Editorial

ACCESS TO ESSENTIAL DRUGS MAY BE UNDERMINED BY GLOBAL PATENT AGREEMENT
December 1, World AIDS Day

A third of the world’s population still has no access to essential drugs. In the poorest countries of Africa and Asia this figure rises to half. With the global agreement on intellectual property rights (TRIPS) forcing countries to introduce new patent protection laws over the next decade, this situation could worsen, according to a new report from the London-based Panos Institute.

Developing countries have until 2005 or 2016 to implement TRIPS-compliant legislation on pharmaceuticals. So far many governments have drafted or enacted legislation that seems to prioritise patent rights over public health. Some countries are being pressurised into adopting policies that go further than TRIPS in protecting patents. Patents give big international pharmaceutical firms monopoly over production of new drugs, including, for example, those needed to treat HIV/AIDS.

There is concern they may push up prices, and the TRIPS rules could thus limit poor countries’ freedom to buy cheaper “generic” versions of patented drugs. For example, in January 2001, South African HIV/AIDS treatment activist Zackie Ahmat went to Thailand to buy 5,000 pills of the generic version of an anti-fungal drug patented by the US pharmaceutical giant Pfizer. He paid $0.21 a pill. The price of the patented version in South Africa was $13.

The Panos Report, 'Patents, Pills and Public Health: can TRIPS deliver?' warns that patent legislation is not being debated widely enough in most developing countries, and the process of introducing it needs to be more consultative and transparent. In Uganda, for example, American consultants were brought in to review the country’s patent laws and make proposals for reform. The result was the drafting of laws which, according to local campaigners, are skewed in favour of business interests rather than social or development needs. The principle of extending access to essential drugs in poor countries is widely supported, but the means of doing this is still hotly disputed, says the report.

According to the World Bank, middle-income countries may benefit from increased foreign investment, but if the cost of drugs rises as a result of patent systems spreading throughout the developing world, there is a real danger of restricting access to drugs, such as anti-AIDS drugs, where they are most needed. The World Health Organisation suggests that implementing patent protection where it did not already exist would result in the average price of drugs rising, with projected increases ranging from 12 to 200 percent.

The pharmaceutical industry argues that patent systems promote innovation and investment in research and development. Without patents, new ones would not be developed to tackle diseases such as tuberculosis and HIV/AIDS. They believe the real barriers to making drugs more available are poverty, weak political leadership, lack of trained health personnel and poor health infrastructures.

The report examines alternative approaches and gives examples where differential pricing (where poorer countries pay considerably less for a product than wealthier ones) and compulsory licensing (where a patent is overridden in return for a payment of a royalty) have potential, although they are not free of problems. Two countries highlighted in the report, show how differently patent protection can impact on the nation’s public health: Brazil is seen as a model for other countries of what can be achieved for public health by boosting local production of drugs such as the anti-AIDS drug AZT, lowering prices through competition and negotiating discounts on patented drugs. Between 1996 and 2001 around 358,000 AIDS hospitalisations were prevented, saving around $1.1 billion. On the other hand, Thailand’s capacity to provide essential drugs for its people has been severely limited in the last decade due to relentless pressure from the US to tighten up its patent laws which, they complained, meant the loss of $30 million a year in sales for the American pharmaceutical industry because it referred only to pharmaceutical processes and not products. The US went as far as imposing $165 millions’ worth of sanctions on eight Thai products exported to the US. The US continued to exert pressure until the patent laws were changed and made even more restrictive than the international TRIPS agreement requires.

“This report should be a wake-up call to developing countries to look carefully at how they go about complying with TRIPS legislation and make sure that access to essential drugs is kept as an overriding right for the entire population – not just a wealthy few” says Martin Foreman, author of the Panos report.

* The full report and additional country studies can be downloaded from this website http://www.panos.org.uk/

* The Panos Institute is an independent, non-profit organisation specialising in communication for development. It works to catalyse informed public debate, particularly in developing countries. It has 12 offices in Africa, Asia, Europe and the Caribbean.

Southern Africa: Famine and AIDS: The Strength to Fight is at the Grassroots
Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa

A Speech to the HIV/AIDS and "Next Wave" Countries Conference, the Centre for Strategic and International Studies Washington, DC, October 4, 2002, on the US National Intelligence Council report, 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', published September 1 2002.*

For more than a decade now, those who have chronicled the sweep of the pandemic have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places, that: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.

But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.

That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources. Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".

And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling, allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".

I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think - I obviously cannot prove - but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.

We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic […]

I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We - and it's the royal, generic 'we' - know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.

What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.

Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.

I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.

I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.

* 'The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', prepared for the National Intelligence Council of the CIA, highlights the rising HIV/AIDS problem in five countries of strategic importance to the United States: Nigeria, Ethiopia, Russia, India and China. It is available as a pdf file at: <a href=http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf>http://www.cia.gov/nic/pubs/other_products/ICA%20HIV-AIDS%20unclassified%20092302POSTGERBER.pdf<a/>

Further details: /newsletter/id/29418
WHO-SADC call to action on food security in the SADC region

We, the SADC Health Ministers gathered at Roodevallei, Pretoria, on 30 August 2002 deliberated over the severe famine facing the SADC region [...]

We, the SADC Health Ministers [...] recognize that the famine is super-imposed on an already severe HIV/AIDS pandemic in the region. Both the famine and HIV will lead to deeper impoverishment of the people of the region, and further compound the magnitude of premature death of vulnerable groups namely children and women, from diseases aggravated by poverty like HIV/AIDS and malnutrition, such as malaria, TB and diarrhoeal diseases.

