[Ip-health] New York Times column: Doctors, Drugs and the Poor

[Ann-Marie Sevcsik]

New York Times, 17 May 2007

Doctors, Drugs and the Poor
By ATUL GAWANDE
It's one of those questions no one tells you about when you enter
medical practice. What do you do when patients come who can't pay? Some
doctors decline to see them. I have expenses to pay and a family to
feed, they'll argue.

But I grew up in a rural part of Ohio where an inordinate number poor
people live. My mother is a pediatrician there, and from the start, she
could not imagine turning children away. Up to 20 percent of her
patients have been without insurance, and more than half were on
Medicaid, which paid terribly and was refused by other doctors. Some
patients were not very grateful. Some were not as poor as they claimed.
But we could count on my father's better-paying urology practice to
cross-subsidize. So that's what she did.

The message from my parents was straightforward: We are in medicine and
that comes with certain moral obligations. So I've understood that part
of my job is to see those who can't pay - even if sometimes it hurts.

I've been thinking about this as I've watched the arguments unfold about
what pharmaceutical companies should charge in the developing world. The
history of H.I.V. drugs has not been pretty. First, for almost a decade,
we in the West ignored the possibility that antiretroviral drugs could
be used in the developing world. (Remember the 2001 claim of U.S.
government officials that Africans couldn't learn to take the drugs on
time because they didn't have watches?) Then, under international
pressure, drug companies made some discounts, but they were not deep
enough. (A year's supply was still more than $1,000 per patient.) Only
when an Indian generic manufacturer provided a copycat three-drug
regimen for $150 per year and major donors stepped forward did
distribution effectively reach poor countries.

We're now in the throes of another round of H.I.V. drug battles, this
time over advanced, but even more expensive drug regimens from Merck and
Abbott Laboratories. Last week, the Clinton Foundation endorsed
decisions by Thailand and Brazil to break the companies' patents and
purchase cheaper, copycat versions of the drugs. Abbott retaliated by
withholding seven new drugs from Thailand, including an antibiotic, a
painkiller, and a medication for high-blood pressure. The fight has
become vicious.

In a way, it's hard to see how the confrontation could be avoided. The
cost of developing a new drug now approaches $1 billion, and companies
do need profit margins to recoup that cost and encourage new innovation.
Yet, once a life-saving discovery is made, it is clearly grotesque to
make millions suffer or die while waiting for a 20-year patent to
expire.

The experience with H.I.V. drugs is oddly heartening, though. There is,
in fact, a spectrum of behavior among pharmaceutical companies - just
like with doctors. Gilead Sciences has granted licenses to generic
manufacturers to supply its blockbuster H.I.V. drug, Viread, to the
world's hundred poorest countries at the reasonable royalty rate of 5
percent of sales. Bristol-Meyers Squibb licensed its second-line drug,
Reyataz, completely free of royalties to generic manufacturers for India
and southern Africa. And through the World Health Organization's bulk
vaccine purchasing arrangements, manufacturers have been able to make
significant profits selling vaccines at low cost but large volumes. This
is the progress we want to build upon.

Pressure to broaden these efforts will grow, and it should. Agreement on
regional pricing tiers and distribution networks for H.I.V. drugs show
likelihood of solidifying in ways that make drugs available and support
innovation, but we have nothing like it for drugs for heart disease,
lung disease, or cancer. Meanwhile, the world is changing. The No. 1
cause of death in India, China, and Vietnam is not H.I.V. It's heart
disease. Cancer is in the top 10. Their people need clot-busting drugs,
chemotherapies, and EKG machines just like everyone else. Manufacturers
need to show the same willingness to make these life-saving technologies
available to the poor.

Some will argue, hey, companies just invent this stuff; it isn't their
job to make sure every country gets some. But that's not right. As
Arthur Caplan, the bioethicist, points out, "You aren't manufacturing
pantyhose when you're in health care. There are special moral duties
attached."

And one of them is: If you're building a lifeboat, you have to think
about how many you can get inside.

Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston and a
New Yorker staff writer, is the author of the new book "Better." He is a
guest columnist this month.



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Ann-Marie Sevcsik
Drugs for Neglected Diseases initiative
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+41 (0)79 814 9147 (mobile)
amsevcsik@dndi.org

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