Access to Essential Drugs: the Ethical Challenge of Allocating Obligations

Abstract

Millions of people in low-income countries have little or no access to safe and high quality medicines. They suffer and die from medical conditions that can be treated in other parts of the world. Effective drug treatment now exists for many infectious diseases that are among the leading causes of death in poor countries: About 10 million people die each year from acute respiratory disease, diarrhea, tuberculosis or malaria. Most disastrous for the people in low-income countries is certainly the HIV/AIDS pandemic. 40 million people have been infected with HIV at the end of 2001, with the majority – almost three quarters (28.5 million) – living in sub-Saharan Africa, which remains by far the most affected region of the world.1 While there is still no cure for HIV, antiretroviral drugs can significantly improve the course of the illness and increase life expectancy. Some drugs have proven to reduce the mother-to-child transmission of HIV. In sub-Saharan Africa, however, less than 30,000 people are estimated to have access to effective antiretroviral drugs and basic medications against HIV-related disease. As a consequence, about 11 million children have lost one or two of their parents due to AIDS. Lack of access to essential medicines not only inflicts tremendous suffering on poor populations, but also keeps them in the poverty trap. Serious illness is one of the major reasons for declining economic productivity and stagnating development. Poverty is both cause and effect of the high burden of disease. Hence, for people living in low-income countries it is virtually impossible to escape from this vicious circle of poverty and illness. Even if drugs are available in these countries, they are often unsafe, not distributed properly in a deficient health care system or not used appropriately. Other factors contribute to this fatal situation: Many people are undernourished; they lack access to safe water and basic sanitations and have no adequate shelter. There have been several initiatives to alleviate this disastrous situation. One of the first was the Model List of Essential Medicines which was launched by the WHO in 1977 to help countries to select, distribute and use essential drugs that satisfy priority health needs. Some pharmaceutical companies have lowered prices for patent protected drugs or offered medications for free. Other organizations and private persons have donated funds to low-income countries (e.g. the Gates Foundation). Yet, these efforts have not been very successful so far: There is still a huge gap between the potential to save millions of lives with safe and cost-effective drugs and the sad reality of extremely high morbidity and mortality in most low-income countries of the world. There is little controversy that this situation is morally unaccept-