Notwithstanding the effect of the famine on productivity, combined with the HIV/AIDS pandemic household food security through reduced productivity is further compromised and an additional burden placed on already overstretched health systems.

We, the Ministers, recognise the current severe shortfall in food production and food availability in the region, with a cereal deficit of 4,071,300 metric tonnes (MTs) in the region. We also recognise the complex causes of the famine but identify the high levels of poverty in the region as a key factor underlying the current disaster. In the countries affected by the famine, between 1996 and 2001, the number of people living below the poverty line has stayed the same or increased, with on average 68% of the population living below the poverty line in 2001. We further recognise that poor people are most vulnerable to any adverse events.

We note with great concern, the environmental and agricultural factors as a cause of the drought and famine in Africa, with an estimated 500 million hectares affected by soil degradation since 1950, including as much as 65% of agricultural land. A combination of inequitable distribution of land, poor farming methods and unfavourable land tenure and ownership systems have led to the decline in productivity of grazing land, falling crops and diminishing returns from water supplied. Nearly two- thirds of Africa is semi -arid, and Southern Africa is one of the sub regions that is most affected. This dryness makes the land vulnerable to degradation.

Economic factors contribute significantly to this situation. High debt burdens and unequal trade have undermined effective responses by Southern African countries. In particular, greatly increased subsidies to U.S. and European farmers threaten the viability of farming in the region [...]

Further details: /newsletter/id/29431
TAC STATEMENT ON EXCESSIVE PRICING COMPLAINT TO COMPETITION COMMISSION
WE WILL SAVE LIVES AND END DRUG COMPANY PROFITEERING

The urgent need for medicines to save lives, families and the fabric of our communities today impels a group of applicants (which includes the Treatment Action Campaign, unions and doctors) to launch a complaint with the Competition Commission in South Africa against two major international drug companies, GlaxoSmithKline (GSK) and Boehringer Ingelheim (BI). The complaint charges these corporations with excessive pricing in respect of several key drugs for the treatment of AIDS. The drugs are: RetrovirAE (zidovudine or AZT), 3TCAE (lamivudine), CombivirAE (AZT/lamivudine) and ViramuneAE (nevirapine).

This is a novel step that engages South Africa's sophisticated competition regulatory system in an effort to secure justice and rationality in drug pricing in the AIDS epidemic. Tens of thousands of people in our country are dying every year because of excessive prices for these medicines and because of government's lack of determined action to reduce the prices.

People living with HIV/AIDS, our doctors and nurses, the Treatment Action Campaign (TAC), the Congress of South African Trade Unions (Cosatu) and the Chemical Energy Paper, Printing, Wood and Allied Workers Union (CEPPAWU) have decided to act jointly against continued, unjust and insupportable drug company profiteering. South Africa needs affordable medicines now.

According to the World Health Organisation, the most commonly recommended triple drug therapy for HIV/AIDS is the combination of CombivirAE AZT/lamivudine) and ViramuneAE (nevirapine). We are placing the following powerful evidence before the Competition Commission: a month's supply of this treatment regimen at retail prices costs R1176.00 from Glaxo and Boehringer. By contrasts, the best-priced generic internationally cost R276.00 per month. The stark fact is that for the cost of one treatment from the brand name companies four people with AIDS can be treated on generics. We have additional evidence of excessive pricing for individual drugs.

Excessive pricing or profiteering by GlaxoSmithKline and Boehringer Ingelheim is directly responsible for premature, predictable and avoidable deaths of people living with HIV/AIDS, both children and adults.

For nearly four years, TAC and our allies have campaigned globally for drug companies to issue unconditional voluntary licences, against a royalty payable to the corporations of 4-5%, to allow generic competition and the lowest prices. This is a rational, fair and life-saving proposal. The drug companies have ignored it. Now we are asking the Competition Commission to investigate the complaint and to refer it to the Competition Tribunal.

We seek the following relief:

An order that GlaxoSmithKline and Boehringer Ingelheim stop the excessive pricing practices; A declaration that the excessive pricing conduct is a prohibited practice for purposes of damages claims by all persons who can establish that they have suffered loss or damage as a result of the prohibitive practice concerned; and An administrative penalty against the companies.

We are taking this action to ensure that:

The right to life is placed before profiteering; People living with HIV/AIDS who work can afford to buy medicines to save their lives; Children living with HIV/AIDS will get access to antiretroviral medicines; Medical schemes can afford to treat people living with HIV/AIDS without going bankrupt; Employers can treat their workers on a sustainable basis; and that Government shakes off the denialist paralysis and develop a national treatment plan.

We call on all people in South Africa and across the world to support this action taken by people living with HIV/AIDS, health care professionals, TAC, Cosatu and Ceppawu. We urge everyone to call on all drug companies to immediately issue unconditional voluntary licences for antiretroviral medicines to save the lives of millions in our country and across the world.


* Note: Equinet jointly with Oxfam GB will shortly be putting out a call for applicants for a grant looking at equity issues in relation to HIV/AIDS and particularly treatment access.

Further details: /newsletter/id/29388
Thumida Maistry

Thumida Maistry will be leaving Equinet as at the end of October 2002. Equinet is grateful to Thumida for her energetic commitment to the network. She has been working for the past three months on background work for an advocacy plan for Equinet that will be more substantively taken up in 2003. Programme co-ordination will continue to managed through TARSC as always and communications should be directed to admin@equinetafrica.org.

