Marys Medicine

Contact163

A publication of the World Council of Churches TRADE OR HEALTH?
Time to take a stand! TRADE OR HEALTH?
14 Action strategy
10-point plan of action
15 Resources
Sources of information on the
TRIPS Agreement of the World
Is the World Trade Organization a
threat to public health?
Tripping up health in India
16 Baby Batandwa is crying! What
Are natural medicines the
18 Useful publications, letters and
contact n°163 - October-December 1998 With respect to pharmaceuticals, the poorer countries and decreased access aims of the TRIPS Agreement are to drug information as a consequence expressed as encouraging innovations, of greater commercial secrecy are also ensuring affordability and access to predicted. All these need to be as- medicines, and reducing barriers to sessed and appropriate steps taken to trade. No one would argue that these minimize their impact on public health.
are anything but worthy aims. It is, The need to find an appropriate bal- however, these very aims that present ance between the interest of the patent a dilemma: while commercial interest (rights) holder and users was noted and can complement public health goals, it considered in the TRIPS Agreement.
can also be in direct conflict! This issue This is particularly reflected in the limi- of Contact looks at the areas of conflict tations and exceptions to rights that are and the possible social effects of the permitted within the Agreement. How- TRIPS Agreement, and particularly their ever, there seems to be a lack of, or impact on the poor. The issue also very little, understanding that countries provides some suggestions on actions do have alternatives – and the right to that can be taken to ensure public health pursue these alternatives in their best interests in pharmaceutical and health interests. Pressure needs to be brought policies are given priority over commer- to bear on WHO, WTO and other inter- cial interests when conflicts between national and regional organizations to the two occur.
ensure that countries are given techni- health goals, it can also Under the World Trade Organization cal assistance, information, and advice agreement (to which TRIPS is an inte- on how best to address the implications be in direct conflict! gral part), all signatories will be forced of the trade policies, legislation, regula- to implement a 20-year patent protec- tion and agreements in order to protect tion on new pharmaceuticals. There is and promote health for all.
irrefutable evidence that patents lead Examples of what NGOs can do to to higher prices than those prevailing reverse the worst effects are highlighted when there is no protection, and that in the article by Darlena David of the prices drop dramatically when patents Christian Medical Association of India.
expire and generic equivalents come In the interview with Dr Hans-Martin onto the market. The implication of this Hirt, an alternative to reliance on western agreement is therefore that generic pharmaceuticals is presented. We also equivalents of any new drugs devel- include a listing of strategizing options.
oped – for example for AIDS or drug-resistant TB and malaria – will take Many of us who are interested in health longer to become available. Such new for all do not consider it appropriate to drugs are therefore likely to remain treat health care as a matter of expensive for longer periods than they commerce only. In the late 1970s and would be without the Agreement. This 1980s, the popular saying was "think is well illustrated by the example of globally and act locally". Today, the rifampicin which was produced in India World Council of Churches believes within six years of its emergence on the that we must not only think globally and market. Had rifampicin been subjected act locally, but that we must also to a 20-year product patent, it would strategize globally to be effective locally have remained very expensive and and globally. We hope this issue will unavailable to many for an extended help you think about how to do this with respect to TRIPS.
Other possible effects are foreseen.
Eva Ombaka
These include price increases, a fall in WCC/CISS Pharmaceutical consumption, local innovation, foreign Trade or health? A street childselling cigarettes and chewing direct investment and transfer of tech- gum in the bars of Addis Ababa, nology to developing countries.
Ethiopia.
Martin Adler/Panos Pictures Research on diseases prevalent in contact n°163 - October-December 1998


IS WTO A THREAT TO PUBLIC HEALTH?
Dr James Love, a consumer activist and director of the Consumer Project on Technology, is concerned about the effect of TRIPS (Trade-related aspects of Intellectual Property, see box on page 4) on health. He attended the World Health Assembly in April 1998 where many countries were lobbying for public health to be put before commercial considerations in trade negotiations and Contact: What effect does the World
– representatives of ministries of trade Trade Organization (WTO) have on or departments of commerce. Within any community, these diplomats do notrepresent all interests.
James Love: WTO has to do with intel-
lectual property, and there are several
Contact: The justification for patents is
parts of the new TRIPS Agreement, to protect the profits of inventions and which are very important for the health stimulate research. Are patents the sector. For example, many poor coun- correct way to stimulate R&D? tries that do not have patents on phar- Love: Policies which enhance the
maceutical drugs at the moment will in public's access to new pharmaceuticals future be required to have them. As – and to other health care inventions – new drugs come onto the market, the are a good thing for public health.
onto the market,. effect of having a patent law will grow.
Increased profits to drug companies Drug prices will be much higher. In the drug prices will be are not an end, but rather one of the United States, for example, once a several mechanisms, which may or may patent expires on a drug and there is not contribute to the size and efficacy of competition from generics, prices fall the R&D effort. National governments very rapidly. The twenty-year patents can increase research and develop- stipulated in the TRIPS Agreement ment by funding research directly from instead of the maximum ten or fifteen- their own budgets or by requiring drug year patents in the past will push up companies to re-invest in health care drug prices.
research. Patents create financial WTO has awesome power. It is much incentives for firms to develop new more powerful than UN bodies because drugs. This is the focus of the TRIPS it has enforcement mechanisms. It is accord and much US lobbying. The going to be a supra government but it is obvious shortcoming is that these run by people with very narrow interests patents create monopolies on important contact n°163 - October-December 1998 health care discoveries. Monopoliestend to seek high prices and high pricesprevent many consumers from obtain-ing access to new technologies.
One's stand on patents must be basedon the questions of "who benefits themost?" and "what are the alternatives?"and "is there a different way of doing itwhich may yield benefits to a maximumnumber of people?".The argument isnot about "having patents" or "not havingpatents". We are not trying to get rid ofpharmaceutical patents. The way tothink about it is: "What sort of a patentsystem are you going to have?" Thevery winnable fights are those basedon defining the type of patent system,which creates most benefit and whobenefits the most. Is there a different Drawing from page 17 of TRIPS report "What do you think about TRIPs?" way of doing this which accomplishesthe same goals but spreads the benefitsdifferently?" Box: Understanding TRIPS
The aim of the TRIPS agreement is to strengthen its emergence on the market. Had rifampicin been intellectual property rights in the global economy.
protected by a 20-year patent in India, it would have Intellectual property is an intangible asset (that is, been either very expensive or not available at all for something of value which cannot be physically a long period.
touched), such as a patent or a copyright. Patents Poorer countries are allowed a breathing space or provide inventors with intellectual property rights.
