Why is it so difficult to ensure medicines for all?

Why is it so difficult to ensure medicines for all?

What is meant by “medicines for all” and how important is it?

In the United Nations Millennium Development Goals, the idea of “medicines for all” is an important and incorporated factor (UN, 2013). Goal 8E states “in cooperation with pharmaceutical companies, we aim to provide access to affordable essential drugs in developing countries”. The World Health Organization have also outlined “medicines for all” as something to be measured to quantify whether or not a developing nation is succeeding from the UN Millennium Development Goals. Indicator 8.13 is taken from “the proportion of the population with access to affordable essential drugs on a sustainable basis” (MDGS 2012). What this tells us is that medicines for all is a subject area of importance to the top organizations aiming to beat poverty and improve the lives of others. As well as this, the UN and WHO identify “essential drugs” as most noteworthy, and so it is apparent that essential drugs also needs to be addressed. The WHO have compiled a list of medicines which they believe are essential and should be not only available to all, but affordable and on a sustainable basis (World Health Organization 2014). The essential medicines list includes simple pain killing drugs such as paracetemol, ibuprofen, but also medicines such as morphine, codeine, insulin, diazepam, levothyroxine, vaccines, salbutamol, and even condoms. These are drugs which are easily accessible from over the counter or a general practitioner in the UK and other western countries. Thereby, to debate “why is it so difficult to ensure medicines for all?” is rather to debate “why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries?” To understand the importance of the question is to see the facts; “about one-third of the world’s population still has no regular access to essential medicines” (World Health Organization, 2004). The situation is never more apparent than in South Africa, with an extremely high HIV prevalence. The MSF South Africa (2009) explains how there are two lines of therapy for treating the HIV positive currently in South Africa, however, a substantial amount of people are failing both lines, and as Dr Eric Goemaere explains, MSF’s Medical Coordinator in South Africa, it is “unacceptable” considering there are a range of 24 different ARV therapies available in the UK. It is undeniable that medicines for all is not a topic to be ignored, however, the question should be re-addressed as “why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries?” as this is the underlying point “medicines for all” imposes.

Marxism

To question the difficulty of medicines for all invites subjectivity, as ‘difficulty’ in itself brings with it a form of measured adjective. The question offers theoretical opinions and therefore it is natural that the big schools of thought will have points to make on each theory. Notably, Marxism will have an interesting point of view. The ideas of Marxism include many criticisms of the Capitalist society and Capitalist markets. And so for a Marxist, they will criticise the way in which medicine acts as a commodity and the fact that there is a market for medicine when medicine is a necessary resource. The way in which a Marxist will approach each challenge to “medicines for all” tells us more about the challenges, and thus how each one can be tackled.

The first challenge: patents

Hoen (2013) analyses the difficulties of ensuring medicines for all by contextualising the matter at hand. Through explaining how the release of patented products in early aeronautical engineering accelerated the first successful airplane, she demonstrates how patent drugs are limiting the ability to provide accessible medication for the poorest countries in the world today. When India created a generic drug to tackle HIV, the rate of people with HIV sharply increased. Nonetheless, this is significantly positive as it meant instead of dying, people were now receiving treatment and living a HIV healthy lifestyle similar to those in the west. When the patent laws changed, new rules meant what India did is now illegal and this exemplifies the patent problem with drugs today. Patented drug laws state that “when a pharmaceutical company first markets a drug, it is usually only under a patent that allows only the pharmaceutical company that developed the drug to sell it” (News Medical, 2014). The expiration dates for these patents is now 20 years, outlined in the TRIPS agreement the World Trade Organisation established in 1994 (World Trade Organization, 2014).

Flint & Payne (2013) have also examined this major challenge in ensuring medicines for all. They extend the argument by suggesting that a HIV free generation is a realistic possibility and developing countries need to attack the World Trade Organization and developed countries after losing control of intellectual property rights. To achieve medicines for all, Flint and Payne argue for universal access. An opaque example of this is, as earlier mentioned, the basic two-line therapy the MSF South Africa (2009) identify for treating HIV in the country, compared to at least 24 different lines of therapy available in the UK. Patent laws means that South Africa cannot “copy” these drugs and they cannot afford to research or buy them for their own patients. Flint and Payne are suggesting that universal access is the only way to combat this as patent laws mean countries are heavily restricted in how much they are able to help their patients. With a disease as serious as HIV, it can be argued that patent laws allow for poverty and death.

