Category Archives: Unit 2 – Trying to Help

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.

Pharmaceutical Industry: Good or Evil?

Bringing attention to certain medications that everyone should ideally have access to by highlighting them as the “essential medications” seems like a good idea. But who gets to decide what medications are essential or non-essential; where do we draw the line? The criteria for the first list of essential medications in 1977 were based on clinical trials of safety and efficacy conducted in the global North (mainly developed countries) and cost-effective analyses in a developed nation’s economy (Greene, p. 19). Does this make sense, considering health outcomes and access to health care are vastly different between developed and developing nations as well as within each category?

As Jeremy Greene explores the (surprisingly) recent history of pharmaceuticals in global health in his article, many questions regarding “essential medications” come to mind. Something that worried me about defining essential medications in the form of a list was that such a list would affect how insurance companies consider coverage for certain medications over others. A focus on medications used to treat common diseases (Greene, p. 18), may pull attention away from essential medications for rare diseases. This could be connected to multiple harmful effects: pharmaceutical companies may not have much incentive to invest in research and development of new medications to treat those rare diseases because such products would only yield small profits from a small market, and health insurance companies may not be inclined to cover treatment involving medications that are not listed as being essential.

Greene mentions the “drug-dumping” of multinational pharmaceutical firms as they purposefully sold their products, some of which had not completed clinical trials and had questionable safety and efficacy reports, in countries with less regulations on the quality of drugs in the 1970s (Greene, p. 16). To me, this situation mirrors that of the tobacco industry, in which major tobacco companies started looking for foreign markets outside of the United States with the rise of foreign demand in the 1960s. Taking advantage of the weaker restrictions on trade and health regulations in developing nations, tobacco companies targeted women and children in Africa and China, for example, to expand their market and increase profits (Brandt, p. 454, 487). In some ways, pharmaceutical companies are just as manipulative and selfish. In response to the South Africa’s Medicines Act of 1997 that allowed for the production of generic versions of patented HIV drugs to make them more affordable to a greater population, thirty-nine pharmaceutical companies filed suit in South African courts just a year later. Furthemore, the U.S. government also expressed its disapproval, even though it later changed its mind in support of the Medicines Act in 1999 following uproar from political activists (Farmer, p. 122, 123)

Nowadays, the “cozy” relationship between doctors and pharmaceutical companies has become controversial. It is no secret that major pharmaceutical companies and doctors often work closely together – drug companies send sales representatives to speak to doctors about new medications and sponsor medical education and research. This has raised questions of conflict of interest – doctors can monetarily benefit from prescribing certain medications, biasing them towards providing certain treatments over others that could be just as effective or more effective (Glover). However, others including cardiologist Dr. Lisa Rosenbaum argue against the stigma surrounding doctor-industry collaborations. In her opinion, such a collaboration could lead to “life-saving therapies whose development requires the combined talents of clinicians and industry” (Rosenbaum). Dr. Rosenbaum contends that the conflicts of interest argument could lead to important viewpoints being discredited or ignored, simply because a doctor happens to work with drug companies

As part of the Affordable Care Act of 2009, the Sunshine Act mandates that all payments over $10 from pharmaceuticals to doctors or hospitals be made public to increase transparency and disclosure (Glover). Even so, there is always the risk of a doctor building close ties with one specific company and endorsing their products at every opportunity, blinding himself to potentially better options available for patients. The Access to Medicine Index (ATMI), implemented in 2008, is another way to keep pharmaceuticals accountable. The ATMI publicly recognizes companies for their efforts to improve access to drugs in developing nations. By ranking countries in order by their commitment to the transnational goal distributing drugs globally at reasonable prices, the ATMI encourages companies to keep up their efforts. Another way of looking at the list and rankings is that the ATMI puts pressure on the companies that ranked low on the list or did not make the list to work towards equal distribution of medications (Greene, p. 27).

