Bring out the Human in Humanitarianism

The context of global humanitarianism has been growing throughout the years. Peter Redfield’s Doctors, Boarders, and Life in Crisis, along with Miriam Ticktin’s The Violence of Humanitarianism in France, really paint a picture of major consequences that are associated with humanitarianism. The first are the consequences associated with this transition of humanitarianism to politics. The second is the possible dehumanization of those who are being helped. After reading the examples provided by both authors, it is clear that there has been a shift in what humanitarianism is and that sometimes it creates a limited version of what it means to be human.

This shift of humanitarianism to politics is illustrated with the “illness clause” in French law. This clause gives people with serious illness the right to stay in France regardless of if they are an undocumented immigrant. This clause was created as an alternative to human rights discourse and for those who did not obtain rights based on the states interests (Ticktin, 5). Due to this, the illness clause made sickness a primary way for undocumented citizens to get papers to stay in France. People would even go as far as infecting themselves with an illness such as HIV/ AIDs just so they could stay in France and “live more fully.” In this case, humanitarianism, seen with the illness clause, shifting to politics resulted in a consequence where the undocumented were giving up bodily integrity for human dignity. These immigrants would rather live a fuller life infected with HIV/AIDS than be completely healthy and deported. Some citizens even took up identities of friends who had died of HIV/AIDS just to stay in the country (Ticktin, 8). In essence, this clause is allowing undocumented immigrants to place less value on their lives and create a limited version of what it means to be human. In France these people are giving up an opportunity to a healthy life just to be considered a citizen.

The dehumanization that can be associated with humanitarianism can be seen in the refugee camps mentioned in Doctors, Boarders and Life in Crisis. Even though these camps foster the possibility of mass survival, the figure of a human still emerges from behind that of a citizen (Redfield, 341). The goal of these refugee camps may be to aid those who have suffered from severe political and ecological instability, however, it is important to note that they do play a role of devaluing human life. In these camps, the refugee’s dignity and citizenship are put into question. Here the only things that matter are calorie intake, hydration and shelter (Redfield, 342). Yes these are very important aspects of life that need to be protected. However, because these aspects are the biggest and only concerns of the camp, individuals loose their ability to voice their opinions and perform acts of civil virtue. In this sense, the person is being seen not as a person but just as another body in the camp.

This is again seen in the worlds second largest refugee camp in Jordan. This camp holds more that 80,000 people whose lives are on hold and going nowhere (Swan, BBC). For some of these refugees, life in the camp holds such little value and hope that they would rather return home to Syria. On one hand obviously these refugee camps are providing safety and life to those who were in danger, but on the other hand these people are losing what it means to be alive. An important question must be asked: what, if anything, should we do to help these people who are already suffering maintain the feeling of what it means to be alive?

 

Discussion questions:

  1. How do humanitarians ensure that in providing necessary materials for living, that they are also providing what is essential to feel human?
  2. Is there a way to stop or at least limit this shift of    humanitarianism to politics?

 

Work Cited:

Redfield, Peter. 2008. “Doctors, Borders, and Life in Crisis.” Cultural Anthropology 20(3): 328-361

Ticktin, Miriam. 2006. “Where Ethics and Politics Meet: The Violence of Humanitarianism in France.” American Ethnologist 33(1): 33-49.

“Lives on Hold: The Scots Helping Syrians in a Refugee Camp – BBC News.” BBC News. N.p., n.d. Web. 05 Nov. 2015.

Expensive Essential Medicines: The Return of the “Appropriate Technology” Dilemma

The WHO recently widened its list to include new (and costly) treatments for cancer and Hepatitis C in a move that opens the way to improve access to innovative medicines that show clear clinical benefits and could have enormous public health impact globally.”(WHO). Emphasis on the “could.” While these new medicines have been deemed highly effective and safe,  they are extremely expensive; they can cost from $63,000 to $94,500, “depending on the drug and regimen.” (Silverman). These new drugs do make curing Hepatitis C a reality, but how realistic is it to make these newly minted essential medicines available and affordable on a global scale when we still struggle to provide consistent access to the more affordable essential medicines and other basic health rights, such as clean water?

