13 May 2004

Botswana: Merck Official Says Partnership in Botswana is Learning from Experience and Passing It On

Whitehouse Station, NJ — The African Aids pandemic has thrust pharmaceutical firms into the news, as companies and their supporters and critics have debated the appropriate role of intellectual property and patented drugs in health emergencies. Less visible have been programmes that pair companies with government and non-governmental initiatives.

The U.S.-based company Merck has become deeply engaged in Botswana, which suffers the world's second highest HIV prevalence rate. The African Comprehensive HIV/AIDS Partnerships (ACHAP) is a collaboration involving the government of Botswana, the Bill and Melinda Gates Foundation and Merck and its corporate foundation. The effort uses multiple interventions to both prevent and treat the infection. AllAfrica's Tamela Hultman asked Dr. Linda M. Distlerath, Merck's Vice-President for Global Health Policy, about the project.

Merck and the Gates Foundation have each committed US$50 million for a five-year programme that began in 2000. What prompted your decision to participate?

Well, Merck is involved in Botswana because we want to make a difference on the epidemic and a difference in people's lives. There was a high level of consternation and frustration around the world, particularly in the public health community, about how to tackle HIV/Aids. The epidemic was so large that it was difficult to think about how you put your arms around the epidemic and have an impact.

It was our feeling that to mount a comprehensive response took a very large infrastructure with trained health-care professionals, secure drug distribution systems, good information, education for patients - and all of that had to come together. We wanted to know: how do you do that at a country level? We felt that by entering this partnership we would gain that experience. By gaining that experience, we bring, I believe, a more credible voice - an informed voice - to the debate and to the discussions about how to tackle the epidemic around the world, and therefore were able to participate in being part of the solution rather than sitting on the sidelines, and being perceived as being the main part of the problem.

You're suggesting that the price of drugs is not the most difficult problem.

Exactly. Merck would say that the real challenge is infrastructure. You need to have drugs, you need to have financing, but it's building that infrastructure that is the real barrier to access to care, treatment, prevention, and support. But when Merck would say that, we would be alleged to be diverting attention from what some perceive as the real issue, which is the prices of drugs and patents on drugs. It took a determined amount of discipline and focus to look at the goal that we have to make a difference in people's lives, to work in partnership with the government and provide enabling resources and expertise to allow the government to do what it felt was best to tackle the epidemic, and to continue to work and make progress in helping to save lives and helping to prevent new infections.

At the same time, you wrote in a recent Yale health policy journal [Yale Journal on Health Policy, Law, and Ethics, IV:1 (2004)] that, in those situations of poverty and disease you've mentioned, "Merck and other large producers should help remove the barriers that stand between patients and the therapies they need." What does that mean about drug pricing?

First and foremost, Merck knows that we need to facilitate access to our drugs and vaccines. For us to spend years and make major investment to discover new drugs and vaccines but not allow those to get to people who need them, for a variety of reasons - perhaps the price or perhaps the lack of health-care infrastructure - we need to work on those parts that we can influence.

Secondly, we also believe on principle that drugs need to be priced in some accord with ability to pay. That was the guiding principle as we established a pricing policy for Merck's HIV/Aids drugs. For the world's poorest countries and those hardest hit by the epidemic, Merck sells our two Aids drugs at prices where we make no profit. In other countries that are in a mid-tier economic category and have an HIV/Aids epidemic, but perhaps not quite as bad as some of the countries, particularly in sub-Saharan Africa, we offer substantial discounts for both of our Aids drugs.

We believe these pricing policies are helping to make our drugs more affordable and more accessible. But that being said, when you look at the totality of people in the developing world who are on treatment, and I believe it's only about 300,000 when, in fact, there should be about 6 million on treatment, there's more going on, or not going on, to prevent access to care than just the price of the drugs. So that's why we get involved in partnerships, as we've done in Botswana, to help build the infrastructure, help train physicians, help work with employers so that they can provide treatment programs.

You also said in the journal piece that making social investments of that kind requires supportive shareholders. How do you make the argument for that support?

