Just as it was in the [.pdf] between France's Louis Pasteur and Germany鈥檚 Robert Koch, medicine, much like sports, remains an arena of international competition and national pride. In turn, the pursuit of international prestige can lead states to engage in duplicitous practices in both arenas. Indeed, these two domains intertwine in state-sanctioned programs for developing and administering performance-enhancing drugs, with perhaps the most notorious example being East Germany, which used to raise its international profile as a top athletic contender. Such acts on the sporting field can both undermine the [.pdf] and (particularly for children and others whose participation did not involve informed consent), and 鈥� if uncovered 鈥� sully national reputations. Meanwhile, state-sanctioned fraud in the development of new 鈥渕edicines鈥� that fall far short of their lofty claims, and potentially cause new harms of their own, can have deadly consequences that extend far beyond national borders.
Nevertheless, even as egregious examples of state-sanctioned doping make , state-level medical fraud attracts comparatively little attention. Indeed, it is the more outlandish examples of cures touted by states that tend to receive the most international media coverage, even if only as an object of curiosity or mockery (see: the skeptical international reception of North Korea鈥檚 Kumdang 2, ). Such an approach is akin to covering the outsider underdogs (even if everyone loves the ) while ignoring those standing on the podium.
Furthermore, even those medicines whose dubious nature is immediately apparent have real consequences beyond providing fodder for a quirky sidebar newspaper stories. For instance, in 2007, Yahya Jammeh, ruler of the Gambia, announced that he had personally developed a secret blend of herbs, which, accompanied by ritual practices, was capable of . Unsurprisingly, while Jammeh was in power, the country鈥檚 Ministry of Health supported his claims, even as news reports highlighted ever more improbable claims, such as the cure . Far more disturbingly, efforts to administer this miracle cure to actual patients and tragic consequences. Those who received treatment at the hands of their president were confined for its duration, during which they were denied life-saving antiretroviral drugs while being slathered in pastes and fed concoctions of unknown substances. Some of them 鈥� the precise number is unknown 鈥� died as a result. Unfortunately, foreign interest to sustained pressure by the international community to get Jammeh to end the practice and protect the rights of people living with HIV.
It was only after Jammeh was pressured out in a military intervention by neighbouring states, following his refusal to relinquish power after losing an election in 2016, that accountability could be sought. Under the new government, survivors of his treatments against Jammeh, seeking both financial damages for harm suffered and a declaration from the Court that their human rights were violated. Although still underway, these legal proceedings, the international NGO AIDS-Free World, have attracted much-needed attention to the tragic aftermath of state-sanctioned and the need for accountability for human rights violations under the pretense of medical treatment.
At the same time, other examples of fraudulent medicines supported by the State remain insufficiently outlandish to attract similar international attention or pressure for accountability, despite the very real harms they cause. Contrast the situation in the Gambia, where Jammeh鈥檚 fake cure likely garnered his country more international headlines than any other event during his time in office, with how similar issues have played out in Latvia.
Intriguingly, these two small countries 鈥� each has a population of about two million people 鈥� share a linked history. Before the British incorporated it into their empire, the Gambia was briefly a colony of Europe鈥檚 smallest colonial power, the Duchy of Courland and Semigallia, now itself the Western part of modern Latvia. Today, however, the Gambia remains in the bottom tier of the Human Development Index, while Latvia has emerged from Soviet occupation to become a member of the OECD and the European Union. In turn, Latvian-approved medicines boast a greater veneer of international legitimacy than their Gambian counterparts, making fraudulent claims more difficult to detect.
It was a high-profile doping case that drew rare international attention to one of Latvia鈥檚 pharmaceutical innovations, after former top-ranked tennis player Maria Sharapova was , a Latvian heart drug registered in a handful of Eastern European and Central Asian states that has also found its way onto the World Anti-Doping Agency鈥檚 [.pdf]. Lacking the same potent mix of celebrity and scandal, there has been far less attention outside Latvia to a more concerning product: Rigvir. Domestically, its status as a matter of national pride begins with its name, which honours Riga. Rigvir is marketed as a virotherapy medicine for cancer treatment. On the surface, its claims are less outlandish than Jammeh鈥檚 regimen; indeed, after largely being the preserve of Soviet science during the Cold War, the use of viruses to tackle and even has recently begun to regain international attention and credibility. There is little evidence that Rigvir should be at the vanguard of this rejuvenated field, however.
