The 18 to 23 July International AIDS Conference held in Vienna this year, subtitled “Rights Here, Right Now” was a platform to raise, yet again, the values based universal and indivisible human rights and the political commitments that inform our response, globally, to the unacceptable level of new HIV infection and mortality from AIDS. At the same time the shrinking provision of aid to low income countries and persistence of avoidable inequities globally in the progressive realisation of these rights starkly raises the reality of the competition between social rights to health, and private rights to intellectual property.
International aid to developing countries has declined in the past two years, with a fall of $1.1 billion in high income country support for developing country AIDS programmes between 2008 and 2009, according to UNAIDS and Kaiser Foundation. At the same time rich countries continue to pursue with vigour stronger protections for intellectual property rights (IPR) – in what is now known as the ‘IP Enforcement Agenda”. The effects of strong IPR protection may have been abated in earlier years by aid support for purchase of patented medicines, but low income countries seeking to meet needs in the current financial squeeze by procuring cheaper options or initiating their own local production of medicines, including of anti-retrovirals, face an unabated challenge to their implementing even those measures that are legal under the World Trade Organisation's (WTO's) Trade-Related Intellectual Property Rights (TRIPs) agreement.
The fall in funding to AIDS has itself been challenged by many, including the President of the International AIDS Society, Dr. Julio Montaner, and Stephen Lewis (former UN special envoy for HIV/Aids in Africa). As Dr Montaner said: “International governments say we face a crisis of resources, but that is simply not true: The challenge is not finding money, but changing priorities. When there is a Wall Street emergency or an energy crisis, billions upon billions of dollars are quickly mobilized. People’s health deserves a similar financial response and much higher priority.”
At the same time the fall in funding has made very clear the need to implement long-standing calls by progressive civil society to put in place more predictable means of global financing, and for African countries to maximise use of TRIPS flexibilities and to advance local production of pharmaceuticals. Yet is it precisely in this arena that measures are being taken to strengthen and enforce intellectual property rights and reduce the flexibilities needed by developing countries. There have been numerous examples of this, included those reported in prior issues of the EQUINET newsletter.
Measures to reinforce IPRs include in regional and bilateral agreements provisions that exceed TRIPs requirements and reduce the flexibilities provided by TRIPS (TRIPS plus); and also pressures on African countries not to exercise rights to compulsory licensing or parallel importation. The EU, which stated its commitment to access to medicines, has pursued measures that exceed TRIPs obligations in its trade agreements with developing countries including with India, in spite of an EU Parliamentary resolution on 12 July 2007 (P6_TA(2007)0353) urging it not to do so. There have been seizures in the EU of generic medicines in transit, not destined for Europe, performed at the insistence of EU pharmaceutical companies for allegedly being counterfeit. The EU has contributed to work on anti-counterfeiting legislation in East African countries that has raised new IPR restrictions on legitimate generic medicines, defining them within the scope of counterfeits (see EQUINET Newsletter 111). Similar seizure laws are being supported through a global initiative called IMPACT.
Significantly at the July AIDS conference, attention was also drawn to the use by the USA of its ‘Special 301’ law which it uses to list and “shame” countries for violating US commercial interests by not providing sufficient protection to IPRs. Health Gap, the Foundation for AIDS Rights and the Thai Network of People Living with HIV/AIDS with others have filed a complaint with the UN's Special Rapporteur on the Right to Health, Anand Grover, alleging that use of this law reduces access to medicines in low and middle income nations and violates international human rights obligations.
Global institutions appear to be offering weak protection to developing countries in their efforts to assert their rights, and the rights and flexibilities provided for in global treaties. In the 2006/7, during the WHO's negotiations on Public Health, Innovation and Intellectual Property (for so-called “neglected diseases”) efforts were made to contain the challenge to IPRs from neglected diseases by including a proposal to limit the scope of the discussion to only 14 diseases, a due process violation as no country proposed this for inclusion in the negotiating text. The IMPACT programme referred to earlier has had an association with WHO that was heavily criticised at the 2010 World Health Assembly. The WTO Dispute Settlement Body (DSB), instead of the defending the flexibilities provided in its own instruments through multilateral measures, has allowed the US room for unilateralism on its Special 301 law in a January 1999 dispute raised by the European Community. This was a decision that Chakravarthi Raghavan of the South-North Development Monitor termed as blatantly based on politics, rather than legal interpretation.
Almost a decade since the 2001 Doha Declaration on TRIPS and Public Health made the important step of asserting more clearly the rights countries already enjoyed to promote access to medicines, few countries have been able to use the rights enshrined in it. The Declaration was needed then because poor countries were precluded from using these rights by the rich countries. The cases cited in this editorial suggest that the last decade has been one of countless efforts to restrict and reverse those rights.
