A naïve audacity and a singular sequence of events helped shape the massive contribution Aspen’s strategic trade chief has made to healthcare in Africa, writes Terry Shapiro
Stavros Nicolaou, head of Aspen Pharmacare’s strategic trade, is a born problem-solver with an epic career every bit as riveting as the novel that helped him choose it.
He’s the son of middle-class Greek immigrants who ran a café in Highlands North in the 1970s. The café formed the backdrop against which he and his sister learnt first-hand, as they did their homework in the back of the shop, about South Africa’s schizophrenic realities. “Most of my dad’s clients would buy one or two candles, because they couldn’t afford a full packet. If they were buying a treat for a Saturday night, it would be bully beef or canned sardines. And if they were really doing okay, they would buy some peanut butter. It gives you a different perspective.
“My dad came here with nothing, worked for a pittance for a while, and then like all Greek immigrants, opened a café. He didn’t care whether he had a cent to his name; he just wanted his kids to be educated and to be professionals, so they didn’t experience the same hardships he experienced. He wanted us to be doctors or lawyers.”
In his matric year, Nicolaou’s father was diagnosed with lung cancer. “He passed away five days before prelims. It was a very difficult year.
Short-listed for medical school, Nicolaou just missed the cut, and was told to pick a different health science. With his father’s pain still raw in his mind, he chose pharmacy.
Transfixed
During the holidays after first year he picked up a copy of Arthur Hailey’s novel Strong Medicine, which revolves around the Thalidomide debacle. The drug, used to treat morning sickness in the 1960s, caused deformities in thousands of babies.
“It was really a story about a salesperson’s conscience, but it cut across so many themes – clinical trials, the benefits of medicine, exercising moral judgement, ethics…. That disaster could have been prevented if there had been proper clinical trial peer review.” Transfixed, Nicolaou read through the night. By dawn he knew pharmacy was the right choice.
On his return to Wits, he was invited to move across to medical studies, but turned down the opportunity, realising pharmacy could have a much greater impact than medical practice.
Nicolaou loved the multidisciplinarity of pharmacy, spanning everything from research, pharmacy, and regulatory policy to manufacturing, and read everything about it that he could get his hands on. He also started attending things outside his curriculum, doing things like watching postmortems with his medical school buddies.
While serving his internship he represented South Africa at the International Student Pharmacy Conference in Philadelphia. He set out for the US expecting a quick round trip, knowing that Sweden had moved to expel South Africa from the organisation.
The first person he met there was Austrian delegate Christian Wurstbauer, who now, decades later, is one of his closest friends and godfather to his son. The Austrian sympathised, and introduced Nicolaou to delegates from Senegal, Nigeria Ghana and other countries. “Four or five days into the conference I started getting a sense of the tide turning,” he says. Someone suggested he stand for the six-person executive, and against the odds, he was elected.
“My proposer was Austria, my first seconder was Senegal, and my second seconder was Nigeria. You had to present yourself to plenary and read a three-minute speech. I focused a minute and a half of it on South Africa’s political situation, and said I was of a strong conviction that Nelson Mandela would be released soon. I attended the conference again the next year, and said that when Mandela was released, we wanted to hold the conference in South Africa. And we did that in 1992.” The international exposure, where he learnt first-hand about others’ traditions and culture, has stood him in good stead. “You are speaking to people who are going to be in the pharmaceutical business, with all the nuances you are going to get around the world, making contacts. Many of those contacts are in my network today.”
Making the stars align
As a member of Wits pharmacy students’ council, he had to organise a gala dinner, conferences, and in final year, the pharmacy students’ ball. He decided the ball would be at the Sandton Sun, and that Miss South Africa and the health minister should attend. Fellow councillors thought he was nuts, given how expensive the Sandton Sun would be.
To raise the money he approached the CEOs of the pharmaceutical industry, “who – to 20-year-old me – were quite intimidating”. At the time, the Pharmaceutical Manufacturers’ Association (PMA) was at loggerheads with government over generic drug substitution, resisting any changes that might impinge on their patents.
