The World Health Organization (WHO) recently released the first set of comprehensive data comparing the prevalence of HIV/AIDS in poor countries with the rates of antiretroviral (anti-HIV) drug access in those nations. The data are striking and disheartening, yet have received little press coverage. Indeed, at the time of their release, some American newspapers ran editorials indicating that antiretroviral access has received "too much attention".
Two problems are implicit in such a contention. The first is political. AIDS is very much a symptom - albeit the most extreme symptom - of the large diseases of inequality and poverty that result not only in HIV, but also in hunger, hemorrhagic fever and housing problems. The same credit and political obstacles that have led to gender discrimination in housing and employment have led women into prostitution and relationships based on sexual dominance [1, 2]. The same structural adjustment programs and neoliberal economic policies that have crashed farming sectors and forced thousands into migration are the same policies that have led migrants to the barracks of minefields to live with depression, alcoholism and the subsequent solicitation of prostitutes [3-5]. And so to address AIDS appropriately would be to appreciate that it does not simply receive "too much attention", but that the attention it receives should be drawn towards its base - and this includes the inequalities in healthcare access that are symbolized by antiretroviral access disputes.
The second problem with the new popular line of thought on antiretrovirals is a statistical problem. The recently-released WHO data are striking but perhaps not surprising. If "too much attention" has been focused on drug access, then why are only six-tenths of a percent of the 1.6 million infected people in Tanzania able to access antiretroviral medications? Why are only 1.5% of the 2.4 million in Mozambique and the Congo able to gain such access? In a country like Zimbabwe, where one of every four adults is infected, only one of every fifth can access an antiretroviral medication. As one scrolls through the WHO's data, the numbers of infected persons continue to be expressed in seven digits, while the percent of those gaining access to antiretrovirals continues into smaller and smaller decimal ranges.
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The World Health Organization (WHO) recently released the first set of comprehensive data comparing the prevalence of HIV/AIDS in poor countries with the rates of antiretroviral (anti-HIV) drug access in those nations. The data are striking and disheartening, yet have received little press coverage. Indeed, at the time of their release, some American newspapers ran editorials indicating that antiretroviral access has received "too much attention".
In the context of Africa’s present health crisis, only people suffering from policy blindness can fail to see that Africa’s survival as a continent depends on going beyond merely declaring emergencies, and actually financing and implementing universal primary health care (PHC).
In September 1978, the International Conference on Primary Health Care was held in Alma-Ata, Kazakhstan, then part of the Union of Socialist Soviet Republics (USSR). Led by the World Health Organisation (WHO), the conference produced the Alma-Ata Declaration, which underlined the need for governments to protect the health of all citizens and emphasised that health for all is both a socio-economic (or development issue), and also a human right. The conference also highlighted the inequalities between developed and developing countries, and between the elite and ordinary people within countries.
One of the most significant outcomes of the conference through the Alma-Ata Declaration identified primary health care as ‘the most efficient and cost effective way to provide health care’. This has been recently reemphasised by the current Director General of the WHO Dr Margaret Chan.
Going by its definition of ‘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 the principle that ‘[h]ealth services must be shared equally by all people irrespective of their ability to pay and all (and rich or poor, urban or rural) must have access to health services’, it was assumed at the time that with effective implementation PHC would lead to health for all by the magical year 2000.
Based also on the understanding of health agencies, professionals and academic institutions that ‘primary health care needs to be delivered close to the people’ through ‘maximum use of both lay and professional health care practitioners’, experts have distilled down the basic principles of primary health care to several core factors, including: • Public education for the identification, prevention, and control of prevailing health challenges • Education on and provision of proper food supplies and nutrition, including adequate supply of safe water and basic sanitation • Provision of maternal and child care, including sexual and reproductive health education, and family planning • Immunisation and vaccinations against major infectious diseases. • Prevention and control of locally endemic diseases • Appropriate treatment of common diseases using the most up-to-date, cost effective and appropriate technology • Promotion of mental, emotional and spiritual health • Provision of essential drugs and commodities.
It cannot be emphasised enough that these primary health care principles can only be possible through long-term sustainable and combined financing of both health systems, and disease specific interventions. The phantom debate over ‘health systems versus disease specific interventions’ is a false one and a diversion equivalent to asking if food is more important than water to human life. It should be reasonably obvious that health systems without medicines and commodities are as useless as medicines and commodities without health systems. This applies to all health issues, whether malaria, TB or HIV/Aids.
Sustainable and long-term health financing must therefore mean identifying the specific challenges and obstacles to primary health care, and on the basis of costed plans work out clear and timely frameworks for resolving these obstacles. In addition to disease specific and wider health system challenges, this includes focusing on the resolution of key obstacles such as the lack of policies and financing sustainable plans for reproductive and sexual health, and resolving Africa’s critical health workforce shortage.
