Editorial

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 [1].

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 [2].

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) [5]. 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 [6]. 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 [7]. 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 [8].

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 [10], 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 [12], factory-labour-associated illness [13], and the crash in primary commodity prices that precedes changes in food use and subsequent diabetes rates [14]) 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 [15]. 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 editor@equinetafrica.org. Click on the link below for references.

Earlier this week, the Clinton Foundation announced the dramatic reduction of AIDS drug prices after its negotiations with several "generic" pharmaceutical manufacturers; the result was a cutting in half of the price of antiretroviral treatment for AIDS patients in several poor countries. While the news was welcome to most persons working on the issue, and while indeed many groups eagerly await specific details that might reveal problems or wonders in this deal, there is an underlying question that will remain unaddressed by technical evaluations of the new drug price reduction: what does it mean when a foundation headed by a person who--years ago--placed trade sanctions on countries attempting to import low-cost medicines now helps to procure such drugs and enters the spotlight of praise in the "AIDS community"?

The issue is not merely one of hypocrisy or even of repentant revelation and progressive reform. At issue, more generally, is the question of what the meaning of AIDS has become as it has travelled through so many powerful institutions and been altered by so many professional "institutionalists", and what the implications of this are for those people genuinely concerned about human well-being. The answer might be found in the frequently-expressed bitter remark from young public health students who now say that AIDS is getting "too much attention." Those who disagree with this perspective will, quite rightly, point to the disease's devastating toll and suggest that such attention is certainly justified and perhaps not even provided in adequate magnitude or appropriate programs. But, perhaps just as importantly, a second rebuttal is needed: that criticisms about one disease becoming too mainstream or too attractive for the institutional crowd assume that public health advocates are not fighting for general well-being, but rather battling against each other to steal the most funds from one another, like slaves competing for maximum output at the mill. If there is one thing that the AIDS activist movement has taught us over the last several years, it is this: that rather than fighting amongst ourselves over a fixed pot of money, those of us who stop thinking through the "cost-effective" framework and think through politically strategic paradigms can make the overall pot of money significantly larger, and can make our set of available options much wider. The funding provision may involve chaining ourselves to things, but the campaigns do in fact work, and few who review the history of AIDS activism can argue otherwise. To expand our paradigms simultaneously has also meant addressing the plain fact that diseases are not isolated and singular entities, but agents with reciprocal effects--that HIV rates affect TB rates, which affect community well-being and family stability (and vice versa), which in turn affect vulnerability to other diseases and social stresses and nearly everything else that matters to living a decent life.

Years ago, the paradigms used to address AIDS were focused on identifying specific "risk groups" and "targeting" them for interventions. These interventions were almost exclusively constructed though a "rational choice" framework (or what I've called "public health behaviourism")--a framework that wrongly assumes that poor women in economically-dependent relationships can negotiate sex, or that assumes that depressed men in the all-male barracks of South African mines (with a 42% injury rate) will care more about a disease that can kill them 10 years down the line than about finding some minor satisfaction through alcohol or sex. The paradigm even promotes "models" like Uganda, failing to account for the fact that much of the data coming out of such countries indicates that "prevention-only" measures were working only among the wealthier sectors, while the poor continue to suffer the greatest burden of disease. I have compared the realities of poverty and the rhetoric of public health behaviourism elsewhere (1); my task here is to argue that something very strange is going on if this behaviouristic paradigm has finally shifted to a new paradigm that addresses the issue of resource (mal)distribution and inequality--in particular, "access to antiretrovirals"--but in the midst of this, the Clinton Foundation, of all groups, has emerged as a central hero.

What is odd about this event is captured by the very framework of the Clinton initiative. I am not, here, referring to the extensive patent law strengthening done under the Clinton administration, which now ironically undermines in some ways the Clinton Foundation's own initiative; this set of issues around hypocrisy is obvious enough. What I am referring to is that the deal made by the Foundation was narrowed to one about AIDS, and more specifically, antiretroviral drugs. This seems appropriate, but I will argue that while it may be technically competent, it is not politically so, and the press releases and narrowing of scope of the negotiations to just antiretroviral drugs avoided the core of the problem. Not only was the scope merely "narrowed", but it was done in a way to suggest that such price negotiations could not lead to questioning of intellectual property issues, and more importantly, could not be used for diseases besides AIDS. This was merely an "AIDS drug access agreement". And AIDS will supposedly be solved through existing behaviouristic prevention measures and a few of these new types of drug negotiations. In essence, the deal moves us back towards the days when AIDS was treated as a singular entity, a problem to be addressed without asking questions of why it has appeared the way it has, and why it continues to sustain itself in the way it does (that is, why it remains a disease of the poor).

