Amira Essam is a doctor, the head of Ramla village unit in the Delta city of Banha, and the campaign officer of “100 Million Healthy Lives” in Ramla. She did not initially have faith in the initiative, through which the state threatened to withhold issuance of documents for citizens who did not get tested for hepatitis C. But after working on the campaign, she changed her mind. Now, she cannot hide how impressed she is with “100 Million Healthy Lives.” The largest medical campaign she had previously attended had lasted 10 days and targeted only a street or two.
“This campaign, however, has lasted two months,” she says, a portion of the way through the first stage of “100 Million Healthy Lives.” “Can you imagine? Exceptional circumstances, a state of emergency, and work from 9 am to 9 pm every day for two months, without days off. We even had to work on Fridays.”
With the World Bank providing US$300 million for testing and another $189 million for treatment, the campaign kicked off in October of 2018 as part of the Egyptian government’s efforts to combat hepatitis C, an effort that started in 2014. The third and initially planned final stage of the campaign ended in April. The Ministry of Health estimates that 50 million citizens were tested during the campaign. And the ministry announced that the campaign would be extended until the end of 2019, so as to give a chance for everyone who missed the window for testing in the past few months.
Throughout her work in the campaign, Essam met a number of citizens who were skeptical about going through testing and treatment because they had no confidence in the government sector. There are historical reasons for this public sentiment: In an attempt to combat the bilharzia epidemic from the 1960s to the 1980s, Egyptian health officials used reusable glass needles, inadvertently spreading hepatitis C nationwide.
After hepatitis C came to the fore and the extent of the epidemic in Egypt was recognized, many promises were made to citizens. In 2006, an Egyptian research team announced it found the cure for hepatitis C in a specific type of single-celled algae, promising to register it and put it on the market soon after. In 2014, the Armed Forces announced the new “kofta machine” — a magical device that would cure both hepatitis C and HIV/AIDS by “sucking the AIDS out of patients and turning it into kofta that patients can subsequently eat” — claiming that it would be ready to function in four years. All of those promises fell through.
But the situation has changed over the last few years, and Egypt became the site of a recipe for success for the Global South. Scientific research led to the design of an effective medication to treat hepatitis and where this medication would typically not be available in countries like Egypt, there was international pressure on the pharmaceutical industry to provide low-cost alternatives. In 2014, the World Bank successfully negotiated with drug companies to make treatment available at reduced prices, and there was enough political will and already existing infrastructure in Egypt to take advantage of the new opportunity. To focus in on Egypt’s journey from the spread of hepatitis C to the beginning of its decline tells a story of a changing power dynamics around global pharmaceuticals and how lower-income countries can benefit.
According to the World Health Organization, hepatitis C is a liver disease caused by the hepatitis C virus (HCV), the existence of which was confirmed in the late 1980s. The incubation period for hepatitis C ranges from two weeks to six months. After the incubation period, only about 20 percent of those who have contracted the virus will exhibit symptoms, such as fever, nausea, vomiting, jaundice, dark urine and gray-colored feces. The other 80 percent will not exhibit any severe symptoms, often for decades, until the body starts to visibly deteriorate, making hepatitis C difficult to diagnose.
Scientific research has located the origin of the spread of hepatitis C in Egypt to the period between the 1960s and 1980s, when Egyptians were facing another serious epidemic: bilharzia. The government organized national campaigns to vaccinate and treat people for the disease caused by parasitic worms. Studies show that around 6 million Egyptian citizens received medical injections during those campaigns. However, disposable needles were not yet in universal use, and the vaccines were administered with sterilized, reusable glass needles, resulting in mass hepatitis C transmission. A 2017 World Bank report established the connection between the hepatitis C outbreak and the bilharzia vaccination campaign. According to the report, the rate of infection among 50-59 year olds (the generation who were injected during the bilharzia campaigns) is 20 percent, compared with less than 1 percent among children and adolescents.
