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CUT THE COST

Katelina Aneca

Make vital medicines


available for poor people

Dominican Republic
Dominican Republic

The high price of medicines in the Dominican Republic is


costing poor people their lives. Mike Lanchin reports

Condemned to death, cheeks. Her lorry-driving husband chastised


because she is poor her for the impulsive decision but, on being
told the news, her eldest child Jessica, eight,
It has been only two weeks since Belkis simply looked up at her mother and said
Perez summoned the courage to tell her quietly: “I think I already knew. Yania (who
eldest children about the AIDS virus that is is two years old) is always getting sick, and
destroying her life and the lives of two of you take medicine all the time. I knew
her young infants. Having kept her secret something was wrong.” Later she told her
for almost three years, worried that her mother that when she grows up she wants
children would be picked on at school, she to be a doctor and work with AIDS patients.
Like many other families
still doesn’t know if she did the right thing. Unable to afford costly life-saving anti-
in the poor district of
Puerta Plata, Belkis and
“It was one afternoon when I felt so retroviral drugs, Belkis, who is only 31 years
her three daughters face down, I just took the decision. I wanted old, fears she may never live to see that day.
a bleak future without them to know. I thought they were ready,” “I can’t really see a future, not for me, not
affordable medicines she says, tears beginning to flow down her for my children. But we will just keep on
struggling.”
Belkis and her second child, Jennifer,
Katelina Aneca

seven, were diagnosed HIV-positive three


years ago when Belkis was pregnant with
her third daughter, Yania. She did not
receive the simple medication that would
have prevented the virus jumping to her
child, so Yania was also born with AIDS.
Since then, a large slice of the family’s
budget goes on buying medicines, since the
little girl is often prone to sickness, with
amoebas, colds, or flu. When I visited Belkis
and her three children, she complained of
stomach pains, but had not gone to the
doctor, concerned about the cost of the
medicines that she might be prescribed.
The family home is a cramped, 20 square
metre tin shack, part of an illegal settlement
just outside Puerto Plata, or “Silver Port”, one
of the Dominican Republic’s major tourist
attractions. It is also top of the national
AIDS’ league. No one has running water
here, nor indoor plumbing. People have to
buy water for washing from a truck twice a
week. Fifteen pesos ($0.91) buy enough to
fill a large tin drum. Drinking water has to
be hauled up from a small store twenty
minutes away.
Dominican Republic

Specialised medicines that


will save lives are out of the
governments reach

Poverty and sickness go side by side in the


Dominican Republic, where tourism, and
factories in the free trade zone have boosted
the economy to an average annual growth
rate of around 7%. The government is now
spending more on health than in previous
years (9.01% of the budget in 1998 compared
with 8.4% in 1993). But expensive specialised
imported medicines, like the cocktail of
anti-retroviral drugs that would change the
lives of Belkis and her girls, are out of the

Katelina Aneca
Treasury’s reach. “We just cannot budget
for them,” says Dr. Raul Benou, head of
the government’s Essential Medicines
Programme, Promese. A monthly course
of the drugs can cost up to 20,000 pesos
($1,200). The minimum monthly wage varies
between 1,800 pesos ($109) and 1,600 pesos
($97.50). While the governmental Social
Security Institute provides some anti- drug companies, on the other. It has become Families in Puerta Plata
retroviral drugs, only 6% of the population a struggle for control over lucrative markets, live in cramped,
of working age are affiliated to the Institute principles of patenting and inventions, but unsanitary conditions;
their houses little more
– and you have to be in full time work to also a battle over the right of poor people to
than tin shacks
qualify. But with one quarter of the eight access medicines.
million population officially classified as
poor, it is not just impoverished AIDS
victims who are unable to meet their In the battle to control the
medical fees. According to some studies, production of medicines, poor
as many as one in five Dominicans cannot people will be left dying on
afford basic medical care or commonly the sidelines
prescribed medicines.
In recent years, the quest by government The latest frontline in this battle is the
and local industry in many developing Dominican Republic, where an undeclared
countries to assure cheap, safe medicines commercial war has broken out with the
for their population has taken on a new US pharmaceutical firms, backed by the
dimension. It has now spilt over into a US Trade Representative, threatening trade
conflict around patent rights on essential sanctions if the government does not
and specialised medicines. On the one hand, protect them against local competitors.
developing nations and their national “This is a fight between David and Goliath.
pharmaceutical industries – which are Some of the multinational companies we
increasingly able to produce more cheap are facing are bigger than the Dominican
generic versions of expensive imported Republic itself,” says Ho-Chy Vega, Executive
medicines – are lining up against the rich Director of the Dominican Pharmaceutical
nations and the powerful multinational Trade Association, Infadomi.