The Johannesburg Declaration of the African Civil Society Organisations attending the WSSD

The World Summit on Sustainable Development included a strong civil society presence, although one, tellingly, kept separate from the governmental proceedings of the main conference. In hosting their own Peoples Summit, civil society groups drafted proposals that were aimed to feed directly into the governmental discussions on a daily basis.

Groups at the Peoples Summit were gathered according to geographic or issue commonality. Equinet was represented in the health, womens and Africa caucus. As the summit drew to a close it became increasingly apparent that whilst NGOs achieved a great deal in their own deliberations, these discussions were becoming increasingly irrelevant in relation to influencing the outcomes within the main Sandton-based governmental discussions. This drew a great deal of anger from civil society groups, with many feeling forced to disassociate themselves from the event. At the same time others, under the banner of the Summit Civil Society Secretariat, seemed to display greater willingness to concede success for the summit, despite clear indications that the critical issues for civil society and sustainable development were being blatantly ignored.

For the Africa caucus, this division paralleled differing views held on the effectiveness of NEPAD. Despite much discussion and agreement on a number of priority areas, their declaration, printed in full below, failed to agree on a unified position and it was eventually agreed that, where NEPAD is mentioned, the draft should contain both points of view.

The Johannesburg Declaration of African Civil Society Organisations

We representatives of African Civil Society organisations meeting during the World Summit on Sustainable Development reaffirm our demand for commitment to the achievement of sustainable and equitable development in Africa.

The Rio Summit marked international commitment to providing political, financial, and technological support for its version of achieving the interlinked goals for human centred, environmentally sustainable and culturally sensitive development, and, poverty reduction.

A decade later, it is evident that the development situation particularly, poverty in Africa has escalated. There has been insufficient commitment by African governments to the ideals of Rio and inadequate financial and technological support by development partners for Africa’s development priorities. The capacity of the people of Africa to lift themselves out of poverty, food insecurity and illiteracy has been undermined by many factors, including declining levels and terms of trade, increasing debt burden, declining overseas development assistance and private investment flows, increasing marginalisation in world relations from globalisation, unfavourable prescriptive donor policies, environmental deterioration, partly from increased exploitation of the natural resource base of the continent, HIV/AIDS prevalence, and, conflict and wars.

We resolve to fully utilise the opportunity offered by the Johannesburg commitment on sustainable development to work towards ensuring urgent and renewed commitment, by African governments and development partners, backed by time bound implementation actions, monitorable deliverable and identified sources and levels of resources, that will assure the achievement of the Millenium Development Goals and Targets in Africa and accelerate the realisation of our sustainable development vision for Africa within ten years.

We, civil society organisations of Africa, envision an African society, characterised by unity in diversity, equality, equity and justice that guarantees the fundamental needs of its people, is participatory and accommodates the interests of all stakeholders in decision-making processes, including the empowerment of women in all areas, and ensures democracy and human rights in which poverty is reduced to a minimal level through knowledge based, culture sensitive and people centred development that is environmentally, socially and economically sustainable..

We recognise the UN secretary General Kofi Annan’s WEHAB initiative as a contribution to the Draft Plan of Implementation of the Johannesburg summit for the WSSD while it seeks to provide focus and impetus to action in the key thematic areas of Water, Energy, Health, Agriculture and Biodiversity that are integral to a global approach to the implementation of sustainable development.

We call for clear processes and transparent criteria to be defined and adopted through the participation of stakeholders in the implementation of partnerships emerging from the Johannesburg Summit

We urge all African Governments to commit themselves to the challenges posed in the “Earth Charter”.

We acknowledge that for the WSSD to ensure the achievement of our vision of Africa it should address the following issues:

a) poverty eradication, b)emergence of African regional groupings and alliances, including the Africa Union and NEPAD c.)human resource development including education, health and combating HIV/AIDS, TB, Malaria and avoidable diseases of poverty, d)Africa and globalisation, e.)sustainable agriculture and food security, f.) water and sanitation, g)natural resource management, including desertification and land degradation, h.)energy, I) science and technology including indigenous knowledge systems and the legal recognition of the rights of local communities, j) democratic governance, k) rule of law, respect for human rights and freedoms, l) gender equity, m) armed conflict and warfare

We call for a commitment by all Governments to reach agreement for a timetable for the phasing out of harmful subsidies of fossil fuels and agree on targets and timeframes for increasing the share of renewable energy supply for Africa.

We recognise that achieving our sustainable development goals requires a supportive international environment, particularly in the areas of macro-economic policy, market access and fair trade, debt relief, ODA and conditions for leveraging private capital flows, human development, technology transfer, capacity development and full implementation of multilateral environmental and sustainable development Conventions and their Protocols. We call for strong and immediate action.

We recognise that while globalisation may bring new opportunities and challenges for sustainable development in Africa, the uneven distribution of wealth and apparent benefits further marginalizes the continent’s role in the world economy. Special attention should be given to grassroots communities where such benefits do accrue.

We acknowledge that peace is a prerequisite for sustainable development and call on African Governments and the international community to adopt measures to ensure a peaceful and stable environment for Africa’s sustainable development.

