Examination of Witnesses (Questions 500
- 514)
TUESDAY 18 JULY 2000
DR PETER
PIOT AND
DR JULIA
CLEVES
480. Can I ask whether thMr Rowe
500. Are you both medical doctors?
(Dr Cleves) No, I am not.
501. That is quite encouraging. Think what kind
of a message that is giving to the original argument of Dr Piot,
that you do not want it all medical-led. Can we turn now to something
you already touched on, which is the concessional pricing from
pharmaceutical companies and the antiretrovirals. Are you engaged
in the debate with the WTO about what provisions there are that
might permit the production of cheaper generic drugs and, if so,
can you tell us about that? The Committee is very interested in
that.
(Dr Piot) That is my number one headache, as you can
imagine, this access to care and treatment. I think that the contracts
that have existed between the pharmaceutical industry and western
nations and governments—and that started basically after
World War II—are now reaching their limits when it comes
to access to these medicines for the poor. The contract is based
on the fact that through patent protection and giving a monopoly
of certain products for X period of time, the efficiency of that
has been very high; high for the shareholders and high for western
society, because new products were developed. The poor countries
have really not benefited from that, that is not new. With AIDS
that has become an overwhelmingly publicised, moral issue. We
need to look into that because if the full TRIPs agreements are
going to be put into practice this is going to restrict even further
what developing countries will benefit from in terms of innovation.
On the one hand, we strongly believe that they need incentives
for new products and, on the other hand, the question is how can
we make sure that the poor have access to them. I am sure that
if discussions and negotiations on TRIPs started today the outcome
would be different, because of the AIDS debate. What are we doing?
There is a working group we started a few months ago with the
WHO and the WTO on intellectual property tariffs and intellectual
property protection. That group is looking into the facts. At
the moment, during this transition period, many of the drugs are
not under patent protection in many of the developing countries,
but they will be soon. The only way out I see is that we have
to keep the incentives so that new products are being developed.
It is the taxpayers in the north who will subsidise that so that
the poor in the south can benefit at equity pricing from the same
products.
502. Basically you allow the companies to float
the product at the protected price and it is the taxpayers in
the north who pick it up to make it cheaper for the developing
countries.
(Dr Piot) Yes, that is something that I see as a model.
That requires a new kind of contract, which goes far beyond the
national boundaries. There is an international type of contract.
I may be naive. I am really looking for alternatives for the current
system. The current system provides the goods for the rich but
it does not provide anything for the poor in the poorer countries.
Any ideas are really welcome.
(Dr Cleves) To supplement Peter's answer, we have
been working through this very closely with the WHO and the WTO.
We invited somebody from the WTO to come to Durban to take part
in the debate in terms of improving access to care. We are working
with them on how to interpret our Article 31 and TRIPs. We obviously
get a great deal of demand from governments in developing countries
as to what TRIPs means for them and how we can work with them.
We have also learned from the experiences, which I mentioned earlier,
in Cote d'Ivoire and Uganda that one of the best ways of bringing
the price of drugs down is competition. When there is a market
then the price starts to fall. We have been exploring the legal
options in terms of access to generics, finding all of the different
options and all of the avenues. We feel that the work we have
started to do with the pharmaceutical companies has got a great
deal of publicity and people have been really interested. We have
said right from the outset that this is one avenue of exploration,
there are many others as well, that we need to explore.
503. Years ago I went to Cuba and they were
very concerned about the effect of the American sanctions, and
so on, and I think the world pharmacopoeia on their own drug manufacturing
industry, which, apparently, is of very high quality. Are there
other countries like that, who are excluded from the world family
by the power of the big multinational drug companies, or whatever?
(Dr Piot) Brazil has a very well devolved generic
pharmaceutical industry. Most of them are state owned—local
states or the federal government—and they are producing
medicines that are under patent in other countries. They are now
discussing with other developing countries whether they can export
or not. That is where competition comes in. We are now in the
grey area of international trade. I think this is going to become
one of the major political issues in international trade in the
coming years, the pressure on developing countries' governments
to provide treatment, particularly to their power base, the urban
elites, which are very heavily affected by HIV, and they will
turn this into a major political issue. I look at what is going
on in some of the industrialised countries, and certainly in the
United States it became an issue with Al Gore's campaign, where
he was followed everywhere by members of ACTUP around this issue.