The Foundation focused on the drug price reduction as an AIDS issue, and AIDS as now primarily an "access to antiretrovirals" issue. If there is any sure indication that "access to antiretrovirals" has become a mainstream concern, this is it. And yet, as someone who has advocated for such access for nearly 7 years, this is a frightening phenomenon.

My concern is that lack of access to antiretrovirals is an indicator of something much broader, and AIDS is also a symptom of much more nested problems. If AIDS is appearing so often in the context of trade agreements, where the crash of primary commodity prices leads farmers to migrate to industrial centres and break off their marriages, making "monogamy" a nonsensical idea (2); if inequalities in access to jobs and education force women into prostitution as the means to survive (3); if the terms of inequitable worker contracts mean that depression and drug abuse are the two primary options for workers in the lowest income sectors (4, 5), then AIDS is not just a "syndrome", but an end-stage "symptom" of a much larger disease.

What is problematic, then, is that as "access to antiretrovirals" has become part of the centre of AIDS discourse, two camps have appeared to negotiate the phrase's meaning. On one side we have the Clinton Foundation, who through technical interventions and isolated negotiations will attempt to disguise its past and avoid coming to terms with patenting and other structural problems as it "solves" the pandemic through the most elite forms of politics: closed-door negotiations. On the other hand, there are those that recognize that "access to antiretrovirals" is merely a group of code words that indicate, most broadly, "the right to resources needed for a decent life." The lack of antiretrovirals in poor countries is part of a broader problem of lack of medicines; this, in turn, is symptomatic of a broader problem of inappropriate resource distribution, which in turn indicates dramatic power inequalities. That form of thinking is precisely what the Clinton Foundation's press releases seem to try to hinder, arguing that this selective price reduction was AIDS-specific, and something that the elites can take care of.

The distinction is not minor, for it brings us to bear upon our role as self-described "activists"--a term that, all too often, carries with it the most extreme forms of self-promotion and self-righteousness, and often a vulnerability to injure those who we claim to advocate for. The problem with treating AIDS as just a disease, and not a symptom of broader inequalities, is that this prescription is more frequently coming from "activists" who have lost touch with the context of the statements they receive from those they claim to represent. In the letters and editorials of papers in neighbourhoods and cities most affected by AIDS, the disease is not merely a concern about drugs. Drugs are crucial; but talk about inequality in access to drugs are also representative--they are indicators, social markers (like conspiracy theories or public protest) that something much deeper is going wrong. And the hegemony exerted by activists who lose this sense is a hegemony that is indeed very dangerous, because it inflates a desire for personal heroism and self-promotion and neglects the structural inequalities few are willing to approach for fear of being left out of elite conversation. The new public health advocates struggle with the task of understanding medicine distribution technicalities and little else; they do not ask if there are other avenues to approach, or even if this is merely one recipe torn apart and read in isolation, because they have forgotten (or have never learned) that this recipe was part of a much larger cookbook. AIDS is reduced to an issue of "access to antiretrovirals", rather than having "access to antiretrovirals" be a representative AIDS issue that serves to hint at the direction of the fuel tanks supplying the biggest fire in human history.

All too often, the "structural problems" fuelling the fire are declared impossible for public campaigning; too difficult for effective activism, or--worse yet--the domain of lunatics and extremists. Once again, the common, day-to-day forces in AIDS activism prove such contentions wrong. At universities across the U.S., U.K., and Canada, students are engaging with activist groups in "the South" to alter university drug development policies in line with the community needs of those who have been excluded from research benefits (www.essentialmedicines.org); in other parts of the U.S., even as federal funds get shredded under neo-conservative fiscal policies, activists have kept pressure on local governments to preserve key social services by promoting ballot initiatives among the poor; elsewhere, labour policies are becoming central parts of AIDS activism movements, which are winning battles to improve housing and terms of contracts after involving mine workers and other affected persons more centrally in the campaigning process. The key, then, to maintaining a representative discourse on AIDS is to diffuse power in this manner and consistently expand the meaning of AIDS to its structural causes rather than its most visible and easily acceptable end-points; the commonality between all of these effective "structural interventions" is that they are operated with a sense of caution, and a fear of exerting dangerous hegemony that forces those involved to re-think what it at stake. Rather than taking a mainstream issue and carving out a field of power within it, these campaigns are directing themselves in the opposite direction: taking an issue that is already mainstream ("access to antiretrovirals") and asking what is unrepresentative about it, what is missing from its ranks ("access to general resources needed for decent life"). And who better to ask than those who are most affected; those who do not gain entrance into the drug price negotiations of the Clinton Foundation (but, importantly, have gained access to the core of South African AIDS activism, 6)?

