De Cruz's life was saved by an emergency transplant after her fiancE, actor Pierre Png, donated half his own liver. She now takes immunosuppressants, which keep her body from rejecting the transplant but leave her weak and vulnerable to further illness. She's wary of planning her wedding to Png, more than a year away, fearing she may not survive that long. "I feel I'm still living a nightmare," she says. She is, at any rate, still living. In June, fellow Singaporean Selvarani Raja, a 43-year-old logistics manager at Singapore Technologies, died from liver failure. She had started taking the same diet supplement, Slim 10, in April.
The deaths—as well as more than 600 illnesses linked in Japan to Chinese diet pills—have alerted health authorities to a hazard they have been almost powerless to stop. Similar drugs were implicated in deaths in China last year, with scores more falling ill in Korea and Hong Kong. Japan last month banned 24 types of Chinese diet drugs—many containing N-nitroso fenfluramine—and rushed through new laws placing the burden on importers to prove product safety or face a fine of up to $26,000. Just last week, health officials in China published a ban on 13 diet products, seven of which were found to contain fenfluramine.
But the regulatory palliatives are likely to be only temporary stopgaps. The region is awash in cheap diet aids manufactured in largely unregulated Chinese factories. Classified by many countries as "health food"—rather than as pharmaceutical products, which must pass rigorous safety tests before they can be marketed—the concoctions are readily imported and sold in Asian pharmacies and natural-medicine shops, even in beauty parlors and spas. Indeed, Asians tend to trust Chinese medicines as natural and safe dietary shortcuts based on 3,000 years of trial and error. Ancient Chinese apothecaries, however, never treated obesity. Lacking a time-tested herbal cure, Chinese drugmakers are lacing their products with artificial chemicals. "These slimming pills are registered as herbal medicines or health food and do not need to pass through drug trials," says Dr. Lo, a liver specialist at the University of Hong Kong. "There's no safety data, and their efficacy is not based on any evidence." Product labels contain no warnings, few guidelines for use, and potentially dangerous ingredients are often not listed. "Anyone who takes these pills is basically acting as a trial subject," says Dr. Chung Mau Lo of the University of Hong Kong Medical Center, who works in its liver transplant clinic.
Many Chinese manufacturers and retailers recklessly disregard the products' health risks. Fenfluramine is banned in Japan, Korea, Singapore, Hong Kong and China, but products containing it can still be found on store shelves in many of those countries. Last week in Shenzhen, shoppers could easily find a supplement called Fenfluramini—each 20-milligram tablet contains pure fenfluramine hydrochloride. "It's pretty strong stuff," says the sole attendant at a closet-size drug shop in the city's sprawling Luohu Plaza. "You should buy two boxes to get the fuller effect."
Manufacturers appear to pay little heed to the substance's dangers. After Chinese health officials outlawed a product made by Guangzhou-based Yuzhitang Health Products that was associated with two deaths, the company simply started making a differently named product containing fenfluramine (that product, too, was banned by China last month. The company could not be reached for comment).
Chen Guangyu, president of Changqingchun—a Huizhou-based company that makes Sennomoto-Kono, a diet drug linked to three recent deaths in Japan—has repeatedly insisted in the Japanese media that counterfeit drugs were actually the cause. "We have many copycats because we have such a good reputation," says the manager of the company's Beijing office, who identified herself only as Zhao. "We use only Chinese herbal medicines, not chemicals." Japan's Ministry of Health, however, found in recent tests that counterfeits of Sennomoto-kono contained no N-nitroso fenfluramine. Authentic Sennomoto-kono did.
The spate of recent diet-pill-related deaths in Japan touched off a round of criticism directed at the country's health officials, who drew fire for being slow to respond when people started getting sick. "Sometimes I wonder how many people had to die before anyone did anything," says Dr. Masayuki Adachi of Keio University Hospital in Tokyo. The 31-year-old doctor alerted the government in late April when two of his patients, both women, suffered liver failure after taking Chinese diet pills. "I couldn't prove a definitive connection," he says, "but I knew these drugs were very popular, that my patients were very sick and that people should be warned." The Ministry of Health, Labor and Welfare, however, turned him away.