Nicolaou wangled his way into a PMA executive committee meeting and told all the men in the room (there were no women) that if the PMA wanted to invest in the future and to secure its members’ futures, they should support the ball, as the people who would attend were the people who would in future influence generic substitution.
Their president, Hugo Snykers, “was wonderful: he bought into a young person having the audacity to come along, and also into my proposition”, says Nicolaou.
So much money was raised from the PMA that students didn’t even have to pay for the tickets.
To get the health minister to attend, Nicolaou approached the health director-general and told him the ministry seemed to have neglected pharmacists, supporting only doctors, and that it would be good for then-minister Rina van der Merwe, politically, if she attended. Securing an appearance from the reigning Miss SA was not difficult; she was a pharmacist. “So all the stars aligned, and we pulled this coup off.” More importantly for Nicolaou, it exposed him to industry luminaries who at the time all had factories in South Africa.
Events have influenced his life, rather than individuals.
Waiting in the University of the Witwatersrand’s Great Hall to graduate with hundreds of other health sciences students, in 1986, Nicolaou “sat there thinking: now what? I’m 21. I’ve got this degree. What do I really want to do? And I realised that what I had to do was make an impact.” His mind wandered to what things might be like should there be a pandemic, and what he would do. “I figured I would either have to invent something or play a massive role if there was a pandemic.”
Little did he know that HIV and AIDS – up to that point understood as a “gay” disease affecting only the Caribbean and the west coast of the US – would soon hit Africa, costing South Africa alone about 350,000 lives every year.
Rookie vs old hand
In 1990 Nicolaou secured his first pharmaceutical job at Adcock Ingram. If he did well, they promised to promote him into a product or brand management position. Shortly thereafter, as the company was about to launch Losec, a product to treat peptic ulcers, its product manager resigned. Adcock had a choice: It could either promote a rookie and take its chances with what was going to be the biggest brand in the country, or go out and headhunt an experienced old hand. And they went on risk – they took on the rookie.
“It was a fantastic product, and largely sold itself. But it was still very challenging.” Nicolaou, then 24, had to see all the luminaries in gastroenterology to introduce the drug. Among them was Professor Solly Marks, doyen of gastroenterology, whose intolerance of product managers was legendary. “But you’re largely fearless at that age, so you think you can take on anything. Thank goodness I left an impression and things worked out. It could have gone the other way!”
The chutzpah that emerged in Philadelphia, and again when he sold the pharmacy students’ ball sponsorship to the industry, was again evident. Losec subsequently became the biggest pharmaceutical product in the country, and Nicolaou won the IMM Healthcare Marketer of the Year Award for it.
“These things are all iterative, and you’ve got to live your life iteratively. It was quite a high benchmark, and you have to keep lifting the bar. You’re always conscious that you can fail. I’m very conscious of the responsibility I carry. So no matter what the circumstance is, you’ve always got to remember the people that depend on you. And if you fail, it’s not just yourself that you’re failing. You’re failing a whole lot of other people.”
Restraint of trade
In 1998 Nicolaou was invited to join Aspen, a global specialty pharmaceutical company that has its roots in Gqeberha, where Berry Grey Lennon, nephew of Cape of Good Hope governor Sir George Grey, opened for business as druggist Lennon Ltd in 1850. Aspen Pharmacare now employs more than 9,100 employees in 46 countries and supplies products to 115 countries. Last year its Africa-Middle East region accounted for a quarter of the group’s R40.7bn revenue.
Nicolaou was unable to accept the invitation, as he was serving a two-year restraint of trade, having been involved in a company that sold its business to SA Druggists the year before. Then Aspen took over SA Druggists. Problem solved.
AIDS was by then in full swing. The co-morbidity between HIV and TB in the early 2000s was around 65% – catastrophic. In South Africa pneumonia and TB were killing patients, unlike in the US, where there was a prevalence of Kaposi’s sarcoma, a skin cancer to which immunocompromised patients are vulnerable.
