Ethics on Film: Discussion of "Fire in the Blood"

Modern medicine is one of humanity's greatest achievements. The discovery of penicillin made once-fatal infections easily curable, and global vaccination schemes have all but eradicated smallpox—a dreadful disease, terminal in up to one-third of cases. But worldwide efforts to stamp out disease are the exception rather than the rule. Pharmaceutical company profits depend on setting high prices for life-saving drugs, so medical breakthroughs often fail to help the poor.

Filmmaker Dylan Mohan Gray is on a crusade against the pharmaceutical industry's profits-first approach. With the tagline "Medicine, Monopoly, Malice," Fire in the Blood sets out to tell the story of how Western drug companies moved heaven and earth to keep discounted AIDS medications from reaching HIV-positive citizens of the developing world. Gray powerfully interweaves the history of AIDS treatment with in-depth interviews of politicians, physicians, activists, and CEOs, juxtaposing the stories of impoverished communities devastated by the disease with those of HIV-positive individuals who survived because they could afford the medications that keep the virus in check.

Overview

Although the world's first documented case of HIV can be traced back as far as to 1959, no effective treatment became available until 1996. Much as the discovery of penicillin revolutionized the treatment of bacterial infections, the discovery of a three-part antiretroviral (ARV) "cocktail" changed everything for AIDS patients. Without treatment, patients diagnosed with AIDS have a life expectancy of 6-19 months, but ARVs extend these patients' lives by approximately 10-40 years, depending on how quickly treatment begins.

When the AIDS cocktail first hit the world's markets, it was as expensive as it was effective. Gray introduces us to Edwin Cameron, a justice of the Constitutional Court in South Africa who became HIV positive in the 80s and gravely ill in the late 90s. He recalls spending one-third of his judicial salary on three daily pills. That was a small price to pay, perhaps, to be given new life after standing at death's door. But at over $10,000 per patient per year, the "wonder drugs" were out of reach for most people in the regions hit hardest by the AIDS epidemic. "These were the most catastrophic images Africa and the world had ever seen," reflects Peter Mugyenyi, a Ugandan medical doctor and leading HIV/AIDS researcher. "I saw so many people who would have lived… I saw them die painfully—excruciatingly. And yet their deaths were not inevitable."

"Big Pharma's" failure to address the African AIDS epidemic was not just an oversight. Its lawyers and lobbyists were hard at work, trying to keep ARVs out of dying people's hands. In a 1998 lawsuit brought against the South African government, a coalition of Western pharmaceutical companies sought to block legislation that would make badly needed cheap generic drugs available to South African AIDS patients. The government's motivation for wanting to circumvent ARV patents was obvious: although the going rate for a year's supply of a branded ARV cocktail was approximately $10,000, the ingredients needed to produce a generic cocktail cost only about $350. By opting for generic drugs over branded ones, the South African government would be able to increase the impact of their AIDS treatment spending almost thirtyfold. The pharmaceutical industry, on its end, argued that patents are crucial to innovation, and that failure to enforce them would discourage further research and development.

When lobbying policymakers to protect their patents, Western pharmaceutical companies met surprisingly little resistance. "Most people in Western Europe and North America accepted that drug manufacturers are entitled to specify price in the open market, which is a market defined by North American and Western conditions," says Cameron, more calmly than one would expect. "And if that price is unreachably high to people in the developing world—Africa and Asia, South America—that's just too bad. Those people must die." "It's fine for people in rich counties to say that this is what it ought to be," adds President Bill Clinton. "They don't have to live in these little villages and watch people die like flies."