This editorial comes from the joint EQUINET newsletter issue with Pambazuka for the thirty years of Primary Health Care. The Africa Public Health Alliance & 15% Now Campaign engages African governments, global and African and institutions on implementation of the AU Africa Health Strategy, Health MDGs and fulfilling the AU Abuja pledge to allocate 15% of domestic national resources to health. For further information on the issues raised contact email@example.com
This editorial is drawn from a speech by Dr Halfdan Mahler to the World Health Assembly in May 2008. Dr Mahler was the Director General of WHO at the time of the 1978 Alma Ata declaration on Primary Health Care. He stated at the 2008 WHA:
Milan Kundera wrote in one of his books: "The struggle against human oppression is the struggle between memory and forgetfulness." So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO's Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
This definition is immediately followed by: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Most importantly, the very first constitutional function of WHO reads: "To act as the directing and coordinating authority on international health work." Please do note that the Constitution says "the" and not "a" directing and coordinating authority.
So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.
My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as "Health for All".
And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.
That is, I believe as it should be.
When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.
Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.
To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today's so-called health professions very conventional, indeed.
It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.
Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.
Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.
These concerns, to which I have just alluded prompted an organizational study on "Methods of promoting the development of basic health services" by WHO's Executive Board in 1973 in which it is bluntly stated that:
"There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer".
It was this organizational study by WHO's Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene "The International Conference on Primary Health Care" in the city of Alma-Ata in 1978.
Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:
"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 the 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."
Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.
Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have-nots" and to adopt concrete measures to reduce it?
Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development?
Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?
Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?
Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?
Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?
Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?
Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?
Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: "I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight."
The Alma-Ata primary health care consensus also reflects a famous truism: "The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!"
In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.
Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.
For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.
Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.
But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.
And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.
And so, distinguished audience, let us use the complete light generated by WHO's Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.
The conception and birth of the Global Health Watch
Five years ago, about 1500 people from 80 countries met in Bangladesh at the first Peoples Health Assembly. The Assembly was organised as a counter-balance to the official World Health Assembly convened every year by World Health Organisation, and represented a protest against the failure to achieve health for all by the year 2000.
The Assembly gave renewed expression to social objectives such as fairness and the universal right to health care, as well as to the public health principle that in addition to providing health care, health systems and health professionals must act to abolish poverty and work towards people having access to education, nutrition, water, sanitation and peace.
It also gave birth to the Peoples Health Movement – a network of individuals and organisations from all regions of the world, formed with the understanding that the principles of the Charter would only be achieved through social mobilisation and political engagement. The Global Health Watch, an alternative world health report from the perspective of civil society, was designed as an instrument to support advocacy and mobilisation. Amongst its aims is to provide a platform that will embrace the science and politics of development, and thereby, simultaneously involve academics, health practitioners, parliamentarians, journalists and civil society in improving health and equity.
More than 120 people – researchers, health workers, non-government policy analysts and campaigners - and 70 non-government organisations contributed to the report. The connection of the Watch to the Peoples Health Movement and a wide range of NGOs will hopefully ensure that it doesn’t end up as another report gathering dust – disengaged from the vehicles that can help translate analysis and recommendations into actual action. Already a number of NGOs have volunteered to host launches of the Watch in other countries, including Malaysia, South Africa, Ireland, Egypt, Germany, Holland, and the US.
The Watch is not designed to report on the state of health and poverty – it is not about the size of the HIV pandemic, or the number of children who die every second; or the declining life expectancy in Africa. The aim is to provide a report on what is being done about improving health by reporting on the actions, policies and programmes of organisations charged with improving health. This idea of “watching” the performance of key institutions can also be viewed as a contribution to democratic deficits that exist at many levels of decision-making and the erosion of public accountability that has accompanied globalisation and the concentration of wealth and power.
Global political and economic institutions
According to the Universal Declaration on Human Rights, people do not just have a right to an adequate standard of living and medical care – they also have a right to live in a social and international order in which the rights to medical care can be realised. However, this right is continually violated. According to the World Commission on the Social Dimension of Globalisation, “none of the existing global institutions provide adequate democratic oversight of global markets, or redress basic inequalities between countries”.
The Watch questions the success story painted by proponents of the current form of globalization, pointing to increases in poverty in Africa, eastern Europe, central Asia and Latin America. Producers in developing countries have often been undermined by increased global competition from powerful nations after trade liberalisation. In Mexico, for example, the liberalisation of the corn sector under the North American Free Trade Agreement, led to a flood of imports from the United States, where agribusiness is massively subsidised. Mexican corn production stagnated whilst prices declined. Small farmers became much poorer and some 700,000 agricultural jobs disappeared over the same period. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased.
