From the corridors of multinational headquarters in the US to the counters of Cairo chemists, Serene Assir investigates how few decision-makers in the pharmaceutical world ponder the human cost of their business In recent years a new industrial giant has been steadily overtaking the financial world. It is a commodity deadlier than arms, more powerful than oil. And its purveyors control the Wall Street charts by virtue of its unique nature: its presence can save lives, its lack is wont to kill. "Imagine the sums of money exchanged when planes and tanks are bought and sold," Amasis Maher Yousri, the owner of Maher Pharmacy in downtown Cairo as well as a medical equipment distribution company, told Al- Ahram Weekly. "Well, drugs may appear to be far less profitable. In fact they are the most powerful movers of capital of the age." Little wonder, then, that so many parties want a piece of the drug cake; the trouble is that, in a very different way to weapons or oil, medicine is absolutely essential. And between the health professional and the patient stands the necessary link: the pharmaceutical company, which constitutes a bizarre amalgam of money and welfare. It is the challenge of maintaining an ethical balance within that amalgam that remains difficult in the Third World, where social security systems remain severely underdeveloped. On 1 January 2005, the laws of the World Trade Organisation (WTO)- linked Trade-Related Intellectual Property Rights (TRIPS) came into force, following a 10-year grace period during which developing countries were given an extra five years over the initial deadline to adapt to new restrictions on the local production of medicines. Starting this year, Egypt's registration and production of generic drugs is no longer possible without purchasing costly licensing permits from the mother company. Generic drugs constitute the bulk of the Egyptian pharmaceutical market. "For every model drug, we have about five or six alternatives on sale," Yousri said, bringing the number of model and generic products on sale in Egypt market up to approximately 7,500. With the implementation of TRIPS regulations, this number is unlikely to decrease. What will happen, rather, is that restrictions on trade rights will by and large disable the introduction of cheap generic drugs; should the Egyptian patient require a newly released medicine, he or she will have to pay the full price of the model drug. Enter the US multinational. "We have a very noble cause that makes us proud of going to work every morning," Ahmed Hakim, director of external affairs and policy at Pfizer's Middle East headquarters in Cairo, explained. "Our aim is to eradicate disease and save lives. And it is our business to bring breakthrough medicines to patients throughout the Middle East as quickly as possible. Besides, we have a policy to make drugs available for a low cost; otherwise they simply will not sell." Pfizer Inc is the pharmaceutical world's leading producer. It is also, according to Hakim, the world's third largest company. Its annual financial turnover is such that it can afford to conduct extremely costly research. Last year alone, it spent $38 billion on "new discoveries". "And it takes about $800 million and about eight years to discover a new medicine." The rationale being that it costs money to create new medicines, Hakim added, "pharmaceutical companies need to function as economic organisations." What Hakim failed to mention, however, is that, according to The Economist, Pfizer also spends approximately 10 per cent of its annual budget on marketing its products. For a medicine to sell, doctors, pharmacists and patients must be made aware of it. Various doctors and pharmacists described to the Weekly how multinationals market their product, by sending salesmen on drop visits to hospitals and clinics, offering free merchandise, and in effect taking up time that could be spent on assisting patients. With the introduction of the TRIPS agreements, what is more, multinationals will have a tighter grip over developing markets, securing a virtual monopoly over new products. Since January 2005, numerous disputes have arisen surrounding the production of generic drugs that, according to Pharmacologists' Syndicate head Zakaria Gad, had been registered and licensed prior to the ending of the grace period. Yet the PhARMA lobby, of which Pfizer is part, sought the support of the US administration, who were asked to put pressure on Egypt to discontinue the production of 500 generic drugs. And while Pfizer claims it acts to make Egypt a pharmaceutical "centre of excellence for the region", the truth is that it is, at bottom, pursuing its own interests. In the years to come, in fact, essential drugs may conceivably prove too costly for the average Egyptian. "That's something that the state will have to deal with," Hakim responds. "It should assume responsibility for dispossessed classes unable to pay for their treatment. Of course," he added, "the US has every right to defend its companies' interests." Yet according to Gad such a defence on the part of the Bush administration amounts to "unethical behaviour". The US, by far the most influential member of the WTO, has "put pressure on the Egyptian Embassy in Washington, sent agents to the office of prime minister Ahmed Nazif to try and coerce him into minimising local production, discussed issues as peripheral as pharmaceutical production with President Hosni Mubarak himself" on the latter's political visits to the US. But unethical or not, Egypt is obliged to put up with such behaviour as it remains economically dependent on USAID and other funds and loans sent from Washington to Cairo each year. "The patient will not in any way be affected by the implementation of TRIPS agreements," Ossama El-Khouli, undersecretary of pharmaceutical affairs at the Egyptian Ministry of Health, reassured the Weekly. "I mean, think about it, when you're not feeling so well and you have a headache, what do you take?" Aspirin? "Exactly. You see? You have the answer right there. And how long has it been since it's been on the market?" Over 100 years? "Pronto," he booms. "So what's likely to happen to make it disappear now?" The basic drugs, in other words, remain as available as ever. As for patients who require more complicated compounds -- those suffering from terminal diseases, for example -- "there are always degrees to the seriousness of a disease. Not all diabetes patients require a daily insulin intake, for example. Besides, there is a bitter honey produced in Tunisia which has been found to help diabetes". But there is no sign of either this honey being imported or the cost of treatment for diabetics, which can be as high as LE5 a day, going down. Yet Hakim insists that "at any given point new medicines will never comprise more than two to three per cent of the Egyptian pharmaceutical market, so the effect will always be minimal". As for the unfortunate few who will require access to such rare drugs, "you need to bear in mind," so exclaims Said Rateb, director of Cairo University Hospitals, "that the Ministry of Health is currently planning the development of a full health insurance scheme", the precise details of which, sadly, remain unclear -- an ambiguity confirmed by El-Khouli response to a question about the exact constituents of the plan in question: "no, you see, you are getting into politics. I thought we were here to discuss medicine. I am not in the position to discuss these issues with you at present." However "minimal" the effect of TRIPS agreements, there remain medicines that low-income patients will be unable to afford. Even prior to their full implementation, there have been occasions, admittedly rare, on which no generic product was offered as an alternative to the model. This happens when the number of patients requiring a particular kind of medicine is too low, and production becomes ineffective for cost purposes. The model drug Plavix, for example, which regulates blood circulation in coronary patients, is sold at LE340. The only available alternative is Aspocid, sold at LE1. But the make-up of the drug -- a 75mg composition of the active ingredient in Aspirin -- is entirely different. Its effectiveness is incomparably poorer, according to a Doqqi pharmacist speaking on condition of anonymity. "The implementation of the TRIPS agreements will be good for us in some ways," on the other hand, as Yousri told the Weekly. "As things stand we have to supply five or six generic drugs that all have exactly the same effect. This is costly but necessary for us, as different doctors will prescribe different brand names. The TRIPS agreements will limit the number of new drugs on sale and make things a lot simpler for us that way." Nor will the negative side be in evidence for years to come. "But rest assured," a downtown pharmacy owner told the Weekly, again on condition of anonymity, "it will be a disaster for this country. Though the government will still try to put a lid on prices, partially subsidising new drugs, the fact remains that we are a poor country. Given that the multinationals will control the market, they, not the consumer, will determine the prices. Ultimately, it is a disaster for the people. Local companies may eventually be forced to close down. And then, people will sell everything they have to get the medicine they need." And even then, it seems, many may still be unable to afford it.
