Great News: MSF / Doctors Without Borders has Closed its Access Campaign

(Image: msfaccess.org)

“Once we realise that imperfect understanding is the human condition there is no shame in being wrong, only in failing to correct our mistakes,” George Soros wrote. Recently, Médecins Sans Frontières (MSF — Doctors Without Borders) fixed a mistake that the foundations linked to Soros are still making. MSF was roundly condemned by the global health establishment, many parts of which are very fond of sticking to old ways of thinking and acting, however misguided history has shown them to be.

Backing out of a dead-end

MSF has decided to close its Access Campaign which had, since the 1990s, pursued a highly entertaining, but deeply damaging, campaign against the global pharmaceutical industry. The videos were genius and the protests were innovative, but the ideology was vacuous and the results were almost wholly negative.

Peak stupidity for the Access Campaign was reached in 2017 when MSF, at the urging of the Access Campaign, refused donations of pneumococcal vaccines to make some abstract, and incoherent, point about patents.

“They continue to offer donations that give Pfizer a tax break rather than offer a sustainable solution by lowering the price of the vaccine overall. Accepting Pfizer’s donation today would not do anything for the millions of children living in countries like Iraq, Jordan, Philippines, Romania, and Thailand, among many others, where neither their parents nor their governments can afford the expensive vaccine,” said MSF at the time. It was an interesting list.

Iraq, MSF’s first example, is one of the world’s largest oil producers. It ranks 154th out of 180 countries on Transparency International’s corruption index, where 1 is good and 154 is not. Iraq’s most recent budget borrowed record amounts to add a million workers to the public payroll; the jobs are doled out by political and religious movements and many of the “employees” never show up at all. Pre-pandemic, Iraq spent about four percent of its government budget on health; almost exactly the same percentage that it spent on fossil fuel subsidies and about a third of what was needed. It has far fewer health professionals per capita than surrounding countries — after all, why train to be a nurse when you can get a plum state job that requires no training, or indeed work? Pfizer was not the problem in Iraq.

Roots in the fight against AIDS

The Access Campaign grew out of the struggles over access to HIV drugs at the end of the last century, as did so many of the anti-industry pressure groups that have secured public and private funding and support over the past 25 years. They took the wrong lessons from that experience.

The price of medicines for HIV were too high for developing countries. The obvious answer was to model these prices on the established system for vaccines, where the price of vaccines was tied roughly to a country’s ability to pay. Vaccines were researched and developed using revenues from high-income markets and then made available in the poorest countries at roughly cost price. The key to the success of that system has been a dedicated pool of international funding to buy the vaccines. The vaccine producers have, since 2000, been part of a highly efficient and professional infrastructure for making decisions about how to improve access in low-income countries. The system also assured demand to support investment.

MSF and others became, though, the useful idiots for Indian and other generic producers which had always produced their own, more or less equivalent, versions of new medicines developed in Europe, Japan and North America a year or so after they became available in their home markets. Asian countries including India had, effectively, refused to recognise patent protection for these medicines. Now, as India’s own economy grew and became more innovative, India sought to join the World Trade Organisation. If India’s IT and automotive patents were to be recognised globally, India accepted that it had to do more to enforce the intellectual property protection of pharmaceutical researchers and developers.

India’s pharma and vaccines industry had long talked about investing in R&D, but had never done so. Without the ability to copy the products of others, India’s industry faced an existential crisis. If activists could be persuaded to force innovators to assign their patents and transfer their technology to developing-world producers, there was a way out. That’s where MSF and other slick campaigners came in. Thanks to their efforts, the developing-world generic producers got permission to produce HIV medicines for low-income countries and promptly started using that wedge to push for permission to supply the Iraqs of the world too. As we’ll see, they also said that if the model worked in HIV, it should apply to everything

In fairness, MSF weren’t really duped. The theatrics of an apparently unequal struggle against big pharma was good for fundraising from MSF’s core progressive supporter base, who never heard about the palatial London apartment and private jet of the head of the largest Indian generic supplier. MSF’s income had soared to $2.37 billion worldwide by 2022.

The actual breakthrough in access to HIV medicines came because of a rare moment in the superpower Zeitgeist which enabled rich-country leaders to set up an international organisation to support treatment. The protests of AIDS activists, not MSF’s YouTube hits, were largely responsible for that remarkable move. As a result of it, the budget for HIV treatment was ringfenced in most countries and the new Global Fund for AIDS, TB and Malaria required NGOs, professionals, faith-based groups and others to be part of the planning and disbursement process in every nation that received funding from it.

The AIDS infrastructure had (and has) high running costs, but it has been effective beyond anyone’s wildest dreams: today in most countries about 90 percent of at-risk people know if they are HIV positive or not, about 90 percent of those diagnosed are on treatment and about 90 percent of those on treatment have undetectable viral load. Where no virus is detected, the disease cannot progress and it cannot be transmitted. Compare this achievement to management of hypertension in advanced economies — doctors there get plaudits for having 60 percent of patients with high blood pressure under adequate control. Today, HIV doesn’t make life shorter for people on effective treatment; high blood pressure does.

It’s the money, stupid

The lesson MSF, Oxfam, Health Action International and allied groups took from the HIV experience was that access to generic medicines could bring change. The real lesson was that providing funds for treatment, and involving a broad swath of society in planning and overseeing it, could change things very fast.

