Historically, the state has played an important role as a social actor. Indeed, the social function of the state was as critical to the constitution of the social contract as the quest for a secured territorial framework within which individuals and groups could exercise their livelihoods. The high point of the development of the social state came in the period after the Second World War with the growth and spread of different variants of social democracy and welfare states.
Not surprisingly, African states at independence were invested with broad-ranging social responsibilities which they pursued with varying degrees of success. However; the onset of the African economic crises in the period from the early 1980s onwards and the rise on a global scale of the forces of neo-liberalism encapsulated the confluence of factors that culminated in the retrenchment of the social state - including from an institutional and expenditure point of view - and the enthronement of a narrow, market-based logic in the provision of social services - including, among other things, the pursuit of cost recovery, the imposing of user fees, the promotion of privatisation, and the employment of new public sector management strategies in the social sectors.
At the same time, the social sectors, including especially the health system, were to suffer a serious erosion of capacity that was connected to the drain of talents, the degradation of the infrastructure of service, and the collapse of professionalism. Perhaps much more serious is the decoupling of social policy from macro-economic policy-making and its treatment as a residual category to which targeting strategies such as safety nets, various programmes for the alleviation of the social effects of economic structural adjustment and a plethora of poverty reduction strategies would be applied. It is suggested that this decoupling of social and macro-economic policy making is at the root of the expansion of the boundaries of exclusion that defines the structural roots of injustice in the social sectors generally and the health sector in particular.
The prospects for the restoration of a socially-conscious state will depend on the capacity of governments to adopt an approach in which social policy is treated as an integral part of macro-economic strategies for growth and development.
* Adebayo Olukoshi, Professor of International Economic Relations and currently the Executive Secretary of the pan-African Council for the Development of Social Science Research in Africa (CODESRIA) which is headquartered in Dakar, Senegal. He has previously served as Director of Research at the Nigerian Institute of International Affairs, Lagos, Nigeria and as a Senior Fellow/Research Programme Coordinator at the Nordic Africa Institute, Uppsala, Sweden. His current research interests centre around the politics of reform and transition in African politics, economy and society.
Editorial
For forty years the 1978 Declaration of Alma Ata on Primary Health Care has inspired and galvanised understanding, analysis and action on health. In our region, the aspirations and content that were included in the 1978 declaration were embedded in liberation movement goals and post- independence policies and informed the organisation and transformation of health services. Indeed a context of growing movements for social justice and emergent national health systems in the South was one source of the political momentum, values and practice that fuelled the Declaration. In various declarations over the past 40 years, African governments and communities have recognised the contribution of PHC to improved health equity in the region and voiced a need to accelerate efforts to implement it, even while resources bled out of public sector services.
In preparation for a Global conference in Astana in 2018 to commemorate 40 years of PHC a new declaration is being drafted: “the Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals”. The text can be found at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf. It notes a “renewed commitment to health and well-being for all based on universal health coverage (UHC)” and locates PHC as “a necessary foundation to achieve UHC”. Its focus is thus on UHC as the end and PHC as the means. It makes reference to the work of other sectors to address other health determinants in line with the Sustainable Development Goals, “ avoiding political and financial conflicts of interest”.
But the Alma Ata declaration was so much more ambitious and comprehensive in its vision and scope! It called for an economic order that would serve the attainment of health and reduce inequalities in health globally, while also recognising that the promotion and protection of people’s health is essential for socio-economic development. Its language on state duties and public rights is unambiguous. Its principles are no less relevant today than in 1978, even if changing contexts, health profiles and knowledge demand creativity in how it is applied.
As new statements and declarations circulate, let’s remind ourselves of key features of what the Alma Ata Declaration says:
“ I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.
IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.
VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”.
There is more, and the full declaration can be found at http://www.who.int/publications/almaata_declaration_en.pdf
Those engaging on statements and processes on PHC should carefully compare with the Alma Ata Declaration and ensure that we do not lose or blur its clarity of principles and content.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the Global conference on PHC see http://www.who.int/primary-health/conference-phc/en/
Zimbabwe’s media has been awash in 2014 with stories of monthly salaries above $50 000 being taken by the executives across a number of public institutions, in a country where the 2011/12 Poverty Income and Expenditure survey found 77% of those in formal employment to be earning less than US$351 and 63% of all households living below the poverty line. A term has been coined for the scandal - "salary-gate".
One of the worst stories of "salary - gate" was in the voluntary health insurance sector. Zimbabwe has about 30 health insurance companies, termed ‘medical aid’, funding health care for about 10% of the population and providing about 80% of the income to private for profit health services. These medical aid societies are private, voluntary organisations and are deemed to be non-profit.
The events of 2014 have shaken these assumptions. The state media, the Herald, on 31st January, 2014 reported that the top fourteen executives of the biggest medial aid society, the Premier Service Medical Aid Society (PSMAS), were getting US$1.1 million monthly in their combined fees and benefits. The chief executive alone was reported in the same media to be paid about a quarter of a million US dollars monthly in direct earnings from PSMAS and from its subsidiary Premier Service Medical Investments (PSMI) and in other benefits and allowances. While the figure remains to be officially verified, other media have made similar report of this figure without it being contested. This is in the context where the majority of PSMAS members- 75% of whom are employed and retired civil servants according to the Civil Service Commission - earn less than US$400 monthly if employed, and significantly less than this if they are pensioners and widows/widowers. While PSMAS paid its managers these huge salaries, they also built up a debt to service providers of US$38 million in unpaid fees. Their failure to pay providers meant that many demanded that PSMAS members pay cash up-front, undermining the financial protection health insurance is supposed to provide.