This is in a context where the latest WHO treatment guidelines recommend that people with HIV should start treatment earlier, bringing treatment for people in developing countries in line with treatment in wealthy nations, to help prevent transmission of HIV. Of the 14 million people needing treatment, only 4 million currently receive it. While private rights to IPRs are being vigorously enforced, who is vigorously enforcing the rights to life and health of these 10 million people, or the millions more who need medicines for other common diseases, including chronic conditions like diabetes and hypertension?
And where will we be ten years from now, with an unabated and expanding IP enforcement agenda?. The evidence from recent years outlined here suggests that basing future access to medicines on a benevolent global market, or even one that prioritises human rights in one region over commercial rights in another may be wishful thinking. There seems to be no alternative but for African countries to set a vision, and to develop, negotiate, build space for and implement strategies for their own local production of medicines, to meet their own market and population needs, while simultaneously fending off an IP enforcement agenda that does not meet their interests, in all its guises.
Editorial
A quarter of the population in Sub-Saharan Africa are young people between the ages of 10 and 19 years. These young people carry the hopes and dreams of their families, their communities and their nation. They are the future leaders and, perhaps as important, the future parents of the next generation.
They live in a world where to be an adolescent is increasingly risky. Adolescents typically take risks, but with the AIDS epidemic, risk-taking can be fatal. When adolescents have unplanned and unprotected sex, sexually transmitted infections can cause infertility or cervical cancer, and pregnancy in adolescents is more risky, with higher rates of death in both adolescent mothers and their babies than in adults. Unsafe abortions amongst adolescents are unacceptably high, and early sexual activity may limit educational attainment and deprive young people of the opportunity to form mature, loving relationships. So it’s a tragic and unacceptable sign that most new HIV infections in sub-Saharan Africa occur among adolescents and young adults.
Adolescents grow up today in a different world. High rates of urbanization, extended periods of schooling and growing poverty contribute to a challenging social context for young people.
Traditional ways of preparing young people for adulthood, which relied on extended family members, are less practiced and might not be adequate to address the pressures that adolescents face. In the past, sexual maturity was closely followed by marriage. Today, young people reach puberty at younger ages and wait longer to marry. Because the aunt or uncle may not be available, or may not be considered relevant, many adolescents turn to other sources. Today, many young people learn from peers or the media. Much of this information is inadequate and sometimes it is just plain wrong.
Schools are an ideal setting in which to reach large numbers of young people with the information they need, including reproductive knowledge and life skills. Yet, wherever it has been introduced, the teaching of reproductive health in schools has generated controversy. Debate exists around what information should be given and how much, especially regarding sexual intercourse, pregnancy and disease prevention. Some adults are resistant to even acknowledging that teenage sex is taking place. Others are concerned that sex education will lead to sexual activity. These viewpoints are often based more on values and beliefs than on facts. Hence the same arguments are repeated again and again, year after year, despite contrary evidence. Its very likely these same views will continue to be expressed into the future.
Nevertheless, facts do help. Studies have shown, both regionally and internationally, that comprehensive sex education is effective in improving knowledge and reducing sexual risk behaviours, and that it does not increase sexual activity. In 1997, a UNAIDS study reviewing 53 sex education programmes globally found that 22 had a positive effect of safer adolescent sexual behaviour, and 27 had no impact. In the 3 studies where there was an increase in sexual activity, there were concerns about the design of the assessment and the validity of conclusions.
Such studies suggest that rather than sex education causing young people to have sex, the opposite is more likely to be the case: Giving young people more complete and accurate information, and more opportunities to discuss issues in an open and non-judgemental environment enables them to make more responsible choices.
Clearly the design and quality of the programme matters. Strengthening sex education programmes can be difficult in resource-strained countries. However some aspects of effective programmes that have been identified from reviews can be applied across different settings, including those where resources are scarce. These include:
• adopting school curricula that provide comprehensive, accurate sexual and reproductive health information;
• supporting teacher training;
• reaching young adolescents with information early, before they leave school and before they begin sexual activity;
• strengthening health and other community services for young people and ensuring that these services are youth-friendly, and
• helping adolescents stay in school. Even if they do not receive sex education, young people who stay in school are less likely then their peers to have sex.
Successful reproductive health programmes are not simply a matter of education. They involve youth issues, gender issues, human rights issues, and health issues. They involve and give a central role to youth themselves. They encourage young people to articulate and discuss issues, to talk about their lives, to understand their options, and to get the skills and support they need for healthy choices. And of course, for young people, they must also be fun.
