The journey of life-saving drugs

The World

As George Bush prepares to leave office an exceedingly unpopular president, he can point to at least one program that’s received widespread praise. That’s his effort to tackle AIDS in the developing world.

The President’s Emergency Plan for AIDS Relief – or PEPFAR – began as a five-year, $15 billion program. Congress recently re-authorized the program for an additional five years and $48 billion. On this World AIDS Day, the President addressed a forum at Washington’s Newseum. He spoke of how his program has brought hope to Africa.

More than two million people in Africa are now receiving life-saving AIDS drugs thanks to PEPFAR, according to the latest White House statistics. Coming up, we’ll talk about the politics and future of PEPFAR. But first, we’re going to take an extended look at the Herculean task America has taken on.

The World’s David Baron has the story of what it takes to deliver AIDS medicine to just one patient in rural Africa.

View a map of the AIDS drug shipment to Grabo, Ivory Coast from Goa, India

Photos by David Baron (except where noted).

Baron: We’ll call her Grace. She lives in West Africa, in Ivory Coast, in a small town in a bamboo jungle. She fell ill last year.

Grace: “I was very, very weak. And I couldn’t eat. I was always in bed.”

Baron: A blood test confirmed she had AIDS. The problem was, living in the town of Grabo, miles from the nearest paved road, how would she get to the drugs that could save her life? Well, earlier this year, the drugs starting coming to her. She gets her prescriptions filled at her town’s tiny health center.

“Grace” holds her anti-retroviral drugs at the health clinic in Grabo. Her face has been hidden and her real name disguised at her request.”Grace” holds her anti-retroviral drugs at the health clinic in Grabo. Her face has been hidden and her real name disguised at her request.

She takes two kinds of pills. One once a day. One twice. And they’re working. She says she’s gained back her weight. She feels stronger. She looks healthy.

Grace’s story is common in Africa today. Yet just a few years ago, many experts thought it would be all but impossible to put patients in such remote places on treatment. Drug delivery systems in Africa are notoriously dysfunctional. Supplies run out. Medicines expire. Many of the drugs that reach patients are counterfeit – worthless.

So the Bush Administration decided that its AIDS treatment program would have to do more than merely buy drugs for the world’s poor. It would have to revamp the systems for delivering drugs. I wanted to see how those systems are working. So I thought, why don’t I take the journey that Grace’s pills took?

Baron: “Do you know where these drugs came from?
Grace: “No.”
Baron: “This says it was made in India.”
Grace: “Yes. I can see that.”

Anti-retroviral drugs manufactured at Cipla’s factory in Goa, India: Photo by Zubair AhmedAnti-retroviral drugs manufactured at Cipla’s factory in Goa, India: Photo by Zubair Ahmed

Baron: Grace’s drugs began their life here: at a factory in the Indian state of Goa. A machine spits out tablets at a rate of two million a day. These are generic AIDS drugs, produced by the manufacturer Cipla. Factory manager Tapas Datta says the advent of generics is what’s enabled the world’s poor to be treated for AIDS.

Tapas Datta: “It brought down the cost of the medications from $15,000 a year to under a dollar a day.”

Baron: This factory is a major supplier to the African market. And the drugs are prepared for a long journey. The packages are sealed against moisture and tampering.

Grace’s pills left this factory for a warehouse in Mumbai and ended up on a South African Airways plane. The drugs flew 4300 miles to Johannesburg, then another 3000 miles to the West African nation of Ghana. AIDS medicines arrive regularly at the airport here. Workers then load the medicine by forklift into the back of a cargo van.

A shipment of AIDS drugs arrives at the airport in Accra, GhanaA shipment of AIDS drugs arrives at the airport in Accra, Ghana

Ghana has become a hub for AIDS drug distribution in West Africa. PEPFAR, the U.S. government program, has hired a consortium to manage this part of the supply chain. The companies include UPS, Northrop Grumman, and a health consulting firm called John Snow, Incorporated. Their goal: to make the drug delivery system here as reliable as it is, say, in California or New Jersey. As the drugs leave the airport, a security vehicle follows close behind.

Christopher Kumawu, Security Guard: “Roger, out of airport. Escort to Tema. Over.”

Baron: These AIDS drugs can fetch a high price if stolen in Africa and then sold in Europe. Craig Usswald manages the logistics for PEPFAR’s Supply Chain Management System. He says his workers have to guard against organized crime.

Usswald: “The syndication people are obviously the ones you have to worry about the most because they’re normally very sophisticated. So this is why we take such precautions.”

Baron: And his team has to guard against another threat: the tropical heat. When the drugs from the airport arrive at PEPFAR’s warehouse in Ghana, they’re met promptly by manager Vera Amon.

Amon: “Because these are temperature-sensitive medicines, we don’t want them to stay outside at the external temperature for that long. Within a matter of ten minutes, we ensure that they all go into the warehouse.”

