Bringing attention to certain medications that everyone should ideally have access to by highlighting them as the “essential medications” seems like a good idea. But who gets to decide what medications are essential or non-essential; where do we draw the line? The criteria for the first list of essential medications in 1977 were based on clinical trials of safety and efficacy conducted in the global North (mainly developed countries) and cost-effective analyses in a developed nation’s economy (Greene, p. 19). Does this make sense, considering health outcomes and access to health care are vastly different between developed and developing nations as well as within each category?
As Jeremy Greene explores the (surprisingly) recent history of pharmaceuticals in global health in his article, many questions regarding “essential medications” come to mind. Something that worried me about defining essential medications in the form of a list was that such a list would affect how insurance companies consider coverage for certain medications over others. A focus on medications used to treat common diseases (Greene, p. 18), may pull attention away from essential medications for rare diseases. This could be connected to multiple harmful effects: pharmaceutical companies may not have much incentive to invest in research and development of new medications to treat those rare diseases because such products would only yield small profits from a small market, and health insurance companies may not be inclined to cover treatment involving medications that are not listed as being essential.
Greene mentions the “drug-dumping” of multinational pharmaceutical firms as they purposefully sold their products, some of which had not completed clinical trials and had questionable safety and efficacy reports, in countries with less regulations on the quality of drugs in the 1970s (Greene, p. 16). To me, this situation mirrors that of the tobacco industry, in which major tobacco companies started looking for foreign markets outside of the United States with the rise of foreign demand in the 1960s. Taking advantage of the weaker restrictions on trade and health regulations in developing nations, tobacco companies targeted women and children in Africa and China, for example, to expand their market and increase profits (Brandt, p. 454, 487). In some ways, pharmaceutical companies are just as manipulative and selfish. In response to the South Africa’s Medicines Act of 1997 that allowed for the production of generic versions of patented HIV drugs to make them more affordable to a greater population, thirty-nine pharmaceutical companies filed suit in South African courts just a year later. Furthemore, the U.S. government also expressed its disapproval, even though it later changed its mind in support of the Medicines Act in 1999 following uproar from political activists (Farmer, p. 122, 123)
Nowadays, the “cozy” relationship between doctors and pharmaceutical companies has become controversial. It is no secret that major pharmaceutical companies and doctors often work closely together – drug companies send sales representatives to speak to doctors about new medications and sponsor medical education and research. This has raised questions of conflict of interest – doctors can monetarily benefit from prescribing certain medications, biasing them towards providing certain treatments over others that could be just as effective or more effective (Glover). However, others including cardiologist Dr. Lisa Rosenbaum argue against the stigma surrounding doctor-industry collaborations. In her opinion, such a collaboration could lead to “life-saving therapies whose development requires the combined talents of clinicians and industry” (Rosenbaum). Dr. Rosenbaum contends that the conflicts of interest argument could lead to important viewpoints being discredited or ignored, simply because a doctor happens to work with drug companies
As part of the Affordable Care Act of 2009, the Sunshine Act mandates that all payments over $10 from pharmaceuticals to doctors or hospitals be made public to increase transparency and disclosure (Glover). Even so, there is always the risk of a doctor building close ties with one specific company and endorsing their products at every opportunity, blinding himself to potentially better options available for patients. The Access to Medicine Index (ATMI), implemented in 2008, is another way to keep pharmaceuticals accountable. The ATMI publicly recognizes companies for their efforts to improve access to drugs in developing nations. By ranking countries in order by their commitment to the transnational goal distributing drugs globally at reasonable prices, the ATMI encourages companies to keep up their efforts. Another way of looking at the list and rankings is that the ATMI puts pressure on the companies that ranked low on the list or did not make the list to work towards equal distribution of medications (Greene, p. 27).
Discussion Questions:
- The Second Model List of Essential Drugs clarified that drugs not listed were not necessarily “inessential” and that the list was mainly meant to be used in the context of developing nations with the goal of making medications more affordable and accessible. Do you feel that the Second Model List of Essential Drugs adequately addressed problems of the first list?