Our efforts towards reducing maternal mortality or new HIV infection cannot be said to be successful as long as we have not made significantly more progress in reducing the risk for adolescents. Achieving this and reaching young people can’t be left to teachers alone. Parents, civic leaders, health providers, other government ministries all have a role to play. Support of youth is a multi-sectoral effort. As adults planning for a better future for our young people, we are all their parents.
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 in this op-ed please visit the EQUINET website at www.equinetafrica.org or see as an example of resources for adolescent reproductive health the Auntie Stella materials on the TARSC website at http://www.auntiestella.org/
With the World Cup football taking place in South Africa absorbing attention, its possible to miss two important meetings taking place at the same time. The first is the 36th G8 and G20 summits taking place in Canada in late June under the theme 'Recovery and New Beginning', and the second the 15th African Union Summit on 19–27 July in Kampala, Uganda, under the theme ‘Maternal, infant and child health and development in Africa’. This newsletter flags concern over these leaders keeping the promise: G8 leaders to their development and aid commitments and African leaders to the Abuja commitments on health, including for 15% of their budgets to go to health. In this issue, a 63rd World Health Assembly resolution points to the need for strengthened health systems to address the relatively slow progress in Africa towards the health MDGs. Geoffrey Njora cautions leaders on taking the advice of finance ministers’ to reverse on the commitments they made at Abuja. Médecins Sans Frontières call the G8 to account over the 'flatlining' of AIDS funding and Oxfam over the inadequate resources allocated for maternal health. African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States on the grave concerns of African citizens to meet crucial commitments on health and social development in Kampala, in particular the 2001 Abuja pledge on health financing, while the Civil Society Forum on the African Charter on the Rights and Welfare of the Child call for the G8 and African leaders to meet their promises on funding health as we get closer to 2015. What governments deliver at these two summits is worth keeping an eye on- it affects millions of lives.
African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States through Malawi President Bingu wa Mutharika, Chairperson of the African Union on the grave concerns of African citizens that some Heads of State are being advised to repudiate crucial commitments on health and social development, in particular the 2001 Abuja pledge on health financing. They note that despite some recent progress, healthy life expectancy in Africa is at a low of 45 years resulting in un-fulfilled personal, national and continental potential and aspirations, and the loss of billions of dollars in productivity. They note that it would be a historic setback for African governments to drop health and social development commitments, or suggest in anyway that the health of African economies exists in isolation from the overall health of African citizens. Giving evidence to support the need for adequate health sector financing, the petition urges heads of state to ensure that the July 2010 AU Summit restates the Abuja commitments; and supports the AU Commission in working with governments and civil society to monitor and report on health gains, and ensure a 10th year review of the 2001 Abuja commitments by April 2011.
The author flags concern about the actions of some African finance ministers to reverse their Heads of state commitments, such as those made on 15% government funding to health in Abuja in 2001. South African, Rwandan and Egyptian finance ministers succeeded in deleting any reference to budgetary targets for education, health, agriculture and water from the report and resolutions of the annual meeting of the African Union and Economic Commission for the Africa Conference of Ministers of Finance, Planning and Economic Development held in Malawi in March 2010. Many consequences are seen to flow from this, if heads of state follow the same path. It could indicate an abandonment of the bold financing that has gone into reversing vulnerability to food insecurity, disease and denial of access to health care and education. It questions how Africa would, after reversing from its own commitments, hold the G8 and international community to their commitments to contribute 0.7% of their gross national product and to double development assistance to Africa. The dismissive nature with which the finance ministers have treated these targets begs the question of whether the MDGs and all the other decisions taken under the auspices of the African Union will go the same way.
The Civil Society Forum on the African Charter on the Rights and Welfare of the Child (ACRWC) has written this open letter to G8 Countries to urge them to meet their promises for external funding to African countries, noting that countries have failed to fulfil their promise for increased aid allocation to Africa – with assistance from France and Germany increasing by just 25%, while Italy is actually set to reduce its contribution by 6% this year. They also urge for continued commitment within Africa to pledges made by leaders. The members note that while domestic allocations are difficult to achieve with all the pressures on very limited resources, they are critical for the health sector if we are to meet the MDGs. The letter draws special attention to the need for investing in maternal, newborn and child health. ACRWC is urging African leaders to endorse the letter. They ask readers to circulate the letter through networks and for those connected, directly to the Africa leaders.
