Thursday, Jul 24, 2008
Love turned to the private sector in part because of his frustration with the South African government's slow response to the AIDS crisis -- a frustration born of his experiences during the South African trial, when he served as an advisor to the Health Ministry, a party to the suit. South Africa's hesitations and missteps on the issue are well-chronicled. President Thabo Mbeki has expressed concerns about the safety of cocktail treatments and even questioned publicly, to international dismay, whether HIV is the true cause of AIDS. The South African government has so far refused to declare the AIDS crisis a national emergency -- although a staggering 4.7 million South Africans are infected. And it has been reluctant to issue compulsory licenses or support proposals like Love's. In a recent interview with the U.K. Guardian, South African Health Minister Manto Tshabalala-Msimang said: "To be frank ... we haven't thought it through." In her Guardian interview, Tshabalala-Msimang asked the reporter whether Anglo American, the company that Love is working with to distribute anti-retrovirals to its workers, would provide the families of its miners with access to the drugs and also what effect the heat in the mines would have on workers taking the drugs. These were not questions that inspired confidence that the minister was fully informed.
To be fair, the South African government also has a more legitimate reason for its ambivalent attitude toward drug treatment: Proper use of retrovirals requires a healthcare infrastructure that the country lacks. Anglo American has a better chance of efficiently delivering and administering the drugs -- which is another reason Love is optimistic about private initiatives. Lending credence to his position is the decision made by auto giant DaimlerChrysler earlier this week to provide anti-HIV cocktail treatments to employees and their families, totaling as many as 23,000 patients.
Mention the global AIDS bureaucracy, centered in the U.N. organization UNAIDS and spread through innumerable NGOs, and Love scoffs derisively. "I pitched this private-sector stuff because if you sit around and wait for these assholes at the U.N. agencies to get their acts together, a lot of caskets are going to go into the ground," he says. "They're not men of action. They're followers, not leaders. There's no leadership taking place at the U.N. agencies. There's a lot of great pensions that are coming down. There are some high salaries being paid and sumptuous meals being consumed and business-class tickets being given out. But I have to say: Leadership? No, I'm sorry. I mean, this is Basic 101 stuff. What are we doing? We're figuring out how much it costs to manufacture drugs, we're figuring out how you can solve the intellectual property problems, how you can solve the drug registration problems. We're trying to get people to act," he says.
Love isn't impressed when I point out that UNAIDS has met with CIPLA, and that international organizations monitoring essential drug pricing routinely cite CIPLA's quotes in their comparison charts. "When things are on the front page of the New York Times, they have to acknowledge them," he says, raising his voice. "They haven't been the people pushing compulsory licensing. Instead, they're the ones making the big bucks. And that's wrong because they're the ones with the big megaphone and the big voice."
The United Nations recently announced that it would create a $7 billion superfund to fight AIDS, malaria and tuberculosis. Details of that plan are expected to be announced at a U.N. General Assembly meeting on the AIDS crisis in New York next week. But Love has little confidence that the money will be used in the most effective way.
Officials from the United Nations and global AIDS organizations, for their part, say that activists like Love, fixated on treatment, ignore the crucial element of prevention. Instead of emphasizing widespread administration of AIDS cocktail treatments, organizations like WHO and UNAIDS have stressed education and prevention programs, which are easier to administer and potentially have the most long-term impact. Pieter Piot, the famous Belgian epidemiologist who helped identify the Ebola virus and is executive director of UNAIDS, recently described his view for how the U.N. plan should work in the New York Times: "We feel strongly that the response to AIDS has to be a balanced one: prevention and treatment. In the current climate, people forget that. I'm really getting tired of the fact that a terribly complex problem of treatment and care for people having H.I.V. is reduced to the price of anti-retroviral drugs."
Those are exactly the kinds of statements that raise Love's ire. "Are we supposed to say that since we can't save all of them, we're going to let them all die? That's an appalling, racist attitude. We're going to do all we can to save them," he says. "We make our little contribution on the intellectual property side and you'd think we'd raped Queen Mary."
