By Philippe Rivere
Le Monde DiplomatiqueJuly, 2001
The Aids war began in South Africa. At the Durban world conference in June last year African sufferers denounced "medical apartheid" and called for universal access to anti-viral drugs. Most Aids victims are in the South, the medicines in the North. In Pretoria, on 19 April, 39 pharmaceutical companies that were suing the South African government took stock of the damage done to their image by their defiant defence of their patents and suddenly dropped proceedings. Their aim had been to show that South Africa's laws, designed to ensure an affordable supply of drugs to the country, contravened the Trips (trade-related aspects of intellectual property rights) agreements negotiated under the auspices of the World Trade Organisation (WTO).
This about-turn would have been a fine victory. But the South African government then claimed it could not afford a large-scale programme of medical care for Aids victims. "Anti-retrovirals are still expensive," explained health department spokeswoman Jo-Anne Collinge (1). Dr Bernard Pécoul of Médecins sans frontií¨res (MSF) condemns this attitude. "In the Cape shantytown where 3m people live, a clinic set up by various organisations has been offering a programme of prevention and screening for 18 months, which also allows opportunistic infections to be treated. In stark contrast to what the government says, we've been offering antiretrovirals since early May."
The donations and price cuts announced by the laboratories and described by French health minister Bernard Kouchner as tremendous sacrifices (2) are, however, far from sufficient. Paying for treatment will require international mobilisation on a new scale, to be headed up by United Nations secretary-general Kofi Annan. After four Security Council meetings devoted to the pandemic, he committed himself personally to setting up a global fund to fight Aids, tuberculosis and malaria.
Annan's initiative (3) follows a proposal from a group of researchers and international experts gathered around economist Jeffrey Sachs at Harvard University, Boston. Noting the medical and moral failure of the international organisations in regard to Aids, they issued "a consensus statement on anti-viral treatments for Aids in poor countries" on 4 April that was widely reported in the international press (4).
Declarations of war
The Harvard document begins by arguing in favour of antiretroviral therapy: despite its success in wealthy countries, it "remains largely inaccessible in the world's poorest countries, where interventions have focused almost exclusively on prevention. With soaring death rates from HIV/Aids in low-income countries, both the prevention of transmission of the virus and the treatment of those already infected must be global public health priorities."
The document refutes past objections such as "poor countries lack the adequate medical infrastructure to provide Aids treatment safely and effectively." It responds that some of the assistance provided will go to improving health care structures. Moreover, according to Dr Pécoul, experience in the Cape shantytown shows that, "unlike the white elephants proposed as pilot schemes by UNAids, quality treatment can be provided with modest resources."
A second objection was that "difficulties with adherence to complicated medication regimens would promote and spread drug resistance". Andrew Natsios of USAid, America's largest international development agency, goes so far as to say that many Africans "have never seen a clock or watch in their entire lives" and cannot be expected to take drugs at set hours of the day (5). If that is the case, why not also deny treatment to illiterate people in the North? This argument overlooks the fact that only a tiny minority of patients will be involved in such rigid drug regimens, those for whom treatments of first resort are not or have ceased to be effective.
The third objection was that paying for treatment would siphon resources away from prevention. But, the Harvard researchers stress, "appropriate treatment can not only prevent infected individuals from succumbing to life-threatening illness from Aids, but may play a major role in prevention both by reducing the viral load of those under treatment and by encouraging greater participation in prevention programmes."
Targets have been proposed: 1m people undergoing treatment in three years' time (compared with 10,000 today). In its fifth year, the full programme, prevention and treatment combined, would benefit 3m people and cost $6.3bn.
Access to drugs has suddenly become a viable proposition in international circles. In Pretoria the pharmaceutical companies are conceding defeat. Kofi Annan is looking to spend $7-10bn every year, which will come from governments, corporations and charitable foundations (6). Things are at last moving, hope returning.
But the small initial contribution announced by the United States in May ($200m, one tenth of the expected amount) has cast a shadow. And the conference held in Geneva on 4 June felt like a calling to order. The Global Fund, born of the need to finance access to treatment, seems to be turning its back on it, again focusing international solidarity on prevention alone. Dr David Nabarro, executive director at the office of Gro Harlem Brundtland, director-general of the World Health Organisation (WHO), said there had been "an extraordinary degree of convergence" among delegates. The outcome of the debate was that victims will receive "a limited and carefully targeted amount of drug treatment" (7).
Sachs believes this "drift of the Global Fund away from a balanced prevention-and-treatment strategy to a prevention-and-no-treatment focus would be a disaster. Prevention and treatment are an inseparable combination. The shocking underfunding of the effort so far can be no excuse for abandoning the cause of treatment. At least $7-10bn a year are needed for a serious effort. The underfunding of disease control remains one of the greatest acts of moral irresponsibility and political shortsightedness in the world today" (8).