Countries anxious to obscure the lesson about needing to spend and plan saw that MSF could be a loud and uncritical ally. Brazil, Colombia, Kenya and others made lots of noise about the inequity of intellectual property. Together, they made interpretation of World Trade Organisation protocols into YouTube videos that tormented the pharma industry and its sleepy national trade associations, none of which seemed to notice that the MSF Access Campaign channel never had more than 189 subscribers in total — most of them probably in monitoring agencies working for PhRMA.

The model of voluntary transfer of patent rights to generic producers picked up speed and soon came to apply to therapeutic areas such as hepatitis C and some cancers. Ellen ‘t Hoon, an MSF graduate, became a fixture at donor gatherings and World Health Assemblies In 2013, she gave TED all the wrong lessons from the HIV story and then said that the Medicines Patent Pool, of which she was the first director, would make all sorts of medicines available immediately throughout “developing countries”, a wonderfully fuzzy phrase that apparently included several EU member states. Participation in the Pool was voluntary but, she warned that pharmaceutical companies which declined to offer their patents through the Pool to generic producers, “might face forcible measures, so they better jump now”.

It was here that Soros’s Open Society network decided to run with the herd. In 2015, it published a paper fretting that the Global Fund for AIDS, TB and Malaria was engaged in, “a progressive rollback of its previous position of the promotion of generic competition as a key driver for lowering costs to a more opaque, centralized, collaborative approach with both generic producers and originators that risks reducing individual country ownership and threatening the continued supply of low-cost generic production.”

Patents flowed, but very few in the poorest countries were treated. Even if you accept all of the claims by the various promoters of “voluntary licensing” , about five million people worldwide have been treated with generic medicines against hepatitis C. That five million includes lots of middle-class patients who bought the generics with their own money.

Another Hepatitis C story shows how different things could have been without the strident narcissism of the MSF Access Campaign and its emulators. Egypt reached an agreement with Gilead over access to its hepatitis C treatments. The agreement committed Egypt to treat a lot of people fast and, if it did so, Gilead to provide medicines at a very steep discount, to support with know-how and then to equip local producers to continue to supply. By 2023, the New York Times reported that Egypt had treated four million people in its territory alone. It had gone from 10 percent of Egyptians being hepatitis C positive to under 0.4 percent. All without a single middle-class young person chaining themselves to anything.

No MSF protest, video, cartoon, poster or expletive-filled quote ever discussed the middle income countries that spent under two percent of GDP on public health provision or the attacks on human rights by repressive governments that crippled health care delivery. Occupying reception at the Ugandan parliament might, however, have been a little riskier than installing themselves in the Pfizer HQ.

Removing the threat of things that work

More threatening to MSF and its allies than the occasional collaborative success story, such as Egypt, was the continuing model of access to vaccines. The latest vaccines were made available by their originators at very steep discounts to low-income countries almost as soon as they were available in high-income ones. Where companies needed to make heavy investments to step up production for vast numbers of children in developing countries, a guarantee scheme was devised that would ensure that there would be a market in the short-term in return for further price cuts in the medium term.

The barriers to successful adoption of new childhood vaccines were rarely linked to supply, and usually came from the efforts of scientific sceptics and anti-vaccine advocates — sometimes funded covertly by developing country vaccine manufacturers, which were trying to produce their own versions of successful vaccines and anxious to keep foreign competitors out while local research efforts stumbled along. An example of the damage that ideological extremists can inflict is a wicked campaign of rumour and misinformation that has, over the past decade, condemned a million Indian women to die of cervical cancer when Gavi, the Vaccine Alliance was willing and able to supply vaccines that would have stopped the women from being at risk.

The MSF-linked activists went to work to try to get donors and UNICEF, which has a position as the middle-man in many vaccine purchases, to offer higher prices and less onerous terms to developing country vaccine suppliers. Many of these suppliers reached Patent-Pool-style agreements with global companies to transfer intellectual property and know how to permit them to produce modern vaccines. Philanthropies poured money into subsidised development and production of vaccines made under these agreements or based on even more heavily subsidised, and usually wholly redundant, national research.

The most spectacular consequence of this misguided policy came when the global organisations awarded contracts for yellow fever vaccines to new producers which then failed to deliver doses that met international quality standards. A global shortage of yellow fever vaccines ensued.

Less obvious examples are the inferior vaccines used to combat some diarrhoeal diseases and respiratory infections in many developing countries because of an ideological bias to buying from companies that are not big pharma.

Shrill and counter-productive

In the midst of the activist-induced furore, one of our clients behaved quite badly on access to one of its medicines in developing countries. I got the impression that senior management had simply not been paying attention. Protests and creative activism by the affected community soon put the behaviour at the top of the CEO’s agenda and he ordered an expensive and high-profile campaign with an élite US university to right things (the delusion that the Ivy League has some particular insight into the problems of Africa and South Asia, that can be unlocked for a high-enough fee, requires a separate article).

We were commissioned to do the baseline research on how bad things were at that point. Then we could assess how much better they had become $10 million later. The problem was that our client, which had behaved badly, was not perceived to be any worse than the companies which had been pouring money, talent and CEO time into developing-world access programmes. MSF, Oxfam and their allies had convinced the world that big pharma was universally unprincipled and selfish, which gave a licence to the few who were actually tempted to act that way.

The greatest bonus from the demise of MSF’s Access Campaign may be that we get to differentiate those in the pharmaceutical industry who are working hard to do the right thing from the minority who conform to the caricature that MSF drew so vividly.