That is why, as Julia said, we are exploring many avenues at the
moment. I think all of them will help a little bit. The price
of the drug is critical but it is also the infrastructure and
the system to deliver it. Let us always keep that in perspective.
Mr Colman
504. Like most things, often things are the
opposite of what you originally perceive. When I was in Geneva
I asked developing country delegates what they felt about the
deal that had been done in terms of concessional pricing from
the pharmaceutical companies and they were very angry because
they felt they had not, the developing countries, been able to
take part in those negotiations and they had been done behind
the scenes by UNAIDS and other United Nations organisations with
pharmaceutical companies on a grace and favour arrangement and
they, the developing countries, had been cut out of those negotiations.
They were very pleased that that week there was going to be a
meeting at the WTO where they had a seat at the table, a veto
at the table, in terms of ensuring there was clarity as to what
was on offer and to have a basis for future concessional pricing
and agreements that they would have a say in. They wanted the
WTO to be centre-stage because that is where they had their votes
and they could assure there was a rule-based approach to ensuring
that future deals were done in the open where they, the developing
countries, could have a say on what went on. Would you agree that,
perhaps, in the future that such deals, if you like, are done
with developing countries at the table which happens in the WTO
rather than behind the scenes?
(Dr Piot) Thank you for that comment. It is a feeling
that lives with developing countries. What we announced in May
was actually not even a deal, it was a statement of intent to
start discussions, but in the whole publicity that got lost, including
with some governments, particularly from southern Africa.
505. Those were the ones I was talking to, they
were very angry.
(Dr Piot) Yes, I know. We had not even started any
discussions. The discussions we had were on the principles that
we are going to work along. When you go into discussions I feel
it is far more important, before you start talking about prices,
to say what the mutual expectations are. I do not expect the pharmaceutical
companies to give up their bottom line and they should not expect
that we give up our values and our principles. We strongly feel
that all the provisions of the TRIPs agreements are there as an
international treaty. That is what we agreed on. For me the breakthrough
was that five pharmaceutical companies accepted the principle
of preferential pricing. With the exception of Glaxo Wellcome,
who accepted that principle some time ago, all of the others had
never explicitly accepted, and that is where the breakthrough
was. We are now in business and we have established a contact
group—South Africa is a member of that—made up, basically,
of the members of our board, the programme coordinating board
of all UNAIDS. We had hoped to make it a smaller group but everybody
wants to be in there. That group is going to accompany the process.
When it comes to actual negotiations with the companies this will
be done on a country basis or on a cluster of countries basis.
Some countries may want to join together, for example the Caribbean
is so small they might prefer to do it together. In any case,
that can only be done with the countries in the driving seat.
Our role is one of facilitating and providing technical support.
506. The role of the WTO, dominated by developing
countries is to provide a rule base approach to this, rather than
grace and favour?
(Dr Piot) Grace and favour is not what we are looking
for. It has to be clear what the price basis is. That is why you
will find in this report a table which gives the price for the
same product in different countries. Some are made by generic
manufacturers and some are made by the original manufacturers.
You have a factor of between a one in three to a one in ten difference
in price. What we are doing is providing that kind of information
to countries and they decide. I agree, we should have done something
better in terms of communication. The difficulty was, really,
bringing the companies to the table and saying, "We accept
preferential pricing as a principle but it would have been difficult
to do so in an open WTO base".
(Dr Cleves) We were also driven by the media, to a
certain extent. There was a major leak to the media, so the whole
thing became public before we had an opportunity for a much fuller,
consultative process, which was always the intention at the outset,
and which is why, as Peter was saying, the only thing that was
announced on May 11th was a statement of intent, which was a page
and a half of text. There were no deals or no negotiations.
(Dr Piot) We got a few days' notice this was going
to come out in the Wall Street Journal on a particular
day.
Ann Clwyd: Lucky to be pre-warned, I
suppose.
Mr Worthington
507. You referred earlier to the increasing
establishment of the National AIDS Commission in countries. What
do you see as the role of these bodies, are they funding mechanisms
for a country or are they think-tanks? What is the ideal position
on their role?