Love says that when famous AIDS bureaucrats like Piot criticize his work, they fail to see the forest for the trees. He says that what he and his organization are doing is just one part of the puzzle, though admittedly one that's currently getting a lot of attention. "We're not saying prevention's not important. We don't campaign against those things -- everyone knows those are important."
What of the argument, proferred by pharmaceuticals and the South African government, that sloppy distribution and administration of cocktail drugs not only undermine their effectiveness but could lead to more resistant strains of HIV -- that it would be more effective to focus on HIV education and prevention, and on use of the drug AZT, which can reduce transmission of the virus from mothers to babies? Such arguments were recently echoed by the Bush administration's highest-ranking foreign aid official, Andrew Natsios, who told the Boston Globe that monies given to the United Nation's new AIDS superfund should be used almost exclusively for prevention.
In his comments to the paper, Natsios cited poor medical infrastructure and a lack of familiarity with Western ways, including the ability to tell time effectively enough to administer cocktail treatments. "You have to take these [AIDS] drugs a certain number of hours each day, or they don't work," Natsios told the Globe. "Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o'clock in the afternoon, they do not know what you are talking about. They know morning, they know noon, they know evening, they know the darkness at night."
Love joins other AIDS activists (and New York Times columnist Bob Herbert, who accused Natsios of perpetuating stereotypes about African culture) in rejecting the argument that anti-retrovirals are too complex to be effective in Africa. He points out that combinations of different medicines now enable HIV patients who have access to such pills to take as few as four pills each day. This treatment regimen is currently being used on HIV-positive homeless both in San Francisco and in South Africa, where Doctors Without Borders is providing cocktail treatments to one village.
The real issue, Love says, is price. And by teaming with CIPLA, he is attempting to prove that AIDS drugs can be made affordable, even in impoverished nations like South Africa. In CIPLA, Love found a company willing to stick its neck out -- and take the heat for doing so. When CIPLA made headlines around the world by quoting $350, the lowest cost ever for a three-drug anti-HIV cocktail, the pricing came as the result of Love's negotiations with CIPLA CEO Yusuf Hamied -- the generic drug mogul who has become a huge thorn in the side of the pharmaceutical giants with his rock-bottom pricing. It was a watershed moment for international activists fighting for inexpensive access to AIDS drugs. Even the international organizations Love scoffs at cite the figure as a standard in international drug pricing.
"It shocked everyone and blew up in smoke the idea that the pharmaceutical companies were making donations," says Love. "It was a third of the best prices you could get out of the branded guys in what they thought were donations."
Not surprisingly, the action didn't exactly elicit praise from the pharmaceutical industry. At a recent industry conference GlaxoSmithKlein CEO Jean-Pierre Garnier described CIPLA as price-undercutting "pirates," and said the company "is not doing this to get a Nobel prize." CIPLA's Hamied responds to such criticism by saying, "Indeed, we are a commercial company. But I market 400 products in India. If I don't make money on a half-dozen of them, it's no big deal. I don't make any money on the cancer drugs we sell or drugs for thalassemia, a blood disorder that's common in India. We sell these drugs virtually at cost because I don't want to make money off these diseases which cause the whole fabric of society to crumble. India alone will have 35 million HIV cases by 2005, and it's something we can't afford."
In fact, CIPLA needs to make a profit, however tiny, to demonstrate that the pharmaceutical companies can lower their prices dramatically and still turn a profit on AIDS drugs in developing nations like South Africa. Although the margins are razor-thin, Love says CIPLA will be able to turn a profit on its generic AIDS drugs in South Africa and wherever else it is able to sell them. But to make that profit it will need to get a compulsory license from the government -- otherwise, it won't have a market. Love believes that if the license is granted, a private medical infrastructure can be gradually built, making treatment possible for thousands. And successes in the private sector will increase pressure on South African and other governments to act, Love says.
"At a certain cost, the private sector and people can pay out of their own pockets for drugs. We're interested in those cases," he says. He also claims that competition among generic-drug manufacturers could push the price even lower than what CIPLA is offering. "We could get to $250 within a year," he says.
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