Open Letter to President George W. Bush
July 11,2001

President George W. Bush
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500

Dear President Bush,

The upcoming meeting of the Group of Eight (G8) leaders in Genoa, Italy, represents an important opportunity for the world's wealthiest nations to focus world attention, funding and political will on key health issues that disproportionately affect the poor. The chance to concretely address major communicable diseases, in particular HIV/AIDS, malaria, and tuberculosis, must not be missed.

The Genoa meeting of July 20 to 22 will take place at a critical moment, when the political momentum built up over the course of several major international conferences can be translated into immediate improvements for those most in need. It is crucial that the decisions and declarations issuing from the G8 meeting in Okinawa last July, the subsequent G8 conference on infectious diseases in Okinawa last December, and the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in New York this June, are now transformed into real tools in the fight against major infectious diseases.

Tangible progress must be made on a number of fronts. In this respect, it is encouraging that a global consensus is emerging which effectively addresses many of the problems we at Doctors Without Borders/Médecins Sans Frontières (MSF) have identified in the course of our medical field work. People cannot be forced to choose between the prevention and treatment of HIV/AIDS-the two approaches are mutually reinforcing. Also, for many neglected diseases where existing tools are either ineffective or non-existent, improving health will require a major effort to discover and develop new drugs and vaccines.

When effective drugs are available, there is also a growing consensus that, although weak health systems in some areas present a formidable challenge in the implementation of treatment programs, particularly for HIV/AIDS, they do not justify denying or delaying access to life-saving medicines to people who need them. Operational research must be expanded in order to simplify and adapt treatment and prevention strategies to resource-poor settings.

Despite recent initiatives, the unaffordable price of existing medicines remains a significant barrier to access. However, the Declaration of Commitment on HIV/AIDS that was adopted by all member states at UNGASS offers clear recognition that the high cost of medicines must be addressed at all levels.

At the special session on access to medicines of the TRIPS Council meeting that took place on June 20, 2001, World Trade Organization (WTO) members drew attention to the adverse effects of intellectual property protection on access to medicines. A consensus emerged on the need to ensure that intellectual property rights do not stand in the way of access to essential medicines in developing countries, and to encourage developing countries to make full use of existing legal safeguards to address critical public health issues.

The interpretation of TRIPS will be particularly critical as additional funds are allocated to fight infectious diseases. If the rules of funding mechanisms are too restrictive, the reach of new efforts will be limited.

Prices of medicines and other essential health care goods will have a profound impact on the effectiveness of funding efforts. Antiretroviral drugs provide a good example. If the mid-term objective is to put five million patients on treatment in developing countries, the cost of drugs alone would be $5 billion per year at the current price of $1,000 per patient per year in the UNAIDS Accelerating Access Initiative. If, through a system of equitable pricing, the per patient cost of drugs went down to $200, the cost to treat the same number of patients would be $1 billion per year. The savings could be used to increase the number of patients who could receive access to treatment and to invest in other important components of care and prevention.

Offering financial assistance to countries that will not be able to shoulder the entire financial burden of scaling up AIDS, TB, and malaria efforts is a necessary and vital component of an expanded global response to fighting infectious diseases. Kofi Annan, UN Secretary General, with the support of the World Health Organization (WHO) and UNAIDS, has estimated that developing countries will need between $7-10 billion annually to fight AIDS alone.

But, how this money will be used is now the critical question.

In order to ensure that international funding mechanisms, including the proposed Global Health Fund, can offer treatment to the highest number of people with HIV/AIDS, malaria, and TB, it is essential that funds be available for the purchase of medicines and medical technologies at the lowest possible cost.

The European Union (EU) countries have formulated a common position on the need to link international funding mechanisms to a system of tiered pricing with full price transparency, to procure through international tender, and to ensure that money is untied so the lowest cost medicines and related technologies can indeed be accessed.

In addition, the EU common position supports the use of TRIPS safeguards. The European Commission has stated that contributions to the Global Health Fund will be made only if conditions for a tiered pricing system are met. European Commissioner Nielson said at the Conference for Least-Developed Countries in May this year that "the global fund cannot succeed and will not get our support without a commitment by the industry to a global tiered pricing system."

We urge you at the upcoming G8 meeting to support this position in addition to other mutually supportive strategies that will increase access to essential medicines.

More specifically, in Genoa we urge you to support a combination of strategies that will ensure the availability of the lowest cost medicines and other health-related goods, including:

• Stimulating generic competition, encouraging a differential (or tiered) pricing system, and creating economies of scale through regional or global procurement;
• Encouraging local production through voluntary licensing and technology transfer in countries with domestic drug manufacturing capacity;
• Using TRIPS safeguards (compulsory licensing, parallel imports, and Bolar provisions) through national legislation;
• Encouraging the purchase of medicines from lowest cost suppliers, including generic companies, to maximize the use of the available financial resources (intellectual property barriers need to be overcome by using exemptions to patent rights);
• Implementing health exceptions to patent rights for goods purchased with financing from internationally organized global funds;
• Creating a database of information on drug prices, quality, and patent status to help guide decisions of country purchasers.

It is essential that a long-term, sustainable solution to the crisis of lack of access to medicines be developed-not one that relies solely on the good will of pharmaceutical companies to voluntarily offer discounts on certain medicines. Though such price reductions are important, they are not enough. The mutually supportive strategies outlined above will be important elements of an effective framework for guaranteeing access to essential medicines, even for the most vulnerable populations in the poorest countries. Your leadership will be key to a successful global response to HIV/AIDS, malaria, TB, and other less visible diseases. We hope that you will make addressing the needs of millions of people affected by major infectious diseases in the developing world a priority.

Sincerely,

Nicolas de Torrenté
Executive Director, MSF-USA

cc: Colin L. Powell, Secretary of State, U.S. Department of State
Tommy Thompson, Secretary of Health & Human Services, U.S. Department of Health & Human Services
Robert Zoellick, U.S. Trade Representative
Joseph Papovich, Assistant U.S. Trade Representative for Services, Investment, and Intellectual Property
Scott Evertz, Director, Office of National AIDS Policy
Congressional Black Caucus
Gary Edsen, Assitstant to the President for International Economic Affairs