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Friends of MSF Essay Competition 2009-10 | Category 1: ‘Medical and Practical ---------------------------------------------------------------------------------------------------------------------------------------------------
Medicine for the Sick not just the Wealthy Emily Wilson This essay looks first at the inadequacies of current global distribution of medicine and the system behind it. It discusses why change in the pharmaceutical industry is necessary and briefly outlines the form that change should take and how it may be achieved. Unequal distribution The Inverse Care law stated that availability of good medical care varied inversely with the need for it in the population being served and that this market distribution of medical care was outdated and primitive1. Sadly this law applies to the global distribution of medicine. Medication is not received by those most in need and less research is carried out on the diseases of the poor.2 The diagram below shows the mismatch between need and expenditure on medicine. 42% of medicine expenditure is spent on just 5% of the world’s population while just 13% is spent on 72% of the world’s population who suffer the largest burden of disease.3
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Research is similarly focused on the lifestyle related diseases of the rich rather than the diseases of the poor. Between 1993 and 2004 there were only three new and innovative drugs for diseases affecting the developing world out of 163 new drugs brought to the market.4 A powerful example of the neglect of the health of the poor is the case of eflornithine, which was withdrawn from the market despite being a much needed treatment for African sleeping sickness. Access to the drug was facilitated only after it emerged that eflorinithine could be sold in rich countries as a woman’s facial hair removal product.5 The current system The current patent based system of drug development and production is inefficient from both an economic and a humanitarian perspective. The current system is a remnant of a guild based feudal system rather than an evidence based model that has been proven to be economically superior. Economists promote marginal cost pricing as a basic condition of economic efficiency. This is when the price is set as close as possible to the cost of producing an extra unit of output contrary to the patent system which allows drug companies to set the price much higher. Reduced government intervention in the
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form of tariffs and trade barriers has been widely promoted to avoid prices exceeding the marginal cost and causing the economy to be less efficient. However the losses caused by tariffs and trade barriers are insignificant compared to those caused by patent protection. This inefficiency is predicted to increase if the current situation remains unaltered.6 From a humanitarian perspective the current system drives the pharmaceutical industry to neglect humanitarian interests in pursuit of profit. Companies' monopoly over the price of drugs is a barrier to countries and individuals purchasing the medicine they need. The relatively high price of patented drugs compared to their cost of production encourages the production of counterfeits. The black market is unregulated and counterfeit drugs may be detrimental to health. The patent system also encourages the marketing of duplicate drugs because they are cheaper to develop and can then be promoted over very similar drugs that are no longer under patent. The US food and drug industry reported that 76% of the drugs it approved in the 1990s were duplicates rather than new breakthroughs.3 This results in an excessive investment in advertising to encourage doctors and governments to choose a new drug over others even if it is not necessarily more effective. The industry currently spends as much on advertising as it does on research.6 Research is similarly distorted. Research into areas not likely to produce patentable drugs is neglected and drug companies have reason to withhold research information in order to ensure their profits. This has a direct impact on health because it inhibits production of generic medicine through forcing developing countries to carry out their own clinical trials, which is expensive, and time consuming.3 Drug companies may also manipulate the regulatory process7 and the production of evidence for their own benefit8 because of the direct financial benefit of doing so. This has the potential to cause disastrous effects on health if unsafe medicines are approved. The concealment of evidence indirectly affects health because it impedes the furthering of human knowledge. The process of developing ARVs for children has been hindered because the drugs necessary for the research are held under patent by different companies.9 The TRIPS agreement is the most recent legislation concerning patents and has made medicine an issue of trade rather than public good. The TRIPS introduces a standard patent procedure for all countries making it difficult for poor countries to produce cheaper, generic medicine. It is a threat to the generic drug industries in poorer countries and the health of those who are dependent on the medicine those industries produce.10 Although flexibilities have been introduced into TRIPS they are difficult for poor countries to use. Twenty civil society groups made a joint statement claiming that The WTO deliberately designed an excessively
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bureaucratic process to inhibit the use of the flexibilities.3 Political and economic pressure has been used to deter the use of these flexibilities to produce or import generic medicine. The USA has used bilateral trade agreements combined with the threat of sanctions and diplomatic pressure to achieve this end.11 It is the epitome of the current system that an industry whose aim should be to provide medicine to the sick can enforce an agreement which directly threatens entire populations access to medicine. The nature of change It is clear that the system needs to be changed but the question is what to. There is an economic argument that drugs should be sold on a competitive market.6 In the short term this may increase access to medicine through reducing the price of medicine but it is not a solution. The logical aim of pharmaceutical research and production should be to provide treatment for the sick. If the aim is to make a