Discussion Questions:

  • The Second Model List of Essential Drugs clarified that drugs not listed were not necessarily “inessential” and that the list was mainly meant to be used in the context of developing nations with the goal of making medications more affordable and accessible. Do you feel that the Second Model List of Essential Drugs adequately addressed problems of the first list?
  • While some argue that doctors working with pharmaceutical companies and being financially compensated for prescribing certain drugs will lead to biases that could potentially be harmful to the patient, others firmly believe that we could be losing out on life-saving advancements that may result from such collaborations. What do you think about doctor-industry collaborations? Is there a “happy medium” in this situation?

Course Readings:

  • Brandt, Allen. (2007). The Cigarette Century. New York: Basic Books (p. 448-492)
  • Farmer, A. Kleinman, J. Kim and M. Basilico. (2013). Reimagining Global Health: An Introduction. Berkeley: University of California Press (p. 122-123)
  • Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10–33. http://doi.org/10.1057/biosoc.2010.39

Outside Readings:


UPDATE (on Nov. 25, 2015 at 10:30pm): 

At the end of September, Turing Pharmaceuticals announced a 5000% price hike of their drug, Daraprim (used to treat toxoplasmosis, especially in immunocompromised HIV/AIDS patients), from $13.50 to $750 per tablet, which (unsurprisingly) resulted in a public uproar. As I was following this story, it at first seemed that Chief Executive Martin Shkreli saw nothing wrong with this overnight price increase, reasoning that pharmaceuticals need to make money for drug research and development. (He is quoted as stating, “It is us trying to stay in business” in the New York Times.) Since then, he seems to have finally come to his senses and has announced that the price of the drug will be cut by up to 50% for hospitals only.

However, this shows just how much “power” pharmaceuticals can have over prices of their products and how they can wield this control in a way that affects the public as a whole. This is not an isolated incident in recent news. A similar price increase was applied to cycloserine, a drug used to treat tuberculosis, although this price increase was rescinded soon after. What loopholes in policies regulating pharmaceuticals allowed these significant price increases for important drugs to occur, and how can the government make sure nothing like this happens again?

Dec. 8th, 2015 at 9:50am: Sarah and I have been discussing (in the comments below) about possibly having more interaction between the government (the U.S. government in particular, since several of the major pharmaceutical companies are based here) and an established and reputable international organization such as the WHO. The purpose of this collaboration  would be to ensure that drug companies do not raise prices of their products just to make more profits. Although the WHO, a branch of the UN, does not have any teeth and does not hold direct power over national governments (as we discussed in class), I believe it would be more efficient to utilize an already established organization rather than creating an NGO from scratch, as an NGO would not hold any power over a state’s government and pharmaceutical corporations, either. The WHO would be able to monitor which organizations are engaging in philanthropy by donating important medications that would otherwise be prohibitively expensive to populations in low- and middle-income countries that need the medications, thereby encouraging other pharmaceuticals to follow suit. Because the WHO does have sway over international publicity, the organization could also publish data on what pharmaceuticals have dramatically raised prices on their products, adding to the pressure on these pharmaceuticals to reduce their prices to make their drugs more affordable.

FURTHER UPDATE (on Dec. 7, 2015 at 11:09pm):

I realize I was not very clear about how such pharmaceuticals were “allowed” to raise the prices of their drugs so drastically. Pharmaceuticals like Turing have found a loophole whereby they purchase all rights to the drug and then raise its price. This is perfectly legal, but legality does not always equate to morality, as we discussed in class in the context of corporate responsibility (e.g., Shell’s environmental pollution in the shantytown of Flammable, Argentina). While the connection between the social suffering and corporate responsibility is not as clear-cut in the case of these pharmaceuticals’ price hikes, I believe there needs to be more regulation on drug prices.

According to a Wall Street Journal article from December 5th, 2015,    there will be a congressional hearing on December 9th between the Senate Special Committee on Aging and pharmaceuticals with price jumps, including Turing Pharmaceuticals, to investigate the problem. Hopefully, this will further emphasize the message that we civilians (and most politicians) will not tolerate drastic price surges of important drugs and push forward policies to prevent another occurrence.