This was not the first time that PSMAS and some other medical aid societies had come to public attention. PSMAS became the second biggest provider of health services in Zimbabwe after the government in 2003, setting up a subsidiary, PSMI, and using it to acquire and develop private health services. It expanded to accommodate private sector members and became a significant employer of doctors in Zimbabwe. This integration of funder and provider had already raised questions. In 2000 the Competition and Tariff Commission (CTC) raised that such monopolies across all spheres of a sector limited patient choice, and the Medical Aid Societies Statutory Instrument 330 of 2000 regulated such vertical integration. Nevertheless PSMAS and others were given latitude to continue the practice throughout the 2000s, despite beneficiary complaints about restrictions in the providers covered.
The case raises a number of questions, particularly in terms of the effectiveness with which insurers are monitored by their members and regulated by authorities. PSMAS largely covers government as contributors and civil servants members, although it is not a public enterprise. Government as employer nominates four people to the board while six are elected by the members at an annual general meeting, another member is appointed by an affiliated employer organisation and two are nominated by elected members of the board. The chief executive is an ex-officio member. Ironically, civil service members did not elect themselves to the Board. The Board in 2014 included private professionals and heads of several ministries. It was alleged to have been paid US$1million in allowances in 2013 and dissolved itself in February 2014. As na sign of the lack of oversight of the organization the state media citing the Acting Health Minister Dr Mombeshora reported in February that the society’s operating license was not renewed at the end of 2013 for failing to submit audited financial statements. This raises the issue that members of all such insurance schemes should more actively engage with what is happening in their schemes, include through representation on their Boards.
There also seem to be questions about how effectively such schemes are regulated. PSMAS, like other medical aid societies, was regulated as a finance institution by the Ministry of Finance, and as a health institution by the Ministry of Health. Its nature as a society for civil servants additionally brought in the Ministry of Labour and the Public Service Commission. Despite this multitude of regulators, the evidence suggests that there was no effective regulatory control. A number of weaknesses emerge, some of which were pointed out in a 2010 EQUINET Discussion Paper 82 (www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf) and at a meeting held on the findings by Training and Research Support Centre (TARSC), SEATINI, in collaboration with Ministry of Health in 2010. The Ministry should play a stewardship and regulatory role given the health insurance and health service role. However regulations were weakly enforced in the 2000s during economic difficulties; and the Ministry oversight role is post hoc, obtaining report of changes to constitutions and practices after they have already been made, without meaningful blocking power to prevent 'bad' behavior. Ironically the Ministry of Health had no representative on the PSMAS board. Regulatory oversight by the Ministry faces challenges in shortages of personnel, ambiguities in the law, lack of reporting from societies and lack of awareness and advocacy by members.
In response to ‘salary-gate’ at PSMAS and a range of public entities Zimbabwe’s Finance minister in March announced that cabinet had set the salary ceiling for chief executive officers of parastatal and public institutions at US$6000. They included PSMAS in this, but there is question over their authority to do so for a private limited company where government has no shareholding.
Do we expect anything to change? The crisis is an opportunity to raise some critical questions about the private health insurance sector. Is this case the tip of the iceberg? Beyond PSMAS, are members of medical aid societies exercising proper oversight of their insurers? Are the resources being effectively used for their purpose? With the majority of people in two medical aid societies in Zimbabwe, CIMAS and PSMAS, how viable are the other 28 insurers? Are their funding pools large enough to protect the membership against risk? With the benefit packages clearly specified but segmented across schemes, what measures are there for the pooling and cross-subsidy among members needed to ensure viability and equity? Are the monopolies of insurers and private providers not blurring the boundaries of what is for profit and what is not, given that medical aid societies are tax exempt as health funders but earning profits in investments in private health services? Why is the law preventing such integration not being enforced? How are societies earning 'surplus funds' in their service investments, even while service providers are not being paid and beneficiaries not covered for their benefits?
The Zimbabwe story may not be unique within the region, and cost escalation and inappropriate spending may be more common than is being publicly reported. The Zimbabwe experience and the questions raised could provoke those in other countries to do a ‘health check’ of their insurance sector, in a manner that leads to action to address weaknesses identified. The biggest weakness appears to be in the absence of accountability and the checks and balances for this. The state should not be allowed to fall short on its obligation to protect members from predatory behavior, and members expect the state to have adequate competencies to regulate the market. The system needs to be more responsive to the community and the community to be more vigilant and demanding of accountability.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org and see EQUINET discussion paper 82 at www.equinetafrica.org/bibl/docs/DIS82zimcapflow.pdf and EQUINET discussion paper 82, 87 and 99 on private insurance and their regulation.
All concerned with international trade should work for salvaging the WTO from the debris of the Cancun collapse. Even those considering the WTO framework as anti-development would certainly see the powerful signals emitted from Cancun indicating a new identity of the developing countries. It will be some time before the WTO recovers from the shock of Cancun collapse. And that too only if the main actors make sincere efforts for its recovery.
Cancun was qualitatively different from Seattle. In Cancun, the deep difference between the developed countries and the developing countries was at the core of the failure of the conference, whereas the chaos at Seattle was due to various other reasons. Though the developing countries, particularly those of Latin America and Africa-Caribbean-Pacific, publicly expressed frustration and disgust at the Seattle process, the final failure was because of other factors, like handling of the conference by the chairperson, public insistence of the host country on some new issues like social clause, deep difference between the two majors, viz., the US and the EU and the chaotic atmosphere outside the conference venue due to several demonstrations. There was really no intense engagement among the countries at the negotiating table. In Cancun, on the other hand, there was engagement of the countries, but there were grave differences among the developed countries and the developing countries.
The problem started because the Chairman of the General Council, and later the Chairman of the Ministerial Conference too, presented texts for the Ministerial Declaration that had almost fully included the proposals of the major developed countries and totally ignored the specific and firm proposals of the developing countries. The US-EU were not ready to eliminate/substantially reduce their subsidies in agriculture, while demanding from the developing countries to cut their tariffs in agricultural products and industrial products significantly. The EC was insistent until the near end that negotiations should start on the Singapore issues. The developing countries finally got fed up with the unreasonable and unfair demands of the major developed countries when they themselves were not prepared to make material concessions.
