Invisible Threat
How can a real-life pandemic compete with the avian flu of our imaginations?
BY Anurita Bains
Illustration by Raymond Biesinger
In September, US Senate majority leader and Republican Bill Frist warned in the Washington Times that H5N1, or the avian flu, while “invisible to the human eye” could kill as many as 200 million people globally. “We cannot afford inaction,” Frist wrote. The same day, with little fanfare, the Senate voted to tack an extra $4 billion US onto the Centers for Disease Control and Prevention (CDC) budget. The money came after the CDC predicted that an avian flu epidemic could kill up to 207,000 Americans. Half of the money was earmarked for bulk purchase of Tamiflu, the antiviral flu drug made by Swiss-based multinational Roche Pharmaceutical.
A few days later, H5N1 had been found responsible for the deaths of 65 people in South-east Asia. In the weeks following, as the death toll in the region slowly climbed—one could argue at a snail’s pace—the response around the world reached a frenzied pitch. Panicked governments talked of initiating national lockdowns if the disease spread to their borders; US President George Bush indicated that the US military might be used to enforce a quarantine in the event of an outbreak.
Fifteen days after the first human death from avian flu, the World Health Organization (WHO) recommended that countries stockpile antiviral treatments. The US said it intended to procure enough for 75 million Americans. Norway built a reserve of 1.4 million doses. And Canada snapped up enough to treat 3.5 million people. (Just because citizens were warned not to hoard the drug didn’t mean their governments couldn’t make a grab for it.)
All this at a time when Bush acknowledged that an H5N1 pandemic was not imminent, something echoed by Canadian Health Minister Ujjal Dosanjh on national radio: There is no pandemic; there is no human to human transmission. One day we could practically smell the coming death, the next, we were speaking sensibly about a bunch of dead ducks.
The message might have been contradictory, but the response was not: Western governments would not be caught unprepared and would go to whatever lengths necessary to keep their citizens alive. By November, President Bush announced a $7.1 billion US pandemic-preparation strategy.
No doubt, “invisible” threats are serious business. Between 1918 and 1919, the Spanish Flu killed 40 million people worldwide. No one knows exactly how many died during the 14th century pneumonic plague, or Black Death, although it’s estimated to be in the tens of millions. It is the spectre of these kind of disasters that’s raised in the talk of avian flu. But you don’t have to look to the past to find a pandemic. Every day, 8,000 people in developing countries die because of AIDS. And where I do my work—Africa—it is estimated that AIDS has already caused 22 million deaths. Experts believe that HIV has surpassed the numbers of people sickened by the Black Plague. A recent Council on Foreign Relations report noted that when those currently infected with HIV—40 million (almost 26 million of them in Africa)—have succumbed to the disease, AIDS will rank as the worst plague of all human history.
I work closely with Stephen Lewis in his role as UN special envoy on HIV/AIDS in Africa. I spend a lot time travelling in Africa with Stephen, meeting sick and dying people, young children orphaned by AIDS, and government officials distraught and overwhelmed as they struggle to keep their people alive. I have seen first-hand the push to get life-saving antiretroviral treatment (ARVs) to Africans. Last August, in Lesotho, a small country of approximately two million people with an adult HIV-prevalence of nearly 30 percent, Stephen and I visited a clinic where patients, wrapped in big, wooly blankets to ward off the bone-chilling cold of winter, were spilling out of the corridors into the parking lot. There were young women—babies on hip—and old men hobbling along with the help of sticks. They looked tired, but mostly they looked—they were—very, very sick: emaciated, blistered bodies and hollow cheeks, the padding worn away after years of not being treated for HIV. Many of them, it turns out, also now have tuberculosis, a disease that kills half a million Africans each year. Lesotho’s minister of health quietly confided that while ARVs can literally turn a patient’s life around, there is little hope for those with AIDS and TB; they die while on a course of TB treatment, before they are able to start on ARVs. The lack of early HIV treatment has cleared the way for all sort of horrors, and an endless stream of death.
In 2002, when I first started this job, 50,000 Africans, or one percent who needed it, were receiving antiretroviral therapy. Today, it is estimated that at best one in 10 Africans who need antiretroviral treatment are receiving it. In most African countries—but especially in a place like Lesotho—the slow rolling out of ARV treatment has felt like Chinese water torture. (About 6,500 people out of an estimated 56,000 in need of treatment are receiving ARVs in Lesotho.) The legal, political and financial battle to get even this woefully inadequate level of response to the AIDS pandemic in Africa has taken years. Which is why those of us working on the issue can’t help but look at the response to H5N1 in complete wonder. The double standard is so obvious it practically slaps you in the face: the lightning-speed response by governments; the billions of dollars immediately available to fight a pandemic that doesn’t yet exist, when the one that we can see right in front of us has been allowed to mushroom out of control.