Dec. 9th, 2015 at 7:41 pm: Read more on the congressional hearing held this afternoon in Washington, D.C., where Senators Susan Collins and Claire McCaskill, along with specialists in the U.S. health care system such as Drs. Erin Fox and David Kimberlin, criticize four pharmaceuticals that have sharply increased the prices of their drugs out of greed for profits: http://www.theguardian.com/us-news/2015/dec/09/drug-companies-turing-valeant-martin-shkreli-daraprim

Sources:

 

Moralizing Bodies: HIV and the Politics of Aid

In America, the image of HIV/AIDS activism has consistently been perpetuated and co-opted by the primarily upper class, cisgender, gay male members of the LGBTQ+ community. While I have no intention of undermining the experiences of suffering of anyone with HIV, the dominant narrative perpetuated by films like The Normal Heart[1] are wildly under-representative of the complexities and burden of this disease. The reality of HIV/AIDS – that it is one of the largest killers of people in the lowest income countries worldwide such that 66% of all HIV related deaths occurred in sub-Saharan Africa alone in 2014[2] – is one that can’t be ignored.

The privileging of the upper-class, western HIV experience in the understood cultural history of this disease is implicated by the example of Haiti, which Paul Farmer catalogs in his chapter, “The Exotic and the Mundane”.[3] Farmer argues that the spread of HIV in urban Haiti (mostly centered in the suburb Carrefour, home of Port-au-Prince’s redlight district[4]) is a textbook example of the “geography of blame.” Measures of guilt and accusation have been tied to the spread of HIV since it’s initial rise. Though the conservative right in America were quick to blame the “immoral,” urban men who had sex with men (MSM) for the spread of the disease, placing a moral judgment on a biological disease outcome and therefore conflating the biological body with the moral one, seropositive Haitian immigrants in America “denied homosexual activity or intravenous drug use.”[5]

Farmer criticizes American media outlets for effectively blaming Haiti for the American HIV epidemic, exoticizing and alienating the nation, as exemplified by Vanity Fair’s description of Haiti as the “black hole” of our hemisphere[6] in addition to exploiting Haitian voodoo acts as a potential source of transmission[7]. The relationship between cases of HIV in America and Haiti are clear: wealthy American vacationers came to Port-au-Prince and transmitted the disease to local sex workers, who, though many self-identified as heterosexual, would be paid into homosexual activity.[8] This conflated issues of homophobic sentiment in the U.S. with racial, gender, and economic inequality in Haiti. From here, it was found that the largest population of HIV positive individuals in Haiti were female sex workers, and Haiti became the evidence needed to suggest that HIV transmission was “more efficient” from men to women.[9] By 1986, it was impossible to deny that heterosexual activity was an ‘accepted risk factor.’[10]

Soon, a grand sentimental switch occurs in the evangelical right. Franklin Graham convinced the senator Jess Helms that “AIDS afflicted the ‘blameless’ just as often as it afflicted homosexuals.”[11] By positioning AIDS efforts towards that of the blameless, inherently moral children, we quickly saw a huge increase in the political capital of the west in AIDS treatment. The Clinton Administration, which had at first sided with pharmaceutical companies in the debate surrounding South Africa’s Medicines Act,[12] an attempt to provide more affordable, generic versions of antiretroviral therapies to HIV positive individuals, soon sided with the suffering and began providing aid directly to mothers and children who were HIV positive. By applying a moral judgment on those who were deserving of aid, there becomes a complication in the way that medications are transferred.

However, it was also this moral judgment that stirred action from abroad. The 3×5 campaign, which the WHO established as a goal to provide ARV treatment to three million people living with AIDS by the end of 2005, was unique in its efforts of establishing success as a measure of the number of people reached as opposed to the amount of money raised. By humanizing donor support under the framework of the “deserving” ill, we see the perpetuation of the implications of moral medicine. While it took until 2007 for the 3×5 campaign to be completed, it was considered a massive success in “galvanizing” the global AIDS effort.[13] By centering this mission around that of the suffering children – the people behind the disease and not the financial needs of the disease treatments itself – we see a re-affirmation of the complex power structures inherent in the way that the wealthy choose to spend their money – along moral and political lines.

 

___

[1] Cast by almost exclusively white males, it is very clear where Hollywood is looking to spend their money insofar as narratives surrounding the HIV crisis.

