India takes on drug makers in drive to cut healthcare costs

Alka Kudesia needs an expensive drug to treat her breast cancer, but refuses to tell her children for fear they will take out loans to buy the medicine and spend the rest of their lives in debt. “We’re barely able to afford the treatment I’m already getting,” Kudesia (48) said with quiet defiance. “My kids are just starting out in life. There is no way I’m going to be a burden to them.”

The drug, Herceptin, is one of the most effective treatments for an aggressive form of breast cancer. But in India, at a cost of at least €13,000 for one course of treatment, only a small fraction of the women who need it get it. The Indian government last year threatened to allow production of less costly, generic versions of Herceptin. Its maker, Roche Holdings of Switzerland, initially resisted, but surrendered its patent rights this year in large measure because it concluded that it would lose a legal contest in Indian courts.

The skirmishing over Herceptin and other cancer medicines is part of a new and critical phase in a long-running struggle to make drugs affordable to the world’s poorest people, one that began in earnest more than a decade ago when advocates campaigned successfully to make Aids medicines accessible to millions of Africans.

Overriding patents
"Cancer is the next HIV/Aids issue, and the fight has only begun," said Shamnad Basheer, a professor of law at West Bengal National University of Juridical Sciences in Calcutta. US trade officials have voiced concerns about India's treatment of drug patents, including its reasons for sometimes overriding them. President Barack Obama discussed the issue earlier this year with Prime Minister Manmohan Singh of India during a meeting in the Oval Office, administration officials said.

Executives in the international pharmaceutical industry, increasingly dependent on drug sales in emerging markets such as India, China and Brazil, contend that India’s efforts to cancel patents threaten the global system for discovering cures while doing little to resolve the health challenges most patients here face.

“We are open to discussing what the best way is to bring innovative medicines to patients,” said Daniel Grotzky, a spokesman for Roche, which has a large portfolio of cancer medicines. “But a society that wants to develop new medicines and technology must reward innovation through a solid protection of intellectual property.”

Some health experts say investing in earlier diagnosis of breast cancer and improved testing, surgery and access to radiation therapy is more important than access to expensive drugs. But health advocates say similar arguments were made by the US government and the pharmaceutical industry as they sought to protect patents on Aids medicines through much of the 1990s. It would be unfair to delay improving access to cancer drugs until India’s broken system for cancer care was fixed, they say.

Survival into old age
As the world has made progress against malnutrition and infectious diseases, more people are living into old age and dying of chronic illnesses such as heart disease and cancer, which now cause two-thirds of deaths globally. In 2012, there were 14.1 million new cancer cases across the world and 8.2 million cancer deaths, according to the World Health Organisation. And the number of breast cancer cases is growing. About 6.3 million women were living with the disease last year.

The rise in the cancer caseload is already a heavy burden on India's health system. About 115,000 women here are diagnosed with breast cancer every year and, in 2008, some 54,000 died from it, according to WHO. At intersections in New Delhi, women carrying doctors' notes beg for money for their prescribed treatments. India has just 27 dedicated public cancer centres for 1.2 billion people. The government has promised to add an additional 50 in the coming years, but medical experts say even that will be grossly inadequate.

India, one of the world’s leading producers of generic pharmaceuticals, has long viewed patent rights on medicines sceptically. It has already ruled invalid patents protecting exclusive sales of Novartis’ Gleevec, Pfizer’s Sutent and Roche’s Tarceva, all cancer medicines.

In a landmark decision in 2012, the government agreed that the patent protecting Bayer’s Nexavar, also a cancer drug, was valid but overrode it anyway because a generic company promised to lower the price from €3,200 to about €101 per month of treatment.

The government is now considering cancelling the exclusive sales rights on two other cancer medicines.

An Indian government committee is soon expected to announce the start of a formal process to set aside patents on 15 more medicines, according to a committee member who agreed to speak about secret deliberations only if granted anonymity. Malini Aisola of the Public Health Foundation of India said the expanded list “will create ripples around the world”.

For drug companies, the most worrying aspect of India’s efforts to lower drug prices is that other countries are beginning to follow its lead. Both Indonesia and the Philippines recently adopted patent laws modelled on India’s, and legislators in Brazil and Colombia have proposed following suit.

“One of the concerns of the industry is not just what India is doing in India, but we realise that the whole world is watching India,” said Amy Hariani of the US-India Business Council, which is affiliated with the US Chamber of Commerce and is fighting India’s patent policies.

“Why should we be giving away Herceptin in India and China when we have insured women in the United States who can’t even afford the co-pay?” asked Dr Peter Bach, a drug price expert at Memorial Sloan-Kettering Cancer Centre. “Nobody really asked that question about Aids drugs in Africa. But with cancer medicines, people will ask, and that’s what scares the pharmaceutical industry.”

For the Obama administration, the fight over drug patents in the developing world is a minefield. The drug industry was a major contributor to Obama’s campaign and an early and crucial backer of his healthcare programme. But Obama’s advisers hope to avoid the mistakes of the Clinton administration, harshly criticised by Aids activists for its initial stand against providing generic antiretroviral drugs to Africa.

Generic solution
Roche's decision to surrender its Herceptin patent has had a rapid impact on the market here in India. Last month, Biocon, an Indian drugmaker, announced that it had won approval for a generic, less expensive version, which it expects to begin selling early next year.

Manjeet Kaur (51) of New Delhi may benefit. Her husband, an account manager at a technology service company, spent his life savings on a full course of Herceptin for her. Every three weeks, the couple takes two vials of the medicine to the All India Institute of Medical Sciences.

She often waits many hours for the life-sustaining infusion. On a recent day, she sat cross-legged, wrapped in a saffron scarf, in a room with six other women. Outside, hundreds of people lined up hoping for care. About 25,000 Indian women would benefit from Herceptin treatment every year, but, at most, only 1,500 get it, says Kalyani Menon-Sen, a patient advocate in New Delhi.

Kudesia, afraid to tell her children about Herceptin because of its cost, is already having trouble affording her cocktail of less expensive generic medicines.

Her daughter borrowed €1,150 from a bank for her mastectomy. After begging relatives, Kudesia got the nearly €1,400 she needed for three rounds of chemotherapy. She needs more treatment, but has no idea where the money will come from. Her husband died in 2011 from a brain tumour, and his three-year treatment drained their savings.

To save money, she must move out of the three-room, $80-per-month apartment she shares with her mother-in-law and son and sell most of their possessions. Buying Herceptin is out of the question. She prays to Krishna, Rama and other Hindu gods for help.

"I want to spend the rest of the time I have left resolving our debts, not making them worse," she said. "I cannot tell my children there is another drug that will help me." – (New York Times service)