A few years ago, a surprisingly frank
encounter with a pharmaceutical salesman made me see prescription
drugs in a new light. At a cafe in San Francisco's Castro District,
an impeccably dressed young man sat next to me and struck up
a conversation.
``I've always wanted to live in San Francisco,''
he told me. ``The job's tough, though. I sell physicians a new
drug to treat CMV retinitus in AIDS patients. The trouble is,
the other drug is better, with fewer side effects.''
A look of discomfort momentarily clouded the young man's bright
expression. Then it passed. ``Oh well,'' he said, ``a job's
a job.''
I have often thought of this conversation while
reading about South African President Thabo Mbeki's controversial
views on AIDS and his strained relations with AIDS drug makers.
Mbeki has made headlines recently by making sympathetic comments
about ``AIDS dissidents'' who claim HIV is not the cause of
AIDS and by claiming that AIDS drugs are too toxic and expensive.
But instead of being put off by his comments, American observers
should take Mbeki's criticisms about the drawbacks of AIDS drugs
seriously. Given the Third World context within which they are
made, his suspicion of pharmaceutical companies is understandable.
Furthermore, on closer analysis, Mbeki's comments apply to
America's overall health care situation as much as they do to
Africa's. As America is beginning to discover -- witness the
current national outcry over our high prescription drug prices
relative to other countries' -- a little more scrutiny of pharmaceutical
companies may be just what the doctor ordered.
Although most Americans are unaware of it, Mbeki's comments are just
the latest complaint about drug companies made by poor countries.
Third World countries have long argued that the market forces
driving medical research have caused pharmaceutical firms to
ignore the pressing health needs of poor countries that cannot
pay the prices necessary to recoup research costs.
Their complaints have been backed in recent years by influential Western
observers. Doctors Without Borders, last year's Nobel Peace
Prize winner, has criticized the lack of corporate interest
in Third World health problems. Project Censored, a media watchdog
group, lists the lack of pharmaceutical research in tropical
diseases high on its Top 10 list of news stories underreported
by the media.
Third World governments and Western critics
back their claims with some pretty revealing statistics. North
America, Europe and Japan together account for 80 percent of
pharmaceutical sales, valued at $303 billion a year, while Africa
generates only 1 percent, according to IMS Health, a market
research firm covering the field.
The numbers precisely
reflect this overwhelming industry focus on Western health needs.
According to a recent study by Doctor Without Borders, only
1 percent of medicines patented between 1975 and 1997 -- 13
drugs out of a total of 1,233 -- were for tropical diseases.
This despite the fact that World Health Organization (WHO)
statistics show that tropical diseases afflict hundreds of millions
of people (there are an estimated 300 million to 500 million
cases of malaria alone each year) and threaten several billion.
Most of the afflicted live in Africa, with growing numbers in
Asia, Latin America and former nations of the Soviet Union.
The consequences of such skewed statistics are grim. According
to Doctors Without Borders, the majority of tropical medicines
were developed more than 40 years ago. Many are no longer effective,
due to the mutation of microbes into drug-resistant strains,
or are being discontinued due to lack of profitability.
Sleeping sickness, a tropical disease caused by the tsetse
fly, is a good example of pharmaceutical neglect. A major scourge
of Africa, sleeping sickness often causes lasting neurological
disorders, even when treated. An estimated 300,000 to 500,000
people contract the illness every year. Untreated, it is overwhelmingly
lethal.
Melarsoprol, the only treatment for the advanced
state of sleeping sickness, was developed more than 70 years
ago. The drug is painful to ingest -- arsenic and antifreeze
are literally its two key ingredients -- and it kills 5 percent
of those treated with it. Worse yet, a strain of Melarsoprol-resistant
sleeping sickness is spreading, and the only replacement therapy,
Ornidyl, is four times as expensive.
The response of drug
companies? Aventis, the European company making Ornidyl, which
was originally developed to fight cancer, has discontinued production
of the medication due to lack of profitibility, ceding the patent
rights over to the WHO to seek a new manufacturer (which it
has not yet done).
To explain his company's actions, an
Aventis spokesman told the New York Times: ``We know what's
happening in the Third World, but we don't act. We can't deny
that we try to focus on top markets -- cardiovascular, metabolism,
anti-infection, etc. But we're an industry in a competitive
environment -- we have a commitment to deliver performance
for shareholders.''
Meanwhile, WHO estimates that 60 million
people are at risk of infection in 36 sub-Saharan countries,
most of them among the poorest nations in the world.
Given this dearth of drug research and development for tropical diseases,
President Mbeki's claims that current AIDS drugs are not tailored
to fit the unique aspects of Africa's AIDS epidemic situation
make more sense. After all, in Africa, the epidemic is fueled
by a different strain of HIV than in the West, and possesses
significant differences, such as spreading along heterosexual
lines.
The absence of new, specifically designed drugs
is not the only problem undeveloped countries face. Modern medicines
are simply too expensive for poor countries, with AIDS drugs
being a perfect example. Even at an 85 percent discount offered
by drug companies in response to Mbeki's criticisms, South Africa
would still have to spend more than its entire health budget
to pay for enough AIDS drugs to treat its infected citizens.
