Health equity in economic and trade policies

2007 Victories: Fewer Deaths, more compulsory licenses
Baker B: Health GAP, 11 December 2007

Given India's victory against Novartis in the drug company's challenge to section 3d of the India Patent Act and given Thailand's highly publicised campaign to issue compulsory licenses on both AIDS and heart disease medicines, we are now seeing a new wave of patent withdrawals and a growing wave of compulsory licenses. This reciprocal wave action creates a wider opening for continuing access to newer and lower costs medicines. But the promise of this opening will only be realized if more countries amend their patent acts to take advantage of the TRIPS-compliant, definitional flexibilities that India has enacted and if more countries use the TRIPS compliant flexibilities for issuing compulsory licenses for generic medicines that Thailand has used.

A blank cheque for abuse: the Anti-Counterfeiting Trade Agreement (ACTA) and its impact on access to medicines
Medicins Sans Frontieres: Access Campaign, February 2012

In this update to Medicins Sans Frontieres’ (MSF) November 2010 report on the Anti-Counterfeiting Trade Agreement (ACTA) - which has so far been signed by most developed nations - the impact of ACTA on access to medicines is investigated. Although a number of provisions that were harmful to access to medicines in developing countries were removed during the negotiations, the final text remains problematic, according to MSF. The agreement, for example, will undermine the ability of developing country governments to apply the Doha Declaration to protect public health. It puts medical distributors, non-governmental organisations and public health authorities at risk of severe penalties, while allowing for continued border detention of in-transit medicines destined for developing countries. ACTA undermines the role of the judiciary in protecting the right to health and balance private intellectual property rights with the larger public interest, and acts as a deterrent to the production and trade in generic medicines, as it provides for excessive punishment, shifts the risks entirely on to the generic manufacturer, and grants few protections against abuse. MSF states that it does not recognise the legitimacy of ACTA because it has been negotiated in secret with little room for public engagement. The authors conclud that ACTA is a cynical exploitation of concerns around unsafe medicines and is not a legitimate response to the problem of counterfeiting.

A call for more equitable economies and some ideas on how to get them
Chang C: CAFOD, April 2013

What can we do collectively to tackle inequality? The author of this article argues that first we need to ensure that governments are providing proper support to the livelihoods of poor men and women. At present, governments are a very long way from knowing if the money that they are spending on economic development is having an impact on poor entrepreneurs. Second, we need to ensure that the rules of the game governing our economies are not stacked against the poorest, resulting in distorted and unfair markets. These issues need to be addressed collectively by governments and included in an international setting. For example, taxing companies that operate across borders requires governments in different tax jurisdictions to cooperate. However, on these difficult, structural issues, promising first steps have been made. George Osborne led the call for a crack-down on tax-dodging multinationals at a G20 meeting last month, while in 2012 governments agreed to rethink investment rules at a United Nations conference in Doha.

A call to the 2007 G8 Summit to support African national health plans and comprehensive health workforce strategies
African Council for Sustainable Health Development (ACOSHED), African Medical and Research Foundation (AMREF)

The full call and signatories are found here to this call from African organisations to the G8 presented in the editorial section of the newsletter.

Further details: /newsletter/id/32346
A cross-sectional survey on knowledge and perceptions of health risks associated with arsenic and mercury contamination from artisanal gold mining in Tanzania
Charles E, Thomas DS, Dewey D, Davey M, Ngallaba SE and Konje E: BMC Public Health 13(74), 25 January 2013

An estimated 0.5 to 1.5 million informal miners, of whom 30-50% are women, rely on artisanal mining for their livelihood in Tanzania, and are exposed daily to mercury and arsenic. The primary objective of this study was to assess community risk knowledge and perception of potential mercury and arsenic toxicity in Rwamagasa in northwestern Tanzania, an area with a long history of artisanal gold mining. A total of 160 individuals over 18 years of age completed a structured interview. These interviews revealed wide variations in knowledge and risk perceptions concerning mercury and arsenic exposure, with 40.6% and 89.4% not aware of the health effects of mercury and arsenic exposure respectively. Males were significantly more knowledgeable (36.9%) than females (22.5%) with regard to mercury poisoning. An individual’s occupation category was associated with level of knowledge, and individuals involved in mining (73.2%) were more knowledgeable about the negative health effects of mercury than individuals in other occupations. Of the few individuals (10.6%) who knew about arsenic toxicity, most (58.8%) were miners. Overall lack of knowledge, combined with minimal environmental monitoring and controlled waste management practices, highlights the need for health education, surveillance, and policy changes, the authors conclude.