- While some argue that doctors working with pharmaceutical companies and being financially compensated for prescribing certain drugs will lead to biases that could potentially be harmful to the patient, others firmly believe that we could be losing out on life-saving advancements that may result from such collaborations. What do you think about doctor-industry collaborations? Is there a “happy medium” in this situation?
Course Readings:
- Brandt, Allen. (2007). The Cigarette Century. New York: Basic Books (p. 448-492)
- Farmer, A. Kleinman, J. Kim and M. Basilico. (2013). Reimagining Global Health: An Introduction. Berkeley: University of California Press (p. 122-123)
- Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10–33. http://doi.org/10.1057/biosoc.2010.39
Outside Readings:
UPDATE (on Nov. 25, 2015 at 10:30pm):
At the end of September, Turing Pharmaceuticals announced a 5000% price hike of their drug, Daraprim (used to treat toxoplasmosis, especially in immunocompromised HIV/AIDS patients), from $13.50 to $750 per tablet, which (unsurprisingly) resulted in a public uproar. As I was following this story, it at first seemed that Chief Executive Martin Shkreli saw nothing wrong with this overnight price increase, reasoning that pharmaceuticals need to make money for drug research and development. (He is quoted as stating, “It is us trying to stay in business” in the New York Times.) Since then, he seems to have finally come to his senses and has announced that the price of the drug will be cut by up to 50% for hospitals only.
However, this shows just how much “power” pharmaceuticals can have over prices of their products and how they can wield this control in a way that affects the public as a whole. This is not an isolated incident in recent news. A similar price increase was applied to cycloserine, a drug used to treat tuberculosis, although this price increase was rescinded soon after. What loopholes in policies regulating pharmaceuticals allowed these significant price increases for important drugs to occur, and how can the government make sure nothing like this happens again?
Dec. 8th, 2015 at 9:50am: Sarah and I have been discussing (in the comments below) about possibly having more interaction between the government (the U.S. government in particular, since several of the major pharmaceutical companies are based here) and an established and reputable international organization such as the WHO. The purpose of this collaboration would be to ensure that drug companies do not raise prices of their products just to make more profits. Although the WHO, a branch of the UN, does not have any teeth and does not hold direct power over national governments (as we discussed in class), I believe it would be more efficient to utilize an already established organization rather than creating an NGO from scratch, as an NGO would not hold any power over a state’s government and pharmaceutical corporations, either. The WHO would be able to monitor which organizations are engaging in philanthropy by donating important medications that would otherwise be prohibitively expensive to populations in low- and middle-income countries that need the medications, thereby encouraging other pharmaceuticals to follow suit. Because the WHO does have sway over international publicity, the organization could also publish data on what pharmaceuticals have dramatically raised prices on their products, adding to the pressure on these pharmaceuticals to reduce their prices to make their drugs more affordable.
FURTHER UPDATE (on Dec. 7, 2015 at 11:09pm):
I realize I was not very clear about how such pharmaceuticals were “allowed” to raise the prices of their drugs so drastically. Pharmaceuticals like Turing have found a loophole whereby they purchase all rights to the drug and then raise its price. This is perfectly legal, but legality does not always equate to morality, as we discussed in class in the context of corporate responsibility (e.g., Shell’s environmental pollution in the shantytown of Flammable, Argentina). While the connection between the social suffering and corporate responsibility is not as clear-cut in the case of these pharmaceuticals’ price hikes, I believe there needs to be more regulation on drug prices.
According to a Wall Street Journal article from December 5th, 2015, there will be a congressional hearing on December 9th between the Senate Special Committee on Aging and pharmaceuticals with price jumps, including Turing Pharmaceuticals, to investigate the problem. Hopefully, this will further emphasize the message that we civilians (and most politicians) will not tolerate drastic price surges of important drugs and push forward policies to prevent another occurrence.
Dec. 9th, 2015 at 7:41 pm: Read more on the congressional hearing held this afternoon in Washington, D.C., where Senators Susan Collins and Claire McCaskill, along with specialists in the U.S. health care system such as Drs. Erin Fox and David Kimberlin, criticize four pharmaceuticals that have sharply increased the prices of their drugs out of greed for profits: http://www.theguardian.com/us-news/2015/dec/09/drug-companies-turing-valeant-martin-shkreli-daraprim
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