Thanks to three major developments, the tide in the fight against HIV / AIDS started to turn in 2001. First, Cipla, an Indian generic drug manufacturer, announced it would sell a three-part ARV cocktail to governments and NGOs in the developing world for $350 per patient per year. The price was made possible by a 1972 Indian ban on drug patents and the extraordinary generosity of Yusuf Hamied, Cipla's chairman, on behalf of his company. "We're doing this on a humanitarian basis," he says in an interview with Gray. Second, the World Trade Organization (WTO) declared that states have a right to prioritize public health over international patent and trade agreements. Third, rich countries started giving more money to developing states combating the disease. Between 2000 and 2010, spending on HIV programs went up from $2 billion to $15 billion. With ARV prices in free-fall (by 2011, drugs that once cost $10,000 could be purchased for $62 in some developing countries), these programs had also become significantly more cost-effective.

However, as Gray somberly notes, the tug-of-war between Western patent holders and AIDS advocates is far from over. While outdated treatments can be bought at a fraction of what they cost when they first hit the market, newer, more effective drugs remain prohibitively expensive. Access to these newer drugs will become even more important as new strains of HIV prove increasingly resistant to treatment. What's more, developed nations have recently started to up the pressure on developing nations to uphold Western patent standards in renegotiated WTO treaties. Some experts are concerned that this intensified pressure (particularly on India, which is referred to by Michelle Childs of Médecins Sans Frontières as "the pharmacy of the developing world"), could be a major setback to the fight against HIV/ AIDS.

The Film's Argument

Clocking in at about 80 minutes, Fire in the Blood comprises an impressively thorough history of AIDS treatment in the developing world. William Hurt's narration is well interspersed with quotes from some of the foremost figures in the ongoing struggle, including Cipla chairman Yusuf Hamied, President Bill Clinton, AIDS activist Zackie Ahmat, Nobel-winning economist Joseph Stiglitz, and AIDS researcher Peter Mugyenyi. The quotes are chosen with care, and woven seamlessly into the narrative. Numbers and statistics, too, are employed with great effect at carefully chosen moments.

However, viewers should keep in mind that Gray's focus is on a narrow—though crucial —aspect of the fight against HIV/AIDS. Practically all of his interview subjects are sympathetic to his views, and every included statistic and anecdote points to the inevitable conclusion that "Big Pharma's" greed has killed millions of people in the developing world. Gray is right; pharmaceutical companies do prioritize profits over lives and the death toll caused by that policy is still growing. But it also bears mentioning that in 2011, 60 percent of HIV-infected individuals who would benefit from treatment (as judged by the standards set when treatments were becoming available) were receiving it.

It is easy to see why Gray would choose to downplay positive statistics; emphasis on progress might put a damper on the viewer's moral outrage. But omitting them altogether seems like a serious oversight. Overall, these statistics would strengthen, rather than weaken, Gray's case. Pharmaceutical companies showed no interest in lowering prices until developing world generics manufacturers took matters into their own hands, ignoring the patents altogether.

Although Fire in the Blood may be one-sided at times, its message remains important. There is a strong case to be made that the Western response to the developing world's AIDS crisis in the 90s was indeed "the crime of the century," as the film's website boldly proclaims. Still, Gray would have been wise to bolster his own argument by showing that he has carefully weighed and rejected those of his opponents.

Despite this weakness, Fire in the Blood is a powerful, compelling, and informative film, addressing an important global issue that is far too often overlooked.

Discussion: Patents and Public Health

Proponents of strict patent enforcement argue that patents play a crucial role in promoting innovation. Because research and development costs are so high, companies have no incentive to develop new drugs and technologies without assurance of exclusive rights over them, since freeloading generic drug manufacturers would run innovating firms out of business. Critics respond that drug patents derive heavily from publicly funded research. Indeed, a 2006 report by the Global Forum for Health Research found that public sources pay for 84.2 percent of basic medical research, compared with 12 percent spent by the pharmaceutical industry.

It makes sense for the public to foot the lion's share of the bill. Research is expensive, and outcomes are often hard to predict—many of history's greatest medical discoveries were made by accident. Pharmaceutical companies need to make a profit in order to survive, and they cannot afford to be the sole funders for thousands of studies that may lead nowhere. But, if a vast majority of basic medical research is funded by public spending, then is it really fair to let pharmaceutical companies retain exclusive rights to these discoveries' medical applications?

