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Drug World War

Who could argue that lowering the cost of AIDS drugs for Africa is a bad thing? No one -- but noble choices can have disastrous effects.

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Back in 1974, the post-watergate campaign-finance-reform laws were going to clean up politics. For the first time in history, contributions to federal candidates would be disclosed, and were limited to $1,000 from individuals and $5,000 from political-action committees. The Times even crowed that we had achieved at last "the possibility that a man or woman may pursue the presidency without becoming seriously beholden to any person or organization in the land." No one could see how the new laws would make fund-raising-obsessed politicians even more beholden, much less how all-but-untraceable "soft money" -- the phrase hadn't even been coined yet -- would find its way into campaign coffers without filing past the eye of the public.

In 1963, President Kennedy signed the Community Mental Health Center Construction Act to get the mentally ill out of institutions and into a semblance of normal life, supported by community mental-health centers and then-new drug therapies. "If we apply our medical knowledge and social insights fully," said Kennedy, "all but a small portion of the mentally ill can eventually achieve a wholesome and constructive social adjustment." The bill flew through the Senate. No one could see how the new law would lead to a 70 percent reduction in the resident population of state mental hospitals, the release of patients with psychotic symptoms, and, eventually, the homeless crisis of the eighties and nineties.

These are but two of the tragic and obviously unanticipated consequences of governmental good intentions outlined in That's Not What We Meant to Do, a new book by University of Oklahoma professor Steven M. Gillon. Republicans are now predicting a similarly unhappy outcome for the well-meaning recent movement to force pharmaceutical companies to lower the prices of AIDS drugs in Africa. After nearly a year of controversy, President Clinton issued an executive order stating that he wouldn't enforce U.S. patent laws as they apply to such pharmaceuticals in Africa. One day later -- although the deal had been in the works for months -- five major drug companies announced they had reached an agreement with the United Nations to begin offering AIDS drugs in African countries at dramatically reduced prices.

Some Republican trade-policy purists saw no difference between Coca-Cola's protecting its secret formula and the pharmaceuticals' protecting theirs.

Last June, AIDS activists disrupted the press conference at which Gore announced his candidacy to protest the fact that America's policy of protecting its patents abroad was preventing Africans from getting access to AIDS drugs. Last month, California Democrat Dianne Feinstein got an amendment attached to an African trade bill that would give sub-Saharan countries permission to manufacture and purchase generic versions of these medicines. On the Senate floor, Feinstein presented a tragic but familiar picture of a continent that "has only 10 percent of the world's population, but has 70 percent of the worldwide total of infected people." In some countries, she said, "20 to 30 percent of the population is infected."

Not surprisingly, pharmaceutical companies opposed Feinstein's amendment; without their intellectual property, they literally don't have a business. The House listened intently enough to kill the amendment. Indeed, some Republican trade-policy purists saw no difference between Coca-Cola's protecting its secret formula and the pharmaceuticals' protecting theirs. American trade policy defends intellectual property, it can be argued, for the simple reason that -- from Microsoft to Motown to Merck -- we make more of it than any other country.

What to pharmaceutical companies was a matter of protecting intellectual property was, to Feinstein, a matter of "profits and corporate greed." She said the companies "would prefer to be able to sell drugs for $18 a dose rather than $1 per dose, with the additional $17 going straight to fattening the bottom line." Later Feinstein noted that pharmaceutical profit margins average a more modest 16 to 18 percent. Even that's more than enough, according to Feinstein. But while it's morally true that we must do something, health care depends on not only drug-company products but the drug-company profits that get reinvested in research that could lead to an AIDS vaccine.

After her amendment was killed, Feinstein got personal on the Senate floor. "I don't know how they sleep at night," she said. "I don't know how they can look at a country with 1 million or 2 million aids-produced orphans and sleep at night."

Maybe they couldn't. According to some industry insiders, the pharmaceuticals' decision was at least partly a matter of conscience. Of course, Clinton essentially forced their hand -- they had to cut their profits in the short term or risk undercutting the patents that protected their business over the long term -- but they all said they opposed Feinstein's amendment because they wanted to achieve the same objective voluntarily.

So everyone agrees: Less expensive AIDS drugs are as hard to object to as campaign-finance reform or getting the mentally ill back into mainstream society. And the discounts are substantial. Glaxo Wellcome says it expects to be able to sell Combivir -- average worldwide price, $16 -- for its marginal cost of $2 or less in Africa. But that doesn't mean the issue is closed. Last week, South African president Thabo Mbeki indicated that he wouldn't accept the proffered discounts if it meant giving up his option to make generic versions of drugs.

And drug companies are trumpeting the risk of unintended consequences even in countries that accept their compromise. For one, they argue that drugs discounted in Africa could be diverted to American and European markets, undermining sales and cutting into future research. Perhaps more persuasively, some scientists worry that misuse of AIDS drugs could produce drug-resistant strains of the disease. Many of the drugs require hydration, careful dietary habits, and a strict routine -- a typical "triple cocktail" regimen consists of two protease inhibitors every eight hours and two combination RTI pills every twelve hours -- and imprecise use could allow the virus to develop resistance. Of course, any new strains of AIDS that develop in Africa could eventually spread throughout the world.

Feinstein is right to push the drug companies to take responsibility for the human cost of protecting their patents; the companies are right to be cautious about the implications of being the world's druggists. In the struggle of competing goods that constitutes our political system, sometimes the consequences of taking no action seem to outweigh all other risks.


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