MSF/Doctors Without Borders is
an international humanitarian medical organization working around the world in
over 80 countries, assisting the most vulnerable. Our experience with HIV/AIDS
started in the late 80’s.For a decade, we focused exclusively on prevention
programs, constrained by the unavailability of treatment options. In 1997 we were running 30 projects, in
majority aimed at prevention, only 4 countries with a curative component. This
was the public health thing to do, given the need to slow down the epidemic and
to accommodate the constraint of the unreasonable costs of curative options. But
it become progressively an untenable position, humanly, socially, and in medical
ethics terms.
We know now that we must
recognize the limits of public health reasoning, in particular for this
pathology. We have patients before us and their numbers are crying out to us.
These are patients who do not have access to effective treatments established
here or in Europe. The logic of
cost-effectiveness is too often is put first in the fight against Aids in
developing countries – placing
emphasis on prevention rather than curative care. But hospital beds in sub-Saharan Africa
are filled with patients considered incurable for whom treatments nevertheless
exist! We support the arguments of cost effectiveness when it is a question of
proving that a measles vaccination is ultimately less expensive than the
response to an epidemic. But in the
case of AIDS we have to understand that this type of reasoning is simply
inhuman, especially when it reinforces the total indifference of the rich
countries with respect to the 30 million people currently infected in the
economically disadvantaged world.
We are now focusing on the
curative challenge in East and Southern Africa, South East Asia, and Central
America. And rather than accept the constraints, we’re challenging them.
The issue of
infrastructure:
Many, and especially the
industry, argue that the worst affected countries do not have the infrastructure
or medical expertise to adequately administer the complex regimen of HIV/AIDs
drugs. This is true… to
some extent. Our response to this
issue is several folds.
1.
Even without ARVT, there
is a lot of work to be done around the treatment of opportunistic diseases of
Aids, such as cryptococcal meningitis, a common systemic fungal infection
that can be deadly to people whose immune systems have been crippled by HIV. The
fungal infection can kill within a month or so, but daily Fluconazole/Diflucan
treatments can keep the fungal infection at bay. And there’s plenty of room for
improvement as Pfizer has priced the drug worldwide beyond the reach of most
patients. Many people are
needlessly dying in hospital beds in sub-Saharan Africa or poor parts of Asia,
when simple drugs are available that would cure their ailment, prevent relapse,
increase their comfort, and restore their capacities.
2.
ARVT is
more complex. But we take issue
with the standard denial of care arguing the complexity of ARVT and the lack of
infrastructures. While this may be true in some Sub-Saharan countries, it is not
true of all developing countries.
Public health systems in economies in transition such as Thailand have
the capacity and the will to deal with complex regimen. The problem is more that
prohibitive pricing and strict enforcement of trade and patent laws have made it
virtually impossible for governments in developing countries to cheaply produce
or grant licenses for the generic production of the most basic anti-retroviral
medicine.
3.
And for
those countries who do not have the lab and health infrastructures required by
the most complex regimen of ARV, what are we supposed to do? Abandon the patients to their fate? We cannot accept that, and must look
again and again for a solution to their plight.
To address the crisis in access to critical drugs for communicable
diseases including HIV/AIDS but also such neglected diseases as Sleeping
Sickness, Kala Azar and others, MSF has launched the Access to Essential
Medicines Campaign.
The first issue is ensuring
there is adequate research efforts around neglected diseases. Research
for such communicable diseases as tuberculosis and malaria has ground to a halt.
Between 1975 and 1997 out of 1,223 new drugs developed only 13 (1%) were to
treat tropical diseases. Only four of these were the result of human R&D
activities of the pharmaceutical industry.
Even when effective treatments exist, as they do for diseases like
multidrug-resistant tuberculosis and many AIDS-related infections, when
lifesaving medicines are available, they are simply too expensive, due in large
part to patent protection and pricing strategies aligning on the wealthiest
markets. A lucrative market for lifesaving drugs addressing infectious diseases
simply does not exist in the developing world despite the fact that more than 90
percent of all deaths and suffering from infectious diseases occurs
there.
