Defying the Drug Cartel: The South African Campaign for Access to Essential Medicines

an interview with Zachie Achmat

Zackie Achmat runs South Africa's Treatment Action Campaign (TAC). TAC's main objective is to campaign for greater access to treatment for all South Africans, by raising public awareness and understanding about issues surrounding the availability, affordability and use of HIV treatments.

Multinational Monitor: What is the Defiance Campaign?

Zackie Achmat: The Christopher Moraka Defiance Campaign Against Unjust Trade Laws and Patent Abuse was launched by the Treatment Action Campaign (TAC) after the International AIDS Conference in Durban in July 2000 against drug company profiteering.

In May 2000, Christopher Moraka gave evidence to the South Africa Parliamentary Portfolio Committee on Health. At the time, Christopher was suffering from severe systemic thrush. Speaking in Xhosa and with dignity he said: "I'll speak in my own language. I am HIV-positive and I was diagnosed in 1996. ... Let me turn to the pharmaceutical companies. Companies like Pfizer make a lot of profit. We ask them to lower the price of drugs because we HIV positive people suffer the most. Other people don't feel this pain. They want to make profit you see." On July 27, 2000, Christopher Moraka died.

The Defiance Campaign has three objectives -to save lives where possible, to draw public attention to patent abuse and profiteering by drug companies and to set a moral example for the government to follow. TAC wants to expose the forces of inequality and privilege, and to build a social movement to develop a just international regulatory system for intellectual property rights that places people above profits.

Defiance campaigns have a long tradition in South Africa's anti-apartheid struggle. During the 1950s, the African National Congress, the trade unions and many civil society bodies engaged in a range of non-violent actions of civil disobedience against apartheid. The notorious Pass Laws that confined black people to townships and reserves were a key target of defiance. Under the Pass Laws, more than 17 million children, men and women were unjustly but "lawfully" imprisoned by the apartheid state. Defiance campaigns led by the Federation of South African Women, the ANC, the Pan Africanist Congress and the Communist Party challenged these laws. In the 1980s, the focus of Defiance Campaign shifted to segregated facilities after the first president of COSATU [the Congress of South African Trade Unions], the late Elijah Barayi, again called for a Defiance Campaign against the pass laws. P.W. Botha - one of the last apartheid presidents - abolished the pass laws under this threat.

TAC's Defiance Campaign against the drug companies builds on this tradition.

South Africa would not be a democracy had Nelson Mandela, Robert Sobukwe, Lilian Ngoyi, Frances Baard obeyed the pass laws and other unjust legislation. Steve Biko, Winnie Mandela, Trevor Manuel, Christmas Tinto and others deliberately broke laws that banned and banished them. The liberation movement's moral tradition of disobeying unjust laws mobilized millions of people to constitute a force for democracy and social justice. Defiance of unjust laws also exposed the forces of inequality, privilege and minority rule.

The Defiance Campaign has a separate committee in TAC. This committee is tasked with the logistics of bringing good quality, safe generic medicines into the country in defiance of patent laws and raising funds for the campaign. Hundreds of people from all walks of life - unemployed people with HIV/AIDS, pensioners, teachers, doctors, actors, lawyers, workers, youth - of all races have volunteered to courier medicines should this become necessary.

The Defiance Campaign is named after Christopher Moraka who felt the horrible pain of dying without being able to swallow, dying because he could not get access to medicines because of profiteering.

MM: How did TAC launch the Defiance Campaign?

Achmat: TAC's first act of defiance was against drug giant Pfizer's billion dollar sales per annum drug Diflucan (fluconazole). I was the first Defiance Campaign volunteer to visit Thailand to buy generic fluconazole (Biozole). Since then, actor Morne Visser has brought another shipment of the medicine into the country.

TAC had asked Pfizer to reduce the price of fluconazole, a drug needed to treat systemic thrush and cryptococcal meningitis. Both conditions are HIV/AIDS-related opportunistic infections that can be fatal if left untreated, or, if treatment is delayed.

In March 2000, TAC - supported by all the major South African religious bodies, trade unions, children's rights bodies and nongovernmental organizations (NGOs) - wrote to Pfizer to reduce the price of their drug to US$0.50 per 200 milligram or to give the South African government a license to produce or import generics. A 200 milligram capsule of this drug costs nearly US$15.00 in a retail pharmacy - Pfizer sells it to the private sector for US$12.00 and to the government US$7.50. TAC imported the same pill for US$0.25 from Thailand.

For every one person treated at the most advantageous Pfizer price, 30 people could be treated at the generic price.

At the end of March 2000, Pfizer offered the South African government a limited donation of Diflucan for people with HIV/AIDS. The donation was limited to cryptococcal meningitis (excluding thrush), only South Africans would benefit and the donation would last for two years until Pfizer's patent expired.

TAC gave Pfizer the benefit of the doubt and suggested that they include thrush, extend the offer to other poor countries and reduce the price to US$0.50 in the private sector. TAC was ignored.