Murphy, Ryan, Larry Kramer, Scott Ferguson, Julia Roberts, Mark Ruffalo, Jonathan Groff, Jim Parsons, Matthew Bomer, Taylor Kitsch, Julio F. De, Alfred Molina, Cliff Martinez, Adam Penn, Danny Moder, and Larry Kramer. The Normal Heart. , 2014.

[2] The American Foundation for AIDS Reserach. http://www.amfar.org/worldwide-aids-stats/.

[3] Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press, 1999. Print.

[4] Ibid. 103

[5] Ibid. 99

[6] Ibid. 100

[7] Ibid. 106

[8] Ibid. 119, 122.

[9] Ibid. 113

[10] Ibid. 114

[11]Messac & Prabhu, Redefining the Possible: The Global AIDS Response. Reimagining Global Health: An Introduction. ed Paul Farmer. Berkeley, Calif: University of California press, 2013. Print. p 127.

[12] Ibid. 122

[13] Ibid. 114

Is some help better than no help at all? How do we handle the complexities of HIV/AIDS interventions in the developing world?

In her book, Professor Benton writes, “Herein lies the double-bind of HIV exceptionalism: to deem HIV a run-of-the-mill public health problem is to understate one of the most challenging biomedical and social problems of our time.  When we ascribe such enormous cultural weight to the disease, however, it becomes almost impossible to justify sublimating HIV to a broader health care agenda–even in low-prevalence settings.”  Throughout the entire book, Professor Benton highlights how HIV/AIDS in Sierra Leone has become an exceptional disease; almost all health development programs and funding is HIV-related, while HIV prevalence is not actually that high (~1%).  This brings us back to our discussion about unintended consequences–while providing care for HIV/AIDS patients is important, and indeed a ‘good’ thing, through the reading we see that these disease specific health interventions can take away funding from other diseases and health issues that are less ‘sexy’/’attractive’ to donors, and can therefore leave people sick and at risk of mortality and morbidity from diseases that could have been prevented through primary care.

I must admit, I chose this topic to blog about for a reason.  Over three years I have conducted cardiovascular research in Kenya and assessed the rising rates of chronic non-communicable diseases (CNDCs) in the country.  Over the last year or so I have been researching ways to integrate chronic non-communicable disease care with HIV/AIDS care structures that are already in place because of high funding for HIV/AIDS programs.  To me, it makes sense to integrate HIV (which is a chronic disease with proper treatment and adherence to care) with cardiovascular, diabetes, and hypertension care because they require similar things–adhering to drug regimens, living healthy lifestyles with proper diet and exercise, counseling, support systems, etc.  But something that I’ve struggled to answer is that by integrating HIV/AIDS with CNDCs in health care structures, are we undermining the severity and complexities of the HIV/AIDS epidemic?  By integrating care, would we be cutting options for poor persons living with HIV/AIDS, people who are already at higher risk for discrimination, stigma, poverty, etc.?  While there are unintended consequences of creating HIV-only health interventions, what are the possible unintended consequences of integrating care structures?

This relates back to the debate between the primary health care (PHC) movement and the selective primary health care (SPHC) movement.  Although both the PHC and SPHC movements were in some ways trying to address declaration III of the Alma Ata: “Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace,” the PHC movement was a horizontal approach and the SPHC movement was a vertical one.  Like the HIV/AIDS programs highlighted in Professor Benton’s experiences in Sierra Leone, the SPHC movement was specifically targeted and in some ways much more practical than the idealistic PHC movement.  This raises the question of how much idealism and how much practicality make up good health policy?  Is practicality more useful in policy-making than idealism?  Were the health gains brought about by the vertical SPHC movement better than what might have occurred from the PHC movement?  In my opinion, while the SPHC movement didn’t address or even come close to attaining access to primary health care for all, I think that the PHC movement was too broad and that without specific funding guidelines would have made even less gains than what actually occurred.  What are the unintended consequences of creating a broad public health intervention, and what are the unintended consequences of creating specific interventions?

