Iran: encircled and under pressure *
Iraq: the Shia contenders *
Israel: a contemporary ghetto *
US: a pro-Israel system *
US: the pro-Sharon thinktank
Watch and tell
Paraguay: no real democracy *
Mexico, devourer of migrants
Haiti: short and bitter lives
Deprivation is also a symptom
Hong Kong: prospects dim *
Spain: anti-terrorism begins at home *
US: feminism lite *
Islam's rebel women *
Court in session *
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DRUGS SHOULD BE A COMMON GOOD
Sars epidemic this spring affected the world economy very quickly and
was therefore fought publicly and urgently. This does not happen with
the millions of annual deaths caused by ordinary yet preventable
diseases. We live in a world where the diseases may be shared, but the
remedies remain the private properties of wealthy nations and selfish
By GERMAN VELASQUEZ *
cost of pharmaceutical drugs is already a desperate problem for
developing countries, but during the next two decades the rest of the
world is likely to be affected. People in industrialised countries have
become used over the past half-century to automatic and free access to
the drugs they need. But that right could disappear.
We do not know how far the health systems of industrialised countries
can continue to meet the rising drugs bill, considering the therapies
linked to ageing populations, the new drugs to treat cardiovascular
diseases or cancer, or the treatments that will be developed and
patented on the basis of research into the human genome, even though
this research is publicly funded (1).
the United States experts on public programmes for provision of care to
the elderly (Medicare) and the poor (Medicaid) estimate that national
expenditure on healthcare will increase from $1,400bn in 2001 to
$2,800bn in 2011 (2). During that 10 years expenditure on drugs will
triple, reaching $414bn in 2011. Private insurers will have to choose
between reducing benefits or increasing contributions. The gap will
widen between people able to finance their own health- care and those
who have reduced cover.
European countries are already devoting a higher percentage of their
health spending to drugs than the US, where the figure is 10%. In
France the figure is 17% (3), in Belgium 16.3%, in Greece 17.1% and in
Germany 12.8%. The same trend can be seen in all wealthy countries: in
Canada drugs cost 15.2% of the health budget in 2000 compared with
11.4% only 10 years earlier (4). The pattern is the same in Japan.
the World Trade Organisation (WTO) was set up in 1995, the cost of
drugs has been increasingly influenced by Trips, a commercial agreement
on trade-related aspects of intellectual property rights. But it took
the health sector three years to realise this; the World Health
Organisation (WHO) then published a report citing the agreement's
possible effects on access to drugs (5). That report and the concerns
of many developing countries were soon backed by awareness campaigns
run by Médecins sans frontières (MSF), Oxfam and others.
in 2000, 39 drug companies took the South African government to court
to challenge the legislation, based on WHO recommendations, there were
mass public protests. After an intense international campaign backing
the South African government - especially the work of the Treatment
Action Campaign (6) - the issue finally arrived before the WTO on 20
June 2001, as a result of an initiative by a group of African
countries. After long discussions the Doha Declaration was drawn up in
November 2001. Under its terms, WTO members confirm that Trips "can and
should be interpreted and implemented in a manner supportive of WTO
members' rights to protect public health and, in particular, to promote
access to medicines for all".
logic behind the system - if it is logical - is that generalising the
application of patents (of a minimum duration of 20 years) under Trips
is essential to allow private drug companies to continue their
research. The argument is that research is expensive but will be funded
through patents; but by guaranteeing a monopoly through patents, they
enable the drug companies to keep their prices high. Yet those high
prices prevent most people who need new products from getting them.
Research and development of drugs must continue, but it is vital to use
those drugs to save lives as soon as they have been developed, not 20
years later. (Unless the idea is to perpetuate the current situation,
where millions die because they cannot get drugs that already exist.)
