Drug wars

Slashing the prices of AIDS drugs in Africa isn't going to make a difference -- but letting cheap generic drugs onto the market might ease the crisis

by Tom Witkowski

The plan for five international pharmaceutical companies to drop the prices of their AIDS drugs by up to 80 percent in some African countries should be good news for Malawi. Landlocked by Tanzania, Zambia, and Mozambique, the Pennsylvania-size country is home to about 10 million people who make, on average, $250 a year. That's enough for the average citizen to live on pretty comfortably -- unless he or she is HIV positive or has AIDS. The Malawi government estimates that about 10 percent of its population is afflicted with the deadly virus; the United Nations places the number even higher, at nearly 16 percent.

The cost of a typical AIDS cocktail, the combination of drugs that fights viral infections and extends the life expectancy of people with AIDS, is about $15,000 a year. Clearly, few people in poor African countries such as Malawi can afford that. That's why the pharmaceutical companies' May 11 announcement that they would work with the United Nations to lower the price of AIDS drugs was so welcome. The New York Times published an editorial shortly

after the announcement that listed the benefits of the lower prices: doctors and health-care officials will now learn how to administer these drugs, and more people will be encouraged to get tested for HIV. The Chicago Tribune also weighed in, calling the move a "watershed on several fronts."

But was it?

A closer look at the numbers puts the decision of the drug companies -- Boehringer Ingelheim of Germany, Hoffmann-La Roche of Switzerland, Glaxo Wellcome of England, and the US-based Merck and Co. and Bristol-Myers Squibb -- in a different light. An 80 percent drop in a $15,000 price tag is dramatic, but it still leaves the price of anti-retroviral treatments at $3000 a year -- or $250 a month, which, of course, is about what the average Malawi citizen makes in a year. In other words, cutting prices 80 percent still keeps AIDS drugs unaffordable for the majority of people in poor African countries. Nor does it answer any of the questions about how the drugs will be distributed, how people will be tested for HIV, or who will pay for the tests. The drug companies said they would announce their plans for purchasing, testing, and distribution this month at the International AIDS Conference, in South Africa. Not a word on the subject has been heard from the companies since May. The Phoenix contacted representatives of both US-based pharmaceutical companies for this story; neither returned calls.

So what's really going on? AIDS activists and international health-care experts charge that the pharmaceutical industry's promise of cheaper drugs is, at best, hollow. At worst, they say, it's a cynical public-relations ploy to distract attention from the lobbying efforts of pharmaceutical companies that are trying to block the supply of cheap, generic versions of their drugs to Africans infected with HIV. Making such generic drugs available would dramatically increase the number of people who get treatment, but it would also violate the patents of pharmaceutical companies. The price-reduction announcement, says one activist, was a "scam."

AN INTERNATIONAL treaty, Trade-Related Aspects of Intellectual Property Rights (TRIPS), protects patent rights of companies located in countries that are members of the World Trade Organization. TRIPS stipulates that patents must be respected for 20 years. But it also provides exceptions to patent protection, in which governments can grant companies the right to produce and sell cheap, generic versions of patented drugs. The practice, called compulsory licensing, is allowed in times of national emergency.

In the past year, the government of South Africa has been pushing hard for compulsory licensing of AIDS drugs. Pharmaceutical companies have been pushing just as hard to keep it from happening. In early 1999, the drug companies had the Clinton administration on their side. President Clinton threatened South Africa, which was pursuing cheaper generic AIDS drugs, with economic sanctions if its government did not stop. Vice-President Al Gore even went so far as to travel to South Africa in February 1999 to make the point in person.

Then, in June, Gore officially announced he was running for president. AIDS activists were present at the rally where he made this announcement; they yelled, unfurled banners, and threw around printed "blood money," embarrassing the Democratic candidate.

Soon afterward, the Clinton administration changed its tune. The president declared in April that the AIDS crisis in Africa is a threat to US national security. On May 10, he issued an executive order saying the United States will not impose economic sanctions if African countries violate patents in search of cheaper AIDS drugs. The very next day, the five pharmaceutical companies made their dramatic price-reduction announcement.

The timing of each development could be coincidence. Or it could be politics. Regardless, last week the UN issued a report on the global AIDS crisis stating that half of all 15-year-olds in Zimbabwe and South Africa will die from the disease. Last year four million people in sub-Saharan African countries were infected, the report said. In 16 African countries, more than 10 percent of adults now have the virus. Surely such a high rate of HIV infection meets the national-emergency standard of TRIPS.

But the pharmaceutical industry continues to lobby against any laws that would allow for compulsory licensing or parallel importing of cheaper generic drugs for developing countries. Further, AIDS activists charge that when generic drugs become available, the drug companies thwart their use by toying with the formulas of their own drugs and applying for new patents, thus sending the generic drugs back into the approval process.