I think that the HIV/AIDS interventions described in the Benton book really highlight what we’ve been struggling to find an answer to all semester in class: How can we do something good for health that doesn’t somehow also have unintended negative impacts?  In the book we see that HIV/AIDS funding comprised more than half the country’s health budget in 2004, but in many cases, “HIV exceptionalism actually serves to amplify existing disparities.  On the other hand, it also provides a means by which poorer HIV-positive people can benefit from a health care system that normally privileges the priorities of its wealthy donors.”  Thus it seems to be sort of a damned if we do, damned if we don’t situation–we want to help sick people, but we also don’t want to hurt other sick people in the process of that, so what do we do?

Questions:

  1. In the case of Sierra Leone are there any solutions to the problems created by HIV exceptionalism?  Would strengthening primary health care systems in order to prevent preventable diseases inherently harm people living with HIV/AIDS who already face poverty, stigma, and other inequalities?
  2. When creating health policy and health interventions is practicality or idealism more important/useful?  What are the possible negative outcomes that can occur by using one or the other?
  3. When trying to get funding from donor organizations and donor countries who should be in control of determining what programs are funded with this money?  Is there really anything we can/should do to influence where donors put their money?  Is it bad for programs that have unintended consequences to be funded in the first place?  Should donors therefore just stay out and not help?

Sources:

Alma Ata Declaration.

Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.

Cueto 2004 The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health 94(11)1864-74.

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

The Right to “Rights”: Conducting Illness and Response, Performing HIV/AIDS and Activism

In several of the class readings that touch on both anthropological and global health perspectives on HIV/AIDS and attempts to control and treat the disease around the world, a theme that arises again and again is the one of “rights.” There is, of course, the apparent “right to know” the HIV-status of someone in your family or community and the right to “know your rights” (Biehl et al., 93) in navigating the HIV-positive identity, amongst other “rights” that seem to illuminate a projected path of dignity after diagnosis, and dignity in disease.

Throughout my own work with patients who must navigate the social circumscriptions of their health statuses and health choices, I have encountered other “rights” that patients either seek to engage: the right to be ill, the right to their identity as it either transforms through illness or does not, and – in an amalgamation of the two – the right to be an ill person. The meanings of these can be nebulous, and certainly fluid between individuals and contexts of illness. They are, however, important to the development of an inclusive and thoroughly caring rubric for the protection of human health.

Since its recognition as a “distinct clinical syndrome” in 1981, HIV/AIDS and discussions about the disease have permeated public concern about health and captured the focus of international health objectives (Farmer, 60-61). Due to its prevalence in the public imagination about transmission, socialized mythologies have arisen, type-casting the apparently susceptible based on initial circumstances of visibility amongst HIV/AIDS victims. Members of the LGBTQ community, Haitians, drug-users, and people believed to be of a certain form and level of sexual activity where they may make sexual contact with these “types” of people (especially through “anal intercourse” [61]) are among some of the people who did, and still do, experience judgment and are inundated with concern (either personal, social, or both) about their HIV-statuses. Additionally, cultural pictures were painted with related assumptions about the lifestyles and habits a person susceptible to or diagnosed with HIV/AIDS enacts; these mythologies continue to reproduce themselves through certain tactics for sexually-transmitted illness screening as well as the marketing particulars of prevention and awareness programs. In Zimbabwe, Dr. Beth Barr reports that the stigma which links HIV transmission to certain behaviors, as well as certain frightening consequences of HIV/AIDS, repels people – particularly sexually active youth – from counting themselves among those in need of screening, protection, and possibly treatment. The co-production of a sort of HIV/AIDS-identity by 1) beliefs about the transmission and progression of the disease and 2) the moral valences of the behaviors believed to be responsible has driven people away from testing and treatment for fear of having to surrender their personhood in exchange for this frightening and unappealing identity (Mwakalyele, 2015).

In HIV Exceptionalism, Benton writes how, in Sierra Leone, there are established ways of appropriately disclosing one’s HIV-positive status, and, thus, how there exist established ways of appropriately enacting HIV-positivity. The performative value of disclosure of one’s status, as Benton discusses (67-88), represents a social process of transforming the identity of the person – from healthy to sick, from presumably HIV-negative to certainly HIV-positive, from one type of person to another type of person (Benton discusses the varied assumptions and cultural valences that orbit “HIV/AIDS” as it has been constructed in the social imagination) – that becomes inscribed on the the biological process of infection and disease within the body.