Whether it is idealism that placed these drugs on the list of essential medicines or not, the placement of these new and expensive drugs on the essential medicines list is a mark of the huge disparity and inequality present in global health. Simply conceding that  some “uniform measure” to lower the prices of these essential medicines needs to be put in place in order for the health benefits to come to fruition is not enough to justify the decision to sponsor these drugs (in a way, putting a new drug on an essentials list is a form of advertising…).  

Farmer argues that we fall back too often into low-tech solutions  because they are deemed “appropriate,”  and “sustainable” instead of providing high quality treatments and care, even though both are needed to improve health on a global scale (Infections and Inequalities 21). Making a list of essential medicines attempts to encourage providing higher quality treatment, but including expensive therapies in an “essentials” list without any clear direction as to how their cost can be lowered continues to perpetuate the low-tech approach to improving global health. I would even argue that it is counterproductive to prioritize these new Hepatitis C and cancer treatments, though they are new and effective, if more affordable, newer (though not the newest) medicines exist and have yet to be implemented. Quite the opposite of blazing a trail in global health for innovative medicines.

More importantly, making new pricy therapies essential could jeopardize the funding for providing other basic rights: “On paper, essential medicines joined clean water, adequate housing, and a safe food supply” in a list of universal human rights (Greene 11). These rights lead to better health outcomes, but essential medicines weigh more heavily than due their higher relative expense and (more) immediate benefit. Additionally, these new and innovative drugs are so costly that providing them would logically come at the expense of providing other essentials, such as clean water and adequate housing, in a global health delivery. It seems intuitively wrong that a basic necessity would come at such a cost. This being said, if the prices were to be successfully lowered, the benefits alluded to in the WHO report would then be twofold: lowering the cost would make the medicines more accessible in general and would lower the competition between essential medicines and basics like clean water and housing for funding and attention.

Access to medicine and to care is essential, clean water is essential, safe housing is essential, food is essential… but prioritizing one essential  over the others in our approach to Global Health implies that some of the essentials can be overlooked, and are therefore secondary to that essential that takes precedence, whether that is effective drugs or sustainable changes to the infrastructure.

Questions for discussion:

  1. When do the essentials stop being essential? Does prioritizing one negate the others?
  2. Should the list of essential medicines be narrowed or done away with entirely?
  3. Should there be a system of weights that prioritizes more affordable medicines? What about more effective ones?
  4. How should the human rights relating to health listed by Greene be weighted, if they had to be weighed?

 

Works Cited:

Farmer, P. (1999). Infections and inequalities: The modern plagues (p. 21). Berkeley: University of California Press.

Greene, J. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10-33.

Silverman, E. (2015, May 8). WHO Adds Gilead Hepatitis C Drugs to its List of Essential Medicines. Retrieved November 2, 2015, from http://blogs.wsj.com/pharmalot/2015/05/08/who-adds-hepatitis-c-and-cancer-drugs-to-its-list-of-essential-medicines/

WHO moves to improve access to lifesaving medicines for hepatitis C, drug-resistant TB and cancers. (2015, May 8). Retrieved November 3, 2015, from http://www.who.int/mediacentre/news/releases/2015/new-essential-medicines-list/en/

 

Are Essential Medicines Really Essential?

The field of global health is constantly evolving. From its murky origins in colonial medicine, to its shift from vertical to horizontal care, to today’s technological age, global health has been shaped by a variety of societal forces. Today, we observe the phenomenon of pharmaceuticalization (Biehl et. al).  With scientific and technological innovations, diseases like tuberculosis, malaria and AIDS, that were once thought to be fatal are now treatable. It is unjust to discriminate who deserves biomedical cures for life-threatening diseases based on race or socio-economic status. Doing so would deepen inequities and promote forms of structural violence (Farmer 265). In response to this problem, in 1975, WHO Director-General Halfan Mahler highlighted the need for a list of basic, essential medicines that every individual deserves access to. The WHO published this list of “essential medicines” two years after his speech. This list was assimilated after consulting ministry officials, doctors and health care providers across over twenty-five countries (Greene 17).