In a landmark moment on May 21 2010, the World Health Assembly adopted the Code of Practice on the International Recruitment of Health Personnel. It marks the culmination of a decade of advocacy on the recruitment and flow of skilled health workers, particularly from Africa to high income countries. In 2001 Southern African Development Community (SADC) health ministers called recruiting health workers from their understaffed, overburdened health systems ‘looting’ and observed that the outmigration of skilled people ‘further entrenches inequitable wealth and resources’. In 2009, despite having 25% of the global disease burden and 60% of people living with HIV, Africa had only 1% of global health spending and only 2% of the global health work force. It is clearly inequitable to lose health workers from low income countries with high health need to the richest countries in the world with significantly lower disease burdens.
Migration is not the sole factor leading to understaffing. In 2000, WHO estimated that African-born doctors and nurses working in high income OECD countries represented no more than 12% of the total shortage in the region. Inadequate production, limits to health worker training, employment and conditions imposed by resource shortages and fiscal thresholds, the disincentive of falling real wages in the health sector and other factors have been cited for shortfalls. Neither are the drivers for migration solely due to pull factors from high income countries. Economic, political, social and health system conditions in Africa are significant push factors driving migration.
In 2004, motivated by African countries, the World Health Assembly (WHA) requested the Director-General to develop a code of practice on the international recruitment of health personnel and to give consideration to the establishment of mechanisms to mitigate the adverse impact on developing countries of migration. Notably African countries sought to address both ethical recruitment and compensation for the losses they were experiencing through migration, including lost public investments in training, weakened capacities in health systems, loss of expertise and social disruption. Estimates set this at $60 000 in training costs alone for each doctor. In 2001 WHO estimated that South Africa lost US$37 million annually in direct financial losses in training costs, against OECD report of a combined (multilateral and bilateral) total education assistance received by the country in 2000 of US$35.5 million. Further, having experienced continued and rising outflows and foreign employment of health workers even in the face of codes such as the 2001/4 UK Code of Practice, African countries were concerned about how to ensure compliance with any instrument for managing recruitment. Within the SADC region, more binding measures were being used, such as the 2006 South African policy on recruitment and employment of foreign health professionals, which forbade individual applications from identified developing countries, in particular from SADC countries.
After six years of advocacy and work on the issue, the 2010 WHA adopted the global Code of Practice on the International Recruitment of Health Personnel. Its development has included multi-stakeholder consultation and review, including civil society through the Global Health Workforce Alliance, and the WHO regional forums. EQUINET was one of the more than 75 organisations making submissions on the draft. Country submissions on the draft submitted to the Assembly through the WHO Executive Board continued to reflect polarised positions on certain issues (see A63/INF.DOC/2 at http://apps.who.int/gb/e/e_wha63.html). The consensus outcome on the code was thus cause for specific recognition of role of the USA and African delegations in reaching agreement. The new Code of Practice is now the fourth WHO global legal instrument. The Framework Convention on Tobacco Control (FCTC) and the International Health Regulations are legally binding international treaties, while the Code of Practice on the International Recruitment of Health Personnel and the International Code of Marketing of Breast-Milk Substitutes are both voluntary instruments.
The new Code includes ten articles advising both source and destination countries on how to regulate the recruitment of health personnel, as a core component of national to global responses to health systems strengthening. The text makes clear that it is voluntary, and serves as a reference for countries in establishing or improving more binding national laws, policies, bilateral agreements and other international legal instruments on health worker recruitment. It links “properly managed” recruitment to health systems strengthening, especially in developing countries, and to safeguarding the rights of health workers, including their labour and social rights. It raises that countries should mitigate the negative effects and maximise the positive effects of migration on the health systems of the source countries, should plan workforces to reduce dependency on migration and should facilitate circular migration. It provides for gathering and sharing of data and information on international recruitment of health personnel.
Will it address the equity concerns that African countries have raised?
The commitment to developing countries, to health systems strengthening, to fair treatment of migrant workers and to ethical recruitment all signal that the code is a major step towards just outcomes.
Equity is less explicitly addressed within the code than in the debates that led to it. There is no reference to compensation. This was resisted by countries such as Canada, UK and Australia, who did not sign the earlier 2003 Commonwealth Code of Practice in part for its reference to this. Even reference to “mutuality of benefits” or “balancing” of gains and losses included in earlier drafts has been removed in the final draft. The code does make reference to the obligations of governments to protect population health and to equitable health systems. It recognises the “negative effects of health personnel migration on the health systems of developing countries” (Article 3.2), and the greater need of developing countries to health systems strengthening. In its remedies, while Article 5.1 seeks to ensure that both source and destination countries derive benefits from international migration, it does not include any reference to balancing or fairly distributing these benefits. Measures of technical assistance, training and other areas of support are thus included as means to “promote international co-ordination and co-operation on international recruitment of personnel” (Article 5.2), and not as measures of redress for negative effects of migration.
