Going Too Far: Downplaying the Broader Context
There is a widespread public perception that the pharmaceutical industry has been unfair in its dealings with governments, regulators, healthcare providers, and the public (Huebner 2014). In particular, some activist groups have argued that drug companies constantly violate health-related human rights, prioritizing patents and profits over people’s access to essential medicines (Gruskin and Raad 2010). As human life and health are highly valuable, there exists a common perception that an individual’s posited right to essential medicines should not be encroached upon by premium pricing (Huebner 2014). Given that access to ARTs is crucial in conquering the HIV epidemic and that the pharmaceutical industry’s pricing and other business strategies have strong influence on access to these medicines and health systems more broadly, drug companies are often singled out as the villains in the fight against the HIV epidemic in LDCs. Sociological research has found that consumers are indignant toward profit-oriented justifications for essential therapeutics, even though they find similar pricing rationalizations for other products acceptable (McGraw et al. 2011).
Indeed, access to ARTs has been important in controlling the epidemic, adding support to the call for more affordable treatments for those in LDCs. In countries that witnessed a significant decline in AIDS-related deaths, such as South Africa (48%), Rwanda (76%), Eritrea (67%), Burkina Faso (58%), Ethiopia (63%), Kenya (60%), Zimbabwe (57%), Malawi (51%), and the United Republic of Tanzania (44%), the success was directly due to the rapid increase in the number of people on ARTs (UNAIDS 2014b), made possible by pricing and licensing strategies. According to the 2014 Access to Medicine Index, out of the 33 ARTs on the market, 26 have been licensed, 22 of which to five or more generic medicine manufacturers to make and distribute these essential medicines (Access to Medicine Index 2014). As studies have shown, early initiation of HIV treatments can reduce the viral load in bodily fluid to “undetectable” level, decreasing an individual’s risk of HIV transmission to one’s sexual partner by 96% (Cohen et al. 2011). As treatment also serves as a form of prevention, new HIV infections have also declined globally by 38% since 2001. Such success is particularly important in HIV-prevalent countries such as Botswana (Thigpen et al. 2012). With recent progress, the global prevalence rate for adults between 15 and 49 years old has leveled in recent years, at 0.8% in 2013 (UNAIDS 2014b). In the period 2002-2012, life expectancy in sub-Saharan Africa increased by 5.5 years due mainly to the dramatic scaling up of antiretroviral treatment (UNDP 2013).
However, the glimpse of hope attributed to increasing pharmaceutical access notwithstanding, the story of the HIV epidemic in LDCs is a more complex one. Even if pharmaceutical companies continue to allow parallel imports, donate ARTs, grant generic licenses, and adopt differential pricing in LDCs, the success of such strategies in improving treatment availability will depend greatly on other contextual factors that are also hindering treatment access. It is noteworthy that while only 37% of HIV patients in sub-Saharan Africa are getting ARTs, the percentage of those treated in some other regions such as Eastern Europe and Central Asia (21%) as well as Middle East and North Africa (11%) are reportedly even lower (UNAIDS 2014a), partly due to stigma, discrimination, and worries of unauthorized disclosure of HIV status (Setayesh et al. 2014). Even Latin America (44%) as well as Western/ Central Europe and North America (51%), which are comparatively more affluent regions, have substantial unmet needs (UNAIDS 2014a).
Indeed, it is important to note that cultural practices, lack of access to credible medical information, government policies, and other geopolitical factors have contributed to the crises in many countries in sub-Saharan Africa. For example, in the case of South Africa, infant feeding practices, women’s inability to refuse sexual advances, healthcare workers’ limited training and capacity, and the reluctance of the former President Thabo Mbeki and the counter-epistemic community to acknowledge the causal relation between HIV and AIDS have all contributed to the epidemic in that country (Youde 2005). It is also noteworthy that while 90% of people in sub-Saharan Africa who know their HIV status get treatment, an estimated 19 million of the 35 million people living with HIV globally do not know their HIVpositive status (UNAIDS 2014c). In South Sudan, where many residents continue to be displaced due to ongoing fighting, there is not only a shortage of laboratory space required to diagnose patients and the equipment needed to monitor the virus but also a scarcity of community health outreach resources (UNAIDS 2014d). In 2012, South Sudan spent 9.3% of its GDP on military activities (World Bank 2015a) while only 2.6% on healthcare (World Bank 2015b). In Central African Republic, minimal involvement of civil society and ineffective financial management have contributed to the epidemic in that country (UNAIDS 2010). An absolute shortage of physicians (less than 5 physicians per 100,000 people in 2009) also exacerbated the desperate situation in this country (WHO 2015b). With high job vacancy rates within the public health sector in the most vulnerable parts of Africa (Schneider et al. 2006), there is an additional challenge of ensuring that potentially infected people are educated about the disease, tested, and treated accordingly. In other words, the broader contexts of poverty, malnutrition, and underdevelopment in this region, which are primarily the responsibilities of governments, have been framing people’s general health status and illness experience (Hanson et al. 2003). Mere provision of ARTs to LDCs without the necessary infrastructure and education to promote patient adherence and safe administration of these medicines may risk suboptimal therapeutic success as well as resistance to ARTs and important antibiotics in the long run (Leisinger 2005).
In determining the extent of pharmaceutical companies’ duty to aid, we thus need to consider the larger realities. While the call for drug manufacturers to negotiate with governments and NGOs to promote affordable distribution of ARTs is legitimate, singling out the industry’s moral duty to assist ignores how sociocultural and geopolitical barriers may shroud the reality that many impoverished countries have not or are not able to develop the necessary infrastructure to deliver basic healthcare, let alone ARTs (Schuklenk and Ashcroft 2002). Even when ARTs are available, stigmatization may inhibit serostatus disclosure to sexual partners and potential treatment supporters, delay ART initiation, and contribute to treatment nonadherence (Tsai et al. 2013). As the WHO contends (2011), long-term strategies to combat the epidemic will require various countries to strengthen their health and community systems, tackle the social determinants of health that both drive the epidemic and hinder the response, and protect and promote human and gender rights. Some of the aforementioned countries such as Malawi and Tanzania, which have enjoyed sharp decline in HIV-related deaths, have also been experiencing better infrastructure, access to water/sanitation, and higher political stability (World Bank 2014). As effective distribution and administration of ARTs depend on states to set up infrastructure, train healthcare personnel, provide surveillance, coordinate various services, and promote prevention and testing, the level of pharmaceutical companies’ moral obligation to aid depends partly on whether the local governments and other relevant actors are first and foremost upholding their responsibilities to promote the necessary infrastructure for such endeavors.
If we recognize that other infrastructure and social conditions are necessary for efficient and effective distribution of ARTs, and if we also accept that the main criterion supporting the duty of rescue is the ability to do so, it would seem that we cannot attribute all or even most of the responsibility to assist to the pharmaceutical industry. Other industries—be it labor, construction, water sanitation, electricity, automobile, or petroleum—that can help to build the necessary infrastructure for a responsive primary healthcare system that can facilitate safe and effective distribution of HIV treatments may also have a prior obligation to assist. Unless there are morally relevant differences between the pharmaceutical and other industries in the overall goal of curbing the HIV epidemic, which will be explored in the next section, holding only pharmaceutical companies responsible without calling upon other industries to assist under the duty of rescue is going too far and unfair to the drug companies (Chang 2006).