The Pharmaceutical Journal
Vol 270 No 7250 p717
24 May 2003

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Villains or heroes? Are profits growing at the expense of the developing world?

By Karen Thomas

The Channel 4 documentary, "Dying for drugs", accurately portrayed the impact of pharmaceutical company policies on developing countries. In addition, it was supported by many respected figures and organisations that have expert knowledge of the relationship between the pharmaceutical industry and access to essential drugs in developing countries. Based on knowledge and experience accrued over the past three years as a relief and development worker in under-developed countries, I repudiate the views expressed in The Journal's editorial of 3 May (p602) on the policy and practice of the industry in developing countries as misguided, and on the health needs of people there as outdated.

Although not the only factor, pricing of essential drugs is central to access. Pfizer announced profits of $4.7bn for the last quarter. GlaxoSmithKline announced similar profits last year. So should the pharmaceutical industry be entitled to protect such profits? At the World Trade Organization meeting in Doha in November 2001, 142 member countries declared that drugs should not be treated as usual patented commodities because of their direct impact on health. It was agreed that price and profit were not to be factors when considering the lives of millions of human beings. The Doha declaration permitted developing countries to use three exemptions to the Trade Related Aspects of Intellectual Property Rights (TRIPs) so that they could access cheap, quality drugs to combat public health emergencies such as HIV and AIDS, malaria and tuberculosis.

Influence on US government

Indeed, the one country that strenuously disagreed with the declaration was the United States, the same country that only months previously wanted to invoke exactly these exemptions so that it could issue a compulsory licence for the production of ciprofloxacin for use in its anthrax scare. Why does the US so strenuously deny to others that which it readily accepts itself? The industry comprises a major part of the US economy and contributes substantial funds to the US electoral campaigns, while many White House administrators are linked to the executive boards. So when Thailand and Brazil started to produce generic antiretroviral drugs for the huge number of HIV+ in their populations, they were threatened with trade embargoes and massive import tariffs on unrelated exports by the US government, the strings being pulled by the industry. Generics stimulate competition and without them pharmaceutical companies can impose high, monopolistic prices. Perhaps this is the reason for promoting the prescription and supply of generic products within our National Health Service. So, why is this acceptable for a country that has considerable wealth, but unacceptable for a country that could not afford even a few highly priced branded drugs? Do these double standards and manipulations have any moral difference to more blatant corruption? Do developing countries have "bad" debts because international markets are self-protecting and manipulated in favour of developed countries?

The validity of the argument that R&D costs justify high prices is still debated, largely because the debate continues over the actual figures attributed to the "huge" investment by the industry. An article in The Economist for 26 April 2003 states that divestment of profits towards R&D has remained at an average of 18 per cent for almost six years, despite the increased volume of profits over that time. Marketing has been the recipient of the industry's financial success, not R&D. In addition, the authors reject the argument that price controls are detrimental to innovation, even in the US market, largely because of differential pricing between nation states.

Indeed, the marketing pharmaceutical companies do not always incur major R&D costs due to substantial human and financial resources provided by national government agencies. This was a precipitating factor for the GSK pricing change of its ARVs. GSK was facing challenges from the California Public Employees Retirement System over the concern that drug pricing inhibits access by Americans and Africans. This group currently invests $1bn in GSK but it was questioning the price of zidovudine in particular, because it was originally developed without GSK investment. Since this group had already divested away from companies linked with the former apartheid regime in South Africa, GSK had cause to be concerned.

The problem of millions of people dying because they are denied access to essential drugs is not simple. The health of people in developing countries has marched beyond the need for "clean water supplies, good sanitation and better housing". HIV/AIDS, diabetes and hypertension are all increasingly prevalent in Ethiopia but none of these diseases has strong epidemiological links to clean water and improved housing. Indeed, have these three factors improved our health here in the UK? Cancer, coronary heart disease and mental illness are all major killers that can afflict anyone. Shall we stop the practice of issuing "free" drugs to our population (albeit through a taxation system that still allows those in society unable to pay taxes free access to drugs), since good sanitation and better housing have done more to improve the health of the UK than "any number of free drugs"?

Supplying essential drugs in even the most rural and resource-poor areas in developing countries is effective in saving lives. Médecins sans Frontières provides assistance to local health care staff in many highly successful ARV programmes running in Central America, Africa and Asia, which continually produce unequivocal evidence that many lives can be saved beyond improved sanitation and housing by supplying essential drugs.

Global movement to change

The reality is that there is a global movement to press for change in international policies. More than 40 Swiss organisations are now campaigning for their government and pharmaceutical industry to alter their policies regarding access to health care and essential medicines in developing countries. Even the UK Chancellor of the Exchequer has demanded that pharmaceutical manufacturers of ARVs should do much more to cut prices and provide meaningful aid to developing countries overwhelmed with the burden of the disease. Coupled with shareholders now being more vigilant about the ethics of the companies in which they invest, we are not back to square one, but we have taken many steps in the right direction.

As a relief and development worker I cannot afford the luxury of indulging in such a patronising emotion as "tug at the heartstrings". As a pharmacist, I am inherently a "health activist" since it is unacceptable to sit idly by while a patient receives poor quality of care or inappropriate medicines. Should the profession's principles and standards extend only to the boundaries of our nation? The international pharmaceutical industry is a global business and some companies are altruistically motivated, but none can ignore the fact that so many people on this planet depend on it to develop and share the drugs needed to alleviate their suffering and save their lives. At what point do profits become necessary to generate R&D and satisfy the shareholders, and at what point are they made at the expense of those in the developing world?

In the meantime, when I am next in the Niger Delta, the Lagos slums or rural Ethiopian villages without effective drugs, I will be sure to pass on the sentiment of this editorial: "We are saddened by your health misery but pharmaceutical companies are not to blame". And I will remember to ask my patients exactly what they think are the real reasons for their poor health.

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