Indian generics and AIDS

Interview with Dylan Mohan Gray, director of the documentary film Fire in the Blood.

Published : Oct 16, 2013 12:30 IST

Dylan Mohan Gray.

Dylan Mohan Gray.

THE human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) was identified in the early 1980s and soon emerged as one of the most dreaded diseases in the world. The history of the disease and the search for better treatments and, perhaps, eventually a cure are well documented. What is not known, though, is that for a long time treatment was prevented from reaching Africa, where millions were dying from AIDS.

The recently released Fire in the Blood is a critically acclaimed and compelling documentary that explains why this happened. In a layered and yet straightforward commentary, the film traces those tragic days when Western pharmaceutical companies aggressively blocked low-cost AIDS drugs from reaching those who needed them, causing the death of close to 10 million people. The film has been shot across four continents and reveals the poignant stories and inspirational struggles of ordinary people. Interviews with global figures—former United States President Bill Clinton; the Nobel laureate, social rights activist and retired bishop Desmond Tutu; and the Nobel laureate Joseph Stiglitz—give the documentary credibility and depth.

One of the most significant aspects of Fire in the Blood is that it highlights India’s role in the scheme of events. Standing up to massive resistance from Western pharmaceutical companies, India went into Africa with generic HIV/AIDS drugs that cost about $1 a day a patient. By doing this, it completely ended the pandemic. Another crucial point the film makes is that the global fight for access to medicine is still not over.

Fire in the Blood became the first Indian film ever to be selected for the World Cinema Documentary Competition at the 2013 Sundance Film Festival, a prestigious and competitive film festival for independent and documentary films. On the eve of the release of the film in India, Frontline spoke to its director, Dylan Mohan Gray, about the film and how it came about.

In the quarter of a century since it was recognised, HIV/AIDS has become manageable and appears to be largely under control. Why make a film on this subject now?

Ten to 12 million people in the Global South died completely unnecessarily because of the blockade of AIDS medicine that we describe and deconstruct in Fire in the Blood . It was a holocaust on an almost unfathomable scale that has largely been swept under the rug and all but forgotten. It’s hard to conclude anything other than that these people’s lives were ultimately not important to anybody.

With shockingly few exceptions, they weren’t important to their governments or to AIDS activists in rich countries, and they certainly meant nothing to leading Western governments and the giant drug companies they serve. Nobody really cared. This was undoubtedly the most startling aspect of the story for me.

How did you come across the story?

As is often the case with films, it all started with an article I happened to read in the newspaper way back in 2004.

I’ll be totally honest in saying that the subject was completely off my radar and as far as I know had never crossed my mind before that moment. I generally think of myself as being a fairly well-informed person, and I think what initially got under my skin was the idea that “I should know so much more about this. Why don’t I know about it?” That said, it turned out to be a far bigger story than I initially fathomed.

Could you speak about the pandemic and how serious it was at that time?

There’s a headline which appears in the film: “8,000 Deaths a Day”. That’s what was happening even though highly effective and extremely affordable medication which could have saved almost all of those people was available in India and certain other parts of the world.

Could you speak about your research on Big Pharma and what it did to prevent access to AIDS drugs?

The multinational pharma industry uses its immense political and economic power to influence Western governments, above all those of the United States and the European Union [E.U.], to obstruct and eliminate supplies of affordable medicine it perceives as threatening its astronomical profit margins.

Western policymakers know very well which side their bread is buttered on and can be counted upon to tow the line with astonishing ruthlessness, even when it is clear that by doing so they will help ensure millions of lives which could easily be saved are lost.

This behaviour is in no way unique or specific to HIV/AIDS medication; it’s equally applicable to any product area in which Big Pharma sees a potential threat to its profits or, conversely, an opportunity to expand its market share by eliminating lower-cost competition.

If it was such a holocaust, why was something not done at that time? Why did this not become a global issue?