No4C, a blog that was set up to raise awareness about hepatitis C, prevention methods and treatment, points out that the first sign of the epidemic emerged in 1992, when a research group conducted a study on 2,000 blood donors and discovered that 10 percent of the donors were infected. “This number was shocking. Most reports from around the world presented an infection rate of 2-3 percent, which meant that we were dealing with an outbreak of hepatitis C in Egypt,” the blog asserts. Two years after that, the research team conducted another study in a village in the Nile Delta. It was discovered that 18 percent of the village inhabitants were infected with the virus. And, in 1996, the Ministry of Health estimated that 15 to 20 percent of Egyptians had hepatitis C.
The government started to pay attention to the danger that outdated medical practices posed, and, in 1994, Parliament passed legislation requiring that all blood donations be screened for HCV antibodies.
In March 2003, Egypt’s health minister announced the launch of a national program aimed at reducing the rate of viral infections in Egypt, with a specific focus on hepatitis C. The ministry also published the National Handbook for Infection Control (the latest copy of which was published in 2016).
The first serious attempt to deal with the epidemic was in 2006, when the government decided to establish a national committee for fighting viral hepatitis. The committee included a group of university professors and experts who laid out a strategy to combat the disease, focusing on medical malpractice. The committee also established 23 low-cost treatment facilities across the country.
According to a report by the US Center for Disease Control and Prevention, the rate of viral transmission during dialysis sessions dropped from 28 percent to 6 percent after an infection control program was implemented at health ministry facilities in 2001. In 2008, the National Handbook for Infection Control was revised to comply with international standards.
But this was still not enough. In 2008, 15 percent of citizens aged 15 to 59 had HCV antibodies in their blood. In 2016, governmental statistics cited in a World Bank report show that 4.5-5 million citizens had active hepatitis C infections, and 150,000 of them had contracted the disease in 2016.
In 2014, the Egyptian media reported that the Armed Forces discovered a cure for both hepatitis C and HIV/AIDS, later dubbed as the “kofta machine.”
“The military made the first scientific discovery of a mechanism to detect and cure both hepatitis C and HIV/AIDS. The mechanism does not require us to take a blood sample from the patient. Results are fast, and it all costs very little,” the military spokesperson announced on TV, adding that the Armed Forces Engineering Authority had filed a patent for the discovery.
The statements that were made during the official announcement lacked the seriousness expected from scientists who are about to change the course of medical research. Ibrahim Abdel Aaty, the inventor of the curing device, stated that the secret of his invention is as complicated as the secret of how the pyramids were built. He also stated that a foreign intelligence body had kidnapped him and offered to pay him $2 billion in exchange for the device. For his part, Taher Abdallah, the chief of the Armed Forces Engineering Authority, said that the device would not be exported in order to protect it from “the pharmaceutical mafia and the monopoly of the global pharmaceutical market.”
The whole issue turned into a joke, however. The TV report showed Abdel Aaty telling a patient, “Your tests are looking great. You had AIDS, and now it’s gone.” In a roundtable held by Mada Masr to discuss the “invention” at the time, a participating doctor recounted his visit to the Egy Medical exhibition (an exhibition held in Cairo to showcase medical equipment and devices), which the Armed Forces took part in to present its new invention. “It was being tested by two guys. One of them held a plastic box that supposedly contained an HCV sample. He was moving it in front of the device, which was held by the other guy. The device’s antennas were pointing toward the sample,” the doctor said.
“This was happening in front of an audience. I asked them if I could use the device myself, but they refused. So I asked them if they could do the experiment again while having the guy holding the device close his eyes. The antennas did not move this time, even though the other guy kept moving the sample in front of the device. Then, the antennas pointed to the left, when the sample was to the right. When the guy opened his eyes again, he said that he’d only been trained to use it for two weeks, and that the device would only work if your eyes were open,” the doctor recounted.
Other than the one patient who was told by Abdel Aaty that he no longer had HIV/AIDS, Abdel Aaty claimed to have treated at least 200 patients, and he vowed to “go to court in order to prove that the device works.”
In 2016, the Doctors Syndicate referred the team of doctors who were responsible for the device to the syndicate’s disciplinary committee. They were accused of “advertising and promoting a device that has harmed millions of Egyptians who hoped to be cured.” Later, the Armed Forces denied its affiliation with Abdel Aaty’s invention.