Well, at Merck we look at ourselves as a single entity as a business involved in the discovery and development of new drugs and vaccines. Merck is a multinational research-based pharmaceutical company, and we have many therapeutic areas and many products, both drugs and vaccines, that we sell around the world. Merck is a for-profit business, and we are profitable. But in focusing on how we help improve access to medicines, by contributing to the policy debates, we're able to create an environment where overall, globally, Merck is able to succeed as a pharmaceutical company. It's the revenues we generate, in totality as a company, that allow us to improve access to medicines, including selling our Aids drugs at no profit in the world's poorest countries - while at the same time, again on a global basis, being able to generate the revenues necessary to invest in research and development for the new drugs and vaccines for tomorrow.

You're now more than half way through the funded five-year programme in Botswana. What have you learned?

One, I think we have learned it is possible to make a difference. The partnership between Merck and Gates is helping to support the government of Botswana in offering a treatment program. There are now more than 24,000 people enrolled, over 14,000 actually on therapy today. That's the largest government-run treatment program for Aids in all of Africa. We see that people's lives are beginning to be saved. There's now less than a 10% mortality rate among those who are treated, and these are the people who go back to their community and work and become the loving parents for their children. You are able to see that difference.

We are able to see the difference in reaching out to teachers in Botswana's primary and secondary schools, giving them the information about HIV/Aids, so they not only can protect themselves but can help educate the children in the classroom about the risk of HIV/Aids and how to care for people who are living with Aids. So I think that's number one: you can make a difference.

Two, it's really difficult, [even in] a country like Botswana where you have tremendous political will and government leadership. President Festus Mogae has openly and repeatedly talked about the Aids epidemic in Botswana and the need to overcome the epidemic, because if they don't, the country will go into extinction. It's that type of leadership that can permeate the system and inspire others to join in that fight - and inspired Merck and Gates to join in that fight as well. Third, the major barrier is infrastructure: human resource capacity; physical buildings, whether it's clinics or storage facilities to hold the drugs; building laboratories and equipping the laboratories; training people; and helping to build capacities of systems so all the efforts can be coordinated effectively by the government to make sure that you're having the maximum impact on preventing new infections and treating people already affected by Aids.

I've been hearing it said that countries like Swaziland and Botswana are beyond help or hope. The epidemic is already too far advanced for the countries to survive.

Whether it's Botswana or Swaziland, where the adult prevalence of HIV is 40%, first you have to remember 60% are HIV negative. You must do something so that those who are HIV negative stay that way, and there are prevention programs - education programs. We do have the tools to educate people so that they can protect themselves, their families, and their communities.

For the 40% infected with HIV, if there is an intervention that can help improve the quality of someone's life and extend their life, if only for a few years, you can have very positive benefits, not only at the individual level, but at the family level, where you're enabling an adult affected with HIV - a mother or father - to go back to their home and to take care of their children. Perhaps they can go back to work. That results in positive economic benefits for the community and for the country. To write off people because of the burden of HIV/Aids is not only to write off a country. It will reflect poorly on the entirety of humanity around the world - that we did not care enough about people, we did not care enough about nations, to do whatever we can to be able to help prolong lives and improve the quality of lives. Yes, there will be many people who will die of Aids because they don't have access to treatment today, or did not have it years ago. But you need to look forward and not look at what didn't happen in the past but at what's possible to do going forward. To me, that is the only path that the world and the world community can take.

Swaziland is seeking money from the Global Fund to Fight Aids, Tuberculosis and Malaria to compensate caregivers, particularly in rural communities, who are struggling - often at personal risk, because of lack of protective materials or disinfectants - to cope with the overwhelming task of taking care of orphans and tending to the sick and dying. Do you know of other instances of aiding caregivers in that way, and how do you see that as a need?

First, I'm not aware of particular programs to pay people in rural communities to take care of others, at least an on-going program, although I know there have been discussions. But to the point, where do you find the resources and the human energy and the capacity that's going to be needed to collectively mount the community response and support system for those impacted by HIV/Aids?

It is a very admirable aspect of culture for communities to take care of each other, particularly for communities to take care of children when their parents have died. That's a workable solution when the number of children that might be needing that care is relatively low compared to the number of people and adults in the community able to provide that care. But when you look, for example, at the growing number of Aids orphans - and Botswana is one example - you look at entire villages where it's only the very young, and the very old, who are left.