Although first developed in the 1960s, Rigvir was only registered in Latvia in 2004, Latvia joined the European Union (and the EU鈥檚 accompanying legal framework came into force). Since then, credible scientific evidence supporting its utility . Nonetheless, the Latvian state has provided this home-grown cure with support and exposure far exceeding its evidentiary base. Once it was placed on Latvia鈥檚 domestic list of medicines reimbursable by the state, Rigvir became . Furthermore, the Baltic state sought to export Rigvir abroad. Until recently, the official Latvian tourism portal the fact that 鈥淟atvia offers a unique method of treatment for oncological diseases [i.e., cancer], utilising viral therapy based on RIGVIR鈥� and that 鈥淰iral therapy is available in all Latvian public and private health care facilities that deal with the treatment of oncological diseases鈥�. Meanwhile, although Rigvir is only approved for medical use i of post-Soviet states, it has nonetheless been available through a range of clinics all around the world, most of them specializing in so-called alternative therapies.
Rigvir and its registration have not been without in Latvia. Nevertheless, the Latvian government has long proven reluctant to consider criticisms of the drug. In 2017, the Health Minister to complaints about the drug by a range of health organizations by saying 鈥淎 letter by some social group saying they don't like something - it's just not helpful. Show us data that this medicine does not work for your patients. We don't have anything to react to at the moment.鈥� Around the same time, the government awarded to the company holding the rights to Rigvir, explicitly naming the drug in the process; this prize 鈥渞eaffirms the potential of Latvian businesses, which allows development of new and innovative products that can be successfully offered to various national markets鈥�.
It was not until the spring of 2019 that Rigvir was pulled from Latvian shelves by the State Agency of Medicines. This occurred not over questions of its claimed effectiveness, but after it was discovered that samples of the ostensibly active ingredient. An agency spokesperson was widely quoted as likening the situation to buying lemon juice and ending up with lemon-flavoured water. Finally, on May 31st, 2018, without publicity or fanfare, the Ministry of Health that Rigvir鈥檚 registration had been suspended the day before, with some exceptions made for patients with it.
While Rigvir has been removed, at least for now, from Latvian shelves, and local legal experts have to ensure patients have access to effective medicines, the state鈥檚 longstanding role in the legitimization of Rigvir remains largely unaccounted for. Further digging by a group of Latvian critics of Rigvir has of politicians and civil servants involved in its registration and sale. In turn, there has been little follow-up regarding further measures against a medicine that has cost both the Latvian health system and many patients around the world a considerable amount of money, and perhaps in some cases . The current Minister of Health, Ilze Vinkele, has downplayed calls to investigate the registration of the drug and its placement on the reimbursed medicines list, saying the situation is 鈥溾��.
However, while some individuals have certainly benefited materially from the registration and sale of Rigvir, it is far from clear that this is the case for all those who have dragged their feet in responding to serious concerns about the drug. Even for those without compromised intentions, it can be difficult to besmirch the onetime hometown hero. In the Gambia, progress towards accountability required international action 鈥� first to ensure the departure of Jammeh himself in order to permit legal action, and now in support of such action by those harmed as a result of his 鈥渢reatment鈥�. In Latvia, influence from outside may also help move matters forward. For instance, if domestic remedies fail patients, it would be interesting to see how the European Court of Human Rights would view the issue, particularly in view of previous jurisprudence indicating [.pdf] under Article 2 (Right to Life) of the European Convention of Human Rights to ensure both a regulatory framework and its effective functioning within a healthcare context. More broadly, pressure from the international community letting Latvia know that Rigvir is less a mark of national distinction than a national embarrassment, may also help to foster change. Patriotism, it seems, can be a powerful drug.
About the author
Adam Rainis Houston is a PhD Candidate (Law) at the University of Ottawa working at the intersection of health and human rights. He has worked in all over the world with organizations like the Pacific Islands AIDS Foundation, Treatment Action Campaign, Avocats sans fronti猫res Canada, and the Institute for Justice & Democracy in Haiti. His current research focuses on access to essential medicines, and on the relations between human rights and infectious disease. You can follow him on Twitter: @HealthLawAdamH
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