Still catching up with reviews from my holiday reading – Alex de Waal’s new book (already reviewed) and AIDS Drugs for All, which came highly recommended. (I also read and enjoyed Marlon James and Elena Ferrante – I’m not completely sad/obsessive, honest.)
AIDS Drugs for All is a forensic account of ‘a heroic effort on the part of social activists, policy entrepreneurs and sympathetic corporate executives’. Between them ‘the AIDS treatment movement was able to catalyze a profound transformation in the market for antiretroviral (ARV) medicines at the turn of the millennium, from one whose business model was ‘high price, low volume’ to one characterized by ‘universal access.’’ Conceptually they were able to change the definition of ARVs from private good to something closer to a ‘merit good’ whose price should be determined by need, not supply and demand.
The ambition of that ‘market transformation’ was stunning: ‘On the demand side, stakeholders had to change their perception of whether ARVs would work in the developing world, while on the supply side changes had to be made regarding pharmaceutical patents, pricing and competition. This change in the market needed to be supported by institutions that made these changes credible, in particular, institutions that would ensure that funds would be made available for the purchase and uptake of high-quality ARV medications at the reduced prices.’
The authors identify multiple success factors – the universality of a message about ‘bodily harm’; the turbulent state of Big Pharma in the late 90s and early 2000s, with big-earning pipeline drugs running out and new challenges from biotech and generics (off patent) manufacturers in India and elsewhere.
Activists also found an obscure, but in the end vital, forum to raise these issues on the global level – the WTO discussions on ‘trade-related intellectual property rights’ (TRIPs). This led to a big fight on whether and when poor countries should be ‘allowed’ to waive patent rules during health emergencies such as the HIV pandemic in order to get life-saving medicines at affordable prices. This all reached a peak at the 2001 WTO ministerial that launched the Doha round – I was there, but working on agriculture.
They won. According to the authors, ‘no matter which side of the patent debate one falls on, most observers would agree that the WTO decision of 2001 helped solidify the confidence of developing countries to pursue strategies that defended public health.’
The effectiveness of the activists was in no small measure down to the power of networks – enabled by the rise of ICT and some star policy entrepreneurs such as Jamie Love. Oxfam and MSF were also key players. I remember in Doha being baffled by the arcane arguments of the TRIPs lobbyists, but very impressed by their energy and organization.
But success also depended on an often under-rated factor – the stupidity of the enemy. Campaigning 101 says you need a problem, a solution and a villain. Step forward Big Pharma, which in 1998 decided to sue the South African government for breaking patent rules on HIV medicines. As the Wall Street Journal rhetorically asked ‘Can the pharmaceuticals industry inflict any more damage upon its ailing image? Well how about suing Nelson Mandela?’
The ensuing PR disaster led to the case being withdrawn in 2001, but by then it had spurred the creation of South Africa’s Treatment Action Campaign, catalysed the global AIDS movement and become an issue in the US election campaign in 2000.
So much for the historical account, what about the broader conclusions? The authors distil 5 generalizable success factors for activists wishing to pursue similar market transformations in other drugs-related areas, food and agriculture, extractives or finance.
- A highly contestable market. If a few companies have it all sewn up, they are less likely to listen, but if there are genuine threats from insurgents, they will either enter the market, or the threat of entry will force the incumbents to change. The authors suggest a spate of mergers and acquisitions is a good indicator of a sector in turmoil and ripe for campaigns of this type.
- A compelling frame: narrative matters – in this case ‘drugs companies are killing people by denying them access to medicines’ was almost impossible to resist.
- A coherent ask. The AIDS movement eventually settled on access to treatment as its big ask, but only after a difficult discussion on whether it should give priority to prevention (that issue hasn’t gone away).
- Low/favourable costs. The involvement of generics producers was crucial in driving costs, as was the fact that Big Pharma was already experimenting with ‘differential pricing’ between different markets.
- Stabilizing institutions. This was (for me) the most striking factor – by getting agreement to set up multi-billion dollar institutions such as the Global Fund, PEPFAR and UNITAID (funded by the world’s first global tax, on airline fares), the movement created institutions that would carry the work forward after the spike of mobilization faded (as it always does).
It’s a thought-provoking list, but I think it misses a lot of what matters in practice: the need for legitimacy/authenticity of advocates (the fact that TAC and other activist groups were organized by people living with AIDS was crucial); the importance of critical junctures, such as the South African court case or the Doha ministerial; luck; stupidity (South Africa again); broader normative shifts on rights, women etc that often underpin specific changes to policies and institutions. I would have liked to hear their views on the differences between anti- or pro- campaigns.
The authors end by applying their conclusions to a bunch of other potential change campaigns – from maternal mortality to malaria to climate change, and back test against the movement for the abolition of slavery. Nice idea but they cast the net far too wide – big systemic shifts like tackling climate change are most unlikely to have the same logic as a specific campaign such as access to medicines. As a result, the comparison is a bit vague and inconclusive.
Final criticism: these ‘success conditions’ reveal a deep preference for market-based solutions. There is little discussion of moral or justice arguments for change, or straightforward legislation to stop bad stuff – I fear in the case of anti-slavery the authors would have ended up proposing subsidies for more comfortable slave ships.
But putting aside the overstretch, corporate campaigners will find a lot of food for thought here – highly recommended.