(Dr Piot) I think their roles are to provide a platform
for coordinating the various sectors and monitoring that they
do their job. Secondly, they have very important political policy
setting to do. For example, in many countries, particularly in
southern Africa, there has been a debate which, we have been involved
in, to make compulsory disclosure of your HIV status a law. That
is something a body like that has to handle. Developing the strategy,
allocation of resources within budget, these are political decisions.
Technicians can provide information but these are political decisions.
The implementation has to happen through existing channels, particularly
at the periphery, be it NGOs or government. I think, ultimately,
local government and NGOs are going to be, and should be, the
main implementers of this. We are going away from the old model
of the national AIDS control programme in the capital, which was
fulfilling all or trying to fulfil all of these functions from
policy setting, resource mobilisation, politics and implementation
up to the periphery. That is something that does not work. It
is quite comparable to UNAIDS function at the international level,
strategy, de-mobilisation, co-ordination and facilitation. The
actual implementation has to be done where it can be done best
and cheaper.
508. Can I ask a question about the private
sector, however you want to define that—it might be foundations,
it might be pharmaceutical firms, NGOs, and so on, we are talking,
in many cases, about countries who have a very, very poor structure
as far as government is concerned, they are embryo ministries,
and so on—what do you see as the role of the private sector?
Are you trying to push the private sector further in some countries
in terms of its role? Can we have your thoughts on that?
(Dr Piot) For the time being let us narrow down private
sector to business and the unions. Part of the job of all theme
groups is to stimulate the creation of a business council on AIDS.
That has happened in many countries. I was present in Zambia where
the theme group on HIV/AIDS was instrumental in bringing together
business leaders. Once they are convinced they can do it themselves
they certainly do not need the UN system or a donor to do that.
They need us to provide them with technical support and we are
trying to do three things with these business councils. One is
that they are advocates amongst their peers and also with the
politicians, because they have influence. Secondly, they organise
AIDS-in-the-workplace programmes for their work force to be protected.
They accept and respect a code of conduct of non-discrimination.
These are the basis for the business councils. Another thing that
we are doing is with major multinational companies. For example,
we are working a lot with Unilever, which has a major network
in Africa, in employees' distribution systems and plantations.
We are discussing with a number of other companies where they
have the money and the resources but what they need is know-how.
Thirdly, we are working with various groups of unions regionally,
they are part of the International Partnership against AIDS in
Africa and in South Africa. The unions have now become very active,
particularly around the issue of access to care and treatment.
There was a demonstration in Durban which was co-organised by
the unions and primarily a white gay activist group—which
is quite an interesting combination, even into today's South Africa—that
were fighting for access to treatment. For me that is something
that is really essential when you look at expanding the private
sector. I would like to look at religious organisations, again
sometimes very powerful, even in delivery of social services,
controlling schools, hospitals. UNAIDS was created as a body that
would focus on the UN system. I can tell you that we have gone
out of that quite a long time ago. I believe in the UN system
and I am committed to it, it is an incredible platform and instrument
but we have to link up with society, with government and civil
society. In an increasing number of countries we now have representatives
of the private sector on what were the original UNC groups on
HIV/AIDS. I think there is a great future there.
509. Going back to an earlier theme about research,
does UNAIDS prioritise in terms of research or can you direct
us to where someone has objectively said, "Look, there is
lot of money going into this area, we need not worry about that,
if it is going to come up with the goods, it will but there are
neglected areas"? Who can you direct us to in terms of an
assessment of where the money should be going in terms of research?
(Dr Piot) The WHO are the best to do that. The research
that we are directly involved with is a more operational type
of research, the evaluation of programmes in the field, and so
on, particularly when it comes to biomedical types of research.
The WHO definitely.
(Dr Cleves) The EC are also in the process of taking
a global look at research and where the needs are and where they
might put more resources to stimulate new research.
Mr Khabra
510. The question of human rights has been raised
many times with respect to HIV/AIDS, what is UNAIDS' assessment
of the adequacy of human rights protection and the legal framework
for those with HIV/AIDS in countries with high rates of infection?
How does UNAIDS attempt to improve the human rights of those living
with HIV/AIDS and remove stigma and discrimination?