To change this will require a shift away from the dominant human rights discourse which focuses on the obligations of national governments towards their own citizens, towards more of a focus on a) the obligations of governments to the citizens of other countries; and b) the obligations of non-government actors, as well as the rules by which the world economy is controlled and governed. Furthermore, whilst some countries have social contracts, progressive taxation systems and laws and regulations to manage the human consequences of market failures at the national level, there is no ‘global social contract’ to manage the failures of globalization.
World Health Organisation (WHO)
A key chapter in the report is dedicated to WHO. The report argues that WHO is insufficiently resourced, inadequately empowered, undermined by national political agendas and handicapped by internal management problems. WHO does many things well and repeatedly demonstrates the need for a multilateral agency charged with protecting and promoting health, but the Watch calls for better funding and improvements in WHO’s operating environment. The report also notes that the proliferation of public private initiatives, vertical programmes and the insidious influence of the World Bank has resulted in WHO being further undermined as the leading global health agency.
But we need, for example, a WHO that can challenge and aspire to block trade and economic agreements that threaten to harm health and human rights. As a starting point, the Watch calls upon WHO to convene a delegation of public health and trade experts to attend the trade talks in Hong Kong this year, mandated with the role of providing public health advice to Ministries of trade and finance. But this simple request is unlikely to be granted without public lobbying. At the most recent Executive Board meeting of WHO, a mild resolution put forward by developing countries requesting WHO to conduct a more active analysis on the impact of trade on health was blocked by the US and other countries – illustrating the impotence of WHO in tackling the more fundamental determinants of health.
Other recommendations aimed at WHO include:
Steering the global health ship
- Substantially increase funding for WHO with more proportionately devoted to its core budget with fewer strings attached;
- Open a debate on WHO’s key roles to avoid mission-creep and to develop consensus within and beyond the organization;
- Strengthen WHO’s role at country level and give it a mandate to help governments co-ordinate global, bilateral and international NGO initiatives to improve health.
An organization of the people not just of governments
- Expand current efforts to reach out to civil society, especially in the developing world;
- Ensure that public-interest civil society organizations are differentiated from those acting as a front for commercial interests;
- Improve the nature of the WHO leadership elections – possible solutions include a wider franchise, perhaps of international public health experts and civil society organizations. Candidates should be required to publish a manifesto and debate their vision for the organization publicly.
Improve the management of the organization
- Improve the mix of the professional staff, ensuring that there are more social scientists, economists, public policy specialists, lawyers and pharmacists. More representation from developing countries should be coupled with stronger regional offices run by experienced professionals.
The corporate sector
Of the 100 largest economic entities in the world, 51 are businesses; and the combined sales of the top 20 businesses are 18 times the combined income of the poorest 25% of the world’s population. Transnational corporations wield immense power through their wealth, control of resources and influence on governments and key decision-making bodies, with profound consequences for health and development.
The price of medicines and the radical changes to the way we construct patents; the resistance to making the required changes to address climate change; widespread labour exploitation and occupational health hazards; the dumping of cheap, subsidised food in Africa; the corrupt trade in weapons; the unchecked pollution of many extractive industries; and the unhealthy changes in food eating practices are just some examples described in the report, of the causal relationships that exist between profit-seeking corporate activity and the state of global health.
While commercial activity and free enterprise in themselves should not come under attack, the deterioration of democratic control and oversight over corporate actions and power must be highlighted. The imbalance between corporate freedom and social obligations is unhealthy, and health professionals need to assert their public health authority to limit the negative consequences of corporate actions, and ensure proper regulatory frameworks.
The attention paid to the corporate sector also leads us to shift thinking away from an exclusive focus on poverty towards an equally necessary focus on wealth, and in particular one what many would call obscene wealth. One of the demands we make is for the establishment of an international tax authority to help recover the conservatively estimated US$255 billion that is lost annually through tax avoidance.
This is an amount of money, in spite of the low tax rates, that would fund comprehensive and functional health care systems in every poor country. Public-private partnerships and corporate social responsibility programmes are great, but the Watch calls for the greater use of legitimate, fair and non-punitive instruments of public policy to ensure the universal provision of health care and social security, and the redistribution that is required to reverse the politically unsustainable deepening of global disparities.
The chapter on health systems sets a very different agenda from the one currently popular with donors, where the emphasis is on fragmented, vertical health programmes usually focussed on one or two diseases, or on particular selected interventions. The Watch describes how Ministries of Health in poor countries operate in a policy circus, pulled in a hundred different directions by different programmes, donors and agencies, undermining coherent and integrated health systems development. In many instances, these agencies also contribute to an internal ‘brain drain’ – sucking many of the most skilled professionals out of public health care systems.
In the poorer countries, this has come on top of economic crises, structural adjustment programmes and neoliberal reforms that have decimated public health care systems and extended the commercialisation of health care to the detriment of equity, accessibility and efficiency.