This article may be written as a formulaic prescription, and the more educated groups will criticize my simplicity and extravagance even as I discuss hegemony and preach humility. Their criticisms may be warranted; but in spite of that, a healthy warning should remain: that the fear of hegemony, the fear of being unrepresentative, can drive us much farther towards improving each others' livelihoods than any attempt to force our issues to be arbitrated by the mainstream sources of power in isolation from the core of active suffering, or to force social space into our preconceived visions by selectively filtering the voices and livelihood realities of those we claim to defend.

References:

(1) AIDS, Empire and Public Health Behaviorism:
http://zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988

(2) Bello, W., S. Cunningham, et al. (1998). A Siamese Tragedy: Development
and Disintegration in Modern Thailand. London, Zed Books.

(3) Farmer, P. E., M. Connors, et al., Eds. (1996). Women, Poverty and
AIDS: Sex, Drugs, and Structural Violence. Monroe, Common Courage Press.

(4) Campbell, C. and B. Williams (1999). "Beyond the biomedical and
behavioural: towards an integrated approach to HIV prevention in the
Southern African mining industry." Social Science and Medicine 48: 1625-39.

(5) Connors, M. M. (1994). "Stories of Pain and the Problem of AIDS
Prevention: Injection Drug Withdrawal and Its Effect on Risk Behavior."
Medical Anthropology Quarterly 8(1): 47-68.

(6) www.tac.org.za

All concerned with international trade should work for salvaging the WTO from the debris of the Cancun collapse. Even those considering the WTO framework as anti-development would certainly see the powerful signals emitted from Cancun indicating a new identity of the developing countries. It will be some time before the WTO recovers from the shock of Cancun collapse. And that too only if the main actors make sincere efforts for its recovery.

Cancun was qualitatively different from Seattle. In Cancun, the deep difference between the developed countries and the developing countries was at the core of the failure of the conference, whereas the chaos at Seattle was due to various other reasons. Though the developing countries, particularly those of Latin America and Africa-Caribbean-Pacific, publicly expressed frustration and disgust at the Seattle process, the final failure was because of other factors, like handling of the conference by the chairperson, public insistence of the host country on some new issues like social clause, deep difference between the two majors, viz., the US and the EU and the chaotic atmosphere outside the conference venue due to several demonstrations. There was really no intense engagement among the countries at the negotiating table. In Cancun, on the other hand, there was engagement of the countries, but there were grave differences among the developed countries and the developing countries.

The problem started because the Chairman of the General Council, and later the Chairman of the Ministerial Conference too, presented texts for the Ministerial Declaration that had almost fully included the proposals of the major developed countries and totally ignored the specific and firm proposals of the developing countries. The US-EU were not ready to eliminate/substantially reduce their subsidies in agriculture, while demanding from the developing countries to cut their tariffs in agricultural products and industrial products significantly. The EC was insistent until the near end that negotiations should start on the Singapore issues. The developing countries finally got fed up with the unreasonable and unfair demands of the major developed countries when they themselves were not prepared to make material concessions.

The collapse did appear to be sudden; but there was grave simmering discontent among the developing countries right from the final phases of the preparatory process in Geneva. It all boiled over in Cancun. One may be tempted to diagnose the reason for collapse in some sudden move here and there; but the reason appears to be more deep rooted. Over the years, the major developed countries have followed the strategy of squeezing maximum concessions from the developing countries, but it cannot continue indefinitely. The developing countries, if pushed to the wall, are bound to resist. The governments of the developing countries cannot go on explaining to their people indefinitely that they have been pressurized into accepting one-sided and harmful results. Their people will soon ask them firmly to resist pressures. Cancun gave us a glimpse of this trend.

Pressures on the developing countries by the developed countries in Cancun and in preparation to Cancun were no less than at the time of Doha. But the imperatives on the developing countries gave them strength to resist these pressures. This situation also worked as a cementing factor in the cohesion of some groups of the developing countries. Moreover the developing countries are fast improving their understanding of the WTO and its processes. They have been effectively aided in it by some dedicated NGOs.
The Cancun collapse is a symptom of the instability of the GATT/WTO system as it has been emerging lately. A multilateral system has to be based on the perception among its members of the shared benefits. Once the large membership feel that the system demands only “give” from their side without any possibility of “take”, the system is bound to be unstable. And instability in the system will hurt all the countries, big and small.

The much publicised parting statement of the U.S. Trade Representative in Cancun that they would follow different alternative tracks like bilateral and regional arrangements in the wake of the Cancun collapse has a certain emptiness in it. The U.S. may have a multitude of bilateral and regional arrangements, but when it comes to enforcement of commitments in the areas of goods, services and Intellectual Property Rights, it has to take shelter in the WTO framework. After all it has had tremendous gains in the Uruguay Round in all these areas and it continues to enjoy those gains. In that background, its threat to give up or underplay the WTO route does not appear serious. What is needed is to understand the deep-seated malady in the system and to take corrective measures quickly before it is too late. All parts of the system, viz., the developed countries, the developing countries and the institutional machinery, have to play active role in it. The developed countries should consider the following approach.

