Over the past two-decades and continuing into these millennial years, the continent of Africa has been at the epicenter of global pharmaceutical debates. These debates have primarily focused on the production, distribution, and access to affordable and essential life-saving medicines—for both infectious and non-infectious diseases. These debates were sparked by the rapid spread and extensive human suffering of the HIV/AIDs epidemic in Africa.
Further, they just as quickly highlighted the predominately western controlled pharmaceutical industry’s disinterest in backing the production and distribution of vital life-saving medicines, essentially blocking those that offer little return on investment—forget lowering the costs of much needed treatments. These debates also made evident the comfortable neglect of the global pharmaceutical industry towards treatable and curable diseases, either not prevalent in the global north or having long been eradicated; such as polio, tuberculosis, malaria, sleeping sickness, and yellow fever.
Even while the pharmaceutical industry ganged up and invested dearly in launching Big Pharma vs Nelson Mandela, an aggressive legal action against Nelson Mandela’s South African government in retaliation for having modified their country’s health and drug policy, enabling their right to produce and sell generic pharmaceutical products, the message was clear—the global pharmaceutical industry does not work for charity; it works for profit.1
Despite the pharma industry's drive to block access to essential medicines and maintain their control in the global pharmaceutical markets, civil society and homegrown activism intervened, driving citizen engagement and public support. It was these civil society movements, backed by global partners and campaigns such as Doctors Without Borders' (MSF) Access to Essential Medicines that served in constructing crucial instruments for mobilizing policy impact and achieving some, yet far from sufficient, shifts in the access and distribution of life-saving medicines.
Pharmaceutical companies, often rightfully, lay blame to Africa’s weak institutions and their "endemic" issues of corruption, poor financial oversight and lack of accountability as primary reasons for the inability to develop constructive relationships with African governments and respective counterparts. These are perfectly legit and well-grounded claims, however, what is rarely made explicit is how these "weak" environments play host to even weaker regulatory controls, serving to the advantage of the giants of global pharma when seated at the negotiating table. These advantages have contributed to the constant pressure faced by African governments and its leaders in navigating the global pharma’s use of pharmacological monopolies and bio-patent battles, distracting and draining national budgets while serving to intimidate its competitors.
Not Just an Emerging Terrain
Mobilizing access to essential medicines has been a tough battle for many African governments, seen by many to have resulted in too much human suffering. As Africa’s public health statistics have staggered and plummeted over the past two decades, as treatable illnesses and curable diseases continue to be neglected, wrecking families and community infrastructure and leaving behind over 20 million children orphaned by HIV related deaths and other treatable diseases, the global pharma industry has, for the most part—been unmoved.2
In recent years the international pharmaceutical giants have become fixated on Africa, not particularly for improving the delivery of essentials medicines but on its soaring economic potential and growing population, its expanding middle class and emerging consumer society, and how this translates into a consumer-based, demand-driven marketplace. A white-paper released in early 2014 by marketing research and strategy outfit IMS Health entitled, Africa: A Ripe Opportunity emphasizes that "Africa will be a significant economic force in the future and pharmaceutical companies have much to gain" with pharmaceutical spending expected to reach $30 billion by 2016.3 As it stands, Africa is not just an emerging terrain, a looming economic powerhouse—it is also a continent which remains living free of anti-depressants and pharmaceutical dependancies. This is real.
As expressed by Chris Viehbacher, Chief Executive of Sanofi, Africa’s most profitable pharmaceutical provider, Africa is “the strategic continent” and despite the unpredictable temperament of the region, “we are still pushing with our third factory in Algeria and will continue expanding our commercial presence in Africa” and transfer of expertise to local environments. In 2012, Sanofi emerged as leader of the pack in the African terrain, harnessing over one billion in prescription drug sales and are in process of developing a fourth manufacturing site in Algiers to add to those already developed in Morocco, Senegal, and South Africa.4 And it is these same companies that hold a monopoly over essential medicines needed that can actually save lives right now.
The report, which is not unique among industry players, goes on to emphasize that in order to harness this growth potential, pharmaceutical companies “must acknowledge the similarities and differences in market optimization strategies relative to other western and emerging markets.” Borrowing from market optimization strategies relative to other western and emerging terrains presents one absolute trend, that is, a growing dependency on prescription drugs, painkillers and opiates, and a portfolio of tricyclic antidepressants (TCAs) as an increasingly common treatment for mental health and psychological disorders among national populations.