"transition period" in which to adapt to the new To be patentable an invention needs to have novelty situation. Developing countries have until 1 January (previously unknown to the public), non-obvious- 2000 to fulfil their obligations to the treaty, and least ness (containing sufficient degree of innovation to developed countries have until 1 January 2006.
merit protection), and industrial applicability. When Developed countries had only a one-year transition a product is patented, it tends to earn a higher price.
period following the introduction of the TRIPS Agree- All countries which signed the "Final Act" ending the ment on 1 January 1995.
Uruguay Round in 1994 automatically becamemembers of the World Trade Organization, and How should these countries be responding to thus subject to the condition of the TRIPS Agree- TRIPS? According to Dr Eva Ombaka, WCC's ment. Compliance with TRIPS means that instead Pharmaceutical Adviser who attended a WHO/NGO of an individual country being able to decide for meeting in October 1998 on the issue: "Countries itself on patent legislation, all WTO members have should make themselves aware of the provisions of to accept 20-year patents on new pharmaceutical TRIPS (especially Article 8) such as opportunities for compulsory licensing and parallel importingwhich allow members to adopt necessary measures What will be the effect of TRIPS? Drugs currently to protect public health. To help them take advan- available as generics (that is, not protected by a tage of these provisions, a technical body, such as trademark) will not be affected. However, as soon the World Health Organization, should advise them as TRIPS is in full force worldwide, any new drug on how to revise their legislation in the interests of coming on to the market will be under patent for 20 public health. WHO's technical support should also years. This presents a fundamental change. In the provide ongoing monitoring of the impact of TRIPS, past, India developed its own means of producing especially in developing countries." rifampicin and made it available within six years of contact n°163 - October-December 1998 Contact: How should readers of Contact
data or treat trademarks and patent. It is respond to TRIPS? important for people who represent con-sumer interests not to rely entirely on Love: The first thing they have to do is
that process. They need to have a to start adopting policy statements or proactive way of developing their own positions. We circulated a petition on the Internet on health care and intellec-tual property to be presented in the Contact: What are some of the specific
The exceptions that "Free Trade Area for the Americas" issues that should be addressed? are given with regards negotiations earlier this year. The only Love: Patents may make it more diffi-
to patents are as groups that signed on were Health cult to get generics on the market. That important as the Action International and our group. That essentially means prices would be looked pretty bad in my opinion when higher for drugs in poor countries. How- we went down to Costa Rica. We should ever, we also know that countries have have had 150 groups signed on.
authority under the WTO to mitigate Part of the problem is that many non- those problems through things like com- governmental organizations (NGOs) pulsory licensing.
have not thought enough about it even Suppose a new AIDS drug comes on to take positions. It was such a new the market but that the price is so high topic for them they did not have any that poor people in sub-Saharan Africa board resolutions to sign on to the docu- cannot buy the drug. Suppose further ment. So the first step is to find out what that the drug company refuses to go is going on. The best way is through the along with price control – saying, "If you Internet. We have a Web page that make me sell the drug for this price, I will covers health care issues and intellec- not import it into your country." In this tual property with links to other groups situation, the government could issue a that are active in this area, such as compulsory licence that would permit Health Action International, or other anyone who wants to sell the drug in the resources that are available. The World country to do so. A royalty has to be Health Organization issued a publica- given to the com- Selling drugs in Angola tion which is very helpful for people in health groups called "Globalization and patent, but it does access to drugs: the implications of the not give the com- WTO/TRIPS Agreement" in November pany the power to 1987 (see Resources page 15). Health determine whether Action International (HAI) has held that drug is made meetings and taken positions.
There are many things that can be done population and on within the context of the TRIPS to protect the public health interest. It is a compli- pulsory licensing is cated agreement but the exceptions a power that gov- that are given with regards to patents ernments have and are as important as the rights them- sometimes, though Peter Williams/WCC selves. Many of the controversies will rarely, exercise.
have to do with how those exceptions are treated under the TRIPS.
very little compul- One important thing to remember is sory licensing in that WTO is a political body, and that tribunals will be influenced by "interna- tional norms" or the opinions of experts cally countries that on these topics. Various industry groups were poor did not are already "manufacturing" norms.
have patents at all.
They actually pay people to write articles and hold conferences to establish the had patents on the right way to protect health legislation contact n°163 - October-December 1998 facture but they did not have patents on importing. The reason they wanted to the products themselves. As a result do this was to be able to go out and get there were few cases of compulsory the best world price for any particular licence. Compulsory licensing has probably been done more in the United South Africa's "parallel importing" legis- States than it has in developing lation allows it to import patented drugs countries. Although it is allowed under from any country where it is available TRIPS, another international agreement cheaply. Typically, when a patent owner currently being discussed, the Multilat- holds patents in more than one country, eral Agreement on Trade (MAI), aims to the same pharmaceutical is sold at different prices in different countries.
Compulsory licensing is particularly The patent owner is able to charge important because medicine is changing higher prices in smaller markets where radically. Think about biotechnology and there is less competition. For example, Today, the legislation gene therapy, for example. In Europe competition in the large US pharma- that South Africa has right now a company is trying to get the ceutical market keep prices relatively patent on a bacteria. People working low compared with prices in smaller on a new vaccine for meningitis are markets of many African countries. The concerned that royalties might have to pharmaceutical industry has lobbied be paid to the holder of the meningitis against the South Africa legislation is patent every time someone takes a arguing that it goes against the TRIPS Agreement. The South African govern-ment has responded that the legislation Contact: What is the pioneering action
is in the interest of public health – a South Africa has taken? provision which is allowed for in TRIPS.
Love: What South Africa wanted to do
Today, the legislation that South Africa was two main things. One, they wanted has introduced provides an important to promote the use of generic drugs.
model for other countries to follow.
They wanted doctors who work for the Dr James Love, Consumer Project on Technology, public health services to prescribe drugs PO Box 19367, Washington DC 20036, USA. Tel: 1 by generic name - a proposal that faced 202 387 8030. Fax: 1 202 234 5176. E-mail: opposition from the industry. The other love@tap.org More information about the ConsumerProject on Technology is available on website: http:// thing they wanted to do was parallel Where is the World Health Organization?