1. They should lower their sights and ambitions in the WTO. They have already got a lot in their favour in the Uruguay Round. They should consolidate these gains and stop demanding new concessions from the developing countries.
2. They should allow the system to settle down and not destabilize it by insisting on introducing new subjects in the negotiations.
3. They should be constructive in the area of agriculture and try to understand the sensitivity and importance of this sector in the economics and politics of the developing countries. Positive action in this area is likely to result in spread of gain among the weak sections in the developing countries. Hence agriculture is generally perceived as a test case for assessing the intentions of the developed countries.
4. They should give up their old mind set of monopolizing the management of the GATT/WTO and realize that this organization has to keep in the forefront the interests of a large number of its membership, i.e., the developing countries.
5. More basically, they should realize that their own growth will be helped by the development of the developing countries, because it is there that the prospect of future fast growth of demand lies. They should come out of the thick shell that they have built around themselves over the last two decades or so, thinking that they can sustain their growth on their own without counting on the role of the developing countries. In this mind set, their linkage with the developing countries is limited to their targeting them for extracting more and more concessions.
The institutional machinery of the WTO, including the Chairpersons and the Secretariat, have also to change their approach and style of functioning. Some points are important for them to note.
1.They should realize that the strategy of “clean text” is not always the best. It is not the “clumsy” and “overburdened” text that hinders agreement, as is often alleged about the text for Seattle which accommodated the diverse view points and put them in square brackets. Even the cleanest text, as for example the two texts for Cancun, can result in disaster, if the process of preparation has not been fair and objective. A “clean text” can facilitate negotiations only if the process of preparation has been open and transparent and it is a fair and objective balance between the differing positions. The General Council Chairman’s text for Doha which was confidently taken as a model for the Cancun text also suffered from similar defects as the latter. But there was a big difference in the two situations. While the GC Chairman’s text for Doha was mainly in the nature of a framework in most of its part (except Singapore issues), the texts for Cancun contained specificities of obligations which had been widely opposed by a large number of the developing countries and the alternative suggestions given by them had been totally ignored by the Chairmen of the General Council and the Conference.
There was also the difference in the environment. A large number of the developing countries got confused in Doha by the tactics of the US-EU, whereas, after having learnt their lesson in Doha and later, the developing countries could not be deviated from their determined track in Cancun. Also, during the two years passage between Doha and Cancun, the developing countries had gone through a process of introspection and consolidation. The NGOs of the world had a big role in it.
2.The institutional machinery of the WTO has to show without a trace of doubt that it is not influenced by the major developed countries. It has to be neutral and objective and clearly appear to be so. Much damage has been done by the perception that the machinery is being used by the major developed countries for advancing their own narrow interests. The machinery should work for the system and not for individual countries, howsoever powerful.

The developing countries have found a new identity in Cancun. They showed they could not be pushed around any more. The following steps may help them in future.
1.The various groups of the developing countries that became effective in Cancun should interact with one another to forge a broader and deeper alliance. They should try to identify their common interests and also differences, if any. It may be possible for them to build upon their commonness and smoothen their differences through the process of mutual understanding. After all, one common factor with all of them is that they have all been serious losers in the Uruguay Round and have been the target of the major developed countries for squeezing concessions out of them even later. Though it may be possible for these individual groups to stop some thing here and there and thereby reduce damage, their combination is essential for getting positive benefits.
2.They should counter the divisive tendencies among them. For example, often the division among them is promoted by urging that they should cut their tariffs on industrial and agricultural products in the interest of expanding south-south trade. Though expansion of south-south trade is a laudable objective, undertaking obligation of tariff reduction in the WTO is not an appropriate way to go about it.

A preferred path should be to use the framework of Global System of Trade Preferences (GSTP) for reduction of tariffs among the developing countries. It has two special benefits for the developing countries over reducing the tariffs in the WTO framework. Firstly, a developing country while reducing its tariffs under the GSTP does not have to extend this benefit to the developed countries; thus there is less revenue loss for the committing importing developing country.

Secondly, the beneficiary exporting developing country will face less competition from the developed countries as the latter will not get the advantage of this lower tariff in the developing countries. Over a course of time, this process is likely to enhance investment in the developing countries in manufactures and agriculture, because of larger market access opportunities among the developing countries. The developing countries should give fresh impetus to the GSTP framework which is administered in the UNCTAD and is dormant at present.

