June 5, 2002
President George W. Bush
Dear President Bush,
The upcoming meeting of the Group of Eight (G8) leaders in Kananaskis, Alberta, in Canada takes place at a time of much needed political attention to global health crises. Critical health issues include the HIV/AIDS, tuberculosis, and malaria pandemics, other less visible neglected diseases, and in particular the crisis in access to effective and affordable essential medicines for the treatment of these major killers in developing countries.
In Kananaskis, leaders of the world's wealthiest nations will review progress made in the fight against HIV and other infectious diseases. G8 leaders will either redouble efforts to support concrete, wide-scale access to treatment, resulting in millions of lives saved, or will squander the opportunity, leading to millions of preventable deaths. We are deeply concerned that the latter is now a foregone conclusion. Because of our medical presence in the field, and in particular our experience providing treatment for AIDS, TB, malaria, and other infectious diseases, Doctors Without Borders/Médecins Sans Frontières (MSF) cannot tolerate this level of indifference.
We have been profoundly disappointed by the lack of leadership of G8 countries, particularly the US, in terms of mobilizing resources and ensuring that the desperate need for access to treatment-the driving force behind the calls for greater attention to global health needs generally-is central to the global response to HIV/AIDS and other diseases. Your announcement last week of a "new" $500 million initiative by the US government to prevent mother-to-child-transmission (MTCT) of HIV in Africa and the Caribbean has diverted precious attention and resources from existing, cash-starved funding mechanisms such as the Global Fund to Fight AIDS, TB, and Malaria. This lack of funding could very well doom the Global Fund to failure. And as one of our field volunteers in Mozambique recently said, "Every rejected proposal that is linked to a lack of sufficient funds is a missed opportunity to save lives."
Furthermore, at the TRIPS Council meeting this week in Geneva, the US delegation will be advocating for a narrow and restrictive solution to the production for export problem highlighted in Paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health, which runs contrary to the spirit and letter of the Declaration.
Resources must be mobilized and policies enacted that allow for countries to implement wide-scale treatment programs for AIDS, TB and malaria-all of which are treatable diseases. Not-for-profit research and development toward effective and affordable treatments for other neglected diseases, such as sleeping sickness and kala azar, must also be actively supported. To this end, we urge you to support the following recommendations during the G8 Summit.
More Funds and Clear Treatment Policies are Desperately Needed for the Global Fund and Other Financing Mechanisms
At the June 2000 G8 Summit in Okinawa, Japan, and at the December 2000 Okinawa Conference on Infectious Diseases, an initiative was proposed to tackle major infectious diseases worldwide. This commitment was reiterated at international gatherings over the past two years, including the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in New York in June 2001, and the G8 Summit in Genoa in July 2001. The result has been the creation of the Global Fund to Fight AIDS, TB and Malaria (GFATM), whose board of directors met in New York in April 2002 to make its first grant disbursements.
The GFATM holds a promise-as yet unfulfilled-for the millions of people in Africa, Asia, Latin America, Eastern Europe, and other high-burden countries living with and dying from AIDS, TB and Malaria. While the UN Secretary General has made repeated calls for an annual fund of $7-10 billion alone to fight HIV/AIDS,1 total pledges to the GFATM by April 2002 were less than $2 billion, and the first grant disbursements from the GFATM in April2 have left it nearly bankrupt.
This is a shameful political failure of the richest countries of the world. Despite many lofty declarations of the past two years, it is painfully clear that G8 countries' actions lag far behind their words. Now is the time to concretely and frankly take stock of what has-and, importantly, what has not-been achieved since Okinawa and to boldly transform the ambitious goals and commitments that now exist only on paper into real, life-saving interventions.
The GFATM has yet to take a clear policy position supporting treatment as part of a comprehensive approach to fighting these three killer diseases. In the face of re-emerging calls to prioritize prevention strategies over treatment interventions, it is essential that the GFATM and other international financing mechanisms put this false dichotomy-which creates an unnecessary and artificially forced choice based only on the acceptance of the availability of scarce resources-to rest once and for all. Treatment and prevention must be seen as mutually supportive interventions that prevent or relieve suffering, and that synergistically contain and control the spread of deadly epidemics such as AIDS. Prevention and treatment strategies must go hand in hand, and patients already infected must not be written off as not "cost-effective" enough to treat. Access to treatment must be extended to all those infected, and not simply to those demographic groups that have political appeal.