In July 2000, Pfizer relaunched its same "offer" to the government with great fanfare.

TAC announced its Defiance Campaign against Pfizer's patent should it fail to reduce the price or include systemic thrush. TAC also pointed out that a donation can never be a substitute for self-reliance and sustainability in the health-care sector.

In October 2000, our patience had run out. The government had not responded to a TAC request to issue a compulsory license against the company and Pfizer announced record profits. In the interim, thousands of people continued to die of systemic thrush and cryptococcal meningitis. TAC declared that the right to life, health and dignity were more important than unjust trade laws.

MM: How has the government, Pfizer and the public responded to the Defiance Campaign?

Achmat: Faced with an enormous crisis, the South African government dithered.

It took cover behind the Medicines Control Council (MCC, the equivalent of the U.S. FDA). The chief director of the national HIV/AIDS program, Dr. Nono Simelela, suggested that "handing out pills on the street corners by TAC was irresponsible." TAC had made it clear that only doctors would diagnose and prescribe the medicines. The Minister of Health, Dr. Tshabalala-Msimang, declared that "she understood the frustration of people with HIV/AIDS but could not condone unlawful actions."

A bio-equivalence study was offered to the chairperson of the MCC, Dr. Helen Rees and the registrar of medicines, Dr. Precious Matsoso. Both were informed that TAC supported the enforcement of safety, efficacy and quality standards of the MCC and that we had taken every effort to ensure that Biozole was a good quality generic made by a reputable Thai company.

Yet, the MCC chairperson Dr. Rees went on to national television and called TAC actions "criminal" because the Biozole was "unsafe." Her words were later to prove rather imprudent. The MCC laid charges against TAC and me.

TAC made it clear that the MCC had delayed HIV/AIDS drugs - for instance, the provision of Nevirapine for use in preventing mother-to-child-transmission - because of political pressure. More than 250 doctors and nurses signed a statement indicating their willingness to distribute Biozole with or without MCC permission.

The MCC then offered TAC a section 21 exemption - permitting the drug to be imported - should the organization find a medical facility that would apply to import Biozole. Brooklyn Medical Center then applied for a Section 21 exemption and supplied the name of more than 20 doctors.

Meantime, TAC picketed the MCC and placed an advertisement in the Mail and Guardian, a newspaper regarded as progressive and read by all decision-makers, calling on the body to enforce the safety, quality and efficacy of medicines, not patents. TAC also called on the MCC to register patented generics.

On 28 November 2000, the MCC then offered Brooklyn Medical Center a section 21 exemption - the key condition was that an assay identification test at an approved South African facility should prove that Biozole contained fluconazole. TAC complied and supplied two tests, one from a French WHO-approved laboratory and done by Medecins Sans Frontieres [Doctors Without Borders] and another done by a South African facility. Both proved Biozole's equivalence and quality. A bio-equivalence study was also forwarded to the MCC.

Pfizer is putting pressure on the government while a defensive Mirreyena Deeb, CEO of the Pharmaceutical Manufacturers Association, has insisted that TAC should apply for a compulsory license because that is "legitimate and legal."

The Defiance Campaign has captured the public imagination. From all parts of the country and from every level of the society, people in South Africa have expressed their support for the campaign.

This has caused the government to become increasingly positive regarding generic production of medicines including anti-retrovirals. TAC demands that a plan for the production of generic anti-retrovirals and their distribution along the Brazilian model be undertaken by the government before the end of August 2001.

MM: Do you anticipate further steps as part of the Defiance Campaign?

Achmat: TAC will continue to import Biozole from Thailand and distribute it through the Brooklyn Medical Center. This is a challenge to Pfizer and the entire profiteering industry to sue TAC. The organization will also prepare to challenge the patents of Glaxo SmithKline, Bristol-Meyer Squibb, Boehringer Ingelheim, Merck, Abbott and Roche to anti-retroviral drugs. We don't want to give them advance warning.

MM: What level of resources would you like to see South Africa invest in healthcare?

Achmat: TAC hopes that the ANC's municipal election promise of free water and free electricity is implemented, but we desperately need the leading advocacy groups in South Africa, like Jubilee 2000 and Cease Fire, to work closely with trade unions to redirect the budget to that end, and to increase the health budget. We need a 33 percent increase to develop infrastructure, to train, and to employ more staff, up from R24 billion [$3.2 billion] to R32 billion [$4.3 billion]. Recently, per capita health spending has been declining, which can only be considered politically irresponsible, in the midst of the AIDS disaster.

MM: This would be aimed at assuring all who are HIV-positive ultimately get treatment.

Achmat: Yes, but for us, a move away from the multinational corporate drug producers to local generic production is crucial. We actually need not only state production of drugs, but also private generic competition here in South Africa.

MM: Are governments in the region ready for that kind of challenge to corporate prerogatives?