This is not to suggest that the developing countries should not engage in the tariff reduction exercise in the WTO framework at all. Of course, they may engage in this exercise there, but only with the objective of getting tariff concessions from the developed countries. An attempt should be made by all to usher in a reformed WTO process. International trade is important for all including the developing countries. And a multilateral framework is useful for that purpose. It is not practicable to create a totally new framework in the current international environment that is characterised by mutual suspicion, lack of goodwill and erosion of confidence. It should be a much-preferred choice for all concerned to work for a reformed and improved WTO. Foundation should be laid for it even before reverting to the Doha work programme in the post-Cancun phase.
http://www.twnside.org.sg/title/twninfo78.htm

'NO LONGER DINNER': AFRICAN ACTIVISTS SPEAK ON CANCUN
“Yea, we are sick and tired of being dinner, we should make dinner for a change,” declared Crystal Overson, a media activist with the Alternative Information and Development Centre-South Africa. Overson was participating in a discussion with five other African activists about the recently collapsed WTO Ministerial meeting in Cancun. The interview delves into the nuts and bolts of the African position at Cancun, the thrills and spills and the way forward to the next Inter-ministerial. Read the full transcript of the interview at www.pambazuka.org

In the wake of U.S. President George Bush's trip to several African nations, and after his State of the Union speech declaring $15 billion of spending for global AIDS prevention and care, American newspapers have rallied in support of the "compassionate conservatism" represented by Bush's "commitment" to anti-AIDS efforts. Certainly, the $15 billion number has turned out to be an inflated figure, as most of the money is recycled from existing spending and only $1.4 billion has been appropriated this year (with little indication of renewal in subsequent years) [1]. But where the money is actually going has been left mostly unexamined. Not only is the funding circumventing the Global Fund for AIDS, TB and Malaria, being spent almost entirely through bilateral USAID initiatives known for their inefficacy (and diversion towards abstinence-only, anti-abortion initiatives), but more importantly the majority of funds are being spent in line with a common and fallacious public health dogma: that "information is everything", and preventing the spread of HIV means "promoting education" [1-5].

This "health belief model" seems intuitive and obvious: if people just know how HIV is transmitted (and stop being in "denial" about it) -- the rhetoric goes -- the transmission of HIV will diminish [6]. Sounds credible enough; but this argument has been consistently promoted by a group of public health workers and international financial institutions who ignore most of the available data we now have on AIDS prevention initiatives [2]. While the development banks and others have promoted the Ugandan case as a "model" (at one point claiming that effective "bereavement counselling" in the country was a reason for praise, rather than preventing the deaths to begin with [7]), the Ugandan "model" appears to be promoted without much examination of the data. Certainly, prevention initiatives in Uganda have reduced HIV prevalence in certain populations. But the prevalence rates have increased in some sections of Uganda while decreasing in others; in particular, the wealthier urban areas have seen a decrease in infection rates, while infection has rocketed upwards in the rural and poorer zones.

What is also often ignored is that even in sectors where prevalence has reduced, the reduction mathematically represents a decline in incidence well before the government's prevention initiatives began, and corresponds more to social demographic changes and economic reforms than "education" initiatives [8]. What is perhaps most problematic about the Ugandan case is that the so-called "model" it offers makes several wrong assumptions. Given that the top epidemiological predictor for HIV infection around the world is not "risk behaviour" but rather a low income level, those most vulnerable to infection will not benefit from a model focused on "education" -- a model that assumes people in poverty have the agency to control the circumstances of their lives, even in the context of gender inequality or in environments without income opportunities other than trading sex for money [9-15]. As Dr. Paul Farmer and colleagues recently noted, "Their risk stems less from ignorance and more from the precarious situations in which hundreds of millions live" [7]. And dozens of surveys support this fact, confirming that -- despite our presumptions -- those most at risk for HIV often do know how the virus is transmitted, and even in the highest prevalence areas have sex rates lower than in many regions of the U.S. and Japan [13, 16-20].

Sex is not as much the issue as the context under which sex occurs, yet several social scientists studying AIDS are guilty of trying to define an African "system of sexuality" and render sexual behaviour the problem rather than examining why sex among the poor seems to lead to HIV transmission so much more often than sex among the wealthy [21-24]. In interviews, those most vulnerable regularly discuss other concerns about life (access to clean water and food, gaining financial independence, and so forth) that take precedence over preventing HIV transmission [19, 25-30]. Yet the "targeted" public health rhetoric ignores these and even equates the concerns of the poor with the rhetoric of politicians by labelling both "in denial" [30, 31].

In the South African mining sector, for example, a recent group of surveys established that the "norm" of masculinity (expressed through soliciting prostitutes) in "South African culture" increases the risk of HIV transmission [32]. To locate "culture" as the problem is to ignore the perspectives of the miners themselves (who, in fact, are from a variety of different locations as distinct as rural sectors of Malawi and Mozambique and urban areas like Johannesburg). As one miner put it: "Every time you go underground you have to wear a lamp on your head. Once you take on that lamp you know that you are wearing death. Where you are going you are not sure whether you will come back to the surface alive or dead. It is only with luck if you come to the surface still alive because everyday somebody gets injured or dies"[32].