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Dominican Republic

development costs can be recuperated and


further investigation will be stimulated.
“Although we have to provide some
protection for the local medicine industry,
there has to be some way of compensating
the inventors and the capital they have
invested,” says José Maria Carbal, Executive
Director of the Dominican-British Chamber
of Commerce, and a lawyer for several inter-
national pharmaceutical companies.

New patent rules could force


local pharmaceutical companies
out of the market
Katelina Aneca

The Dominican Republic had until the year


2000 to incorporate the new patent rules
into its national law. But, like other
developing nations with an expanding
domestic industry producing a wide range
of cheaper generic medicines, the intro-
Government-run The root of this conflict lies in global duction of TRIPs in the Dominican Republic
community pharmacies, rules on patenting called Trade Related has had a rough ride. Initially, many of
or boticas, like this one Intellectual Property Rights, or TRIPs. those working in the health sector were
in Los Guandules,
Subscribed to by more than one hundred unsure of what TRIPs really meant. “To talk
provide cheap
medicines for poor
nations at the World Trade Organisation about TRIPs some years ago was totally
families six years ago, the TRIPs accords standardised unknown, it was something from another
global patent rules. Although they were planet to most of us,” said Ho-Chy Vega. But
termed a set of “minimum standards”, soon, doctors, researchers and local pharma-
TRIPs increased the scope, length and geo- ceutical companies began worrying that
graphical coverage of patents. Under the tighter patent rules could mean less
agreement all countries must provide 20 competition in the domestic market, forcing
years protection for patents – not just for out local companies and eventually leading
products and processes in all areas of to higher prices of not just more common
technology. In the case of medicines – areas medicines presently in use, but also new
often excluded from patent laws in those drugs. “Since there are active ingredients
few countries where such legislation already being used for which the patent will have to
existed prior to the TRIPs accords – it was be paid... this will mean a price increase for
argued that the agreements would allow medicines,” says Dr. José Matos, National
multinational drug companies to recoup Director of sexual health and reproduction
and protect their investments made in for the government Health Secretariat. “The
researching and developing new drugs. knock-on effect of having to pay for a patent
By patenting each new medicine in each means costs are passed onto the consumers.”
country, the argument went, the manufac- According to research commissioned by
turers guarantee that local pharmaceutical Oxfam GB in November 2000, a mere 10%
firms will not copy their product and “steal” contraction of the local market, would
their invention. That way research and result in a rise in the price of the most five

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Dominican Republic

commonly consumed medicines (antibiotics, “I get these here, because they are cheap
analgesics, anti-acids and anti hypertensive and seem to work for me,” says 47-year-old
and anti inflammatories) of between 4.7% Catalino Sanchez, an unemployed bus
and 18.2%. driver, holding up two bottles of generic
anti-acidic medicines, for which he paid
the equivalent of 36 cents each. Another
Small, government-run customer, Ignacio Batista, 66, says he has
dispensaries are a vital life-line bought a locally produced analgesic for his
for poor communities sick wife at about one third of the price of
what he would have to pay for a foreign
The $300m pharmaceutical market in the brand name at the local chemist. But today
Dominican Republic is currently shored up he has also come away disappointed, since
40% to the locals and 60% controlled by the the botica does not stock another medicine
multinationals and their distributors. The that his wife needs.
cheapest locally-produced medicines are At the moment,
Distribution and availability of stock are
people like 47-year-old
found at the government-run Botica a problem at the government outlets.
Catalino Sanchez can
Populares, located in almost every poor Hernandez admits that she put in an order buy cheap medicines
district or hospital throughout the country. for Vitamin A tablets over a month ago and at the local botica.
That is where generic antibiotics can be is still waiting. Matching quality to cost is But availability of stock
bought at one quarter of the price of another difficult issue, says Dr Johnny is a constant problem
imported brand names, and a locally
produced anti-flu tablet can cost a ninth
of its imported version. According to
representatives of multinational pharma-
ceutical firms, a whole range of medicines
currently in circulation in the Dominican
Republic would have to be withdrawn once
full patent rights under TRIPS come into
effect. The Association of Representatives
and Agents of Pharmaceutical Producers,
ARAPF in Spanish, provides a list of 24
active ingredients being used in medicines,
both generic and local brand names, which,
it says, are in violation of current patents.
These include antibiotics like Cipro-
floxacine, produced locally at half the
price of its foreign competitor. “To get ill
in Dominican Republic is a luxury, but if
there is something that has helped us
tackle the problem of health in this country,
it has been the generics,” says Dr Frank
Alvarez Sanchez, director of biomedic
investigation for the private Pro Familia
clinics. “We are giving a vital service to
people – low cost medicines at a good
quality,” says Ana Cecilia Hernandez, in
charge of the government chemist in the
Guandule district.
Katelina Aneca
Dominican Republic

