Locost: Low-Cost Standard Therapeutics

When I was an undergrad I was involved with a student group called UAEM (Universities Allied for Essential Medicines) that tried to pressure universities to cater their research policies to developing country needs. Part of our activities involved pressuring Columbia to play around with its patenting and licensing policies. Generally when a researcher at a university discovers a promising new chemical that might treat some disease, the university patents the chemical, giving itself ownership for 20 years. Since it usually doesnt have a large enough research budget to conduct all the safety and efficacy trials needed for FDA approval, it then licenses the chemical to a private pharmaceutical company, which does the rest of the work. In exchange, the company is usually the sole producer and distributor of the medicine for the remainder of the 20-year patent period, paying the university royalties from its sales.

This neat arrangement is usually sad for poor people, because the company's monopoly allows it to charge super high prices as a payoff for its research and development work. Part of UAEM's mission it to try to get universities to put more pressure on the pharma companies to relax their patent enforcement, especially in developing countries.

We had some success during my last year in school, as Columbia decided it would start trying a policy called mandatory sublicensing. The basic idea was this: if a government or ngo or someone complained that a company was not making a drug available at a reasonable price in their country, the university would reserve the right to issue another license to a producer who would only produce and sell for "humanitarian" uses.

This confused me at the time, as I had never heard of a pharmaceutical producer that wasn't a profit-making company, and wasn't sure who these humanitarian entities would be. At some point last year I was talking with another friend from UAEM, who realized that UAEM did a lot of clamoring for allowing more companies and producers to make and sell drugs in developing countries, but we didn't really have a clear idea of who these producers would be.

Which brings me to my point: When I was at Prayas, I was in touch via email with a man named Chinu, who helped me with the medicine pricing FAQ I was writing. He had written a book called "A Layperson's Guide to Medicines", which helped consumers understand issues like quality control, medicine pricing, branded vs. generic, research policies, etc. He ran an organization called Locost, which in addition to making helpful resources and engaging in pharmaceutical policy advocacy, actually produces essential medicines and sells them with little mark-up to NGOs working with the urban and rural poor in India. Eureka! This was just the type of producer referred to in the Columbia policy.

What was particularly cool was that at both Vivekananda Girijana Kelyana Kendra and Chinmaya Organization for Rural Development, the hospitals and OPD clinics stocked Locost drugs.

(OPD Clinic at CORD with Locost drugs)

Thus I encountered the organization at all three NGOs I visited, and thought that this kind of impact deserved its own post. Here is their website for anyone whose interested:

http://www.locostindia.com/

Kokilaben Dhirubhai Ambani Hospital

[May 17th, 2010]

After leaving VGKK, I went to Mumbai for a few days to stay with relatives. One of my relatives is a dietician at a very famous and high-tech Mumbai hospital called "Kokilaben Dhirubhai Ambani Hospital." This is what Indian's refer to as a "corporate" hospital, and is actually owned by Reliance Industries, a huge cell-phone and communications and pretty much everything else conglomerate.

http://www.kdah.in/index.html

My relative was nice enough to use her sway to arrange a tour for me. My tour guide usually gives tours to donors and famous people, so it was surprising he consented to giving a tour to lil' ol' me. However, it also meant that I had to be very polite and tactful in the questions I asked, so I probably didn't get all the information people might want.

For people moving from place to place, India is full of many of its own internal culture shocks. After a few lengthy trips in the country, I had pretty much gotten used to the drastic differences in wealth/culture/lifestyle from region to region, but my culture shock from VGKK Tribal Hospital to Kokilaben was unavoidable. The lobby was enormous with plush chairs, TV screens, air condition, information help desk, check-in counter, gift shop, etc. There were separate check-in counters for patients with insurance and those that paid out-of-pocket, and both counters had enormous computer screen registrations. The demographics of the patient population was wealthy, with many foreigners coming for medical tourism (I actually feel like this is the best term to describe my trip. Alas, its already taken, so I'll have to settle for "public health tourism").

I wasn't allowed to take pictures and unfortunately did not take notes, so the following details might be slightly off. From what I remember, the hospital had roughly 750 inpatient beds, and saw a large number of out-patients in various clinics. I was first brought to their emergency room, where they had about six beds and one room devoted to emergency trauma operations. Emergency patients were only brought in by the hospital's ambulances. They were not dispatched through emergency called to government lines, but only if the hospital's own emergency line was called. There was apparently constant communication between the ambulance crew and the emergency room staff while the patient was in transit. There were no patients in any of the beds while I was there, but I think one was on his way.

I then got tours of a bunch of radiology devices, such as MRIs, CAT scans, etc. They have cute additions like painting the ceiling with pretty murals so patients feel relaxed. I also got a tour of their massive radiation oncology machines, of which they have two. From the high-tech perspective, they seemed probably better equipped than a lot of American hospitals. As far as recruitment power, I think they basically tapped people from other famous hospitals in India, and many of them came, so their physicians were probably pretty excellent at their jobs. I briefly met a famous infectious disease doctor who does a lot of travel medicine work. It was funny to imagine Indians consulting travel medicine physicians, as most Americans make travel med appointments before coming to India.

The most interesting part of the whole tour had to do with room categories. It is obvious that there are going to be issues of access in expensive corporate hospitals in which patients need to either have a lot of money. But what was really interesting was that patients paid different rates for their rooms, creating an internal division of patient class. There were shared rooms, single patient rooms, deluxe rooms, super-deluxe rooms, and luxury suites. Patients in these different classes also paid different rates for some of the services, although the tour guide said all medicine prices were the same, because there was some law against elevating prices past the Maximum Retail Price. The shared rooms were already in much better shape than any of the previous hospitals or clinics I'd been in, but the luxury suite was insane. It had an ultra-comfortable patient bed and room on the top floor with a window view, as well as a personal waiting room for visitors, which had its own couches, TV, fridge, and other amenities. I asked as politely as I could about differences in quality of care for these classes, and the tour guide assured me that everyone received the same care, with differences only in comfort. But it was pretty clear that the luxury patients (who were often famous people) received much more attention from nurses and staff than patients in lower categories, and constant attention itself likely leads to different quality outcomes.

The government District Hospital in Chittorgarh, Rajasthan (see previous post) was also in the midst of constructing a luxury ward of a few beds. This ward had air-conditioning, as well as amenities like storage closets and nice bathrooms. Dr. Narendra at Prayas was against this in principle, likely for the same concerns about quality of care discrepancies. The number of different classes at Kokilaben took this to a whole new level. It kind of made me finally realize that the "corporate hospital" label is really not synonymous with US "private hospitals".

Nonetheless, it was heartening to see patients receiving high quality care in India. In a sense, it is nice that some Indians have enough money to keep such hospitals running, keeping health professionals in the country and decreasing the brain drain. Then at least doctor availability becomes a national distribution problem rather than a international one. Also, larger public health perspective and moral principles aside, if my family member was in an emergency and I had the money, I would bring them to Kokilaben.

Late Posts

I haven't written a substantial post for about a month, but I've seen a lot since then. I'm going to break stuff up topic-wise in different posts, adding the date of when they should have been written.