A resolution at the 51st World Health Assembly in May this year urged MemberStates "to ensure that public health rather than commercial interest haveprimacy in pharmaceutical and health policies, and to review their optionsunder the Agreement on Trade Related Aspects of Intellectual Property Rightsto safeguard access to essential drugs". This proved highly controversial andwas referred back to the WHO Executive Board. It may, however, be broughtback to the Assembly next year. According to Beryl Leach of Health ActionInternational: "If WHO is not given the right to speak on health aspects of tradethen we have lost a key voice at the international level. The internationalcommunity relies on WHO to speak on public health concerns. If it is to showits commitment to Health for All, it needs to be able to speak out on all issues,including trade." contact n°163 - October-December 1998 TRIPPING UP HEALTH IN INDIA
Darlena David, Communications Consultant with the Christian Medical Association of India (and editor of Contact from September 1998) outlines the fears associated with TRIPS, and describes some of the principles and actions taken by community groups in India.
Will essential medicines and affordable examples are acyclovir, albendazole, and nutritious food for all people become cefotaxine, ciprofloxacin, enalapril, a utopian dream? The conditions fluconazole, ketoconazole, ketorolac, imposed by the World Trade Organiza- norfloxacin, and ranitidine. Drugs are tion's trade-related aspects of intellec- often available at much lower prices in tual property rights are likely to seriously India than they are elsewhere (see chart affect people's access to medicines with example of prices in India for and food, particularly in Asia.
ranitidine) because foreign pharmaceu- Transnational companies involved in tical giants face competition from local pharmaceuticals and agriculture-based manufacturers. Under TRIPS, India will industries will be able to monopolise be prevented from producing its own new varieties of medicines, seeds, versions of drugs that are under product genes, fertilisers and chemicals for up Farmers from Bhardoni Village, Patiala District, Punjab protest to 20 years with drastic consequences against the World Trade for food self-sufficiency in the Third Organization In September Products and pro- World. In the area of medicines, prices cesses derived from will rise and the potential for domestic plants and based on industry to produce new drugs will be the knowledge of lo- much reduced.
cal communities are also being patented India will be particularly badly affected under TRIPS. This because it has a highly developed phar- has become a major maceutical industry. India's pharmaceu- area of conflict and tical industry ranks number four in the world after USA, Western Europe and Japan. In 1970, the Indian Patent Act introduced process patents leading to a patenting will lead to rapid growth of the domestic pharma- a loss of control over ceutical industry, and a dramatic fall in the knowledge that the price of pharmaceuticals. Now, is an ancient herit- Indian companies produce 75% of the age of indigenous drugs consumed within the country, and also export in quantity.
Much is at stake.
India has started to manufacture and More than two-thirds export a number of drugs while they of the world's plant were still protected by patents. Some species – at least contact n°163 - October-December 1998 35,000 of which have medicinal value - have no option but to sell their land.
come from developing countries. The Landlessness is bound to lead to large- value of germ plasm (part of the cell scale urban migration bringing its own containing hereditary material) to the chain of hardships and unprecedented pharmaceutical industry was estimated impoverishment. An agrarian people, in the early 1990s at US$32,000 million deprived of their livelihood, may turn to per year. In India, over 50% of health violence to seek justice.
care needs are being met by traditionalsystems of medicines. Practitioners use What to do?
over 7,500 varieties of plants as part of Many groups of traditional healers, their healing work.
farmers' groups, social movements foralternative development, and scientists are discovering that in the age of How does all this affect food? Poor monopolies, there is strength in com- people in Asia will find it more difficult to munities who stand together to articu- obtain essential food items as a result late the principle that people's health of the implementation of TRIPS. Take and well-being matters far more than the example of the effect on rice. Patents trade and profits.
will increasingly be applied to paddy Poor people in Asia will varieties, bio-pesticides and bio-fertilis- One important assertion of these groups find it more difficult to ers. The monopoly power created by is that of the collective rights of local
obtain essential food these patents will push up prices creat- communities over community
items as a result of the ing higher food prices. Food production resources. In India, a legislation on
will tend to concentrate on a small local self-government, named the number of profitable cash crops endan- "Panchayats (Extension to the Sched- gering the security of food supply. At uled Areas) Act, 1996" has provisions the same time, cropping patterns based which recognise the villagers' right to on just a few varieties of seeds will be have control over their common vulnerable to large-scale loss through resources. Community groups resist what they consider to be the privatisingof people's knowledge.
Dr Vandana Shiva, Director of theResearch Foundation for Science, Groups like the RFSTE work on several Technology and Ecology (RFSTE) fronts. They lobby on legal and policy predicts a gloomy scenario. Seventy- issues, and work with the media to five per cent of the total population of ensure that their perspective is heard.
India is dependent on agriculture for They also educate the endangered com- their livelihood, and 90% of farmers are munities of farmers and practitioners of small and marginal with less than two indigenous systems of medicine argu- acres of land. If farmers are no longer ing that knowledge in the public
able to buy seeds from each other and domain cannot be patented.
are forced to buy patented products Experts in the indigenous systems of from multinational companies, many will medicine at a workshop convened in not be able to make ends meet and will April 1998 in Delhi declared all
Price Comparisons of Medicines, 1996 (Indian Rupees)
Ranitidine (Zantac)300 mg x 10s Diclofenac sodium (Voveran) Novartis (Ciba-Geigy) Reference: New Patent Regime: Implications for Domestic Industry, Research & Development and Consumers,B K Keayla January 1996 contact n°163 - October-December 1998 biological resources and the herit-
age of indigenous knowledge to be
the national asset of the Indian
people
. They said that the State was
not the owner but a mere trustee of this
rich heritage. They demanded effec-
tive legislative measures be introduced
to pronounce traditional indigenous
knowledge and the medicinal plants of
the Indian systems of medicine as the
common and collective property of the
people.
Community groups also argue that
since indigenous knowledge is not
"novel", it is not patentable
. Novelty
comprises one of the grounds for
establishing a patent on a plant use.
Neem has long been used in agricul-
ture as a bio-pesticide and fungicide.
Happiness is a plate of rice.