The collapse did appear to be sudden; but there was grave simmering discontent among the developing countries right from the final phases of the preparatory process in Geneva. It all boiled over in Cancun. One may be tempted to diagnose the reason for collapse in some sudden move here and there; but the reason appears to be more deep rooted. Over the years, the major developed countries have followed the strategy of squeezing maximum concessions from the developing countries, but it cannot continue indefinitely. The developing countries, if pushed to the wall, are bound to resist. The governments of the developing countries cannot go on explaining to their people indefinitely that they have been pressurized into accepting one-sided and harmful results. Their people will soon ask them firmly to resist pressures. Cancun gave us a glimpse of this trend.
Pressures on the developing countries by the developed countries in Cancun and in preparation to Cancun were no less than at the time of Doha. But the imperatives on the developing countries gave them strength to resist these pressures. This situation also worked as a cementing factor in the cohesion of some groups of the developing countries. Moreover the developing countries are fast improving their understanding of the WTO and its processes. They have been effectively aided in it by some dedicated NGOs.
The Cancun collapse is a symptom of the instability of the GATT/WTO system as it has been emerging lately. A multilateral system has to be based on the perception among its members of the shared benefits. Once the large membership feel that the system demands only “give” from their side without any possibility of “take”, the system is bound to be unstable. And instability in the system will hurt all the countries, big and small.
The much publicised parting statement of the U.S. Trade Representative in Cancun that they would follow different alternative tracks like bilateral and regional arrangements in the wake of the Cancun collapse has a certain emptiness in it. The U.S. may have a multitude of bilateral and regional arrangements, but when it comes to enforcement of commitments in the areas of goods, services and Intellectual Property Rights, it has to take shelter in the WTO framework. After all it has had tremendous gains in the Uruguay Round in all these areas and it continues to enjoy those gains. In that background, its threat to give up or underplay the WTO route does not appear serious. What is needed is to understand the deep-seated malady in the system and to take corrective measures quickly before it is too late. All parts of the system, viz., the developed countries, the developing countries and the institutional machinery, have to play active role in it. The developed countries should consider the following approach.
1. They should lower their sights and ambitions in the WTO. They have already got a lot in their favour in the Uruguay Round. They should consolidate these gains and stop demanding new concessions from the developing countries.
2. They should allow the system to settle down and not destabilize it by insisting on introducing new subjects in the negotiations.
3. They should be constructive in the area of agriculture and try to understand the sensitivity and importance of this sector in the economics and politics of the developing countries. Positive action in this area is likely to result in spread of gain among the weak sections in the developing countries. Hence agriculture is generally perceived as a test case for assessing the intentions of the developed countries.
4. They should give up their old mind set of monopolizing the management of the GATT/WTO and realize that this organization has to keep in the forefront the interests of a large number of its membership, i.e., the developing countries.
5. More basically, they should realize that their own growth will be helped by the development of the developing countries, because it is there that the prospect of future fast growth of demand lies. They should come out of the thick shell that they have built around themselves over the last two decades or so, thinking that they can sustain their growth on their own without counting on the role of the developing countries. In this mind set, their linkage with the developing countries is limited to their targeting them for extracting more and more concessions.
The institutional machinery of the WTO, including the Chairpersons and the Secretariat, have also to change their approach and style of functioning. Some points are important for them to note.
1.They should realize that the strategy of “clean text” is not always the best. It is not the “clumsy” and “overburdened” text that hinders agreement, as is often alleged about the text for Seattle which accommodated the diverse view points and put them in square brackets. Even the cleanest text, as for example the two texts for Cancun, can result in disaster, if the process of preparation has not been fair and objective. A “clean text” can facilitate negotiations only if the process of preparation has been open and transparent and it is a fair and objective balance between the differing positions. The General Council Chairman’s text for Doha which was confidently taken as a model for the Cancun text also suffered from similar defects as the latter. But there was a big difference in the two situations. While the GC Chairman’s text for Doha was mainly in the nature of a framework in most of its part (except Singapore issues), the texts for Cancun contained specificities of obligations which had been widely opposed by a large number of the developing countries and the alternative suggestions given by them had been totally ignored by the Chairmen of the General Council and the Conference.
There was also the difference in the environment. A large number of the developing countries got confused in Doha by the tactics of the US-EU, whereas, after having learnt their lesson in Doha and later, the developing countries could not be deviated from their determined track in Cancun. Also, during the two years passage between Doha and Cancun, the developing countries had gone through a process of introspection and consolidation. The NGOs of the world had a big role in it.
2.The institutional machinery of the WTO has to show without a trace of doubt that it is not influenced by the major developed countries. It has to be neutral and objective and clearly appear to be so. Much damage has been done by the perception that the machinery is being used by the major developed countries for advancing their own narrow interests. The machinery should work for the system and not for individual countries, howsoever powerful.
The developing countries have found a new identity in Cancun. They showed they could not be pushed around any more. The following steps may help them in future.
1.The various groups of the developing countries that became effective in Cancun should interact with one another to forge a broader and deeper alliance. They should try to identify their common interests and also differences, if any. It may be possible for them to build upon their commonness and smoothen their differences through the process of mutual understanding. After all, one common factor with all of them is that they have all been serious losers in the Uruguay Round and have been the target of the major developed countries for squeezing concessions out of them even later. Though it may be possible for these individual groups to stop some thing here and there and thereby reduce damage, their combination is essential for getting positive benefits.