In the context of a 42% injury rate, it would be natural to think that catching a disease that could kill you ten years down the road might be less pressing than trying to gain some control over life -- or perhaps even enjoying life in some minor way (through alcohol or sex) before getting crushed by falling rock. But the psychologists who quoted this miner (and published their analysis in a top-ranked medical journal) labelled him "in denial," and claimed that his "low self-esteem" was the cause of his increased risk for HIV infection [32]. A similar survey among prostitutes labelled them "liars" (in "denial" of their agency) when they attributed their prostitution to lack of opportunity and coercion [25].

"Culture" (whether a distant African one or a "culture of poverty" among the poor in wealthy countries) is often described as a barrier to effective intervention, assumed to be a fixed, unalterable thing defined by the dominant groups in power, while the marginalized have no culture themselves or are guilty of having a sub-culture that renders them vulnerable to HIV or promotes crime and delinquency [20, 21, 33-38]. Culture, denial, stigma and conspiracy theories are taken to be the causes rather than the effects of social and economic problems. At other points, culture is focused upon to devise "culturally-competent" solutions to change the low efficacy of HIV prevention initiatives [39, 40]. In both of these cases, "culture" is conflated with the structural violence of inequality and lack of access to resources -- and when these issues are un-addressed, even the most "culturally-competent" prevention initiatives still focus on merely co-opting local culture to suit the needs of "targeted" interventions [41]. In this context, even after messages are adapted to "local norms" (ignoring the universal context of HIV-transmission, that of inequality and lack of access to resources), "providing information about health risks changes the behaviour of, at most, one in four people -- generally those who are more affluent and better educated" [42].

In response to accumulating data that the majority of education initiatives are failing, the public health community is now committing another behaviouristic mistake; instead of examining the political and economic contexts of prevention, it has now returned (unawares, I suspect) to a colonial rhetoric: claiming that the inefficacy of such initiatives is due to the individualistic nature of the interventions, ignoring the "collectivist African traditions" (thereby conflating all of the many social scenes in Africa into one "African system") [39, 42]. In colonial times, "venereal" syphilis among miners (which later turned out to be non-venereal syphilis and yaws) would be explained by the loss of "African traditions", which reportedly promoted female chastity by exerting group control over young women (paralleling the modern "revival" -- and partial invention -- of "traditions" like virginity testing in the context of AIDS [43]) [44, 45]. Mine workers were simultaneously taught to be individualistic and capitalistic in the mines, then returned to be collectivistic at their rural homes when they became ill (a very "cost-effective" strategy for mine owners to avoid paying for medical care) [18, 46]. The context of illness, and its relationship to their position in the economic field of relations, went unquestioned. Now, public health behaviourism aims to solve HIV transmission by holding "group rituals" for education -- so, perhaps, the "self-esteem" problems can be pushed aside as "traditions" solve all of the barriers to effective HIV prevention [39, 42].

What this rhetoric ignores and often disguises is that the background for increasing HIV transmission is a background of neoliberalism -- a context where the movement of capital is privileged above the ability of persons to secure their own livelihoods. Increasing migration is correlated precisely to the break-up of marriages as rural farms are destroyed after the liberalization of markets results in sharp drops in primary commodity prices; (mostly male) labourers travel to urban areas to work [13, 47, 48]. In vast sectors of southern Africa, miners are housed in all-male barracks for months at a time, worked six days a week, and given alcohol to "keep them happy" (or keep them from rebelling) on the seventh day -- when intoxication and depression lead to the solicitation of prostitutes. They are returned home to die, and find either their wives have left them to find a better source of income and support, or are waiting themselves to be infected with HIV [13]. The "rural women's epidemic" of HIV -- that is the sub-epidemics of women in rural zones who have been infected by their migrant male husbands (most of whom have already died at the time of surveys) -- is not so "surprising" or "unusual" in this context [47].

AIDS, then, is a symptom as much as it is a disease. In the context of the new South African Customs Union (SACU) trade agreement with the United States, it will be a most severe symptom. The SACU deal promotes rapid liberalization and the movement of capital over the securing of stable employment and better livelihoods, privileging companies who wish to set-up base temporarily and shift the means of production at will. If similar deals in East Asia and the Caribbean are any indication, both TB and HIV will increase markedly in this context as migration and poverty render "monogamous marriage" a nonsensical idea and force both women and men in poverty to move constantly and find new sources of income wherever they can [13, 47].