Perhaps this outcome reflects the balance of resources, political forces, power and formal evidence. The resource flows between source and receiving countries are neither simple to collect nor manage. The costs and returns accrue at different levels to individuals, households, communities, private and public sectors. Many of the flows and the measures to manage them lie outside the health sector, in economic, tax, immigration, employment, social security and other areas.
Nevertheless, these constraints and the goodwill around the code should not make it a smokescreen for the continuing research, innovation and dialogue needed to build on the code to further improve fairness and equity in managing these flows. The code has not limited itself to health sector measures, as some measures proposed such as “circular migration” will have implications for immigration, citizenship and labour market laws. Further, an explicit commitment to equity in Article 5.7 provides that “member states should consider adopting measures to address the geographical maldistribution of health workers” could be read to call for measures and resources at national, regional and international level. The code should thus be taken as a platform from which to further explore, develop and raise through its future review at WHA the options for measuring and fairly managing the resource flows between countries, including through tax and funding measures.
Taking the voluntary code to binding agreements and practice is the next front of action, as is monitoring and raising evidence to inform implementation for the next formal global review of the code at the 2012 WHA. Both areas raise challenges if countries in the region are to keep the push for equitable outcomes: to overcome information and evidence gaps, to inform and negotiate fair bilateral agreements, and to ensure that bilateral agreements reinforce and do not disrupt agreements that encourage skills production, circulation and retention within the region, such as the SADC protocols and strategies on education and training, on the movement of persons and on attracting and retaining health professionals.
Experience on prior codes suggests that civil society can play an important role in advancing implementation if effectively engaged. In particular, health workers, and especially female health workers, should not become commodified ‘objects’ to be traded in negotiations, but actively informed and involved through their associations.
Philemon Ngomu of the Southern African Network of Nurses and Midwives (SANNAM) reminds us, further, that the code is only one of a number of measures to address the conditions affecting recruitment and migration: “The very negative implications of political unrest and socio-economic crisis are major driving factors, and the code should not be taken in isolation of peace keeping and socio-economic and welfare initiatives. We cannot stop brain drain without addressing these issues”. When countries report back to the next United Nations General Assembly on the code, as feedback on Resolution 64/108 on Global Health and Foreign Policy, hopefully they will raise this, and make the point that the code is a significant milestone, but not a finishing line, in the path towards the fairer outcomes for health that African Health Ministers sought in 2001.
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 in this op-ed please visit the EQUINET website at www.equinetafrica.org. The next newsletter will provide the text of the code and all final resolutions from the World Health Assembly. Interim documents can be found at http://apps.who.int/gb/e/e_wha63.html
African countries face a dilemma that if not reasonably resolved could threaten access to essential medicines. On the one hand countries need to protect their populations against potentially harmful counterfeit medicines, and to protect producers against unfair competition. On the other hand, the laws and measures that do this should not act as a barrier to cheaper, generic medicines. The current proposals for laws to protect against counterfeits in east Africa seem to be excessively weighted towards protecting intellectual property at the cost of access to legitimate generic versions of medicines.
There seems to be no universally accepted definition of ‘counterfeits’. This has caused confusion and created a loophole in determining what a counterfeit product is. The World Health Organization (WHO) has defined a counterfeit medicine as: ’one which is deliberately and fraudulently mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging.’
This definition makes the element of fraud essential in defining a counterfeit medicine, either in relation to the identity or the source of the product. WHO points to the public health risk of using products that have the wrong ingredients or which lack active ingredients.
From an intellectual property perspective, counterfeits are defined in Article 51, Footnote 14 (a) of the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement which limits the definition of counterfeits to trademark and copy right infringements. Under this provision, counterfeit trademark goods mean ’any goods, including packaging, bearing without authorization a trademark which is identical to the trademark validly registered in respect of such goods, or which cannot be distinguished in its essential aspects from such a trademark, and which thereby infringes the rights of the owner of the trademark in question under the law of the country of importation’. This definition refers to only one aspect of intellectual property, that is trademarks, and associates counterfeiting with the issue of trademark infringement.
In their efforts to address counterfeits, East African countries are enacting anti counterfeit legislation. Kenya has a law in place, Tanzania has regulations while Uganda has a draft Bill. These laws have adopted a broad definition of counterfeits. For example section 2 of the Anti Counterfeit Act in Kenya provides that: ’counterfeiting includes manufacture, production, packaging, re-packaging, labelling or making, whether in Kenya or elsewhere, of any goods identical or substantially similar to protected goods without the authority of the owner of any intellectual property right (IPR) subsisting in Kenya or elsewhere in respect of those protected goods….. In relation to medicine, this includes the deliberate and fraudulent mislabelling of medicine with respect to identify or source, whether or not such products have correct ingredients, wrong ingredients, have sufficient active ingredients or have fake packaging’.