2.They should counter the divisive tendencies among them. For example, often the division among them is promoted by urging that they should cut their tariffs on industrial and agricultural products in the interest of expanding south-south trade. Though expansion of south-south trade is a laudable objective, undertaking obligation of tariff reduction in the WTO is not an appropriate way to go about it.
A preferred path should be to use the framework of Global System of Trade Preferences (GSTP) for reduction of tariffs among the developing countries. It has two special benefits for the developing countries over reducing the tariffs in the WTO framework. Firstly, a developing country while reducing its tariffs under the GSTP does not have to extend this benefit to the developed countries; thus there is less revenue loss for the committing importing developing country.
Secondly, the beneficiary exporting developing country will face less competition from the developed countries as the latter will not get the advantage of this lower tariff in the developing countries. Over a course of time, this process is likely to enhance investment in the developing countries in manufactures and agriculture, because of larger market access opportunities among the developing countries. The developing countries should give fresh impetus to the GSTP framework which is administered in the UNCTAD and is dormant at present.
This is not to suggest that the developing countries should not engage in the tariff reduction exercise in the WTO framework at all. Of course, they may engage in this exercise there, but only with the objective of getting tariff concessions from the developed countries. An attempt should be made by all to usher in a reformed WTO process. International trade is important for all including the developing countries. And a multilateral framework is useful for that purpose. It is not practicable to create a totally new framework in the current international environment that is characterised by mutual suspicion, lack of goodwill and erosion of confidence. It should be a much-preferred choice for all concerned to work for a reformed and improved WTO. Foundation should be laid for it even before reverting to the Doha work programme in the post-Cancun phase.
http://www.twnside.org.sg/title/twninfo78.htm
'NO LONGER DINNER': AFRICAN ACTIVISTS SPEAK ON CANCUN
“Yea, we are sick and tired of being dinner, we should make dinner for a change,” declared Crystal Overson, a media activist with the Alternative Information and Development Centre-South Africa. Overson was participating in a discussion with five other African activists about the recently collapsed WTO Ministerial meeting in Cancun. The interview delves into the nuts and bolts of the African position at Cancun, the thrills and spills and the way forward to the next Inter-ministerial. Read the full transcript of the interview at www.pambazuka.org
When US Trade Representative Robert Zoellick met representatives of the US pharmaceutical industry in April this year hopes were raised in the international community, particularly in developing countries, who viewed the meeting as a way forward in breaking the impasse in the WTO over how to provide developing countries with access to affordable generic drugs.
It is now six months after the Doha-mandated deadline passed on the 31st December 2002 for WTO members to come up with a solution to public health crises exacerbated by unaffordable patented drugs. With only three months left before the 5th WTO Ministerial Conference in Cancun, Mexico, nothing is expected to materialise before the conference.
Hopes were pinned on the US compromising on its earlier decision to limit the scope of diseases but nothing came out of that meeting, which Zoellick attended. In fact industry representatives last year had pressurised Zoellick to reject a proposal that would be open-ended in terms of allowing developing countries (without or with limited manufacturing capacity) to grant compulsory licences for the manufacture and importation of generic drugs to combat a variety of health problems. This made the US government issue a moratorium that carried the concerns of their pharmaceutical industries, basically on strict limits on the number of diseases covered by these new flexibilities.
The TRIPS (Trade-Related Aspects of Intellectual Property Rights) Council, which last met sometime in February, met again in Geneva to try and see how best to break the impasse. The TRIPS Council meeting on June 4-6, in its last formal session before the Cancun Ministerial Conference in September, did not make progress towards agreement on a solution for the Paragraph 6 problem.
Reports coming from Geneva said although the WTO members had not expected a breakthrough at this meeting, many developing country negotiators expressed their frustration at the seemingly unbreakable impasse in the negotiations. It is reported that the US had reinforced this perception by stating that a consensus was not yet possible, in response to the Kenyan negotiator's comment that there appeared to be no objection to the 16 December 2002 text.
The US objection to the December 16 text was based on the issue of scope of diseases and the reference to Paragraph 1 of the Doha Declaration which refers to “the public health problems afflicting many developing and least-developed countries, especially those resulting from HIV/AIDS, tuberculosis, malaria and other epidemics.” The reference to "public health problems as recognised in Paragraph 1 of the Declaration" was too broad for the US. The US then proposed that the scope of diseases in the December 16 text should be limited to "HIV/AIDS, malaria, tuberculosis or other infectious epidemics of comparable gravity and scale, including those that may arise in the future". This had been opposed by the majority of the WTO Members as an attempt to limit the scope of diseases already agreed to at Doha.
The TRIPS Council considered two submissions, one from the group of African, Caribbean and Pacific (ACP) countries, and the other, from the European Communities (EC).
The ACP countries basically reiterated their previous position that they would want to see a solution that covers all public health concerns, without limiting agreement to specific diseases. The Group also rejected attempts to confine the application of the Paragraph 6 solution to national emergencies and other circumstances of extreme urgency.
The European Communities last year made a proposal on an initial list of diseases that would be covered under Paragraph 6 of the Declaration. The EU Trade Commissioner Pascal Lamy argued that other diseases applicable under the Declaration could be checked or approved by the World Health Organisation (WHO) as the situation arises. Such proposals were nothing but measures to protect the corporate world. In addition to limiting the scope of diseases, the EC effectively wanted to add bureaucratic and political hurdles for poor countries, who would have to go through the rigours of the WHO system to prove that a health problem actually exists in the country for a disease that is not on the initial WTO list.
Again in their submission to the TRIPS Council the EC did not move away from their previous position. The EC suggested that WTO Members could agree on an initial list of diseases that would be covered by the December16 text, and any Member wishing to import medicines to meet a public health concern that was not explicitly covered in the list would be encouraged to seek WHO advice on the matter. The ACP group rejected this, saying it was designed to place limits on the scope of diseases.