But, joking aside, 2014 also witnessed the beginning of a serious attempt to deal with the epidemic, which was primarily aimed at counting the number of people exposed to and infected with HCV and making medication accessible.
Magda Saber, a 61-year-old woman who lives in Alexandria, contracted hepatitis C in 2006, and was diagnosed in 2008. Until this time, she had relied on a combination of interferon and ribavirin as treatment. The course of treatment involved required weekly injections for a year. “It was very exhausting,” her daughter, Dina, tells Mada Masr. The injections were not always available, and storing them was difficult, but missing an injection was not an option. “We were responsible for all expenses. One injection cost LE1,400. And then there was the ribavirin and comprehensive tests every three weeks,” Dina explains.
Saber’s doctor helped her continue her treatment with state funding to cover the interferon. She bore the cost of the ribavirin and medical tests and also had to sign a document stating that she was aware of the 60 percent success rate of the treatment course and that the hospital was not responsible for any negative results.
Saber suffered from major side effects due to the treatment. “Every week, the injection would cause new side effects,” says Dina. In the beginning, Saber’s test results showed significant progress, and she ended her treatment after the end of the first year. But six months after the treatment ended, the test results showed that she was still carrying the virus.
However, in 2013, Gilead Sciences, a US biotechnology company, acquired a license to sell a new drug to treat HCV. Sold under the brand name Sovaldi, the medication had a cure rate of 97 percent. Saber asked her doctor about the new drug, but he advised her to wait.
The price of the new drug was a major problem. A 12-week treatment course cost US$84,000. “It was unimaginably expensive,” says Alaa Awad, a professor in hepatology at the Theodor Bilharz Research Institute.
Awad explains that there were many attempts to negotiate with the multinational pharmaceutical companies that produced the drug. It was imperative that the medicine became accessible to people in poorer countries who could not possibly afford the original price. But the negotiations ultimately did not amount to much.
Gilead Sciences had an earlier experience in India that forced it to change its policies. In 2005, India took advantage of the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights and passed legislation that redefined the parameters of “innovation” in patent claims and intellectual property rights. The new legislation allowed local pharmaceutical companies to produce HIV/AIDS antiretroviral drugs — first developed by Gilead — at 80 percent below global market prices.
“The company learned the lesson from its experience with the HIV/AIDS treatment,” Awad states. In February of 2014, three of the biggest manufacturers of hepatitis C drugs — including Gilead — agreed on a new policy regarding access to medication. The policy involved dividing the world into three segments according to per capita income, as outlined by the World Bank.
Adopting the new policy, Gilead offered to sell Sovaldi to low-income countries at price up to 99 percent less than the drug’s original price in the US. Egypt took advantage of this new policy, and, in March 2014, the US company announced its new agreement with the Egyptian government to sell Sovaldi at $900 for a full 12-week treatment course. This marked a new chapter in Egypt’s plan to eradicate hepatitis C.
Awad explains that the agreement with Gilead provided enough medication to treat 50,000 patients, which was obviously not enough for the 1.2 million Egyptian citizens who had applied for treatment after the campaign began.
During the negotiations, Gilead requested a patent for its product in order to prevent local manufacturers from producing their own alternatives to the brand. But according to Wahid Doss, the head of the National Committee for the Control of Viral Hepatitis, the Egyptian government refused Gilead’s request in 2014.
Following this development, local manufacturers raced to work on producing a version of the drug. That was in 2016, a moment that Doss describes as the “big break.” And, because the companies had a theoretical estimate of the market size, which was more than the actual number of people who knew they were affected with hepatitis C, prices plummeted. Each company raced to lower the price of its own product, a situation that was “utterly unprecedented in the history of Egypt’s pharmaceutical manufacturing,” as Doss puts it, especially at a time when many pharmaceutical companies were accused of monopolistic practices. The price of the Egyptian generic version of Sovaldi dropped from LE2,670 to LE500, making the cost of the treatment course come in at LE1,500, according to Awad.
