by John Sulston

A year ago, in March, I visited South Africa and went to some of the township clinics that are at the front of the battle against the AIDS epidemic. By then a quarter of the adult population was infected with the AIDS virus; of these many were incapacitated and most would die.
In 2001 a lawsuit had been brought by the pharmaceutical companies, in an attempt to prevent the importation of cheaper medicines. After an international protest, the lawsuit had been withdrawn, but now Treatment Action Campaign (TAC) was involved in legal action against the South African government, which was itself opposed to treatment of AIDS with anti-retroviral drugs. The reason for this opposition isn’t clear, but at least part of the cause may have been economic: there was no way that drugs could be available for everyone at full commercial prices, so politically it made sense to deny their value. But of course if the drugs weren’t used then there would be no clinical trials to demonstrate their efficacy under South African conditions.

The impasse had been broken in Cape Town by TAC and Médecins Sans Frontières, which was importing cheap generic versions of the drugs from Brazil. At its clinics in the township of Khyelitsha, I saw some of the results – the reports from people who had been stabilised, the way in which the complex dosage regime was organised using boxes with compartments for morning and evening doses each day, the training of community nurses to supervise patients.

A few days later I went with workers from Oxfam to the Johannesburg township of Soweto; at the hospital there I saw the reduction of mother-to-child transmission by means of the drug Nevirapine and the provision of powdered milk, again supervised by a care system spreading into the community. Tragically, I met a group of mothers, who asked us why only their babies could be saved while they themselves were doomed to die. What could I reply? That the drugs were too expensive, because our society is more concerned with its wealth than with their lives?

I could see that it was working, that the catastrophe could be halted. The claims from the government that the drugs were ineffective, and from the companies that the patients wouldn’t follow dosage regimes properly and that healthcare couldn’t be scaled up, were all false. Whatever might be the problems elsewhere, South Africa had already made huge strides in public health since the ending of apartheid, and increasingly people could access clean water and electricity. To continue the movement out of poverty, rightly identified by the government as the ultimate cause of the problems, a key step was to avoid losing a generation. Medicine had the means to do so, if only the drugs could be provided.

At that time the future looked hopeful for poor countries. The Doha Declaration on intellectual property rights and public health - issued, after international outcry, by World Trade Organisation (WTO) trade ministers in 2001 – had confirmed governments’ right to override patents and authorise the manufacture of cheap generic versions. Even then the drugs would be costly, but the combination of lower prices through generic manufacture and a global fund to pay for them seemed a feasible course.

But somehow during the year the solution continued to slip away. The US, influenced by the pharmaceutical lobby, blocked an agreement at the WTO to lift restrictions on exports of cheap generics to countries that cannot produce affordable versions themselves. What is going wrong? What are we and our companies afraid of?

Most of the reasons given by the companies against allowing cheap generic competition or tiered pricing are without real foundation. Loss of profits: but poor countries constitute such a small market that there’s not much profit, regardless of patent rights. Diversion of cheap drugs back to rich countries: but rich countries are highly regulated and accustomed to maintaining tariff barriers. Loss of research funding: but drug research, though indeed expensive, is much less expensive than it appears, for large pharmaceutical companies spend only some 15% of their budget on research and development.

This AIDS drug thing is simple. It’s a chance to dip our well-fed toes in the water, by actually using our collective discoveries and inventions to benefit humanity.

The heart of the matter is that our society and our economy increasingly depend upon private finance. That in turn means that decisions are short term and controlled by the accountant’s balance sheet. We are all locked in – our personal investments and pension plans directly or indirectly share in the profit that come from pharmaceuticals. We worry about our jobs, about the prospect that if we take a moral stance over drug prices our industries will move to places where profits are uncontrolled. But this thinking is blinkered as well as unethical. Other than in the very short term we shall lose out financially by trying to garner our wealth rather than using it to make a fairer world.

These comments are not novel. Two reports out last year - from the Nuffield Council on Bioethics and the Commission for Intellectual Property Rights – said in effect that current patenting practice is benefiting the haves against the have-nots. Médecins Sans Frontières and Oxfam have issued well-documented reports, and campaign actively. And today the Guardian is launching its own campaign.

This AIDS drug thing is simple. It’s a chance to dip our well-fed toes in the water, by actually using our collective discoveries and inventions to benefit humanity. Maybe we shall find that it isn’t so dangerous and that our economic system doesn’t collapse. And the health benefits will be immediate and spectacular.

But it must be done properly - handouts are not enough. For example, the recent US pledge to provide $15bn for AIDS drugs seems admirable at first sight. But if, as reported, it is to be tied to bilateral agreements that help to maintain trade restrictions on poor countries then it will not improve their situation in the long run. Treatment of other diseases must follow, and the infrastructure to do all this must be encouraged to grow in the developing countries.
The thousandfold gap in spending on healthcare between the richest and poorest countries must be reduced, and this will require fairer trading conditions. Perhaps it will feel uncomfortable at first for us rich 10%. But we’ll get used to it, and indeed relish living in a world that’s becoming more just, more uniformly wealthy and more secure.

John Sulston, founding director of the Wellcome Trust Sanger Institute, shared the Nobel Prize for medicine in 2002
This article is reprinted with permission from The Guardian, 18 Feb 2003
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