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Alka Kudesia needs an expensive drug to treat her breast cancer, but refuses to tell her children for fear they will take loans to buy the medicine and spend the rest of their lives in debt.

“We’re barely able to afford the treatment I’m already getting," Kudesia, 48, says with quiet defiance. “My kids are just starting out in life. There is no way I’m going to be a burden to them."

The drug, Herceptin, is one of the most effective treatments for an aggressive form of breast cancer. But in India, at a cost of at least $18,000 (around 11 lakh) for one course of treatment, only a small fraction of the women who need it get it.

The Union government last year threatened to allow production of less costly, generic versions of Herceptin. Its maker, Roche Holding AG of Switzerland, initially resisted, but surrendered its patent rights this year in large measure because it concluded that it would lose a legal contest in Indian courts.

The skirmishing over Herceptin and other cancer medicines is part of a new and critical phase in a long-running struggle to make drugs affordable to the world’s poorest people, one that began in earnest more than a decade ago when advocates campaigned successfully to make AIDS medicines accessible to millions of Africans.

“Cancer is the next HIV/AIDS issue, and the fight has only begun," says Shamnad Basheer, a professor of law at The West Bengal National University of Juridical Sciences in Kolkata.

US trade officials have voiced concerns about India’s treatment of drug patents, including its reasons for sometimes overriding them. US President Barack Obama discussed the issue earlier this year with Prime Minister Manmohan Singh during a meeting in the Oval Office, administration officials said.

Executives in the international pharmaceutical industry, increasingly dependent on drug sales in emerging markets like India, China and Brazil, contend that India’s efforts to cancel patents threaten the global system for discovering cures while doing little to resolve the health challenges most patients here face.

“We are open to discussing what the best way is to bring innovative medicines to patients," says Daniel Grotzky, a spokesman for Roche, which has a large portfolio of cancer medicines. “But a society that wants to develop new medicines and technology must reward innovation through a solid protection of intellectual property."

But health advocates say similar arguments were made by the US government and the pharmaceutical industry as they sought to protect patents on AIDS medicines through much of the 1990s, a stance that former president Bill Clinton has since said he regrets. It would be unfair to delay improving access to cancer drugs until India’s broken system for cancer care is fixed, they say. They note that more than twice as many people in India die of cancer than of AIDS.

The rise in the cancer caseload is already a heavy burden on India’s hobbled health system. Indian women, while less likely to get breast cancer than those in the US, are far more likely to die of it. About 115,000 women here are diagnosed with breast cancer every year and in 2008, some 54,000 died from it, according to the World Health Organization (WHO).

India, one of the world’s leading producers of generic pharmaceuticals, has long viewed patent rights on medicines sceptically. It has already ruled invalid patents protecting exclusive sales of Novartis’ Gleevec, Pfizer’s Sutent and Roche’s Tarceva, all cancer medicines. In a landmark decision in 2012, the government agreed that the patent protecting Bayer’s Nexavar, also a cancer drug, was valid but overrode it anyway because a generic company promised to lower the price from $4,500 to about $140 per month of treatment.

An Indian government committee is soon expected to announce the start of a formal process to set aside patents on 15 more medicines, according to a committee member who agreed to speak about secret deliberations only if granted anonymity.

For drug companies, the most worrisome aspect of India’s efforts to lower drug prices is that other countries are beginning to follow its lead. Both Indonesia and the Philippines recently adopted patent laws modelled on India’s, and legislators in Brazil and Colombia have proposed following suit.

“One of the concerns of the industry is not just what India is doing in India, but we realize that the whole world is watching India," says Amy Hariani of the US-India Business Council, which is affiliated to the US Chamber of Commerce and is fighting India’s patent policies.

For the Obama administration, the fight over drug patents in the developing world is a minefield. The drug industry was a major contributor to Obama’s campaign and an early and crucial backer of his healthcare programme. But Obama’s advisers hope to avoid the mistakes of the Clinton administration, which was harshly criticized by AIDS activists for its initial stand against providing generic antiretroviral drugs to Africa.

Meanwhile Kudesia, afraid to tell her children about Herceptin because of its cost, is already having trouble affording her cocktail of less expensive generic medicines. “I want to spend the rest of the time I have left resolving our debts, not making them worse," she says. “I cannot tell my children there is another drug that will help me."

©2013/The New York Times

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