The Marxist perspective credits Flint and Payne’s view, for a Marxist would argue that the instable drugs market means people from developing nations are forced into labour to prepare for when they will need healthcare. On a larger scale however, it also means that the instable and expensive drugs market stops developing nations from researching and developing their own drugs and therapies. In effect, if these countries were “allowed” to make their own, there would be no market and no profit for the rich west selling on their researched and developed drugs. A Marxist would say that the workers of developing nations have no choice but to submit to the exploitation as healthcare fees for when they fall ill or have a child are vital but unfairly too extortionate. Once again though, on the larger scale, developing nations have no choice but to submit to the exploitation of the rich west as they are the ones with the drugs and the knowledge, and so the ones with the power. For a Marxist, Flint and Payne are correct when they argue that the market needs to be eradicated and medicine should be universal.

The second challenge: lack of medication

One of the biggest problems with providing medicine for all is that there is a general lack of medication. Drugs are a finite resource, but the real problem is the lack of research, known in global health as the 10/90 gap (Lewis, 2002). The 10/90 gap is term used to describe how less than 10% of research and development in medicine accounts for the medicine needed by 90% of the world’s population.

Hogerzeil (2013) summarises the theory by explaining that medications for some conditions don’t exist, such as there is no heat-stable insulin for diabetics in tropic climates. Hogerzeil also explains that medicines that do exist are expensive, unavailable, of unassured quality, safety, efficacy, and may be formulated in unsuitable ways, for example, there are hardly any ARV medication for children with immunodeficiency syndrome. Hogerzeil argues that the difficulty in ensuring medicines for all is not monocausal, however the pharmaceutical industry plays a key, strategic role. He argues that if the pharmaceutical industry were to aim to ensure medicines for all rather than profits for themselves, then tackling the issue would be a great deal easier. Marxist point of view can strengthen this; the marketization of medicine means that profit is the motivation rather than provision and so to ensure medicines for all, it is extremely necessary to remove privatization and capitalist incentive. To extend the argument, there has been the neo-liberal counter to the question. Henry (2002) quotes the pharmaceutical companies who argue that “high drug costs are to compensate for the vast amount they invest in developing products”, but as Angell (2007) illustrates, $37bn was spent on research and development by 500 of the top US pharmaceutical companies in 2006, compared to $73bn they spent on marketing that year. This also amplifies the truth in the 10/90 gap, which altogether improves Hogerzeil’s and Marxist position that to ensure medicine for all we need to ensure that is the goal, and not ensure medicine for profit.

The Third Challenge: Lack of help and assistance

This challenge is best explained by the case study of Thailand. As argued by Songkhla (2009), the former health minister for Thailand, “medicines for all” is something unachievable in the current state of affairs because there is no support from those which can give the help. In the 00s, Thailand moved towards universalism and this included healthcare. They introduced compulsory licensing for universal coverage and essential medicines for all. However, this move faced global backlash. Developed nations retaliated with undue political pressure to end the introduction of safeguarding measures and cannot only be considered extremely “unhelpful”, but more destructive as they imposed trade sanctions and threats on Thailand’s lesser economy. Pharmaceutical companies are seen to have done a similar thing by applying pressure to Thailand to stop. It is considerably more shocking when the situation is compared to the Anthrax scare in USA and Canada. Governments of both countries distributed Ciprofloxacin universally to treat the infection, and the pharmaceutical companies allowed it to happen. There was no backlash to their universal approach to ensure medicines were available for all. Finally, the WTO and WHO lack of response and support to the situation left Thailand fighting on their own. Powerless themselves, the WHO’s minimal assistance highlights a problem in their own makeup in that a country trying to achieve one of their goals is burdened by rich nations and the organisation can’t do anything about it. The relationship can be argued as “under the thumb” in that the WHO serves the powerful nations, but what a Marxist may argue as Capitalist exploitation. Songkhla goes on to suggest that the debate has been left open purposely to discourage other middle-income and low-income countries from doing the same thing for public health purposes, regardless of the fact that Thailand have been successful in moving a step closer to ensure essential medicines for all. In 2008, there were 20,000 people receiving treatment for HIV/Aids compared to just 5,000 if the generic drug was not available. Songkhla concludes her argument by suggesting that global health governance needs to put human faces into their policy decisions when it comes down to health; “it is a moral imperative and global responsibility to ensure better access to essential medicines in other resource-poor countries”.