profit, disregarding other considerations then we should mourn the loss of a sense of shared humanity. A profit orientated approach to medicine may eliminate economic inefficiency but will only exacerbate the current inefficiency in providing medicine to the sick by continuing to focus research and production of medicine on the diseases of the richest and the healthiest. Poverty and poor health are closely related. Poverty causes poor health and poor health can often cause poverty.12 Those least able to afford medicine will be most in need of it. This is true of individuals and governments who often function as a third party in the purchasing of medicine. The majority of the world's poor live in countries where infra structure and health systems are poorly developed. They are the ones most likely to have to pay for their medicine out of pocket. This can have catastrophic effects and plunge the family into deeper poverty.4 Even if the government has the infrastructure to provide medicine; poorer countries have higher burdens of disease but significantly fewer resources to provide their people with the necessary medicine. Research would also continue to be driven to produce drugs that will make the most profit. These will inevitably be the diseases of the rich. Human rights legislation gives intrinsic, equal value to all human life13 but our current system places different price tags upon the lives of the rich and the poor. The humanitarian goal of pharmaceutical development and production needs to be placed at the forefront of any dialogue about improvements14 if progress towards a solution to this problem is to be achieved. An understanding of development and economic growth that prioritizes human well being15 is needed.
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Marx's philosophical reflection that man should rule the market rather than be ruled by it needs to be taken heed of.16 The market may be a useful tool for improving access to medicine but it should be treated as such. An over emphasis on market efficiency and concepts like the invisible hand of the market and the trickle down effect of neo-liberalism17 can be used to justify decisions that appear to neglect the interests of the marginalised.18 In a perfect neo-liberal or free market environment it may be that these mechanisms will have the desired effect but the world is not a theoretical arena and it is irresponsible to place the lives of the sick in the invisible hands of the market rather than in the hands of the politicians and governments who can directly act towards solving the problem. The recognition that the market alone cannot improve health prompts an increased role for the state in both the provision of public goods and the regulation of private enterprises. A system needs to be intentionally developed through collaboration between governments that eliminates the direct relationship between producing a drug and profit. Achieving change In the short term governments have a responsibility to provide their people with essential medicine paid for through progressive taxation or other policies appropriate to specific scenarios. Internationally mechanisms for financing the provision of medicine to the world’s most needy population’s need to be strengthened and poor countries need to be enabled to use the flexibilities within TRIPS to provide their people with medication while the global community works towards abolishing the agreement. In the long term governments need to work towards creating a system that is efficient at promoting the health of many rather than the wealth of a few both nationally and internationally. This may be through increased integration of the pharmaceutical industry into the public sector, through new financing mechanisms such as taxation of Transnational corporations or development of a global fund to support essential research19 and through an alternative to the current patent system. A set of competing publicly funded research centers, an auction system in which governments purchase most patents and place them in the public domain and an employer-based research fee for researchers have been suggested.6 Possible alternatives are in their infancy but solutions to the current situation are not the obstacle to improvement. The skills exist to develop the solutions. Human innovation has proved itself in the massive developments made in medicine in the last century. The TRIPS agreement and other trade policy have shown that it is possible to implement policy with global
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consequences. What is needed is the will to develop and implement policy that will change the current situation for the better. The pharmaceutical industry currently exerts extensive influence in both national governments and international bodies of governance. The drug industry contributes large amounts to political campaigns in the US. In 2003 over $100 million was spent promoting the industry’s interests in Washington.3 The industry's influence extends to international governance because the US is the WHO's largest donor20 and has the power of veto in the economically weighted voted systems of the World Bank. 21 Civil society needs to empower governments to take action through utilizing its power as both voters and consumers.14 The medical profession is particularly important because it is a respected voice and because of its direct link to the pharmaceutical companies and influence over which drugs are purchased. Recently encouraging change has been achieved in the process towards improving access to medicines and provides an example of how civil society may effect change. The patent pool was suggested in response to the patents restricting access to ARV treatment and also limiting progress towards developing ARVs for children. On the 14th December 2009 thanks to extensive public and government support for the initiative drug companies signed up to the idea and will place their patents in a pool, which others can access, in exchange for a fair royalty.23 Change is necessary if the sick are to be provided with the medicine they need and is possible if civil society can act together united in the conviction expressed by MSF's founder, Bernard Kouchner that 'mankind's suffering belongs to all men.'24
References
1. Hart T. The Inverse Care Law. The Lancet. 1971. 297 (7696) pp. 405-412. 2. McCoy D, Sanders D, Baum F Pushing the international health research agenda towards equity and effectiveness. The Lancet. 2004. (364) pp.1630–31.
