Rogue doctor without borders

In convicting Dube, the Douglas County criminal justice system nailed one doctor who ignored the prescribing limits set by the Food and Drug Administration (FDA). But it could not solve the problem with the system itself. While both oxycodone and hydrocodone have been available for decades, prescription opioids increased in popularity as the pain management movement picked up speed from the 1970s onward. Their usage skyrocketed post-1995 in the wake of the registration of a new formulation of oxycodone, branded OxyContin and made by Purdue Pharma. To much criticism, the FDA accepted the company’s argument that the drug would be less prone to lead to addiction due to its time-release formulation, and thus could be used for long-term chronic pain instead of simply for short-term use, as was previously typical of opioids.

The company marketed the drug for use in patients with moderate to severe pain and boasted on the label that the risks of addiction were small. Purdue hired hundreds of sales reps, who focused their efforts on general practitioners like Dube rather than pain specialists.

The campaign worked: Doctors wrote opioid prescriptions for all types of pain, ranging from migraines to arthritis to cancer. Many family doctors, particularly in poorer communities where pain patients are often concentrated, were sold on the prospect of a miracle cure. And other regulatory malfunctions added fuel to the fire. For example, compounds of drugs containing hydrocodone, the country's most popular opioid painkiller, were placed in a drug class that allowed it to be prescribed relatively easily and often, without stringent medical oversight as compared to other potentially dangerous drugs.

Contrary to Purdue's initial claims, many patients got hooked on prescription opioids. In the last decade, the use of prescription pain pills has increased 400 percent, with up to 125,000 people dying of overdoses. But despite concern from doctors, the DEA, the Centers for Disease Control and Prevention and health advocates, the FDA has dragged its feet in tightening regulations. For example, in 2004 the DEA asked the FDA to reclassify drugs containing hydrocodone so as to limit access, after doctors began noting concern in the late 1990s. But it was only after the FDA was forced by Congress to consult outside experts that a panel finally suggested reclassification, nearly a decade later, in 2013. Additionally, it wasn't until 2013 that the FDA announced that it would bar manufacturers from marketing long-acting and extended-release versions of opioids for moderate pain. While a federal case was brought against Purdue for its claims that OxyContin was not as addictive as older forms of the drug, and the company and three company executives faced millions in fines, no one served any jail time.

With prescription drug abuse continuing to rise, a response that has rested on individual prosecutions isn’t working. Georgia continues to have some of the highest prescribing rates in the nation, with 91 opioid prescriptions written for every 100 people. Despite the Georgia Drugs and Narcotics Agency (GDNA) and DEA pursuing criminal charges against hundreds of individuals, including doctors and pharmacists caught illegally prescribing, "the appetite for the drugs has not gone away," says Rick Allen, director of the GDNA. "We can't arrest our way out of the problem."

Dube himself slipped through the cracks. After serving three years in jail and two years of probation, Dube skipped town, 10 years before his sentence ended, and landed in South Africa.

His American medical license expired in 2002 and he was barred from practicing medicine in the U.S. for 10 years because of his conviction, yet Dube was issued a medical license by the Health Professions Council of South Africa (HPCSA), which is responsible for registering and overseeing the country’s medical workers. In 2009, he was working at a small public clinic in KwaZulu-Natal province. His employment was assisted by the NGO Africa Health Placements (AHP) and by the South African department of health. All three bodies insist that they followed regulations in ensuring that Dube met the necessary requirements. 

In 2011, AHP facilitated Dube’s transfer to Messina Hospital, in Musina, Limpopo, where his behavior soon came under scrutiny from hospital staff, patients and NGOs working in the area. After placing Dube on paid leave, the provincial health department investigated complaints that he harassed foreign staff and patients and gave inadequate medical care. As part of the investigation, health officials contacted the Douglas County DA's office to confirm Dube's criminal past. But instead of penalizing him for his actions, they instead returned him to the hospital, promoting him to CEO.

Meanwhile, several hospital workers who went on strike to protest Dube’s mistreatment of foreign doctors and patients were dismissed. The Limpopo health department told a national newspaper that Dube could not be fired without the due process required by South African labor law, but there are rumors that he was protected because he had connections to those high up in the provincial health system.

Like many developing countries, South Africa is facing a chronic shortage of doctors, with rural areas like Musina experiencing a particularly extreme drought. At the time of Dube's instatement, staff retention at the hospital had been poor for years, with key clinical positions remaining open in seeming perpetuity. That AHP and the department of health jumped at the chance to snag a foreign-trained doctor who worked in America for years is hardly surprising. 

But there are also large cracks across South Africa’s regulatory health system. For example, the HPCSA has been heavily scrutinized for its 13-year lag in stripping a medical license from an apartheid-era doctor, nicknamed "Dr. Death" for his role as head of the government’s chemical and biological warfare program. In this position, Wouter Basson oversaw the production of psychoactive drugs for the state. He also helped the army in equipping mortars with tear gas to use against civilians and in accessing disorienting substances and tranquilizers to facilitate kidnappings of anti-apartheid activists, many of whom were killed. Commenting on the case, Mark Heywood, a leading public figure, told a national newspaper that the HPCSA lacks the ability to properly “police the medical profession” and is in dire need of “better leadership and more resources to conduct itself better generally.”

As for Limpopo, the country’s health minister has called the province’s health system the most corrupt in the nation. Amid concern at widespread mismanagement and ineptitude, in 2011 its administration was placed under national control, where it remains today.

While some of the mistakes made by the country’s health institutions are understandable, AHP and the South African department of health have fewer excuses for not properly vetting Dube. AHP is a privately run organization that has received funding from, among other sources, the US government, and the national health department has seen a significant boost in leadership and accountability under the current minister, Aaron Motsoaledi. 

After he had spent nearly three years at Messina Hospital and with increasing pressure from the international NGO AIDS-Free World (AFW), the HPCSA finally stripped Dube of his medical license in February 2014, claiming it was issued "in error or through fraud." The revocation was not made public until April 2014, when AFW asked for a judicial review by South Africa’s high court of the council’s failure to act on the matter. The council has said that despite the doctor's case, they do not think that reforms are needed. Neither does the Limpopo health department, which finally fired Dube in May 2014. However, Joe Maila, spokesman for the national department of health, says, "this particular case has been an eye opener…. [W]e will make sure that stringent processes are put in place to prevent this from happening again."

For now, Dube is nowhere to be found. Some say he will open up his own private practice, or that he has gone to Cape Town; others say he is in Zimbabwe.

Meanwhile, the Douglas County district attorney's office has put out a warrant for Dube's arrest, as he is in violation of probation. The county has a thirst for bringing back convicts who have escaped probation, and the DA's office says that steps are being taken to extradite Dube. If he is caught, they expect he will serve the remainder of his sentence – six years – behind bars as punishment for violating probation and given what they consider to be the seriousness of his crime. What Douglas County authorities cannot do, however, is put handcuffs on the systems in the U.S. and South Africa that Dube exploited.