Pécoul, B

Veeken, H

English

MSF Field Research

Tropical Medicine and International Health
volume 5 no 5 pp 309–311 may 2000
Editorial: Drugs for ‘neglected diseases’:a bitter pill
Hans Veeken and Bernard Pécoul
Médecins sans Frontières
correspondence Hans Veeken, MSF, P.O. Box 10014, 1001 EA Amsterdam, The Netherlands. E-mail:
hans_veeken@amsterdam.msf.org
TMIH576
© 2000 Blackwell Science Ltd 309
Health is determined by many factors, yet pills remain the
key to the cure of many diseases. Provided you can get hold
of them, that is. People in poor countries often have no access
to essential drugs; this can be a matter of life or death. For
some diseases drugs do not exist (e.g. Buruli ulcer); for
others, drugs have been withdrawn from the market (such as
eﬂornithine for treating sleeping sickness); or are too expen-
sive (antibiotics, antimalarials, antiretrovirals) (Pécoul et al.
1999). Cost is the main obstacle. To put it simply: greed in the
West curtails the availability of life-saving drugs for all.
Lack of research
Research and development into tropical diseases have come to
a virtual standstill due to low proﬁts. Of 1223 drugs globally
licensed between 1975 and 1997, only 13 were for treatment
of tropical diseases (Trouiller & Olliaro 1999). Two of these
were an outcome of military research (halofantrine, meﬂo-
quine), six resulted from veterinary research (albendazole,
benznidazole, ivermectin, oxamniquine, praziquantel and
nifurtimox) and two were merely modiﬁcations of existing
drugs (pentamidine and amphotericin B). Thus, over more
than 20 years only three drugs were developed speciﬁcally for
the tropics (artemether, atovaquone and eﬂornithine).
Artemether was a Chinese Academy discovery; the develop-
ment of atovaquone for malaria would have been endangered
had it not turned out that it is effective against AIDS-related
opportunistic infections (Hudson et al. 1985); and eﬂor-
nithine is no longer produced. Apparently it is more prof-
itable to develop and market Viagra than to research a new
drug to treat patients with visceral leishmaniasis, a fatal dis-
ease if left untreated. Such a drug is more likely to be devel-
oped through veterinary research if it has economic potential
on the pet market.
Patent protection
A wide range of international trade regulations protect mar-
ket rights of producers through implementation of the World
Trade Organization agreement (Aventin & Mathys 2000).
Patent protection guarantees income for the industry and
stimulates drug research, but patents also increase drug prices
world wide and place them out of reach for many. The sce-
nario is extremely bleak for patients suffering from diseases
restricted to poor areas, diseases without commercial incen-
tives to invest in solutions. Two typical examples of such
neglected diseases are sleeping sickness and visceral leishma-
niasis.
Sleeping sickness
Sleeping sickness is rapidly re-emerging in Africa after it had
nearly vanished from the continent in the 1960s. It is esti-
mated that 60 million people are at risk and half a million are
infected, predominately in war-torn countries such as Sudan,
Angola, Democratic Republic Congo and Uganda (Barrett
1999). Therapy of ﬁrst-stage sleeping sickness is with suramin
(developed in the 1920s) for Trypanosoma brucei rhodesiense
and with pentamidine (developed in the 1940s) for T. b.
gambiense. These treatments have remained unchanged for
more than half a century.
The long-term supply of suramin is by no means secure.
The producer, Bayer, planned to stop production on several
occasions, and only continued after intervention by WHO.
Pentamidine (Aventis) was originally developed for treating
sleeping sickness. Once its potential to treat Pneumocystis
carinii pneumoniae in AIDS patients was established, the
price went up. The company donated a limited stock to
WHO, which kept the market price low (US$ 3 per vial) for its
restricted use in treating sleeping sickness. But the donation
has been used up and over the next few years the price of pen-
tamidine will gradually increase to the market price of US$
14 per vial. Donations are often preferred to dual pricing (for
rich and poor customers). Dual price-setting could jeopardise
sales of expensive compounds also marketed for nonparasitic
indications. Alternative treatment options for ﬁrst-stage
sleeping sickness do not exist.
Therapy for second-stage (cerebral) sleeping sickness relies
mainly on the organic arsenicol melarsoprol, introduced in
the late 1940s. This drug requires intravenous administration,Tropical Medicine and International Health volume 5 no 5 pp 309–311 may 2000
H. Veeken and B. Pécoul Editorial
and lethal complications occur in a substantial number of
patients (Pepin et al. 1989a; Veeken et al. 1989). Even though
melarsoprol is toxic and resistance to it is increasing (Legros
et al. 1999), we should be glad it is still on the market. Its
future production is not guaranteed and can only be secured
with commitment from the industry. Due to its speciﬁc com-
ponent arsenic, environmental lobbyists keep putting pressure
on the manufacturer to stop production.
Currently we have only one drug for treating relapse sleep-
ing sickness. This drug, eﬂornithine, was developed through
anticancer research, where it performed unsatisfactorily. It
was introduced successfully for treating refractory sleeping
sickness patients (Van Nieuwenhove et al. 1985). In 1995 the
manufacturer Hoechst, Marion, Roussel (HMR) stopped the
production of eﬂornithine. The drug was not turning an ade-
quate proﬁt. A last batch of 8000 vials was produced at the
end of 1999, enough to treat approximately 1200 patients. At
the same time, HMR transferred the license for eﬂornithine
to WHO. This liberates the company from further obliga-
tions to manufacture the drug. A new producer for eﬂorni-
thine remains to be identiﬁed.
Nifurtimox is normally used to treat Chagas disease
(American trypanosomiasis). It has been used in African
sleeping sickness, mostly for second line treatment, with
mixed success (Pepin et al. 1989b; Van Nieuwenhove S 1992;
Doua & Boa Yapo 1993). Its potential use for combination
therapy, in ﬁrst and second stage, is not evaluated yet. It can
be administered orally and costs only US$ 10 for a 14-day
course. A new drug (benznidazole) has been introduced to
treat Chagas disease and the manufacturer (Bayer, Argentina)
of nifurtimox stopped its production. The company is willing
to produce further batches, but will not take responsibility
for commercializing and marketing the drug.
Research and development of new treatments for sleeping
sickness has come to a standstill. There are compounds in the
preclinical pipeline, such as megazol and diminazene acetate
(used in veterinary trypanosomiasis), but due to lack of funds
no progress is being made.
Leishmaniasis
Visceral leishmaniasis (kala-azar) is a fatal disease caused by
a parasite of the genus Leishmania. Half a million people
become infected each year world wide (WHO 1996). Organic
pentavalent antimonials (e.g. stibogluconate) have been the
mainstay of treatment of kala-azar since their discovery in
the 1920s (Goodwin 1995). Branded antimonials are expen-
sive, approximately US$ 185 per patient treated, and need to
be given daily, intramuscularly, for one month. In this case
too, we should be grateful that this old-fashioned drug is still
available. The future supply of antimonial drugs is by no
means certain, and demand at times exceeds output.
Generic sodium stibogluconate is available for US$ 13 per
patient treated, 1/14 of the price of the branded drug (Moore
et al. 2000). Governments do not license the generic drug
simply because it is produced in India. The trial described in
this issue (Veeken et al. 2000), comparing the efﬁcacy of
branded stibogluconate and generic stibogluconate under
ﬁeld conditions, demonstrates that the drugs are equivalent.
Hopefully this result will facilitate introduction of cheap,
affordable treatment for thousands of kala-azar patients.
Resistance to drugs used for treating kala-azar is increas-
ing, especially in India (Thakur et al. 1998). Treatment of
relapses requires drugs that kill Leishmania parasites through
different modes of action. Alternative treatments for kala-
azar are few and either expensive (pentamidine or
Ambisome®, a lipid amphotericine formulation (Davidson et
al. 1991)), potentially toxic (amphotericine B) or currently
unavailable (aminosidine). With the exception of miltefosine
(Jha et al. 1999), which has potential as an orally adminis-
tered drug, no further research is underway.
What should be done?
We cannot accept that the dearth of effective drugs for tropi-
cal diseases is simply the consequence of a global market
economy. Drugs for neglected diseases do not belong in the
free market; they require a centralized, public, nonproﬁt
approach. Drugs are not a consumer commodity. Govern-
ments, manufacturers and nongovernmental organizations
have a shared responsibility. The public sector must invest in
research and development and secure the market. This neces-
sitates centralized estimation of the needs and global distrib-
ution. Pharmaceutical companies must be engaged in the
sustainable production of life-saving drugs. Registration and
legislation should be adapted to overcome barriers of export
and import between different countries. The pill should not
be that bitter.
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© 2000 Blackwell Science Ltd 311