One of Adachi's patients was saved by a transplant. The other, a 60-year-old woman whose identity has not been released, died. That's when Adachi went to the press. In the resulting explosion of news coverage, he learned his cases weren't the first—three other Japanese deaths, all due to liver failure, had been linked to Chinese diet drugs since 2000. After the news broke, more than 600 other Japanese contacted the Health Ministry saying they had been sickened by the pills. Japan's government finally banned the drugs by name and enacted tighter controls in mid-July.
Adachi was joined by other critics, including the influential Yomiuri national daily, in condemning official inaction. "The government cares less about consumers than about Big Business," says Hiroshi Satomi, director of the Health Information Research Center, a nonprofit organization that conducts independent food and drug research for public safety. "Yes, the buyer must beware. But that doesn't absolve the government of all responsibility. Why should they get our tax money if they don't care if we die?"
Akira Miyajima, director general of the Health Ministry's pharmaceutical and food safety bureau, defends his agency's cautious pace. "It's difficult for us to move on just one case," he says. "If we claimed publicly that a product was dangerous before we know for sure, it would cause a lot of trouble for the business and open us up to lawsuits. Given the circumstances, we think we moved with extreme speed."
So pervasive is diet-pill proliferation that no government can offer blanket protection, least of all to a public that wants desperately to believe it can lose weight without willpower. The popular media pour on the pressure to be thin. Diet aids (non-deadly ones) are heavily advertised throughout the region, often with the endorsements of pop singers and TV personalities, like Takuya Kimura in Japan, Chen Liping in Singapore and Shirley Cheung Yuk-san in Hong Kong. Says Hidehiko Sekizawa, head of Japanese research group Hakuhodo Institute of Life and Living: "Japanese people are not yet obese in the American sense, but because the average person is skinnier here, even slightly plump people think of themselves as fat. And they're willing to go to any length to reach the ideal."
Some consumers say risks are minimal and worth taking. Li Gang, 30, lost 15 kilos in a month while taking a Chinese diet pill. There were troubling side effects. "I became very impatient, and I felt my brain was slow," says Li, who works for a foreign consulting company in Beijing. But he says he was pleased to be slimmer and "In any case, (the side effects) went away when I stopped taking" the drug.
Dr. Sing Lee, director of the Hong Kong Eating Disorders Clinic, estimates that of 350 patients his facility has treated, up to 70% have used diet pills, often popping a variety of them. "It's just like drug abuse," he says. Even pills that do not contain fenfluramine can pose health risks. Some contain diuretics or laxatives that can cause skin rashes, diarrhea and irritable bowel syndrome. "I've encountered women who are taking diuretics without being aware of it," says Dr. Lee. "They lose water and with it, potassium and other vital body-regulating electrolytes." Reduced potassium can cause an irregular heartbeat, even coma. "What can be O.K. for a month can cause serious damage over the long term," says Professor Leung Ping-chung, chairman of the Institute of Chinese Medicine at the Chinese University of Hong Kong. He performed a recent study of 15 diet pills available in Hong Kong and found the packaging of only one mentioned potential long-term side effects.
For some, the damage has already been done. Over the objections of her parents, Wang Ting, a 16-year-old computer student at a Shanghai technical school, started taking an outlawed Chinese diet pill called Qingzhisu several years ago. By September 2001, she had succeeded in dropping from 78 kilos to 57 kilos, but she also complained of headaches and her eyes seemed to bulge.
She passed away last year. "The diet pill companies take advantage of young girls and boast results that aren't real," says Wang's father, Wang Quikan. "Why aren't these things more controlled?" Wang sued the manufacturer but the case was dropped by a Shanghai court for insufficient evidence. "Society's influence is very bad," he says. "It took away my healthy young girl."
News reports may scare consumers off dubious diet drugs for a while, and outlawed brands will disappear from the market. But other potentially dangerous products seem sure to crop up. Already, ephedrine—an amphetamine-like stimulant cited in 80 deaths in the U.S.—is reportedly gaining popularity as a diet drug in the region. "Humans have short memories," sighs Adachi, the Japanese doctor who sounded the alarm over pills containing N-nitroso fenfluramine. "So long as people insist on being thin, dangerous diet drugs will persist." In other words: as long as Asians are dying to be thin, there's a good chance some of them will do so trying to reach their goal.