The Watch presents new evidence which suggests that higher levels of private finance and provision lead to worse health outcomes, and explains how private financing and provision leads to a commercialisation of health care systems which widens health care inequities, lowers access to care for the poor, causes inefficiencies and deteriorates levels of trust and ethics.
Unless a common vision of health care systems development is established, we will not achieve the health-related Millennium Development Goals. The Watch therefore calls for the adoption of a 10-point agenda to repair and develop health care systems (more detail on the recommendations is available from both the Watch itself and the accompanying advocacy document, Global Health Action):
1. Provide adequate funding for health care systems;
2. Take better care of public sector workers;
3. Ensure that public financing and provision underpin health care systems;
4. Abolish user fees that push people into poverty;
5. Adopt new health systems indicators and targets that incentivize countries to improve the health system rather than simply tackle specific diseases;
6. Reverse the commercialization of health care systems by using regulatory and legislative instruments; and search for ways in which the private sector’s resources can be harnessed for the public good;
7. Strengthen health management and adopt the District Health System as the model for organising health care systems;
8. Improve donor assistance within the health sector;
9. Promote community empowerment to improve the accountability of the health system;
10. Promote trust and ethical behaviour to combat the corrosive effects of commercialization.
At the moment international health agencies consistently stress the importance of strengthening health care systems – but with little debate or discussion as to what this actually means. This is one area where WHO can really play a positive role and demonstrate health sector leadership.
Global Health Watch 2
Planning for the second edition of the Watch has begun. But between now and then, the challenge will be to actively mobilise the broader health community around the Watch and the advocacy agenda that accompanies it.
At the launch of the report in London, NHS organisations and professional associations were asked to think of institutional responses to the global health crises by:
- Developing long-term ‘partnerships’ with counterparts in poor countries - involving support, the transfer of material resources, skills and technology – and also providing a mechanism by which health workers in the NHS can learn and understand the impact of UK actions and policies on global health);
- Daring to put aside a proportion of money to promote global health until such time that we have a mechanism to recompense poor countries for training so many of our health workers;
- Implementing fair trade and ethical purchasing policies within our own organizations; and
- Campaigning for change. Medact, which was established specifically as a membership organization for health workers to promote global health, provide one concrete vehicle by which individual health workers can work together to lever change.
In southern Africa, the health and development community should consider ways in which the Watch can be used as a tool to strengthen and develop a progressive global public health movement and greater public accountability.
* David McCoy and Mike Rowson are managing editors of GHW
* Please send comments to firstname.lastname@example.org
The number of people in the global South without access to adequate basic services is staggering, not least in Africa. For more than two decades, international financial institutions have prescribed private sector participation as the remedy, often with disastrous consequences. Recently, critics of this approach have given new visibility to ‘alternatives to privatization’ to counter this trend.
Although the debate about alternatives to privatization in the water sector has been particularly dynamic, the health sector has been slower to recognize and promote new models. Similarly, Africa has developed fewer alternatives than Asia and Latin America – although the African health sector has seen some innovative community health insurance schemes and reliable non-state provision on a not-for-profit basis.
The Municipal Services Project (www.municipalservicesproject.org) is at the forefront of such research and action, and is releasing a new book this February – Alternatives to Privatization: Public Options for Essential Services in the Global South – in an effort to stimulate further debate and research in this field. The authors who contributed to this book address questions of what constitutes alternatives to privatization, what makes them successful (or not), and what lessons are to be learned for future service delivery debates. The analysis is backed up by a comprehensive examination of initiatives in over 50 countries in Africa, Asia and Latin America, looking at three sectors: electricity, health care and water/sanitation. As the first global survey of its kind, it provides the most rigorous platform to evaluate alternatives to date, and compares them across regions and sectors.
We conceive of alternatives to privatization as those involving public entities that are state-owned and operated, or non-state organizations functioning on a non-profit basis. We propose a normative set of ‘criteria for success’ to make sense of case studies because we believe that some universal claims are necessary if we are going to have a coherent global dialogue about the kinds of service delivery alternatives we want to promote. We have focused on current efforts to make public services more democratic, participatory, equitable, transparent and environmentally sound.
Equity emerges as an important criterion for alternatives because inequity is arguably the single largest concern with privatization, leaving scores of marginalized groups with little or no access to health care and other services. We are particularly interested in equity along class, gender and ethnic lines, and how public services have attempted to overcome these disparities.
Our aim has been to construct a bridge between universal criteria (such as equity) and the particularity of different locations. We recognize the unique realities of each region and the fact that there are no ideal models (in opposition to the neoliberal approach that sweeps away differences and pushes a one-size-fits-all solution). Uganda is not Uruguay is not Ulan Bator, but there are core values and objectives that underscore our definitions of what it means to provide a successful public service and consistent ways to evaluate this success.
Africa may be the weakest region in terms of such successful initiatives, as identified by our researchers, but there is robust popular resistance to privatization and it may play to the continent’s advantage that lessons can be drawn from experiments in other parts of the world.