The effort to get essential AIDS medicines to Africa—medicines already available to people living with AIDS in the West—has been a decade-long struggle, one defined by global trade agreements, the power of the pharmaceutical industry, bureaucratic delays, and political haggling about clauses and articles, rather than lives. Put another way, it’s been a lesson in how easy it is for Westerners to value the lives of one group of people (us) over another (them), and how the mantra of “health as a fundamental human right” can be so readily recast as “patents have rights too.”
The struggle came to the fore in 2001 in a historic World Trade Organization (WTO) document called the Doha Declaration. It affirmed the right of countries to take necessary measures to protect the health of their citizens. It was a genuine victory considering the US, Canada and other allies had proposed the inclusion of language that stressed the protection of intellectual property (patent protection for companies like Roche). It’s a gain that likely happened only because of an accident of timing. The Doha meeting took place in November 2001, when, after five reported deaths from anthrax, Canada and the US were prepared to override Bayer’s patent on the antidote ciprofloxacin. (Canada did; the US didn’t. As a result, the US waited almost two years to create the stockpiles experts had recommended.)
For non-trade experts, the Doha Declaration simply stated the obvious, that countries have the right to determine what constitutes a public health crisis—HIV/AIDS, TB, or any other public-health emergency—and a trade agreement should not prevent them from taking necessary measures to protect public health. Looking at it now, after having watched negotiators make developing countries jump through legal hoops while I met sick and dying people across southern Africa, the Doha Declaration seems positively revolutionary. If it had been immediately acted on, what a difference it would have made. Instead what followed Doha was two more years of international trade rounds, and endless negotiations. In the end, when a (pseudo) solution was crafted in 2003, activists and Stephen Lewis called on the Canadian government to change its patent law and allow for the manufacture and export of AIDS drugs, something that was now legal under WTO rules. The government did, despite the suggestion from the International Pharmaceutical Association that this would be “a negative black eye” for the country and could very well affect the investment climate. One manufacturer has expressed serious interest in making and exporting generic medicines, but today, not a single pill made in Canada has reached an African living with AIDS.
Within weeks of the first reported deaths from H5N1, there was serious talk among WTO-abiding countries of breaking the patent on Tamiflu and producing the generic version oseltamivir. Despite calls to break the patent—one senior American senator said Roche was putting profits ahead of world safety—at the time this article went to press Roche had shown no signs of giving it up. Rather, they had threatened to fight Cipla Ltd., the Indian generic company, if they tried to produce a Tamiflu knock-off: “If we determine that there has been an infringement, we’d move to protect our rights and interests.” (Ciplas’s intervention is desperately needed; India has been able to secure less than one percent of Canada’s Tamiflu stockpile for a country with population 25-times the size of ours.) And this for a drug Roche didn’t invent; the company bought the rights for an estimated $50 million US, a cost long since recouped.
It is estimated that the total dollar value for Tamiflu orders is now well in excess of $1 billion US. As one newspaper reported, Roche founders, who already rank among the world’s richest families, could see their combined $31 billion fortune reach “giddy heights.” Activists continue to be puzzled at Roche’s refusal to allow the generic manufacture of Tamiflu. Not only would it be great PR to be a little more community-minded, but as the patent-owners they would still receive royalties on sale of the generic.
Even though the response to avian flu has been remarkably speedy compared to that of the AIDS pandemic, the obstacle to gaining access to life-saving medicine is the same. Different pandemic, same old patent problem. When, in the fall of 2005, Secretary-General of the United Nations, Kofi Annan, said, “I wouldn’t want to hear the kind of debate we got into when it came to HIV antiretrovirals,” it was as if he was stating a fear, rather than articulating a hope. After years of fighting for a shift away from pharmaceutical profits toward a focus on patients, we seem to be back at the same place. Have we really learned so little? Do patents and profits still seem to merit the consideration we give patients?
Perhaps a look to the past can yield a lesson worth learning from: In 1947, during a smallpox outbreak, the mayor of New York locked drug-makers in City Hall and told them they couldn’t leave until they agreed to make a vaccine. They did, and five million people were vaccinated.
If what Director-General Lee Jong-Wook says is true—that “we don’t know when [the avian flu pandemic] will happen, but we do know that it will happen”—then we may in the not-too-distant apocalyptic future find ourselves extremely grateful to our governments for acting so quickly. But in the meantime, those of us working on HIV/AIDS issues will continue to lobby and call for adequate funding, although I’m not so naïve to believe that the billions needed will materialize.
In Lesotho, you don’t need a lot to save a life. The cost of generic ARVs for one person for one year is now less than $165 Canadian. Considering the billions that have been, and will continue to be, found to save us from the avian flu, it doesn’t seem like much at all.