Bristol-Myers Squibb, for instance, produces ddI, an AIDS anti-viral drug that, in order to work, must have a simple antacid as an ingredient. In Thailand, the company is continually changing the antacid used in order to get new patents, says Richard Jefferys, director of the
Access Project of the AIDS Treatment Data Network, in New York.

DRUG COMPANIES charge that the manufacture of generic drugs will not solve the sub-Saharan AIDS problem. They're right. Some of these countries don't even have access to clean water. Condom use is not as commonplace as it needs to be. The infrastructure and education that are part of more-successful AIDS treatments in Thailand and Brazil are practically nonexistent in African countries.

"It's too late to do much in Africa," says John Ziolkowski, whose Boston company, AIDS Care Initiative, helps Thailand and India acquire the drug compounds they need to manufacture generic AIDS drugs. "Unless we have a vaccine or a cure, these drugs are a drop in a bucket. There's not a level of infrastructure in place for the treatment that is required."

Even if his own dire assessment of the crisis in Africa is correct, Ziolkowski adds that's still no reason to deny people there access to drugs. "I do believe these governments and people do have a right to access these drugs if they choose. There's no reason not to make drugs accessible to anybody that wants them. It's providing people hope," he says.

One year ago a Malawian woman with AIDS made a statement to Congress asking for more access to drugs. Chatinkha Nkhoma has lived in Germany and the United States, and received her bachelor's degree in international relations from George Washington University in 1995. She was working in the Malawi foreign-affairs ministry when her illness was diagnosed. She is one of the relatively few Africans able to buy AIDS drugs.

"Please allow us to have access to the treatment drugs so we can raise our children a little longer and not leave them as orphans," she told Congress. "Every time I take these drugs, I cannot help but feel guilty, knowing that my brothers, sisters, mothers, fathers, daughters, sons, uncles, aunts, our children, tomorrow's leaders -- they are all dying, slowly and painfully, because they are too poor to afford them."

Nkhoma dismissed the argument that improper use of the drugs could result in resistant strains of the virus, or that African health-care workers do not know enough about the treatments to administer them. "To say we should be condemned to death is practicing the politics of genocide," Nkhoma said. "It is no secret that we are in need of many other things. But that is not a valid reason to allow millions of people to die because they are poor."

George Carter, a member of ACT UP New York, echoes Nkhoma's charges, though somewhat more cautiously. "The pharmaceutical association has basically been committing a form of genocide. What they're doing is specifically attacking countries who have a right to seek compulsory licensing," says Carter, who spoke at 1998's World AIDS Conference, in Geneva.

"When a group or individual commits an act they know the consequences of, which will be enormous hurt and pain . . . in my view this is genocide." Carter considers the drug companies' UN agreement "glib and sickening," although he acknowledges the validity in the argument that drugs should not be made more accessible without proper education.

SOME AIDS activists believe that drug companies are fighting the use of generic drugs in African countries because they fear those cheaper drugs will find their way into the US market. But that would never happen, says the Access Project's Jefferys.

"There's been generic versions of these drugs around in India for years now, and I don't think you bump into many people in the US that are on generic versions of 3TC from Cipla," Jefferys says, referring to the Indian manufacturer.

It's more likely that pharmaceutical companies are simply trying to protect what little profit they do get from the African market. The increased sales that will result from their decision to cut the prices of AIDS drugs in Africa will keep those profits from dwindling. The decision was just good public relations.

David Scondras, a former Boston city councilor who has become an expert on the AIDS crisis in Africa, calls the companies' price-cut decision "a con game." "It's absolutely outrageous," says Scondras, whom South African president Thabo Mbeki recently appointed to his presidential panel on HIV and AIDS. (Mbeki, incidentally, was the deputy president Gore visited in February of last year to lobby against a move toward compulsory licensing.)

The international organization Doctors Without Borders also expresses skepticism toward the drug companies' plan. "The fact that a serious discussion has begun among drug companies on dramatically reducing the price of AIDS drugs is a victory, but a small one, much like an elephant giving birth to a mouse," says physician Bernard Pecoul, director of Doctors Without Borders' Access to Essential Medicines Campaign.

It would have been much better if the drug companies had announced May 11 that they would stop blocking compulsory licensing of AIDS drugs in Africa and start helping African countries build their own pharmaceutical-manufacturing plants. Building these plants would not only make cheaper drugs available, but also create jobs and get more money into the people's hands -- thus, for the long-term visionary, creating a new potential market for other drugs. Of course, that's not likely to happen.

"By permitting companies to manufacture cheap copies of products, you don't take anything away from companies, because they don't have a market there," says James Love, of the Washington, DC-based Consumer Project on Technology. "What you do is stop people from dying."

Tom Witkowski can be reached at tomwitkows@aol.com.