The SACU deal also links this neoliberal context to the distribution of resources, particularly medicines, which are often discussed through a rhetoric divorced from the context of HIV prevention. The trade deal will render generic medicines extremely difficult to procure, providing a more than two-decade-long monopoly for patented medicines [49]. Public health officials have not strongly voiced their opposition to this (leaving NGOs to take on the task), and have focused on the "cost-effective" prevention initiatives instead. The "prevention versus treatment" dichotomy should have been defeated by the numerous models indicating that access to vital health resources like antiretroviral drugs is part of the process of improving livelihoods, rather than being dichotomously opposed to effective disease prevention. Indeed, effective treatment provision often helps to reduce stigma, denial and blame, in addition to reducing HIV transmission [50, 51]. Brazil has certainly demonstrated this definitively, having reduced HIV prevalence (and incidence) after providing universal access to antiretrovirals. Despite being threatened by the US Trade Representative for producing generic medicines, Brazil has allowed the use of generic medicines, saving the country hundreds of millions of dollars and reducing HIV prevalence by over 50% [51].

The claim has been that such measures are not "cost-effective" in the manner of education initiatives (which themselves are declared cost-effective by predicting "high return on investments" in spite of the emerging data to the contrary). But "cost-effectiveness" is not based on a law of nature -- in its current form, the means for calculating such effectiveness assume that distinct health interventions are competing with one another, as if all health outcomes were pulling from the same pot of money, and the overall effect on society will be discrete, whether or not a plague is taking place [41, 52, 53]. The logic, like the "health belief model", seems intuitive, but it is notable that not all societies think this way; indeed, many assume instead that health is multiplicative -- that healthiness among some members of society contributes to healthiness among others as work-capacity and social esteem are promoted by the lack of disease [54]. As WHO senior advisor Jim Yong Kim recently declared, "For years, we have assumed that health spending must be pulled from a fixed pot of money, without examining who determines how big the pot is or how ill health plays upon the maintenance of the economy and general society." Brazil decided to counter the World Bank claims about the "cost-ineffectiveness" of its programs by calculating the "cost-effectiveness" differently; when it took into account the cost of hospitalizations saved by properly treating AIDS patients and thereby preventing them from having recurring opportunistic infections (reducing hospital visits by 80%), and included the costs of mass death to the Brazilian economy, the cost of antiretrovirals suddenly seemed quite affordable [51].

Yet in this context, a new rhetoric against generic medicines was deployed to counter the idea that other countries could follow Brazil's path. The US Trade Representative threatened Argentina, Thailand, South Africa and other countries when all of them attempted to regulate the prices of pharmaceuticals or introduce competition into the monopolistic patent regimes [55]. The USTR's claim was that generic drug use would reduce innovation, but like many claims about AIDS, this one ignored all available data. According to the industry's own tax records (obtained from the Securities and Exchange Commission), Merck this year spent 13% of its revenue on marketing and only 5% on R&D, Pfizer spent 35% n marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D [56].

Most AIDS drugs were produced under significant public funding, and 85% of the research (including clinical trials) for the top five selling drugs on the market were produced through taxpayer funding [57]. Meanwhile, all of sub-Saharan Africa constitutes only 1.3% of the pharmaceutical market, so as one former pharmaceutical executive put it, providing generics to this market would result in a profit loss equivalent to "about three days fluctuation in exchange rates" [58, 59]. But the drug industry's fight for this market and middle-income country markets is serious, as the growing inequality in poor countries under the context of neoliberalism manufactures a new market among the wealthy and a sector for industry expansion [60].

Realizing the problems with claims about patents and pharmaceuticals, developing country trade ministers pushed through a deal at the November 2001 trade conference in Doha, Qatar. The resulting "Doha Declaration on TRIPS and Public Health" (referring to the Trade Related Aspects of Intellectual Property Rights, or TRIPS, Agreement) would allow poor countries to import generic medicines, especially if they lacked the capacity to produce such medicines themselves [61]. Although it passed unanimously, the US Trade Representative managed to become the only trade minister out of the WTO's 145 member country ministers to block the implementation of the Doha accord [62]. A deadlock still exists as the US insists upon limiting the scope of countries eligible to import generics. The US has once again co-opted the public health rhetoric, claiming that only a few iconic, extremely poor countries should be the focus for the deal [60]. Such an exclusionary policy would not only violate the Declaration itself (which claims that the WTO will promote "access to medicines for all" [61]) and deny medicine access to the majority of people who need it, but would destroy economies of scale and other necessary means to build efficient and effective generic drug production facilities, and prevent competition to lower prices and increase quality [63, 64]. Such is the nature of "free trade".