What good has come of these declarations of war by top international figures? "No war in the world is more important," General Colin Powell intoned during his visit to Kenya at the end of May. "I am the secretary of state of the United States of America, not the secretary of health, so why would I pay this kind of attention to this sort of an issue? This is more than a health issue. This is a social issue. This is a political issue. This is an economic issue. This is an issue of poverty" (9).
Deal and counter-deal
The US National Security Council had previously identified the Aids epidemic as one of the greatest long-term threats to world stability. Apart from the health risk, the anticipated population imbalances will have drastic consequences beyond the borders of the countries concerned. What will become of a country where half the adult population is dying? What about the 13.2m Aids orphans?
But there was also an important legal issue that drove the new US administration to look at the matter again. President George W Bush's trade representative, Robert Zoellick, sees the controversy over access to drugs as an important test of the administration's broader drive to increase the adoption of free-trade principles in the US and around the world. He has voiced concern that a backlash is building against the drug industry for aggressively asserting its patent rights in the face of a monumental health crisis. He says: "The hostility that generates could put at risk the whole intellectual property rights system" (10).
A highly restrictive reading of the international agreements on industrial property has the effect of prohibiting the countries of the South from producing generic drugs; it also prevents the poorest of them from importing generics produced elsewhere at the lowest cost. But this interpretation is challenged by many organisations, including MSF, South Africa's Treatment Access Campaign and Act Up. They are lobbying governments, international organisations and in the streets for wider use of compulsory licences and "parallel imports". The Trips agreement allows both these methods to be used in the event of a health emergency, for example.
Early this year the backlash occurred. Arraigned before the WTO by the US, Brazil mounted a forceful challenge against the financial burden of patents for its policy of making anti-Aids drugs available free of charge. On 25 June the US withdrew its complaint in exchange for a promise of talks before any compulsory licence was granted in an American patent. Convergence is emerging in international forums between Brazil, India, Thailand and South Africa. France is timidly putting forward proposals. "We must explore other avenues, like producing new drugs in the developing countries themselves," President Jacques Chirac told the Durban conference on 9 July last year. Prime Minister Lionel Jospin took up the same point during a visit to South Africa this June. And the European communities are trying to take better account of public health imperatives in their interpretation of the Trips agreements (communication of 11 June 2001).
The Indian firm Cipla's offer to MSF to provide a cocktail of antiretrovirals for less than $350 a year (compared to the big boys' $10,000) resounded like a thunderbolt. Suddenly, the emergence in the South of very low cost generics producers seems credible.
James Love, coordinator of the Consumer Project on Technology in Washington and kingpin of the Cipla offer, stresses: "The success in the developing world of the southern producers is quite important. Otherwise there is no real leverage. It is important not to link use of the global fund to purchases from European and US producers, but rather, to permit competition and buy from the firms with the best price that have acceptable quality. Sachs has been terrible on this, urging purchases from big pharma exclusively."
Is that why the Harvard mechanism found favour with the Bush administration, the European Commission, the WHO experts, UNAids, the Bill and Melinda Gates Foundation and the pharmaceutical industry? It offered an answer to "medical apartheid" without dropping the guard on patents.
And yet, following Cipla, a lot of generics manufacturers have come on the scene, making treatments available for $200 a year. The Harvard formula would supply them for around $1000. "It would be extremely dangerous for the Global Fund to centre around this deal between the pharmaceutical companies and the American administration," says Dr Pécoul. "An open reading of Article 30 of the Trips agreements would in fact allow the fund to purchase from the generics manufacturers. The total costs of drugs for 5m patients would then fall from $5bn to $1bn. That would resolve the prevention-treatment dilemma from the outset and release funds for infrastructure and patient follow-up."
In 1955 Dr Jonas Salk, creator of the first polio vaccine, was interviewed on television. When asked who the patent belonged to, he said: "Well, the people, I would say. There is no patent. Can you patent the sun?" At the end of his life Salk was devoting most of his work to the search for an Aids vaccine. Will his successors manage to shed a ray of sunshine in this present darkness?
(1) Financial Times, London, 5 June 2001.
(2) France 2 television channel, 31 May 2001. The minister appears unaware that as a result of tax deductions a donation actually earns the generous manufacturer 25% of the drug's list price - and that the US taxpayer could buy between two and 10 times as much from the generics manufacturers (source: MSF).
(3) The only precedent, with disappointing results, is the International Therapeutics Solidarity Fund (FSTI) launched by Kouchner in 1999. Now back in the government, he has just launched a European hospital cooperation initiative.
(4) http://aids.harvard.edu/
(5) John Donnelly, "Prevention urged in Aids fight", Boston Globe, 7 June 2001.
(6) These figures may seem high, but if the EU were to fund the operation on its own, it would amount to around $30 per inhabitant per year.
(7) Financial Times, 5 June 2001.
(8) Email, 5 June 2001, distributed on the pharm-policy list
(9) Karl Vick, "General Powell's War: Aids in Africa", International Herald Tribune, Paris, 29 May 2001.
(10) Paul Blustein, "US Trade Envoy Signals a New Approach to Tough Issues", International Herald Tribune, 14 March 2001.
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