Such a definition goes beyond the provisions of the TRIPS Agreement Article 51 above.
It implies that legitimate generic versions of medicines fall within the scope of counterfeits. The provisions have thus raised deep concerns among manufacturers and consumers of generic drugs in low income countries as they effectively withdraw the flexibilities provided in the TRIPS agreement to produce and procure generic medicines for public health reasons, and may thus deny patients access to safe and effective, high quality generic drugs.
Generic drugs are produced and distributed without patent protection. They should contain the same active ingredients as the original formulation and be tested to ensure that they are safe and effective. They are usually available once the patent protections afforded to the original developer have expired. However generic drugs can be available during the life time of a patent if national laws provide for the TRIPS flexibilities, under which governments may issue compulsory licences to purchase generic drugs if they are needed for public health reasons. The provisions for compulsory licensing allow for exact copies of the brand to be produced without the consent of the patent owner. Generic drugs made available on under compulsory licensing are not counterfeits, as they are neither fraudulent nor do they infringe trademarks. The proposed legislation on counterfeiting in many east African countries does not recognise this.
For instance the law already enacted in Kenya (Kenya Anti-Counterfeit Act 13 of 2008) and that being proposed in Uganda (Uganda Counterfeit Goods Bill 2009) require the consent of the intellectual property owner to produce a generic version of the drug. This implies that should the manufacture of the generic drug take place without this consent, then what is manufactured is a counterfeit. This requirement undermines the States’ ability to use the TRIPS flexibilities and wrongly applies controls for fraudulent medicines to producers of generic medicines.
The TRIPS flexibilities have been contested in the past as they bias trade law towards social equity and away from corporate interests. The new counterfeit laws open a new possibility for multinationals to limit the flexibilities. The East African Community (EAC) is currently working on a policy and law on Anti-Counterfeiting, Anti-Piracy and Other Intellectual Property Rights Violations, as a “robust legal framework for the protection and enforcement of Intellectual Property Rights” in the region. The technical inputs to this need to be adjudicated for the interests they are advancing. For example, the East African Business Council has reported receiving support for its inputs on anti counterfeiting laws from the Investment Climate Facility. Based in Dar es Salaam, Tanzania ICF describes itself as a unique partnership between private companies, development partners and governments. As viewed from their website, ICF aims to work with receptive African governments to make the continent a better place to do business (http://www.icfafrica.org/). While there are legitimate business interests in protecting against fraud or infringement of trademark, it seems unlikely that an organization like ICF would thus draw attention to provisions that limit business, like the TRIPS flexibilities, when these open branded drugs to price competition from generics. An imbalance in the focus on intellectual property to the cost of access to medicines is precisely what motivated the TRIPS flexibilities, and the same imbalance appears to be creeping back.
Governments should ensure that their counterfeit laws continue to protect gains won through the TRIPS flexibilities and use these fully. For this, counterfeit laws should be clear in their definitions and exclude any possibility of generic medicines being covered by these definitions. Producers of generic medicines should not have to apply for permission from the intellectual property when they are covered by government compulsory licenses and provisions for parallel importation. Drug regulatory authorities should have a role in administration of proposed anti-counterfeit laws where this relates to determinations on counterfeit medicines. It is important for countries in East Africa, and the region as a whole, to ensure that in solving one problem they do not create another. The harm caused by communities in African countries not accessing essential medicines would be enormous.
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 in this editorial please visit the EQUINET website at www.equinetafrica.org.
“I feel free- I am liberated by this new skill- I am now able to communicate my world.”
Meso Ulola, a community member from Bunia, eastern Democratic Republic of Congo pointed to his camera as the instrument of his liberation. Behind him a sequence of photographs from his community told a story: a pregnant woman blocked by a river from the road to health services; community members discussing issues around chalk images on a board; young men heaving logs across a river and images of a motorbike crossing a newly constructed bridge.
In the last five years EQUINET has through Training and Research Support Centre and Ifakara Health Institute been supporting institutions that work at community level to carry out participatory action research studies in east and southern Africa. In each of the nine country sites, in both rural and urban settings, these studies have explored how communities are interacting with health systems. The issues they addressed ranged from how to overcome the barriers people who consume harmful levels of alcohol face in adhering to ante-retroviral treatment, to how to improve communication between people and health workers in local health planning. The reports of these studies can be found on the EQUINET website (www.equinetafrica.org). However, we struggled with how the communities involved could themselves communicate the realities of their lives, actions and insights, and be useful to community discussion on how to address the determinants of health.