We reaffirm our engagement with NEPAD, despite our insufficient involvement in its formulation, and urge African leaders to partner with African Civil Society organisations in all processes for its refinement, implementation and monitoring. We are concerned that NEPAD does not replicate structural adjustment programmes, which have increased poverty and inequality on the Continent.

We reaffirm that sustainable development requires active participation of women and men on equal footing at all levels of decision making, implementation. Monitoring and evaluation. We call for the integration of gender equity in all aspects encompassed within Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development.

We reaffirm the unconditional need for African Governments themselves to initiate appropriate steps to ensure good governance as a major prerequisite for sustainable development.

We commit ourselves to the monitoring of the implementation of Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development through existing and newly formed African regional, National and Local NGO coalitions on sustainable development.

A commentary on the WSSD from South Africa
Mohau Pheko, Gender and Trade in Africa

International Trade and Gender Network Bulletin, Volume 2, No. 7, July 2002

There are many opportunities and challenges facing women in the upcoming World Summit on Sustainable Development. Perhaps it is worth reflecting on the whole notion of what our forefathers and foremothers meant when they conceptualised what freedom and emancipation for the African people would mean to future generations in Africa.

The most common word we heard in terms of development during the independence explosion, and the fight to decolonise and kill apartheid in South Africa, was self-determination. Where has this discourse gone? What is the difference between sustainable development and self-determination? It is critical to reflect on this in order to locate the gender perspectives in the upcoming summit.

Self-determination is the right to determine our future, to shape it, nurture it in ways that reflect our desires, goals and aspirations as African people. Self-determination opens the space for us to innovate, experiment with new ideas, to fail and from these failures reconceptualise our destiny until it fulfils the vision we have as a people. The vision and hope of preserving the sky, the land, and placing adequate food for everybody to consume not just a few, security of body, mind and soul above everything a peaceful stable environment where everybody can earn a living. Some people call this idealism and are skeptical about attaining this equilibrium.

Sustainable development is a new term. It takes on different nuances depending on who happens to be articulating this concept. How do women fit into this agenda? What sort of development are we sustaining? Is this notion of sustainable development an environment that can promote gender equality?

In reading through the Chairperson’s text towards the summit on sustainable development a number of concerns arise. I want to flag just a few issues that need to be interrogated by gender activists in general and feminists specifically.

1. The concept of sustainable development as framed in for WSSD repositions development perspectives within economic globalisation. This is extremely problematic for women because research is emerging that women have experienced globalisation more negatively than other sectors of society. There is increased feminisation of poverty. Increased flexible labour among women and more women have entered the informal sector. The privatisation of services like water, electricity, healthcare and education has increased rather than decreased women’s work as more people fall through the social safety net. Repositioning development within globalisation introduces a new form of sustainability - sustaining poverty, not eradicating it, and sustaining debt relief, not debt cancellation.

2. The Chairperson’s text reinterprets sustainable development within the neoliberal trade paradigm and the liberalised trade system. This is happening with the background of Africa experiencing the worst terms of trade. For example, industrialised countries control 68.4% of global trade with 15% of the world population.

3. Developing countries control 27.5% of global trade with a world population of 75%. Africa’s share of this is 1.6% with 11% of world population. Africa produces the bulk of raw materials in the world. Women produce sugar, corn, coffee, cotton, tea and many other products yet, the prices of these products has declined steadily in terms of the way they are traded. It is not the producers who set the prices, but the stock exchange in London and New York. There is no access for women farmers to these institutions. Women have no power to negotiate the price of these products. The returns on their products in monetary terms are not sufficient to sustain livelihoods nor bring about development in the true sense.

It is critical to note that the repositioning of development in the WSSD also creates a relocation of development issues from the United Nations to other institutions. This is an important shift for gender activists to study. The World Bank and the World Trade Organisation specifically are the two institutions that are in explicit and implicit ways taking over the development agenda as we once knew it. Under the new term of global governance the World Trade Organisation in particular is attempting to take on issues of environment, labour, and agriculture to name a few. In the meantime, the World Bank is whittling away the power of the state through its’ policy advise. It is advising countries to privatise basic social services through, for example, introducing user fees to healthcare services and education. It is advising countries to sell water, electricity and telecommunications to the private sector. Using the efficiency argument it is convincing governments that the state has no capacity to provide basic services and that this function should be taken over by the private sector. After all, the World Bank claims the private sector has a tradition of running business more efficiently than governments and governments, it says, are corrupt. This dysfunctional ideology of placing profit before people’s development, and gender equality particularly reinforces the exclusionary manner in which the state treats women.

Linked to NEPAD, the New Partnership for Africa’s Development, the new development framework offers the same market-oriented economies that are not compatible with the protection of women’s rights, nor do they promote gender equality in Africa. Framed with a neoliberal stance, this plan strengthens the principle of private property. African women have never had any entitlements under this paradigm. NEPAD, like the new development framework being put forth at the upcoming World Summit on Sustainable Development, does not address the social relations within the market in terms of women’s access to and control of resources in this space. The World Summit on Sustainable Development must be a space that allows for the self-determination of peoples and nation states and promotes sustainable development that incorporates human development and gender equality into its definition and implementation. However, as it currently stands the WSSD further pushes the Northern trade agenda and role of the International Financial Institutions while marginalizing the role of the United Nations. This process will further threaten national sovereignty and further marginalize women.