With the differences that exist between and amongst the WTO members, particularly the rift between the EU and the US and between both the developed and developing countries, it is highly unlikely that a solution will be found before Cancun. It is reported that the TRIPS Council chairman, Ambassador Vanu Gopala Menon of Singapore, told the meeting that he would continue to hold consultations in small groups and bilaterally until a permanent solution is found.
At the Southern and Eastern African Trade, Information and Negotiations Institute (SEATINI) 6th Workshop held in Arusha (April 2003), participants from fifteen African countries urged African governments and delegations “to stand firm before Cancun, by insisting on a solution that is true to the spirit and letter of the Doha Declaration”. They went on to say that whatever the final outcome of the negotiations, it must cover “all diseases and public health issues”. Governments must have the right, they argued, “to determine what constitutes a public health problem”. The solution, in other words, should not be confined only to some diseases, or to emergencies, or to circumstances of extreme urgency.
Again this recommendation was apparently in reference to the 2002 year-end moratorium issued by the US, which effectively was not consistent with the spirit of Doha. The US had rejected the text that primarily carried the concerns of developing countries due to concerns over the scope of diseases covered.
Western industrial and pharmaceutical corporations, aided by bilateral donors, in the meantime, are putting pressure on certain African countries to amend their patent laws so that they protect the property rights of these corporations. This is the case, for example, with Uganda, where, alarmingly, under pressure from certain quarters, the Government is pressing for legislation in the Parliament - the Uganda Industrial Property Law (IPL) – that seeks to modify the laws of Uganda to conform to the TRIPS provisions of the WTO, when, in fact, Uganda, as an LDC, need not have such a law until 2016.
Meanwhile, the Third World Network reports that WHO Member states meeting at the World Health Assembly (May 19-28, 2003) in Geneva adopted a resolution on Intellectual Property Rights, Innovation and Public Health, directing the WHO Director-General to establish a "time-limited" body that would study and make concrete proposals on the question of appropriate funding and incentive mechanisms to promote the creation of new medicines for diseases affecting developing countries.
The resolution also asks the WHO to cooperate with Member states to develop "pharmaceutical and health policies and regulatory measures" to "mitigate the negative impacts" of international trade agreements.
Other operative parts of the resolution include references to the WTO TRIPS Agreement, in which Member states were urged to "use to the full the flexibilities contained in the TRIPS Agreement" in their national laws. The resolution also called on governments to agree on a "consensus solution" for Paragraph 6 of the Doha Declaration on TRIPS and Public Health before the Fifth WTO Ministerial Conference in September this year.
The Paragraph 6 problem refers to the inability of many developing countries to effectively use compulsory licences to obtain affordable medicines from domestic generic drug producers, since the majority of the developing countries do not have domestic manufacturing capacity in pharmaceutical products. WTO Members have not been able to agree on the solution for this contentious issue, even though the end of 2002 deadline set in the Doha Declaration has passed.
The compromise text of the resolution was adopted only after prolonged consultations and negotiations, primarily between the US, Brazil and a number of African countries. Developed countries, in particular the US, had not been in favour of a strong mandate for the WHO to address IPR issues. Developing countries, on the other hand, had been pressing for a clearer mandate to permit the WHO to properly assess the public health implications of tightened IPR protection, as a result of obligations under the TRIPS Agreement, as well as regional and bilateral trade agreements.
* Rangarirai Machemedze is the SEATINI Programmes Coordinator.
From the SEATINI BULLETIN: Southern and Eastern African Trade, Information and Negotiations Institute
Produced by SEATINI Director and Editor: Y. Tandon; Advisor on SEATINI: B. L. Das Editorial Assistance: Helene Bank, Rosalina Muroyi, Percy F. Makombe and Raj Patel.
For more information and subscriptions, contact SEATINI, Takura House, 67-69 Union Avenue, Harare, Zimbabwe, Tel: +263 4 792681, Ext. 255 & 341, Tel/Fax: +263 4 251648, Fax: +263 4 788078, email: seatini.zw@undp.org,Website: www.seatini.org
Can criminalising deliberate HIV infections curb the HIV transmission rate, and so be good for public health? Or would such legislation negatively impact on voluntary counselling and testing (VCT), and therefore be bad for public health? With many countries in east and southern Africa either enacting or amending legislation to criminalise deliberate HIV infections, there has been mixed response to these questions and mixed reaction to such law reform.
Kenya, Tanzania and Uganda are currently introducing or amending laws to criminalise wilful HIV transmission as they view such laws as an effective tool to curb behaviour that carries the risk of HIV transmission and a legal contribution to the supportive environment for behavior change. These laws generally provide for sanctions when an individual who knows their HIV status knowingly and wilfully infects another individual with HIV. They are proposed as a measure to protect people with less power. By providing sanctions against wilful transmission of HIV, such laws are argued to protect the more vulnerable groups, usually women and young girls, in their sexual relations with those who are more powerful - usually men and wealthy people. They intend to reduce the impunity with which the powerful coerce others into sex, through acts such as rape and defilement, or into practicing unsafe sex (for example through commercial sex work), and so act as a deterrent against these practices.
However, a range of stakeholders involved in HIV related work, from legal, health rights and public health backgrounds, argue that ordinary criminal law provides sufficient legal mechanisms to hold someone accountable for wanton and deliberate infection of sexual partners. A special law to mandate criminalisation of HIV transmission could be bad for public health, harming initiatives such as voluntary counseling and testing (VCT) by deterring individuals engaged in high-risk or criminal sexual behavior from finding out their HIV status, in order to avoid prosecution under this law. Knowledge of HIV status is an entry point to many public health interventions to both prevent HIV and manage AIDS. With women commonly tested for HIV status through antenatal programmes, such laws may increase women’s vulnerability. Laws criminalising deliberate HIV infections could increase stigma, and violate the rights of persons living with HIV to life, health, treatment and freedom from cruel, inhuman or degrading treatment if effective care is lacking, or discontinued, through imprisonment. Emmanuel Mziray, GIPA Adviser to UNAIDS in Tanzania, observes that: ‘prohibiting alcohol and other drugs, consensual sex, or prostitution has never succeeded in preventing these behaviors’.