The social processes that hinge HIV/AIDS onto socially-projected information about identity and conduct, as well as that connect the perceived severity of the disease to equally severe, implicit moral allegations stemming from socialized fictions of AIDS etiology contort the social privilege of those experiencing the disease from all angles: there are intense personal, cultural, religious, interpersonal, public, and bodily sensations that follow diagnosis. The right to retain and mold one’s own identity in and through illness is squeezed through an apparatus of the “rights” of others “to know,” the consideration for the health of the community, and the urgency imbued in certain forms of disclosure. While disclosure proves a sometimes-useful tool to cultivate social support and build trust, it mandates a surrender of control over one’s own health information (Benton, 71), as well as a relinquishment of the way one may be perceived into a realm of public assumption and judgment, where one’s conduct, personhood, and legacy may be discriminated against, misread, and miscarried.

Negotiating a balance between the “rights” to community awareness of infection and the patient’s right to preserve their personhood in a climate of mythology and judgement circling HIV/AIDS may break down barriers of socialized illusions about susceptibility to transmission, and subsequently may not only strengthen prevention but also render every member of a community equal in sharing concern about HIV/AIDS transmission. Thus, each member of a community is called to responsibility in creating an environment of participation and proactivity to support the health of the whole community. Establishing a livable balance for those living with illness between the risk of stigma and the protection of others, reconstructing the cultural storytelling that once seemed to safeguard the uninfected, and cultivating attitudes of shared responsibility and equal susceptibility is integral to true protection, as well as fair and successful distribution of knowledge, prevention, treatment, care, and dignity. This, in my opinion, is activism.

 

Discussion questions:

  1. What concrete problems do you see with the stigma that underlies disease and the effectiveness of appealing to community awareness and/or delivering screenings, treatments, and care?

2. Is it possible to untangle the realities of transmission from the cultural etiologies and local beliefs that are important to respect when developing strategies for responding to infection and disease internationally?

3. What are the dangers of these sweeping cultural mythologies about transmission and susceptibility to disease, which inaccurately depict certain “types” of people as carriers from which the uninfected should distance and protect themselves? How might these forms of storytelling about disease create yet more inequality and prove damaging to overall health in a community?

 

Sources:

• Benton, Adia. 2015 HIV Exceptionalism. University of Minnesota Press.

• Biehl, João, and Adriana Petryna. 2013. When People Come First: Critical Studies in Global Health. Princeton University Press.

• Farmer, Paul. 1999 Infections and Inequalities. Berkeley: University of California Press.

• Mwakalyele, Ndimyake. 2015 Stigma, Complacency Threaten Zimbabwe’s Gains in HIV/AIDS Fight. http://www.voazimbabwe.com/content/stigma-complacency-threaten-hiv-gaings-fight/3013729.html accessed October 20, 2015.

 

Defining Efficacy: The Pharmaceutical Industry and Access to Treatment

During the 1990s and 2000s, HIV/AIDS activism made huge strides in reducing antiretroviral treatment (ART) prices and making HIV treatment more globally accessible. Through extensive human rights campaigns, activism efforts, and support from a host of governmental and supranational bodies, expensive drugs that were once deemed not cost-effective to provide in developing nations were made available to many of the world’s poor suffering from HIV/AIDS. The authors of Reimagining Global Health note that “The lowest available annual per-patient price of the most common first-line HAART regimen in the developing world fell from $10,000-$15,000 in the late 1990s to $300 in 2002 to $87 in 2007” (Farmer et al., 2013). For many infected with HIV, these improvements meant that HIV/AIDS would no longer be a death-sentence, but could be managed as a life-long chronic illness.