A randomised comparison of branded sodium stibogluconate and generic sodium stibogluconate for the treatment of visceral leishmaniasis under field conditions

A randomised comparison of generic sodium stibogluconate (sodium antimony gluconate, Albert David Ltd., Calcutta) and Pentostam (GlaxoWellcome, London) for the treatment of visceral Leishmaniasis in Kenya. Bulletin of the WHO,

Access to essential medicines in poor countries: a lost battle?

Advances in sleeping sickness therapy. Annals de l a Société Belge de Médecine Tropicale

An open trial of nifurtimox for arseno-resistant Trypanosoma brucei gambiense sleeping sickness in central Zaire.

Does the diminishing efficacy and increasing toxicity of sodium stibugluonate in the treatment of visceral leishmaniasis in Bihar, India, justify its continued use as a first line drug? An observational study of 80 cases.

Drug development output during 1975–96: what proportion for tropical diseases?

Editorial: Do we negotiate human health?

Human trypanosomiasis in the Ivory coast: therapy and problems.

Liposomal amphotericine B in drug resistant leishmaniasis.

Miltefosine, an oral agent for the treatment of Indian visceral leishmaniasis.

Novel antimalarial hydroxynaphthoquinone with potent broad anti-protozoal activity.

Pentostam (sodium stibogluconate); a 50 year personal reminiscence.

The fall and rise of sleeping sickness.

Therapeutic failure of melarsoprol among patients treated for late stage of T. b. gambiense human African Trypanosomiasis

Treatment of gambiense sleeping sickness in the Sudan with oral DFMO (DL-alpha-difluoromethylornithine), an inhibitor of ornithine decarboxylase; first field trial.

Trial of prednisolon for the prevention of melarsoprol induced encephalopathy in gambiense sleeping sickness.

Drugs for 'neglected diseases': a bitter pill.

Drugs for 'neglected diseases': a bitter pill.

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