But since 1985, US, European and based products for the local market in Japanese firms have taken out 65 India for decades. At the same time, patents on various formulas for stable, RFSTE working with the International neem-based solutions and emulsions, Federation of Organic Agriculture Move- and even on neem-based toothpaste.
ments and 200 other associates, filedtwo claims challenging Neem patent Patenting the Indian Neem tree
applications. One was successful. The ‘Azarichdita Indica is a tree native toIndia and widely known as Neem'. For European Patent Office agreed with the centuries, it has been used as a bio- campaign claim that there is nothing pesticide and medicine. The Neem is novel or original about the process or worshipped as sacred. People in rural products for which patents were being communities start their day by using the neem datun (toothbrush) to protect their teeth with its medicinal proper- ties. Communities have invested According to Gandhi no tyranny can consider it immoral to centuries of care, respect and knowl- enslave a people who consider it immoral edge in propagating, protecting and to obey laws that are unjust. A massive obey laws that are using neem in fields and common movement – the Seed Satyagraha – lands. For millennia, many complex has emerged over the past few years in processes were developed for using it response to the threats of intellectual in specific purposes, though the active property right clauses on agricultural ingredients were not given Latinised products. Seed Satyagraha proclaims names. An IPR claim on Neem is the common intellectual rights of Third absurd because it claims nature'screativity and creativity of other World Communities. It has created an cultures as its own. Moreover, there is alternative to patented seeds by building a false claim that the medicinal prop- community seed banks, strengthening erty is created by the patentee." farmers' seed supply, and searching forsustainable agricultural options suitable Courtesy: Shiva, Vandana, Biopiracy – The plunder of nature and knowledge, for different regions.
South End Press, Boston (1997) But the real battle is beginning on The "Neem Campaign" was launched another front. A number of well-known in India to challenge the patenting of activist groups and NGOs have filed a characteristics of the neem tree. Over a petition to restrain the government from million people gave their signature to signing Article 27.5(3b) of TRIPS. The the petition, including small industrial- article allows patents on life forms. The ists who have been producing neem- Court has ruled that it could not "go into contact n°163 - October-December 1998 change its Patent Laws. Like other de-veloping countries, India has until1 January 2001 to fulfil her obligationsunder the Agreement. (Forty-eight "leastdeveloped countries have an additionalfive years.) Some key elements need tobe kept in mind in developing patentlaws, which would respect indigenousknowledge, cultural values and socio-economic context.
Patent laws should make it very clearthat life forms cannot be considered aninvention (and therefore cannot bepatented). In particular, the followingmust not be considered inventions.
a) The whole or part of natural living beings and biological materials foundin nature, even if isolated from it orpurified, including the genoma (orgerm plasm) of any natural livingbeing.
b) Essentially biological processes.
c) New uses of a known product or process, including the second use ofa medicine.
d) Patents on life should be excluded because they are contrary to Drawing of Neem leaf morality*, or injurious to human,animal or plant life, or health, or tothe environment.
e) Diagnostic, therapeutic and surgical methods for the treatment of humansor animals.
f) Plants and animals in whole or any part, including DNA, cells, seeds,varieties and species.
the wisdom of the economic policies" of g) The human body and all its elements the government." However, activists in whole or in part.
are banking on the fact that only Parlia- h) Biological processes and products ment has the right to make laws for the derived from them.
country. If sufficient pressure is createdagainst seed, plant and animal patents Community groups say that Shalom the Parliament will block laws that requires diversity, and that we all need threaten the health and well being of Shalom to survive! the people. The people will decidewhat is good for them and they will let Darlena M David, Consultant, Communication the government know, perhaps through Department, Christian Medical Association of India,Plot 2, A-3 Local Shopping Centre, Janakpuri, the ballot box, whether they approve of New Delhi 110 058, India. Fax: 91 11559 8150. E-mail: the government's policies or not.
Changing patent law
* Indian philosophy considers life forms as kin, not as India is under tremendous pressure to contact n°163 - October-December 1998 ARE NATURAL MEDICINES THE ANSWER?
Even without TRIPS, most people in the Democratic Republic of the Congo cannot afford imported pharmaceuticals. Dr Hans- Martin Hirt, medical adviser in what was then Zaire from 1985 to 1991, believes that some imported pharmaceuticals are nothing more than expensive, neatly-packaged replacements for something already growing in many people's back gardens.
Unfortunately, today most local people have lost the skills their ancestors had for producing and using natural medicines.
Doctors in Kisantu, Democratic Republic of Congo, learn to Interview by Keith Lindsey.
make medicines themselves.
Keith Lindsey: Hans-Martin, how did
founded the organization "Anamed", you become an expert in tropical which stands for "Action for Natural medicinal plants? Medicines", and I have been doingweek-long training workshops at home Hans-Martin Hirt: I am not an expert.
and abroad, in which, with a range of Nobody is. Out of 10,000 medicinal health workers and doctors, we make plants I know virtually nothing. But medicines out of medicinal plants.
I developed a great commitment tonatural medicines when I was responsi- Lindsey: Are you encouraged by the
ble for the importation of European developments you see in health provi- medicines into one particular region in sion in the so-called developing Zaire. The longer I was there, the more medicines I found that could be made Hirt: Not very much. There is a lack of
from locally grown plants. Of course, working together. In some countries, not all medicines could be made, but in the church is divided into many groups.
some cases locally produced medicines And too often pharmacies that belong were equally or even more effective to the churches are empty – many and had fewer side effects than imported bishops seem to see them as a means of making money. I would like to see the Lindsey: I believe that you had to leave
churches and the pharmacies working Zaire in 1991. What did you do then? together to demand lower prices fromEuropean pharmaceutical companies.
Hirt: Together with a colleague in Zaire,
Bindanda M'Pia, I had written a practi-
The very survival of many people today cal handbook, "Natural Medicines in depends entirely on their rediscovering the Tropics". We found that our work their traditional skills of growing healing was appreciated throughout the tropi- plants, and using the leaves, flowers, cal world, and so we translated this stems or roots in appropriate ways as book into English and German. We natural medicines. Pharmacies contact n°163 - October-December 1998 resource available to many hospitals isa copy of my book. Even when bettertimes come, they will have a muchgreater degree of self-reliance if theysuccessfully relearn their traditionalskills.
