A Bitter Pill to Swallow

As the morning temperature rises over the sprawling slum of On Nuch, one of Bangkok's eastern suburbs, 33 year-old Somying and her teenage son are standing on the canal's bank. For the last three months, waiting for the iceboat in the simmering heat has become part of their daily routine.  The little bags of ice they purchase every day are extremely precious to them, as precious as the life saving AIDS drugs they have to take every day. "When I saw my doctor, after a series of tests, he told me I was sick because I had become resistant to my anti-retroviral treatment" remembers Somying, who's been on ARV for seven years. "I was desperate, I thought there wouldn't be any medicines working on me anymore." But Somying and her son would become the lucky few in the country to be offered Kaletra, an expensive second-line AIDS treatment produced by American pharmaceutical company Abbott. Under Thailand's universal health care programme, Somying receives for free, medicine that she would otherwise have never been able to afford.

But, for Somying, these pills have a major flaw. They must be kept at cool temperatures, a serious challenge for people in tropical countries who, like her, are too poor to own a fridge.  In the corner of the two-room shack, where she and her two children live, is a blue icebox given by Médecins Sans Frontières.  Everyday she removes the melted ice and places three new ice bags along with a plastic bottle containing her monthly supply of Kaletra. Although she doesn't have to pay for the medicines, buying the ice remains a substantial financial burden. Years ago, when she became too sick to work, Somying left her job as a cleaner in a sausage factory. "I would be sick five days a week and people started gossiping" she recalls. I became too weak to work there and needed to go the clinic very often". She's since been working from home, making flower garlands out of ribbons that she sells for 40 Bath per hundred to Buddhist temples.

A local charity also supplements her income, bringing it to a total of 2300 Bath a month.  Still, over a third of the household budget is spent on ice. "My husband died of AIDS before ARVs where available in Thailand and I'm alone to provide for the whole family. Buying the ice is expensive and I could really spend this money on other things" she stresses. But asked if she sometimes fails to buy the ice and a sparkle flickers in her eyes. She knows that properly storing the drug is critical to adherence to her treatment and if she or her son came to develop resistance to this treatment, there would be few other alternatives.

 "I've always bought the ice!" she insists "But sometimes water gets in the bottle and the pills get damp" she worries.

Another drawback is that Somying, must also make sure she takes her daily intake at regular time and keeping the pills cold often proves unpractical. "I live far from the hospital and when I have an appointment I leave from here at 4 am" she explains. Follows a long journey involving taking several buses and getting stuck in Bangkok infamous traffic jam. "I have to take the icebox everywhere I go so I can take my drugs on time. I drag it on the whole trip with me and it's cumbersome and awkward" she explains, "It would be so much easier if there was a drug that didn't need to be refrigerated".

In fact there is. A newer heat-stable formulation of Kaletra, called Aluvia, has been available in the US since October 2005, but in Thailand it is not clear whether the growing numbers of patients failing their first line treatment will ever have access to Aluvia. Last April, Abbott, promised to register its heat-stable formulation at reduced price in more than 150 developing countries, but not Thailand. The company said it would not market seven new drugs, including Aluvia, a move that came as a clear attempt to punish Thailand for issuing a compulsory license for Kaletra in January. Such licenses are fully compliant with the World Trade Organisation's international trade rules and allow developing countries to import or produce generic versions of a drug otherwise unaffordable. This is a right that Thailand is ready to enforce in order to provide this life saving drug for free to the estimated 10,000 people who will need second line drugs in the coming years.  At its original price, the ministry of health said it had only a budget for 2,000 patients.  The move has infuriated Abbott which has since exerted constant pressure on Thailand to revoke its decision and has even made this a condition to the registration of Aluvia. 

Thailand's commitment to make ARVs available for free to all, has received international praise. Around 100,000 people are currently given first line ARV treatment, thanks to generic copies produced by the state-owned Government Pharmaceutical Organisation (GPO).  Yet, today the country finds itself embroiled in a bitter dispute with powerful pharmaceutical lobby groups ready to put patient's lives at risk to protect their commercial interests. The Thai ministry of health has repeatedly been obliged to justify its lawful decision to provide access to lifesaving drugs to the poorest fringe of society. Abbott spends endless energy hampering and delaying efforts to produce affordable versions of this key AIDS drug to those who need it in Thailand. In the meantime, many are waiting for life saving drugs to be made available. Until then, they will continue to pay the price for the greed of some pharmaceutical companies. 

> Thai version