A quarter of a million South Africans died of AIDS last year, but that figure could soon be dwarfed: By some estimates, half of the current population of 15-year-olds will be killed by the disease. As many as half of the people in the frame of any photograph in a public setting in South Africa today may be doomed to die.
This is the backdrop to the case that opened Monday in a Pretoria courtroom, over the intellectual property rights of the international pharmaceutical corporations who manufacture the drugs that could serve as a lifeline to those in the snapshot currently doomed to die.
There's a hideous absurdity, of course, in the realization that their deaths are actually preventable. There are drugs available, after all, that can contain the disease and prevent it from stealing lives, complicated cocktail treatments developed by brilliant scientists that can make AIDS manageable.
In the United States, those cocktail treatments cost an AIDS patient some $15,000 a year. That puts them way beyond the reach of the overwhelming majority of the millions of South Africans at risk. Even at the substantial discounts the drug companies have offered many African countries, the treatments remain prohibitively expensive for most.
But there's a growing movement in the Third World to not simply accept the limits imposed by their poverty on their ability to fight AIDS. Brazil and India have led the way in manufacturing cheap copies of the patented AIDS drugs, and making those available for a fraction of the prices charged in the West. One Indian company, for example, has undertaken to supply the cocktail treatment for somewhere between $500 and $800 a year per patient. The authorities in South Africa want the right to import the cheapest possible version of the drugs that can contain their AIDS emergency, but the drug companies want to protect their patents from being undermined by cheaper copies. Both sides claim the backing of World Trade Organization statutes for their positions. Laws governing intellectual property and international trade will be the formal concerns of the Pretoria trial.
But there's obviously a lot more riding on it. AIDS activists are painting the trial as a moment of truth in a clash between the wretched of the earth and corporate behemoths looking to grow larger still by profiteering from human misfortune. Drug companies are seeing it as a basic challenge to the principle of patent and profit, which they see as essential to their industry's capacity to develop new drugs capable of saving lives.
But the issues raised by the trial go far beyond the 39 drug companies involved in the suit. The case highlights fundamental questions over to what extent the profit principle and the free market should apply to the field of medicine. The drug companies insist that without protected patents and the ability to turn a handsome profit, they would have no incentive to make the capital outlays required to develop new drugs. Critics will argue, of course, that the scale of the profit requires some explanation: After all, if an Indian company is able to supply the AIDS-drug cocktail at 5 percent of the price charged in the U.S. and still turn a profit, that speaks of a margin for which "handsome" seems too benign an adjective. It certainly poses the question of what might be a socially acceptable profit margin for lifesaving potions.
There's a natural concern among pharmaceutical manufacturers that allowing AIDS drugs to become available in Africa at a fraction of the price charged in the U.S. might prompt patients (and even governments) in the industrialized world to begin asking why they ought to continue paying the higher price. Or worse still, that those Brazilian or Indian companies who undercut them in Africa may decide to challenge the pharmaceutical giants in other markets, even in their own backyards.
Even if it represents something of a p.r. nightmare to the drug companies, the trial concerns a principle they deem sacrosanct — that in the market economics of the pharmaceutical industry, profit remains the only incentive for the development of new cures. It's a compelling argument, of course, within its own logic (even though its critics like to point out that some of the AIDS drugs, such as protease inhibitors, were originally developed in taxpayer-funded institutions). But it's difficult to fault the drug companies for behaving according to corporate logic, which is based, above all else, on the profit motive.
Still, as a society, we may have to ask ourselves whether allowing market forces and the profit motive to govern the distribution of medicines and health services is a rational choice. Indeed, we have to ask whether we're comfortable allowing millions of people to die simply because they are unable to afford medicines we are capable of producing in plentiful supply. And let's be very clear about this — it's not the drug companies that are at fault here. They're behaving as corporations behave. If they behaved like nonprofit organizations then they wouldn't be corporations. In other words, the questions raised by the Pretoria trial are a challenge to our society as a whole, or at least to the very principle of medicine for profit.
The pharmaceutical corporations insist that scientific innovation cannot occur in the absence of a profit motive. And given the experience of socialism, it's a fair challenge. The collapse of socialism in Eastern Europe was in the final analysis a product of its stagnation. The absence of a market mechanism, Mikhail Gorbachev argued in his book "Perestroika," meant that planned economies were fundamentally lacking an engine for economic innovation, and were therefore doomed to stagnation.
But Gorbachev was writing about the economy, not about science. Despite Stalinist totalitarianism (which often interfered with science and scientists), science continued to blossom in the Soviet Union. They beat us into space and in countless other areas of science. And Western scientists always engaged with their Soviet counterparts on a plane of mutual respect quite inaccessible to their governments. Scientists, in whatever society, are a quirky lot, motivated by enigmatic incentives comprehensible only to their own kind. Stock options and corporate bonuses are no more fundamental to the achievement of scientific advance than were Soviet medals and patriotic exhortations.
Of course, translating scientific innovation into efficient production and distribution may indeed require a profit motive. But the scale of such profits, and the framework within which they're made, are worth discussing.
The Pretoria trial offers an opportunity to ponder the relationship between science and medicine on the one hand and markets and profit on the other. Rather than demonizing individual corporations or getting stuck on the mantras of intellectual property, it has become imperative to see the bigger picture. Because in that bigger picture, millions of people are dying every year of a treatable disease. And there's nothing inevitable about their deaths; they are a product of our cultural choices.