Copyright 1999 The Washington Post
The Washington
Post
View Related Topics
December 4, 1999, Saturday, Final Edition
SECTION: A SECTION; Pg. A01
LENGTH: 1696 words
HEADLINE:
African AIDS Victims Losers of a Drug War; U.S. Policy Keeps
Prices Prohibitive
BYLINE: Karl Vick, Washington Post
Foreign Service
DATELINE: NAIROBI
BODY:
The body of Josphat
Nyakundi features a concise history of the century's three great plagues and the
world's responses to them.
Just below his left shoulder is the faint
circle left by a smallpox inoculation. In the recesses of his memory lingers the
taste of the sugar cube placed on his tongue with the drops that would protect
him against polio.
And swimming in Nyakundi's spinal fluid--inflaming
the lining of his brain, keeping him braced in his Nairobi hospital bed against
the flashing pain that comes with the slightest movement--are rampaging cells of
cryptococcal meningitis, an opportunistic infection that means he has
AIDS.
But neither Nyakundi nor the other 22 million
Africans infected with HIV, the virus that causes AIDS, can get
the medicine they need. Medical advances that stalled the AIDS
epidemic in the West are not reaching Africa largely because
these countries and their citizens face a stark choice: buy drugs at their
market price, far beyond the means of all but a few Africans, or risk trade
sanctions by the United States for buying or developing generic drugs at lower
prices.
Critics have accused U.S. trade policy of placing the profits of
drug companies above public health, moving to block poor countries from
manufacturing the drugs themselves, despite international laws that permit
countries to do so when facing a public health emergency.
Responding to
this criticism, President Clinton, speaking to members of the World Trade
Organization on Wednesday, announced that the government would show
"flexibility" in granting countries the right on a case-by-case basis to obtain
cheaper drugs during a health emergency.
But the government has yet to
draw up the criteria for judging a country's claim, and it is not clear what
impact the change may have. For now, even palliative treatments like
fluconazole, which would give Nyakundi the strength to make his way home to die,
remain out of reach.
"Developing countries say: 'You're asking us to
comply with rules and regulations. These are our obligations. But what are our
rights under globalization?' " said Joseph Saba, who headed the U.N. program
testing advanced HIV treatments in Africa.
Access to
drugs is more than a life-and-death issue on the continent that accounts for
two-thirds of the world's HIV infections. With AIDS in
Africa transmitted primarily through heterosexual sex, the
disease already has hurt economic development. Some countries stand to lose a
quarter of their populations to AIDS, which one observer noted
"is wiping out the middle class as quickly as it's created."
In Nairobi,
where an estimated 14 percent of the Kenyan capital's 3 million inhabitants are
infected, the leading public hospital refuses to admit patients with
AIDS-related meningitis unless they show up with the drug to
treat it. The hospital has no supply of its own.
Clinton administration
officials, in defense of the policy, have emphasized the importance of
protecting patent rights in a pharmaceutical industry that invests heavily in
research.
It costs about $ 500 million to bring a drug from idea to
market, said Shannon S.S. Herzfeld, senior vice president of international
affairs at Pharmaceutical Research and Manufacturers of America, a drug-industry
trade group. "For every 15,000 compounds that you look at, three become
medicines," said Herzfeld. "Of those three, one makes a profit."
But in
the name of protecting patents overseas, he said, the drug companies may have
pushed so hard that they risk looking like bullies.
Developing countries
say they are only beginning to appreciate the public health consequences of
joining the World Trade Organization, which many have done in the 1990s. Before
joining the WTO, they could avoid the high retail prices charged by
pharmaceutical companies, which historically have viewed their primary market as
the Western nations where the price of drugs is typically covered by insurance.
If those prices were beyond the means of places like
Africa, which accounts for just 1 percent of drug industry
sales, poor countries were free to shop for generic equivalents sold for a
fraction of the price by nations that did not observe international patent laws.
India, for example, makes a $ 2 version of fluconazole, the drug that
the 42-year-old Nyakundi would take every day for his meningitis if his family
could afford the $ 17 retail price charged by Pfizer Inc., which holds the
patent.
But in joining the WTO, a country agrees to honor foreign
patents and acknowledges it would face sanctions for dealing in generics
produced before a patent expires. The thrust of the patent agreement, known by
the acronym TRIPS, requires every country to pay full retail price. However, to
countries facing a health emergency, the agreement held out a loophole: A
desperate country could make (or commission) the drugs itself, provided it paid
a negotiated royalty to the patent holder.
