An Unequal Calculus of Life and Death

'No More That They Could Do'

The first and pivotal negotiations over global access to AIDS drugs began in Geneva in 1991. They lasted two years, but confidential minutes suggest they were doomed the first day.

Presidents, vice presidents and directors of 18 pharmaceutical giants arrived at the WHO's glass hilltop headquarters on Avenue Appia on May 23, 1991. Director General Hiroshi Nakajima described the occasion as a "landmark meeting" to ensure that "vaccines and drugs against AIDS are developed and produced at a cost all can afford."

He opened the talks with a sober tour of the horizon. "By the end of this decade," he said, "there will have been a cumulative total of . . . 40 million HIV infections--I repeat, 40 million--in men, women and children. Over 90 percent of these will be in developing countries."

Rich countries, he noted, had new drugs to improve survival rates and quality of life. Recent studies showed that Burroughs Wellcome's AZT slowed the progress of the AIDS virus even before symptoms appeared. Anthony Fauci, director of AIDS research at the National Institutes of Health, heralded the 1990s as "the age of early intervention" against the disease.

But this was not true everywhere. Patients in poor countries still died in six months or less. The cost of the new drugs--$ 10,000 or more a year--put them beyond all but the imagination of most people with the disease.

The Geneva discussions took their starting point from a concise six-page framework drafted at WHO. Patented new treatments for AIDS were priced to produce high profits for investors and support future research. Those prices, the paper said, made the medicines, "even if technically 'available,' unaffordable to most of those in need." But because the companies could never hope to sell to the poor at rich-country prices, and because unit costs of additional production were relatively low, the paper suggested gently that "a certain flexibility in terms of pricing is available for developing countries."

Observers looking back from the year 2000, the paper concluded, would judge whether "the recognition of AIDS as a truly new global threat" persuaded industry and public authorities to join in a response "that went beyond 'business as usual.' "

The executives around the table were not encouraging.

John Petricciani, a senior lobbyist for the drug companies in Washington, had told his friend Roy Widdus at the WHO more than a year earlier that the companies were talking among themselves about "a preferential price to developing countries for AIDS therapeutics." He said he had even approached the Bush administration about subsidizing the discount, according to a memorandum Widdus wrote soon afterward.

But now, in the Geneva conference room, Petricciani closed the door on AIDS drug discounts.

"The predominant contribution that the research-based pharmaceutical industry could reasonably be expected to make is in their predominant area of competence--research and development," he said, according to minutes kept under seal in the WHO Registry and obtained elsewhere by The Washington Post. "The broader responsibility for ensuring that such products are delivered to those they could benefit should be borne by society, particularly governments."