On a warm day in the port city of Ismailia, we arrived in Sayed&rsquo;s neighborhood. Among cramped buildings, bursting at the seams, lined side by side, Sayed guided us to his home through a small opening where the sun cannot reach. The poor infrastructure of his neighborhood was the least of his worries. At first glance, he appears to be a healthy middle-aged man, but in reality he is a chronic patient of the blood disorder, immune thrombocytopenic purpura (ITP). What was meant to be a trip to the dentist turned into an ongoing battle with a disease, much of which was directed towards securing the medication prescribed to him by doctors. Unable to secure the medication, the disease would worsen, not only affecting his ailing body, but causing him to lose his job, through which he supported his family. Sayed was the sole breadwinner for his wife and two children, as well as his elderly father. Before his diagnosis, he was a schoolteacher of geography and history.
From the moment of diagnosis three years ago, Sayed found himself in a limbo between clinics, hospitals and government offices. Well aware of the issues surrounding access to medicine, especially for rare diseases, for years his doctors tried exploring alternative pathways to treatment with no avail. As with many chronic patients, treatment means prolonged access to the most effective medicine. This would be made worse with the onset of the pandemic, where COVID-19 could be critical to him due to his immunocompromised body. Sayed is only one of millions of Egyptians who are stuck in Egypt's pharmaceutical web of private multinational and local companies, publicly owned pharma, and the healthcare system. Revolade, the medication he needs, is manufactured by GlaxoSmithKline, a British multinational pharmaceutical company. Sayed&rsquo;s story reveals the inefficiencies that plague the issue of access to medicine in Egypt, characterized by a deep disenfranchisement due to administrative deficiencies.
<h3 style="text-align: justify;">&nbsp;Intellectual Property Rights: Entrenching Inequalities</h3>
The Trade Related Aspects of Intellectual Property Rights (TRIPS) agreement between member nations of the World Trade Organization (WTO) came into effect in Egypt in January 2005. TRIPs effectively fostered the monopolization of life-saving drugs by multinational pharmaceuticals through patent rights. This form of protectionism has led to skyrocketing prices of medicine in developing countries like Egypt (Mortada, 2009), where individuals are unable to afford it, having to rely on state welfare, much like Sayed. The country&rsquo;s recognition of patent rights coming under TRIPS has garnered criticism, mainly that TRIPS creates the same axis of inequality that has come to be characterized by the differentiation of &ldquo;industrialized nations&rdquo; and &ldquo;developing countries&rdquo;, where the former reap the benefits while the latter bear the cost (Egyptian Initiative for Personal Rights [EIPR], 2005).&nbsp;
This unequal setup makes it difficult for states to secure this expensive medicine for a largely low-income population (Rizk &amp; Shaver, 2010). This is compounded when you consider Sayed&rsquo;s case, a patient of a rare chronic disease with a relatively low incidence. Hence, it is most likely not accounted for in lists such as World Health Organization&rsquo;s (WHO) &ldquo;essential medicines list&rdquo; (WHO, 2014). However, Egypt has taken steps towards securing access to medicine. Following the 2016 medicine shortage, and many calls from relevant stakeholders, Egypt created the Egyptian Drug Authority' (EDA) as a higher body guaranteeing the regulation of pharmaceutical products (EDA, n.d.). The EDA is a regulative authority that acts as a watchdog for the pharmaceutical industry, ensuring the quality of drugs, enforcing regulations and maintaining stock for essential medicines. The EDA has the potential of being a mediator between the intricate and large network of the pharmaceutical industry by creating guidelines for these bodies to report on the needs/gaps in the health system. The groundwork and premise of state-sponsored medicine exists, but with many systemic inefficiencies. As Sayed&rsquo;s journey illustrates, already hindered by recurrent shortages, there are numerous time-consuming bureaucratic and administrative obstacles for patients to bypass.&nbsp;
