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This week, the Washington Post reports that, even in some countries with lesser standards of living than the US, access to medical care surpasses ours.  In Thailand, only 1% of the population lacks health insurance.  The Mexican government created a safety net to insure 50 million people who are not covered by existing plans.

And in former communist countries, the urge to capitalize medical treatment that followed the fall of the Soviet system has been replaced by a social-service sensibility:

Two decades ago, many former communist countries in Eastern Europe and elsewhere dismantled their universal health-care systems amid a drive to set up free-market economies. But popular demand for insurance protection has fueled an effort in nearly all of these countries to rebuild their systems. Similar pressure is coming from the citizens of fast-growing nations in Asia and Latin America, where rising living standards have raised expectations for better services.

In the US, about 50 million people have no health insurance, roughly 16% of the population.  This percentage rises for the poor:  a 2009 study by the Kaiser Family Foundation reported that 45% of low-income Americans under the age of 65 have no health insurance.   The Affordable Care Act of 2010 will reduce these numbers — but we won’t know until next month whether the Supreme Court will find some or all of it unconstitutional.

Even if the ACA stands, it doesn’t abolish for-profit insurance companies (or constrain their power much), and its direct effects on the costs of medical diagnosis and treatment remain to be seen — so while more Americans will have insurance, some will continue to be unable to pay for some of their care.

Big question: why is the US different from Thailand, Mexico, or China?  What makes the idea of universal access to medical treatment so complicated for us when it seems to be increasingly simple for countries that have lesser GDPs?

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AFP reports that the Indian drug manufacturer Cipla will drastically reduce the price of three important cancer drugs — each of them under patent to one of the big western pharmaceutical firms.  With Cipla’s new pricing scheme, the drugs will be purchasable for about 25% of the price charged by the patent holders, Bayer, AstraZeneca, and Schering.

As the Wall Street Journal reports, the break point came when the Indian patent office required Bayer to grant a license to an Indian manufacturing firm (not Cipla, actually) for its liver/kidney cancer medication Nexavar.

The head of the European Federation of Pharmaceutical Industries and Associations said that the companies would prefer to make drugs affordable through so-called tiered pricing schemes, wherein the price of a drug varies from country to country in regard to local cost of living.

In a 2009 article in Global Health magazine, Andrew Jack notes that some big pharmaceutical companies have lowered their prices to try to compete in the huge Indian market, including selling the diabetes drug Januvia (Merck) for one-fifth its US price.  GSK, Jack notes, even has different prices in different parts of India.

Tiered pricing or patent busting — a big problem remains unresolved:  even when prices are lowered to $100 per dose, many people can’t afford them.  Last year, an article in The Economist showed results of surveys by Abhijit Banerjee and Esther Duflo:  over 90% of respondents in rural India (and about 80% of Pakistanis, 70% of Bengladeshis, etc.) live on $2 a day or less.  For such households, the cost of a single dose of cancer medication — even at the Cipla price — is equivalent to weeks worth of food.

A Reuters article today describes the problem of access to cancer medications for India’s poor.  Even though India has allowed local manufacturers to make a cancer drug that is elsewhere patented by Bayer, and might allow the same to happen with Novartis’s Gleevec, many Indians are too poor to afford even the generic medications.

With around 40 percent of the population living below the poverty line, healthcare is an upper-middle-class luxury in much of India where spending in private clinics is four times the amount of that in government hospitals. The poorest would-be patients literally beg for treatment on the outside of a chronically underfunded and overstretched health system.

If compulsory licensing still leaves millions of people untreated, what else should be done?

A briefing paper issued by Doctors Without Borders (Médecins sans Frontières) takes issue with Novartis’s response to the contention that the company should not be granted a patent on the leukemia drug Gleevec in India.

Basically, the humanitarian organization disagrees with Novartis’s claim that there’s no connection between patent protection and drug cost/availability.  They explain their own experience, for instance with patent protection on AIDS meds:

When AIDS treatment first became available in the late 1990s, the price of first line patented AIDS medicines was—even after discounts—US$10,439 per patient per year. Millions died in developing countries, particularly in Africa, as prices were too high. Generic competition brought prices down, making treatment possible.

And, whereas Novartis argues that it should be able to have a monopoly on Gleevec in India because 40 other countries have recognized its patent, MSF says

Although the World Trade Organization’s (WTO’s) … TRIPS Agreement obliges all WTO members, including India, to grant patents on medicines, nothing obliges developing countries to replicate the patent systems of wealthy countries.