I remember visiting Botswana and going into a rural community and walking by a home where there was a two-year-old child being taken care of by a woman who clearly looked to be 85, 90 years old and very frail. The woman's daughters and sons had all died of HIV/Aids, leaving her to care for this child. This was just one child. There are many grandparents in these communities that are not only taking care of their own grandchildren, but also the children of their nieces and nephews or others in the community. It's overwhelming. And people have large hearts, great capacity to love and to care, but when the numbers of people who need care grows much faster than the community has the capacity to provide that care and support, something needs to be done.

And whether it is paying people for services that they provide to the community, or other types of compensation, it's also a matter of recognizing and valuing the care that people provide. It is a value. To just depend on the good hearts of people - as much as they want to, they'll quickly become burnt out because the job is overwhelming. Yet, it is the community resources and vitality that we need to tap into. So we need to think of a good solution to enable the community to provide the care that they need, but do it in a way that the caregivers are taken care of as well.

Would you speak a bit more about infrastructure constraints and what the epidemic has taught us?

I think the HIV/Aids epidemic and the impact in developing countries, particularly sub-Saharan Africa, has shown us the fragility of the public health systems in these countries. When public health systems are stressed, as Aids has stressed all of them, it really shows the weaknesses in the system, or creates new gaps that might not have been there before.

It's the same public health systems, the hospital systems, the training of nurses and doctors, the same system that should be there and should be strong to respond to other infectious diseases - and actually even to morbidity, and mortality caused by non-infectious disease. It's all one and the same system. Aids has taught us that, for too long, countries and donor countries and international organizations have under-invested in the infrastructure needed for a strong health care system. That needs to be redressed.

There's also the realization that to have economic growth and development, to be a global trader and participate in the global marketplace, countries need to have a healthy workforce to produce the goods that can help bring countries out of poverty. Investment in health is the critical path to being able to achieve economic growth and prosperity. And that, actually, has only been recognized over the last couple of years. So I think the imperative around a public health need - and the realization that investment in health is the path to economic growth and development and stability - I think, I hope, that these two forces converging will galvanize the world and the funders to invest more in health systems so that people, communities, and nations can prosper.

To sum up then, what are three or four important impediments to making progress against HIV in Africa?

You need government leadership [and] political will from the top - that's where it starts. You need to invest in infrastructure, human capacity, physical capacity, and systems capacity. And you need to address the stigma and the denial and the discrimination that is associated with HIV/Aids.

It's very frustrating in a country like Botswana - frustrations that have been expressed by President Festus Mogae. His country, his government, is providing Aids treatment for free. Testing is provided for free. But people are still reluctant to come forward to be tested. They don't come forward because of the fear of discrimination and the stigma associated with HIV. And unless you're tested, you don't know whether or not you're positive and therefore might benefit from treatment. That must be broken through. We're going to be initiating new programs through our partnership between Merck and the Gates Foundation in Botswana to try to really drill down and understand and intervene and release the strangleholds that stigma and discrimination can cause in preventing an effective response to the epidemic and that prevent people from getting help.

Is the status of women a major issue?

Absolutely. First of all, women need to be empowered to control who they have sex with and when and under what conditions. They need to be empowered to be able to have legal rights, property rights, so that when their husband dies, they are able to inherit and able to acquire the property that was part of their marriage. It's only through addressing gender inequities that it would be possible to build up the strength of communities, the strength of the family. Also, women can be extraordinary leaders at the community level and at the government level, but we have to allow and enable women to bring their strengths, to bring their innovative approaches to dealing with issues.

That will be a critical and vital component to any country's national Aids response. We encourage that process by our support of programs that directly or indirectly address inequity issues, particularly in helping to build health care systems and train health care workers. Our programs in Botswana are supporting community-based initiatives, particularly support groups for people living with HIV/Aids, which - if not predominantly run and managed by women - have a good number of women. Through these non-governmental organizations and community-based organizations and the faith-based organizations, we're really building up this strong network of women in Botswana to effectively deal with the epidemic.

How do you articulate ACHAP's purpose?

One to make a difference. Two, to identify what it would take to mount a comprehensive response to HIV/Aids. And, three, to share those learnings with others around the world, particularly the experience supporting Botswana's treatment program - now the largest in all of Africa. As other countries in sub-Saharan Africa and other areas of the developing world are mounting treatment programs, we hope that the experience and lessons learned will be helpful to other countries so that they may more rapidly and efficiently scale up their treatment programs.

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