Moreover, by creating effective monopolies, strictly enforced patents allow companies to charge astronomical prices for life-saving drugs. Western drug companies were still charging $10,000 per patient per year for their ARV cocktails when Cipla chairman, Yusuf Hamied, announced they could make one for $350. Since up until that point only 1 percent of HIV patients in Africa who would benefit from treatment were receiving it, one could argue that Cipla's decision to break the American patent was simply a response to a tremendous market failure.

But where do we draw the line between the patents that should be upheld, and those that ought to be broken? And, who should set the bar for overriding intellectual property concerns? Drug companies charging nearly 30 times production cost for a product people desperately need for survival is clearly an extreme case, but what if they charged three times the production cost? At $1,050 a year, ARVs would still have been far too expensive for most sub-Saharan Africans. Pharmaceutical companies could set prices on a market-to-market basis, but that could potentially generate new headaches, like smuggling of branded drugs from low-income countries to wealthier ones.

Clearly, something should be done. The tougher question is what? Philosopher Thomas Pogge argues in favor of a Health Impact Fund, where pharmaceutical companies willing to produce and sell drugs at cost become eligible to claim a portion of a reward pool, based on the impact of their drugs on global public health. Other advocates, like Medicines Patent Pool founder Ellen 't Hoen, are working within the current system to encourage pharmaceutical companies to share their patents with generic manufacturers in exchange for small royalties. But Hoen and Pogge's programs are voluntary and, unsurprisingly, major pharmaceutical companies are not lining up to share their most profitable patents on the cheap.

Arguing that intellectual property laws reinforce inequality, economist Joseph Stiglitz contends that Western patent laws must be entirely revamped. Another alternative would be for governments in the developing world to present "Big Pharma" with an ultimatum: work out some kind of acceptable solution amongst yourselves, or we will come up with one for you. If having millions of lives at stake is not a powerful enough motivator to start talking solutions, maybe billions of dollars' worth of revenues will be.

Ethical Issues and Discussion Questions

1. Do pharmaceutical companies have a moral obligation to save lives?
   
2. Does the current patent regime for pharmaceuticals need to be reformed?
   
3. WTO "TRIPS plus" standards require developing nations to grant pharmaceutical patents lasting at least 20 years. Is 20 years a reasonable time for drug companies to regain their investments? If not, how long should patents last?
   
4. Do pharmaceutical companies have a right to set drug prices themselves? Why, or why not?
   
5. Should patents come with strings attached? If so, what can governments demand from patent holders?
   
6. Can governments ever be justified in stripping companies of their patents if they feel that the patents are being abused?
   
7. Expanding the production of cheap generics in the developing world would certainly help millions of poor HIV patients receive much needed treatment. But what about poor people in the developed world who lack access to life-saving medications? And what about those who can afford branded drugs, but only barely?
   
8. Because there are only so many ways in which a single disease or symptom can be effectively treated, drug patents often create monopolies, thus presenting consumers with only two options: buy this particular drug, or die. Can this be remedied, or can there never be a true free market for life-saving commodities?

Selected Carnegie Council Resources

The Intersection of Global Health and Business Derek Yach, PepsiCo; Yanzhong Huang, Council on Foreign Relations How can global health be improved? PepsiCo executive Derek Yach speaks about the positive changes corporations are making, and Professor Yanzhong Huang discusses China's health care challenges. (Just Business, May 2012)

Interview with Karl Hofmann on Private Sector Tools in Promoting Global Health Karl Hofmann, Population Services International "We strongly believe that markets can be made to work for the poor in ways that far surpass the ability of the public sector and other interventions to really have the impact that we need at scale," says PSI President Karl Hoffman. (Advocates for Ethics in Business, April 2011)