Why half the planet is hungry
Amartya Sen

Widespread hunger in the world is primarily related to poverty. It is not principally connected with food production at all. Indeed, over the course of the last quarter of a century, the prices of the principal staple foods (such as rice, wheat etc) have fallen by much more than half in 'real' terms. If there is more demand for food, in the present state of world technology and availability of resources, the production will correspondingly increase. The demand for food is restrained mainly by lack of income. And the same factor explains the large number of people who are hungry across the world. Given their income levels, they are not able to buy enough food, and as a consequence these people (including their family members) live with hunger.

But it is not adequate to look only at incomes. There is need to look also at the political circumstances that allow famine and hunger. If the survival of a government is threatened by the prevalence of hunger, the government has an incentive to deal with the situation. Incomes can be expanded both by policies that raise overall income and also by redistributive policies which provide employment, and thus tackle one of the principal reasons for hunger (to wit, unemployment in a country without an adequate social security system). In democratic countries, even very poor ones, the survival of the ruling government would be threatened by famine, since elections are not easy to win after famines; nor is it easy to withstand criticism of opposition parties and newspapers. That is why famine does not occur in democratic countries. Unfortunately, there are a great many countries in the world which do not yet have democratic systems.

Indeed, as a country like Zimbabwe ceases to be a functioning democracy, its earlier ability to avoid famines in very adverse food situations (for which Zimbabwe had an excellent record in the 1970s and 1980s) becomes weakened. A more authoritarian Zimbabwe is now facing considerable danger of famine. Alas, hunger in the non-acute form of endemic under-nourishment often turns out to be not particularly politically explosive. Even democratic governments can survive with a good deal of regular under-nourishment. For example, while famines have been eliminated in democratic India (they disappeared immediately in 1947, with Independence and multi-party elections), there is a remarkable continuation of endemic under-nourishment in a non-acute form. Deprivation of this kind can reduce life expectancy, increase the rate of morbidity, and even lead to under-development of mental capacities of children. If the political parties do not succeed in making endemic hunger into a politically active issue, hunger in this non-acute form can go on even in democratic countries.

What should rich countries do, and is trade liberalisation the answer?

The rich countries can do a great deal to reduce hunger in the world. First, the displacement of democracies in poor countries, particularly in Africa, often occurred during the Cold War with the connivance of the great powers. Whenever a military strongman displaced a democratic government, the new military dictatorship tended to get support from the Soviet Union (if the new military rulers were pro-Soviet) or from the United States and its allies (if the new rulers were anti-Soviet and pro-West). So there is culpability on the part of the dominant powers in the world, given past history, and there is some responsibility now for rich countries to help facilitate the expansion of democratic governance in the world.

Second, hunger is related to low income and often to unemployment. Poverty could be very substantially reduced if the richer countries were more welcoming to imports from poorer countries, rather than shutting them out by tariff barriers and other exclusions. Fairer trade can reduce poverty in the poor countries (as the recent Oxfam report Rigged Rules, Double Standards discusses in detail). Third, there is a need for a global alliance not just to combat terrorism in the world, but also for positive goals, such as combating illiteracy and reducing preventable illnesses that so disrupt economic and social lives in the poorer countries. Trade liberalisation on the part of the richer countries could certainly make a difference to employment and income prospects of poorer countries. The situation is a little more complex in the case of liberalisation of the poorer countries. Even those countries which have greatly benefited from the expansion of world trade (such as South Korea or China) often went through a phase of protecting industries before vigorous expansion of exports and trade. So, trade liberalisation is partly an answer, but the economic steps involved have to be carefully assessed: the policies cannot be driven by simple slogans.

What is the solution?

There is no 'magic bullet' to deal with the entrenched problem of hunger in the world. It requires political leadership in encouraging democratic governments in the world, including support for multi-party elections, open public discussions, elimination of press censorship, and also economic support for independent news media and rapid dissemination of information and analysis. It also requires visionary economic policies which both encourage trade (especially allowing exports from poorer countries into the markets of the rich), but also reforms (involving patent laws, technology transfer etc.) to dramatically reduce deprivation in the poorer countries. The problem of hunger has to be seen as being embedded in larger issues of global poverty and deprivation.

Countries of the South increasingly seek food self-sufficiency. Could this solve the problem of hunger and starvation?

Food self-sufficiency is a peculiarly obtuse way of thinking about food security. There is no particular problem, even without self-sufficiency, in achieving nutritional security through the elimination of poverty (so that people can buy food) and through the availability of food in the world market (so that countries can import food if there is not an adequate stock at home). The two problems get confused, because many countries which are desperately poor also happen to earn most of their income from food production. This is the case, for example, for many countries in Africa. But if these countries were able to produce a good deal of income (for example through diversification of production, including industrialisation), they can become free of hunger even without producing all the food that is needed for domestic consumption. The focus has to be on income and entitlement, and the ability to command food rather than on any fetishist concern about food self-sufficiency.

There are situations in which self-sufficiency is important, such as during wars. At one stage in the Second World War, there was a real danger of Britain not being able to get enough food into the country. But that is a very peculiar situation, and we are not in one like that now, nor are we likely to be in the near future. The real issue is whether a country can provide enough food for its citizens - either from domestic production or imports or both - and that is a very different issue from self-sufficiency. We have to look at ways and means of eliminating poverty, and to undertake the economic, social and political processes that can achieve that.