In the chapter on alternatives to privatization in the African health care sector – African Triage – Yoswa Dambisya and Hyacinth Eme Ichoku identify and evaluate promising models for more equitable health systems. First, they explore community-based health insurance schemes (or mutuelles de santé), which aim to extend benefits to populations excluded from traditional social protection programs and operate on voluntary and non-profit bases, promoting principles of mutual aid, solidarity, and pooling of risk. These systems offer protection from catastrophic health costs and facilitate cross-subsidization. In Rwanda and Tanzania, it appears that such schemes would increase the chances of seeking assistance from formal health care providers rather than opting for self-medication or traditional healers. Ghana also developed an interesting alternative at the community level, sending nurses to live in villages to reduce barriers to geographical access, and setting up local health oversight committees. However, these schemes can also suffer from limited revenue due to low population coverage and can result in a situation where the poorest cross-subsidize the less poor. In short, these types of insurance models can complement, but not substitute, strong government involvement in health system financing.
Second, Dambisya and Ichoku review national health insurance schemes. These are more formal than community-based models but also allow pooling of risk and cross-subsidization of health services, equalizing financial access. Important shortcomings are that they do not erase geographical barriers, leaving rural populations at a disadvantage, and that they cover those in the informal sector last – even though these groups are probably the neediest. Further, such initiatives may not be viable where there is rampant corruption and high mistrust of authorities, as the failure to implement plans for national health insurance in Uganda and Zimbabwe may indicate.
Finally, faith-based organizations emerge as the largest single health care provider outside of government in most of Sub-Saharan Africa. Mission hospitals appear to offer the best quality care, generally operate in an efficient manner, and have stood the test of time. What may be more problematic is the issue of accountability and community participation. Policy makers should look into ways of better integrating these large players into national health systems.
Findings from Latin America and Asia present a very different picture of alternatives to privatization in the health sector, however, and offer some intriguing lessons for Africa, as do lessons from the water and electricity sectors in all regions studied. But despite the differences it is the commonalities that are most encouraging, highlighting a commitment from policy makers, frontline workers, activists and academics to a world that is not dictated by the demands of the market, celebrating public systems that work and pushing for innovative reforms where they don’t.
In the end, the book is just a start and the final chapter concludes with a series of future research and activist priorities, pointing to a long-term and exciting challenge for those committed to a world of social and economic equity.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. For more information on the issues raised in this op-ed please read the book Alternatives to Privatization: Public Options for Essential Services in the Global South published in Africa by HSRC Press and available at http://www.hsrcpress.ac.za.
The 2017 World Health Assembly (WHA70) will be held in Geneva from 22 to 31 May 2017. The agenda and initial documents are being made available at http://apps.who.int/gb/e/e_wha70.html.
WHA70 has a wide ranging agenda, including the election of a new Director General; the management of emergency responses and antimicrobial resistance; research and development (R&D) for neglected diseases; the capacities for and evaluation of preparedness for the International Health Regulations (IHR) 2005, migrant health; and the Sustainable Development Goals (SDGs), amongst other items. It will discuss progress in the implementation of resolutions from prior WHAs and the governance and programmes of the World Health Organisation (WHO).
The WHA is being held at a time when military conflict has terrorized populations and forced displacement internally and across borders, disrupting lives, livelihoods and food supplies, and heightening the risk of epidemic outbreaks. African migrants leaving due to conflict or to seek economic opportunity face many health challenges, including physical and psychological stress and abuse, and poor access health services. Migrancy affects transmission of infectious diseases, including to northern countries now experiencing warmer temperatures due to climate change. WHO has proposed migrant-sensitive health policies that incorporate a public health approach, with universal, equitable access to quality health services that would also assist in surveillance, detection and control of infectious and other health problems and financial protection for migrants. However, there is a wide gap between this and the situation in practice.
Progress has been made in the development of a vaccine against Ebola and control of the yellow fever epidemic in central Africa. The accelerated process for use of the former as an experimental vaccines in health care and frontline workers has raised ethical and equity concerns, while non availability of yellow fever vaccine stocks in the latter case led to fractional dosing (of one fifth of the normal vaccine dose) to stretch resources as an emergency response, which, as indicated by WHO, does not confer longer term protection and is not a measure for routine vaccination. These issues and a Zika virus disease outbreak recently reported in Angola from the Aedes vector responsible for transmitting dengue fever, yellow fever and chikungunya virus infections points to the need for strengthened public health measures to prevent, detect and control communicable diseases, within and across countries. Although much attention has been given to acute infectious disease emergencies, the rising level of non-communicable diseases (NCDs) in ESA countries, including trauma/injuries and cancers represents a major immediate and long term challenge, driven largely by conditions and policies outside the health sector, with health systems that are poorly equipped to detect, prevent and manage them.