Research and development is mostly done by the private sector, and
depends on the potential market for the product, not the health needs
of the poorest. Over the past 20 years, there has been almost no
research into diseases that afflict millions in developing countries,
including Chagas disease, Leishmaniasis, Schistosomiasis or sleeping
seemed as if an impending Aids catastrophe might provoke action, but no
headway has been made on access to drugs: it is as if we had learnt
nothing since the start of the epidemic. In 1986 WHO director Halfdan
Mahler acknowledged that almost four years had been lost because he had
failed to realise the gravity of the situation. As a result of
political gamesmanship and intrigue, Mahler's successor, Dr Hiroshi
Nakajima, was forced to dismantle the Global Programme on Aids set up
by Jonathan Mann, and all that had been achieved was "thrown out of the
window", according to a participant. Later Dr Peter Piot, director of
Unaids, the United Nations programme to combat Aids, confirmed that
another four or five years were lost when responsibility was shifted
from the WHO to Unaids.
almost 10 years after the first antiretro viral drugs came on to the
market, 99% of those able to access them live in developed countries.
In Doha, in November 2001, the WTO ministerial meeting gave its Trips
council a year to find a solution to "paragraph 6": to look into how
countries with insufficient drugs manufacturing capacities can use
compulsory licensing - the legal mechanisms in the agreement that make
it possible to circumvent the monopoly conferred by certain patents.
was no positive outcome to this investigation except to confirm that
the negotiators had lost any sense of the seriousness of the issue (7).
Paragraph 6 was not the answer to the ills of humanity; the problem of
costs is not the only problem. Other crucial elements include a
suitable selection of drugs authorised for sale in particular
countries; the existence of funding mechanisms; and the maintenance and
development of reliable health care systems and infrastructures. But
the issue of costs must first be resolved.
most important agreement of recent years to reduce the cost of
antiretrovirals in developing countries, the accelerating access
initiative, has made it possible to cut the annual cost per patient
from $12,000 in 2000 to $420 in 2003. It was launched in May 2000 by
Unaids, in partnership with several UN agencies and five drug companies
(Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Merck
& Co and Hoffmann-La Roche), but there is little to show for it.
Over three years, 80 countries expressed an interest; 39 have
developed action plans, but less than half have finally concluded
agreements with the companies, and under 1% of the patients in those
countries are receiving antiretroviral treatments: a total of 27,000
people benefit in Africa where 30 million people are HIV-positive (8).
up in April 2001 at the initiative of UN Secretary General Kofi Annan,
the global fund to fight Aids, tuberculosis and malaria has so far got
only 20% of required funding. In China, where the authorities estimate
that a million citizens are HIV-positive, a Western drug company has
offered, very publicly, free antiretrovirals for eight years. But only
200 patients will benefit. Even if all these initiatives could be made
adequate, they do not represent a long-term solution for developing or
developed countries. It is not feasible for the cost of drugs to
continue to rise exponentially, outstripping the economy.
hope the international Aids vaccine initiative, on which drug
companies, including the main private laboratories, public laboratories
and NGOs, are collaborating, soon produces results. The vaccine must be
made available to as many sufferers as possible, as quickly as possible
and at the lowest possible cost. But that can only happen if a solution
is found outside the current system of patents.
latest novel by Antonio Gala begins: "To whom does a letter belong? To
the sender or the recipient - or to the postman, at least when it is in
transit?" (9). One in three people in the world has no regular access
to drugs, and three out of four live in developing countries that
account for only 8% of global drugs sales. But the technical and
financial capacity to manufacture those drugs exists. Of the 10 million
children under five who die every year, four out of five could be saved
if they had access to essential drugs. The only positive aspect of the
failure of the Doha process has been an end to the legal quibbling over
international rules on trade, which has had the result of refocusing
the debate at an ethical level. What matters now is Gala's question: to
whom does a vital drug belong: the person who invented it, the patient
who needs it or the intermediary who buys and resells it?
