Originally appeared March 26, 2001, in the author's "TRB From Washington" column, The New Republic.
Let's see if I can paraphrase the current consensus about drug companies and AIDS in Africa. Oh, why bother when I can simply quote Anthony Lewis? Here he is:
In the United States and Europe, the anti-retroviral drugs that have made AIDS a containable disease for many sufferers cost either the patient or the society $10,000 to $15,000 a year. It has been widely assumed that poorer countries cannot afford them, and in any event do not have health systems that could use them effectively. ... [Tina Rosenberg in The New York Times Magazine] showed that those assumptions are false. Brazil now makes the drugs itself and has cut the cost by nearly 80 percent; government commitment has produced clinics to supervise the treatment effectively. Many lives, and much money, have been saved. The big drug companies are frantically resisting the precedent. And they have great lobbying power in the United States, achieved by campaign donations.
Voilà! AIDS in the developing world, described by Lewis as "the most profound and immediate threat to life on earth," is easily solved. Only the evil drug companies, abetted by evil Republicans, stand in the way - companies whose only argument is their ability to buy politicians using campaign cash. The only problem with this line of thought is that the drug companies, not all of which are "big," actually do have an argument, and the closer you look, the stronger it is.
Start with a simple question: Ever wonder how we have drugs to treat HIV in the first place? Lewis doesn't address this, but those of us who are alive today because of those drugs have had reason to figure it out. You could argue that anti-AIDS drugs are the gift to the world of legions of brilliant scientists and researchers. But that misses the point. The reason we have a treatment for HIV is not the angelic brilliance of anyone per se but the free-market system that rewards serious research with serious money. Ever wonder why the vast majority of such treatments come from U.S.-based companies? Because European pharmaceutical companies have been clobbered by socialized medicine and have moved much of their research and production to the United States. (Ten years ago, half of the ten top-selling drugs in the world were made by European companies. After a decade of price controls and regulation, Europeans now make only three of the top 25.) Ever wonder why Indian scientists are working in U.S.-based labs rather than in India? Because our free-market system gives them incentives to discover rather than reasons to flee. The knockoff companies in India and Brazil so beloved by the left are at best copiers of American products and at worst thieves. They're the Napsters of the drug world - only worse, because they charge for what they steal rather than give it away for free.
So the hard question is: How do we maintain the system that gave us these drugs in the first place while getting them to the largest number of infected people? It seems to me that the recent offer by Merck to sell key anti-retrovirals at one-tenth their Western price is an admirable, if partial, answer. HIV, after all, is not like cancer. It is an epidemic, spreading exponentially across the globe. Waiting for patents to run out and prices to drop in the natural course of events is a death sentence for a generation or more. As long as the domestic markets remain unmolested by populists and regulators, a massive discount from the major pharmaceutical companies for poor countries overseas is actually a stunningly generous gesture. Drug companies, after all, are not designed to cure diseases or please op-ed columnists. They're designed to satisfy shareholders. At least that was the shareholders' assumption when they invested.
What if the drugs are still too expensive? Well, that's where governments and international organizations come in. If we wanted to, we could go a long way toward funding discounted HIV meds for the developing world from Western taxpayers' pockets. In saved lives and rescued economies, it would pay for itself. Besides, in times like this it's simply the right thing to do. But such aid should come with realistic caveats. It's vital to ensure that these meds are taken in the right amounts at the right times - or else they will be ineffective in the patient and generate incurable viral strains in the process. Believe me, ensuring this is harder than it sounds. For almost eight years now I've juggled more than 30 pills a day - with food, without food, at night, in the morning, and on and on. Every year or so the regimen changes. I have more than ten prescriptions to keep track of. Most of the time, you feel sick and exhausted after a dose - a subtle but deep incentive to put off taking it, forget, or just give up. I'm not whining, I'm just making a point. Even with educated, motivated patients, 80 percent adherence is an achievement - and 80 percent still means new drug-resistant viral strains gain a niche in the population at large.
Now think of the consequences of doling out hundreds of pills to people who can barely afford a decent meal or a regular trip to the doctor. Keeping track of the drugs will be hard enough. If Western food aid results in massive theft, corruption, and re-exportation, can you imagine what Africa's kleptomaniac dictators could do with expensive HIV meds? Sure, Brazil has shown that drugs can be successfully administered in controlled circumstances. But Brazil is currently an exception to the rule. Elsewhere our best bet is modest, controlled treatment centers where anti-HIV drugs are delivered with medical monitoring and advice. If these work, let's expand them.
For those without access to these drugs, we can also do a lot, and quite cheaply. For people with AIDS there are plenty of relatively inexpensive post-patent drugs with simple dosings to treat the opportunistic infections that prey on depressed immune systems. This can relieve at least some of the pain and suffering, even if it cannot solve the underlying problem.
This means, tragically, that most people with HIV right now will die of it. That is an appalling prospect - as appalling as the thousands who die of dysentery for lack of clean drinking water or who are killed in war, lost in childbirth, or ravaged by malaria. In the face of this, there is the duty to do all we possibly can. But there's also an imperative not to engage in rituals of easy blame, or to attempt something that cannot realistically be achieved, or to demonize those who are a critical part of the solution. In the current debate, it's worth remembering one simple thing: Most African and Western governments have done virtually nothing to halt this global epidemic and are still balking at major aid. The American private sector, which has been responsible for the lion's share of HIV research, is now offering to pay for 90 percent of the cost of drugs for the developing world at the expense of future profits and research. Now you tell me who the real villains are.