These health threats take place against the backdrop of underfunded health systems and inadequate skilled health workers and medicines in our region, particularly in areas of high health need. While 18 million workers are estimated to be needed globally to achieve Universal Health Coverage and maintain pace with SDGs, by 2030 Africa is projected to have a shortage of 6 million health workers. Inadequate and increasingly costly medicines and health technologies undermine equitable access, in a global environment of growing microbial resistance and one that still raises investment, technology transfer and intellectual property barriers to development and production in areas of high health need. This directly links measures to combat antimicrobial resistance to those that ensure community health literacy and equitable access at affordable cost to good quality old and new antibiotics, vaccines and diagnostic tools, and measures for public investment in R&D, local production, pooled procurement and the lifting in practice of intellectual property barriers affecting public health.
There has been progress, particularly in emergency responses. For example, the WHO has set up a Health Emergencies Programme to co-ordinate emergency prevention and response; a collaboration agreement with the Africa Centre for Disease Control (AU-CDC) has stimulated work to build a regional health workforce for emergencies. Incident Management Systems have been established in a number of African countries to strengthen coordination of responses to emergencies and nine African countries have implemented Joint External Evaluations of their IHR core capacities. The WHO Contingency Fund for Emergencies and the Africa Public Health Emergency Fund have been established and have enabled quick response to zika, cholera and yellow fever outbreaks, although with challenges to address, including their alignment to national resources and delays in operationalising and slow disbursement of these funds.
This investment in detection and control of epidemics is welcomed, but the concern in the region is also to prevent epidemics from occurring in the first place. This needs continuous strengthening of health information systems and population surveys to map disease risks and burdens and assess vulnerabilities in the region, to raise and ensure that African priorities are planned for and responded to at local, national, regional and global level.
An East Central and Southern African Health Community (ECSA HC) April 2017 meeting of senior officials and technical actors with input from Geneva-based diplomats in the Africa Group of Health Experts noted that this calls for a pooling of efforts, to respond to emergencies, to co-ordinate R&D and to share capacities and experience in building integrated health systems. Such comprehensive measures recognise that health systems are not simply technical in nature, but signal our social values, including for example in the way migrants are treated, or in how the health workers in conflict and emergency zones are cared for and protected.
Delegates at the ECSA HC meeting called for integrated systems and a one-health approach, rather than a proliferation of new silo’ed vertical programmes and committees. Health for population groups like mothers and children or for settings like urban health should not be treated as another vertical programme, but addressed through making clear linkages with comprehensive health systems and ‘health-in-all-policies’. After a long period of investment in specific disease programmes, investments are now seen to be needed in the institutional arrangements, processes and information systems that support coordination, collaboration and integration of actions within health systems, with other sectors and within and across countries.
A focus on prevention demands action upstream, to map and identify risk and vulnerability and to control vectors and risk environments, both for infectious and non-infectious risks, including those related to chemicals, radiation and food safety. Integration calls for resources and strategies for prevention and response to epidemics and emerging challenges such as NCDs to be linked to broader measures applied to build robust, competent and comprehensive health systems that enroll and involve their communities. It calls for measures to reduce the costs of health technologies and treatment programmes, and to strengthen the independent country and regional regulatory agencies, databases and public health agencies needed to inform and support responses within and across countries.
This resonates with the WHO 2030 agenda calling for a One World One Health approach, that involves strengthening health systems for universal health coverage and inter-sectoral action for health. However two years from the declaration of the SDGs, it is surely time to focus attention on moving from pronouncements to what actions have been taken to implement the SDGs, particularly in terms of the public health issues that are a priority for the region. These are issues for whoever is elected as the new DG, whether from Africa or not. How far are the necessary actions being financed and delivered? What progress has been made in equitable development of and access to research and innovation? What progress is WHO making in reclaiming its leading role in health within the United Nations system, backed by the necessary increase in fixed contributions from countries to ensure its autonomy as global public health authority? What progress have countries made in improving progressive financing and reducing dependence on out of pocket funding? How far have all countries put in place the integrated, comprehensive primary health care oriented systems and public health leadership and capacities needed to meet these challenges and to progressively meet the right to health, leaving no-one behind?
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In this issue we provide in full the communique of the Second BRICS Health Ministers’ Meeting held in January 2013. How far does this emerging concerted voice provide new impetus for the social justice needed for equity in health? While the familiar commitments are included to reducing major disease burdens, there are also welcome signs in the communique of attention to dealing upstream with the "risk" environments for health, of assessing the impact on health "of all public policies at national and international levels" and of commitment to "community empowerment". Equally the communique refers to a commitment to implementing measures for technology transfer and co-operation across low and middle income countries, such as for ensuring production and access to generic medicines as part of realising the right to health. The communique was less clear on two aspects: the active role of the 43% of the world’s population living in BRICS countries in realising these commitments, and the regional solidarity and integration needed in each of their regions to ensure to benefit to the weaker economies of their regions.