In a sense it’s easy now to look back and ask why more people didn’t make an effort to do something, or even to draw the public’s attention to the situation. Some people, to their credit, have admitted that they were completely on the wrong side of history on this. I’m sure many others feel that way even if there’s no public mea culpa . I suspect President Clinton might fall into the latter category. He’s a politician. He’s never going to come out and say, “I was wrong and I regret what I did.” But I do believe he wishes he had acted differently.

Inspirational peopleThere are some key people in the documentary who led the fight for access to medicine. Could you tell us about them and their struggle?

The heart and soul of Fire in the Blood and the thing that really excited me about making the film is this small band of incredibly inspirational people whom almost nobody listened to, who weren’t well-known or particularly well-connected.

They were laughed at, ridiculed, accused of raising false hopes. But they persevered and eventually managed to change the world in the face of incredible odds. That to me is extremely powerful, and something which has applications for all of us, in any area of human life where we might see a problem and think we don’t have the power to change things for the better. These people prove you can, and if it’s important to you, you must.

Interviewing President Clinton must have been crucial to the film. Could you elaborate on how he was a big part of the story?

President Clinton set up his foundation shortly after leaving office. One of the major initiatives of the Clinton Foundation was focussed on helping to bring down the costs of antiretroviral treatment for people living with HIV/AIDS in the Global South. What it essentially does, and has done very successfully, is to put together orders for antiretroviral drugs [ARVs] from developing countries and essentially become a clearing house for those orders where they guarantee payment for the medicines primarily using funds from large donor programmes.

For instance, one of the problems Indian generic drug manufacturers often had in the past was that when they got an order from, say, Nigeria, half the time the promised money wouldn’t actually come, so they would end up doubling prices to hedge their bets. What the Clinton Foundation did was say, “We’ll take care of the transport, registration, guarantee timely payment and consolidate orders to create huge volume for you.” By doing this it was in a position to negotiate massively lower prices for ARVs, which of course had a monumental impact. But even more important I would say is that Clinton was the one who made people in Africa and elsewhere fully trust generic AIDS drugs from India. The whole focus of the Clinton Foundation’s work was to get these high-quality, low-cost Indian drugs and use them in its programmes. The fact that someone like Bill Clinton wholeheartedly endorsed Indian generic drugs was a priceless seal of approval. Clinton’s embrace of Indian generic ARVs changed that equation completely.

You say that India is a true beacon of hope and plays a massive role in ensuring access to medicine across the world.

For me, a very important aspect of the story told in Fire in the Blood is that of India as a vital beacon of hope and humanity. In some ways, it’s almost absurd to think of our country in such terms in this day and age, but that is precisely the role that India plays as, by far and away, the leading supplier of affordable, high-quality medicine to the world, and especially to the Global South.

I honestly feel that perhaps this is the only area in which India fulfils the legacy and promise of the freedom struggle, its belief in self-reliance and the fundamental importance of prioritising human lives over corporate profits.

That legacy, which made India a country that colonised peoples all over the world looked to as an example in the early years of Independence, has been almost completely betrayed and squandered; however, as I say, this is one important area where one can say without irony that it most certainly survives.

Affordable genericsIndia, in spite of economic reforms and liberalisation, has held out to pressure from Big Pharma. Your comments.

This is something which perplexes a lot of people. India changed its patent law in 1970 on the principle that the country simply couldn’t afford monopolies on food and medicine. Drug prices fell dramatically within a very short period of time as a result. Few Indians realise that just next door, in Pakistan, drugs cost many, many times more than they do here. India has the most affordable medicine in the world. That came to be primarily through intense competition between drug makers, which resulted from the liberalisation of the patent regime.

There are supposedly somewhere in the order of 25,000 pharmaceutical companies in India today, and maybe 100 big ones which export to literally every corner of the globe. Together they make this country the biggest producer of generic drugs in the world, in an environment so competitive that they have also had to work very hard to become the most efficient companies in the field. Government price controls have also played a role in ensuring essential drugs remain affordable here at home.

A lot of other countries have been emboldened by India’s strong stance on access to essential medicine, and many wish to emulate it. Civil society in South Africa, for example, is actively trying to get various features of the Indian patent system adopted in that country because the bar for granting patent monopolies on drugs there at present is quite low, meaning many medicines are priced out of reach to the vast majority of the population.