In
summary, our patients are dying, not because their diseases are incurable, but
because as consumers, they do not provide a viable market for pharmaceutical
products. Clearly, market forces alone are not enough to address the need for
affordable medicines or to stimulate research and development for neglected
diseases.
Our
intuition was that progress would come from a confluence of efforts: public
mobilization, public-private partnerships and regulation. Two years ago, we initiated a campaign
to develop “Access to Essential
Medicine”, partnering with activists groups, academics, philanthropic
institutions, corporate interest groups (drug manufacturers and associations),
the media and governmental institutions such as the World Bank to stimulate
development and appropriate pricing of drugs for the developing world. Together
we must ensure that trade of essential medicines is regulated in the interest of
public health. We are not questioning the importance of patents in stimulating
research and development, but rather we are insisting that a balance be found
between protecting intellectual property and ensuring individuals’ access to
medicines. And we are seeking to
provide an impetus for both policy development and practical solutions to
specific access problems.
Our campaign is developed around three key directions:
-
Stimulating research
-
Addressing the access deficit
-
Humanizing trade agreements
Briefly,
Stimulating research:
The reason for the research gap is clear: drugs for tropical diseases are
not profitable for drug companies. The pharmaceutical industry is focusing
investment to meet the needs of people living in wealthy countries and
increasingly funds research devoted to lifestyle diseases.
Our campaign seeks to communicate the urgent need for new treatments for
communicable diseases ignored by industry. We are challenging the drug
industry’s attitude, at most charitable (donations programs) but not yet
responsible, and we are inviting developed countries, international
organisations and non-governmental organisations to help fill the void.
Overcoming access barriers:
Many drugs are too expensive for those in the developing world to buy.
Other life-saving treatments are not available because manufacturers have
abandoned production in favour of making more profitable drugs for customers in
wealthy countries.
This second effort of our campaign is attempting to increase
accessibility to specific treatments.
To achieve this, we
·
Conduct global
price analyses of selected essential drugs that are too expensive. This pricing
information can be used to negotiate better prices and demonstrate price
differences from different manufacturers around the world.
· Study
the quality of all sources of select expensive essential drugs to identify
high-quality low-cost producers.
· Support
health ministries that are working to increase access to essential drugs.
· Work
with the WHO and industry to restart the manufacture of abandoned drugs such as
DFMO for sleeping sickness.
Humanizing trade
agreements:
The emerging global trade system, which sets the rules for how products
are sold within and between countries, treats medicines like all other products.
This needs to change. The patenting of medicines confers a market monopoly to
pharmaceutical companies who often charge the same high price worldwide. The
result is that people in the developing world cannot afford treatments and die
from curable diseases.
Imagine if food prices were the same in Nairobi, Guatemala City and
Brussels. Would we accept that
people would die because they could not afford the price of food?
Our goal is to support the implementation of existing international trade
provisions that were designed to protect people’s access to essential goods such
as life-saving medicines.
Ž
Compulsory
licensing – the legal right (in certain circumstances) for companies to produce
patented medicines in exchange for a royalty payment to the patent holder.
Ž
Parallel imports –
the legal right to import patented drugs, when the drugs are sold more cheaply
in other countries.
To achieve the
above, we work closely with local partners, medical teams and associations,
organisations of people living with HIV-Aids such as South Africa’s Treatment
Action Campaign, the National
Thai Network of People Living with HIV/AIDS in Bangkok, HealthGap and ACT Up and
others here. We also work with
consumer activist groups such as the Thai Federation for Consumers and here with
Jamie’s Consumer Project on Technology.
We seek to actively
contribute to a civil society movement that will, if we are successful,
challenge the neglect of a major global health and equity issue.
We are also calling on
pharmaceutical companies to use sustainable mechanisms (thus other than charity)
to make life-saving drugs available to people in poor countries. This could be
done most effectively by lowering prices to affordable levels - through tiered
pricing - or by issuing voluntary licenses that would allow for the importation
or production of generic versions of treatments.
Some of our efforts focus on inviting drug makers to reduce the prices of
AIDS drugs or allow for the marketing of generic versions of the medicines in
poorer nations. The challenge ahead is daunting.
Pharmaceutical products responding to
dramatic public health crises should be looked at differently from other goods
and services. Health is not a
commodity; it is a human right.
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