A decade of tobacco control: The South African case of politics, health policy, health promotion and behaviour change
Reddy PD, James S, Sewpaul R, Yach D, Resnicow K, Sifunda S, Mthembu Z, Mbewu A: South African Medical Journal, 103 (11):835-840, November 2013

The South African (SA) government has implemented comprehensive tobacco control measures in line with the requirements of the Framework Convention on Tobacco Control. The effect of these measures on smoking prevalence and smoking-related attitudes, particularly among young people, is largely unknown. This paper describes the impact of a comprehensive health promotion approach to tobacco control amongst SA school learners with evidence from four successive cross-sectional Global Youth Tobacco Surveys (GYTSs) in 1999, 2002, 2008 and 2011 among nationally representative samples of SA grades 8 - 10 school learners. Smoking-related attitudes and behaviours showed favourable changes over the survey period. The surveys demonstrated that the comprehensive and inter-sectorial tobacco control health promotion strategies implemented in SA have led to a gradual reduction in cigarette use amongst school learners. Of concern, however, are the smaller reductions in smoking prevalence amongst girls and black learners and an increase in smoking prevalence from 2008 to 2011. Additional efforts, especially for girls, are needed to ensure continued reduction in smoking prevalence amongst SA youth.

A lifeline to treatment: The role of Indian generic manufacturers in supplying antiretroviral medicines to developing countries
Waning B, Diedrichsen E and Moon S: Journal of the International AIDS Society 13(35), 14 September 2010

This study set out to produce quantitative estimates of the Indian role in generic global anti-retroviral (ARV) supply to help understand potential impacts of such measures on HIV and AIDS treatment in developing countries. It utilised transactional data containing 17,646 donor-funded purchases of ARV tablets made by 115 low- and middle-income countries from 2003 to 2008 to measure market share, purchase trends and prices of Indian-produced generic ARVs compared with those of non-Indian generic and brand ARVs. The study found that Indian generic manufacturers dominate the ARV market, accounting for more than 80% of annual purchase volumes. From 2003 to 2008, the number of Indian generic manufactures supplying ARVs increased from four to 10 while the number of Indian-manufactured generic products increased from 14 to 53. Indian-produced generic ARVs used in first-line regimens were consistently and considerably less expensive than non-Indian generic and innovator ARVs. The study warns that future scale up using newly recommended ARVs will likely be hampered until Indian generic producers can provide the dramatic price reductions and improved formulations observed in the past. Rather than agreeing to inappropriate intellectual property obligations through free trade agreements, India and its trade partners - plus international organisations, donors, civil society and pharmaceutical manufacturers - should ensure that there is sufficient policy space for Indian pharmaceutical manufacturers to continue their central role in supplying developing countries with low-priced, quality-assured generic medicines.

A new debt crisis? Assessing the impact of the financial crisis on developing countries
Edwards S: Jubilee Debt Campaign, 2009

This paper details the extent of what it sees as a burgeoning ‘debt crisis’. With traditional sources of finance drying up, export markets collapsing and a range of other economic impacts, the threat of a renewed debt crisis is very real. Out of the 43 most vulnerable countries, 38 needed at least some debt cancellation to meet their people’s basic needs. Governments with large debt burdens, which are usually denominated in foreign currencies such as the dollar, may struggle to meet the repayment requirements and even default on their debts. Private capital flows to developing countries could fall to around US$165 billion in 2009. The paper recommends canceling more debts, responsible finance and a debt tribunal. Current debt relief initiatives are inflexible, entirely creditor-controlled and wholly inadequate to meet the challenge of the continuing debt crisis.

A new low in the Pharma Drug Wars - Abbott withdraws seven medicines in Thailand
Baker BK: Health GAP, 14 March 2007

Abbott's abrupt decision to withdraw seven pending registration applications, including one for a new heat-stable form of Kaletra, and its threat to make Thailand a no-drug zone for all new Abbott medicines is a truly appalling example of corporate hubris. After touting itself to the be the engine of new life-saving discoveries, Abbott is now willing to withhold medicines altogether in order to extract even greater intellectual property concessions from developing countries.

Further details: /newsletter/id/32159
A paradigm shift for socioeconomic justice and health: from focusing on inequalities to aiming at sustainable equity
Garay J; Chiriboga D: Public Health 149, doi:, 2017

This study measured the ‘best possible health for all’, incorporating sustainability, to establish the magnitude of global health inequity. The authors identified countries with three criteria: firstly, a healthy population—life expectancy above world average; secondly, living conditions feasible to replicate worldwide—per-capita gross domestic product (GDP-pc) below the world average; and thirdly, sustainability—per-capita carbon dioxide emissions lower than the planetary pollution boundary. Using these healthy, feasible, and sustainable (HFS) countries as the gold standard, the authors estimated the burden of global health inequity (BGHiE) in terms of excess deaths, analysing time-trends (1950–2012) by age, sex, and geographic location. Finally, the authors defined a global income ‘equity zone’ and quantified the economic gap needed to achieve global sustainable health equity. A total of 14 countries worldwide met the HFS criteria. Since 1970, there has been a BGHiE of about 17 million avoidable deaths per year (about 40% of all deaths), with 36 life-years-lost per excess death. Young children and women bore a higher BGHiE, and, in recent years, the highest proportion of avoidable deaths occurred in Africa, India, and the Russian Federation. By 2012, the most efficient HFS countries had a GDP-per capita/ year of US$2165, which the authors proposed as the lower equity zone threshold. The estimated US$2.58 trillion economic gap represents 3.6% of the world's GDP—twenty times larger than current total global foreign aid. Sustainable health equity metrics provide a benchmark tool to guide efforts toward transforming overall living conditions, as a means to achieve the ‘best possible health for all.’