Suffering from trade?
This editorial by Jean-Hervé Bradol, MD, President of Doctors Without Borders/Médecins Sans Frontières (MSF)originally appeared in Le Monde.
October 2003

To understand the significance of the measures concerning the importation of generic drugs adopted on 30 August at the preparatory meetings of the World Trade Organization summit in Cancun, it is necessary to review the problems they were supposed to address. Doctors practicing in low-income countries experience failure on a daily basis. They do not have the tools (diagnostic tests, vaccines and treatments) to ensure the survival of patients with the most fatal and common infectious diseases. An estimated 14 million people die from these diseases every year, according to the World Health Organization. The disaster is not that millions of individuals die each year from viral, parasite and bacterial infections, but that several million of them could survive if the appropriate policies were adopted.

Such is not the case, however. Who is responsible? In fact, there is an entire chain of players who abdicate responsibility. The first link in the chain is the physician. Too many physicians tolerate ineffective prescriptions. Raising this issue in a medical institution typically means the doctor will be seen as an irresponsible idealist. Who would risk his or her career to provide appropriate treatment to patients? Our experience - even within MSF - confirms there are very few doctors willing to do so. If the physician does manage to overcome this first obstacle, he or she will crash headlong into the Ministry of Health. If the ministry does not simply deny any need to change therapeutic protocols, it states that it does not have the resources to finance the changes because public revenues are too low and the price of new medicines too high. Make no mistake about it: even though the international environment plays an important role, responsibility for issues of public safety, in this case public health, is primarily a government responsibility. Simple observation leads to the conclusion that abdication of responsibility is the rule and taking action the exception.

In a largely unfavorable international environment (near abandonment of research for the poorest patients, notoriously insufficient public budgets under pressure from international financial institutions and drug prices that are too high), a number of countries have nevertheless responded appropriately - such as national AIDS policies in Brazil, and local efforts in Cameroon and Malawi. Botswana's effort to set up anti-retroviral programs nationwide is continuing but is running into many difficulties. The malaria project in KwaZulu Natal in South Africa was an impressive success but it remains an isolated case. While these examples demonstrate that a national political will can be decisive, their exceptional nature highlights the fact that the necessary will is most often lacking. Not one country in Africa, the most affected continent, has managed to develop an effective national policy for making AIDS and malaria treatment truly accessible to the majority of patients. Yet these two diseases are responsible for about half of all deaths from infectious diseases.

What is the responsibility of the international health, trade and government aid authorities? To take the steps necessary for creating an international environment that supports the extension of local and national efforts that have proven their effectiveness. Pharmaceutical trade must be divided into two separate periods: before and after 2001. Before 2001, multinationals had no special strategy for developing countries, where they sold AIDS drugs at the same prices as in the rich countries. At that time, anti-retroviral therapy cost more than $ 10,000 per patient per year. After 2001, drug companies cut their prices by 30 percent after coming under pressure from public opinion campaigns and generic drug competition. Since then and despite these lower prices, pharmaceutical multinationals based in wealthy countries have made every effort to strictly limit access to generic drugs, an effort underwritten by the American government. We are witnessing the transition from a strategy of selling drugs at the highest possible price to a strategy of reducing prices but making them as little available as possible.

The agreement signed a few days ago by members of the World Trade Organization was described as a success, particularly because many people thought that access to generic drugs had been blocked by the lack of an agreement. Better a mediocre agreement than no agreement at all, it was said. This is far from true, however, because India can legally export its generic drugs to Africa until 2005 and African countries were already importing generics. Cancun is supposed to resolve the special problems of developing countries, who do not have sufficient drug production capacities and who must therefore buy generics on the international market. In fact, the text that will be presented in Mexico raises another barrier in that it makes import procedures more cumbersome. Since 1995, international intellectual property agreements have allowed governments to circumvent patents for reasons of public health, which they have been allowed to define themselves. The United States has never deprived itself of such measures. But when poor countries have wanted to do the same, the rules of the game have suddenly become more restrictive. These additional obstacles are raised even though the drugs are already available, though in small quantities and at prices still too high relative to the millions of patients in need of treatment and the inadequate public resources. That is the true significance of the text imposed by American pressure during the preparatory meetings in Cancun with the plaudits of industry representatives.

The game is neither fair nor transparent. Intimidation through the threat of economic and diplomatic reprisals has become the rule. The most powerful impose their will by behind-the-scenes arm-twisting. Questioned about their role in the negotiations, European leaders declared that it was not their countries, but the United States, "that initiated negotiations", according to comments recently made by the European Commission and the French trade minister. Hostility and abdication of responsibility characterize the position of the richest countries and only intense communication campaigns create the illusion that the contrary is true.