caused by excessive bleeding, infection, and internal injury.
The WHO also published safe abortion guideline using drugs. The requirement to undergo this procedure is, among others, supervision from trained medical staff. According to Yeni, the guideline was only for doctors because Indonesian law prohibited abortion. In the Health Law, abortion can also be conducted for rape victims or on the case of specific medical indications pronounced by three specialist doctors.
Therefore, pharmacists must confirm to doctors when a patient intends to buy abortion drugs. However, according to Noffendri, there are many loopholes that illegal medicine sellers can take advantage to escape from the law. One scheme is buying directly from the distributor without the knowledge of the pharmacists in charge, or pharmacy owner forces the pharmacist to order specific medicines even when they are not needed. These medicines will be stored by the pharmacy owners themselves, instead of in the pharmacy’s storage, to be sold online.
Another loophole is coming from big pharmaceutical companies. Christian, not his real name, a drugs distributor said that the abortion drugs enter black market because of the supply from big pharmaceutical company salesperson, who are pressured to reach sales target. “Medicines that are supposedly distributed to hospitals or pharmacies are distributed to drug stores illegally by forging order invoice,” he said.
Therefore, Christian continued, online drugs distribution is actually a mere extension of offline sales. Black market for abortion drugs is prevalent, especially in cheap drug markets, such as Pasar Pramuka in East Jakarta. In this market, sellers directly ask those coming to the market with a striking question, “Neng, looking for Cyto? We have Gastrul too,” uttered Rian, a medicine scalper, to Tempo. Cyto is a short form of Cytotec.
Rian offered Cytotec packages. One pack that can completely abort fetus contain 10 tablets at the price of Rp1.2 million or Rp120,000 per tablet. According to Rian, even though uncertain, every month, there is a consumer who buy abortion drugs. At the beginning of the year, when abortion rate rose, he could sell the drugs to 10 women a day.
In Pasar Pramuka, there are dozen of young men like Rian. They look for consumers and direct them to drug stores in the market. The scalpers receive a commission of Rp50,000 per tablet. In this market managed by the city operator Pasar Jaya, there are 403 kiosks with operation permit as medicine retail trader (PEO).
According to Health Minister Regulation No. 167/Kab/B.VII/72, PEO holders are only allowed to sell over the counter and registered over the counter medicines and shall not sell or accept orders for doctor-prescripted drugs. PEO holders are even prohibited from storing those drugs. All of these prohibitions seem loosely violated by drug stores in Pasar Pramuka.
Adriantono Malik—not his real name—a manager at a pharmaceutical company, said that official salespersons have ways to sell drugs directly in Pasar Pramuka. They hire a third party or sales freelancer to be a middle person and drug peddler.
The sales freelancers are generally people who have been long time working as salespersons in a large pharmaceutical wholesaler company (PBF). They know the loopholes to obtain a large profit and quit from the company, then become sales freelancers. “They are not bounded by any PBF so they can sell limitless variety of medicines,” said Malik. They look for drug store owners in Pasar Pramuka who are willing to buy products from salesmen.
The BPOM finds another modus: big pharmaceutical company distributes medicines, including those containing misoprostol, using invoices from pharmacies that have closed down. According to Reri Indirani, former BPOM main inspector, several closed licensed pharmacies still received medicines from pharmaceutical company. “The orders are plenty,” she added.
Yoyon, Secretary-General of the Pharmacy Seller Association of Pasar Pramuka, denied all the stories and evidences. He said that there are no traders who sell illegal abortion drugs such as Cytotec or Gastrula due to discontinued production. Yoyon’s statement is supported by Ethica Industri Farmasi. Through written statement to Tempo, the company stated that they had stopped the distribution of the drug.
The company’s claim, however, is refuted when a month after the first meeting with Rian, we contacted him again to ask the availability of Cytotec and Gastrul. Without further questions, he said that both medicines were ready for pick up. “Just come here, six tablets are Rp500,000,” he said. A pharmacist also mentioned that both medicines could be ordered in the pharmacy.
It is not surprising that online sales still operates. Online sellers take the medicines from drug stores. Several traders offer these drugs packages overtly in Shopee or Tokopedia. They put phone numbers if buyers do not want to transact through the online application. These medicines are priced at Rp750,000 to Rp1.2 million per pack containing eight to 12 tablets. Written in the description, sellers state that the medicines are under herbal category.
We contacted a seller in December 2019. He said his name was Wawan. He explained that one tablet of Cytotec was Rp70,000. He sold in five packs. “Just adjust to the gestation period,” he said. He sold the pack at the price of Rp600,000 to Rp1.5 million. Each pack contained Cytotec, antibiotic, and cleansing medicine. Wawan explained the reason he wrote the drugs as a herbal medicine is to avoid rejection from the online store management. Another seller, he said, usually placed the description as drug for diet.
Even though Cytotec and Gastrul are less popular as peptic ulcer medicine, the number of imports are rising within the last three years. In 2017 alone, the total import was 893 kilograms, valued at Rp20 trillion. The annual import rate is estimated about 102 kilograms, amounted to Rp201 trillion.
According to Reri Indiani, the BPOM does not have the exact number of Cytotec or Gastrul circulation or the amount in the licensed pharmacies. Although the agency awares of the misuse, these drugs are not under category of being controlled. This loophole have made illegal abortion drugs trade such a big hit in the real world and cyberspace.