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In global public health, it’s politics versus patients
Part II, Ideology Unhinged

Philip Stevens
Medical Progress Today
July 25, 2008

The powerful NGOs, however, demanded that treatment should take the highest priority. The WHO bowed to this pressure and created its ill-fated '3 by 5 programme', which hoped to put three million people on treatment by the end of 2005. This failed to hit its (arbitrary) target, infections continue to rise, and treatment is delivered in a haphazard manner. Globally, treatment programmes consume far more of the spending pie than prevention (including in the US's AIDS programme, PEPFAR)

Worse, in a bid to drive down costs, the WHO succumbed to activist pressure to rely on cheap and potentially sub-standard copy drugs. This risked the safety of thousands of poor patients, as well as the emergence of new drug-resistant strains of the virus.

Meanwhile, AIDS activists accused the South African government of inhumanity and of being dilatory for not following the WHO treatment model—one that revolves around getting as many people on treatment as quickly as possible. In reality, South Africa took its time in building up health infrastructure in a sustainable way, so that treatment could be delivered and monitored safely. By ignoring the activists, South Africa now has the highest number of patients on treatment in the developing world (outside of Brazil) and is a model for other countries.

A similar political hijacking occurred with malaria treatment. For many years, countries from India to South Africa successfully controlled malaria by spraying the inside of houses with DDT. From the 1960s, environmentalists and NGOs played up scientifically unsound scare stories to demonize the pesticide and subsequently pushed WHO to stop recommending its use, which it did following a resolution at the 1997 World Health Assembly. Malaria cases soared globally.

Recently, however, South Africa unilaterally reintroduced DDT spraying and, as a result, cases plummeted. Encouragingly, WHO in 2007 took DDT off its black-list, and USAID and the Global Fund have recently decided to finance DDT spraying once again.

Activists have also managed to distort the debate around intellectual property and public health. Activist NGOs such as Doctors without Borders consider the notion of intellectual property and profit in medicine unethical, and have for many years been pushing to nationalise where possible drug R&D. Their effective and emotive campaigning has narrowed the debate about health care in poor countries to a single, fallacious, premise: Patents drive up the cost of medicines, so patents are bad.

This is based more on anti–capitalist fantasy than solid analysis. As anyone who has visited Africa will tell you, access to quality healthcare is far more dependent on the existence of functioning health infrastructure than on pharmaceutical intellectual property rights. In most developing countries, doctors, nurses and clinics are in very short supply. What other explanation is there for India's appalling record on healthcare, when it has had for years a massive generics industry churning millions of cheap copy drugs?

The consultative status afforded by the UN to these NGOs made it easy for them to start turning their rhetoric into policy. In particular, by working through the Kenyan government, and latterly the governments of Bolivia and Barbados, these NGOs have managed to set in motion a whole string of policy initiatives that have the goal of undermining market-based drug R&D and replacing it with various state-driven interventions—such as state–funded prizes, compulsory patent pools, government–funded clinical trials, and even an R&D treaty.

If the more outlandish of these proposals ever become part of a legally binding, international treaty, the consequences for pharmaceutical innovation will be severe, as property rights and other private sector incentives are eroded.

There are lessons in all of this for US as it considers its international aid commitments. The Senate recently approved a $50 billion re–authorisation for PEPFAR over the next three years, which will constitute the lion's share of the soaring global AIDS budgets. The US is also the largest contributor to the operating budget of the WHO, which has made many politically–influenced mistakes on global health, and is now attempting to dismantle the system which has underpinned pharmaceutical innovation.

With America's high financial commitment to global health, it has a duty to patients everywhere to make sure its money is properly spent. Making sure that the WHO bases its programs on clinical and economic evidence, rather than ideology, would be a good start.

To read the first part of this special Spotlight article, click here.

Philip Stevens is director of policy at International Policy Network, a London-based development think tank.

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