Achmat: The problem is partly that the African governments are not able to imagine an alternative. However, we are slightly more optimistic now. Over the past few months, there has been a strong joint statement by health ministers from the Southern African Development Community on bulk drug procurement. Even our own health minister, who we are taking to court for failing to implement a country-wide mother-to-child transmission program, is showing some spine with the drug companies.

However, we have to be vigilant, because as our minister has publicly commented, drug companies and other donor agencies are trying hard to divide the African countries on questions of how to attain sustainable healthcare provision, and particularly drug provision. It's easy to do that, because a country like Malawi doesn't have money to buy medication, compared to South Africa.

MM: What, realistically, can you expect the South African government to do on treatment?

Achmat: We would like to see, by mid-year, the implementation of what the government said it would do last August on prevention/treatment of opportunistic HIV-related diseases. For example, the tuberculosis budget is just R500 million [$66.7 million] per year, which just scratches the surface of what's needed. We have a TB case rate in South Africa of more than 350 per 100,000 people, which is the world's worst. In the mining industry, it's as high as 3,000 per 100,000. The main problem in the lowest-income provinces is that between a quarter and three-quarters of rural clinics don't have TB drugs. This is partly because of limited managerial capacity in rural areas, combined with budget cuts, especially to hospitals, which always drop consumables like medicines first. So the TB budget needs a massive increase.

We are also demanding introduction of cotrimoxazole to prevent PCP-pneumonia, which kills mainly HIV-positive infants. A monthly supply would cost R4 [$0.53] for children and R8-24 [$1.06-3.18] per adult, which is a great savings over hospitalization costs, which are up to R150,000 per patient [$20,000]. But right now, there's not sufficient political commitment from the government to get access to drugs even for these extremely obvious areas of treatment.

MM: It looked like you won the first major battle in the conflict with pharmaceutical companies in September 1999, when then-vice president Al Gore agreed to back off the pressure he put on the South African government to withdraw a South African law which made it possible to import drugs and license generics for local production. Then came Mbeki's turnaround. What did you learn from that struggle?

Achmat: As I said, the bigger problem is the government's unfounded fear of alienating investors in general. But on the positive side, we had the most exciting experience in rallying international solidarity since the anti-apartheid struggle. The most helpful research organization was the Consumer Project on Technology. The most important voice to help generate a global consensus that drug companies were committing genocide against the poor was Medecins sans Frontieres. The most serious activists fighting against profiteering on AIDS and other diseases were ACT UP in New York, Philadelphia and Paris.

But what ultimately also is critical for us, is the conscientization now underway in broader civil society, here and elsewhere. Last year, the Congress of South African Trade Unions and their Southern African allies pushed through a resolution supportive of generics at the Durban conference of the International Confederation of Free Trade Unions. This issue is resonating with trade unions across the South, including Korea and indeed throughout Africa.

MM: The drug companies are claiming that with their donations, they are now doing as much as can be expected.

Achmat: Well, first, the various donations have come only because of protest. These are, in any case, just holding operations for the drug companies, which hope they can delay the import or local production of generics in Africa. And the very large South African private sector is still not covered in one of the largest deals, between Pretoria and Pfizer, for Fluconazole.

Whatever the nature of a particular donation, we can't afford to let up pressure on the drug companies, otherwise prices will go way up again after they capture the market.

In any event, some of these programs are also financially self-interested. In Botswana, for every dollar Merck gives, the Gates Foundation gives a dollar, which comes back to the company when they buy Merck drugs at wholesale price, which can be added to Merck's tax deduction on the donation. The big question about the drug companies' donations is how long they can be sustained, and how many people will be reached? Evidence so far is not encouraging.

What is, however, most disturbing about the drug companies' philanthropy is their ability to buy off potential protest from the established AIDS organizations. Bristol-Myers-Squibb, for instance, has given $120 million to a "Secure the Future" program over three years, directed at women, children and NGOs. That gives them the clout to go into established AIDS organizations and literally purchase loyalty by researchers and NGO leaders. Some NGOs have become much less critical than they should be.

And BMS's two drugs are ddI and D4T, which in any case were developed by the U.S. National Institute of Health and Yale University. Yet both are still priced prohibitively in South Africa.

MM: Is progress being made on a vaccine, and how are drug companies doing in R&D more generally?

Achmat: Of course we would support a vaccine. The World Bank, Gates and other funders, including our government, all hope for a magic bullet. In reality, however, there's no chance of getting even a 50 percent effective vaccine within 7 to 10 years, according to the main scientific researchers.

While they are looking for that magic bullet, millions are due to perish, and millions more will contract HIV.

We wish they would spend a lot more of the resources now going into vaccine work into something more practical, namely a microbicide gell or spray which can prevent HIV transmission during vaginal and anal sexual intercourse, because it kills off lots of STD bugs. It's much more promising, but it's massively underfunded.

I think that so few companies are doing serious work on microbicides because the people who will use them most are poor women. If the perception within the drug companies is that the rich, white heterosexual market doesn't need it, you can expect it to become a fatally low priority.