Amartya Sen, who won the Nobel Prize in Economics in 1998, is Master of Trinity College, Cambridge. This is a longer version of an article, expanded by the author, that appeared in Le Monde

Municipal Services Project Conference: A Report
Rene Loewenson/Thumida Maistry, Equinet

A recent conference hosted by the Municipal Services Project in Johannesburg highlighted a growing tide of defiance from people around South Africa over privatisation and its impact on access to basic services. People travelled from all parts of South Africa to testify in the workshop on their experiences of hardship as a result of privatisation and unaffordable service costs, noting stories of evictions, and water and electricity cut offs. Most of these testimonies articulated the view that basic needs, such as water and electricity, are basic rights. Many highlighted the negative impact of reduced access to basic services such as water supplies on health and quality of life.

Among the delegates were representatives of non government organisations (NGO’s), academics, community based organisations (CBOs), and unionists. They consistently raised the constraints to service delivery under globalisation, privatisation and cost recovery measures, and their negative health impacts. Eddie Cottle of the Rural Services Development Network reported, for example, on the link between the cholera outbreak in South Africa and the introduction of user fees for water.

During the workshops, delegates discussed strategies to address the issue. Would a rights based approach or one centred on claiming legal redress for deprivation of basic rights be successful? Glen Farred from the Community Legal Centre noted that while the establishment of a constitution and a bill of rights provided certain opportunities, They were difficult to apply in the case of access to safe water. The meeting identified the need for a new wave of social mobilisation as being more important than legal battles in achieving constitutional rights around basic services.

The impact of foreign intervention in basic services was also explored. It was noted that the world’s water management continues to be taken up by foreign companies. Large dam projects funded by international finance institutions were also reported to undermine service access in poor communities. Medha Patkar from the Narmada valley India reported at the meeting on the struggle of people in the catchment area of one such large dam to stop the dam from being built. This dam was reported to be threatening 40 000 families, with thousands more homes reported to have been submerged since construction began. She described passionately the irreversible loss of a way of life, livelihood and wellbeing for indigent people and said globalisation, privatisation, and centralised management of the world’s natural resources made humanity itself one of the greatest threats to itself.

Patkar and others noted that the response to such challenges called for a social movement, able to strategise, resisting co-option by international agencies and able to resist neoliberal policies. Some role models were presented of health systems arising out of social movements, such as Daniel Chavez’s description of Porto Allegro, where strong mechanisms exist for citizen participation in municipal affairs.


The conference explored how such social forces for health are organised – and growing. Community struggles around access to basic services were seen to be snowballing, particularly when they have support from social movements around the world. More well established movements, like the youth activists and organised labour all noted their roles internationally in targeting access to serves and in building alliances with other community based organisations.

A growing social movement to pressure for basic services was thus seen as the greatest predictor of service cover. This was particularly the case as neoliberal forces have grown. As Yash Tandon noted:
“At Doha first world countries recaptured the gains won in Seattle through pressure and manipulation and aggressive tactics. The outcome was the pursuit of neoliberalism such that the markets must be opened to international competitors even for public goods. “

Market policies and inequitable development were viewed as primary threats to increasing cover of basic services. This drew attention to the potential impact of the proposed new African recovery plan - NEPAD - on access to basic services. Delegates observed features within NEPAD, including its commitment to deepen neoliberal market policies, that are likely to have negative effects for basic service access and generate increased social conflict over access to water, electricity and other basic rights. Whether poor communities obtain or lose access to safe water and electricity will certainly be one litmus test of whether NEPAD brings real recovery for African households.

Hazardous to Health: The World Bank and IMF in Africa
Action Position Paper

Ann-Louise Colgan, Research Associate, Africa Action April, 2002.
Health is a fundamental human right, recognized in the Universal Declaration of Human Rights (1948), and the Constitution of the World Health Organization (1946). Health is also an essential component of development, vital to a nation's growth and internal stability. Over the past two decades, the World Bank and International Monetary Fund (IMF) have undermined Africa's health through the policies they have imposed. The dependence of poor and highly indebted African countries on World Bank and IMF loans has given these institutions leverage to control economic policy-making in these countries. The policies mandated by the World Bank and IMF have forced African governments to orient their economies towards greater integration in international markets at the expense of social services and long-term development priorities. They have reduced the role of the state and cut back government expenditure.

While many African countries succeeded in improving their health care systems in the first decades after independence, the intervention of the World Bank and IMF reversed this progress. Investments in health care by African governments in the 1970s achieved improvements in key health indicators. In Kenya, for example, child mortality was reduced by almost 50% in the first two decades after independence in 1963 [1]. Across sub-Saharan Africa, the first decades after independence saw significant increases in life expectancy, from an average of 44 years to more than 50 years [2].

In the 1980s and 1990s, however, African governments had to cede control over their economic decision-making in order to qualify for World Bank and IMF loans. The conditions attached to these loans undid much of the progress achieved in public health. The policies dictated by the World Bank and IMF exacerbated poverty, providing fertile ground for the spread of HIV/AIDS and other infectious diseases. Cutbacks in health budgets and privatization of health services eroded previous advances in health care and weakened the capacity of African governments to cope with the growing health crisis. Consequently, during the past two decades the life expectancy of Africans has dropped by 15 years [3].

Africa Action calls for an end to World Bank and IMF policies that undermine health. This requires canceling the debts that prevent African governments from making their full contribution to addressing the health crisis. It also requires ending the imposition of harmful economic policies as conditions for future loans or grants. This position paper provides a brief background overview of World Bank and IMF policies. It focuses particularly on their impact on health.

