Medicines without borders

Big pharmaceutical corporations have a bad rap. They are said to be systematically ignoring the plight of poor countries and their patients. Since 2003 their activities have been monitored by the Medicine Foundation in Amsterdam. And they have seen some hopeful prospects in their new index.

Text: Menno Bosma Illustration: Levi Jacobs

Trends in medicine land

More strict admission requirements/more research: it is harder for medicines to reach the market (aspirin would not be approved nowadays)

Larger growth of the need for medicine in low and middle income countries than in wealthy countries thanks to the ‘double burden’: a combination of tropical and welfare diseases

Tailored medicine: small groups of patients get more specific (and expensive) medicine

More medicine against chronic illnesses and psychological ailments

Illegal medicine production: a major entanglement between the drug and pharma-circuit

Tricks of pharma companies

Slightly changing a drug (its composition, or the way its administered) so they can get a new patent

Getting different patent for the same drug, if it appears effective for curing different diseases

When a drug is also effective for a rare disease, it is then converted into an (much more lucrative) orphan drug

Buying up the licenses of niche-medicines after the patent has lapsed, after which they drastically raise the prices from a monopoly position

Paying doctors under the guise of scientific research to prescribe a lot of a certain drug (seeding trials)

Passing on the costs of failed medicines in the price of patented ones

Not giving any insight into the way a medicine’s price is built up

Alternatives for patients

Early access: terminal patients are getting non registered drugs. If it is actually approved, then this is usually done sporadically and for small groups

Masterly preparation: apothecaries can (re)create their own drugs for patients. But that is only allowed if there is no already registered medicine already. reselling is prohibited

A route abroad: Buying drugs on the internet or abroad, when it isn’t available, or too expensive in their own country. This isn’t always legal or safe however.



The fight against tropical diseases

The German pharmaceutical corporation Merck donated over 200 million tablets of praziquantel to the World Health Organization (WHO). They were given to people suffering from schistosomiasis, also known as bilharzia. With over 200 million infected, and nearly 280.000 deaths annually (mostly in Africa), bilharzia belongs to the list of more severe tropical diseases. The culprits are microscopic worms in sweet water, who penetrate the body, causing fever and diarrhea, and eventually even damage organs.

The unique characteristic of Merck’s efforts is that there is no public-private partnership (ppp) in play. Ppp’s are usually at the forefront of research into treating which diseases prevalent in low and middle income countries. Without public funding few pharmaceutical corporations are willing to work on developing drugs without any profit prospects. ‘Other reasons are that the disease is on the priority list of the Policy Cures Research and the WHO, and that the company has expertise with the disease,’ says Marijn Verhoef, company engagement manager of the Access to Medicine Foundation in Amsterdam. They shine a light on the way large pharmaceutical companies work. Bilharzia fits both components: the WHO and in the London Declaration on Neglected Tropical Diseases focus on schistosomiasis, Merck developed praziquantel half a century ago together with Bayer. That the man who discovered schistosomiasis is the German Theodor Bilharz also played a role.

Oat milk and vegetarian food

The efforts Merck makes under its slogan ‘making schistory’ are a positive development, although we shouldn’t overestimate its worth. The 750 million free tablets of praziquantel have a value of 53 million euro, compared to Merck’s yearly profit of over 2 billion. The independent researchers of the Access to Medicine Foundation have detected similar improvements in the behavior of large pharmaceutical companies. ‘They’re investing more in R&D of medicines against priority diseases than ten years ago. The transparency around patients is also increasing. And medicines against HIV/aids, among others, have become a lot cheaper.’ concludes lead researcher Danny Edwards. The companies are working towards better accessibility strategies and are adapting their business models to people with lower incomes.

Because they are making massive profits, have little transparency, and still have suspect business practices (see framework Tricks of pharma companies), the trust is pharmaceutical companies is low. In a public opinion poll from 2013*) they ended below beer brewers. The pill pushers are seemingly taking this to heart. They are making more of their data publicly available and some of them even request to be ranked by Access to Medicine. ‘Human-resource motives can play a role in this’, says Marijn Verhoef. ‘They are looking for millennials such as us, who drink oat milk, are vegetarians, and who want to work for an organization that takes its societal burden seriously.’ Another factor is that more and more investors see social responsibility as a prerequisite for investments. Over 80 of those investors, who represent more than 10 trillion (among them the Dutch pension fund PGGM) are cosigning the principles of Access to Medicine Index. The Access to Medicine Foundations organizes meetings in which investors and pharmacists can enter a dialogue about the access to medicine.

Double burden

But the new Access to Medicine Index, which was released on the 20th of November, is also critical. It notes that R&D into essential medicines for poor nations is still limited. Only 5 major pharmaceutical corporations, among which Merck, are investing in those diseases on a large scale, and that’s limited to only five of them: malaria, HIV/aids, tuberculosis, Chagas disease, and leishmaniasis. This, while the WHO and other health organizations have identified over 45 priority diseases. There is virtually nothing being done against diseases which mostly occur in Africa, such as rift valley fever or Lassa fever. Remarkable is that R&D on medicine against syphilis, a real baby killer in low and middle income countries, has virtually halted. The index identifies a total of 139 rifts between supply and demand, of which 99 cases are completely ignored by companies, with no investments in drugs or vaccines.

Other bad news is that they are doing little towards increasing access to cancer medication. This, while the prevalence of cancer in low and middle income countries is rapidly growing: two thirds of all deaths from cancer occur in those countries. This is the double burden: besides tropical diseases these countries are now also facing welfare diseases. Medication shouldn’t just be in supply and available, but also should be accessible to those in remote areas. Luckily accessibility is now more of a concern when developing treatments for infectious diseases: over half of R&D into medicine is accompanied by a plan for accessibility. But with cancer medication that’s only the case for 5 percent. ‘That’s something which is addressed on the agenda, but not something we actually see in practice. Besides, we can learn from the experiences around infectious diseases’, says Marijn Verhoef.

Bad news is that innovative new medicine often come to wealthy countries before they make their way to low and middle income countries. As such taking a longer time before they’re available over there. But the countries themselves are also to blame, putting up barriers against registration and having a less developed healthcare infrastructure.

More licenses

But there is also good news. GSK, for instance, developed a promising new malaria drug, tafenoquine, which is being introduced in Brazil, Ethiopia, and Thailand. From that selection of countries it unfortunately becomes apparent that producers still focus on middle income, rather than low income countries.

Other good news is that patent holders are seemingly issuing more licenses. That’s especially the case with HIV and aids medicine. These medications are therefore becoming cheaper, and more easily available, being produced on a larger scale. Medicines Patent Pool, an organization backed by the UN, is, among others, fighting for this. The Access to Medicine Foundation praises that, because this helps people with a smaller income. Danny Edwards does place a footnote: ‘There has always been a lot of attention and public funding for HIV/aids, and there is a lot of competition between pharmaceutical corporations. Besides, the market is stable now HIV has become a chronic disease. These situations are different than malaria for example.’

*) The faith in the pharmaceutical industry in 2013 was, according to Edelmans Trust Barometer, lower (58%) than that in breweries, alcohol producers, and telecom companies (62%).

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