Workers inside PEPFAR’s regional distribution center, GhanaWorkers inside PEPFAR’s regional distribution center, Ghana

Baron: The warehouse is air-conditioned. Workers neatly stack the boxes on metal racks. They track the inventory on computer. This is where Grace’s drugs sat last year, for a month, until an order came from the government of Ivory Coast. Then her pills and others were escorted back to the airport and flown 260 miles to the west, to Abidjan – the commercial capital of Ivory Coast.

The skyline of AbidjanThe skyline of Abidjan

Abidjan is a crumbling city in a country recovering from civil war. Here the AIDS drug supply chain begins to kink. The medicine gets handed off to the Ivorian government at its sprawling central drug warehouse. One of the warehouse managers, Emma Fokouo, assures me the drugs are kept secure. She shows me the AIDS drugs, known as ARV’s. They’re stored behind locked grates.

Fokouo: “We don’t want unauthorized people to get access to the ARV’s. Generally ARV’s are sealed like this.”

Baron: But that’s not the full reality. I discover another part of the warehouse where hundreds more boxes of ARV’s sit out in the open where any worker can access them. Government officials don’t want me to record here, or take photos. For obvious reasons.

The boxes are piled haphazardly – on their sides, upside down. The cardboard is ripped and crushed. Some of the boxes are open, their contents missing. Government officials assure me this is just a receiving area, where the drugs are kept briefly before being stored more properly in the back. But then I see the shipping labels. Some of the boxes arrived at the warehouse six months earlier. They’ve been sitting here in the heat and humidity for so long, the cardboard is damp.

The loading dock at Ivory Coast’s central drug warehouse, AbidjanThe loading dock at Ivory Coast’s central drug warehouse, Abidjan

And problems continue when the drugs leave the warehouse. They get loaded onto government-owned delivery trucks that make monthly rounds to regional health centers. Carine Kodo oversees the drugs’ distribution. She says the regional health centers do a poor job forecasting their needs, so she often doesn’t know how many boxes of ARV’s, and of what kind, to send out.

And when the drugs arrive at those regional centers — for instance, the county hospital in the coastal city of Tabou — there are more complaints.

Pharmacist Kouadjo Kan at Tabou’s county hospitalPharmacist Kouadjo Kan at Tabou’s county hospital

Pharmacist Kouadjo Kan says by the time the drugs reach him, they’re nearing their expiration dates.

Ivory Coast’s drug delivery system needs a lot of work. Jyoti Schlesinger – until recently the head of PEPFAR in Ivory Coast – says the United States is helping to upgrade the system, but the going is slow.

Schlesinger: “Nobody said this was going to be easy. Nobody said this was going to be perfect. It is certainly not.”
Baron: �But why not come in and just deliver the drugs? Hire Federal Express, hire DHL, and send the drugs wherever they need to go?”
Schlesinger: “It’s not a good public health approach or development approach. It is better to suffer through the difficulties and the frustrations to build something that can last versus coming in and putting something that’s going to fall apart the second you leave.”

Baron: And Ivory Coast is making progress. Around 50,000 AIDS patients are now receiving treatment here. Grace’s drugs came through the health center in Tabou. Pharmacist Kouadjo Kan then sent them on a further journey.

Kouadjo Kan: “Voila. C’est notre pickup.”

The road from Tabou to GraboThe road from Tabou to Grabo

Baron: The drugs he distributes go into a Mitsubishi pickup that has so many dents and missing parts, it’s hard to believe it runs. From here it’s 40 miles through the forest to reach Grabo. The road is rutted dirt that turns to mire in the rain. The driver is a man named Vanie Bi Nahoune.

Vanie Bi Nahoune: “It is very, very difficult to reach Grabo because the road is full of mud, and I’m always late because of the conditions of the roads, and also the condition of my car.”

Driver Vanie Bi NahouneDriver Vanie Bi Nahoune

Baron: The late deliveries frighten Grace – the AIDS patient who waits in Grabo to fill her monthly prescription. She sometimes runs out of pills, and she’s afraid she’ll fall ill again. That’s a reasonable fear, especially if the road washes out for an extended period.

This concern highlights the profound challenge the United States has taken on. It’s not enough to deliver AIDS drugs reliably most of the time. To keep patients alive, the drugs must be delivered every time, for years – even decades. So I asked the head of PEPFAR, Mark Dybul, can he assure Grace that the drugs she needs will reach her, without fail, for the rest of her life?

Dybul: “I’d tell her yes, and this is why we will over time have systems to get around the washed out roads, including air drops and other approaches that have been used in other locations. So, yes, she will have a permanent supply. For now, she’s alive, and that’s what we need to keep maintaining.”

Baron: As for Grace, the supply chain for her drugs doesn’t end at the local health center. There’s one more leg in their journey: her half-mile walk home. She points to her house – mud-brick, red roof, on a hill. But she won’t take me there. You see, she lied to her family about why she went to the health clinic.

Grace: “One of my brothers had the same disease, and when the family discovered it, they gave him up. If they discover that I myself am like this, they’ll abandon me.”

Baron: So after traveling 8,000 miles, Grace’s drugs will end up in a locked drawer – hidden – and no one will know that medicine provided by U.S. taxpayers saved her life.

For The World, I’m David Baron, Grabo, Ivory Coast.

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