1. The World Bank and IMF in Africa The World Bank and IMF were created at the Bretton Woods Conference in New Hampshire, U.S.A., in 1944. They were designed as pillars of the post-war global economic order. The World Bank's focus is the provision of long-term loans to support development projects and programs. The IMF concentrates on providing loans to stabilize countries with short-term financial crises. The World Bank and IMF became increasingly powerful in Africa with the economic crisis of the early 1980s. In the late 1970s, rising oil prices, rising interest rates, and falling prices for other primary commodities left many poor African countries unable to repay mounting foreign debts. In the early 1980s, Africa's debt crisis worsened. The ratio of its foreign debt to its export income grew to 500% [4]. African countries needed increasing amounts of "hard currency" to repay their external debts (i.e.
convertible foreign currencies such as dollars and deutschmarks). But their share of world trade was decreasing and their export earnings dropped as global prices for primary commodities fell. The reliance of many African countries on imports of manufactured goods, which they themselves did not produce, left them importing more while they exported less. Their balance of payments problems worsened and their foreign debt burdens became unsustainable.

African governments needed new loans to pay their outstanding debts and to meet critical domestic needs. The World Bank and IMF became key providers of loans to countries that were unable to borrow elsewhere. They took over from wealthy governments and private banks as the main source of loans for poor countries. These institutions provided "hard currency" loans to African countries to insure repayment of their external debts and to restore economic stability. The World Bank and IMF were important instruments of Western powers during the Cold War in both economic and political terms. They performed a political function by subordinating development objectives to geostrategic interests. They also promoted an economic agenda that sought to preserve Western dominance in the global economy. Not surprisingly, the World Bank and IMF are directed by the governments of the world's richest countries. Combined, the "Group of 7" (U.S., Britain, Canada, France, Germany, Italy and Japan)
hold more than 40% of the votes on the Boards of Directors of these institutions. The U.S. alone accounts for almost 20% [5]. It was U.S. policy during the Reagan Administration in the early
1980s, to expand the role of the World Bank and IMF in managing developing economies [6]. The dependence of African countries on new loans gave the World Bank and IMF great leverage. The conditions attached to these loans required African countries to submit to economic changes that favored "free markets." This standard policy package imposed by the World Bank and IMF was termed "structural adjustment." This referred to the purpose of correcting trade imbalances and government deficits. It involved cutting back the role of the state and promoting the role of the private sector. The ideology behind these policies is often labeled "neo-liberalism," "free market fundamentalism,"or the "Washington Consensus." From the 1970s on, this orientation became the dominant economic paradigm for rich country governments and for the international financial institutions. The basic assumption behind structural adjustment was that an increased role for the market would bring benefits to both poor and rich. In the Darwinian world of international markets, the strongest would win out. This would encourage others to follow their example. The development of a market economy with a greater role for the private sector was therefore seen as the key to stimulating economic growth. The crisis experienced by African countries in the early 1980s did expose the need for economic adjustments. With declining incomes and rising expenses, African economies were becoming badly distorted. Corrective reforms became increasingly necessary. The key issue with adjustments of this kind, however, is whether they build the capacity to recover and whether they promote long-term development. The adjustments dictated by the World Bank and IMF did neither.

African countries require essential investments in health, education and infrastructure before they can compete internationally. The World Bank and IMF instead required countries to reduce state support and protection for social and economic sectors. They insisted on pushing weak African economies into markets where they were unable to compete with the might of the international private sector. These policies further undermined the economic development of African countries.
2. What is Structural Adjustment? Structural adjustment refers to a package of economic policy changes designed to fix imbalances in trade and government budgets.
In trade, the objective is to improve a country's balance of payments, by increasing exports and reducing imports. For budgets, the objective is to increase government income and to reduce expenses. In theory, achieving these goals will enable a country to recover macroeconomic stability in the short-term. It will also set the stage for long-term growth and development. The structural adjustment programs of the early 1980s were meant to provide temporary financing to borrowing countries to stabilize their economies. These loans were intended to enable governments to repay their debts, reduce deficits in spending, and close the gap between imports and exports. Gradually, these loans evolved into a core set of economic policy changes required by the World Bank and IMF. They were designed to further integrate African countries into the global economy, to strengthen the role of the international private sector, and to encourage growth through trade. Typical components of adjustment programs included cutbacks in government spending, privatization of government-held enterprises and services, and reduced protection for domestic industry. Other types of adjustment involved currency devaluation, increased interest rates, and the elimination of food subsidies. The underlying intention was to minimize the role of the state.

World Bank and IMF adjustment programs differ according to the role of each institution. In general, IMF loan conditions focus on monetary and fiscal issues. They emphasize programs to address inflation and balance of payments problems, often requiring specific levels of cutbacks in total government spending. The adjustment programs of the World Bank are wider in scope, with a more long-term development focus. They highlight market liberalization and public sector reforms, seen as promoting growth through expanding exports, particularly of cash crops. Despite these differences, World Bank and IMF adjustment programs reinforce each other. One way is called "cross-conditionality." This means that a government generally must first be approved by the IMF, before qualifying for an adjustment loan from the World Bank. Their agendas also overlap in the financial sector in particular. Both work to impose fiscal austerity and to eliminate subsidies for workers, for example. The market-oriented perspective of both institutions makes their policy prescriptions complementary.