While the document was no doubt well intentioned, the subjectivity of the word “essential” itself makes me question its effectiveness. The criteria used to dictate which medicines made the list and which did not, were not necessarily comprehensive. The idea of “local biologies,” itself shows that there is a great deal of regional disparity among the symptoms of various afflictions; certain diseases have more potent effects than others due to cultural and social differences among nations (Lock 1). How can we create a blanket list of only 186 worldwide “essential medicines,” when each region and its government have specific health issues and unique barriers to access drugs?

Furthermore, our list of “essential medicines,” may in fact perpetuate inequities rather than eliminate them. For example, it favors prevalent conditions over rare diseases (Greene 18). In the summer of 2013, I interned with the Rare Genomics Institute, an organization focusing on developing treatments and bringing awareness to those suffering from rare genetic diseases. After interviewing over thirty individuals with rare diseases, a common theme emerged. There was a lack of research and development for cures due to the low profitability of rare disease ventures. Rare disease drugs, also known as “orphan drugs,” were not seen as profitable by large biotech companies (Jessop). Or, if the drugs were available, they were placed at exorbitant prices. Is it just, to tell a woman I interviewed with Gaucher disease, that she deserves to pay $310 250 for one therapy treatment? Neglected by the health care system, many individuals suffering with rare diseases succumb to despair and hopelessness. Is it fair to favor the majority in our definition of “essential”? The blanket statement of the word “essential,” gives biotechnology companies and governments an excuse to not care for those in the minority. In addition, its inflexible structure obstructs new medicines from being added, preventing individuals from benefiting from the dynamic innovation occurring in the global market.

What truly is concerning, is that pharmacologists developed the first list of essential medicines (Greene 24). In today’s market, pharmaceutical companies have the power in deciding what these “essential drugs” are and how much they should cost. A recent controversy regarding drug pricing has emerged from an agreement known as the Trans-Pacific Partnership (TPP). A Wikileaks document shows one of the final drafts of its chapter on intellectual property, which entails policies that will limit the competition of generic drugs. Through allowing patent term extensions and market exclusivity for drugs, this agreement will result in higher drug prices (Gleeson 1). Especially in developing countries, with weakened economies, this agreement will prevent access to affordable medicines. Medicins Sans Frontiers and other international organizations have protested the institution of this plan due to its destructive effects on the poor (Medicins Sans Frontiers). In Julie Livingston’s Improvising Medicine, we can see the devastating effects resulting from a scarcity of affordable medicines. In PMH, “some people shared stories of a profound physical agony and deaths born of the near total lack of medicines, sutures and bandages” (Livingston 177). It is not ethical to have a system where corporations and market- driven governments profit from causing misery and death. Yet, Greene notes that pharmaceutical companies brand themselves as “global health,” companies, falsely portraying themselves as supporters of the WHO’s initiatives.

And so as we shift towards emphasizing PHC, we must recognize that in some ways, the WHO’s list of essential medicines is enabling the oppression of the poor and supporting pharmaceutical companies in their profit- driven initiatives. While the WHO’s list of essential medicines was an important start to promoting health equity, I believe that we must look towards new approaches in the 21st century.

Discussion Questions 

  1. The definition of “essential,” has caused great debate in the global community. Currently, the WHO has defined its list of essential medicines based on popularity, previous establishment, efficacy and cost. How do you think the word “essential” should be defined? Do you think it is necessary to have a list of essential medicines? Should the WHO redefine or modify its list?
  2. In the case of pharmaceuticals, do you think it is possible to balance profit- driven incentives with a desire to improve the common good? In other words, can we still create incentives to innovate while ensuring the affordability of essential drugs?