Much of this price-drop was attributed to the increased production of generic forms of brand-name treatments. Through partnerships with governments of developing countries and adapted business models, generic drug manufacturers were able to sell generic antiretrovirals at set—and comparatively low—price points (Farmer et al., 2013). This new wave of generic antiretroviral drug production was spurred in part by the passage of the South Africa’s Medicines Act of 1997. This act gave the government the right to allow compulsory licensing of brand-name drugs in the case of a public health emergency, meaning that patented antiretrovirals could be made by generic drug manufactures without permission of the patent-holder. Although 39 pharmaceutical companies filed lawsuits against the act in South African courts, political and social support for the Medicines Act caused them to withdraw their complaint three years later. Indeed, later that same year the World Trade Organization recognized that South Africa had not violated trade agreements concerning intellectual property rights, further solidifying the precedent that public health matters could override intellectual property rights (Farmer et al., 2013).

While the HIV/AIDS movement for access to ART is a truly remarkable example of harnessing social and political forces to make life-saving pharmaceuticals available in resource poor settings, it stands as the exception to the rule. Indeed, as Nicholas King describes in his article “Security, Disease, Commerce: Ideologies of Postcolonial Global Health,” pharmaceutical companies continue to have little incentive in developing effective and affordable treatments targeted at populations of developing nations. Not only is the Western pharmaceutical industry ill-designed to cheaply produce and sell important medicines to developing nations, but these same manufacturers whose product is inaccessible in poor settings continue to fight against the production of cheaper generic alternatives in non-Western countries—despite the public health importance of the medicines and the low-purchasing power of developing nations.

The battle surrounding patent protection is far from over. Recent trade negotiations concerning the Trans-Pacific Partnership—a trade agreement that would link nations including the United States, Japan, Australia, Canada and Chile, among others—are rife with controversy over the issue of pharmaceutical patenting. Many countries in the partnership want the United States to reduce their patent protection from the current 12 years to allow generics to enter the market sooner, while members of United States Congress have asserted they will not support the deal without a strong intellectual property rights component (Weisman, 2015).

Incidentally, the timing of these trade negotiations coincided with another controversial case involving the pharmaceutical industry. In September, the American pharmaceutical company Turing Pharmaceuticals made headlines when they purchased the rights to the drug Daraprim—a drug developed 62 years ago that treats toxoplasmosis—and increased the price from $13.50 a pill to $750 a pill (Pollack, 2015). The increase in price was not due to increased manufacturing costs of the drug, but due to the desire for an increased profit margin on part of Turing Pharmaceuticals. Unfortunately, this case is not isolated, but only one of many in a series of similarly inexplicable price-hikes enacted by drug companies.

How did the precedent set by the successful price reduction in HAART due to generic manufacturing during the early 2000s fail to translate to other life-saving medications? Aside from cases of “public health emergencies,” the pharmaceutical industry has near complete control over the production and pricing of many crucial medicines. Advocates of the pharmaceutical industry argue that a system based on profit-motive supports industry innovation and the production of better, more effective drugs. And yet, how effective can a medicine really be when it is out of reach of those who it would help the most? The efficacy of a medicine should not be measured simply by its biomedical utility, but also by its accessibility. If a pharmaceutical treatment is not available to a population for social reasons, it cannot be available to treat or cure on a biological level—bringing into question how exactly pharmaceutical companies should approach creating “effective” medicines.

 

 

Sources:

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

King, N. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science 32(5-6): 763-789.

Weisman, J. (2015, July 30). Patent Protection for Drugs Puts Pressure on U.S. in Trade Talks. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/07/31/business/international/pacific-trade-deal-drugs-patent-protection.html

Pollack, A. (2015, September 20). Drug Goes From $13.50 a Tablet to $750, Overnight. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

 

Discussion Questions:

  • How much control should the pharmaceutical industry have on setting prices for life-saving treatments? If their control should be limited, which governing body should have the power to decide pharmaceutical pricing?
  • How likely is it that another massive activist movement, such as the movement for access to ART for HIV/AIDS treatment, will be able to drastically change the accessibility and affordability of important medicines?
  • Turing Pharmaceuticals argued that their price increase of Daraprim was justified because the drug is not commonly used anymore, and the increased profits generated from this price-hike will allow the company to expand research and development into other more effective drugs to treat toxoplasmosis. Do you agree with this justification? Why or why not?

Forgotten: Emergency Care in the Context of Public Health Care Frameworks

In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.