We proposed to use photography as one tool for this. Facilitators and community members from the participatory work in seven sites coming from DRC, Kenya, South Africa, Tanzania, Uganda, Zimbabwe and Zambia were trained in photography skills and we embedded photography within the participatory work. We wanted the photos to express the lives of the people involved, to show the diversity of views, to allow both painful and hopeful images to surface, to pose questions, probe, give visions of solutions and actions. The photos were as much a means to encourage local community discussion as to raise wider awareness and community voice on issues. This was not an academic exercise, or about outsiders documenting people as victims, but about community members documenting their own situation and actions to improve social justice in health. We called it “Keeping an eye on equity: Community visions of equity in health”.
It wasn’t straightforward. How to recharge batteries of cameras in communities that had no electricity? How to share photographs so all could comment when internet access is limited and slow? However even from remote areas in Western Kenya or a border town in Zimbabwe, the photos were uploaded to a shared website, we sent comments to each other, and the stories began to emerge through the images. After several months, the photographers chose those images that best communicated their reality and stories. These were compiled, have been shown locally in each setting in different ways, and will be used in ongoing work. They were also compiled by TARSC into an exhibit from all the countries at EQUINETs regional conference on equity in health in September 2009, and used to stimulate discussion on the issues raised, and on the power of different kinds of evidence in catalyzing action on health equity. As one participant at the conference commented: “From other sources of evidence I imagined reality. From the photos I saw reality”.
Some of this work is now produced as a book newly available on the EQUINET website at www.equinetafrica.org/bibl/docs/Eye%20on%20Equity%20book2010.pdf. The book introduces and communicates the work underway, and opens discussion on community photography as a tool for change.
Did we achieve our goal, of raising reality and issues as communities see them, and giving communities more direct voice in advancing equity in health?
When we brought the work of all the countries together, new patterns emerged. For example children and women featured strongly across the images. Its clear that we feel injustice strongly when we see children in unfair and harmful situations. It motivates us to act. Women constantly appeared in the images as active not passive. The images showed how women, often invisibly, are using the resources available to take diverse actions for health. The photographs provided a new lens to discuss what was going on in communities, often raising issues that had become invisible or hidden. Discussing the experience, the community photographers observed that “the camera allowed is to connect with people in unexpected ways, and to hear people’s opinions of their health and health care. The camera seemed to open new channels of communication, raising issues that may otherwise have been buried”. Others observed, “our photographs made us look afresh at unhealthy situations. They have also encouraged us by showing what we have achieved”.
This is important given that our participatory research showed that our health systems have high legitimacy, but weak capabilities for social roles. They weakly address barriers and facilitators to uptake of services and there are many communication gaps between health workers and communities. These issues are well within our grasp to change, but communication is vital for this. The most vulnerable in communities often face an imbalance in power, skills and common language in communicating with health workers, and may deal with this by dropping out of services. Our experience suggests that community photography, embedded within participatory, collective processes, may be one way of offering new power to communities to collectively show their realities, without feeling limited by language.
The way we use and respond to photography has as much to with reclaiming the resources for health as the way we implement research or use evidence. We are bombarded by visual images every day of our lives – pictures on billboards, on many of the consumer products we buy, in leaflets, posters, books, on television or media. Every day we unconsciously interpret and respond to these images, influencing our attitudes, beliefs, values and life style. As Susan Sontag said in 1973, photographs invite us to think or feel in particular ways and “… are inexhaustible invitations to deduction, speculation and fantasy.” In our work as health facilitators and activists, we see that photography in the hands of communities has the potential not only to give communities the power to present reality as they see it, but to use these images to move people from a point of feeling to questioning, to thinking about what change is needed. This is the power of the visual in the right context – to play a part in this process.
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 in this op-ed please read the PRA reports on the EQUINET website and the Eye on Equity Book.
In the last weeks of 2009, the UN held a meeting in Copenhagen to thrash out a comprehensive global agreement that could be converted into an internationally legally binding treaty to prevent dangerous global warming. By the end of the Copenhagen conference, the outcome was far from this: The conference accord preserved the Kyoto protocol, and while it recognised that global warming be limited to an increase of less than two degrees centigrade, it did not set targets for greenhouse gas cuts. While it set an aim to provide $30bn a year for poor countries to adapt to climate change rising to $100bn a year by 2020, it did not detail the source of these funds. It set no deadline for the conclusion of the climate talks.
