Fire in the Blood: Entitled to Its Own Opinions, Not Its Own Facts

Fire in the Blood, a film by Punjabi-Irish writer-director Dylan Mohan Gray was first released at the Sundance Film Festival in January 2013. Since then, it made blood boil on at least several continents.  In Global Health Check February 2013, Araddhya Mehtta blogs that the documentary film covering Africa before HIV/AIDs  mass treatment programs got underway “tells a harrowing story of inhumanity and heroism” and details how “millions upon millions of people, primarily in Africa were left to die horrible, painful deaths, while the drugs which could have saved them were being safely and cheaply produced and distributed just a short airplane ride away.”

She goes on to tell how the film accuses multinational drug companies and Western Governments of collaborating “to keep low-cost generic AIDS drugs out of the hardest hit countries.” According to Mehtta, film director Gray described the story as a “real-life David vs. Goliath tale, full of incredibly interesting, daring, courageous mavericks, who took on the world’s most powerful companies and governments to do what virtually everyone else at the time said was impossible (i.e. mass treatment of HIV/AIDS in Africa), and against all odds they won…”

Mehtta and Gray fail to mention some pertinent facts that present an altogether different picture.

First, the global health community and the Clinton Administration throughout the 1990s did not fund any HIV/AIDS overseas treatment programs. They advocated only preventive programs, such as testing, counseling, and condoms. The notion that Africans would agree to testing for the HIV/AIDS virus with the associated stigma and no available treatment was always puzzling to me. President Thabo Mbeke in South Africa was in denial of the entire AIDS epidemic. According to Roy Caroll, “He questions the link between viruses and AIDS, and believes that the correlation between poverty and the AIDS rate in Africa was a challenge to the viral theory of AIDS.” So it’s hard to see who the real “courageous mavericks” were in the 1990s and early 2000s.

It wasn’t until George W. Bush came into office and completely reversed the U.S. Government position against treating AIDS that the global health community changed its tune. President Bush ushered in treatment and created the well-known PEPFAR program in early 2003 which combined prevention and treatment for the first time for patients in poor countries hardest hit by AIDS. Only then, in December of 2003, did the WHO initiate its own program which included treatment for the first time.

Secondly, for Mehtta to proclaim, without any examination of the evidence, that there were “safely and cheaply produced” drugs just a short airplane ride away is misleading. She seems to be referring to Indian companies that were producing knock-off HIV/AIDS drugs for export. It’s safe to say that the drugs were cheap, but not that they were safe since India requires no bioequivalence testing on drugs for export. The chickens came home to roost in May of 2004 when the WHO recalled 36 Indian drugs from the market and mainly in Africa because the Indian companies could not provide proof of bioequivalence. And, while India was the epi-center of low cost production of ARVs, it had as difficult a time of providing treatment to its own patients as to those in the global arena.  In October 2006, the International Treatment Preparedness Coalition criticized India for having 785,000 patients eligible for ARV treatment while only 6% of them were receiving it.

What Mehtta and the film do not acknowledge is the role of the U.S. Government’s FDA, which in May 2004, in an effort to increase AIDS drugs for poor countries, offered to accept any ARV drug file for review from companies in any country that wanted FDA certification to confirm that their drugs were valid ARV generics. In turn, U.S. companies, also wanting to increase AIDS drugs for poor countries, did not challenge the Indian companies for violating their patents. This made it possible for the U.S. Government to purchase these drugs and expand distribution even though the price differentials between the Indian and U.S. ARVs were not that significant.

This successful and innovative program between the U.S. Government and companies resulted in the number of AIDS patients being treated increasing from 400,000 in 2004 to more than 8 million patients by the end of 2012.  Eighty percent of these patients were receiving Indian drugs, but this time, they were drugs that had been tested for safety and efficacy. And finally, even before President Bush allowed treatment of AIDS patients in U.S. programs, and the global health community followed suit, U.S. companies spun into action with multi-country and single country HIV/AIDS programs for vulnerable populations overseas. From 2000 through 2011, companies donated some $76 billion in drugs – often ARVs, and $9 billion in cash donations including capacity building and physical infrastructure. These contributions are greater than the combined health budgets of the World Bank, WHO, and USAID over the same time period.

The story of HIV/AIDS deserves a better documentary than Fire in the Blood if we are to ever learn from our mistakes for future pandemics. Yes, the story of HIV/AIDS is a sad story of unnecessary human suffering, but the film is missing the chapter on how global health experts endorsed only preventive programs without treatment for over a decade.  Yes, ARVs were blocked from reaching Africa but primarily by health policy makers, not in a conspiracy of governments and companies. Yes, it did take some courageous mavericks to set it right, but not the ones generally mentioned, rather President Bush, the U.S. FDA, Dr. Paul Farmer who was the first to demonstrate that AIDS treatment could work in resource-constrained environments, and NGOs that stood their ground on the importance of both prevention and treatment. Documentary filmmakers should at least provide a balanced story and “do no harm” when they turn their cameras to life and death matters.