Works Cited

In Class sources 

Biehl, Joa. When People Come First Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

Greene, Jeremy A. “Making Medicines Essential: The Emergent Centrality of Pharmaceuticals in Global Health.” BioSocieties 6.1 (2011): 10-33. Web.

Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.

Lock, Margaret. “Menopause, local biologies, and cultures of aging.” American Journal of Human Biology 13, no. 4. 2001.

Out of Class Sources 

Gleeson, Debrorah. “Comments on the Completed Trans Pacific Partnership (TPP) Intellectual Property Chapter.” N.p., 10 Oct. 2015. Web. 01 Nov. 2015.

Jessop, Nathan. “The Dilemna with Orphan Drugs.” PharmaTech. N.p., 1 Aug. 2013. Web. 2 Nov. 2015.

“Statement by MSF on the Conclusion of TPP Negotiations in Atlanta.” MSF USA. N.p., 05 Oct. 2015. Web. 01 Nov. 2015.

 

The Benefits and Limitations of an Essential Medicines List

From our discussions in class thus far and our current understanding of global health, accessibility to certain essential medicines would appear to be an idea that has been universally accepted for many years. The reading by Jeremy Greene, however, paints a very different picture as he argues that a list of essential medicines for global health was not successfully achieved until 1977. This marked the first time that pharmaceuticals were featured in the “public health commons” (Greene 10) and integrated into fieldwork.

One point from the reading that was particularly noteworthy was that the concept of essential medicines was originally employed by colonial powers to augment military control over other groups. Yet, it is important to note that one positive legacy of this was the enforcement of “new humanitarian standards for care” (Greene 14) to combat treatable diseases. I would argue, though, that having a standardized list of medicines deemed “basic, indispensable, and necessary for the health of a population” (Greene 10) carries both positive outcomes as well as some unintended consequences.

In lectures, we’ve discussed the issues global health workers face in reconciling their objective analyses of certain groups with their moral obligation to intervene in the lives of those they observe. To me, this parallels the dual role of the WHO in serving as a standard-bearer of pharmaceuticals as well as an active entity in responding to epidemic outbreaks of disease. Personally, I agree with the course that the WHO has taken since the 1970s by deciding to play both roles. The best example of this is the successful eradication of smallpox in 1980. Here, the combination of the WHO’s vaccination campaigns, coupled with its aggressive surveillance and prevention strategies, demonstrates that the organization’s undertaking of this dual responsibility can have positive outcomes at a population level (“The Smallpox”).

However, these strides forward come with their fair share of setbacks. For example, Greene’s articulation of “drug dumping” demonstrates the market power that pharmaceutical companies continue to wield. Firstly, this creates a culture in which outdated drugs are reserved for poorer countries and newer, more effective ones are allocated to more developed nations. This casts doubt over the relevance of the essential drugs list. If these new drugs are not widely accessible, populations may miss out on medications that are essential to maintaining health and consequently, potentially efficacious medicines may slip the public consciousness.

Furthermore, I would argue that an international pharmaceutical regulatory body like the WHO is indirectly affected by the corruption plaguing individual federal entities. For example, the FDA is often criticized for being too slow to approve certain critical medical developments and too hasty to back medications that may lack sufficient data to support their efficacy. With regard to the latter, there has been countless speculation suggesting that the FDA’s close financial ties to big pharma groups has made it more likely to approve drugs that can “cause serious harm, hospitalizations, and deaths” (“Is the FDA”). The internal corruption within these regulatory bodies has made it more difficult to ascertain these drugs’ “proven safety and efficacy via randomized, controlled trials and cost-effectiveness” (“Is the FDA”). This story is not unique to the U.S.; Chapter 9 of When People Come First describes the monopoly-like control exercised by the company Lupin over the production of certain drugs. Ecks and Harper further this point by describing the struggle to obtain certain medicines for government-sponsored programs due to the interest of profit-maximizing companies to privatize certain medications (Ecks and Harper 253). This underscores the greater conflict between moral idealism of health interventions and the economic pragmatism of drug companies.