Criminalising deliberate HIV infections also raises a number of issues relevant to application of the law. It raises questions, for example, about the whether people living with HIV have a legal duty to disclose their HIV status before engaging in sexual activities that can lead to transmission of the virus? If so, then how do you prove in court that the person breached this legal duty? Further there are difficulties in proving the link between the sexual activity and the HIV transmission.
In a bid to address these concerns, USAID recently produced a policy options paper (See: http://data.unaids.org/Publications/IRC-pub02/JC733CriminalLaw_en.pdf) proposing some principles to guide thinking about, and development of, law and policy on the question of criminal law and HIV/AIDS. The paper identifies a number of public policy considerations that countries should consider when making decisions about using criminal law to tackle deliberate HIV infections. It warns that government officials and the judiciary involved in the development and implementation of such policies should be knowledgeable of the best available scientific evidence regarding modes of HIV transmission. Risk levels should form the basis for rationally determining if, and when, conduct should attract criminal liability. This is very challenging in settings where the judiciary may not be familiar with latest scientific evidence regarding on HIV transmission, particularly where there may be debate about levels of risk.
USAID propose that any legal or policy responses to HIV, particularly through the coercive use of state power, should not only be pragmatic in the overall pursuit of public health, but should also conform to international human rights norms, particularly the principles of non-discrimination and due process. State action which infringes on human rights must be adequately justified and policy-makers should always assess the impact of law or policy on human rights, choosing the ‘least intrusive’ measures possible to achieve the demonstrably justified objective of preventing disease transmission. As pointed out by Shanaaz Mathews in the April 2006 edition of the South African Medical Journal, international guidelines on HIV and human rights developed by UNAIDS and the Office of the United Nations High Commissioner for Human Rights (OHCHR) point out that criminal or public health legislation should not include specific offences against deliberate transmission of HIV, but that the latter should be tried under general criminal law, a position endorsed by the South African Law Commission (SALC) in 2001.
The development of such laws in Kenya, Uganda and Tanzania, amongst other ESA countries, suggest that these guidelines are not being followed. In Tanzania the proposed law is under debate, and article 47 of the HIV and AIDS (Prevention and Control) Bill, 2007 provides: ‘Any person who willfully and intentionally transmits HIV to another person commits an offence, and on conviction shall be liable to life imprisonment’. In Kenya, section 26 of the Sexual Offences Act, 2006 makes it an offence for any person who with actual knowledge that he or she is infected with HIV or any other life threatening sexually transmitted disease intentionally, knowingly and willfully infects another person. Though Uganda has not enacted specific legislation criminalising deliberate HIV infections, it has amended its Penal Code Act to create the offence of aggravated defilement and aggravated rape where the offender was infected with HIV.
These laws do not appear to have addressed the human rights or public health concerns raised above, and assign the matter to courts who may have weak expertise in assessing the public health evidence. More generally, the public health impact of these measures are not monitored, neither the costs nor the potential benefits raised above. It is thus difficult to argue that they have been adequately justified, or that they are the ‘least intrusive’ measures possible to achieve their intention. The argument that the issue should be tried under general criminal law perhaps provides a legal remedy for clear violations of rights, without the negative consequences of a specific provision.
Policy and legal reforms are important in tackling the HIV epidemic. If human rights and public health issues are to be respected then it is vital that professionals and activists working on AIDS and people living with HIV be involved in and debate the legal reform processes in this area.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. Further information on health rights and AIDS can be found on the EQUINET website at www.equinetafrica.org
A Speech to the HIV/AIDS and "Next Wave" Countries Conference, the Centre for Strategic and International Studies Washington, DC, October 4, 2002, on the US National Intelligence Council report, 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', published September 1 2002.*
For more than a decade now, those who have chronicled the sweep of the pandemic have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places, that: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.
But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.
That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources. Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".
And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling, allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".
I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think - I obviously cannot prove - but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.
We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic […]
I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We - and it's the royal, generic 'we' - know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.
What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.
Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.
I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.
I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.
* 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', prepared for the National Intelligence Council of the CIA, highlights the rising HIV/AIDS problem in five countries of strategic importance to the United States: Nigeria, Ethiopia, Russia, India and China. It is available as a pdf file at: <a href=http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf>http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf<a/>
This issue of Equinet is dedicated to covering some of the recent research and comment on the complex issue of globalisation and equity in health. Recent events signal that health has gained some profile as a global issue, whether in relation to the deliberations and campaigns around World Trade Organisation provisions on intellectual property rights and access to essential drugs, or in relation to the United Nations launch up of the Global Health Fund.
There are many questions about the impact of such initiatives in dealing with the real impact of globalisation on health, and its potential – or otherwise - to deliver greater equity in health. The conflict over TRIPS has highlighted contradictions between free trade provisions and access to existing technologies for health. Questions exist of how far a Global Health Fund addresses or diverts attention from the economic policies that generate the debt, poverty and marginalisation that produces a major share of the global burden of disease. As Fran Baum has written recently in the Journal of Epidemiology and Community Health "Can you imagine a world in which the spread of globalisation meant the world becoming a more just and equitable place? This seems like an impossible dream. All the indications are that the current forms of globalisation are making the world a safe place for unfettered market liberalism and the consequent growth of inequities. This economic globalisation is posing severe threats to both people's health and the health of the planet” (1).
