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 Take your medicine How to manage a pharmaceutical sector under siege? Health professionals discuss solutions with Al-Ahram Weekly Asked how doctors decide which drug to prescribe to whom, a Doqqi pharmacist told Al-Ahram Weekly on condition of anonymity that "they judge by how well-to-do their patients seem to be. You can tell, I suppose, by just looking at someone." While some dozen people stand outside his door waiting their turn, indeed, consultant Bassem Sobhi sits behind his desk at the National Institute for Coronary Diseases, discussing treatment with a diabetic patient. "There are various options as to which medicine you can take," he explains to her. "There is the model drug, and then there are two cheaper generic versions. The effectiveness of these drugs is equal to that of the original, but still -- how much do you feel you can afford?" To say that the recent implementation of the Trade Related Intellectual Property (TRIPS) agreements (see related article) is the reason medicine is expensive for much of the Egyptian population would be unfair. Yet "it will make things very, very difficult for some patients", as Sobhi told the Weekly : "Until very recently, patients prone to blood clots, for example, had to spend up to LE350 every month on treatment produced by the multinationals, given that there was no generic alternative." According to Said Rateb, director of Cairo University Hospitals, on the other hand, "we cover all medical costs for in-patients. What we cannot do at present, however, is to cover costs for out-patients too" -- a point that Sobhi took up: "This is particularly problematic for patients who depend for their survival on long-term treatment, such as those suffering from high blood pressure." But if the country is on the verge of a situation in which the vast majority of its inhabitants will have no access to new and, according to Sobhi, "expensive" medicines, how can the powers that be start working to resolve the problem before it escalates? At first sight the situation is particularly dangerous given the fact that, while it is putting up a fight, in the end the local pharmaceutical community, according to pharmacology professor Raouf Hamed, of the National Organisation for Drug Control and Research, at least, is likely to give in, for "it is in the nature of such struggles for the balance to eventually tip in the favour of the strongest." Rateb believes one should "not build up an emotional reaction, because the Ministry of Health is devising new plans to cover treatment", but people like Hamed point out that "a real, working Egyptian strategy for the pharmaceutical sector" remains lacking: "Though it is claimed in public that there is one, no such strategy exists." What requires clarification at this point how and why "so far, the availability of essential drugs has not been affected". "The only drugs affected are those produced over the past 10 years," and those yet to be produced, as Hamed added. However, "the essential drug list is revised approximately every two years," as Abdel-Aziz Saleh of the World Health Organisation (WHO) told the Weekly, and according to Saleh, indeed, the greatest danger relates to potentially essential drugs yet to appear. With Egypt seeking to enter free trade agreements with the United States, it seems unlikely that Cairo will turn its back on the World Trade Organisation (WTO)-related agreements 10 years after it signed them. Thinking in terms of the future, "we need to take the impact of TRIPS on access to medicine very seriously", Saleh added, illustrating his point with the fact that in Egypt there is growing resistance to available anti-malarial drugs. When the need to import new drugs arises, they will be extremely costly, and meanwhile the old generic supplies will no longer be of any use. At the international level, the WHO is "advising countries (which are party to the TRIPS agreements) that there is ongoing negotiation within the WTO to revise some articles of both TRIPS and other agreements", Saleh indicated: "We are advising these states to be prepared for such discussions, and to devise joint negotiating strategies with other developing countries." The WHO is also urging Egypt to develop its research skills in order to ascertain the specific needs of the population, while also remaining highly aware of the precise terms of the TRIPS agreements: "By analysing the pharmaceutical market we can expect Egypt to determine the patency status of a given new medicine and to find ways to obtain it and make it available to the patient without overriding TRIPS laws." For now, "even the prices of off-patent medicines are rising," he went on to say, explaining that many local companies are riding the TRIPS tide: "They claim that TRIPS is the cause when it's not." "Civil society and public opinion should help improve things," Hamed said, suggesting that the TRIPS scandal could at some level lead to social emancipation -- if society took matters into its hands. "And by this I am not simply referring to the assumption of a political stand -- people should be able to stand up for themselves. If we are strong and become a force in the global pharmaceutical industry, then the US will respect us and seek our cooperation rather than sideline and marginalise us." According to both Hamed and Saleh, there is no lack of instruments enabling such change. "What we lack so far," Hamed told the Weekly, "are the proper organisms" -- a point to which Saleh agreed: a functional, powerful welfare institution has yet to be invested in, promoted and developed. Without such an institution, "the move from thought to action anywhere in the Egyptian political sphere" is bound to remain slow. Hamed also cited as a point of contention the business interests to which the pharmaceutical sector in Egypt is subject. Businesses by default have a broad, insensitive perspective and so follow the rules of demand and supply, rather than catering to patient needs, regardless of the frequency of a given ailment. "Rather than try to develop long-term goals and invest in research and development to enable Egypt to become a global force in the production of pharmaceutical products, companies simply waited out the duration of the grace period by registering as many drugs as possible. Now there is no turning back," Saleh went on. What can still be done, however, is to urge the government to take greater responsibility in this sector, promoting "professionalism" and a people-before-profit outlook -- something that would benefit both patient and pharmacologist. "India and Brazil have strong local pharmaceutical industries which the US must reckon with," Hamed added. "And likewise, to strengthen ourselves we too must think strategically" and plan ahead -- think how to surmount the obstacles in the interest of everyone, rather than trip ourselves up with short-sightedness and misplaced "conservatism".
