my entirely unacademic-y argument for why Money matters most for pharmaceutical access.
Okay, to start: an anecdote. During the final month of my semester in China last spring, I ran out of a medication that I take daily. Because this drug happens to be a controlled substance, the DEA would not allow pharmacies to give me more than a one month supply, and the logistics (not to mention the expense) of mailing made it impossible to have a friend fill the prescription and send it to me. So imagine my dismay when a doctor at the bougiest clinic in Shanghai (the offices were in the Ritz Carleton!) informed me “We don’t have that here.” Don’t have that brand? Do you have a generic? “Nope. Nothing like it.” What do you mean here? Can I get it at a bigger hospital? Another city? “No, I mean, we don’t have it in China.” His only suggestion: “Try the internet.”
With the help of a Chinese friend (who goes by the name of Brilliant Fong*, and he proved himself worthy of the moniker in this instance) I spent the next two evenings scouring BaiDu, the popular search engine, searching for pharmacies in the industrial south that might carry some version of the drug. Most of the places we found turned out not to be pharmacies, but chemical factories that manufactured pharmaceutical components, not finished products. But eventually we came across a company that bragged it could get any kind of drug in the world. Brilliant Fong spoke with a chipper young woman who assured him they had my medicine, I just needed to make a deposit into a bank account in her boss’s name. While this seemed rather shady to me, it certainly was far from the sketchiest thing I’d done while travelling and I’d run out of options, so I agreed to make the payment (with the caveat that they provide their national ID numbers as security). Dozens of phone calls (Bril refused to use his phone minutes, so we would call then hang up and wait for them to call back), a few more “deposits” (“The drugs only come in packages of 5 bottles!” “The Finance Man has gone to Guangzhou, needs incentive to return!” “The Transport Man, subcontracted, not our employer, is demanding insurance payment!”), three almost-calls to the police, and one threat of physical violence later, a dapper young man on an electric bicycle showed up our dormitory with a plastic baggie full of pills and, voila! I could enjoy the rest of the semester in good health!
The moral of this story, in my mind anyway, is that where there’s money, there’s a way. China had none of the “architecture” health policy analysts describe to make this drug available. There were no domestic producers, no stocks in the pharmacies, no providers aware of how to prescribe or dispense it. But thanks to my financial resources (which not only paid the drug dealers themselves, but also afforded me the time to spend haggling with Phone Lady, allowed me access to phones and the internet, and let me thank Bril with a big turtle dinner) this health-infrastructure was entirely unnecessary. To be sure, the networks present in the age of globalization were crucial, but national drug adoption policies or distribution chains were completely irrelevant to me, a consumer with money.
I couldn’t help but think of this experience when I read the articles on pharmaceutical access. Like most of our readings, they acknowledge that adequate funding is important, but in a way that seems almost defensive, emphasize that what it’s really about is SYSTEMS. “ACCESS”, the Harvard Center for Population and Development Studies’ report on health technology access in poor countries, is quick to state on in its first page “But cost is far from the only barrier to access. Other obstacles abound.” In a Milennium Project report on access to essential medicines, the authors argue that “the woeful state of health systems in most developing countries prevents these effective [health] interventions from reaching those in greatest need.”
I have to admit, reading article after article that self-consciously reminds us over and over “It’s not the poverty! I mean, yeah, health costs money, and people/governments/NGOs in the developing world don’t have much of that, but we’re going to focus on everything else!” can be more than a bit frustrating. When I read things like (from the Milennium Project report) “the greatest obstacle to delivery of HIV/AIDS services…is the appaling state of health systems in much of the developing world,” I want to scream, “WELL WHY DO YOU THINK THOSE HEALTH SYSTEMS ARE SO APPALLING, GENIUSES?!?!
So why are we so scared to talk about the (somewhat obvious, I think) fact that the health problems of the global south can be attributed almost entirely to economic causes? Of the so-called non-cost issues the ACCESS report notes, almost all are at least indirectly related to money; “limited capacity of public health systems” (uh, are you suggesting these systems are crummy because, idk, the people who run them are stupid? That if more money was invested in to studying and improving them, they’re capacity wouldn’t increase?) “lack of political commitment to health improvement” (yeah, it’s hard to be committed to health improvement when you’re busy fending off the IMF loan sharks and struggling just to keep your country’s head above water), “persistent corruption in public and private health facilities” (okay, so this is a problem in rich countries too, but there’s certainly more incentive to skim a little off the top or take bribes when your salary’s crud and your patients/citizens don’t have the resources to go after you for it) “international trade and patent disputes” (how I see intellectual property rights: my people invade your people. My people make tons of money exploiting your people. I learn that a plant in your forest has medicinal properties. I ask you all about it. I take it back to my country and figure out how to put it in a pill. I declare that I own this knowledge, crush you with my sheer political/economic clout when you try to make the medicine yourself, and sell the pill back to you at an exorbitant price and profit off of your people’s suffering) and finally “difficulties in distributing, prescribing, delivering, and using products.” (I don’t suppose those difficulties have anything to do with poverty, do they?)
Obviously, good strong health systems are important. Without hospitals, clinics, providers, and the infrastructures that support them, sick people would never get better. But on the flip side, perfect “architecture, availability, and adoption” aren’t worth a damn if you can’t pay afford the subsidized $.50 cost of your child’s vaccine or to take a half-day off from work to take her to the clinic. And even if the Access Framework for a certain drug is missing all four A’s, a gal with money can find a way to get it.
I suppose I can sympathize with the scholars and policy-makers who write these things. If they admit that 99.9% of the Global Disease Burden in the developing world can be attributed to poverty, to fundamental inequality, then they’d be forced to acknowledge that they’re devoting their lives to applying billion dollar band-aids.** They can work on beefing up cancer care in India, but Pepsi Co will keep dumping carcinogenic waste in her rivers. They can mobilize community health care workers to monitor DOT for tuberculosis in Guatemala, but Nestlé still won’t pay its coffee pickers enough to buy the food their family needs to stomach the medicine. For every million dollar grant a policy maker invests towards strengthening health systems in the Global South, exploitative economic structures will suck billions more to the North.
This week’s reading reaffirm something I’ve often thought about rich countries’ commitments to “global health”: we’ve got to stop causing damage before we can start to fix it.
My final conclusion: screw medical school. When I grow up, I’m gonna be a revolutionary.
*family name has been changed to protect my accomplice’s identity
**While I’m making up statistics, I should note that I’m like 87% playing devils advocate with this last bit here. I’m going to be a doctor, obviously I believe in band-aids. The whole reason I chose medicine over a more root-cause field like social activism or education is that curing the underlying disease of global injustice could take a really, really long time, and until then, someone’s got to treat the symptoms.