A Turning Point That Left Millions Behind

The companies implied, but never stated directly, that they would cut prices of their AIDS drugs steeply in the developing world. But they had five conditions for such a move. These made up the core, nearly word for word, of the "joint statement" that would be issued with the United Nations two months later.

The five things the companies required before making price cuts began with "unequivocal and ongoing political commitment" by the recipient countries. International agencies would have to assume responsibility for building up health care infrastructures capable of monitoring patients and their compliance with dosing schedules. Drugs would be sent only into "an efficient, reliable and secure distribution system" to prevent interruptions of treatment and diversion of products to other markets.

If the U.N. agencies agreed that AIDS drug treatment was "a shared responsibility of all sectors of society," then companies were willing to acknowledge that "affordability is an issue in developing countries." Finally, the firms wanted support from all concerned for "adequate and enforced intellectual property rights" to "provide the prospect of a satisfactory return on investment in the high-risk search for new medicines."

How to frame the last proviso became the most contentious dispute among the companies. Some wanted the U.N. partners explicitly to renounce use of two mechanisms that limited the industry's price-setting power. One was the "compulsory license," which gives a government legal power to permit manufacture of a drug without the patent-holder's consent while paying "reasonable royalties." The other was "parallel importing," in which a country purchases products at lower cost in another market and resells them, without the manufacturer's consent, at home.

Pfizer, meanwhile, was not permitted to sit out the fight. An angry buzz had built up in South Africa, demanding radical cuts in the price of Diflucan, a leading antifungal agent used in combating secondary infections in AIDS patients.

On March 21, the protest group ACT UP New York performed a classic of the gonzo confrontations it had been staging since 1987. Two members in ragged clothing walked into Pfizer's 42nd Street lobby and scuffled loudly, diverting security. Eight more, dressed in conservative suits, slipped into the express elevator for the 23rd-floor executive suites.

"You can't just barge in here!" blurted a receptionist as they raced out of the elevator. ACT UP leader Eric Sawyer headed for Chairman William C. Steere Jr.'s southeast corner office with a letter he intended to deliver personally. Alerted by the commotion, someone began closing the outer doors. Sawyer ended up in a footrace with Steere to the inner door. "He literally slammed it in my face, just as I got there," Sawyer said.

As they waited for security to drag them away, Sawyer and his comrades gleefully telephoned reporters to say where they were and why. They also notified Pfizer managers that they had scheduled a meeting to enlist the support of New York City Comptroller Alan G. Hevesi, who manages $ 100 billion in pension funds that now hold nearly 24 million shares of Pfizer stock. The city, they noted, had a history of socially conscious investment in Africa. Soon after, Hevesi sought out Pfizer executives and asked them to include Sawyer in follow-up meetings.

Ten days later, Pfizer delivered a letter to activist Mark Heywood in South Africa. Signed by country director George Flouty, it said the company would "deliver Diflucan free of charge through appropriate medical specialists for South African HIV/AIDS patients suffering from cryptococcal meningitis who cannot afford this treatment."

According to Jack Watters, Pfizer's medical director for Europe, Asia and Africa, the company had been planning just such a donation since the previous December. Asked by a reporter for documentation of that planning, he replied: "I'm not going to spend a lot of energy trying to disabuse [activists] of their notions because, frankly, I think I should put my energy into making the program work."

U.N. 'Cannot Afford Not To'

In the six weeks after Gilmartin's March 26 call on Brundtland at WHO headquarters, the companies dispatched executives in careful sequence to secure advance support. The "prior to launch" rollout schedule, a copy of which was obtained by The Washington Post, assigned emissaries, dates and a priority of First, Second or Third to 209 individual contacts in government and public health.