Adjustment lending constitutes 100% of IMF loans. In 2001, approximately 27% of World Bank lending to African countries was for "adjustment." In the World Bank's total loan portfolio, adjustment lending generally accounts for between one-third and one-half [7]. The remainder of World Bank loans are disbursed for development projects and programs. The project portfolio of the Bank covers such areas as infrastructure, agricultural and environmental development, and human resource development. In some cases, the projects supported by World Bank loans do make useful contributions to development. But these occasional successes must be weighed against the negative effects of increasing debt, imposed economic policies and their consequences. The past two decades of World Bank and IMF structural adjustment in Africa have led to greater social and economic deprivation, and an increased dependence of African countries on external loans. The failure of structural adjustment has been so dramatic that some critics of the World Bank and IMF argue that the policies imposed on African countries were never intended to promote development. On the contrary, they claim that their intention was to keep these countries economically weak and dependent. The most industrialized countries in the world have actually developed under conditions opposite to those imposed by the World Bank and IMF on African governments. The U.S. and the countries of Western Europe accorded a central role to the state in economic activity, and practiced strong protectionism, with subsidies for domestic industries. Under World Bank and IMF programs, African countries have been forced to cut back or abandon the very provisions which helped rich countries to grow and prosper in the past. Even more significantly, the policies of the World Bank and IMF have impeded Africa's development by undermining Africa's health. Their free market perspective has failed to consider health an integral component of an economic growth and human development strategy. Instead, the policies of these institutions have caused a deterioration in health and in health care services across the African continent.

3. Poverty and Health Care Cuts Health status is influenced by socioeconomic factors as well as by the state of health care delivery systems. The policies prescribed by the World Bank and IMF have increased poverty in African countries and mandated cutbacks in the health sector. Combined, this has caused a massive deterioration in the continent's health status.

The health care systems inherited by most African states after the colonial era were unevenly weighted toward privileged elites and urban centers. In the 1960s and 1970s, substantial progress was made in improving the reach of health care services in many African countries. Most African governments increased spending on the health sector during this period. They endeavored to extend primary health care and to emphasize the development of a public health system to redress the inequalities of the colonial era. The World Health Organization (WHO) emphasized the importance of primary healthcare at the historic Alma Ata Conference in 1978. The Declaration of Alma Ata focused on a community-based approach to health care and resolved that comprehensive health care was a basic right and a responsibility of government. These efforts undertaken by African governments after independence were quite successful. There were increases in the numbers of health professionals employed in the public sector, and improvements in health care infrastructure in many countries. There was also some success in extending care to formerly unserved areas and populations. Across the continent, there were improvements in key health care indicators, such as infant mortality rates and life expectancy. In Zambia, the post-independence government expanded public health care services throughout the country. The number of doctors and nurses was also significantly increased during this time. Infant mortality was reduced from 123 per 1,000 live births in 1965, to 85 in 1984 [8]. In Tanzania, during the first two decades of independence, the government succeeded in expanding access to health care nationwide. By 1977, more than three-quarters of Tanzania's population lived within 5 km of a health care facility [9]. While the progress across the African continent was uneven, it was significant, not only because of its positive effects on the health of African populations. It also illustrated a commitment by African leaders to the principle of building and developing their health care systems.

With the economic crisis of the 1980s, much of Africa's economic and social progress over the previous two decades began to come undone. As African governments became clients of the World Bank and IMF, they forfeited control over their domestic spending priorities. The loan conditions of these institutions forced contraction in government spending on health and other social services. Poverty and Health The relationship between poverty and ill-health is well established. The economic austerity policies attached to World Bank and IMF loans led to intensified poverty in many African countries in the 1980s and 1990s. This increased the vulnerability of African populations to the spread of diseases and to other health problems. The public sector job losses and wage cuts associated with World Bank and IMF programs increased hardship in many African countries. During the 1980s, when most African countries came under World Bank and IMF tutelage, per capita income declined by 25% in most of sub-
Saharan Africa [10]. The removal of food and agricultural subsidies caused prices to rise and created increased food insecurity. This led to a marked deterioration in nutritional status, especially among women and children. In Zambia, for instance, following the elimination of food subsidies, many poor families had to reduce the number of meals per day from two to one [11]. Malnutrition resulted in low birth weights among infants and stunted growth among children in many countries. It is currently estimated that one in every three children in Africa is underweight [12]. In general, between one-quarter and one-third of the population of sub-Saharan Africa is chronically malnourished. The deepening poverty across the continent has created fertile ground for the spread of infectious diseases. Declining living conditions and reduced access to basic services have led to decreased health status. In Africa today, almost half of the population lacks access to safe water and adequate sanitation services [13]. As immune systems have become weakened, the susceptibility of Africa's people to infectious diseases has greatly increased. A joint release issued by the WHO and the Joint UN Programme on HIV/AIDS (UNAIDS) in April 2001 reports that the number of cases of tuberculosis in Africa will reach 3.3 million per year by 2005 [14]. The WHO reported in 2001 that almost 3,000 Africans die each day of malaria. Each year in Africa, the disease takes the lives of more than 500,000 children below the age of five [15]. Most devastating of all has been the impact of the HIV/AIDS pandemic. The spread of HIV/AIDS in Africa has been facilitated by worsening poverty and by the conditions of inequality intensified by World Bank and IMF policies. Economic insecurity has reinforced migrant labor patterns, which in turn have increased the risk of infection. Reduced access to health care services has increased the spread of sexually transmitted diseases and the vulnerability to HIV infection.

Further details: /newsletter/id/29143

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