The Gleevec suit will be decided by an Indian court at the end of March.  Meanwhile, there’s a new development in a related case:  This week, India used compulsory licensing to grant the right to make a different cancer drug, sorafenib tosylate (used for kidney and liver cancers), breaking Bayer’s monopoly.

The director of MSF’s Access campaign said

When drug companies are price gouging and limiting availability, there is a consequence: the Patent Office can and will end monopoly powers to ensure access to important medicines. If this precedent is applied to other drugs and expanded to include exports, it would have a direct impact on affordability of medicines used by MSF and give a real boost to accessing the drugs that are critically needed in countries where we work

 

 

Today’s New York Times offers a long article on the case before India’s Supreme Court regarding licensing of off-patent versions of the leukemia drug imatinib.  Currently Novartis sells this under patent as Gleevec.  The article mentions the potential implication for availability not only of this effective cancer medication, but also for AIDS medications worldwide.  For the pro-patent case, the website IP Watch gives extensive coverage to the industry contentions and intellectual property aspects.

Today, the American Academy of Pediatrics recommended that boys in the US be immunized against human papillomavirus (HPV) beginning at age 11-12, just as they had previously recommended for girls.  The recommendation is to use Gardasil, the vaccine produced by Merck.  It should cost about $360 per person for the 3-dose schedule, not including fees for clinic visits.

By protecting against infection with HPV types 16 and 18, which are associated with development of cervical, penile, and anal cancers (and have been reported in conjunction with some oral cancers), Gardasil is meant to be a cancer vaccine.

What does this mean for people in poor countries — where cervical and penile cancer are much more common than in the US, but the vaccine at American prices would be prohibitively expensive?  There are an estimated 500,000 new cases of cervical cancer worldwide, of which only about 12,000 (2.4%) are in the US.  Penile and oral cancer are even rarer here.

So is Merck using the world burden of cancer as an excuse to sell vaccine that the people who need it — primarily women in poor countries — won’t be able to afford?

Merck has begun an initiative to make Gardasil available in the rest of the world.  They say they will donate 3 million doses of the vaccine (enough to immunize a million people — about 2 years’ worth of new infections) over the next 5 years.  Some of this will be done through the Global Vaccine Initiative, GAVI.

A survey by a York College anthropologist, Prof. Mark Schuller, showed that only a minority of respondents in Port-au-Prince think the UN Stabilization Mission (MINUSTAH) troops are a “good thing” in Haiti.

In describing the results, Schuller points out that more Haitians seem to think the presence of UN troops is a bad thing, and that this is especially true among women.  He also argues that MINUSTAH troops are not helping the security situation.

The results of this sur­vey pro­vide fur­ther con­fir­ma­tion that there is lit­tle sup­port for MINUSTAH in Haiti’s cap­i­tal city. A major­ity of respon­dents wish to see MINUSTAH forces depart within a short time frame and con­sider that the UN force should be held account­able for the mas­sive human dam­age caused by the intro­duc­tion of cholera to Haiti. Fur­ther­more, only a minor­ity of respon­dents con­sid­ers that MINUSTAH helps enhance secu­rity in their neigh­bor­hoods.

Why is MINUSTAH in Haiti?  The force was created in 2004 to deliver aid and maintain security.  It was re-authorized and expanded after the January 2010 earthquake, which killed about a quarter-million Haitians.

But Nepalese MINUSTAH troops have been blamed for starting the cholera outbreak there, as Schuller alludes in the above quote.  The Nepalese left their country for Haiti in 2010 at a time when cholera had broken out in their homeland.  The strain of cholera bacteria causing illness and death in Haiti was essentially identical to the Nepalese strain.  Originally, the UN denied that the Haitian cholera strain came from Nepal, but had to reverse itself later.

(I don’t agree with the finger pointing at Nepalese troops, or the UN.  As I argued back in November 2010, cholera is a disaster that signals a lack of resources and a failure of political will.)

Another problem:  MINUSTAH troops from Uruguay and Brazil have been charged with rape and other sexual violations in Haiti.  The most recent allegations, involving sexual exploitation of minors, were leveled just last month.

What should we make of international relief efforts in Haiti, then?  The Center for Economic and Policy Research reports that as NGOs leave, water quality is declining — a big issue, since the real cause of the cholera outbreak was the government’s inability to deliver clean water to the Haitian people.

If relief agencies withdraw, will Haitians get more autonomy but less safe drinking water?  And will MINUSTAH’s withdrawal, if it happens, help Haiti have the resources to provide the necessities of a healthy life to Haitian people?