Antiretrovirals – an unwieldy, patented regime of triple cocktails that cost $10,000 for a year’s supply in the US – were clearly unaffordable in South Africa. Patients were taking nine pills a day, which didn’t help destigmatise the condition. “Consequently people were not turning up to get their medicine or to be treated, or even to be screened, which worsened the situation. It was spiralling completely out of control. TB had also become extremely resistant to multiple drugs, and we realised the TB treatment protocols also needed to change,” says Nicolaou..
“We couldn’t just sit by and watch a pandemic wipe out a young population, the economic future of the country. We eventually discovered that the TB bacterium was not resistant to some Eli Lilly antibiotics that were 65 years old.”
Eli Lilly didn’t have the regulatory expertise for Africa, or the capacity to produce them, so Aspen and Eli Lilly partnered to manufacture them in Africa.
“Multinationals by nature are reluctant to give up any of their patents or IP. But we said there’s got to be a way.” After some very hard negotiating, Aspen was granted licensing.
The first licence wasn’t actually a licence. It was an immunity of suit, meaning the patent holder wouldn’t sue Aspen for using its intellectual property. Despite Aspen having to develop its own data for the drug because of the immunity of suit, the company got Aspen Stavudine to market in record time. “We got Alec Erwin, who was then the trade minister, to do the launch because the health minister would not come.”
The health minister, Manto Tshabalala-Msimang, advocated consumption of beetroot, garlic and African potato rather than antiretrovirals.
Aspen got the cost of the drugs down to $180 a patient per year. “We went from immunity of suit to voluntary licenses, and eventually to licensing, technology transfer, manufacturing, and distribution agreements.
Poignant moment
After launching Stavudine in late 2003, Aspen became the only African company to sign a deal with the Clinton health initiative, which was founded to combat HIV and AIDS. It was a poignant moment for Nicolaou: “President Bill Clinton’s father also died young. He said to me: ‘Every year that I’ve lived longer than my dad is a blessing. And that’s why I’m doing this; I need to give young people in Africa that same opportunity.’” Nicolaou too benchmarks progress in medicine against what was known and what was possible at the time of his father’s death.
In January 2004 Nicolaou flew to Gilead in California with Aspen COO Lorraine Hill to pitch for access to what was, and still is, the most important antiretroviral molecule, tenofovir. “No one in those days knew Aspen. And they were this high-flying company that bought a biotech firm that had tenofovir, and were suddenly catapulted into being one of the highest market-cap pharma companies in the world.
“We’d done a slick presentation with lots of photos with President Clinton, and we were ready to bowl their board over. Then, in reception, I gazed up and saw a massive portrait of Donald Rumsfeld labelled ‘Chairman of Gilead’.”
Rumsfeld was at the time serving his second stint as US secretary of defence for a Republican president.
“So I said to Lorraine, Lorraine, you’d better remove every single reference to, and photo of, Clinton,” says Nicolaou. “She said: ‘What do you mean? That’s our trump card!’ I pointed to the wall.”
So she changed the presentation, and they made their pitch. Six weeks later they landed tenofovir.
‘You can’t send them to Italy’
Nicolaou found himself back in Wits’s Great Hall in 2019, this time to receive an honorary doctorate in medicine in recognition of his contribution to society in many fields. On the stage, unable to fidget or play with his cell phone, his mind wandered back to 1986, when he sat in the same hall thinking about how he could use his degree to have impact.
“At Aspen we had a massive impact during HIV,” he muses. “Then late in 2019 we started hearing about a strange virus in China. In January 2020, while we were on holiday here in South Africa, our European colleagues, particularly in France and Italy, were in panic mode over a surge in demand for our general anaesthetics and our muscle blockers – not for surgery, but to ventilate patients. You’ll remember those horror images coming out of Italy. Patients dying in car parks and in corridors.