There is debate on the health impacts of globalisation: David Dollar, in a recent World Health Organisation Bulletin on health and globalisation argues that economic globalisation has raised the incomes of poor countries, and that this has generally benefited poor people. Others argue that while globalisation has brought economic growth-promoting potential, these benefits have been restricted to a small number of countries, and have left the majority of developing countries excluded or even negatively effected by such growth potential. (2).
There is perhaps more wide consensus that changes are required to ensure that health outcomes are factored more centrally within globalisation processes. This means providing for measures to promote and protect health in globalisation as global public goods, and not as market or aid. It also means not waiting to act on those areas where health burdens are already accumulating under global economic and trade processes - such as in transfer of tobacco risks to youth in developing countries, or in the shift towards more casual jobs that lack adequate social protection. Nick Drager and Robert Beaglehole point out in the editorial of a special World Health Organisation Bulletin on globalisation and health:
“Public health scientists are still in the early stages of gathering concrete evidence on the effects of globalisation on population health. This evidence is required to inform policies and actions to protect and promote the health of the poor. The productivity of this research would be improved if there was an agreed framework for considering the various mechanisms by which economic globalisation affects population health status… It is already evident, however, that policy measures are required to rectify the adverse effects of globalisation on health and strengthen the positive ones. Policy should be guided by the following principles:(i) growth needs to be inclusive, equitable and sustainable, and this requires policy coherence between economic, social and environment sectors; (ii) opening up of borders should be gradual and preceded by appropriate protective conditions; (iii) international rules and institutions should promote the production of global public goods and the control of global public ‘‘bads’’; (iv) special attention is needed to increase the transfer of financial and technical resources to those left behind in the development process; (v) strong national health policies, institutions, regulations and programmes are essential; (vi) the public health workforce must be equipped with the knowledge and skills to engage with partners across sectors and across borders to achieve health and other social goals.” (3)
In the EQUINET September 2000 conference it was noted that during several decades of structural adjustment in southern Africa health scientists argued about the extent of negative impacts while populations became poorer, hungrier, more at risk of disease and less able to afford or access basic health services. By the time the negative impacts were acknowledged structural adjustment had been replaced by the much wider and more sweeping liberalisation and privatisation of the current phase of globalisation. Globalisation has increased the visibility and evidence of the global resources and opportunities available for health. This makes the contrast with the deprivation of such resources where they are most needed extremely stark.
1. Health, equity, justice and globalisation: some lessons from the People's Health Assembly. F Baum - J Epidemiol Community Health 2001;55:613-6. <a href=http://www.jech.com/cgi/content/full/55/9/613>http://www.jech.com/cgi/content/full/55/9/613</a>
2. Is globalization good for your health? David Dollar; Globalization and health: results and options; Giovanni Andrea Cornia. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>
3. Editorial: Globalization: changing the public health landscape. Nick Drager & Robert Beaglehole. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>
The forthcoming June (volume 16 (1)) issue of the Malawi Medical Journal is a special issue focussing on equity. This special edition of the Malawi Medical Journal attempts to capture, synthesise and present debates and action around ‘how to’ deliver on equitable health service delivery in Malawi. The papers are organised into four sections.
The journal isssue explores the research and advocacy partnerships needed to promote equity in health in Malawi. It presents various equity studies on how the health sector can reach poor women, men, girls and boys. These studies were commissioned by the Equity and Access Sub Group to inform the equity monitoring of the Essential Health Package (EHP). Although each paper deals with a different health issue, cross-comparison of the papers allows system-wide analysis. The studies point to the need to bring essential services much closer to the poor– not only in terms of geographical proximity, but also in terms of affordability, cultural acceptability, and epidemiological relevance. This recommendation is closely in line with Government policy to implement the EHP of basic services. Thus, the recommendation is not to change policy, but rather to ensure its’ more energetic and effective implementation The EHP – free basic services at the point of delivery – lays a strong foundation for equitable health service provision. More energetic delivery then means improving access, strengthening human resources in Malawi at community level (including investing in Health Surveillance Assistants) and addressing stock outs of essential drugs.
The journal captures different viewpoints and perspectives on equity. The
six articles in this section highlight the importance of viewing equity with a holistic lens. The articles clearly illustrate the need for insights on equity drawn through various methods that capture the perspectives of different players - health workers as well as community members for example. They also demonstrate that many disciplines and approaches need to collaborate to understand, document and take action on the different factors that shape equity or inequity in health services.
The journal gives information on staying up to date and presenting information on equity in different ways. This section contains policy briefings, themed abstracts and details of useful websites on equity and health, which readers can use to stay current with equity and health debates and priorities at a regional and global level. The policy briefings and abstracts produced by REACH Trust are included in this journal for dissemination purposes. They cover issues such as linking research policy and practice to improve equity in health care in Malawi and promoting poor women and men’s access to health services through developing partnerships with community groups in Lilongwe. The abstracts provide snapshots of research findings across a number of thematic sub-headings, including equity and gender perspectives on TB and HIV in Malawi, equity monitoring, equity perspectives on TB diagnosis and an equity lens on pathways to care for TB and HIV care and treatment.
For more information on this journal issue contract REACH trust Malawi directly or through admin@equinetafrica.org
There are many occasions during the course of the year to pronounce about the pandemic. On the occasion of this World AIDS Day, I’d like to resist the temptation to run with hyperbole. Rather, I’d like to put two specific proposals which may seem obvious, but which speak, I believe, to the heart of the struggle against the virus.
The first involves dollars. The Global Fund to Fight AIDS, Tuberculosis and Malaria --- the best financial vehicle by far to help break the back of the pandemic --- is in terrible trouble. It is over three billion dollars short for 2006 and 2007, and that shortfall will doom millions to death in the following years unless something drastic is done, and fast.
