E-DRUG: Lancet: Access to essential medicines & the pendulum of power
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Book review
The Lancet 2007 24 March
[copied as fair use]
Access to essential medicines and the pendulum of power
Rhona MacDonald a
The Power of Pills: Social, Ethical and Legal Issues in Drug Development, Marketing and Pricing
Jillian Clare Cohen, Patricia Illingworth and Udo Schuklenk, eds.
Pluto Press, 2006.
ISBN 0-745-32402-9.
Pp 320. £19·99, US$35·00
Many factors have influenced my commitment to campaign for access to
essential medicines, but two immediately leap out. When I was working in
Bangladesh I witnessed a certain drug company promote the virtues of a
sugar-coated vitamin pill as the most important factor in helping children
grow and stay healthy. Families spent a day's wages on these useless tablets
when they could have been buying bananas, spinach, and dahl instead. As I
watched parents make sacrifices to pay for these pills, I realised that I
was obliged to do something about this profoundly unjust situation: now that
I knew what was going on, doing nothing would make me complicit in the drug
company's actions.
Years later, in my role as a medical editor, I accepted an invitation to
lunch with the Association of the British Pharmaceutical Industry. It was
just after the South African Government had won their landmark court case
against the pharmaceutical industry, in April, 2001, and I wanted to hear
the association's view of the outcome. It was in London's Grosvenor Hotel
and everyone apart from me was tucking into a three-course meal under the
chandeliers. I felt alone in my disapproval of drug companies' evangelical
zeal to uphold patents, and uncomfortable about the way those present were
talking about African people. After I said my piece, I left the dining room
and a Brazilian waiter came running after me to thank me for what I had
said.
And here lies the problem. The activities of drug companies that put patents
before public healthencouraged by the World Trade Organisation's rule on
Trade-Related Intellectual Property Rights (TRIPS)places the pharmaceutical
industry and campaigners on different sides of an impasse that is so wide
there seems to be no possibility of meeting in the middle. In the real
world, the outcome of this polarised debate depends on who has the most
power, which unfortunately for now is the drug companies. But if there is
any hope of making progress, there has to be some mutual recognition and
acknowledgement of each other's point of view. Will I find any
thought-provoking reasoning in The Power of Pills to help me appreciate the
position of drug companies?
The Power of Pills explains the social, ethical, and legal issues involved
in drug development, marketing, and pricing and has contributions from an
eclectic mix of academics, activists, economists, ethicists, health-care
professionals, lawyers, and philosophers. There is one contributor from the
pharmaceutical industry. Most of the essays are beautiful examples of moral,
philosophical, and economic reasoning at its best. For example, Michael
Selgelid and Eline Sepers argue that drug companies should be ³incentivised²
to research diseases in developing countries. The need for governments in
the south to implement a comprehensive public-private policy that sets the
agenda is the focus of Joao Carapinha's essay. Steve Miles suggests that the
socioeconomic gap between rich and poor countries is likely to grow unless
developing countries establish their own research capacity that prioritises
the health needs of their populations. The case for abolishing the patent
system is made convincingly by Adam Mannan and Alan Story. And Brook Baker
argues that access to essential medicines is a human right and proposes that
the international community should put it firmly on the human rights agenda.
The drug industry is represented by Robert Freeman, a pharma veteran. He
offers a predictable defence arguing for ³strong intellectual property
rights, a stable regulatory, pricing and reimbursement environment, and the
recognition that pharmaceutical innovation is a major contribution to the
health of nations.² We are back at the impasse. I am not convinced.
Another prime example of pharma dogma is in the 2005 report from the
Millennium Project Working Group on Access to Essential Medicines, one of
the Millennium Development Goal targets, which discusses the way forward.
The report's authors come up with similar solutions to those outlined in The
Power of Pills, such as fair pricing of essential medicines and innovative
methods of research and development that are not led by the pharmaceutical
industry. However, at the back of the report is a statement of dissent by
representatives of the research-based pharmaceutical industry and signed by
Eli Lilly, Merck, and Pfizer. Although representatives for the industry were
part of the working group they refused to sign the report, ³because of the
enormous visionary gap between ourselves and the working group in
identifying root causes of the access challenge². Their reasons are so
important in understanding why there is a stand-off position when it comes
to access to essential medicines that I think their response is worth
quoting. They state, ³We do not believe that the main problem in barring
medicines to the poor is patent protection, nor do we accept that individual
pricing practises are fundamental to explaining why one-third of the world's
poor lack access to basic, low cost essential medicines.² They conclude, ³In
short, the report fails to provide the balanced and accurate perspective
necessary to stimulate fresh policy approaches that could make a real
difference to the lives of the poor. To allow these inaccuracies and
misinterpretations to become accepted truth and as the basis of moving
policies forward does no one any service, least of all patients who rely
most on the commitments we have made. It would significantly diminish our
ability to fulfil commitments to current and future partnershipsmost
importantlyour capacity to produce new drugs, diagnostics, and vaccines.²
I am left wondering how much more evidence and reasoning it will take for
the drug industry to meet somewhere along the impasse. Is there any way
forward? A WHO Intergovernmental Working Group on Public Health, Innovation
and Intellectual Property may offer some hope. The group's aim is to help
devise a global strategy to boost research and development for neglected
diseases, including looking at new ideas such as patent pooling, to address
the barriers posed by patents for individual drugs. But experience to date
shows that drug companies will do everything they can to cling on the status
quo where they hold all of the power. The pendulum of power will need to
swing to the other side before there is any reasonable progress.
So imagine this: after deciding to diversify and invest in its own research
and development, a former Indian generic drug company has come up with a new
compound that could be of major benefit to people with lung cancerthe
leading cause of death from cancer in rich countries. The company has tested
its drug in clinical trials, it has been approved for use, and as is within
the company's rights, according to TRIPS, the company patents it and charges
a premium so that the cost for treating one patient for 1 year with the new
drug is £50?000. Can you imagine the response to this situation, including
the tabloid headlines? Now why should the response to access to life-saving
treatment, such as antiretroviral therapy, for people in developing
countries be any different? Is it because they are poor? Is it because they
are powerless? Or is it because, on the whole, the international community
just does not care? The power is not with the pills. It is with the pill
makers.
nathan ford <nathan.ford@london.msf.org>