The great medicines scandal

Sick people in poor countries are deeply disadvantaged. The millions who have “neglected” tropical diseases lack safe and effective drugs.¹ Those afflicted with “Western” diseases (and 80% of the 35 million annual deaths from chronic diseases occur in low and middle income countries²) can ill afford treatment, a new report states.³

The failure of pharmaceutical companies to invest in research and development of medicines for neglected diseases is long standing. A recent analysis shows that only 21 of the 1556 new chemical entities marketed between 1975 and 2004 were targeted at African trypanosomiasis, leishmaniasis, helminthic infections, schistosomiasis, onchocerciasis, Chagas' disease, malaria, and tuberculosis.¹ Ten of the 21 drugs—including four of only five developed since 1999—were marketed for malaria and tuberculosis.

A different but no less bleak situation is exposed in a new report on medicines for chronic diseases.³ This presents data collected between 2001 and 2005 on the price, availability, and affordability (in both public and private sectors) of a core list of drugs used to treat diabetes, hypertension, asthma, epilepsy, and psychiatric disease in 30 low and medium income countries drawn from all six WHO regions.

Although the picture varies from country to country, common threads emerge. Governments are usually able to purchase drugs at prices close to their international reference price, but in many countries the availability of medicines in the public sector is extremely limited. In addition, the taxes and duties levied on medicines, and the mark-ups made by dispensing doctors and pharmacies, result in high—often prohibitively high—prices for patients. Availability is better in the private sector but prices range from three times to 100 times the international reference price.

The standardised methodology used in the surveys includes comparisons of the cost of a standard course of treatment in each country with the daily pay of the lowest paid unskilled government workers (see figure on bmj.com).⁴ The report's findings make explicit what has long been recognised: that the cost of medical care impoverishes or is simply beyond the reach of many people in developing countries.⁵ Its recommendations thus are unsurprising. All countries, the report states, should measure and monitor the price, availability, and affordability of essential medicines and develop, implement, and enforce policies that lower costs and increase availability.

Amid the gloom, however, there is some light. Simply collecting data and presenting it to governments can stimulate action. (Many governments are unaware of what its citizens pay for drugs, two of the report's authors told the BMJ.) In the Lebanon, the survey included in the report was done by the Ministry of Health, and in response it reduced a number of fixed drug prices. In Kuwait, access to free essential medicines was extended to non-Kuwaitis after its survey was published. Current efforts to develop new drugs for neglected diseases offer further encouragement. Research undertaken by the public-private partnerships set up over the past five years has a good chance of delivering eight or nine new chemical entities within the next five years.⁶

Furthermore, thanks to persistent and passionate lobbying by Kenya and Brazil, augmented by the input and signatures of 5000 eminent scientists, physicians, policy makers, Nobel prize winners, MEPs (members of the European Parliament), and industry representatives, a landmark resolution was adopted at last week's World Health Assembly. This commits the World Health Organization to producing a blueprint for a new system of prioritising and financing pharmaceutical research aimed at stimulating the development of drugs, vaccines, and diagnostics for diseases that member states identify as health priorities: a marked contrast to the status quo, where priorities and prices depend primarily on Western based industries. One of the most important suggestions of the resolution is that incentives for research and development should be linked to health outcomes.

Shock and sadness at Dr Lee Jong-wook's untimely death permeated this year's World Health Assembly. If WHO's commitment to redress the research imbalance delivers on its promise to provide more effective and affordable medicines for the most disadvantaged sick people in the global village, there can be no more fitting legacy.