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3. People’s Health Movement, Medact, Global Equity Gauge Alliance. Medicines in Global Health Watch ; 2005-06. [Online] Available from: http://www.ghwatch.org/2005_report.php [Accessed January 5th 2010]
4. Oxfam. Investing for life: meeting poor people's need for access through responsible business practices. Briefing paper 109. Oxfam. Oxford. 2007
5. Jackson N. Saving lives in the name of vanity. MSF Article. [Online] January 28th 2002. Available from: http://www.msf.org/msfinternational/invoke.cfmcomponent=article&objectid=54D082BE22E1-49E1- A5ACD79DD187CE59&method=full_html [Accessed December 26th 2009]
6. Baker D. Financing drug research: what are the issues? Washington DC, Center For Economic and Policy Research; 2004b.
7. DPhill JA. The Pharmaceutical Industry as a Political Player. The Lancet. 2002. 360 (9344) pp. 1498-1502.
8. Oakland GY. Drug industry writers propose code of ethical conduct. BMJ. 2002. 324 pp.808. 9. Student stop aids campaign. Joining the push for the pool. 2009.[Online] Available from: http://www.stopaidssocieties.org.uk/wp-content/uploads/joining-the- push1.pdf [Accessed January 5th 2010] 10. MSF Access. The beginning of the end of affordable generics. Medicins Sans Frontieres. 2005. [Online] Available from: http://www.msf.org.hk/public/contents/news?ha=&wc=0&hb=&hc=&revision%5fid=12698&ite m%5fid=3605 [Accessed January 5th 2010] 11. Oxfam. USA bullying on drug patents: one year after Doha. Briefing paper 33. Oxfam. Oxford. 2002. 12. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization; 2008. 13. United Nations. The Declaration of Human Rights. Article 1. 1948. [Online] Available from: http://www.un.org/en/documents/udhr/ [Accessed 5th January 2010] 14. Graham Dukes M. Accountability of the pharmaceutical industry. The Lancet. 2002; 360 (9346) pp. 1682-1684. 15. Sen. Development as Freedom. Oxford University Press; 1999. 16. Singer P. Marx: A Very Short Introduction. Oxford University Press; 2000.
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17. Kitthananan A. Developmental states and global neo-liberalism in P. Kenett (eds) Governance, globalization and public policy. Policy press. Bristol; 2008. 18. Hofrichter R. The Politics of Health Inequalities in Hofrichter R. (eds) Health and Social Justice: politics, ideology and inequality in the distribution of disease. Jossey Bass. San Francisco; 2003. 19. Trouiller P. et al. Drug development for neglected diseases: a deficient market and a public-health policy failure. The Lancet 2002 (359) pp. 2188-2194. 20. People’s Health Movement, Medact, Global Equity Gauge Alliance. The World Health Organisation and The Commission on the Social Determinants of Health in Global Health Watch 2; 2008 [Online] Available: http://:www.ghwatch.org/ghw2/ghw2pdf/ghw2.pdf [Accessed: December 26th 2009] 21. Bank. Voting Powers. [Online] Available from: http://go.worldbank.org/VKVDQDUC10 [Accessed: January 5th 2010] 30. Graham Dukes M. Accountability of the pharmaceutical industry. The Lancet. 2002; 360 (9346) pp. 1682-1684. 22. Bagozzi D. UNITAID approves patent pool. UNITAID. [Online] December 14th 2009. Available from: http://www.unitaid.eu/en/20091215237/News/UNITAIDAPPROVES- PATENT-POOL.html [Accessed: December 26th 2009] 23. BBC News. World: Europe Bernard Kouchner: The man behind MSF. BBC news [Online] October 15th 1999. Available from: http://news.bbc.co.uk/1/hi/world/europe/406362.stm [Accessed December 26th 2009]
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