Recommendation 1: To ensure that the largest number of people have access to effective and affordable treatment, G8 countries must urgently mobilize massive additional resources, and insist that the Global Fund Board take unambiguous policy positions that:
Increasing Access To Existing Medicines Through Equity Pricing: Transforming Announcements And Declarations Into Life-Saving Treatment
Over the past two years, there have been reductions in the price of many important branded medicines used in the treatment of communicable diseases, particularly antiretrovirals (ARVs) for the treatment of HIV. These price reductions have come about largely through public pressure from non-governmental organizations, and through the introduction of generic competition. Voluntary price reductions from the pharmaceutical industry are important, but relying on this strategy alone is limited, and dangerous from a public policy perspective. MSF has had disappointing experiences negotiating with companies offering reduced-price drugs through the Accelerating Access Initiative, and has found that the offers can come with onerous conditions and arbitrary restrictions. Brand name ARVs are still, on average, approximately three times more expensive than the lowest cost generic alternatives on the market.5 Prices of medicines and other essential health care goods remain a crucial issue because they have a profound impact on the number of patients treated.6
Strategies that rely on the charity and goodwill of the private pharmaceutical sector are fundamentally unsustainable. They do not represent a long-term solution to the access crisis, which must come through a combination of mutually supportive strategies that support equity pricing. Such a system can only be achieved through a deliberate coordinated effort by governments at the international level.
Recommendation 2: G8 countries must accelerate efforts to ensure that a system of equity pricing is supported and implemented. This must include:
The DOHA Declaration and the TRIPS Agreement: Transforming Paper Into Pills
At the 4th Ministerial Conference of the WTO held in Doha, Qatar, in November 2001, the world's trade ministers issued a landmark Declaration on the TRIPS Agreement and Public Health.7 This Declaration was an important achievement, giving clear primacy to the protection of public health over private intellectual property, as well as an unambiguous road map to all the key flexibilities in the TRIPS Agreement. However this declaration will only have a positive effect on access to medicines if industrialized countries actively support its implementation.
Recommendation 3: G8 countries must support implementation efforts that transform the Doha Declaration from a mere piece of paper into a concrete tool that enables developing countries to protect and promote public health. This support must include:
Neglected Diseases: Increase and Re-start Research & Development for New Health Tools
In the last few decades, major scientific advances have enabled the development of increasingly sophisticated medicines to cure a wide variety of diseases, including non-life threatening "lifestyle" conditions such as baldness and obesity. Global expenditure on health R&D has also increased dramatically. While the public sector has traditionally been the major funder of health research, the private sector has recently taken the lead. Global health research priorities are changing accordingly.
Today it is largely purchasing power that defines drug research and development agendas and priorities. The consequence is that poor people's health needs are left virtually unmet, and diseases such as sleeping sickness, kala azar, TB, malaria and Buruli ulcer remain grossly neglected in terms of research and development for effective and affordable treatments. Ten per cent of global health research is devoted to conditions that account for 90% of the global disease burden-an imbalance described as the 10/90 disequilibrium.9 Public policy failure compounds this failure of the market to produce needed medicines for the neglected diseases of the world's poorest people. Tinkering with market incentives will not stimulate the private sector to invest in drug development for patients suffering with these diseases in for example, Sudan, the Democratic Republic of Congo, or India. Their lack of purchasing power means that a 'viable market' does not exist to ensure the expected return on investment.
Without serious political commitment and a clear realization that there is a public duty to commit to health issues at a global level, advances in science and medicine will not alleviate the suffering of the millions of people who die of neglected diseases in the developing world.
Recommendation 4: G8 leaders must urgently address the crisis in R&D for neglected diseases by:
This letter outlines concrete steps that will increase access to essential medicines for the treatment of AIDS, TB, malaria and other less visible neglected diseases in the developing world, and contribute synergistically to prevention efforts for their containment and control. MSF believes that governments have an obligation to prioritize the needs of millions of people who will otherwise die without effective action internationally. Your leadership is key to a successful global response. For the upcoming G8 Summit, we urge you to support the recommendations in this letter.
Nicolas de Torrenté
cc: Colin L. Powell, Secretary of State, U.S. Dept. of State
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)