In his weekly ‘offline’ musings on global health Richard Horton huffed recently that he’d had an awkward conversation with Head of the Global Fund for Alcohol, TB and Malaria Peter Sands at the World Health Assembly in Geneva. I also bumped (literally) into Sands at a drinks reception at the same event. We shop at the same supermarket (Aldi) so he was totally fine about the spillage, which was good of him – bottled beer can stain so.

I was about to say something flattering, something like:

“Sands is rather more interesting than his employment history suggests. For several years he has built a reputation as a thoughtful advocate for greater attention to the economic costs of infectious diseases”

when he noticed someone moving behind me, hissed “oh no, Horton’s coming, quick look busy!” and slipped away. I’m joking of course (I shop at Waitrose); Sands and I never meet, never talk. But relations have been a little frosty between him and Horton since The Lancet (finally) published an editorial on the Fund’s partnership with Heineken (now suspended), suggesting that Sands take “a remedial course on global health diplomacy” (ouch!).

But the whole partnership thing has got me thinking that I really should write something about them. They’re in the news – this partnership between the Fund and Heineken, for example. Then there’s WHO’s DG Dr Tedros getting all keen on the idea, mentioning the word ‘partners’ forty-three times in WHO’s 13th General Program of Work, and green-lighting to the private sector that WHO is very much open for business (remember, “FENSA… is not  a fence”). And now Horton’s having real issues with the pharmaceutical industry – AstraZeneca in particular for hosting a breakfast symposium at the WHA on NCDs:

“The World Health Assembly is under attack. It is under attack by a private sector that seeks to exploit the growing calls for more partnerships in global health. In particular, the pharmaceutical industry is slowly colonising global health in the same way that it has colonised clinical medicine”.

So, what to say about global health partnerships that hasn’t been said before? Well, partnership per se is no bad thing. We have lots of words to describe our relations with our fellow homo sapiens, partner being a common one – in love as well as business. Having a partner can be a wonderful thing – life affirming and/or just sound economic sense. The trick is not to partner with a psycho. All manner of shit can hit the fan if you do that. The problem is, and this seems to get forgotten in discussion of the multinational pharmaceutical industry, is that corporations are psychopaths and you partner with them at your peril.

In the eyes of the law, corporations have the legal rights and protections of a person, albeit persons with no sense of morality and limited liability. Thus, they don’t care if their products are too expensive for the people who need them; they will obstruct aggressively any efforts to regulate their behaviour or interfere with the pricing of their products to make them more affordable; and because they exist solely as a mechanism for enriching a small number of shareholders – all products (pharmaceuticals, for example) mirror that primary function. Innovation is driven by profit not need, and if a need is required in order to sell a potentially profitable (but socially useless) product, then it is manufactured. Are alarm bells beginning to ring yet?

And boy can they take advantage of their limited liability. Normally, in the world of real people, if you do something bad you pay a price (a fine or a prison term) and endure the opprobrium of society. It’s difficult, for example, to get a job if you have a criminal record. This is not the case if you’re a pharmaceutical (or any) corporation. It really doesn’t matter what you do, or how many times you do it, or how many times your peers do it, or to whom, in whatever devious, cunning, blatant, or disgusting way. It doesn’t matter because a) you don’t care (you’re a psychopath remember so it’s somebody else’s fault); b) you won’t go to prison (and thus remain free); c) you’re immensely wealthy (fines are insignificant and re-interpreted as operational costs passed on to consumers); social opprobrium is ‘patchy’ to say the least, and you’re pretty much  guaranteed continued employment (those libraries of potentially useful drugs sure are enticing).

It doesn’t matter a whole lot which pharmaceutical corporation you choose, but let’s pick a big one like GlaxoSmithKline (GSK). This corporation has form as long as your arm – Wikipedia has a whole section on GSK’s criminal and civil settlements. To summarise:

In 2010, GSK was fined a total of $750 million for production of improperly made and adulterated drugs (including antiemetic, antidepressant, and diabetes drugs). The intriguing detail here is that GSK sent its own expert to investigate but then sacked her when she wrote a report recommending a product recall – leading to her blowing the whistle on the malpractice.

In 2012, GSK was fined $3 billion for actions which included unapproved use over a number of years of its anti-depressant drugs Paxil and Wellbutrin between; unapproved use of inhalers Advair, Flovent, Zofran, Imitrex, Lotronex and Valtrex;  failing to report safety data in relation to its diabetes drug Avandia, and offering kickbacks to doctors to prescribe its own drugs.

Also in 2012, GSK was fined £150,000 by a court in Argentina for unethical trials of its pneumonia vaccine Synflorix.

In 2013, China fined GSK $490 million for a trail of kickbacks dating back to 2007 to managers, hospitals, and doctors who prescribed the corporation’s drugs. Mark Reilly, the then head of GSK’s Chinese operations was given a three-year suspended prison sentence and deported.

In 2016, GSK was fined £37.6 million for paying generics drug manufacturers $50 million between 2001 and 2004 to keep generic versions of its anti-depressant drug Seroxat off the market.

A 2016 report by Public Citizen calculated that between 1991 and 2015, “a total of 373 settlements were reached between the federal and state governments and pharmaceutical manufacturers, for a total of $35.7 billion”.  Ed Silverman of Pharmalot points out that there has been a noticeable drop in the amount of fines being issued – $2.8 billion (2014-15) compared to $9.9 billion for the previous biennium, and a similar amount $2.9 billion for 2016-17. Maybe that’s an improvement, but surely it’s damning with feint praise to say that an industry’s behaviour is slightly less criminal than it used to be?

Apart from the fact that people get killed by some of the illegal activities of pharmaceutical corporations, or that children’s rights are abused and violated in hospitals where they are meant to be receiving life-saving treatment, or that thousands of people globally are knowingly being prescribed the wrong drugs, or drugs when they don’t need any, by doctors in the pocket of the industry, why shouldn’t the WHO partner with pharmaceutical corporations?

This question reminds me of that Steve Coogan sketch, the one where the security guard defends the safety record of the swimming pool on his watch (“in 1980 someone died”). The point of the sketch is the absurdity of the fact that his character remains in post as a security guard. This responsibility is amplified to the nth degree in the case of an industry that displays chronic psychotic behaviour in the production of pharmaceuticals upon which we depend for our good health.

WHO should think very carefully about partnering with GSK, and then stop partnering with it. According to the latest tally, WHO received $7.366 million from GSK in voluntary contributions in 2017. If GSK were an actual person, the WHO wouldn’t touch it with a barge pole. Indeed, it would be incumbent on the Organisation to remind member states whenever possible that the corporation has been found guilty of criminal behaviour multiple times. I would then like WHO to vet all the records of all the other pharmaceutical corporations from which it receives financial support. If they’ve been found guilty in court of a criminal act, then they should be kicked out never to return. This is what I would do on a personal level as a minimum standard of due diligence in any partnership in which I was involved, either in love or business. I’m sick to death of engaging in tortuous discussions with people about the pros and cons of global health partnerships when the obvious is staring us in the face: don’t partner with psychos!

Andrew