Lastly, I think the idea of an essential drugs list takes away from the multifaceted public health approach that we’ve discussed over the course of these past few weeks. As stipulated by Max Weber, one way to understand the biologic processes of a disease is to view it in an appropriate societal, political, historical, and cultural context (Farmer et al.). In so doing, outcomes can be prescribed through a combination of biological and social processes. Furthermore, the labeling of certain medicines as “essential” detracts from the social suffering and structural violence that are responsible for many of the healthcare issues in these areas. Thus, by addressing medication accessibility without regard to these important social issues, the WHO is only remedying a small part of the problem.

 

Discussion Questions:

  1. The Greene reading introduces the reader to the concept of drug dumping yet this is only the tip of the iceberg with regard to the overall issue of updating the essential drugs list. What are some long-term negative ramifications of using less efficacious drugs to combat widespread disease incidence? What are ways to mitigate (if not solve) this issue?
  1. We’ve established that the symptomatic treatment of a disease does little to improve health outcomes and to sustain positive change. Given the many approaches that one can utilize to promote better population-level health, how “essential” is a list of essential drugs? For example, is it more important to treat infrastructural shortcomings?

 

Class Readings:

Biehl, Joa. When People Come First Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties6(1), 10–33.

http://doi.org/10.1057/biosoc.2010.39

 

Outside Readings:

“The Smallpox Eradication Programme – SEP (1966-1980).” WHO. Web. 3 Nov. 2015.

http://www.who.int/features/2010/smallpox/en/

“Is the FDA Being Compromised by Pharma Payments.” Forbes. Forbes Magazine. Web. 3 Nov. 2015.

http://www.forbes.com/sites/johnlamattina/2013/08/07/is-the-fda-being-compromised-by-pharma-payments/

THE LACK OF GLOBAL MEDICINE CONTROL IN SOCIETY

Throughout this course we have discussed the ways in which we can provide medical resources in order to improve the health of individuals in developing countries. A substantial amount of the class readings focused on the lack of medical treatments and limited access to essential resources that are desperately needed by suffering patients. However, how much knowledge and control do people trying to help possess over the quality and distribution of medicines? I believe that WHO needs to establish a more active role and evaluate the drug regulations/policies that are in society today. It is not right to take advantage of people who do not possess access to resources and technologies that inform people of medical remedies.

In a recent study, out of thirty-five samples of co-trim oxazole purchased in Ghana, Nigeria, and Britain, only sixty percent contained the requisite amount of the active ingredients needed! Another study estimated that over 120,000 children under the age of five years-old died because of ineffective malaria medicines (NY Times). The fraudulent crime of marketing these substandard medicines has increased over the past decade. Manufacturers have discovered ways to sell medicines and save money by reducing the amount of active ingredients. By committing this crime, it can accelerate the development of resistant germs, and thus, infect new people (NY Times). What steps need to be taken in order to address these issues and form regulation policies?

If you can recall from the beginning of the semester, we discussed how tobacco companies have inserted themselves in the market to poorer nations. People in the US recognized the direct correlation between tobacco users and cancers, so this once “attractive” product now possessed a “dirty and unhealthy” stigma. Therefore, the trend in the US started to decline, manufacturers had to focus on a new audience to target in order to gain a profit. Today, 80% of smokers live in poorer countries (Mason, Corporate Power Lecture). According to Allan Brandt, “This is not really consent in the meaning of consent, and that tobacco companies purposely engineer consent by marketing,” Poorer people are suffering due to the lack of knowledge and falsely advertised products (Brandt). This demonstrates how powerful marketing is in any industry. It appears that manufacturers in pharmaceutical companies are attempting to replicate similar concepts that tobacco companies successfully implemented years ago by selling “fake” drugs to people who are less knowledgeable and desperate to acquire adequate medications. Ultimately, this can cause more harm, and it also depletes poor people of the little money they have.