(Dr Piot) That is an important question. We have what
is called a rights-based approach to the epidemic, meaning when
you look at AIDS it is clear that violations of human rights on
the one hand are contributing to the spread of HIV and on the
other hand that people with HIV are subject to very severe violations
of human rights. We are engaged in and monitoring that in several
countries with ICASO, the International Council of AIDS Service
Organisations, and also with the office of the High Commission
for Human Rights, where we are funding a professional in the High
Commission's office specifically to monitor that, that is one
person. What we are trying to do is to work through the National
Commission on Human Rights. For example, specifically in India,
the National Commission on Human Rights has a programme, together
with UNAIDS, in terms of monitoring human rights violations. Sometimes
we are involved in political and policy debates, to say the least,
with some governments. I alluded to the fact that some governments
announced last year that they were going to make disclosure of
your HIV status compulsory by law. We were extremely concerned
about that. The intention was very good but the effect would have
been disastrous. Take the well-publicised case of a woman in South
Africa who was stoned to death because she appeared on TV and
declared that she was HIV positive. When she went back home her
community felt that she had brought shame to the community and
she was beaten and stoned to death. I am not even talking about
losing your job, your flat, and all that, that is all still daily
bread for people with HIV. A law that would make disclosure of
your status compulsory would have disastrous implications. We
have been working on that behind the scenes, in front of the scenes
and working mostly through other organisations. I am disappointed
at the moment that major human rights organisations, from Amnesty
International to Humans Right Watch, have not taken on AIDS. I
think it is about time they did. I always say, "As long as
AIDS is only taken on by those who are AIDS activists, people
like us, it is not going to work". They have to take it on.
511. Are you in touch with Amnesty International,
because they emphasise the human rights issues where politics
are involved?
(Dr Piot) We have had contact in the past and we will
continue to do that.
(Dr Cleves) I just wanted to point out that with the
High Commission for Human Rights we have published and launched
the international guidelines for HIV/AIDS and human rights. It
has been hugely successful as a publication and it has been translated
and summaries have been done for NGOs. It has set the standard
for mapping out what human rights issues are and has been a very
useful publication.
(Dr Piot) I had forgotten, we launched a handbook
for legislation here in the House of Commons through video link
with the Parliaments of Scotland, Wales and Northern Ireland.
512. Where has the International Partnership
against AIDS in Africa seen success as a result of its activities?
How does the IPAA mobilise expertise and resources to assist African
countries? Does it remain the case that it is the commitment of
the Government in each country which is the determining factor
in the effectiveness of a response to the epidemic?
Finally, I will also ask you if you can respond
to the views of President Mbeki, because it is a controversial
view, and is it actually affecting the programme in South Africa
or not?
(Dr Piot) Let me start with the end of your first
question, is the commitment of governments the determining factor?
I think, to a large extent, we have to define what that commitment
is. I think without government leadership the environment is not
there for civil society to work. I think that is where most progress
has been made over the last year or so. With the International
Partnership against AIDS in Africa on the one hand, as I mentioned,
we have an endorsement at a political level of the framework for
action. That is important. Now we have an instrument which has
been approved by all heads of state of Africa, members of the
OAU. That is one point. It is particularly at the country level
where the major progress has been made, as a result of this original
model. It is the first endeavour I know that in such an organised
way brings together the governments, the countries, bilateral
and multilateral development agencies, private sector and NGOs,
trying to work under one umbrella. That may be too ambitious but
that is the only way we can make a difference, I think. We had
agreed on six countries in Africa where we would focus our efforts,
one of them was Ethiopia and another one was Mozambique. These
have been a bit delayed because of the flood and war. In Malawi,
in Burkina Faso, in Ghana and in Tanzania major progress has been
made. Most strikingly in Malawi over $100m has been mobilised
to support the next five years in AIDS activities. This has now
become a new approach for the international community to work
on. With an increase in resources that is going to happen. International
resources, strong co-ordination and working under one umbrella
is not an academic issue, it is becoming very important. We can
give you a more detailed report that we have just prepared on
the international partnership.
(Dr Cleves) Do not underestimate the significance
of getting such a wide variety of stakeholders to agree a framework
for action with some common goals, common indicators and some
common ways of working. We would be over-optimistic if we said
that the partnership has been massively implemented and has already
made a huge difference. Between now and October, when there will
be an official launch of the partnership with the Secretary General,
significant progress will have been made. The pharmaceutical company
initiative came under the African Partnership umbrella. A number
of other activities have come under that umbrella, as people see
it as a way of bringing coherence to their efforts.