Another important reason for thechurches and medical organizations towork together is to bring politicalpressure to bear in the fight againstpatents on natural medicines. This maybecome even more urgent with theintroduction of TRIPS. Like others, webelieve that people should have rightsunder international law to use their tra-ditional remedies. They should decidewho has ownership of any patents.
Lindsey: What is the particular prob-
lem of patents?
Hirt: Once a particular process is
patented, no local manufacturer can
make that drug, and the country is
dependent upon imports. Then 95% of
money given for health care in
developing countries ends up in the
pockets of the pharmaceutical
companies. The table giving details of
the treatments for different forms of
sleeping sickness gives an idea of the
extent of the problem. Also, we are
always anxious that what has been
common knowledge to so-called unso- Traditional pharmacy in former phisticated people for centuries might Zaire: the source of many patent be usurped by modern pharmaceutical medicines in Europe? attached to hospitals need to develop concerns and patented as a new their own gardens of healing plants, in order to produce their own medicines.
Lindsey: What sort of role could the
I have been told that, in these troubled World Health Organization (WHO) play? times in what is now the DemocraticRepublic of the Congo, the only medical Hirt: The WHO could do far more to
Pharmaceutical companies profit while patients are forgotten
Example: Sleeping sickness
The changing price of medicines for trypanosomiasis from the manufacturers (prices in Deutschmark) Lampit, 100 tablets, Bayer Argentina (nifurtimox) Lomidine, 37 ampoules per treatment, Rhone-Poulenc (later May & Baker) (pentamidine) Arsobal, 10 ampoules per treatment, Rhone-Poulenc (melarsoprol) Ornidyl, (DFMO), Merrel-Dow, Those people who require Ornidyl or Arsobal will certainly die. There is no possibility that peoplecan afford to pay the price. For purposes of comparison, the monthly wages of a teacher in Zaire/Democratic Republic of the Congoin 1960 were the equivalent of 300 DM. At that time, three hours' work would pay for treatment with Arsobal. This year, a teacher'swage is equivalent to 5 DM. A teacher must work for about 18 months to pay for a treatment with Arsobal.
contact n°163 - October-December 1998 protect developing countries from the Lindsey: Do you have any examples?
scourge of patents. The needs of ill Hirt: Yes, in Uganda. On 3 November
people must surely be more important 1995 our book was publicly handed than the legal rights of patents. In over to the population by Hon. Bagnma Anamed, we are also disappointed that Isoke, Minister of State, in a ceremony the WHO is not prepared to confront the at the conclusion of a seminar. Every- legislation that permits European com- body could see it on the television and panies to manufacture soaps and cos- in the newspapers.
metics that contain mercury. These Lindsey: I understand that two million
products are then distributed in tropical people die each year from malaria. Has countries where they are used to lighten Anamed any ideas about how countries the skin. Mercury is very toxic and can avoid being dependent on imported causes massive health problems.
According to the World Health Organi-zation, mercury poisoning can provoke Hirt: We recommend teas made from
psychotic reactions such as delirium, the leaves of different medicinal plants, hallucination and suicidal tendencies.
for example, the neem and bitterleaf Mercury can also enter the brain of the trees and the paw paw plant. Our current unborn child via the mother's placenta.
research is with artemisia annua. Hos-pitals in tropical countries are monitor- Lindsey: And what are you doing in
ing the effectiveness and the side effects Anamed to tackle the problem of of a particular artemisia annua, and the results are very encouraging. We will Hirt: First of all, we continue to gather
be keeping Contact informed as the recipes from all over the world for pro- ducing medicines out of medicinal Lindsey: You seem to have found a
plants. Also we encourage governments means whereby health workers and to give us an invitation and sponsorship doctors can achieve a significant to run national seminars, and to take measure of self-reliance with regard to our book and present it to the popula- the treatment of malaria. Self-reliance tion of their country as their property.
is the key to the development of a We know that this approach offers a degree of economic independence and protection against the power of patents stability in the face of overwhelming in that country.
international commercial pressures.
Action for Natural Medicines (Anamed)
Being committed to the relationship between peopleand their environment, Anamed runs seminars anddevelops new projects that enable people in thetropics to become more self-reliant with regard totheir health and social and economic well-being.
anamed logo from letterhead 1. To promote the protection and cultivation of healing plants, and the skilled preparation of and initiative that continues their dependency on the treatment with natural medicines.
2. To support people in becoming more active in 4. To promote local and international cooperation the care of the environment.
in pursuing these principles.
3. To support people in becoming more self-reliant Anamed, Schafweide 77, 71364 Winnenden, with regard to their health and material needs, Germany. Tel: 49 7195 910225. Fax: 49 7195 and at the same time to oppose any commercial 65367. E-mail: Keith_lindsey@hotmail.com contact n°163 - October-December 1998 10-POINT PLAN OF ACTION
6. Lobby your Ministry of Health and The suggestions listed here have other relevant government depart- been developed from the material contained in this issue as well as • Ensure promotion of the Essential the recommendations of group • Urge your Minister of Health to discussions which took place at read the WHO paper written spe- the Pharmaceutical Advisory cifically for health ministers, namely Group (PAG) meeting held at the "Health Economics, The Uruguay Ecumenical Centre, World Council Round and Drugs".
• Ensure that policy makers know of Churches, Geneva, Switzerland how best to implement TRIPS in on 30th October 1997.
the interest of promoting public 1. Get informed by finding out what is health. Tell them about the CPT website which provides informa-tion on different country e x p e r i - Read this issue of Contact; write to the World Health Organization for a • "The TRIPS Agreement - A guide copy of "Globalization and access to for the South" is written specifically drugs: the implications of the for policy makers.
WTO/TRIPS Agreement". If possi-ble, use the Internet – website: 7. Provide information to others, and http://www.cptech.org covers health encourage them to lobby your care issues and intellectual property with links to other groups that are • As well as sharing information with active in this area, such as Health other health workers, try to be in Action International (HAI), and contact with as many health and resources that are available.
consumer NGOs, networks andassociations, including medical 2. Organize a meeting about public associations, as possible. They health versus trade.
need to know about TRIPS. Sym- The aim of the discussion would be pathetic journalists will also wel- to develop a policy statement or come information.
position paper. Once your board has 8. Send a message to World Health signed a resolution on the issue, Organization's Action Programme on your organization will be ready to Essential Drugs or to your regional join in the action of groups such as or national WHO office. Send a copy HAI and the Consumer Project on of the letter to the NGO Forum for Health. Your support will strengthen 3. Join a network, such as HAI, provid- the voice for Health for All and against ing information on TRIPS.
commercial and trade interests atthe 52nd WHA in May 1999.