Even drugs that have been donated to poor countries -- in
response to a humanitarian crisis, for example -- have been
a mixed blessing. Doctors Without Borders has documented many
examples of ``drug dumping,'' in which drug companies donate
pharmaceuticals that are obsolete or expired, thereby avoiding
costly destruction or storage costs, emptying inventories and
often reaping substantial tax breaks.
Finally, even when
poor countries get the right drugs at the right price, misleading
advertising and inexperience can cause citizens to use them
in the wrong way. In the Philippines, anthropologists have documented
how advertisements have led to the view that a tuberculosis
drug is a ``lung vitamin.'' The subsequent misuse and overuse
of the medicine has created precisely the type of situation
that breeds drug-resistant TB strains, a growing problem around
the world. If AIDS drugs were used similarly in Africa, which
has huge segments of the population with no experience with
modern health services at all, the results would be disastrous.
As America and the West are sadly discovering, adherence to
the AIDS-cocktail regime is extremely difficult under the best
circumstances, and drug-resistant strains of HIV, as a result,
are increasingly common.
Drug companies freely admit that
because poor countries cannot pay the high prices necessary
to recoup development costs, it is not feasible to put resources
into research on tropical diseases.
As the Aventis spokesman
pointed out, pharmaceutical companies are commercial, not philanthropic,
organizations operating in an intensely competitive climate.
They are not set up to donate large sums of money and resources
to counter the bad health conditions in poor countries -- that
is the role of rich nations like the United States and international
bodies like the United Nations. Drug companies, spokespeople
point out, need to think of their shareholders and the bottom
line.
The question for Westerners, besides how to deal
morally with the resulting neglect of so much of humanity, is
whether the need for profits is also undermining our own health
care.
A brief look at our national situation is not encouraging.
The pharmaceutical presence in the West is the flip side of
Third World experience: Whereas poor countries lack drugs for
dire diseases, the West has access to drugs for nearly every
affliction, no matter how trivial or better served by other
methods of redress.
The top-selling drugs in the U.S. are
for ailments like gastronomic ills and high cholesterol, which,
although they are important problems, could be better addressed
at the root cause with changes in diet and behaviors. Likewise,
top-sellers like Viagra and the new anti-depressants may be
contributing to a ``pill-for-every-problem'' ethos overtaking
our health-care system.
And this takeover seems to be accelerating.
Due to changes in advertising laws and Food and Drug Administration
testing procedures, -- lobbied for intensively by drug companies
in the mid '90s -- new drugs are now sped into development
with vastly shortened safety trials. These drugs are now marketed
directly to customers through slick television advertising.
Last year, drug companies spent $13.9 billion promoting their
products, with amounts spent for direct pitches to consumers
rising by 40 percent over the year before.
In addition, it is not clear that this increasing reliance on drugs is good
for our health. Remember fen-phen? Furthermore, the widespread
use of antibiotics is producing drug-resistant strains of all
sorts of diseases, creating a grave danger of future plagues.
Meanwhile, rates of death and injuries due to mistakes in drug-dispensing
and to toxic drug interactions are skyrocketing.
Finally, this reliance on pharmaceuticals in the West has produced a
great shift in the spending of health-care money. According
to IMS Health, spending for prescription drugs more than doubled
in the last decade, from $37.7 billion in 1990 to $78.9 billion
in 1997. No wonder Fortune magazine has called the pharmaceutical
field the country's most profitable industry, with profits rising
22 percent in 1997 and 21 percent in 1998.
As Americans begin to discuss the ramifications of the growing
pharmaceutical presence in our lives, such as high prescription prices and
adverse effects of multiple drug use, one thing seems clear:
The era of Marcus Welby, M.D., the caring TV family doctor of
a generation ago, is long gone, replaced by the smiling face
of a pharmaceutical salesman with a new pill to sell.
Tim Vollmer is a Bay Area medical anthropologist and writer.
CHART:
WHAT'S AILING THE WEST
This chart shows the top-selling pharmaceuticals in the United States.
.
1998 1999 1999 Sales Pct.
Product/Ailment Treated maker Rank Rank (thousands)Growth
.
Prilosec
gastroesophageal disease Astra 1 1 $4,187,171 21%
.
Lipitor
high cholesterol Warner-Lambert 4 2 $3,001,776 57%
.
Prozac
depression Lilly 2 3 $2,570,983 5%
.
Prevacid
gastroesophageal disease TAP 7 4 $2,363,815 67%
.
Zocor
high cholesterol Merck 3 5 $2,300,825 16%
.
Epogen
anemia Amgen 6 6 $1,841,997 26%
.
Zoloft
depression Pfizer 5 7 $1,737,248 12%
.
Claritin
respiratory disease Schering 9 8 $1,533,734 18%
.
Paxil
depression SmithKline Beecham 8 9 $1,516,428 16%
.
Zyprexa
psychosis/schizophrenia Lilly 11 10 $1,495,424 36%
.
Source: IMS Health, Retail & Provider Perspective
©2000 San Francisco Chronicle
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