“The arc of the moral universe is long, but it bends towards justice.” – Dr. Martin Luther King, Jr.
The past few years have produced a flurry of films documenting (e.g. Fire in the Blood and How to Survive a Plague) and dramatizing (e.g. Dallas Buyers Club) the fight for access to medicines during the early days of the AIDS pandemic. These popular films provide an excellent entry-point into one of public health’s great triumphs. The courage of individuals and unprecedented mobilization of transnational civil society saved millions of lives and transformed the political landscape, helping to reverse the course of a disease once thought to be unstoppable.
However, these films—always set in the past—risk leaving the public with a perception of the campaign for access to medicines as an historical phenomenon. This post attempts to rectify this misconception, showing that, despite the enormous strides made in providing more affordable medicines for those living with HIV/AIDS, much remains to be done. While campaigners have won several strategically significant battles, the war continues unabated.
In particular, this post will focus on three significant battlefields: threats to previous progress (e.g., new trade agreements), the lack of affordable medicines for non-communicable diseases, and the failed global governance system. Threats of Backsliding
Many of the most significant victories in access to medicines have come by achieving popular support for the idea that ensuring life and health ought to take priority over blind devotion to intellectual property rights. Victories such as the WTO Doha Declaration—which reaffirmed countries’ rights to protect public health by making use of flexibilities contained in the TRIPS Agreement—and pharmaceutical companies’ decision to drop their claims in the infamous “Big Pharma vs. Nelson Mandela” case, were significant victories that gave activists leverage and paved the way for vastly cheaper antiretrovirals in developing countries.
Unfortunately, much of this progress is now under threat. Negotiations, led primarily by the United States and other rich countries, are attempting to convince developing countries to give up many of the tools and flexibilities available to protect public health in exchange for better access to rich country markets. These so-called “TRIPS-plus” agreements (among the most prominent is the Trans-Pacific Partnership Agreement or TPP) threaten to reverse much of the hard-won progress made in the last two decades. Moreover, these negotiations are taking place in near-total secrecy and without the opportunity for any meaningful participation of non-governmental groups. The voices of civil society organizations, such as patient groups, are thus drowned out by those of trade ministers and commercial interests. The Rise of Non-Communicable Diseases
Second, most of the gains made in access to medicines have been concentrated on drugs to treat infectious diseases, particularly HIV/AIDS. However, thanks in large part to the progress made in preventing deaths from such diseases, the burden of disease is shifting to non-communicable diseases (NCDs), for which drugs remain unconscionably expensive. Nearly 80% of NCDs now occur in low- and middle-income countries, but a year’s supply of lifesaving drugs can cost tens or hundreds of times the average salary.
Rallying government and popular support for access to these drugs poses unique challenges. AIDS funding began flowing largely because the disease was framed as a security threat. Its fast spread and high mortality rate, particularly among working-age adults, threatened to decimate countries’ workforces and destabilize governments. Indeed, the bill authorizing PEPFAR—the largest program providing drugs to those living with HIV/AIDS, sponsored by the United States government—focused explicitly on the security threat the pandemic posed. Making a similar argument for NCDs, which tend to occur later in life and are common in both the developing and developed world—and are thus less novel a threat, will be more difficult. (It is worth noting that NCDs do cause significant, and increasing, harm to the global economy). In short, simply repeating the advocacy techniques used for HIV/AIDS is unlikely to be effective. Campaigners will need to be willing to retool their strategies and messages in response to a different sort of epidemic. Unsustainable Governance
This leads to a final point: a sustainable solution will not be possible without fundamental governance reforms and innovative non-governmental initiatives . Most progress thus far has been based on piecemeal—and too-often reversible—gains. As discussed earlier, much of civil society groups’ time and effort is spent refighting the same battles in an attempt to prevent erosion of previous gains. Moreover, too much depends on the whims of private industry and government donors. Were rich country aid programs and voluntary pharmaceutical company agreements to end, the majority of those currently on antiretroviral therapy would lose access to these lifesaving drugs. A system that depends so much on voluntary contributions is neither sustainable nor just.
A fundamental rethinking of global priorities and governance is needed, along with innovative solutions for providing new drugs at affordable prices. Many promising proposals have been offered. The World Health Organization is currently contemplating a Biomedical Research & Development Treaty that would impose binding obligations on countries to contribute to R&D for neglected diseases (although rich countries are fighting hard against it). Other proposals, such as the Framework Convention on Global Health (FCGH), would focus on global health more broadly. Such treaties would help counterbalance other international law, such as trade agreements, giving access to medicines a more prominent place in international law.
Working within the current governance system, organizations such as UNITAID are attempting to reshape markets, using tools like the Medicines Patent Pool to help promote generic competition. Other organizations, such as Knowledge Ecology International, promote various mechanisms, such as prize funds, to delink the costs of medicines from research and development expenditures. This is merely a sampling; there are myriad other initiatives designed to reform domestic and global governance or to create innovative solutions to make medicines more affordable—and the system more sustainable.
This post has attempted to highlight a few of the battles that still lie ahead for access to medicines groups and campaigners. In the short term, broad political support needs to be generated to fighting threats to progress already made and to expanding this progress to new disease conditions, such as NCDs. In the long term, governance needs to be reshaped to given preference to health and innovative solutions must be found for progress to be stable and sustainable. Challenges abound, but the end result—rectifying one of the gross injustices of the modern world—is well worth the effort.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.