Health as a Human Right: Rights, Roles, and Responsibilities Workshops for Ethics in Business Roundtable The international community has begun to consider the "highest attainable standard of health" as a fundamental component of the human rights agenda, alongside related issues of poverty and adequate access to water and sanitation. (Workshop for Ethics in Business, December 2008)

Public Ethics Radio: Thomas Pogge on Pharmaceutical Innovation Thomas Pogge, Yale University Philosopher Thomas Pogge explains his proposal for dealing with the thorny intersection of public health, property rights, and poverty. As he sees it, the patent system doesn't work as well for medicines as it does for, say, consumer electronics. (Public Ethics Radio, August 2008)

The Politics of PEPFAR: The President's Emergency Plan for AIDS Relief John W. Dietrich, Bryant University In his January 2003 State of the Union Address, President Bush called for the U.S to commit $15 billion over five years to address the international HIV/AIDS epidemic. For several reasons, the President's Emergency Plan for AIDS Relief (PEPFAR) caught many people by surprise. The surprise quickly was followed by excitement, tempered by skepticism. (Ethics & International Affairs, Fall 2007)

Race Against Time: Searching for Hope in AIDS-Ravaged Africa Stephen Lewis, Aids-Free World Lewis offers his personal, often searing, insider's account of the plight of Africa and Africans with AIDS—and the wealthy world's betrayal. (Public Affairs, March 2006)

Access to Medicines and the Rhetoric of Responsibility Christian Barry, Australian National University; Kate Raworth, Oxfam In Africa fewer than 50,000 people—less than 2 percent of the people in need—currently receive ARV therapy. These facts have elicited strongly divergent reactions, and views about the appropriate response to this crisis have varied widely. (Ethics & International Affairs, Fall 2002)

International Obligation and Human Health: Evolving Policy Responses to HIV/AIDS Paul G. Harris, Hong Kong Institute of Education; Patricia Siplon, Saint Michaels CollegeThose with the ability to help can do so without significant sacrifice. Hence, those countries with the means to provide solutions to the HIV/AIDS crisis, and give succor to those now suffering from it, have a moral obligation to act. (Ethics & International Affairs, Fall 2001)

AIDS and International Ethics Brenda Almond, University of Hull Brenda Almond examines different countries' policies and ways of attempting to deal with AIDS, focusing on their positions in regard to rights. (Ethics & International Affairs, Spring 1988)

Works Cited

"Accidental Discoveries", PBS, NOVA, Lexi Krock, February 27, 2001

"AIDS: Ambition redefined", The Economist, G.C., June 30, 2013

"Aids epidemic update", UNAIDS & World Health Organization, December, 2007

"Battling the virus", The Economist, May 31, 2012

"Direct evidence of extensive diversity of HIV-1 in Kinshasa by 1960", Nature, Michael Worobey, et al., September 8, 2008

"Doctors: Patents keep HIV drugs too pricey to use", Fox News, Associated Press, July 2, 2013

"Ethics Matter: Philosopher Thomas Pogge, Crusader for Global Justice", Carnegie Council, Thomas Pogge and Julia Taylor Kennedy, January 19, 2012

"How Intellectual Property Reinforces Inequality", The New York Times, Joseph E. Stiglitz, July 14, 2013

"Monitoring Financial Flows for Health Research 2005: Behind the Global Numbers", Global Forum for Health Research, edited by Mary Anne Burke and Andrés de Francisco, February 2006

"Pool medical patents, save lives", TED Talk, Ellen 't Hoen, October, 2012

"Rich nations step up assault on generic Aids drugs", The Guardian, Elizabeth Whitman, June 10, 2011

"Trial in AIDS Drug Lawsuit Opens in Pretoria", The New York Times, Henri E. Cauvin, March 6, 2001

"TRIPS, TRIPS Plus and Doha", Médecins Sans Frontières/Doctors Without Borders, Access Campaign, July 2011

"WHO HIV Drug Resistance Report 2012", World Health Organization, 2012