Indians perhaps do not even know the crucial role the country plays.

Activists in the field of public health worldwide are desperately looking to India, hoping and praying it will hold its ground and maintain a strong stand on access to medicine, knowing that if India doesn’t find a way to do this, it won’t just be a disaster for 1.3 billion Indians—it will directly affect billions more around the world who are dependent on Indian drugs. If you go to a chemist anywhere in Africa or Latin America, you’ll see shelves filled with medicines from India. That’s what they use and they’re often the only lifeline people there have available to them. Two aspects need to be appreciated: This is a high-tech, high-quality, zero-error product category which is completely different from anything else that India makes and exports on a large scale. In addition, this is something which shows India, Indians and Indian industry in an extremely good light throughout large swathes of the world. I really don’t think the Indian government appreciates that. In fact, at times they seem to throw a lot of obstacles in the way of the same domestic drug makers who lead the world in quality, reliability and affordability.

On the whole, however, what’s interesting here is that we have a case of something which almost never happens, whereby the Indian government is acting in a way which is unquestionably correct, moral, righteous and humane. Today, people who are familiar with India’s role are desperately hoping that the government does not back away from its courageous stance in the face of tremendous pressure from Western governments.

Will India be able to hold out given that it has signed the TRIPS (Trade-related aspects of intellectual property rights) Agreement?

TRIPS contains provisions for countries to bypass or amend the terms of patents on pharmaceuticals if they decide it is in their national interest to do so. These provisions were included as an inducement for developing countries to sign the treaty in the first place, but they have remained largely a dead letter because virtually every time a low- or middle-income country tries to invoke them, they are threatened by Western governments behind the scenes to back off or face fierce retaliation. In the meantime, the Westerners have since started using bi- and multilateral trade pacts, such as the proposed E.U.-India Free Trade Agreement, to ratchet up patent restrictions and even remove the ability of India’s courts to rule upon them. Nonetheless, it is important to note that every action India has taken to ensure access to essential medicines has been in full compliance with Indian and international law, however much countries like the U.S. and certain members of the E.U. might try to portray this country as a “rogue” or “pirate state” acting contrary to international norms.

I think it is also very significant that people in India have grown accustomed to extremely affordable medicine since the patent law was liberalised in 1970. I would say the Indian government is probably aware that it can expect a very strong backlash from the public and the media when even relatively wealthy people in India find themselves unable to afford the latest medication needed to save their or their child’s or their parent’s life.

A documentary does not just record. It also hopes that something significant comes out of it. What are your hopes from this film?

I always say that the most important objective of the project was really to create a permanent document of this crucially important episode in history. That objective was achieved the moment we finished the film. The document now exists. Because it has been so well received and garnered such great reviews in so many places, the opportunity to put it out into the world and to start some fundamentally important conversations has presented itself, and that could obviously lead in very interesting directions.

What have been the reactions to the film?

The response has been extremely strong wherever we have shown it though the prism through which different communities see it certainly varies a lot. If I had to generalise, I would say that Africans tend to be quite mournful when they watch it. I can only assume that is because people there know the basics of the story all too well.

Westerners, by contrast, often get very angry at what their governments did, and continue to do, in “their name”. Indians, on the other hand, though very much attuned to the tragedy of it all, often come away from the film with a great deal of pride, having been very pleasantly surprised by the strong leadership, the concern for humanity and the moral courage India and Indians have demonstrated in this area. Many are shocked not only to find out that such a hugely important “good news story” about India exists, but by the fact they have never been beaten over the head with it.

I do think it’s also important to underscore the conviction that India’s stance in this area is not accidental but that there is a very strong ideological and philosophical line leading right from the Dandi March, which as we all know also took place against the backdrop of an unjust monopoly on an essential good imposed by a callous foreign power, to the government’s actions today. Gandhi himself thought it was critically important that India’s people had access to essential medicine and that the country needed to produce its own, never again to be reliant on the “favour” of foreign conglomerates to decide who in this country gets to live and who is doomed to die.

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