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[e-drug] Village Voice on free fluconazole

E-DRUG: Village Voice on free fluconazole
[copied from DRUGINFO, a South African based
"E-drug". WB]
HI all

Amid all the jubilation over the Pfizer offer, there have also been 
some sober voices raising concerns. Without detracting from what 
is a real change, and a welcome one at that - it is worth 
considering this one incident in the context of making "access" 
truly broad, sustainable and global.

The article below, from the Village Voice, is reproduced in terms of 
the doctrine of "fair use". Taken from the TAC list, with thanks.

Andy Gray
Discipline Chair: Pharmacy Practice
School of Pharmacy and Pharmacology
University of Durban-Westville
email: andy@healthlink.org.za
Tel: +27 31 2044358 Fax: +27 31 2044792
Send mail for the list to DRUGINFO@healthlink.org.za


GIVING IT AWAY: An American Pharmaceutical Giant Offers to
Donate an AIDS Drug to South Africa

The Village Voice - April 4 - 10, 2000
Mark Schoofs

In an unexpected move, the pharmaceutical giant Pfizer offered last 
weekend to donate a crucial drug to South Africa. Called 
fluconazole, it treats one of the most feared AIDS opportunistic 
infections, a painful and lethal brain disease known as 
cryptococcal meningitis.  

The offer gives hope to South Africa's 3.6 million people with HIV, 
because studies show that almost 10 percent of AIDS patients 
contract cryptococcal meningitis, and, bereft of medicine, most 
South African doctors have been forced to send patients with the 
illness home to die. Yet Pfizer's proposal, which is limited to South 
Africa, sidesteps the larger issue of how to make drugs available 
throughout the developing world.  

Pfizer's move comes in the wake of a worldwide campaign 
orchestrated by the Nobel Prize-winning M decins Sans Fronti res, 
ACT UP, and the South African activist group Treatment Action 
Campaign. This coalition had demanded that Pfizer lower the price 
of fluconazole--also known by its brand name, Diflucan--by about 
90 percent, to match the price of a generic version of the medicine 
made and sold in Thailand. The Thai price is about 70 cents, while 
the South African government pays about $7.50 for the same dose. 
Donating the drug "is more than we asked for in some ways," said 
Zackie Achmat of Treatment Action Campaign. He added that 
activists were in a meeting with lawyers preparing to petition the 
government to take legal action against Pfizer "when the call came 
through" from the drug company. "It floored us," said Achmat.  

The South African government, which has recently criticized 
pharmaceutical companies for profiteering, was more reserved. It 
welcomed Pfizer's offer and agreed to meet with the company. But 
health ministry spokesperson Nothemba Dlali said the government 
feared that the donation might be only temporary--in which case 
South Africa would have to deal with thousands of patients 
demanding that the government pick up the tab when the drug 
would no longer be free. "The intention is good," said Dlali, "but we 
wonder in what position it will leave the government."  

Activists, too, cautioned that donations are not a sustainable way 
to solve the desperate dearth of drugs in the developing world and, 
in particular, sub-Saharan Africa, where more than 23 million 
people are infected with HIV. In a statement released by M decins 
Sans Fronti res, Kenyan physician Chris Ouma said, "We're very 
happy for the South Africans, but for me, as a Kenyan doctor, and 
for the Kenyan patients dying from cryptococcal meningitis, it 
doesn't help much."  

Providing fluconazole at no cost does not alleviate the other 
problems that undermine health care in South Africa. For example, 
hospitals in some parts of the country routinely face shortages of 
basic drugs, such as those used to treat tuberculosis. 
Nevertheless, doctors in South Africa were jubilant, if only because 
most of them can currently do nothing to treat cryptococcal 
meningitis because fluconazole is far too expensive. "The bottom 
line is money," said Florence Tleane, a doctor at Natalspruit 
Hospital, which serves three large townships outside 
Johannesburg. "If the drug is free, we would definitely treat 

So new is Pfizer's offer--made by hand-delivered letter--that at 
press time even the company was unsure of many details. But Dr. 
George Flouty, medical director of Pfizer's public health program, 
said that the company wants to model the fluconazole donation on 
its current program to combat trachoma, the world's leading cause 
of preventable blindness. To treat that illness, which is confined 
almost wholly to the Third World, Pfizer donates its antibiotic 
Zithromax, but only through programs that comprehensively 
address the illness with education and efforts to clean the water 
supply. Similarly, said Flouty, "We don't want to just air-ship 
fluconazole to South Africa. We want to ensure proper diagnosis, 
treatment, and follow-up."  

Follow-up is one of the most crucial aspects of treating 
cryptococcal meningitis in AIDS patients, because once the initial, 
acute attack is treated, people with HIV must take fluconazole 
every day or the disease almost always returns. Will Pfizer donate 
the drug just for the initial treatment or also for the prevention of 
relapse--which could hugely inflate the company's cost? Flouty 
said such "nuances" were still being worked out, but added, "I'm 
going to go out on a limb here. If that's the right thing to do, I think 
we would want to do it."  

Why would Pfizer donate the drug rather than reduce the price? 
"It's better to give it away," said Hemant Shah, a stock analyst who 
tracks pharmaceutical companies. "Otherwise you can have a 60 
Minutes show asking why the product in South Africa is cheaper 
than in the U.S." Instead of negative press, Pfizer can now reap 
public-relations benefits for its charity. Merck, for example, has 
garnered excellent publicity for its long-standing program that gives 
away Mectizan for river blindness.  

But already, activists are asking for more. "This is limited to South 
Africa and to people with cryptococcal meningitis," said Eric 
Sawyer, a veteran ACT UP member who recently infiltrated Pfizer's 
corporate offices in New York. "But people also die of esophageal 
thrush," another common AIDS illness that fluconazole treats. 
"Access needs to be broader and sustainable and global," said 
Sawyer. Indeed, the donation may pressure other companies to 
offer discounts or giveaways, and it could pave the way for 
negotiating two-tiered pricing for fluconazole throughout Africa.  

Pfizer's offer hangs on its ability to negotiate an acceptable 
program with the South African government, which may prove 
difficult. In 1998, Glaxo Wellcome offered a 75 percent discount on 
its drug AZT, which can reduce mother-to-child transmission of 
HIV. But South Africa has rejected that offer. And recently 
President Thabo Mbeki's spokesperson, Parks Mankahlana, 
compared pharmaceutical companies to "the marauders of the 
military industrial complex," and Mbeki himself, in a letter to a 
prominent South African doctor last month, defended his decision 
not to provide AZT to pregnant women by accusing "many people 
in our country" of sacrificing "all intellectual integrity to act as 
salespersons of the product of one pharmaceutical company!"  

The South African government's stance on AZT has angered and 
alienated AIDS workers, locking the two sides into an adversarial 
relationship. But Pfizer's offer could "break the logjam," says 
Achmat, noting that the health ministry has invited his group to 
discuss the fluconazole proposal. "We will be working very closely 
with the department of health," he predicts, "and we will be looking 
at all drugs, not just this one."  

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