4. Organize a workshop on the use of natural and herbal medicines.
9. Ask HAI how you can participate in Encourage the sharing of informa- lobbying on behalf of public health at tion and make sure that the process regional trade negotiation meetings.
includes education on how to mini- 10. Create a data-base of who is doing mize the risks, such as intoxication.
what and who could do what.
Seek help from Anamed (see page13).
5. Document your national experience For more details of groups and publications mentioned and share them with others.
here, please turn to page 15.
contact n°163 - October-December 1998 This list includes names and addresses of some useful contacts and publications to helpyou campaign for people's health to be put before trade and commercial interests.
Director, CPT (address on immediately prior to the Advisory Group (PAG)
World Health Assembly holds annual meetings Health Action International
each year. Contact: Dr Eric Health Action Interna-
which address various is a global network of health, Ram, Secretary NGO tional (HAI) HAI-Europe
issues concerning pharma- development, consumer Jacob van Lennepkade, ceuticals and health.
and other public interest Contact: Dr Eva Ombaka, groups in more than 70 1053 NJ Amsterdam Pharmaceutical Adviser for countries working for a more The Netherlands.
World Council of Churches, rational use of medicinal Tel: 31 20 683 3684.
based in Nairobi, Kenya.
drugs. HAI is currently in- Fax: 31 20 685 5002.
Consumer Project on Tech-
volved in efforts to evaluate nology was created in 1995
the impact of the World to investigate a wide range Trade Organization and the of issues concerning tech- TRIPS Agreement on public NGO Forum for Health
nology and consumer health. It has regional offices Address box
Dr Eric Ram, Secretary interest. CPT is involved in in Peru and Malaysia.
NGO Forum for Health issues relating to intellec- tual property, information NGO Forum for Health
CISS International 6 Chemin de la Tourelle technologies, medical tech- brings together non-gov- nologies, and electronic ernmental organizations commerce and privacy.
involved in the promotion of Tel: 254 2 445160/445020 Tel: 41 22 798 4183 Contact: Dr James Love, health. The group meets Fax: 254 2 440306 Fax: 41 22 798 6547 WHO reference materials Economics, WHO/TFHE/ Papers in several Globalization and access
97.1. Free of charge.
languages are listed. Free to drugs - Implications of
Health Economics, Drugs
the WTO/TRIPS Agree-
and health sector reform,
"The implications of the
ment, Health Economics
WHO Task Force on Health TRIPS Agreement for the
and Drugs DAP Series No.
Economics, WHO/TFHE/ protection of pharmaceu-
World Health
7, World Health Organiza- 96.2. Free of charge.
tical inventions" is an arti-
tion, Action Programme on Health economics: The ef-
cle by Adrian Otten, World Action Programme on Essential Drugs, WHO/ fects of international trade
Trade Organization, DAP/98.9. Free of charge.
liberalization on the health
Geneva, published in World Health Economics, The
of poorest population
Drug Information, Vol. 11, Uruguay Round and drugs,
groups: annotated bibliog-
No. 1, 1997.
Fax: 41 22 791 4167.
WHO Task Force on Health E-mail: dapmail@who.ch Pharmaceutical as Com-
assesses the costs and seminar organized by WCC Bookshop
modities in Public Health:
benefits stemming from the 150, route de Ferney The implication of the
TRIPS Agreement. Unctad/ The TRIPS Agreement - A
TRIPS agreement from the
ITE/1/96.II.D.10 Cost: guide for the South draws
1202 Geneva, Switzerland perspectives of the Devel-
US$22.00, 65pp. Address: attention to the aspects of oping Countries is a report
UNCTAD, Marketing and the agreement to which South Centre
of WCC's PAG annual Sales, UN Geneva, Palais des policy makers and techni- Chemin du Champ-d'Anier 17 meeting in 1997. It is avail- cal personnel should pay able from WCC bookshop.
Tel: 41 22 917 4872 special attention when for- The TRIPS Agreement and
Power, patients and pills:
mulating policy and legisla- Developing Countries a
an examination of GATT/
tion in this field.
Tel: 41 22 798 34 33 report prepared by the WTO and Essential Drugs
Fax: 41 22 798 85 31 UNCTAD Secretariat. It Policies, the report of a
contact n°163 - October-December 1998 BABY BATANDWA IS CRYING! WHAT CAN I DO?
Batandwa is born with a very good way to tell you he needs you. He cries. Whenhe cries, he is trying to tell you that he needs your help to make him comfortableagain. Below, Gabriel Urgoiti, a doctor working with the National ProgressivePrimary Health Care Network in South Africa, writes more about why babies cry,and what parents can do about it.
As you become more familiar with Batandwa, you will discover that his cries sounddifferent depending on what he needs. Learning the meaning of his cries helps youto know how to answer them. And when you do you are building a relationship withhim, based on confidence and trust.
All babies have their own way of crying, but all have three clear cries to tell you thatthey are hungry, upset or have pain.
"I'm hurting"
When Batandwa has pain he cries in an unmis-
takable way. You will definitely know that some-
thing is wrong. Of course you will go to him when
you hear this cry and do whatever is needed to
make him comfortable.
This is a time when your gentle attention andwarmth are very important. If he is not well andcrying you must take him to the community healthworker or clinic so that they can find out what iswrong with him. Don't wait.
"I'm hungry"
Usually Batandwa's "hunger cries" starts slowly
and builds up to a loud, demanding cry. This
means "I want to eat". Many babies do not get
hungry at regular times during their first few
months. So whenever you hear the hunger cry,
think of feeding him.
Food is not the only thing for which he hungers.
Every baby also needs attention and stimulation.
Maybe when he cries, and does not want to eat,he tries to say "I want to be with you".