The failure at Copenhagen has deep implications for people’s health, particularly in Africa, where the Intergovernmental Panel on Climate Change warn that consequences of global warming, such as loss of wetlands, will lead to increased frequency and severity of drought, further jeopardising food security (http://www.ipcc.ch/ipccreports/tar/wg2/index.php?idp=667). But what role do health activists play in this struggle? What are the special interests of health activists in relation to climate change and what special leverage might people’s health networks contribute in controlling the drivers of global warming? With the prevailing global inequities and the heavy disease burden and high barriers to health care in low income countries, such as in Africa, we need to understand the North- South dimensions of the Copenhagen fiasco.
It appears that the high income countries approached Copenhagen with low ambitions and high conditions, including conditions that tied their own action to comparable commitments from the big developing countries like South Africa, downplaying the role that emissions from high income countries have played in the historical accumulation of greenhouse gases. It appears that the big developing countries, led by China and India, were unwilling to accept the kind of restrictions on their economic development that were being canvassed and were unwilling to slow down what they described as the liberation of millions of desperately poor people from poverty. With pathways to less harmful economic development dependant on access to the necessary non-polluting technologies, the developing countries were not happy with the offers from the rich countries on this front.
Control of global warming and opportunities for economic development are both framed by the wider regime of global economic governance. The inequities, imbalances and instabilities of the global economy, manifest in the global food crisis and the global financial crisis, are direct reflections of this regime. Neoliberal globalisation is built upon a consumerism (with concomitant carbon pollution) that marginalises a billion humans, who are required neither for their labour power nor their buying power. In Copenhagen these inequities were again unmasked, in relation to the crisis of global warming.
It is untenable that these global policy challenges should be allowed to force a choice in low income and developing countries between economic development OR a mitigation of global warming. Rather we need to work towards a regime of global economic governance which reconciles the need for sustainable economic development for countries in Africa and other parts of the global south, and the need to contain global CO2 levels to 350ppm. Such a regime is technically and economically possible. The main challenge is political.
What does this mean for health activists? It raises four imperatives:
Firstly, we need to get our facts straight and build a robust analysis. We need to understand clearly the positions that were advanced by the various groups of countries at Copenhagen, put them in the context of the political economy of energy and global economic governance, and explore their health implications.
Secondly, we need to put sustainable economic development at the forefront of a shared struggle for health and for tackling global warming. This is not the high consumption, low employment, neoliberal globalised production model of development, but a more sustainable autonomous development, based to a large degree on local production and supply.
Thirdly, we need to build pressure on all governments, north and south, to accelerate the reform of domestic energy production and energy use, while continuing to work for binding international agreements.
Fourthly, in addition to energy efficiency and the move to renewables, we need to profile energy equity, or the fair distribution of energy resources across countries, social groups and generations. This has implications for high income countries, where the profligate use of carbon based energy is embedded in culture, economy and infrastructure. It also has implications for the elites and middle classes of low income countries. It calls for an alternative culture of global solidarity.
These four imperatives have implications for the work of health activists.
Comprehensive primary health care is fundamental for improving access to health care and action on the social determinants of health. It is also a strategy of social change through community mobilisation based on partnerships between PHC practitioners and the communities they are serving. It follows that energy reform must be included in the discourse on ‘the social determinants of health’ and community mobilisation for health. It must also be clearly contextualised in relation to the same problems of current economic globalisation that drive inequity in health, raising the challenge of global economic reform.
Global solidarity is central to taking forward comprehensive PHC. This calls for health activists to build communication channels and opportunities for collaboration across various axes of difference (nation, race, gender, religion as well as class) so that the forces for progressive global change can be more coherent and effective. Energy reform (including energy equity as well as efficiency and the use of renewables) must be included in this communication, in the context of economic globalisation.
Intersectoral collaboration is a core principle of all public health work. This calls on health social movements, like Peoples Health Movement, to build relationships with social movements who share common perspectives and values within other sectors, including with those engaging on global warming, environmental justice and energy reform.
Under the banner of the ‘right to health’, health as a basic human right de-normalises the status quo and inspires communities in their struggle for access and for decent living conditions. This is a political struggle as much as it is a moral claim. The political analysis which guides this practice must take us beyond the noise of Copenhagen to explain the workings of neo-liberal globalisation in relation to health, economic development and global warming. Opportunities like the Third People’s Health Assembly, planned for Cape Town in July 2011, are thus important for us to deepen our understanding of these relationships and what this means for our work as health activists in Africa, and globally.
Editor's comment: This issue EQUINET includes a focus on what the climate change discussions mean for health in east and southern Africa. We welcome materials, comments and editorial input from others working in this area, to further develop our work and understanding in the region. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please also visit the websites of the People’s Health Movement http://www.phmovement.org/ and International People’s Health University http://www.phmovement.org/iphu/