Indeed, there is no doubt Africa’s public and mental health infrastructure is complicated and severely lacking, but the concern here should focus more on what kind of power the pharmaceutical giants will have in Africa’s explosive economy and how this will shape the future health and well-being of Africa’s populations. How might the pharmaceutical industry influence Africa’s public and mental health policy—will this interfere with democracy? Will Africa have any leverage determining its own future of public and mental health, or will the global pharma industry move in with its own vision?
Africa - More Important Than Ever
As the pharmaceutical industry has made clear before, its focus in Africa is driven by profit, not by a humanitarian spirit. Its simple, essential medicines have little return, if any, on investment—treatment for bacteria-based, infectious and non-infectious diseases have a finite cycle and often are administered to patients already crippled financially. Treatments for chronic illnesses and diseases where life can be prolonged with "indefinite" treatment cycles of therapeutic products and pain management (including mental health), offer the global pharma giants a much more appealing longer-ranging return on investment. This is a model already tested and pioneered in western markets. In this context, and well known by global pharma, the ever-growing population of Africa alone will make the continent more important than ever to the global economy.
However, the global pharma industry’s strategic moves to join in on the scramble for Africa are not just Africa’s problems, but point to larger, much more disconcerting issues of the increasingly and seemingly intrinsic connection between the global economy and that of global public health. The concern is not the idea of global public health, but what kind of health, how it impacts our ideas of citizen agency and democracy in highly prescribed environments, and the dissolving role of community resilience and collective healing as an undeniable factor in the heath, well-being, and sustainability of people. How does the global pharma industry’s role in Africa impact our future concepts of public health—but also does it threaten our future concepts of democracy and our humanity?
So what does the introduction of pushing more consumer-driven prescription drugs across Africa, most notably antidepressants, symbolize when clearly adverse effects are being felt, experienced, and seen amongst populations around the world living in heavily prescribed environments? What reason would Africa have to emulate the United States, where 70% of the population is taking at least one prescription drug, with 20% of that population taking five or more prescription drugs, and where 1 in 10 Americans are now users of antidepressants?5
As it stands, Africa is the largest geographical space and largest collective population on the planet that is un-medicated. And while it has a largely invisible mental health profession, a continent where billions have experienced violence, ongoing political strife and repression, and the pressure of being marginalized in a globalized world has enormous needs for mental health provisions and resources. However, the threat is that this burgeoning pharmaceutical industry dominated by western players will merely be focused on investing in a future of prescribing Africa’s 1.1 billion in exchange for the bottom-line.
The pharmaceutical approach in the United States has grown extremely aggressive to say the least, and reflects internal shifts within the industry itself. Such as Pfizer’s move in 2011 to dissolve its research and development unit focused on the engineering of antibiotics.6 This move comes at a time when Pfizer, with more than 80 years vested experience in the field of antibiotics, understood the emergence of super bugs and drug resistant bacteria – also know as gram-negative bacteria. The emergence of gram-negative bacteria has in many ways signaled an end to the antibiotic era and in effect pharmaceutical companies have restructured their portfolios into more profitable ventures. Again the message is clear—big pharma is big business.
Another bacteria-based and highly infectious disease, tuberculosis, also presents challenges to the future of global public health. While largely eradicated in the U.S. and the global north, tuberculosis has remained persistent in Africa and other parts of the world. Africa’s nations of Botswana, Ethiopia, Kenya, Lesotho, Mozambique, Rwanda, and South Africa have all been categorized by the U.S. Center for Disease Control (CDC) as high-burden TB countries. With limited treatment to 50-year old drug protocols with even fewer modifications have not only been met with mutated forms of drug resistant TB (DR-TB) but have morphed into more advanced mutations of XDR-TB (extensively drug resistant TBs).
As of 2013, with limited options for treatment, 92 countries reported cases of XDR-TB with Africa accounting for the most new cases of TB.7 Spread person to person through the air, TB is now killer number one in South Africa—a nation also faced with critical public health threats with the world’s most reported cases of XDR-TB. With an overall survival rate of 20%, most patients do not survive the side effects of the three-to-five-year treatment currently available to treat XDR-TB.