"I'm upset"
Batandwa may cry in a mild, fussy way when he
is tired or in a bad mood. Or maybe he needs
company or a change of scenery. The longer the
crying is ignored, the louder it becomes. Crying is
one way of trying to discover what he needs. You
can also look for other clues, for example the way
he moves. If you see him repeatedly throwing his
legs up and straightening them again while cry-
ing he is probably telling you that his tummy
hurts.
contact n°163 - October-December 1998 Try to always go to him when he cries
Because crying is Batandwa's clearest way of saying he needs you, you should
go to him when he cries. Some people feel that answering all the time when a baby
cries will spoil him. They say that he will become more and more demanding if you
go to him every time he cries.
This is not the case. When you answer Batandwa's cries promptly, he learns totrust you. But more than that, he learns that you will react when he expresseshimself in a less urgent way. As time goes on, he will start to use his facialexpressions, movements and sounds to tell you what he needs.
If you cannot always answer his cries
Many times you are going to be delayed. Batandwa's trust in you is based on
consistency, and consistency does not mean immediately responding to each and
every cry.
Sometimes you will not understand why Batandwa cries. You will feel upset if hecries a lot. Many parents feel this way. You are not a bad parent. It is normal.
If this happens to you, it is important not to blame yourself or your baby.
Babies who cry all the time
Some babies suffer from tummy pains. Some people call this
colic. These babies cry for hours at a time and are very difficult
to calm. If you have this problem with your baby it is
important to relax as much as you can and try your best
to comfort him. At about 3-4 months many of these
babies are well.
Other babies seem to cry more without a knownreason. There will be some times when nothingyou do seems to help calm your baby. You arelikely to become tense and upset and feel likeyou failed. This too is natural and happens toall parents. When you are tense, your babysenses it by the way you hold him and hemay even cry harder. If there is agrandparent or neighbour or other friendhandy, let them take your baby so youcan get a few moments to yourself.
If all else fails, put the baby to bed for awhile. Being apart briefly, helps both ofyou to calm down and gives you a betterchance to figure out what he needs.
When you have done your best to comfortBatandwa and he is still crying rememberthis: You will both survive the experience.
And maintaining a sense of humour cando wonders at these times.
Article taken from The NETWORKER, the official maga-zine of the National Progressive Primary Health CareNetwork (NPPHCN), Western Cape, South Africa. Ad-dress: PO Box 34572, Groote Schuur, 7937, SouthAfrica. Tel: 27 21 472482. Fax: 27 21 479483. E-mail:pphcmtc@wn.apc.org contact n°163 - October-December 1998 Tuberculosis – an
A book that looks at the social, economic The second section, "Tuberculosis from a and political dimensions of treatment-seek- patient's perspective", comprises the ing and intervention edited by John D H economics of tuberculosis diagnosis and Porter and John M Grange covers many treatment, socio-cultural dimensions in issues of relevance to readers of Contact.
tuberculosis control, tuberculosis and HIV, The first section, "Introduction to tubercu- tuberculosis in ethnic minority populations losis and its control", includes chapters on in industrialised countries and gender is- the global burden of tuberculosis, determi- sues in detection and treatment of tuber- nants of the tuberculosis burden in populations, a critique of the global effort, The final section points the way forward the politics of tuberculosis, public health with the help of several case studies and and human rights: the ethics of interna- by describing alternative approaches.
tional public health interventions for tuber- Details: John M Grange, Imperial College culosis, and tuberculosis in high preva- School of Medicine, Dovehouse Street, lence countries.
London SW3 6LY, UK. Tel 44 171 3518456, E-mail:j.grange@ic.ac.uk LETTERS
LAP Programme in

Thank you for the "The ‘bottom-up' approach to health planning" (Contact 160) describing the LAP Programme in Cameroon. Such developments are excellent but thedescription does not tell how they are integrated into secondary biomedical health careprovision.
How does the community see the possibility of referring individuals and communityhealth problems on to this level? What should be the relationship between theadministration of the two levels of health care? The programme starts where the peopleare but how does it lead on to health education? At a time when evidence-based medicine is being promoted, the other extreme of asubjective approach to health needs is being taught. It must be better in planning toinclude the perceptions of the community and not just those of the health careprofessionals, but are we in danger of ignoring the findings of scientific research andmeasurement over the centuries? If health professionals' clinical impressions can bemisleading, how reliable are the impressions of communities in which the diseases ofpoverty are common? Christian Medical Fellowship and Medical Missionary Association Ruby Eliason responds:
Thank you for your questions about how Community-Determined Health Care (CDHC),
using the conscientization approach, is integrated into secondary biomedical care
provision. The first question about referrals ties in with the second question about the
relationship between the administration of the two levels of health care.
Before the CDHC approach to planning is implemented, there has been considerableinteraction between the community and project staff. The process begins when thecommunity, after hearing about the Life Abundant Programme (LAP) from individuals orsatisfied communities, makes application for LAP ministries. The area Field Supervisorthen visits the community to learn about the people and their expressed needs, to explainLAP's philosophy of community self-reliance and also LAP organization, and to answervillagers' questions about LAP. The community appoints a Village Health Committee,which becomes the liaison body between the community and project. The Committeeselects candidates for Village Health Worker (VHW) training, and collects village-widedonations for training the VHW, and for purchase of the basic medicines to be used bythe VHW in simple symptomatic treatment. The Supervisor and Committee plantogether for two events, a quantitative health survey of the community, and conscientizationactivities leading to CDHC.
There are education sessions for the VHW and the Committee before the VHW is contact n°163 - October-December 1998 installed. VHW training includes the integration of health promotion, disease prevention,treatment of common disorders with about 20 drugs, and rehabilitation. The VHW learnsthe importance of making referrals to an Integrated Health Centre or Hospital for patientsbeyond his/her scope of treatment. The committee Seminar is about management of thevillage Primary Health Centre and the general activities of the VHW (the Field Supervisorsupervises clinical work).
How does the CDHC approach lead to health teaching? Before introducing CDHC, thewriter found there was little interest in health promotion teaching in villages with LAPministries. However, this has dramatically changed with the introduction of CDHC.
Communities have not only named health promotion activities as their priorities for howto get health, but they have been motivated to implement their health promotion goals.
For example, treatment for sickness was 7th on Ngang's prescription for health. Thepeople gave more importance to health promotion by the following priorities: communityparticipation in health activities, spiritual care, general development, care of children,adequate food, and the practice of cleanliness. The Makoup community placedtreatment after seven health promotion activities. In the five communities researched in1998, treatment ranged from 5th to 9th, giving place to health promotion activities. In oneof these communities, there was immediate village-wide participation in the cleaning ofwater sources. Furthermore, the main work of the VHW is teaching of individuals,families and groups on all aspects of health. He/she is assisted in this by the Committee.