This do-it-yourself
alternative, called "compulsory licensing," was intended as a
lifeline. But in practice, any country reaching for it has been handcuffed by
U.S. trade negotiators.
U.S. officials have explained that, although the
United States signed the TRIPS agreement, they have regarded its provisions as a
minimum standard, and the office of the U.S. Trade Representative has urged that
countries follow a higher standard--payment of full licensing fees. In
negotiations with individual countries, the trade representative can threaten
the loss of U.S. trade if the nation goes forward with compulsory
licensing.
The threat worked against Thailand last year: It
dropped plans to produce the anti-AIDS drug ddI after U.S.
officials threatened sanctions on key Thai exports.
And last year when
South Africa, where one in 10 people is HIV positive, passed a
law permitting the government to make drugs it deemed too expensive, U.S. Trade
Representative Charlene Barshefsky reacted swiftly. At the urging of the U.S.
pharmaceutical lobby, South Africa was placed on the "301 watch
list," which is seen as a prelude to trade sanctions.
South
Africa's case was buttressed when activists from the advocacy
group ACT-UP began pushing the cause and found a target in the presidential
campaign of Vice President Gore. After protesters repeatedly disrupted campaign
appearances, Gore met privately with South African President Thabo Mbeki. On
Sept. 17, the United States removed South Africa from the
sanction watch list.
"My understanding is that any country can do what
we said we're going to do," said Ian Roberts, an adviser to the South African
health minister.
The U.S. policy has been attacked by humanitarian
organizations, led by Doctors Without Borders, the Paris-based
aid group that won the Nobel Peace Prize last month. Its
campaign to broaden access to "essential medicines" recently gained a
significant ally in the World Bank, which under President James D. Wolfensohn
has put new emphasis on health care in the poor and emerging countries it is
mandated to help.
Ok Pannenborg, the World Bank official who oversees
health investments in Africa and the bank's purchase of up to $
800 million a year in pharmaceuticals, said the drug-price structure "shows an
increasing disconnect with the needs of the majority of the people in the
world."
Calling the South Africa outcome "a symptom
that times are changing," Pannenborg said the World Bank "is comfortable" with
compulsory licensing and a second practice permitted under
TRIPS, known as "parallel importing," or shopping abroad for the best retail
price on patented drugs.
By supporting cheaper alternatives, Pannenborg
said the pharmaceutical industry might be nudged toward a "tiered pricing"
arrangement in which the West would pay one price for a drug, and developing
countries another.
"I believe with all my heart that a way can be found
to make money through numbers," said Kahama Rogo, president of the Kenya Medical
Association. "It will not be a big margin, but it will be a profit."
Even if the drugs were available, African medical professionals
acknowledge that most African countries lack the expertise and facilities to
monitor the most sophisticated drugs, such as protease inhibitors and other
ingredients in the "cocktail" that has extended the lives of
AIDS patients in the West. But they say that making the drugs
affordable would provide a strong incentive.
A U.N. pilot project is
demonstrating it can be done. At six clinics in Uganda, HIV patients are taking
combinations of two or three drugs for $ 220 to $ 673 a month, less than half of
what Western patients pay, thanks to discounting arranged by the United Nations.
The therapy is proving roughly as effective as in the West, yet still
remains beyond the financial reach of all but about 800 Ugandans. Even if the
price fell to $ 100 a month, "cocktail therapy" would remain beyond the means of
most people, said program coordinator Dorothy Ochola.
Subsidies from
Western governments and aid groups might eventually make up the
difference, she said. But for now, most patients focus instead on getting the
drugs that help them manage the opportunistic infections that cause 80 percent
of AIDS deaths.
Doctors say that is where high drug
prices hit hardest in Africa. The meningitis that freezes
Josphat Nyakundi to his bed is the third-leading cause of death in Kenya, behind
two other AIDS-related ailments--tuberculosis and diarrhea. He
took fluconazole until his family ran out of money, then landed back in the
hospital while waiting for a friend who works for Kenya Airways to return from
abroad, where many drugs are cheaper.
Christopher Ouma, the doctor who
admitted him, said that at a public hospital where half the patients cannot pay
the $ 2.60 daily bed charge, he usually does not even tell patients' families
the drug exists.
"This is where the doctor's role goes from caregiver to
undertaker," said Ouma. "You talk to them about the cheapest method of burial.
Telling them about the drugs is always kind of a cruel joke."
Staff
writers David Brown and John Burgess in Washington contributed to this report.
LOAD-DATE: December 04, 1999