The EQUINET website and bibliography and newsletter databases will be undergoing a significant software upgrade in February 2016 so we will not be producing a March issue of the newsletter on 1 March 2016. We hope we have given you alot of interesting material ranging from papers, reports, bibliographies, online books and graphics in this issue the meantime and the newsletter will resume on 1 April 2016. We aim to ensure that any periods in which the bibliography databases will be unavailable during the upgrade are as brief as possible. Please email us on email@example.com if you have any queries or feedback, and we also look forward to receiving submissions, reports and articles from you!
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.
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Two months ago, after heavy pressure (including non-violent street protest) from the Treatment Action Campaign (TAC), the South African government announced that it would provide antiretroviral treatment to 1.4 million people within the next five years. This massive victory for South Africans was followed by December’s announcement that two major pharmaceutical companies - GlaxoSmithKline (GSK) and Boehringer-Ingelheim (BI) - who own more than half of the world AIDS drug market, would allow production of three of their antiretrovirals by generic companies in South Africa. The licensing deal - which will substantially drop the price of drugs throughout sub-Saharan Africa - was a result of a settlement after TAC filed anti-trust complaints to the Competition Commission, a unique South African government body.
TAC’s complaint was more than generous, arguing that a “reasonable profit” for the two companies would be the average profit margin of the patent-based pharmaceutical industry. TAC calculated the “economic value” of each of the three drugs in question by adding the price of the lowest-priced generic equivalent (an estimate of production cost) to the cost of research and development, and adding to that number the average profit of the patent-based industry. Even when using this generous formula, TAC found that a 300mg pill of AZT was priced at 2.58 times its economic value and a 150mg pill of Lamivudine was priced at 4.01 times its economic value .
GSK and BI have monopoly patents on the drugs AZT, lamivudine and nevirapine; these patents would not have expired until 2005 (AZT) or 2010 (lamivudine and nevirapine). While all three drugs were produced through taxpayer funded- research at the National Institutes of Health (nevirapine and AZT) or Emory and Yale Universities (lamivudine), the NIH and universities gave the research to private entities for a 1 to 4% royalty, and the private companies sold the drugs at prices upwards of 173% of production cost without any form of competition to regulate prices .
The companies, in pursuing their own profit motives, were therefore smart to settle the case rather than allow it to go to the South African Competition Tribunal. Had the Tribunal heard the case, the two companies would have been forced to defend their pricing, and therefore would have had to reveal their true production costs (estimated to be below 98% of drug price in many cases) and their profit margins (which are nearly three times higher than the rest of the Fortune 500 industry when calculated as a percentage of revenue, making the industry the most profitable in the world) [3, 4]. The Tribunal’s hearing would have also affirmed the principles of the WTO’s “Doha Declaration on TRIPS and Public Health” (referring to the Trade-Related Aspects of Intellectual Property Rights agreement), which calls for patent rules to be subsumed in the case of public health needs (not only in emergency cases, as often wrongly stated) . Thus, a precedent would have been created to allow for tighter regulation and increased competition to challenge the current global pharmaceutical monopoly. In settling the case with TAC, GSK and BI therefore agreed to some forms of regulation. The terms of the settlement required that:
1. GSK will grant licenses to four generic companies (including Aspen Pharmacare and Thembalami Pharmaceuticals) to produce and/or import, sell and distribute the antiretroviral medicines AZT and lamivudine. Before the agreement with GSK was concluded and signed, GSK had only granted a license to Aspen Pharmacare, which included a massive royalty to GSK (increasing the price of the generic version of the drug) and had required Aspen to market exclusively to NGOs and the public sector, which is inappropriate in any sub- Saharan African countries, where the lack of public infrastructure in the wake of neoliberalism means that even the poorest classes often see private providers.
2. BI will grant licenses to three generic companies to produce and/or import, sell and distribute the antiretroviral drug nevirapine. Before the agreement with BI was concluded and signed, BI had only granted a license to Aspen Pharmacare. This provision will produce competition between generics, likely lowering price.
3. The royalty fee on the licenses will be no more than 5% of net sales of the antiretroviral medicines. Before the agreements with GSK and BI were concluded and signed, the royalty fee that GSK requested was 30% and with BI it was 15%.
4. The licenses will be for both the private and public sectors. Before the agreements with GSK and BI were concluded and signed, the licenses granted by GSK and BI to Aspen were limited to the public sector only.
5. The agreements with GSK and BI will also allow licensees to export AZT, lamivudine and nevirapine that are manufactured in South Africa to all 47 sub- Saharan African countries. Before the agreements with GSK and BI were concluded and signed, exports to sub-Saharan African countries were not permitted.
