Markkula Center of Applied Ethics

The Global Distribution of AIDS Pharmaceuticals

By Dr. David Perry

The international organization UNAIDS estimated recently that over 36 million people around the world are living with HIV/AIDS and that nearly 22 million have died of the disease. About 70 percent of those currently infected live in Africa, according to Lawrence Altman of the New York Times. In 13 African countries, the infection rate exceeds 10 percent of the population; and in South Africa, Botswana, and Zimbabwe, over a quarter of the adult population is HIV-positive.

How should we assess this human disaster from an ethical perspective? Principles of both compassion and fairness demand that we respond in some way to the AIDS crisis though it isn't entirely clear how best to do so.

One of the reasons why it has often been difficult to generate action on this problem is the widely held assumption that people who are HIV-positive are responsible in some sense for their condition. In this way, they're thought to be different from the victims of other epidemics or of floods, earthquakes, and famines, who typically inspire both compassion and generosity.

There is a certain grain of truth in this way of thinking. The majority of HIV infection around the world is the result of risky sexual activity, which generally means sex without effective condom use. To the extent that someone willingly has sexual relations with multiple partners without using condoms and is aware of the risk of HIV and other sexually transmitted diseases, that person is at least partly responsible if he or she becomes infected. But to conclude from this that we are not morally obligated to help HIV-positive people would be a serious mistake, for three reasons.

First, a very large number of those who have died from HIV/AIDS or are living with the disease cannot plausibly be blamed for their fate. Nearly 5 million AIDS victims are children, who obviously did not choose to be born HIV-positive. And many other victims are married women who have been faithful to their husbands but became infected anyway because their husbands had unsafe sex with prostitutes. Many wives don't find out that their husbands are infected until they give birth to HIV-positive children.

A second reason why we shouldn't assume we have no moral obligations to people with HIV/AIDS is that in other cases, even when we know that people acquired a medical condition due to their own irresponsibility, we don't deny them medical care for that reason. For example, everybody knows that it's foolish to ride a motorcycle without a helmet. But if a motorcycle rider has a serious accident while not wearing a helmet, we don't refuse to provide emergency and rehabilitative treatment. The same principle ought to apply to people who are infected with HIV through their own carelessness. They should not be denied care on that basis alone.

And third, we are citizens of a wealthy country and should not turn away from the suffering of the poor. Like the person who was helped by the Samaritan in the parable of Jesus, people living with HIV/AIDS are our neighbors in need.

What, then, is the current situation of our neighbors in Africa regarding the distribution of AIDS drugs? The short answer is that it is extremely uneven. Most Africans cannot begin to afford to buy the drugs that could extend their lives or prevent children from being infected by their mothers. In most cases their governments are also too poor to pay for the medications. The best drug therapy now available in the United States to inhibit the growth of HIV in an infected person costs $10,000—$15,000 per year, which even many Americans can't afford on their own.

That wouldn't necessarily raise questions of justice per se–heart and liver transplants are expensive, too–if it weren't for the fact that most of the companies producing the drugs are extremely wealthy. For example, Pfizer is a large multinational corporation that manufactures a drug called Diflucan, which is effective in treating many bacterial infections including deadly cryptococcal meningitis, which is often associated with AIDS. Pfizer has until recently charged a fairly high price for the drug, because many Americans and their health insurance companies can afford it.

In addition, Pfizer also sells other highly profitable drugs like the antibiotic Zithromax, Lipitor for cholesterol, Zoloft for depression, and Viagra for impotence. In light of this, AIDS activists and developing country governments have asked, Why can't companies like Pfizer cover the cost of AIDS drugs with the profits they make on other drugs?

Critics of the pharmaceutical industry also point out that their research is often funded by government grants rather than private investment alone. It doesn't seem fair for companies to make big profits on drugs needed to promote public health, especially when the public has already paid in part for the cost of developing those drugs and often pays for them again through federal health programs like Medicaid. Critics also believe that companies could charge much less for their drugs if they spent less on marketing and advertising, which by some estimates is nearly three times the amount they spend on drug research and development.

Corporations holding patents on AIDS-related drugs have been strongly criticized by developing country governments and groups such as AIDS Action for the high prices they charge. Some governments such as South Africa, India, and Brazil have allowed other companies to infringe foreign patents and produce their own versions of AIDS drugs, in many cases at substantially lower prices. According to New York Times reporter Donald McNeil Jr., some of the major pharmaceutical companies responded to those pressures last year by substantially lowering the prices of their drugs in selected countries. But 39 of those companies also sued the government of South Africa in an effort to protect their patents.

Then, in a dramatic turn of events, those companies announced in May that they had dropped their lawsuit. The implications of this decision are mixed, though. On the one hand, it may enable thousands or even millions of people in developing countries to obtain AIDS drugs that otherwise would have been out of reach financially, drugs that can extend their lives, alleviate their suffering, and reduce their chances of infecting others. And it's at least a plausible claim that the major pharmaceutical companies were profiting excessively on life-saving drugs.

On the other hand, it's not clear that allowing patent infringements is wise in the long term. It sets a bad precedent under international treaties for the protection of intellectual property. And it could be counterproductive if it makes companies less likely to invest in new drugs to treat other infectious diseases.

Also, if in the future pharmaceutical companies are going to be expected to charge little or nothing for HIV-related drugs in developing countries, they're going to have to recoup the cost of developing those drugs elsewhere. As a result, they may be unable to significantly reduce the prices of drugs that we might consider essential for treating diabetes, cancer, depression, pain, and other debilitating diseases or conditions.

Recall that one of the main issues debated during the 2000 presidential campaign was the high cost of pharmaceuticals for our nation's elderly. In other words, there are tradeoffs, or what economists call opportunity costs, connected with the desired goal of providing free or nearly free HIV treatments in Africa and other developing regions. That doesn't mean that the goal is misguided or wrong; it's just important to consider these things in weighing our options ethically.


AIDS Action,

Altman, Lawrence. "Parts of Africa Showing HIV in 1 in 4 Adults." New York Times, June 24, 1998.

Pollack, Andrew. "Defensive Drug Industry: Fueling Clash Over Patents." New York Times, April 20, 2001.

David Perry is the Director of Ethics Programs, Markkula Center for Applied Ethics, and Lecturer in Religious Studies.

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