From company boardrooms, it might seem that many sacrifices have been made. But few patients in developing countries are aware of these efforts. Progress in reducing drug prices has depended mostly on market competition (which the industry, through lobbying on global trade rules, is trying to squash) and media attention (which is fickle and exhaustible).

"The doctor's role goes from caregiver to undertaker. You talk to them about the cheapest method of burial. Telling them about the drugs is always kind of a cruel joke," said Dr Chris Ouma of Kenya, where 2.5 million people are infected with HIV, and most cannot afford AIDS drugs

Millions of people in the developing world are dying because they cannot access the medicines they need. This made international headlines during the World Trade Organisation's meeting in Seattle in December 1999Sleep less in Seattle. Lancet 1999;354; 9194.. The high price of AIDS drugs became a banner of the world's iniquities: on one side of the globe, Western multinationals made billions of dollars; on the other side, millions of people suffered and died of treatable infectious diseases.

For decades the pharmaceutical industry was the Golden Boy of Wall Street. By the end of the 1990s it began to acquire a new reputation, featuring as the villain of spy novels (like John Le Carre's The Constant GardenerLe Carré J. The constant gardener. London: Hodder and Stoughton, 2001) and Hollywood blockbusters (like Mission Impossible II). The industry has responded to growing public criticism by reducing some drug prices for some countries. From company boardrooms, it might seem that many sacrifices have been made. But few patients in developing countries are aware of these efforts. Progress in reducing drug prices has depended mostly on market competition (which the industry, through lobbying on global trade rules, is trying to squash) and media attention (which is fickle and exhaustible).

Drug prices down, but not nearly enough

Three years ago AIDS treatment cost $15,000 a year whether you lived in London or Lusaka. Today, some pharmaceutical companies provide discounts for sub-Saharan Africa. This is clearly good, but companies are not doing all they can. At the beginning of 2003, while one company was claiming that "the pace is picking up" in providing antiretrovirals to poor countriesHirschler B. Aids drugmakers say they're boosting Africa supply. Reuters, 14 January 2003. (accessed 29 May 2003), another was charging $2,000 a year more for its AIDS drug in Guatemala than in SwitzerlandRoche cuts price of AIDS drug to nations. Associated Press, 13 February 2003. (accessed 29 May 2003).

The responsibility to ensure access to essential medicines lies with governments. In 1996, the Brazilian government began to provide AIDS treatment for all in need by making their own version of expensive brand drugs, reducing costs by around 80%. Over 115,000 people in Brazil now receive antiretroviral treatmentGalvão J. Access to antiretroviral drugs in Brazil. Lancet 2002;360: 1862-6.[CrossRef][ISI][Medline].

But few have been able to follow Brazil's example: only 5% of the six million people in the developing world who need antiretroviral drugs are receiving them. The problem extends well beyond AIDS: access to treatment is denied for many people who have diseases such as leukaemia, pneumonia, and diabetes, because brand medicines are too expensive. In many cases generic drugs are much cheaperWorld Health Organisation/Health Action International. Medicines prices. WHO/HAI, Geneva, May 2003.  (accessed 29 May 2003).. Although the right of governments to override patents whenever needed was affirmed at the World Trade Organisation's November 2001 meeting, few developing countries have the manufacturing capacity to make their own medicines, so they depend on exports from countries like Brazil and India that produce quality, affordable generics.

Summary points

Most medicines are developed in the West, for use in the West, and priced accordingly This seriously undermines the doctor-patient partnership in the developing world, where many medicines are too expensive, others are old and ineffective, and some diseases are completely untreatable because no medicines have been developed The pharmaceutical industry's efforts to date are insufficient Governments worldwide must make greater efforts to ensure the development of and equitable access to medicines

Essential goods as luxury products

Medicines are big business. The pharmaceutical industry is among the most profitable in the world, with profits nearly four times the average. Because market prospects, not health needs, drive production lines, drugs are developed for Western diseases while diseases of the developing world are ignored.

Lack of profits dictated that eflornithine, a lifesaving drug needed by hundreds of thousands of people with sleeping sickness in Africa, was withdrawn from production in the 1990s; this left doctors with a 50 year old, arsenic based drug—which is becoming increasingly ineffective and whose side effects kill 1 in 20 patients. (Eflornithine production was later restarted, but long term production is not guaranteed.)McNeil D Jr. Profits on cosmetic save a cure for sleeping sickness. New York Times 2001 February 9.

In many clinics throughout the developing world doctors are forced to use old drugs that are toxic and don't work well. For some diseases, no medicine is available at all. Buruli ulcer, a disfiguring and debilitating infectious disease, is a good candidate for antibiotic treatment, but because no drugs have been developed the only option is surgery, including amputation.

Industry can be relied on for another half a dozen impotence drugs, but the next generation of tropical medicines is nobody's business—only 1% of medicines developed in the past 25 years are for tropical diseasesTrouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N, Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet 2002;359: 2188-94.[CrossRef][ISI][Medline].

Better business behaviour  

A group of major UK investors recently published a report urging drug companies to improve poor people's access to medicines Dyer G. Investors warn drugs industry of backlash over health crises. Financial Times 2003 March 24..

The report proposed a framework of good practice to audit companies' behaviour on issues like anti-monopoly enforcement, fair pricing, and unfair use of political influence.

The response of the Association of the British Pharmaceutical Industry to the concerned share-holders was: "The problem is not the attitude or commitment of the pharmaceutical industry. It is one of poverty, lack of infrastructure, and lack of political willCurl A. Patents are no bar to healthcare for the poor. Financial Times 2003 March 28.. "Everyone's fault, in other words, but not the industry's. And yet the drugs industry can do much to contribute by reducing prices systematically for poor countries and directing some of its enormous drug development capabilities to neglected health needs.

Ensuring social responsibility from industry in the long term depends on socially responsible government policies. An international convention should be developed to ensure that new medicines are developed according to global health needs, and equitable drug pricing should be ensured through a mandatory framework. However, such policies are unlikely to be forthcoming while the pharmaceutical industry continues to influence government to the extent it currently doesAbrahams J. The pharmaceutical industry as political player. Lancet 2002;360: 1498-502.[CrossRef][ISI][Medline].

The director of the International Pharmaceutical Manufacturers Federation recently said: "For people with no income or little income, price is a barrier. I mean I can't afford certainly a car of my dreams, you know, which might be a Jaguar XJESaving grace: defeating Aids needs a global approach. Guardian 2003 February 18. Guardian article (accessed 28 May 2003).."But medicines are not the same as sports cars, and patients are not consumers: they cannot choose between AIDS and leukaemia, and few can move from Guatemala to Switzerland. Over 90% of the world's medicines are produced in Western countries by companies that develop drugs according to profit prospects, not health needs.

This needs to change. While medicines are treated like luxury consumer products, millions in poor countries will continue to go without the lifesaving medicines they need, and doctors will continue to play the part of undertaker, advising on funeral costs because it is the only option availableVick K. African AIDS victims losers of a drug war. US policy keeps prices prohibitive. Washington Post 1999 December 4..