The point is that both gram-negative bacteria and all forms of TB and drug resistant TB are highly infectious diseases and present problems that are unlikely to remain isolated in either the U.S. or in hidden away in Africa. This combined with the impact of the pharmaceutical industry’s shift towards an almost exclusive focus on neuropathic pain and high-value global initiatives (read: highly profitable) in product development and distribution in Africa, exposes a global affair, a clear pattern—a real global concern.
Indirect Forms of Influence?
Earlier this month, the second annual African Pharmaceutical Summit is taking place in Accra (Ghana), an event that boasts being the most strategic pharmaceutical event in Africa focused on sales and distribution. The event is being hosted by Pharma Africa, a South African entity of Litha, Africa, which formed out of an acquisition backed by Europe’s BlackStar Group whose main holding is also South Africa’s Times Media Group.8 This event and its upcoming conference in February 2015, among many others, has become more and more popular as Africa’s elite, its entrepreneurs and its growing sector of professional come together to make deals. This is where it gets complicated. Global pharma does enter into the African economy with plenty of deal offerings that are fueling on the ground expertise and entrepreneurship. This is a good thing. The question remains: is this the necessary thing?
We need to better demonstrate how the global pharma industry is surrounding the terrain in terms of interests, influence, and implications. What Ron Phillip, Pfizer’s Head of Middle East and Africa, describes as “partnerships with national Ministries of Health, Institutions and private sector to help diagnose, treat and manage neuropathic pains,” can sound helpful, but with pharma giants current portfolios such moves tend towards hegemonic characteristics. Such characteristics can be evidenced exactly through an indirect form of influence within national governments and their ministries of health, mixed with much needed medical infrastructure investments; including administrative and diagnostic tools that also usher in a sort of indirect form of governance through renewed protocols across both the medical and mental health sectors.
Most of the 11 predominant global pharma players are engaged in extensive collaboration in local contexts, offering training programs, professional development, and advisory services to national governments. It should be noted that in their advisory roles, the global pharma industry in Africa has worked extensively to import and integrate neuropathic guidelines for governments to adapt, focused on managing pain and depression. As Phillip goes onto state, that in order to unleash growth capabilities, it is to the companies’ advantage to work with local health care communities “to better understand, and manage pain and depression, right here, where we all live.”
On the one hand, pharmaceutical giants can easily claim this shift is in direct response to emerging public and mental health concerns across cardiovascular fields, oncological therapies, non-infectious diseases and chronic pain management, alongside depression and other mood-related disorders. This is to be expected. Their rhetoric is tightly wound, though for the most part—heavily transparent. On the other hand, antibiotic and bio-research initiatives have been launched in South Africa, in partnership with the Ministry of Health and the Bill and Melinda Gates Foundation.9 These moves are commendable and research on bio-meds and antibiotics needs to be advanced as the concern of gram-negative and or drug resistance diseases become more common; however, they do not adequately address the growing concern over the future of Africa’s public health, and the role of the global pharma industry in any cohesive or explicit way.
As Africa’s economy swells its youth population has also swelled and are coming of age. Behind them, generations of even greater numbers will soon be coming. In the meantime, Africa is not just emerging, but it is actually best positioned to be thriving. From my present research, the youth for the most part are unaware of any talk of anti-depressants. If they can conjure up some familiarity of them, it is usually in reference to having heard someone in the upper classes taking them.
While most youth have already faced numerous hardships either directly or indirectly in their upbringing - whether poverty, the marginalizing forces of globalization, or violence and political disasters—they have also overcome these myriads of challenges, harnessing technology and global networks, deeply desiring to be part of Africa’s future at home and in the world. As one Ugandan Poet, Slim MC, puts it “Africa is the future…. Africa is Now!”
For the older generations, particularly the politically enlightened and activist driven, conflict, hardships, and trauma have too often become the norm; including chronic stress disorders, navigating authoritarian, corrupt, and democratic dictatorships. This is not to mention internal ideological struggles, as well as ethnic and tribal strife. The African women’s movement knows this best, where women’s experiences in conflict and post-conflict have significantly contributed to both physical and mental handicaps.
