By Sameer Sharma, Writing Competition Second Prize 2016
Topic 2: Write a persuasive piece detailing your controversial opinion on a contentious topic
It’s enjoyable to attack corporations that prey on human frailty. Whether it’s Martin Shkreli being eviscerated by interviewers, or the Mylan CEO being admonished by US Congress for Epipen price increases, we love to sit back and watch the fat cat be slapped. A lot of this is fair – big pharmaceutical companies are occasionally predatory, or use vested interests to alter research outcomes. We very rarely hear about, however, some of the good things they do – compassionate access for unreleased medication, or undirected research scholarships. This largely one-sided narrative continues in medical school, and is why a fellow student, after seeing me use a Glaxo-Smith-Kline pen, told me that the company performed drug trials in Indian slums, and that my using one of their gel-gripped fine-ball point pens was tacitly condoning their tactics. I smiled – I didn’t care. I’m fine with the idea that drug companies test their drugs in poor countries such as India and Nigeria, and here’s why.
Drug companies spend enormous amounts on research and development (around $2 billion per drug1). They need to – drug resistance, discovery of intolerable side effect profiles, and changes in pathophysiological understanding of disease whittle away the effectiveness of medications that they release. And whenever they have a medication that appears to be effective in the longer term, they eventually lose their ability to be the sole providers as generics are allowed to be produced by competitors who never had to research and develop as they did. Over the past decade, however, India (and other areas of the subcontinent) has used their far less protective patent legislation to justify becoming what many call the “pharmacy of the developing world”2. What this means, practically, is that Indian drug companies have the ability to buy a medication made by a Western company that has spent years developing it, reverse-engineer it, and sell their own generic at a price that radically undercuts the ability of Western companies to gain access to Asian and African markets.
Thus, my first reason that GSK or Pfizer should go to India (or any other poor country) and test their drugs on that population is because it’s fair. If these populations in developing countries are going to have access to that drug in ways that bypass the West, it’s wholly unjust for them to not also bear the burden of drug testing and side effect evaluation. The current status quo, in many cases, is that drug side effects are evaluated in Western populations, the drug is altered, tested again to be sure those effects are gone or minimised, and then sold (after significant investment). This puts all of the economic and physical harm of this drug creation on Western populations. Developing nations, however, probably benefit more from these drugs than we do, for three reasons.
Firstly, there is a higher burden of disease there – life expectancies are lower with a higher prevalence of uncontrolled lifestyle diseases and infections. This means that putting an Indian male on a statin therapy probably is better for that man than it is for an Australian – general differing levels of health mean the Indian has more years to gain. This analysis holds true for many aspects of disease when comparing the health of Western or developing populations. Secondly, they are able to get these drugs for cheaper – there are many drugs that India mass produces at low cost that do have significant deductibles or costs to a Western consumer, even comparing for differing purchasing powers. Finally, their populations are either larger, or growing far more rapidly than ours – apart from the higher disease burden then, the consequence is that their gross usage of medications copied from Western companies is likely to outweigh the usage by Western consumers, especially for medications that treat infective agents.
In a world, then, where developing country populations have more to gain from these drugs than Western populations, pay less for them, and use more of them, it’s morally justifiable for them to also bear the brunt of testing and suffer the side effects – which these companies have incentives to minimise anyway, because too many means their drug is rejected by authorities – that have so far been borne by Western populations.
However, there’s a secondary level of analysis that looks at the effects of the ability of poorer countries to access those medications so cheaply, especially when considering antibiotics. In 2010, India was the world’s largest consumer of antibiotics for human health, and a review by Laxminarayan and Chaudhury3 argued that increased income, unregulated antibiotic sale, a high burden of disease and poor public health infrastructure has led to burgeoning levels of antibiotic resistance in India. In this country of over a billion people, the ability to purchase carbapanems over the counter is a terrifying one, with several implications for this discussion. Firstly, the rampant use of top-shelf antibiotics makes those users more responsible for that resistance. Thus, as before, it’s more justifiable to test our antibiotics in these developing countries. Secondly, the increased resistance renders futile much of the research and development by Western pharmaceutical companies worthless, and also makes future drug development more difficult and more expensive – it becomes imperative to thus perform testing areas that are cheaper to do so in, such as developing countries. Lastly, if countries like India have the worst antibiotic resistance, or have new strains, there is a direct incentive to test the ability of drugs to combat these strains in their local settings to maximise effectiveness.
However, many students see drug testing on poor uneducated Indians (etc.) as coercive and ignoring their right to be adequately informed. I’ll end this article by responding to these notions. Firstly, simply saying that they “can’t consent” doesn’t balance that amorphous harm against the overwhelming moral justness of testing on those populations, or the necessity to do so created by, for example, antibiotic resistance. Secondly, and as a direct refutation, consent is a spectrum. We let patients who are consent to complicated life-saving procedures after only rudimentary explanation. We let patients request to not be told the risks of a procedure, such that they don’t back out of the option to have an outcome they deeply desire. Similarly, even if we only ever did drug testing in slums (which isn’t true, because the amount of confounders and likely non-compliance would make research unfeasible), the idea that these people shouldn’t sacrifice getting side effects they might not fully understand for money is one that comes from privilege and elitism. It’s one that doesn’t recognise that for a poor person, being poor is really awful, and that maybe having some side effects in exchange for being able to consistently feed your family and access better housing is a viable trade-off, not coercion. They gain significant benefits from the money and housing these companies provide, and the crusades of social justice warriors deprive them of these.
It’s not spite with which I justify testing drugs in poor developing countries. It’s recognising that the people there are able to consent to better finances, and that our opposition is intellectually misplaced. It’s with a sense of fairness and justice, where their access to medication without giving back fails both of those principles.
- Thomas, Kim, 30th March 2016, The Guardian, “The price of health: the cost of developing new medicines”, accessible from https://www.theguardian.com/healthcare-network/2016/mar/30/new-drugs-development-costs-pharma
- Medecins Sans Frontieres, 29th March 2016, “At EU-India Summit, India must defend its ‘pharmacy of the developing world’”, accessible from http://www.msf.org/en/article/eu-india-summit-india-must-defend-its-%E2%80%98pharmacy-developing-world%E2%80%99
- Laxminarayan R, Chaudhury RR, March 2 2016,“Antibiotic Resistance in India: Drivers and Opportunities for Action”. PLoS Med 13(3): e1001974. doi: 10.1371/journal.pmed.1001974, accessible from http://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1001974
Featured image by user Ragesoss at Wikimedia Commons.