The Flip: An Issue of Medicine and Commerce in the Third World

“A lack of medicines in the public sector forces patients to purchase medicines from the private sector, where generic medicines cost on average 610% more than their international reference price. Such low public sector availability and high private sector prices drive many families into catastrophic poverty…”

 -from the World Health Organization report World Health Statistics 2012


This text selection struck a chord with me.  I read it and thought, “Who are these private sector sources they are referring to?” At first, it seemed as though the authors of the report were referencing large pharmaceutical corporations.  This explanation appeared to fit.  What with the popular perception of Big Pharma as an illness-exploiting caricature of itself, one could easily believe that they would drive up prices on the poor.  Third world families probably can’t sue either, so that’s a bonus. However, the quote above had to do with lower income countries and therefore less industrialized countries, and it was also referring to generic medications.   I put two and two together, and it equaled the black market.  That conclusion paints a nasty picture of the human condition.

In the past, I have had the opportunity to discuss the conditions in underdeveloped regions, particularly sub-Saharan Africa, with three people who have seen it firsthand.  The first was my high school art teacher, who went on a hunting expedition to South Africa with his family.  The second was my half-brother, who spent time doing missionary work at orphanages in Kenya and the Sudan.  They both had plenty to say about the poor sanitation standards in the cities, high crime, and higher rates of communicable disease.  They both commented on the general lack of basic public information and sex education services.  Both of them had seen too many children who were far too undernourished.  Their stories affected me quite a lot.  Still, it was the nurse from our local hospital who had the most interesting perspective.  She had the background to understand more of what was going on and the curiosity to inquire further.  During her stay, she observed that the local bosses, mostly tribal leaders, took a heavy cut of almost all foreign aid.  This included medications for HIV, TB, and other illnesses.  A local man confided in her that much of this medication was sold to neighboring villages or to smugglers.  He said people in his village would often buy medicine and divide it among themselves incorrectly.  As a result, the medication would often be ineffectual against the disease.   Two would die when one might have lived. 

According to some socially conscious people, the lack of access to affordable medications for those living in lower income countries is just another result of exploitation and/or neglect by developed nations.  However, in light of all I’ve heard on the subject, there might be an alternative explanation.  The culprit that might, at least, share the blame is the ever-present middleman.  Since the dawn of the earliest civilization—or since the founding of the currency system—there have been people whose sole purpose in society was to buy things at one price and sell them at a higher price, often without contributing anything to the exchange.  It has been done with everything:  gold, silk, livestock, lumber, and even human beings.  Today, it is being done with mass-produced medications.  It is being done in some of the most troubled places on the map.  It is being done illegally.  Worst of all, it is being done without proper medical oversight.  When cast in this light, “middleman” starts to sound like a dirty word.  Nevertheless, for the sake of argument, it is always a good idea to play the devil’s advocate.

                                                                                 Image courtesy of www.business-strategy-innovation.com

 

Extolling the virtues of the middleman in plain language is difficult.  When I was trying to think of a good analogy, the above image of a bucket brigade came to mind.  (For those readers who are unfamiliar with it, this was a method of firefighting developed in the days before high pressure pumps and fire hoses.)  Consider two scenarios.  In Scenario #1, there is a burning house fifty feet from the nearest water well.  Fifty men from the town grab their buckets and run to help.  Each individual man fills his bucket at the well, runs to the house, dowses a few flames, and runs back to start again.  Problems arise immediately.  The men get in each other’s way at the well, each man pushing to get ahead of the next.  This impedes their attempt to fight the fire.  In addition, they begin to tire as they repeatedly run back and forth.  Efficacy is lacking, and the entire town is soon engulfed in flame.   In Scenario #2, the men form a line between the well and the house, passing buckets of water from man to man.  A few fill buckets at the well while one or two retrieve the empty ones.  This approach cuts down on both fatigue and confusion while supplying a steadier stream of water, and the town is saved.  This analogy is meant to support the middleman as an integral part of any enterprise.  Unfortunately, this analogy is fallacious.  When fighting a fire, the middlemen need to be there to physically pass the buckets.  In the black market medicine trade, middlemen are only cut in to keep them from smashing the buckets.

 

To quote Captain Malcolm Reynolds of TV’s Firefly, “About fifty percent of the human race is middlemen and they don’t take kindly to being eliminated.”  To add context, this line was taken from an episode where Reynolds and the crew of his spaceship are selling stolen medications to crime barons on impoverished planets, rather than directly to the local physicians. This quotation is relevant in a number of ways.  For one, it neatly sums up this obstacle to delivering affordable medications to impoverished regions.  For another, it illustrates the alarming indifference of the United States and other developed nations to the reality of curable diseases killing millions of people each year.  The simple fact that a television program depicted its protagonists taking part in such activities was callous enough.  The fact that viewers accepted these problems as being likely to last for another 500 years was appalling.  Maybe this is attributing too much importance to fiction; there’s no way to know for sure.  Popular culture does have a way of mirroring the popular perception.  In this case, the perception is that wheeler-dealer middlemen are so thoroughly engrained into the global reality that it can’t be helped.  The innocent are the ones who suffer, but still it can’t be helped.

 

-Stephen Adams