This proposes an issue to implement pharmaceutical infrastructures globally when we lack control over the quality of the supplements on the shelves. In Improvising Medicine, Dr. P expresses the urgent need for access to medicines for his patients. It is true that individuals in poorer countries are not provided with essential medicines, and if they are, they are listed at an unaffordable price. Not only do they not have medicines that US citizens acquire, but they barely have basic medical technologies, infrastructures, supplies-bandages, syringes, glucose sticks, and antiseptics (Livingston). Thereafter, it appeared that Halfdan Mahler had the same ideology of ensuring essential medicines were provided and affordable price to people in underprivileged nations. However, distinguishing what is an “essential” drug provoked huge debates, and people argued that the WHO was exceeding its role (Greene). Is there some way combine these ideologies that will provide fairness and equality to all people? Do we really want to implement pharmaceutical infrastructures that contain overpriced and falsely advertised drugs to poor and sickly patients? After reading “Stemming the Tide of Fake Medicines,” I am a little more skeptical about how people in developed countries should approach this issue. We could potentially making the situation worse by funding for infrastructures that contain harmful drugs.

This is not only a problem in poor nations, but this is also found in wealthier countries such as the US. The FDA is constantly recalling drugs in our local pharmacies (Prescription Drug Ads). Overall, I think this exposes the flaws that are currently found in pharmacies, and I believe that we need to address this problem before endangering the lives in other countries as well. At least we have access to knowledge about supplements; people in developing countries take what they can receive especially when it is listed at an affordable price. If the medicines are overpriced, this causes even more of a problem because now people are purchasing inadequate medicines at a price they cannot afford. They could use this money for other necessities such as food and water, which arguably could have cause the need for medicine in the first place due to the lack of sanitation.

Discussion Questions:

 

  • Harsh Chandra’s post (October 2nd, 2015) discusses how overpriced drugs are being offered to people in developing countries. It is heart-breaking to see that developed countries are scamming these poor people by selling drugs that do not contain the full active ingredients, and on top of that, they are selling these fake medicines at a price is equal to a person’s monthly salary. How do you think we (or the WHO) should address this issue? Is there a way we can regulate the drugs that offered to developing nations? Is it our responsibility?
  • Health as a human right is still not present in the US today. We have access to an abundant amount of drugs, but they are costly. Prices in the US can be up to ten times higher than other developed countries (Syrmopoulos). This is due to the US manufacturer’s freedom to set their own prices. That being said, how are we supposed to instill this ideology of “health for all” that Halfdan Mahler once advocated for? It seems implausible to implement this idea considering the US has yet to even accomplish this. Should we take a different approach to improve global health rather than the implementation of drugs?

Sources:

Outside Sources:

“Stemming the Tide of Fake Medicines.” The New York Times. Ed. Editorial Board. The New York Times, 17 May 2015. Web. 27 Oct. 2015.

“35 FDA-Approved Prescription Drugs Later Pulled from the Market – Prescription Drug Ads – ProCon.org.” ProConorg Headlines. N.p., n.d. Web. 28 Oct. 2015.

Syrmopoulos, Jay. “Chart Comparing Global Drug Prices Exposes How US Govt Creates Mega Profits for Big Pharma.” The Free Thought Project. N.p., 23 Sept. 2015. Web. 30 Oct. 2015.

 

In-Class Readings:

Greene, Jeremy A. “Making Medicines Essential: The Emergent Centrality of Pharmaceuticals in Global Health.” BioSocieties 6.1 (2011): 10-33. Web.

Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.

Mason, Katherine. “Corporate Power.” BioMed Center, Providence. 21 Sept. 2015. Lecture.

Brandt, Allan M. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. N.p.: n.p., n.d. Print.