At the outset of the pandemic, there was a shortage of medicine for chronic diseases (El-Mahdawy, 2020), and if COVID-19 has showcased anything, it is that chronic disease patients pay the highest price. These shortages are not a new phenomenon; having numerous interdependencies, Egypt&rsquo;s pharmaceutical sector is considerably vulnerable. Egypt heavily relies on imported drugs, or even imported raw materials for locally produced drugs; consequently, the 2016 devaluation of the Egyptian pound severely affected the availability of drugs. During the 2016 medicine shortage, the cost of importing medication rose by 100% and production costs rose by 50% respectively (Sanchez, 2016).&nbsp;
<h3 style="text-align: justify;">The Precarious Path of Seeking Treatment</h3>
Despite about half of the population being covered by the Health Insurance Organization, Egypt&rsquo;s health system is still characterized by a high rate of out-of-pocket expenses, much of which goes to the purchase of medicines. A growing production of essential generics coupled with the ambitious 2018 universal health insurance plan introduced by Law 2/2018 (Hassan, 2019) can establish a pathway toward the achievement of accessible medicine for all. The EDA can monitor patents, especially to detect those that have fallen into the public domain. This could enable the local pharmaceutical industry to make gains in generics production to meet Egypt&rsquo;s high medicine demand, especially for non-communicable disease (NCD) drugs, as Egypt has one of the highest NCD burdens, with an estimate of it accounting for 85% of all deaths (Ministry of Health and Population, 2017, p.7).&nbsp;
Sayed and many others hope that the rollout of the new universal coverage means the erasure of some of the barriers to navigating the system, including the geographical disparity in the delivery of medicine and the provision of specialized medicine (Radwan &amp; Adawy, 2019). Residents of Ismailia dependent on the state&rsquo;s welfare have to rely on one specialist, who only comes in once a week, which leads to long waitlists and impedes access to medicine. The new Universal Health Insurance Law must also accompany policies to train health workers towards a patient-centered culture that does away with the dismissal of patients as &ldquo;ignorant&rdquo; because of their welfare status.&nbsp;
Throughout his journey, Sayed has had to cultivate a wealth of medical knowledge to assert his right to access medicine. He&rsquo;s continuously had to convince hospital administrators and government employees alike why Revolade was what he needed without being dismissed. Even the consistent contact with medical professionals did not alleviate the physically and emotionally taxing process. Administrators or hospital workers responsible for facilitating the dispensary would take a glance at his medical record and dismiss his prescription, insisting on a splenectomy against his own doctors&rsquo; recommendations. Consequently, Sayed had to also cultivate a network of medical professionals who would work outside of their job description to ensure that the system responds to his needs. Oftentimes his doctor had to physically demand his prescription, or call on other colleagues to help her patient. Reliant on the benevolence of medical professionals and charity foundations, Sayed&rsquo;s case is illustrative of the precarity so many Egyptians experience.&nbsp;
<h3 style="text-align: justify;">Moving Forward</h3>
Sayed&rsquo;s predicament is one among millions, one that can be alleviated if Egypt reworks its national intellectual property policies to stimulate the production of life-saving generics. TRIPS has flexibilities that can enable Egypt to maximize momentum in making medicine accessible (EIPR, 2005). While TRIPS gives developing countries the short end of the stick, under the guise of providing incentives for innovation through patent protection (despite a significant gap in technology and funding), the agreement also stipulates the importance of access to medicine, especially in public health emergencies. This is where compulsory licensing &ndash; as outlined in the Doha Declaration on the TRIPS Agreement &ndash; represents an opportunity to secure the know-how for local industry and stimulate production.&nbsp;
Compulsory licenses enable countries to license the use of a patented medicine to a third party or government agency without the consent of the patent holder. As asserted by EIPR&rsquo;s report, &ldquo;the power to grant a compulsory licence does not necessarily entail the granting of licences and sometimes the mere threat can be enough to bring down prices&rdquo; (EIPR, 2005, p.18). Such threats have been successful in reducing the price of certain medicines, such as that of the antibiotic ciprofloxacin in the U.S. (Ooms &amp; Hanefeld, 2019).