After an arduous treatment journey, Saber’s doctor prescribed her one of these Egyptian generic versions to Sovaldi in 2017. She went on a six-month treatment course, which cost LE3,000. The new drug caused far fewer side effects for Saber than the interferon injections. But, most importantly, the drug treated the disease. All of Saber’s tests in the past two years have come back negative.
According to a World Bank report, Egypt’s campaign against hepatitis C tallied a number of successes. Making medication available and accessible was a major step toward the overall goal of eradicating hepatitis C in Egypt, which officials have announced a plan to achieve by 2021. But medication was not the only issue — treatment requires a diagnosis. The World Bank estimates that 5 million people had active hepatitis C infections in Egypt in 2016, and only 1 million of them were aware that they had contracted the virus. The biggest challenge, then, was to determine the number of affected people who are not aware that they carry the virus, identify their geographical distribution and minimize the risks of infecting new people.
The next step for the government was to diagnose people who had not been formally diagnosed, which is why the government launched the “100 Million Healthy Lives” campaign in October 2018.
Essam, the campaign officer and the head of the Ramla village unit, participated in the first stage of the campaign. She explains that the testing and examinations are performed at public health facilities and centers nationwide. Those who test positive are then referred to a specialist hospital to undergo further tests and/or directly sent to a hepatologist to begin treatment immediately, if the situation warrants it.
In a testing facility located in the Maamoura Youth Center in Alexandria, there are dozens of citizens who want to get tested. Some of them have been waiting for two hours. There are old and young people, and it is obvious that they have been encouraged to come because testing is free. The medical team makes sure to answer everyone’s questions.
According to Essam, the campaign takes into account all important details. The doctors and nursing staff receive extensive training to prevent the spread of infection during tests and treatment sessions, and medical personnel use self-destructing syringes that eliminate the risk of re-use. The campaign is primarily geared toward data collection, but also focuses on raising the necessary awareness on how to avoid infection.
Shaaban, a 46-year-old electrician with no fixed income, was among those treated as part of the campaign. His health used to be on the bottom of Shaaban’s list of priorities. “I’m not rich like so many others. I have three daughters, one of whom is getting married, and I have to pay her expenses. I also have to pay rent,” says Shaaban.
Initially, Shaaban did not care much about going to get tested. But he was told that he would not be able to renew his government documents if he did not: his food ration card had expired, which is why he decided to go get tested in March.
Shaaban was devastated when his test results came back positive, and he locked himself in his room for three consecutive days. Eventually, however, he headed to a hospital specializing in endemic disease for retesting.
“I have a phobia of needles and do not like to get injections. But they insisted that I had to. They said that this is for my children and that I would get free treatment. Then, they sprayed the anesthetic and took the sample,” Shaaban tells Mada Masr.
Shaaban started taking his medication on May 13, as his viral infection did not require immediate treatment.
He was surprised at the attention and care he received. “When I found a government body caring about me, when I saw my name on a computer, I felt that I was valuable,” he says.
According to the Ministry of Health, more than 2 million people — 5 percent of those who were tested during the campaign — were found to have hepatitis C.
What happened in Egypt has set a good example for eradicating epidemics among countries with large populations. The campaign succeeded in treating more than 1 million patients in just a few years, with a success rate of 95 percent. According to a World Bank report, this progress has “attracted global attention to Egypt, and it is expected that the Egyptian model will be adopted by low- to middle-income countries facing a similar HCV crisis.”
According to Ayman Sabea, a health researcher at the Egyptian Initiative for Personal Rights, the main reason for the campaign’s success is the availability and accessibility of an effective medication, one that was never available before. Other factors that contributed to this success include the combined efforts and political will of the government, civil society and international community in ensuring that there are enough resources to execute an effective campaign for testing and treatment. Pressuring companies to lower their prices and utilizing existing medical resources and clinics at universities and Ministry of Health facilities also helped the campaign succeed.
Obliging citizens to get tested may have not been necessary, even if the epidemic represented a matter of “national security,” a buzzword for the current government (since the security of the nation is embodied by the health and safety of its citizens). In the case of future crises, perhaps what is necessary is a combination of cheap and accessible medication, the combined efforts of the government, civil society and the international community, and the requisite political will.