The "culture" rhetoric also re-appears in this framework. U.S. presidential candidate Howard Dean, claiming to be the "Democratic wing of the Democratic party", has argued that antiretrovirals are of humanitarian importance but should not be emphasized because they are not as "culturally appropriate" as prevention initiatives. Culture once again becomes the basis for justifying inequality. And it is simultaneously blamed as reports are produced about the increasing prevalence of drug resistance in the U.S. and Europe. Drug resistant strains of viruses emerge when patients intake medicines irregularly, and while the reports of resistance are all from Northern countries, they have been projected onto the South under the assumption that "if drug resistance emerges here, it'll emerge there", particularly in the "cultures of denial" (as The Boston Globe put it) [65-67]. Some public health workers have even suggested that antiretrovirals should only be accessible to those patients "most likely to comply", yet what this denies is that those most likely to comply are those least likely to have HIV -- they are the wealthy and the people with resources needed to control the circumstances of their own lives.

Drug resistance can be more effectively countered by scaling-up antiretroviral treatment and providing sustained and equitable distribution; resistance propagates most often because people who are denied medicine are desperate to get it, so a black market flourishes, allowing people to trade medicines and take improper regimens [50]. The drug resistance excuse is, like most excuses about AIDS, a vestige of past public health excuses, first deployed to suggest that persons with drug-resistant TB should not receive treatment (resulting in multi drug resistant TB as those people -- fated to die -- struggled to survive and receive pills wherever they could). Only when multi-drug resistant TB hit New York City populations did treatment for it suddenly become "cost-effective" [68].

Yet the public health community uses examples like these to suggest that they have no options besides meagre education-based interventions. As one group of health workers put it, "as ordinary citizens, we are not in a position to change the political and economic system" [69]. While such an analysis effectively loses the marathon before the race has even started, it also ignores the numerous health models (often constructed by activists rather than public health programs) that have effectively changed political and economic contexts for HIV transmission rather than subscribing to fatalism. In the context of the poorest location in the poorest country in the Western hemisphere (the central plateau of Haiti), public health workers have managed to provide free antiretroviral treatment without producing primary resistance and have effectively begun to stem HIV transmission by providing new models for food provision, income generation and continuity of health care distribution [7, 50].

In the context of southern Africa, campaigners have forced the Coca-Cola company to change its labour policies and provide family housing, reduce migration-based networks of product distribution, and provide complete health packages including antiretroviral drugs (www.treat-your-workers.org). So the fatalism must be tempered by an awareness of such models, which are now abounding as those infected and affected by AIDS refuse to sick back and watch the inefficacy and behaviouristic prevention initiatives produced by the public health community.

What the health community ignores is that that public health must be less about coercion and more about facilitation. In addition, there are many campaigns focused exclusively on inequality between countries -- but these often present the idea that "Third World" starvation will be solved when "First World" people eat less ice cream. Indeed, between country inequality is tremendously important. But increasingly the First vs. Third World rhetoric produces claims that public health work has competing interests -- for example, between lowering prescription drug costs in wealthy countries and lowering them in poor countries (although the data indicate that the pharmaceutical industry can easily afford both) -- instead of questioning the rhetoric of "cost-effectiveness" and the zero-sum approach to health provision. We must increasingly focus on the inequalities that take place within countries, as these point us toward routes to facilitate better health rather than attempt to coerce people whose life circumstances render the rhetoric of hygiene ineffective and often ridiculous [70-75].

When we examine within-country inequalities, we begin to see the major trends -- that the poor (even the relatively poor in wealthy nations) are consistently those marginalized in the context of AIDS, whether they are located in the poor neighbourhoods of Washington D.C. or the mining fields just outside of Johannesburg; that the wealthy in both rich and poor countries use migrant labour and threaten the health of the poor to increase their share of capital; and that AIDS is a symptom of the breakdown of social relations that occurs in the context of growing inequalities [12-14, 20, 25, 26, 28, 38, 41, 47, 48, 50, 53, 76-81]. AIDS is effectively a symptom of Empire, which operates by producing inequalities everywhere, keeping resources inequitably distributed so that they may be accumulated by a few, and rendering problems like disease a side-effect of capital accumulation [82].

Empire is threatened not simply by local resistance but by resistances that occur when people in similar circumstances between different nation-states -- people in both poor and rich countries -- realize that inequality is central to this issue. Anti-AIDS efforts are funded currently to increase labour potential and prevent economic collapse by keeping workers economically productive, or by focusing so much on "behaviour" and "culture" that the context in which "behaviour" occurs is rendered unproblematic [82-84]. Therefore, the current anti-AIDS efforts bolster and disguise the mechanisms of Empire. AIDS becomes the product of individual irresponsibility and anonymous Third World destitution -- the plague captured in pictures of dying babies and public health saviours desperate to convince the natives to adopt better hygiene practices. To expose this rhetoric's basic fallacy will require serious questioning of public health's behaviouristic trends, as well as the dominant economic and political themes that render HIV a plague of the poor.

* For a list of the references used in this article please click on the link provided.