The spread of steroid in the Northeast through itinerant sale person/hawkers has attracted the attention of people in public health in Thailand. All these hawker caravans function as a major conduit to bring steroid solution mixed with herb, traditional medicine, and food supplementary to the consumer.   

The reason the itinerant sellers manage to get the steroid supplies is they must be able to buy them for sale from somewhere. 

Thailand is supposed to not produce the raw material or reactant for steroid production. All of the steroid supplies are imported and reproduced as pills and then distributed to drug stores and medical facilities. Meanwhile, the Food and Drug Administration Thailand (FDA) insists that it has placed strict control on the supplies. Therefore, there must have been steroid which has been smuggled outside the system and has gone through undisclosed process. For those who monitors the FDA regulation, they found it leaves much to be desired. 

Nevertheless, according to our source, the steroid that has been smuggled outside the regulation of FDA might be incomparable to the “underground” steroid made by illegally imported substance and then supplied through various outlets. 

The raid of a huge supplier of steroid in Khon Kaen

In the middle of December 2014, TCIJ took part in a raid to Tek Kuang Pharmacy drug store in Ban Phai District. Cherdchai Ariyanuchitkul, a pharmacist expert of the Provincial Public Health Authority disclosed to media that this drug store sells unlicensed Dexamethasone without label to general public. The sale is quite brisk. According to the volume of drug seized by, we found it to amount to at least one million pills. 

According to one source, this drug store is a major supplier distributing the pills to itinerant sellers. For every single itinerant seller busted by the officials, they would refer to this drug store as their supplier.

In reply to a question from the official to the owner of Tek Kuang Pharmacy as to how he has obtained the drug, he said one sale person has approached and sold it to him. He only knows the person by nick name and his phone number, but nothing else. 

‘White Bill’ the pathway for the leak of steroid

Asst. Prof. Niyada Kiatying-Angsulee, a pharmacist and manager of the Thai Drug Watch said that the purchase of drug without indicating the name of supplier is known as ‘White Bill’ and it has become a key channel through which steroid has spread widely. Our source told us that in the Northeast, there are at least four factories that illegally manufacture and distribute steroid through ‘White Bill’.

In a normal procedure, any import and distribution of the drug and its chemicals has to be reported to the FDA. It has been found, however, that unlabelled and unlicensed steroid is hidden in bottles of non-steroidal anti-inflammatory pills. Some manufacturers rely on raw materials illegally imported.  The sale persons may approach a drug store or medical facility and through the ‘White Bill’, they can arrange for the factories to manufacture the drug according to the orders. The drug can be made into any shape and form or color.

As for the mixture of the steroid with the herbal solution, as explained in Part I, the factories that produce the solution might have no idea about this mixture since for instances, it is the itinerant merchants who mix the drug themselves. Albeit, some of the producers of the herbal traditional solution involved with the steroid racket are those active in politics as well. 

According to drug distribution statistics in 2008 (January-April), it is interesting that 28.44 million pills of Prednisolone (a steroidal drug) have been distributed to either hospitals or clinics, or 46.1% of the total volume. But 53.8% of this steroidal drug could potentially leak outside the system and not arrive at either the drug stores or medical facilities. Meanwhile, 118.1 million pills of Dexamethasone (another steroidal drug) have been distributed to either hospitals or clinics, or 2.6% of the whole volume. But the leak could amount to as high as 97.4% The information is attested to by the fact that most hospitals shun ordering Dexamethasone given its high risk of side effects.  

It could then be assumed that a lot of Dexamethasone manufactured in Thailand have leaked outside and then reproduced as a set of generic drugs or traditional medicine. According to Asst. Prof. Niyada;

“The use of steroid in state hospitals is minimal. It is mainly used for injection in emergency unit or ICU, but in a rather small amount. Steroidal pills are available, but not in sheer volume. But we have found clinics in the province have a huge stock of the drug and according to the Drug Act, they are not required to report it to the FDA. The leak could be made through clinics. These clinics are regulated by the Medical Facility Act under the supervision of the Bureau of Sanatorium and Art of Healing under the Department of Health Service Support. They are subjected to a yearly inspection during the renewal of license. The agency has no outfield officials like the Provincial Public Health Authority. And even though the Public Health Authority has the power to carry out the inspection, but the medical doctors who run the clinics may be reluctant to have any pharmacists to inspect their places. And even though the FDA has asked the drug factories to report the data, but it seems they have not made use of it to address the problem.”

According to the inspection of various herbal products during 2010-2014 by the laboratories of the Bureau of Drug and Narcotic, the Department of Medical Sciences, Ministry of Public Health, of 670 samplings, 118 were found to contain either Prednisolone and/or Dexamethasone.

Huge stockpile of underground steroid in Hat Yai

According to a source in the MoPH and Asst. Prof. Niyada, the leaked steroid could be just the tiny when compared to the steroid smuggled from abroad.

According to our source in MoPH, in the Northeast, there are 77 border passes between Thailand and Lao. Of this number, officials in only ten of these are rather strict about the imported and exported goods, but the rest are quite lax. 