“Then we started getting phone calls from heads of state, the prime minister of France, the president of France, saying: ‘We need general anaesthetics. You can’t send them to Italy, you’ve got to send them to us.’ “
On March 22, President Cyril Ramaphosa convened a meeting with business leaders at the Union Buildings to figure out how to keep South Africa’s economy alive in the face of lockdown. The Business Unity South Africa board on which Nicolaou sat had already started work.
Nicolaou says: “I spoke last. And I said, Mr President, unless you address the public health issue, you’re not going to have an economy to worry about.” He took everyone through what happened with Spanish flu in 1918, and how that lockdown was managed. Three hours later, the president sent the business teams out to create an economic recovery plan, having asked Nicolaou to lead the public health response. Their first order of business was to set up a coalition to mobilise business resources and capacity to work with government.
Four days later South Africa went into lockdown.
“What did we do as business? We had to source ventilators. Personal protection equipment (PPE). Vaccines. We worked 20 hours a day with one concern in mind.”
Again Nicolaou’s mind flits back to 1986. “Sitting in the Great Hall. Thinking about having an impact during a pandemic. And here it was.” Preoccupied with the work, he didn’t give his prescience much thought. “What drove me personally is we had to protect doctors and healthcare workers, fighting an enemy far stronger than them.”
The effort included a huge marketing drive using sports personalities and other influencers to deliver safety messaging. Coalition leaders met Ramaphosa weekly to brief him.
“We were supposed to get vaccines from Covax, the international vaccine alliance. Then we realised that the richer nations were hoarding the vaccines.” Eventually the coalition managed to secure two million doses of the AstraZeneca vaccine.
In October, as the second wave of Covid hit, Nicolaou, sitting a prescribed distance from the health minister at a presidential dinner in Sandton, mentioned that the Rage festival, an annual end-of-matric celebration in Umhlanga and Plettenberg Bay, was worrying him. He’d banned his own son from attending. “And boy, was I right about Rage. That triggered the second wave.”
The mortality rates doubled. But youngsters weren’t dying. Their parents and their grandparents were.
On December 16 South African scientists sequenced the beta variant behind the second wave. “And suddenly South Africa was the source of it. Just because we sequenced it.”
Tourism had just geared up to restart when the international community imposed travel bans on South Africa. It was a catastrophic period for hospitality.
The beta variant was worse than alpha, with the number of cases peaking on December 16. And then at the start of January news broke that the AstraZeneca vaccine could not be used to combat the beta variant.
A clinical trial of the Johnson and Johnson (J&J) vaccine was under way in South Africa. But even if the vaccine had been available, it couldn’t be used because it couldn’t be registered. ”There wasn’t even the full data to register it. The only way you could get the vaccine administered was if you turned this into a clinical trial.” So that’s exactly what the researchers did: they turned the trial into an implementation study, which meant they were no longer experimenting with the drug, but assessing its post-event safety profile.
It also helped the alliance persuade J&J to provide 500,000 doses for a health workers’ vaccination programme that launched on February 17.
Not cricket
At the request of the minister of sport, Nicolaou was also chairing Cricket South Africa at the time to help get its governance in order. Cricket Australia chairman Earl Eddings called him to say the body’s medical team had advised that the tour scheduled for February 2021 should be cancelled because of the beta variant. Nicolaou said: “Mr Chairman, I think you should ask for a refund. ‘He said, no, don’t worry. All the costs incurred, your time, worked out.’” Nicolaou responded: “I’m not talking about those costs. Whoever did your medical due diligence should refund you every single cent.” He showed Eddings a graph demonstrating that mortality rates had dropped from a peak of 844 to about 80 a day, and said: “You tell me if you think this is an out-of-control picture. He didn’t quite know what to say.” The Australians cancelled anyway.
In September 2020 Aspen sealed a deal to manufacture the J&J vaccine under contract at its Gqeberha plant. Then rumours surfaced that the drug substance supplied to the plant by biodefence company Emergent in Baltimore was contaminated. And where there is smoke, there is fire: four of the 12 batches made were contaminated. Two of the four arrived in Gqeberha.
