Dangerous delusion: why plans to spend billions on drugs for Africa could backfire

Short-term relief, followed by long-term disaster is not sound policy. Nonetheless, that could be a result of the AIDS strategy being contemplated by the World Health Organisation, which on December 1 – World AIDS Day – announced a plan to treat 3 million people with HIV/AIDS by 2005. The WHO is proposing that billions of dollars be spent on increasing access to anti-retroviral drugs. That is a noble intention. However, it may not be the most cost-effective way to stem the tide of HIV/AIDS that threatens to drown Africa in a sea of death. Indeed, it may even be counterproductive.

Let’s be clear. Reducing the cost and increasing the supply of medicines to the poor is a good thing. But on its own it is not enough. Nor should it be today’s priority. The roots of Africa's health care crisis run far deeper and broader than a mere shortage of drugs. Spending billions on drugs is likely to prove a disappointing waste of resources. In fact, without vast improvements to Africa's health-care infrastructure, it could even make things worse.

For years well-intentioned people have claimed that Africa’s Aids problem has been aggravated by patent owners charging too much for medicines. In reality, few antiretroviral drugs have ever been on patent anywhere in Africa and there is no evidence to suggest that treatment has been any more accessible in countries with little or no patent protection, such as Mozambique or Somalia, than in countries where patents are in force. Moreover, for several years the manufacturers of anti-retroviral drugs have offered their products at very steep discounts or even for free.

Nonetheless, activists continue to concentrate on this debate. The mistaken belief that increasing the supply of drugs will, of itself, control Africa’s Aids epidemic has, unfortunately, become received wisdom. Pharmaceutical companies are being pressured to voluntarily license drugs to local suppliers. If they don’t comply, the activists demand that governments impose compulsory licenses – depriving the drug developers of any right to benefit from their investment. By making the research-based pharmaceutical companies the scapegoat for the AIDS crisis, activists have done the people of Africa a disservice – diverting attention from the realities of the situation as well as undermining investments in new drug development.

The hefty discounts and free medicines offered to poor countries by most companies suggest that profits from the developing world are not an essential part of their business strategies. But there is a real threat that drugs subject to compulsory licences in developing countries could leak back into rich countries, undermining profits and the incentive to develop new drugs. In the past year, several large hauls of Aids medicines produced by the patent owners and intended for sale at low prices in Africa have found their way back to Europe. If this can happen to medicines that are under reasonably strict controls, it isn’t difficult to imagine what will happen when the drugs are being produced and distributed by organisations that hold no allegiance to the company that developed them.

Developing a new drug is an expensive business – estimates put it at between $500 million and $1 billion. If companies can’t recoup returns from the few drugs that they actually get to market, then they’re unlikely to make that investment. Worryingly, there is growing evidence that drug companies are reducing their investment in anti-retrovirals – the number of new drugs in development has fallen almost 30 per cent in the past three years. Though AIDS can’t be cured, it is treatable, sometimes for years, but only if new drugs emerge for the large number of patients who build up resistance to their current regime of anti-retrovirals.
What Africa really needs is investment in its healthcare infrastructure. If the continent is to avoid the tragedy of widespread resistance to AIDS medicines, it needs to guarantee that patients comply with the requirements of their treatment. This involves both patient education and training programmes to help healthcare professionals and para-professionals monitor and promote compliance in rural areas. Yet Africa currently lacks the personnel and the infrastructure to do this.

There simply aren’t enough hospitals and clinics, especially in rural areas, to ensure effective delivery of medicines. Even those that do exist face severe staff shortages, often lacking qualified healthcare professionals. Poor roads and transportation also hinder drug delivery. In Nigeria, huge consignments of drugs expired due to lack of effective controls and delivery procedures. Meanwhile, Botswana’s world-class treatment programme, run by a partnership between pharmaceutical company Merck and the Gates Foundation, faces continuing difficulties due to a dearth of health workers and the slower-than-expected pace of building clinics, laboratories and drug warehouses.

Africa also needs adequate regulatory supervision: formal mechanisms which ensure that drugs are not adulterated by the time they reach patients. African countries already suffer from dangerously high levels of drug counterfeiting, in some locales more than 80% of drugs are fake. Poor quality drugs are a threat to patients and will spread drug resistance.

The majority of the funds currently earmarked for Aids treatment should be spent on long-term programmes to address these essential facets of healthcare infrastructure. Without such infrastructure, drugs, whatever the price, will be ineffectual, even counter-productive. The WHO’s “3 by 5” may grab headlines but sadly it is unrealistic. Money spent wisely will ensure that current and future treatment programmes are fully effective, but the WHO must be careful not to be seduced into squandering billions on a fashionable, but unobtainable, quick-fix solution.

Prevention of HIV/AIDS used to be the WHO’s priority. And for good reason: the only way really to control the epidemic is through education and prevention. In Uganda, my home, the government promoted the ABC of Aids prevention: Abstain, Be faithful, or Condomise. As a result, Uganda managed to halve its HIV infection rate in a decade.

Author: Dr John Kilama, who is from Uganda, is the President of Global Bioscience Development Institute www.gbdi.org. This article may be republished without prior consent but with acknowledgement to the author. The views expressed in the article are the author’s and are not necessarily shared by the members of the Free Market Foundation.

FMF Feature Article\16 December 2003