“We have tried sending someone to buy the stuff from China and take it through Lao border pass. It was ok. One barrel costs thirty thousand baht and contains 50 kg of steroid. It takes just 0.5 mg to product one steroid pill.”

The factories that illegally import steroid have to be legally licensed factories. An ordinary person would not dare to possess a manufacturing machine for steroid. When imported, it was falsely declared as either a drug or an animal feed. 

According to Asst. Prof. Niyada , steroid from China has been smuggled across the Mekong River. Some have been carried in.  She believes the number of imported steroid reported to FDA is two to four time less than the actual import. It is possible that when it is imported, it is not declared as a drug to the customs similar to the case of Sudo drug in the past.

“The raw material importers have to be closely monitored.  Those involved with the import, manufacturing, and sale should be required to have three separate licenses. Any illegal import could not be detected since it was not declared as ‘medicine’. The Customs Department often let it go since it was not declared as medicine. If they become suspicious, they might ask the border control to check, but such inspection is done only during daytime. But the stuff like this is brought in during night time without being declared.”

According to various sources, there are about four or five major importers of the illegal steroid. They are the major suppliers who receive the orders. One of them is located in the province of Pathumthani. 

FDA’s intensified control

Pharmacist Prapon Angtrakul, FDA’s Deputy Secretary General, said that until now, FDA has imposed measures to regulate the matter. Importers, manufacturers and distributors are kind of required to report the data online every time a purchase or a sale is carried out. It is done real time. Previously, it was done only annually which made it too late for them to be aware of the movement of steroid. Nevertheless, drug stores are still not accounted for in this system. 

As for risk groups such as those in the Northeastern provinces, Pharmacist Prapon said that now the data has been computerized and it can be retrieved by the officers so that they are aware as to the drug has arrived at which provinces, and how much. 

“You’ve got to understand that FDA has no outfield offices and we have to rely on cooperation from the Provincial Public Health Authority to help monitor to which hospitals steroid supplies are harnessed, which clinics place so big the orders. We keep monitoring this information. We have a team to watch out.”

“If the situation does not get better, we have to intensify the effort. For example, we might set out a quota system to fix the amount an order can be made. Right now, the relevant Ministerial Regulations have been adopted to empower us to set out the quotas. And if it still does not get better, we might try to put more control on the outlets. Maybe it will be completely banned from drug stores and is only available in hospitals or clinics and the quota system will be imposed as well” explained Pharmacist Prapon.

But to intensify the control including the imposition of quotas and restrictions placed on the outlets, the authorities need to have data as to the actual need of steroid. It seems the FDA has no such official information. 

“We want to be able to figure it out how much steroid is actually needed in Thailand. We do not have such information. Thus, we hope that by establishing the system, it will help us to track down the information. Since steroid has been classified as a specially controlled drug, its purchase or use warrants prescriptions. We want this system to come on so that we know the actual demand. We will primarily concern ourselves with the figures of demand in hospitals and clinics. The data used in our system since October 2014 has been well segregated.” 

Nevertheless, an initial survey would not be hard to do, but the actual implementation is hard to come by. Until now, there has been no effort made except for giving our information to the press. According to our source, there have been large exports in certain provinces, but no investigation has been made as to the detail of such big lots. Or some clinics place huge orders, hundreds of steroid pills, more than the actual need. It is not clear if collaboration has been made among the MoPH’s agencies to work on the issue. 

Issues of the management, FDA assures the problem will be addressed this year

Nevertheless, the actual strict implementation might not be that very easy. First of all, FDA and the Provincial Public Health Authority are not security agencies and therefore are not allocated with sufficient financial and technical resources to bring to justice the perpetrators and to gather relevant evidence. Meanwhile, related legal provisions are quite complicated and inconsistent. For example, the FDA has no power to initiate a raid by itself. The power vests in the Customs officials. Therefore, any operation is only made possible by efficient cooperation among the agencies. 

The police themselves do not place much importance on steroid issues since narcotic problems tend to command much of their attention. 

As for the FDA’s monitoring system on the spread of steroid, both the monitors and officials find the existing database and information system still fail to ensure effective and ongoing monitoring system.

Luckily, the 7th National Health Congress has included as an agenda “the management of steroid which is harmful to health of Thai people” and the agenda has been adopted by the meeting in last December. Concerned agencies have received instructions to set out how intra agency cooperation including the police, Customs Department and FDA can be made.

“It was agreed by the Congress to set out comprehensive and local monitoring on the issue. We can provide them test kits to detect steroid substance in any products. The screening and referral system of patients has to be established. In the province, many of the patients have been treated with steroidal medication for a long time. It is impossible to bring it to a sudden halt. We have developed a model and shall replicate it to provide for patient screening and their referral. The measures require collaboration” said Pharmacist Prapon. 

Pharmacist Prapon further said that the real time tracking system currently developed by FDA shall help to bridge the gaps. The concrete result shall be witnessed within this year.”

Whether or not it will happen as such, we have to wait and see.

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