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The offer gives hope to South Africa's 3.6 million people with HIV, because studies show that almost 10 percent of AIDS patients contract cryptococcal meningitis, and, bereft of medicine, most South African doctors have been forced to send patients with the illness home to die. Yet Pfizer's proposal, which is limited to South Africa, sidesteps the larger issue of how to make drugs available throughout the developing world.
Pfizer's move comes in the wake of a worldwide campaign orchestrated by the Nobel Prize-winning Médecins Sans Frontiéres, ACT UP, and the South African activist group Treatment Action Campaign. This coalition had demanded that Pfizer lower the price of fluconazolealso known by its brand name, Diflucanby about 90 percent, to match the price of a generic version of the medicine made and sold in Thailand. The Thai price is about 70 cents, while the South African government pays about $7.50 for the same dose.
Donating the drug "is more than we asked for in some ways," said Zackie Achmat of Treatment Action Campaign. He added that activists were in a meeting with lawyers preparing to petition the government to take legal action against Pfizer "when the call came through" from the drug company. "It floored us," said Achmat.
The South African government, which has recently criticized pharmaceutical companies for profiteering, was more reserved. It welcomed Pfizer's offer and agreed to meet with the company. But health ministry spokesperson Nothemba Dlali said the government feared that the donation might be only temporaryin which case South Africa would have to deal with thousands of patients demanding that the government pick up the tab when the drug would no longer be free. "The intention is good," said Dlali, "but we wonder in what position it will leave the government."
Activists, too, cautioned that donations are not a sustainable way to solve the desperate dearth of drugs in the developing world and, in particular, sub-Saharan Africa, where more than 23 million people are infected with HIV. In a statement released by Médecins Sans Frontiéres, Kenyan physician Chris Ouma said, "We're very happy for the South Africans, but for me, as a Kenyan doctor, and for the Kenyan patients dying from cryptococcal meningitis, it doesn't help much."
Providing fluconazole at no cost does not alleviate the other problems that undermine health care in South Africa. For example, hospitals in some parts of the country routinely face shortages of basic drugs, such as those used to treat tuberculosis. Nevertheless, doctors in South Africa were jubilant, if only because most of them can currently do nothing to treat cryptococcal meningitis because fluconazole is far too expensive. "The bottom line is money," said Florence Tleane, a doctor at Natalspruit Hospital, which serves three large townships outside Johannesburg. "If the drug is free, we would definitely treat patients."
So new is Pfizer's offermade by hand-delivered letterthat at press time even the company was unsure of many details. But Dr. George Flouty, medical director of Pfizer's public health program, said that the company wants to model the fluconazole donation on its current program to combat trachoma, the world's leading cause of preventable blindness. To treat that illness, which is confined almost wholly to the Third World, Pfizer donates its antibiotic Zithromax, but only through programs that comprehensively address the illness with education and efforts to clean the water supply. Similarly, said Flouty, "We don't want to just air-ship fluconazole to South Africa. We want to ensure proper diagnosis, treatment, and follow-up."
Follow-up is one of the most crucial aspects of treating cryptococcal meningitis in AIDS patients, because once the initial, acute attack is treated, people with HIV must take fluconazole every day or the disease almost always returns. Will Pfizer donate the drug just for the initial treatment or also for the prevention of relapsewhich could hugely inflate the company's cost? Flouty said such "nuances" were still being worked out, but added, "I'm going to go out on a limb here. If that's the right thing to do, I think we would want to do it."
Why would Pfizer donate the drug rather than reduce the price? "It's better to give it away," said Hemant Shah, a stock analyst who tracks pharmaceutical companies. "Otherwise you can have a 60 Minutes show asking why the product in South Africa is cheaper than in the U.S." Instead of negative press, Pfizer can now reap public-relations benefits for its charity. Merck, for example, has garnered excellent publicity for its long-standing program that gives away Mectizan for river blindness.
But already, activists are asking for more. "This is limited to South Africa and to people with cryptococcal meningitis," said Eric Sawyer, a veteran ACT UP member who recently infiltrated Pfizer's corporate offices in New York. "But people also die of esophageal thrush," another common AIDS illness that fluconazole treats. "Access needs to be broader and sustainable and global," said Sawyer. Indeed, the donation may pressure other companies to offer discounts or giveaways, and it could pave the way for negotiating two-tiered pricing for fluconazole throughout Africa.
Pfizer's offer hangs on its ability to negotiate an acceptable program with the South African government, which may prove difficult. In 1998, Glaxo Wellcome offered a 75 percent discount on its drug AZT, which can reduce mother-to-child transmission of HIV. But South Africa has rejected that offer. And recently President Thabo Mbeki's spokesperson, Parks Mankahlana, compared pharmaceutical companies to "the marauders of the military industrial complex," and Mbeki himself, in a letter to a prominent South African doctor last month, defended his decision not to provide AZT to pregnant women by accusing "many people in our country" of sacrificing "all intellectual integrity to act as salespersons of the product of one pharmaceutical company!"
The South African government's stance on AZT has angered and alienated AIDS workers, locking the two sides into an adversarial relationship. But Pfizer's offer could "break the logjam," says Achmat, noting that the health ministry has invited his group to discuss the fluconazole proposal. "We will be working very closely with the department of health," he predicts, "and we will be looking at all drugs, not just this one."