Conception, Director of the public health more accessible prices. We need them for
clinic adjoining the Botica Popular. “We the development of our people.” Ponce de
always ask people first if they can afford to Leon says that his company has been
buy the medicines or not. We prescribe what reproducing copies of foreign-produced
they can afford, which is not always what medicines only once their patents have
they need. We have to balance our efforts to expired. But he says: “The danger from the
resolve their medical problems against the tighter patent law is what could happen in
reality of what they can pay.” It is a moral the future, what will happen to new
and human dilemma for doctors, but not medicines for new illnesses.” According to
unique to the Dominican Republic. In many Guillermo de la Rosa, Director of INSALUD,
developing countries, the cost rather than an umbrella organisation of private and
the quality of a medicine has become a charitable groups working in the health
more important criteria, not just in prescrip- sector, the increasing resistance of TB
tion practices but also in the buying policies patients to medicines currently on offer
of government-run essential medicine under the government’s anti-TB programme
Katelina Aneca

programmes. According to Dalila Castillo, a is a case in point. He says that the pro-
specialist in essential medicines at the Pan gramme uses cheaper generic medicines,
American Health Organization: “In countries which are slowly losing their effectiveness.
with sound financial situations, the price of He says that what is at stake is how the local
a medicine is not the first determining industry will be able to produce later
factor, rather the effectiveness and security generations of these anti-biotics at accessible
Guillermo de la Rosa, that the medicine offers the patient.” She prices, while patent laws protect their
Director of INSALUD, an adds: “If there is a good medicine on the foreign “inventors” from competition for
umbrella organisation of market but the population in general up to 20 years. “The tendency will be
private and charitable
cannot afford it, then that obviously has towards good medicines only for the rich
health groups, is worried
an impact on public health. But equally, if and poor quality medicine for the poor – or
that good-quality
medicines will only be
we were to have a system (of control) here in none at all.”
available to the rich the Dominican Republic that allowed us to For now, there is a kind of legal limbo in
determine which medicines are of a poor the Dominican Republic over the TRIPs
quality, then we could also say they are rules. Despite much pressure and lobbying
having a negative effect on people’s health.” from Washington and some European Union
countries, in May of this year the outgoing
Dominican government of President Leonel
Medicines could end up as Fernandez pushed through Congress new
luxury items which only the intellectual property and patent laws –
rich can afford slightly later than the 1 January deadline.
The legislation, passed by both chambers of
“After TRIPs we knew that we had to prepare the legislature, has caused fresh controversy
ourselves... but for commercial and humani- and the source of a renewed onslaught by
tarian reasons, we are now worried for the the US pharmaceutical industry and US
future,” says Rafael Ponce de Leon, Sales government officials. In an article published
Director at Dr. Collado Pharmaceuticals, one 13 September in the local press, the US
of the Dominican Republic’s leading phar- Ambassador to the Dominican Republic,
maceutical firms. “We have always believed Charles T. Manatt, wrote of the concern that
that patents are important for recuperating he said is shared by potential US investors
research and development costs. But Third regarding the climate of “uncertainty” for
World countries cannot be left out of investing in the Caribbean country. While
getting new generation of medicines at “recognising” the efforts made to bring the