513. What sort of organisation has the partnership
got?
(Dr Cleves) The UNAIDS Secretariat is also the Secretariat
to the partnership. One of the key aspects is information exchange
and ensuring that individuals know exactly what is happening.
That is an area where we are investing very heavily at the moment
in creating those mechanisms. There is no separate organisation
of the partnership, it is a collation of actors who have chosen
to come together to work under a common framework in order to
overcome the problems of addressing the epidemic in Africa at
the moment. It is highly fragmented, it is characterised by a
boutique approach, where there are lots of little islands of excellence
where good things are happening but there is no overriding stronger
process taking place. That is what the partnership is designed
to catalyse.
Mr Robathan
514. May I apologise for missing the best part
of an hour of your evidence. I have two points to make, both to
pick up on things you said. One was that the flooding in Mozambique
has put back the strategy in Mozambique against AIDS. Whilst I
understand the fragility of the health service sector and I understand
the problems, nevertheless the flooding claimed the lives of 500
people whereas something between four to five million in Mozambique
are already estimated to be infected with HIV. How can one concentrate
more on that, what is really a side show, tragic as it might be?
The second point I would like to raise, which you might like to
answer when you deal with President Mbeki, is of the poor woman
stoned to death for going public. There is a very big issue about
the denial of HIV status, surely that was a case where the government
had a role to play in establishing the fact that people must come
to terms with the fact that an enormous number of people are HIV
positive in South Africa and how does that tie in with President
Mbeki?
(Dr Piot) Mozambique is doing a good job at the moment
when it comes to responding to AIDS. Because of the floods we
had some delays in what was going to be an intensification of
the plans. They established a Presidential Commission. Mondlane
has been appointed as a national AIDS coordinator. The strategic
plan is nearly finished. There will be a round table with all
of the donors. They have just experienced two or three months'
delay. You are right, I do not know the number, I think there
are two million-plus infected individuals, and it is true, in
Africa AIDS now kills about ten times more people than in armed
conflict. It is silent death, it is people dying from something
else. That then brings me to the Mbeki point. I think that we
have to put it in several perspectives. Just imagine if Britain
had between six and ten million individuals infected with HIV,
how would the Prime Minister react here? At the moment there is
some kind of—panic may not be the right word—really,
really strong concern about what to do and what we are facing.
A lot of the reactions in South Africa, and some other countries,
are legitimate ones on that side. Where our position is extremely
clear, is about the cause of AIDS. We know it is caused by HIV,
that has been proven over ten years ago, there is no doubt about
that. That debate can only confuse people, we are very clear on
that. When Mbeki in his opening speech at the conference in Durban
put so much emphasis on probity as a driving force that, of course,
is true not only for AIDS but for many other things. AIDS is very
different from most other infectious diseases because it affects
the educated and the middle-class as much as the poor. Yesterday
at the Security Council debate the Ambassador from Uganda made
a very strong statement, he said, "Uganda is one of the poorest
countries but none of the friends that I lost were poor—politicians,
ambassadors, teachers, professors, pilots". He went on and
on. We have to put things in perspective. Our approach has been
to try to orient the debate on what can and should a country like
South Africa do in response to this epidemic. That is where the
debate should be. It is not by focusing on some pseudo-scientific
question that will move the agenda forward. It is through a very
sobering look at what causes us to have such a big problem in
our society. What I now see is that on the one hand we have a
government that is extremely aware and committed to deal with
AIDS, perhaps more than in any other country, and on the other
hand the spin is so negative, including in this country, and the
debate is not where it should be. I do not know what else to say
on this.
(Dr Cleves) I think one of the things we see in South
Africa is AIDS is not just a crisis of public health, it is not
just a crisis of development, it is also a crisis of identity.
When that happens reactions are unpredictable.
Ann Clwyd: Doctor Cleves and Dr Piot,
I know you have to catch a plane. You managed to keep people who
went to bed at about 3 o'clock this morning, because we had a
late night session, awake for the past two and a half hours. Thank
you very much for a very stimulating morning and thank you for
making the time to come and see us. Thank you very much indeed.
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