What has happened was completely unexpected. The G8 leaders met at Gleneagles in July, and emerged with ringing promises of financial assistance for Africa. The first test of those promises came just eight weeks later, in early September, at the replenishment conference for the Global Fund. The G8 flunked the test. The assumption was that the Global Fund would go right over the top given the rhetoric of the Gleneagles Summit, but instead, having requested $7.1 billion, the Global Fund fell billions short.
It’s fair to say that everyone was stunned. It took only eight short weeks for the G8’s signed agreement to fall apart.
I’ve just spent the last three days in Rwanda at the regional conference of the Global Fund for East Africa and the Indian Ocean. It’s absolutely astonishing to see how determined the countries are to achieve the goal of universal treatment by 2010, but they’re frightened by the prospect of not having sustainable resources. They know they can’t interrupt treatment once it’s started, but what guarantee do they have, under present circumstances, that the G8 will be by their side as promised?
All they can count on, for certain, is betrayal.
That must somehow be reversed. The year 2005 showed that treatment is possible in great numbers, and there is a strong sense that if the momentum can be sustained, the back of the pandemic can be broken. But that will depend on a continuing, reliable flow of resources. It depends on the commitments of the G8 being honoured. With the loss of honour goes the loss of life.
However, in addition to keeping the pressure on governments, we need a new source of dollars. That source must be the private sector. It was always hoped -- indeed, even expected -- that private sector money from major multinational corporations would help to keep the Global Fund going. It hasn’t happened. The contributions are negligible. It’s as though most of the private sector doesn’t know the Global Fund exists.
I want to suggest that companies contribute 0.7% of pre-tax profits annually to the Global Fund. To maintain the symmetry with governments and the Millennium Development Goals, they should phase the money in and reach the full target by 2015. Which corporations? Pretty obviously, I think, the big multinational corporations that have exacted such huge wealth from Africa’s mineral, diamond, oil and other resources over the decades, and certainly the pharmaceutical industry, which resisted the lowering of drug prices for an unconscionable length of time.
But there may be an even better and fairer way to select the corporate contributors. The Global Business Coalition on HIV/AIDS has a membership of some two hundred multinational corporations. Many of these corporations deal admirably with their workforces, providing antiretroviral drugs to their workers where necessary, and sometimes to the workers’ partners and children. Others of these corporations make in-kind contributions, or investments in research and training centres. But the true expression of corporate social responsibility would be a 0.7% contribution to the Global Fund. If the principle spread, the dollars would mount unto the billions.
There’s no reason to feel cynical about such a proposition. People mocked when Gordon Brown talked of his International Finance Facility, but now it’s well and truly launched. People mocked when France advanced the idea of a tax on airline travel to fund development, but now President Chirac seems determined to proceed. There’s room for every genuine initiative.
This effort would show the world that the pandemic can be beaten.
Now allow me to switch gears and deal with a particular aspect of children and AIDS which reveals an appalling double standard, and must be dealt with. In fact, it should have been dealt with several years ago.
The overwhelming majority of HIV-positive children are infected by the virus during and following the birthing process. Children infected in early infancy usually die before the age of two. There are more than half a million deaths of children from AIDS every year.
In many countries, primarily in Africa, there are programs in place called PMTCT, Prevention of Mother-to-Child Transmission. Unfortunately, most of these are merely pilot programs: fewer than ten per cent of HIV- positive pregnant women have access to PMTCT. That, in itself, is scandalous.
In most countries the PMTCT program uses what is called single-dose nevirapine … one tablet of that drug to the mother during labour and a liquid equivalent of the drug for the child within 48 hours of birth. Incredibly enough, the transmission is cut by close to 50 per cent! Half the babies who would otherwise be born positive are born negative.
That, of course, is wonderful. But compare it with North America (or anywhere in the western world). North American hospitals do not use the drug nevirapine; they use full antiretroviral triple-dose combination therapy from approximately 28 weeks through to the end of the pregnancy. The result? The transmission rate drops to between one and two per cent!!
Why do we tolerate one regimen for Africa (second-rate) and another for the rich nations (first rate)? Why do we tolerate the carnage of African children, and save the life of every western child? Is it possible to do full therapy in Africa rather than single dose nevirapine? Of course it is. Doctors Without Borders does it in Uganda; Partners in Health does it in Rwanda; Saint Egidio does it in Mozambique. In fact, Rwanda is introducing a formal protocol to make sure that full therapy is provided in every setting where PMTCT is available. They are the first country to do so.
It leaves the mind reeling to think of the millions of children who should be alive and aren’t alive, simply because the world imposes such an obscene division between rich and poor. That’s about to change, but why does it always come after an horrific toll is taken?
There is another aspect of saving children’s lives that is much neglected and much rationalized. Even when transmission is prevented during pregnancy and birth, the virus can still be passed through breast milk. Therefore, we require safe solutions to infant feeding, including secure supplies of formula where feasible, with careful instruction about clean bottles and preparation, and all of it provided free: there’s just no possibility of rural village women in Africa being able to pay for breast milk substitutes.
Research available so far indicates that that, too, must become public policy wherever possible. And where it’s not possible or safe, exclusive breast-feeding for six months is undoubtedly the best course. It’s worth noting that it took almost a decade to finally develop antiretroviral drug preparations for children with AIDS. The time has come to reduce, dramatically, the numbers of children who begin their lives infected.
On this World AIDS Day, 2005, I have the deep impression that if only we could galvanize the world, we’d subdue this pandemic. We’re terrific when it comes to studies and documentation. Reports like the Epidemic Update issued by UNAIDS last week are models of statistical compilation, containing pockets of fascinating material. But the report itself acknowledges that real progress against the pandemic is hard to find.
We need a superhuman effort from every corner of the international community. We’re not getting it. At the present rate, we’ll have a cumulative total of one hundred million deaths and infections by the year 2012. We call ourselves an advanced civilization.