Alongside civil society, religious groups and community associations are engaging with child soldiers and orphans of war and communities of conflict. To assume that Africa is lacking mental health support, to claim mental health is an invisible problem in Africa, is merely to overlook or refuse to see the array of holistic, traditional, and contemporary African conceptualizations of mental health—arenas of collective health and healing which has been noted by Jack Saul, Director at New York University’s International Trauma Studies Program in his most recent book Collective Trauma, Collective Healing.10
In 2011, Psychologist Dr Hobfoll, Professor and Chair at the Department of Behavioral Science at Rush University, put the call out that the West has “so much to learn from Africa in terms of collective spirit and collective support.”11 There is merit to his statement, particularly as the CDC launched a public notice regarding the over-diagnoses of anxiety, depression, and other psychiatric disorders, and the abuse and misuse of prescription drugs - most notably pain-killers anti-depressants. In its report, the CDC states “deaths from prescription drug overdoses, particularly overdoses of prescription painkillers, have skyrocketed over the past decade.”12 The rise of prescription drug-related deaths outdoes fatal overdoses of heroine, cocaine, and other recreational drugs combined.
Giants Over Africa
An additional issue is what happens in the future when sick people are vulnerable to activities directed by the global pharma industry, such as the proposed Trans-Pacific Partnership (TPP) that plans to greatly strengthen corporate ability to use patent law to block entry of cheaper generic drugs into the United States.13 In France, the pharma industry is being drained by a socialist health-care system that has basically over-prescribed its national population, indeed with incentives from the pharma companies themselves. Now a nation where the majority of its citizens are medicated, the pharma companies have announced to the government that the costs of these drugs must increase to handle demand and supply. These rising costs will fall directly onto the shoulders of the taxpayers. In following this trend, Africa can expect a similar circumstance within the next 10 to 20 years.
The pharmaceutical giants are all over the African continent with a strategy that has become a reliable global trend and highly adaptive business model focused on chronic illness and long-term relationships with patients in the form of prescribed pharmaceuticals. As is typical in Western dominated neoliberal practices, these environments lack the infrastructure to get the biggest bang for their buck. As a resource rich environment, the consumer environment is as much under demand as the extractive minerals industry. The gains of the pharmaceutical giants, while buried in legal jargon and scientific rhetoric, are undeniable and perhaps shaping an intractable future of medicated citizens.
Not only does this approach stand to distort existing public health priorities, it completely negates enabling, as much as learning from, already existing achievements being implemented and made within Africa’s limited but enlightened mental health networks and practitioners by integrating treatment protocols that ultimately serve profit over well-being. This is not cost effective to the individual, nor does it respond to the growing mental and public health concerns taking place within already heavily prescribed environments. While progressing alongside is the evolution of gram-negative bacteria, greater antibiotic resistance, and highly infectious diseases, most notably the real emergence of XDR-TB. All of which draws into question the concept of well-being in Africa’s future, who decides, who determines, who stands to benefit, who sets the vision?
1. Doctors Without Borders / MSF Access Campaign. 1998: Big Pharma versus Nelson Mandela.
2. UNICEF Millennium Development Goals (MDGs): Goal 6: Combat HIV/AIDS, malaria, and other diseases / AVERT: History of HIV & AIDS in Africa.
3. IMS Health. Africa: A Ripe Opportunity.
4. Reuters (Apr 2, 2014) Sanofi Eyes More Acquisitions, Sees Growth in Africa.
7. World Health Organization (2013) Global Tuberculosis Report.
9. Winters, C; Gelband, H. Part I. The Global Antibiotic Resistance Partnership (GARP). South African Medical Journal, [S.l.], v. 101, n. 8, p. 556-557, jul. 2011. ISSN 2078-5135.
10. Jack Saul (2013) Collective Trauma, Collective Healing: Promoting Community Resilience in the Aftermath of Disaster.
11. Think Africa Press: Mental Health Remains An Invisible Problem in Africa.
12. Center for Disease Control (CDC), Prescription Drug Overdose PSR 2013, The Prevention Status Reports
13. The Trans-Pacific Partnership Agreement ("TPP") is a free trade agreement currently being negotiated by nine countries: The United States, Australia, Brunei Darussalam, Chile, Malaysia, New Zealand, Peru, Singapore, and Vietnam. Although the TPP covers a wide range of issues, this site focuses on the TPP's intellectual property (IP) chapter.
Photography provided by:
Danielle St. Laurent - New York
Siaka Soppo Traore (aka Calo Yeleen Vision) - Dakar
Africa, Consumerism, Drugs, Neoliberalism