What this case study of Thailand can tell us is that if a low or middle income country is willing to put the effort in to reach “medicines for all”, there is no outside support for them to do so, especially if it’s done in a way that will not be advantageous for richer countries. In metaphoric terms, “the books are there but there isn’t a librarian around to help find the books needed”. The case study also signifies the powerless WHO and the free-market mind-set of the WTO, for which Marxist analysis would describe as the two organisations serving a Capitalist ideology; “medicines for all” implies universalism for which are not in the interests of pharmaceutical companies looking to make money off the ill-health.

The Fourth Challenge: Structural Adjustment Programmes

Structural Adjustment Programmes, or SAPs, are “economic policies for developing countries that have been promoted by the World Bank and International Monetary Fund (IMF) since the early 1980s by the provision of loans conditional on the adoption of such policies” (World Health Organization, 2014). Daly (2013) argues that the programs have made many developing nations roll back the state to a minimal model, and therefore many public sector services have been relinquished of government control. To expand on this, the argument is being made that one of the challenges to “medicines for all” is the inability of the developing nations to do as they choose because they are limited by the economic power of the World Bank and the IMF. Contrast to the powerless WHO, the IMF and World Bank can easily control the dynamics of developing nations and so have much more power than some may argue necessary. The structural adjustment programs, Daly argues, have undermined health policy and medicine which has been identified as crucial to the development of the workforce. Because the structural adjustment programs are established by the World Bank and the IMF, they have a free-market (or as a Marxist would argue, Capitalist) aim, and so are neo-liberal. The neo-liberal model within developing countries has made it particularly difficult to implement policy and health programmes. This is because the neo-liberal model requires debt to be the main priority – developing nations have to put debt repayment as the first objective before they can spend money on introducing policy programmes, including healthcare. Shah (1998) defines this as “the IMF and World Bank have demanded the poor nations lower the standard of living of their people”.

One good example of how Structural Adjustment Programs have worked to the detriment is explained by James (2002) and the trade of nuts from Senegal. Because Senegal was a poor nation with limited resources, they took out loans to grow and develop their nut industry. But because of their success, other countries began to follow suit and so the price of nuts worldwide plummeted, leaving Senegal with large amounts of debt and not enough trade to compensate for the money lost in the nut market. This left Senegal with little choice but to invest in structural adjustment programs, resulting in reducing the role of the government as well as cutting spending. Global Issues (2007) goes on to explain how “the pressure to embrace ‘free market’ economics, with its promise of a wealthy, abundant market place has actually driven many countries further into poverty”. With many developing nations being pushed further into poverty, the increased reliance of structural adjustment programs has never been more present and so it leads us to summarise that “medicines for all” is part of the bigger problem of resolving absolute poverty. Nevertheless, for this debate, it can be seen that medicines for all is so difficult to achieve because one challenge is the structural adjustment program limiting developing nations ability to tackle healthcare in the best way they can.

For a Marxist, this underlines more than ever the unfairness and exploitation Capitalism encourages. Richer, developed countries argue for free-market and less trade restrictions, yet they have the resources to do so, compared to the economically impaired developing world who are further limited by these structural adjustment programs. For a Marxist, medicines for all is not a plausible reality with the free market pressure.

Conclusion

In conclusion, there are 4 main challenges as to why it is so difficult to ensure medicines for all. As previously discussed, the debate should rather be why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries? The 4 challenges explain how the answer to this question explicitly lies in the gap between the rich and the poor: the rich have the economic power to be able to control the worldwide medicines market and so have been successful in establishing expensive and protected drug patents. As well as this, the rich pharmaceutical companies aim to make profit and so they will not try to reduce costs or create products which will not help them achieve their goal. Thailand provides an extensive case study of how the rich are in reality not trying to ensure essential medicines on an affordable, sustainable basis, additionally implying that the organization who is trying to achieve the goal, the World Health Organization, have no power to help. Finally, the structural adjustment programs put into context the limitations of developing nations of achieving medicines for all. One of the biggest schools of thought that promote medicines for all, Marxism, expose Capitalism as the reason for these challenges, arguing that they are the biggest evil of them all. However, in my opinion, the fact that medicines for all is a subject area of absolute poverty contributes to the reason why these challenges exist and the goal is so difficult to achieve. This is because to achieve essential medicines on an ‘affordable’ and ‘sustainable’ basis requires economic power and stability, and although this can be blamed for by Capitalism, it is more to do with the fact that those in need of the essential medicines are also in need of many things for which they are unable to afford and sustain, such as food and water. Therefore, I conclude that medicines for all is so difficult to achieve because it is part of the wider scope of absolute poverty, a problem which won’t be solved overnight.

References

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