<hr>
&nbsp;References
<ul style="text-align: justify;">
<li style="font-size: 10pt;" aria-level="1">Egyptian Drug Authority. (n.d.). Establishment of the authority. [Ta&rsquo;sis al-hay&rsquo;a]. [In Arabic]. Retrieved 14 April 2021, from <a href="https://cutt.ly/IvFjIGK">https://cutt.ly/IvFjIGK</a></li>
<li style="font-size: 10pt;" aria-level="1">Egyptian Initiative for Personal Rights. (2005). The TRIPS agreement and Egypt's responsibility to protect the right to health. Cairo: EIPR. Retrieved from <a href="https://eipr.org/sites/default/files/reports/pdf/TripsReport_EIPR_2005_EN.pdf">https://eipr.org/sites/default/files/reports/pdf/TripsReport_EIPR_2005_EN.pdf</a></li>
<li style="font-size: 10pt;" aria-level="1">El-Mahdawy, H. (2020). As COVID-19 panic builds, pharmacy shelves run out of vital drugs. Mada Masr. <a href="https://www.madamasr.com/en/2020/04/13/feature/economy/as-covid-19-panic-builds-pharmacy-shelves-run-out-of-vital-drugs/">https://www.madamasr.com/en/2020/04/13/feature/economy/as-covid-19-panic-builds-pharmacy-shelves-run-out-of-vital-drugs/</a></li>
<li style="font-size: 10pt;" aria-level="1">Hassan, T. (2019). The universal health insurance law 2/2018. Sharkawy &amp; Sarhan, February 10. <a href="https://sharkawylaw.com/stay-informed/the-universal-health-insurance-law-2-2018/">https://sharkawylaw.com/stay-informed/the-universal-health-insurance-law-2-2018/</a></li>
<li style="font-size: 10pt;" aria-level="1">Ministry of Health and Population. (2017). Egypt national multisectoral action plan for prevention and control of noncommunicable diseases. Cairo: Ministry of Health and Population. Retrieved from <a href="https://www.iccp-portal.org/system/files/plans/EGY_B3_NCDMAPEgypt21March2017%20FINAL%20%20RS.pdf">https://www.iccp-portal.org/system/files/plans/EGY_B3_NCDMAPEgypt21March2017%20FINAL%20%20RS.pdf</a>&nbsp;</li>
<li style="font-size: 10pt;" aria-level="1">Mortada, F. (2009). Egypt&rsquo;s pharmaceuticals &ndash; Tripping over TRIPS?. Retrieved 14 April 2021, from <a href="https://www.aucegypt.edu/auc-academics/core-curriculum/egypt%25E2%2580%2599s-pharmaceuticals-%25E2%2580%2593-tripping-over-trips">https://www.aucegypt.edu/auc-academics/core-curriculum/egypt%25E2%2580%2599s-pharmaceuticals-%25E2%2580%2593-tripping-over-trips</a></li>
<li style="font-size: 10pt;" aria-level="1">Ooms, G., &amp; Hanefeld, J. (2019). Threat of compulsory licences could increase access to essential medicines. BMJ, 365, l2098. <a href="https://doi.org/10.1136/bmj.l2098">https://doi.org/10.1136/bmj.l2098</a></li>
<li style="font-size: 10pt;" aria-level="1">Radwan, G., &amp; Adawy, A. (2019). The Egyptian health map: a guide for evidence-based decisionmaking. Eastern Mediterranean Health Journal, 25(5). <a href="https://doi.org/10.26719/emhj.18.048">https://doi.org/10.26719/emhj.18.048</a></li>
<li style="font-size: 10pt;" aria-level="1">Rizk, N., &amp; Shaver, L. (2010). Access to knowledge in Egypt: New research on intellectual property, innovation and development (pp. 56-91). Bloomsbury.</li>
<li style="font-size: 10pt;" aria-level="1">Sanchez, L. (2016). In search of medication in Egypt. Mada Masr. Retrieved from <a href="https://www.madamasr.com/en/2016/11/29/feature/society/in-search-of-medication-in-egypt/">https://www.madamasr.com/en/2016/11/29/feature/society/in-search-of-medication-in-egypt/</a></li>
<li style="font-size: 10pt;" aria-level="1">World Health Organization. (2014). The selection and use of essential medicines: Report of the WHO expert committee, 2013 (including the 18th WHO model list of essential medicines and the 4th WHO model list of essential medicines for children). World Health Organization.</li>
</ul>
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