The World Trade Organization has long faced angry accusations that its patent rules deny patients in poor countries life-saving medicines by making them too expensive. But starting three years ago, two academic studies -- one in the Journal of the American Medical Association and the other in Health Affairs -- expressed doubts at the magnitude of the problem. Both argued that most of the medicines that WHO terms "essential" in developing countries are no longer patented -- fully 98% of them are off patent. As a result, efforts to assail and reform patent law would only affect health on the margins. Far more alarming, from a public health perspective, was the stingy government financing earmarked for population health (worldwide, no more than $200 million for malaria in 2003; a bit more for AIDS, less for tuberculosis), and the careless expenditure of foreign aid money on medically useless interventions, or on certain developing countries with a long record of treating their poor and sick citizens with contempt. The evidence, collated by one of us (Attaran), proved as much, and had to be reckoned with.
Despite the overwhelming evidence that patents aren't an obstacle to essential medicines, India led a phalanx of developing countries and antiglobalization NGOs intent on doing away with the WTO's patent rules for medicines. They pushed so aggressively that at the WTO summit in Cancun in 2003, their interventions nearly scuppered the Doha Round of trade discussions and the future of the entire WTO. Only after a series of face-saving but ineffective compromises did India relent, and four days shy of a January 2005 deadline, it introduced pharmaceutical patenting.
But while India has been vacillating over patents, its health systems are crumbling, making it patently obvious that its government cares not a jot for its people. A prime example of its lack of attention to healthcare is that by some estimates it may have more HIV positive people (over 5 million) than any other nation, including South Africa.
But most amazing is this: the same Indian government that for years held the WTO to ransom never itself believed that medicine patents were a problem. Speaking at a medical conference in Bangalore two weeks ago, Indian Health Minister Anbumani Ramadoss confessed that "there is no need for any apprehension" over patents driving up the price of essential medicines in India, since 90 percent of them are not patented.
The health minister's rounding errors aside, this is basically the right answer, and Mr. Ramadoss is correctly, if belatedly, concluding that India will be only slightly affected by medicine patents.
But where was India's acknowledgement of that fact as recently as 2004, when it was leading the anti-patent voices at the WTO? At that time, India justified its tergiversation by insisting that it was concerned for its citizens' health. How very untrue. At the same conference in Bangalore, Indian Finance Minister Palaniappan Chidambaram explained why his fellow citizens are among the most diseased in the world. Calling his own government's efforts "inadequate for [the] health sector", he unveiled figures showing that India spends 4.5% of its GDP on health, of which only 0.9% is public expenditure. No government in South Asia spends less, making New Delhi dead last (tragic pun intended) in providing for its citizens' health. What's more, India stalled forward progress on trade liberalization at a time when other poor countries desperately required the benefits it would bring. India sold out Africa, one could say.
Far from being actuated by health concerns, in hindsight India's cynical diplomacy seems motivated by a desire that disputes over patents not interfere with India's now burgeoning pharmaceutical export trade ($460 million to the USA last year).
Meanwhile, seen from a slowly-propelled bicycle, the health of poor Indian villagers is shockingly worse than in much of Africa. Few medicines, whether patented or not, are available in public hospitals, principally because the government does not care to provide them. We are haunted by the sight of a man, crossing the road, dragging behind him a leg made lame and elephantine by lymphatic filariasis -- a disease for which Western pharmaceutical firms offer the medicines not just cheaply, but for free, if only the elites and Brahmins officiating in New Delhi cared to distribute them.
The international community should not forgive India's perfidy lightly. The next time Indians arrive at the WTO with a pressing demand, let it chill on the agenda. And the next time India seeks foreign aid for AIDS, malaria, tuberculosis, et cetera, donors such as USAID and the Global Fund should absolutely refuse. Any country having spent billions of dollars to acquire nuclear weapons, or on follies such as a lunar exploration probe (coming in 2008!) clearly has significant sums to spend on public health; frankly, India neglects its citizens' health out of choice rather than fiscal stringency.
This advice may sound harsh, but any government having India's aspirations must be taught that both globalization and human health are precious -- but desperately fragile -- things. To mock them as India has done is to destabilize the edifice upon which the welfare of billions of the world's least privileged people lies. Having knowingly deceived, India now belongs at the back of the queue for international respect and cooperation, for there are other poor countries far more deserving.
Amir Attaran is associate professor of both law and international population health at the University of Ottawa, associate fellow of the Royal Institute of International Affairs, London, and author of Delivering Essential Medicines: The Way Forward (Chatham House, 2004). Roger Bate is a fellow of the American Enterprise Institute.
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