In CDHC planning within the framework of LAP ministries, community values becomeintegrated with the practice of biomedical care. The process is dynamic as dialoguecontinues, and praxis, the core of conscientization, occurs; praxis is movement fromaction to reflection, and again from reflection upon action taken to a new action. Theresult is better health for communities and families.
Our efforts continue to rehabilitate the CHAL library, which was scattered during the war.
Can you help?
Health/development workers and health promoters in Liberia are starved of health anddevelopment information. Any suggestions/assistance you may be able to offer CHALin this effort will be highly appreciated.
Deanna K Isaacson Christian Health Association of Liberia (CHAL) 1000 Monrovia 10, Liberia We are glad to be able to resume sending bulk copies of Contact to CHAL. We have alsoasked Healthlink Worldwide (formerly AHRTAG) to send a copy of "List of freeinternational newsletters" to CHAL, and forwarded details of TALC's health library fordistrict health workers. The books included in this small library include Where there isno Doctor, A Book for Midwives and Helping Health Workers Learn. The library costs 90pounds sterling including postage and packing by surface mail worldwide. TALC, POBox 49, St. Albans, Herts AL1 5TX, UK. Tel 44 1727 853869. Fax 44 1727 846852.
Sustainability of church hospitals in
Departure of Dr Kofi Asante
In January of 1999, Dr Kofi Asante, our The report of CMC-Churches' Action for Executive Secretary for Health, will leave Health study on the determinants of the WCC. Kofi has focused on resourcing success in sustaining church hospitals by and networking with Christian health coor- Dr Kofi Asante is now available. A limited dinating agencies, and has developed number are available free of charge, at significant new contacts. Currently, he has present in English only. A directory of recently completed an analytical study of Christian health and medical associations Christian health care institutions, will be available in the very near future.
addressing the question of their Write to Dr Kofi Asante, Executive Secre- sustainability. We thank him for his tary, CMC - Churches' Action for Health, dedicated service and bid him Godspeed PO Box 2100, 1211 Geneva 2, Switzerland.
as he returns to Ghana.
contact n°163 - October-December 1998 Contact's new editor
tive media, and development journalism.
Darlena David who takes over as editor ofContact after this issue is currently New editor - new address
consultant in the Communication Depart- From 1 January 1999, Contact will operate ment at the Christian Medical Association from India. All correspondence and of India. She is ideally suited to her new requests for back copies should be sent to task having edited several newsletters and the following address from that date magazines, including most recently the Christian Medical Journal of India. Darlena Ms Darlena M David, Editor Contact, c/o has a Masters in English, a Diploma in Christian Medical Association of India, 2, Hospital Administration, and gained a A-3 Local Shopping Centre, Janakpuri, distinction in her Masters degree at New Delhi 110 058, India. Tel: 91 11 Manchester University (Mass Media and 559991/2/3, 5521502. Fax: 91 11 5598150.
Education) in 1990. During the 1980s, she worked with ACHAN (Asian Community Contact will continue to be published in Health Action Network) in Madras and the French and Spanish. However, the Portu- Voluntary Health Association of India guese version of Contact has been tempo- (VHAI) in New Delhi. Her interests include rarily discontinued. Those interested in gender and justice; community health; helping to restore it are invited to write to pharmaceuticals and baby foods; alterna- REMEMBERING DR JONATHAN MANN
In the 1980s when the world was gripped against HIV required good organization in by apprehension over the realisation of constantly changing scenarios.
what the HIV virus might mean to human- Jonathan was a brilliant and outstanding ity if left unchecked, the figure of leader who had the capacity to listen, to be Dr Jonathan Mann appeared on the world humble, and to inspire those who worked stage. With quiet determination he set with him. Although GPA underwent various about creating the global programme on changes, including absorption finally into AIDS – commonly known as "GPA" at the new UNAIDS programme, the legacy World Health Organization headquarters of Jonathan is clear. It was he who, at a certain point in time, had the courage to I remember, when working as a consultant take the reins of leadership in an appre- to GPA in 1989, Jonathan called for a hensive world. He did that with great lunchtime meeting of the expanding GPA.
sensitivity, style, and compassion.
Ranged around the room were close to a Today, Jonathan Mann's legacy is found hundred people. It was typical of Jonathan in various corners of the world. It is evident that he encouraged everyone to publicly when people get a chance to understand introduce themselves. At last, his turn about HIV and AIDS – and to protect came, and very simply he said "Jon Mann, themselves, and others – and when people GPA". During the meeting he had reached living with HIV and AIDS get compassion- out to all present, and created the basis for ate care. Let us be determined to ensure what came to be called the "GPA family".
that his legacy is continued and expanded.
Life in GPA was tough, because the chal- May he, and his wife, rest in peace, and lenge of a rapid response to the needs of may their family be comforted.
countries to strengthen their defences Marie Thérèse Feuerstein
Contact is the health and Contact is published by a Articles may be freely reproduced, Mailing list: Christian Medical
community development partnership of the World Council of providing that acknowledgement is Association of India, 2, A-3
magazine of the World Churches (WCC); Christian Medical made to: Contact, the publication of Local Shopping Centre,
Council of Churches. The Association of India (CMAI); the World Council of Churches. A Janakpuri, New Delhi 110 058,
publication deals with various German Institute for Medical complete list of back issues is India. Tel: 91 11 559991/2/3,
aspects of the churches' and Missions in Tübingen (DIFÄM), and published in the first annual issue 5521502. Fax: 91 11 5598150.
community's involvement in Medical Coordination Secretariat of of each language version.
health, and seeks to report the Netherlands (MCS). It is Editorial Committee: Rainward topical, innovative and published four times a year in Bastian, Christoph Benn, Sara Contact is also available on the courageous approaches to English, French and Spanish.
Bhattacharji, Cherian Thomas World Council of Churches the promoton of health and Present circulation is approximately Darlena David, Christina de Vries, Elizabeth Moran, Eva Ombaka andDiana Smith. Editor: Darlena David.
contact n°163 - October-December 1998

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