two years, the Doha process set health against trade. The debate
centred on which came first and what exceptions should be made. It is
now realised that the right to health and the expansion of trade are
different issues. Promoting the right to health involves guaranteeing
the right to benefit from technological advances, and a recognition of
the supreme value of human dignity, principles recognised in many
international treaties and accepted by most states. The rules of trade
should contribute to the wellbeing of society. They cannot be used to
prevent much of society benefiting from the wealth that trade is meant
to a healthcare system, perceived as a fundamental right, must be
actively protected by public authorities. If they fail in that, we will
be accepting a sick society. After Doha, it is clear that if drugs are
considered as goods, health will remain an extension of the market,with
remedies and treatments available only to those with enough purchasing
drugs must be considered a global public good. That approach will
require significant changes, and the international community and public
authorities will have to find answers. Can a global public good be
patentable, so that a few have a monopoly over it to the disadvantage
of millions? Can the drug that makes it possible to exercise a
fundamental right be bound by rules that thwart access for 20 years?
How can research and development of new drugs be organised to ensure
that they are immediately accessible to all who need them? How can the
pharmaceutical industry be reoriented towards goals compatible with
improving health and the quality of life rather than economic expansion
and profit? How can tomorrow's society secure the manufacture of those
drugs at global level? We shall have to answer those questions over the
next decade, and we need to set them out clearly now.
is a complex problem involving players, interests and views very
different in nature and origin, and requires an integrated,
multidisciplinary approach. We need to find a way of reconciling the
international law in force with the different domestic legal systems,
and of ensuring that trade respects human rights. There is no immediate
and sustainable answer. We need to ensure the mistakes over Aids, and
the wasted years, will not be repeated.
like MSF, claim that the WHO, "as the only legally mandated
international governmental agency responsible for global health, should
work toward establishing an essential research and development agenda"
for drugs of the future (10). Whether it, or an international public
consortium, takes the lead, the agenda for research will have to serve
real needs and not market opportunities. To fund this, many states will
be able to provide contributions and investments, and Dr James Orbinski
(awarded the Nobel Peace Prize in 1999 on behalf of MSF) has suggested
a tax on international drugs sales to fund a public body responsible
for research (11). Part of national taxes on tobacco could be
ringfenced for an international fund, which would enable developing
countries to take part and ensure research into tropical diseases.
of attacking drug companies, we should try to identify needs and create
solutions that will enable scientists to research, industrialists to
manufacture and patients to be treated on a sustainable basis. If we do
nothing, we will face more serious crises even than the Aids pandemic,
and it will be no use claiming that we could not have predicted this.
Germán Velásquez is coordinator of the Drug Action Program at the WHO,
Geneva. The opinions expressed in this article are his own personal
(1) See John Sulston, "Heritage of humanity", Le Monde diplomatique, English language edition, December 2002.
(2) Stephen Heffler, Sheila Smith, Greg Won and others, "Health Spending Projections for 2001-2011. The Latest Outlook ", Health Affairs, Bethesda, March-April 2002.
(3) The French government announced a cut in the level of reimbursement for 617 drugs, Le Monde, 23 April 2003.
(4) EcoHealth OECD 2002, Organisation for Economic Cooperation and Development, Paris, 2003.
(5) Germán Velásquez and Pascale Boulet, "Globalisation and access to drugs: Implications of the WTO/TRIPS Agreement", World Health Organisation, Geneva, 1999.
(6) See Philippe Rivière, "South Africa's Aids apartheid", Le Monde diplomatique, English language edition, August 2002.
(7) See James Love, "Prescription for pain", Le Monde diplomatique, English language edition, March 2003.
(8) Taken from a forthcoming study that the WHO commissioned from Cheri Grace, Geneva.
(9) Antonio Gala, El Dueño de la herida, Planeta, Madrid, 2003.
(10) "Fatal Imbalance. The Crisis in Research and Development for Drugs for Neglected Diseases", Médecins sans frontières, Geneva, September 2001.
(11) Op cit.
Translated by Julie Stoker
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