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country’s laws into compliance with WTO We cannot be irrationally over-protection-
rules, including TRIPs, Manatt warned: ist.” The US pharmaceuticals and their
“The active application of these laws will be allies are now awaiting discussion of the
key to eliminating the concerns of investors secondary legislation that will govern the
regarding intellectual property rights.” application of the new laws, in the hope
Equally, during a visit to Santo Domingo that their objections will be resolved there.
in the first half of November, Deputy US Meanwhile, pressure has been mounting
Trade Representative, Richard W Fisher on the Dominican Republic in the form of
made it plain to the new president, Hipolito veiled and not so veiled warnings about
Mejia, that the eyes of Washington the possible trade sanctions.
Dominican Republic still fails to “adequately
protect” patent and intellectual property
rights. Poor workers fear the double
The controversy revolves around the whammy of expensive medicines
inclusion in the law of clauses, which, and unemployment
critics claim, directly violate the terms of
the TRIPs documents. These include The government’s weakest flank is the
granting the authorities the power to issue threat to withdraw its recently acquired
what are termed “obligatory licences”, and extended access to the lucrative US clothing
to authorise “parallel imports” of medicines market. As of 2 October more than a dozen
that are patented in a third nation. Much Central American and Caribbean nations
of the criticism has been centred on the became eligible to benefit under a revised
Dominican lawmakers’ decision to allow version Caribbean Basin Initiative (CBI).
licences to local producers in the event of In the case of the Dominican Republic,
a multinational patent holder “refusing to this could mean between 10,000 and 15,000
deal” – ie. refusing a reasonable monetary new jobs each year in its free trade zone
offer for the right to use the patented factories, says José Torres, Director of the
medicine, or active ingredient. “It was Dominican free trade zone association,
important for us to have a law that ADOZONA. The clothing and confection
guarantees that the legal monopoly being industry currently employs around 200,000
granted with 20 year patents will not be Dominicans, over half of them working
open to abuse,” explains Ho-Chy Vegas. He class women. The free trade zone factories
adds: “We have tried to give the law as wide exported US$4.2bn worth of goods last year.
an interpretation as possible, taking Half of the factories are North American-
advantage of all the limits set by TRIPs, but owned, which is another reason why the
without going any further. For a country Dominicans are taking the possibility of
like ours, complying with TRIPS is not easy. trade reprisals very seriously. Torres says:
It’s a challenge. But the US has wanted us to “We have made great efforts to comply
go even further than that.” Rafael Ponce de with international rules and standards.”
Leon goes further: “Obligatory licences are But he adds that many of his members are
the only thing that makes the law viable for concerned about the devastating effects
us. They represent an opening, a doorway that sanctions would have on the textile
for local drug companies.” industry. Like other Dominican business
But José Maria Cabral of the British- representatives, Torres stresses that the
Dominican Chamber of Commerce, who current debate over whether or not the
maintains that the new laws are not legislation is TRIPs compliant should be
compliant with WTO standards, retorts: resolved through the established channels
“The legislation has gone way past TRIPs... of conflict resolution at the WTO – not by
Crispin Hughes
Dominican Republic

lobbying and threats from Washington. “The something totally different. “This is not
WTO are the ones who have to decide, let a conflict between local and foreign
them say.” industries. It is a struggle concerning how
But if there is one thing that those on best to satisfy the basic health needs of a
both sides of this controversy do agree upon poor population.”
on, it is that the current battle is not about Belkis Perez and other AIDS sufferers also
who controls the US$300m Dominican phar- understand it best in those terms. “It is not
maceutical market. Cabral admits that what right that we cannot get the medicines we
is at stake in the dispute over the Caribbean need. If we had access to anti-retrovirals we
nation’s interpretation of TRIPs is the would have a future. I demand that our
dangerous example that other developing government gives them to us,” she said.
nations with a capacity to produce cheaper Roque Cid, who runs the self-help group
medicines might choose to imitate. “If we for AIDS victims where Belkis first sought
let this one go, others will follow,” he says. help for coping with the disease, says:
Rafael Ponce de Leon, who himself worked “In developed countries with these anti-
for a multinational drug company for many retrovirals, AIDS has become a chronic
years before going on to a Dominican disease, but not a fatal one, like here.”
company, agrees. He says that it is the 500 Ironically, last year a multinational pharma-
million-strong Latin American market that ceutical company – which he preferred not
is the real cherry on the pie for the multi- to name – offered a free trial cocktail of anti-
Without access to
cheap, good-quality
national pharmaceuticals. retrovirals to members of Cid’s group.
medicines, the future For those who work in the public health Fifteen sufferers volunteered. None of them
looks uncertain for sector in the Dominican Republic, like withstood the as yet untested side effects,
the next generation Guillermo de la Rosa, the battle is about and all withdrew from the experiment.
Katelina Aneca

For more information, visit: www.oxfam.org.uk/cutthecost

Front cover photograph:


Community pharmacy in Los Guandules

Oxfam GB is a member of Oxfam International, registered charity no. 202918

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