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The past few years have generally been good for pirates, with the release of the popular “Pirates of the Caribbean” movies, their capture of the general public’s imagination, and the quietly anti-establishment but ubiquitous piracy of digital media (primarily music MP3s) by young people everywhere there is Internet connectivity. However, little do most people know that there are also pirates in health care!

For a number of years, the pharmaceutical industry in India has reverse-engineered and produced generic versions of drugs produced under patent by companies elsewhere, including in the U.S. and Europe. Thus far, American and European pharmaceutical companies have failed to successfully lobby for restrictions that would prevent Indian companies from producing these generic drugs. One concern, however, is that drug prices continue to increase as patent protections extend to developing countries, potentially putting large populations at risk of being unable to afford patent-protected drugs. In order to protect the integrity of patent protection as an incentive for drug innovation while attempting to prevent deaths worldwide due to the inability of developing and middle income countries to afford drugs at the prices American and European drug companies charge, the World Trade Organization established TRIPS, the Agreement on Trade-Related Aspects of Intellectual Property Rights. TRIPS has, however, a few important measures to put pharmceutical companies in check. The following are excerpts from a lecture given by Dr. Christopher Murray, formerly of the WHO, on this topic:

<blockquote>The original TRIPS agreement provides for two mechanisms by which governments can minimize the risks to their people’s health: compulsory licensing and parallel importation.</blockquote>

Compulsory Licensing

<blockquote>Compulsory licensing or government use of a patent without the authorization of the right holder can only be done under a number of conditions aimed at protecting the legitimate interests of the patent holder. The person or company applying for a license must have first attempted unsuccessfully to obtain a voluntary license from the right holder on reasonable commercial terms. For “national emergencies”, “other circumstances of extreme urgency”, “public noncommercial use” or remedying anti-competitive practices, there is no need to try for a voluntary licence. If a compulsory license is issued, adequate remuneration must still be paid to the patent holder, taking into account the economic value of the authorization.</blockquote>

Parallel Importation

<blockquote>Countries also have the right to import a product from another country where the patent holder or its licensee are selling the product at a more favorable price.</blockquote>

These measures were recently taken by Brazil in order to obtain the HIV/AIDS drug Efavirenz from Merck & Co. When Merck refused to provide the drug at the same price it was offering to Thailand (it offered a discount, but not matching the Brazilian government’s request), Brazil decided to obtain the drug from India.

Merck’s price: $1.59 per pill
Merck’s offer: $1.11 per pill
Brazil’s request: $0.65 per pill
Brazil’s cost importing the generic from India: $0.45

Brazil is currently undergoing a national campaign to provided free AIDS treatment that has received international attention and praise. However, despite dropping a previous complaint, the Bush administration’s U.S. Trade Representative’s Office may consider remove Brazil’s status as a trading partner. The Bush administration recently included Thailand on its “list of pirate nations” that fail to protect (or perhaps actively seek to break) American copyright protections, although Thailand did the same thing that Brazil is doing by issuing a compulsory license to obtain and/or produce generic pharmaceuticals. This list included countries such as China and Russia that are in poor standing in the eyes of the Bush administration due to the rampant, large-scale piracy of digital media such as DVDs and CDs.

Conclusions

I find this public scolding and posturing by the Bush administration toward Thailand (and possibly soon, Brazil) as being frivolous, considering the complaints issued toward the other countries on the list. It’s very difficult to equate piracy of videos and music with the production or purchase of generic drugs for national public health programs. One saves lives and treats diseases, one doesn’t. Doctors Without Borders has spoken up about this issue. While I think that patent protections are important and don’t necessarily agree with the decisions made by the various parties involved in these instances, the concessions made in TRIPS to protect health are absolutely necessary and shouldn’t be so readily challenged by pharmaceutical companies when the need for affordable treatments are clear.

Of all the depictions of medicine in creative media, Scrubs is by far my favorite. Sometimes it’s difficult to really put your experiences into perspective until after you have been able to laugh, complain, cry, and stand in awe of them: this TV show, unlike most of the medical dramas, is able to capture the full gamut of emotions and complicated experiences. Moreover, it is based on the experiences of a real physician!

One of my good friends, bnjammin, recently interviewed Dr. Jonathan Doris, the inspiration for the character “J.D.” played by actor Zach Braff. Dr. Doris was a good friend of the show’s creator, Bill Lawrence, who listened to Doris’s tales of his zany experiences during medical school and an internal medicine residency.

“So, while even the most enthusiastic fan probably won’t be able to pass any medical licensing exam just by watching the show, Dr. Doris maintains that the show does, in its own quirky way, communicate some of the essential emotional experiences of medical training. “Bill is such a comic genius in that he’s able to extract what is universally funny. The show, and especially the pilot, expresses the anxiety that comes with being an intern, the sudden change in expectations from nobody expecting anything from you as a fourth-year medical student on June 30th and everybody suddenly expecting you to know the answer as an intern on July 1st. The show really captures that well and really captures the humor that stems from those situations.”

One part I found particularly encouraging and meaningful:

Dr. Doris notes, “No matter how technology improves or aids in resident education, there will never be a substitute for patient care, learning how to interact with patients and how to feel comfortable with treating patients… It’s those first times that really count and that define and shape someone’s medical training—the first time you see someone bleed out from a GI bleed or the first time you see someone code during an MI—those things never leave your brain. They never leave your mind, and there’s just no substitute for it.”

On a personal note, hopefully all this early experience I’m getting will make a big difference in making me a better physician than I would be otherwise! (My last scheduled shift this semester is my third shift at a free clinic for residents of two halfway houses for former drug addicts. I’m really looking forward to it, now that I’m armed with better physical examination and clinical diagnosis skills. I have really enjoyed my comprehensive anatomy, physiology, and clinical skills curricula, and I’m hoping that I can retain as much of it as possible through clinical work and a translational research project this summer.)

Our Chief of Medicine and instructor of clinical skills and diagnosis came to talk to the first year medical students about Internal Medicine. During the small group discussion, someone asked about potentially becoming depressed or disheartened by only seeing dying patients. The physician, however, emphasized that it really has to do with one’s perspective. I’ll try and make an attempt to recreate his perspective because it resonated very much with me and reflects my views:

“Imagine how frightening and intimidating it would be to be suddenly being dropped in a foreign country where you don’t know anything about the language or culture. However, imagine how comforting it would be to run into a friend who knows the place and says to you, “Here, let me show you around.” Everything is still new, but it’s not longer as frightening as it might have been otherwise. While many doctors early in their training try to avoid the patients they know are dying because they see them as reflections on their failures as doctors, I see it as being a privilege to be their guide. Most people only come into intimate contact with death maybe five times during their lifetime (burying parents, a sibling, a spouse, and a friend), and each time may be a very disorienting and new experience. They don’t know where they are going, but you, as a physician, see death all the time. You can say to them, “Hey, I don’t know if there’s anything after this, or maybe there is, and wouldn’t you want to check that out? Either way, you’re scared, right? I’m here to help you through this.”

Helping guide patients through this transition from life to death is as much a motivation for me as are saving lives and improving quality of life for my patients. I know this isn’t something that gets most people out of bed in the morning, but I hope I can do a good job of helping people find the path that is best for them (particularly if I do decide to work in Critical Care and would be in the position of counseling patients on whether or not to continue treatment or withdraw life support).

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