6. The licensees will be able to manufacture AZT, lamivudine and/or nevirapine in combination with each other and/or any other medicines for which the licensees have contracts. This is critical because it will allow triple-drug fixed-dose combinations, currently manufactured by at least two generic producers, to come to the market, dramatically simplifying treatment protocols and reducing the number of pills that HIV+ persons have to take each week and the frequency of dosing.
These terms provide us with some insights about the power of threatening anti- trust litigation (if not actually using it in countries where such complaints are possible). But they also provide us with cautions about how such litigation must be constructed if it is to produce public health benefits. There are several terms of the South African settlement that are not ideal, giving evidence to the power of strong pharmaceutical company lawyers. As pointed out by James Love of the Consumer Project on Technology, we must wonder why the two companies still gain a royalty on taxpayer-funded research after gouging consumers in the context of a plague, and why the companies are allowed to choose their own competitors . One of the most important generic companies - Cipla of India - has consistently operated under an “alternative” business model of producing near or below cost to provide several drugs as quickly and safely as possible to poor countries, but has been excluded from this arrangement, limiting the ability of countries to make use of Cipla’s excellent production capacities and to produce the sort of “free trade” that might actually benefit consumers.
Nevertheless, the settlement is clearly beneficial for those in need of AZT, lamivudine and nevirapine in sub-Saharan Africa. The irony is that the day after the settlement was announced, a major study of HIV therapies was published in The New England Journal of Medicine, revealing that the best combination of drugs to treat HIV infection for those persons not yet receiving treatment was AZT, lamivudine and efavirenz . Efavirenz and nevirapine are members of the same class of drugs, but are unlikely to work in the same manner. Efavirenz is also produced by DuPont, and is not part of the South African settlement. Therefore, as pointed out by Rahul Rajkumar of the Yale Medical School, South African physicians and their patients will still not be able to make use of the latest research on HIV therapies; such research is only beginning to emerge, as large trials of different combination therapies have taken years to conduct and evaluate. Treatment decisions in South Africa and elsewhere will be guided by trade rules and a patchwork of litigation, not by best practices and new research .
The context of the settlement and of this limitation faced by South African physicians and patients parallels the sort of problems faced by public health advocates after the US Trade Representative (USTR) resisted the implementation of the Doha Declaration on TRIPS and Public Health. A year after signing the Doha Declaration, the USTR began a long process of adding stipulations to the agreement, which have excluded most countries from allowing generic drug competition into their markets, as I have described elsewhere [9, 10, 11]. The result was a stringent and complex series of rules requiring countries to demonstrate a public health need and then submit themselves to a WTO tribunal before regulating their own drug markets. And so both in the case of the Competition Commission settlement, and in the case of Doha, those persons attempting to lower the prices of pharmaceuticals - both for AIDS and for other diseases -will have to bend-over-backwards to enter into specific drug-by-drug litigation, or disease-by-disease WTO approval processes that are unlikely to succeed.
The lesson here is that anti-trust litigation is immensely helpful, as is reform of WTO processes; but both are limited currently because they are so specific to AIDS, or to individual AIDS drugs, that their specific rulings will limit the flexibility needed for appropriate system-wide health improvements. Therefore, an appropriate second step for AIDS activists, beyond the kind of litigation that TAC has been so successful at, is to examine more critically the new sets of trade rules that are being proposed through the free-trade agreements crafted by the USTR. Challenging these new agreements (some of which call for over three decades of patent protection for new pharmaceuticals) will require joining with already-mobilized forces working against the South African Customs Union (SACU) trade deal and its accompanying New Economic Partnership for African Development (NEPAD), as well as those currently working to expose and transform the Central American Free Trade Agreement (CAFTA), the Free Trade Area of the Americas (FTAA), and the Enterprise for ASEAN Initiative. I have reviewed the specifics of these agreements in a separate piece , and some student organisations have begun to join international NGOs to work on the issue (www.fightglobalaids.org, www.amsa.org/global).
Linking our work on drug prices to the larger scheme of trade-associated problems promoting the spread of infectious and non-infectious diseases (such as forced migration , factory-labour-associated illness , and the crash in primary commodity prices that precedes changes in food use and subsequent diabetes rates ) will likely take us to a new level of public health advocacy, one that will hopefully move beyond our behaviouristic and disease- specific leanings and onto effective system-wide critiques that can offer a good complement to the work of groups like TAC . So while anti-trust litigation offers the precedent we need to push the line of acceptable outcomes, our activism on trade agreements can extend specific cases to larger themes and wider practices that currently limit the success of our interventions.
* Sanjay Basu is at the Yale University School of Medicine. http://omega.med.yale.edu/~sb493/
* This article was originally published on the website www.zmag.org and is reproduced here with permission of the author. Please send comments to email@example.com. Click on the link below for references.