Aspen then arranged with J&J to supply the drug substance from a facility in the Netherlands. Aspen received it in May and was back in production in record time. But then the European Union (EU) claimed the stock on grounds that it had given Janssen Selag, a J&J company in Belgium, a €1-billion grant to produce it.
The incident stoked tension between the African Union and the EU that Nicolaou says has not yet fully dissipated. He notes that at the time, other countries were sitting on five times the stock they needed.
Explicitly banned
When international borders closed in 2020, India explicitly banned export of drugs used to relieve covid symptoms. Trade and Industry Minister Ebrahim Patel drew on the Brics trade bloc to speak to his counterpart in India, and persuaded the Indians to release products to South Africa.
Then China refused to take back a R150-million shipment of faulty PPE. Again Brics was used to resolve the matter. “Our Chinese counterparts put pressure on the company and they took it back,” says Nicolaou.
While the Brics relationships proved useful during covid, it does not mean all participants back one another politically. “Our view as business in South Africa is that we’ve got to act in in a way beneficial to us in terms of where our interests lie,” says Nicolaou. “Our interests lie in the West, they lie in the East, and they lie in the South.”
He points out that the single biggest African donor to Ukrainian victims of war has been Aspen. “We’ve sent six shipments of medicine because we’ve got to take a moral stance. A patient is a patient – I don’t care where they are. They could be in Russia, they could be in North Korea, they could be in Vietnam, they could be in the United States.
“I’m not talking about the military – that’s a different issue. You sign up and you take your chances. When there’s a humanitarian crisis, you cannot overlook it. And when there’s a business opportunity, you’ve got to act in the best interest of the country.”
An evolution
He describes his career as an evolution. “I went from my own business into corporate, which not a lot of people do. So you’ve got to be very comfortable with the organisation that you’re working for. And its value system has got to resonate with you. If you had asked me 26 years ago whether I would work for a corporate, I’d probably say maybe for a year or two until I set up the next thing.” That’s not what happened; he’s been with Aspen for 25 years.
“Why do I get up in the morning? I am motivated by trying to make a difference in people’s lives … trying to have an impact. Many people live their lives like they’re going to be on this planet for 2,000 years. You don’t know how long you’re here for – 50, 60, 70 years. But boy, you better make those 70 years count. And the only way you make them count is if you have an impact on society.”
Nicolaou doesn’t measure his life by setting great big hairy goals or counting his successes. Rather, his objectives are incremental, with everything he does building on previous events. “There are loads of initiatives I’ve been involved in. Hopefully I’ve made some impact.”
He ensures enough time is allocated to deal with the vast number of committees and boards he serves, and while many of them feed into a bigger country narrative, he is always conscious that his main job is at Aspen. “Everything’s important, but some things require less of an investment. I’m very fortunate when that’s the case.”
Factoring in AI
After being shot in the chest on walking into a robbery in his uncle’s shop in 1990, he could easily have been among those who left South Africa. The bullet nicked his aorta, perforated a lung, and exited through his right arm. His anger lasted about a fortnight. He watched two of the Death Wish (vigilante) movies and then decided it was time to move on. “If you don’t, you’ll be crippled for life.“
Asked what he’s most proud of, he doesn’t hesitate. “My family. My daughter is studying medicine, my son is studying economics and finance. Both fields that they can make a future contribution in. We’ll see how they turn out. The signs are good so far!”
He’s also excited about how pharmaceutical R&D innovation is being combined with AI. “The technologies that are coming out, along with the ability to consolidate and analyse data, will accelerate clinical trials. And the quicker you get to market, the more lives you save.”
He expects the next generation of drugs to be more customised and taig price tags.
“Bespoke drugs are the future,” says Nicolaou. “Getting them scalable to make them accessible to everyone will be the next challenge.”