Secretary of State Hillary Clinton on the Global Health Initiative

This C-SPAN report is worth considering: “Secretary of State Hillary Clinton spoke at Johns Hopkins University’s School of Advanced International Studies on the Obama Administration’s Global Health Initiative. She discussed the six-year, $63 billion investment that focuses on improving the health of women, children and newborns throughout the world.”

You can see the video (or the transcript) by clicking on the picture.

Recommended Reading: Recent Legal Scholarship on Issues in Global Public Health

Redressing the Unconscionable Health Gap: A Global Plan for Justice (published in the Harvard Law & Policy Review). In this article Lawrence Gostin brings a big picture issue — the vast global health gap between rich and poor — into perfect focus. Professor Gostin reminds us of an “uncomfortable truth” — “that closing the health gap is well within the means of the international community” — and he proposes a simple (in concept if not execution) plan to do just that.  No international treaty would be required; Professor Gostin’s Global Plan for Justice would take the form of a World Health Assembly resolution.  No new organization or governance structure would be required either; rather, the World Health Organization would “assume its place as the global health leader.”  States would be asked to contribute a small percentage — Professor Gostin suggests 0.25% — of their Gross National Income each year to a Global Health Fund.  The WHO would then allocate the Fund’s resources based on “the health needs of developing countries measured by poverty, morbidity, and premature mortality.”  Professor Gostin suggests that the mission of the Fund be threefold: “(1) ensure the fair allocation of essential vaccines and medicines, with particular attention to low- and middle-income countries in a public health emergency; (2) meet basic survival needs [e.g. food, water, sanitation, and vector controls] and create the conditions in which people can be healthy; and (3) help countries that will suffer most to adapt to the health impacts of climate change.”  Existing efforts, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, demonstrate the power of voluntary collective action; unlike the proposed Global Health Fund, however, they are too narrowly-targeted and inconsistent to close the global health gap.  Professor Gostin’s article is short (it’s based on the text of a speech), straightforward, and provocative in the best sense of the word.  I highly recommend it.

I also highly recommend Kevin Outterson’s The Legal Ecology of Resistance: The Role of Antibiotic Resistance in Pharmaceutical Innovation (published in the Cardozo Law Review) in which he uses proprietary sales and volume data for the important hospital antibiotic vancomycin to test a number of widely-propounded theories about the interplay between antibiotic resistance and intellectual property law.  The vancomycin case study fails to support the hypothesis that a patent holder is likely to zealously market an antibiotic with an eye to the drug’s dwindling patent term, without regard for the risk that increased uptake could accelerate the evolution of antibiotic-resistant bacteria.  It also fails to support the hypothesis that if patent terms for antibiotics were extended, patent holders would better manage the sales and use of their drugs to forestall the development of resistance.  By contrast, the story of vancomycin is consistent with the hypothesis that antibiotic resistance stimulates innovation — as bacteria evolve that are resistant to an existing antibiotic a market for a new antibiotic arises.  All of this suggests that “tinker[ing] with the patent system” is unnecessary and could even backfire.  Professor Outterson concludes that a more direct and potentially more effective approach to preserving the antibacterial effectiveness of our antibiotics would be to fix our broken health care reimbursement system, under which infection control is an unreimbursed cost and “hospitals and doctors have generally gained revenues from additional infections[.]“

Developments In Domestic and Global HIV/AIDS Strategies

The White House recently released its HIV/AIDS strategy to reduce the number of new infections in the United States by 25% over the next five years.  During a press conference, President Obama observed that “[t]he question is not whether we know what to do, but whether we will do it.  Whether we will fulfill those obligations… to prevent a tragedy.”  Those obligations primarily concern reducing the number of new infections through HIV prevention programs, increasing access to and quality of care for those living with HIV, and decreasing HIV-related health disparities.  Right now there are 56,000 new infections in the United States every year.  Approximately 1.1 million Americans are living with HIV, but 1 in 5 don’t know it.

Advocates have criticized both the administration and Congress for failing to adequately fund HIV/AIDS efforts at home and abroad.  A recent AIDS Healthcare Foundation (AHF) “Who’s Better on AIDS?” advocacy advertisement unfavorably compared President Obama’s track record to that of President Bush.  (In 2003, the Bush administration implemented the President’s Emergency Plan for AIDS Relief (PEPFAR), a multibillion dollar initiative which has proved successful in lowering the AIDS death rate in Africa, though not the rate of HIV infection).   Michael Weinstein, President of AHF, told CNN that:

“when you see what this administration has done on AIDS, you have to give them very low grades.”

Obama has “consistently underfunded AIDS” programs, Weinstein said.  The president “did not mention the word AIDS for the first five months of his administration.  This national AIDS strategy has been worked on for 15 months, [and] I think it could have been done in 15 minutes.  There’s nothing new in it.”

Weinstein [also] criticized the administration’s intention to redirect money to those groups at greatest risk of contracting HIV/AIDS.  “It’s not good to pit one group against another and it’s unnecessary,” he said.  “The bottom line is that we should be seeking to get all sexually active people to get an HIV test.”

Some recent Canadian research also suggests another bottom line: treating people with HIV reduces the number of new infections.  And there the treatment is free.

The Center for Disease Control (CDC) recently presented its findings that heterosexuals living below the poverty line ($10,000 or less) in American cities were twice as likely to be infected with HIV as their higher-income neighbors.  The statistics translate to 1 in 42 people (the national average is 1 in 222 people).  Most studies focus on sexual orientation, race, and/or intravenous drug use.  None of those factors were included here though.  Kevin Fenton, a CDC HIV/AIDS expert, said that “HIV clearly strikes the economically disadvantaged in a devastating way.”  Researchers found that the risk of spreading HIV came from a lack of access to medical care and unawareness of infection.  Dr. Carlos del Rio, Chair of Global Health at Emory University’s Rollins School of Public Health, frames the issue differently as “[y]ou can talk about ‘Can we decrease the HIV burden in the United States?’  I would say, ‘What can we do to decrease poverty in the United States?’”

The 18th International AIDS Conference took place last week in Vienna, Austria.  Policymakers, researchers, advocates, and persons living with HIV met to draw attention to the epidemic and assess the global response to it.  According to the Associated Press, Julio Montaner, President of the International AIDS Society and Chairman of the Conference, opened the event by pointing to how:

the G-8 group of rich nations has failed to deliver on a commitment to guarantee so-called universal access and warned this could have dire consequences.

“This is a very serious deficit,” Montaner said.  “Let’s rejoice in the fact that today we have treatments that work … what we need is the political will to go the extra mile to deliver universal access.”

With the global economic crisis in full swing, AIDS activists are concerned about developed countries reducing their foreign aid, including funding for AIDS assistance.

In its annual report released last week, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Kaiser Family Foundation found that global AIDS spending has “flattened.”  Although public and private sources contributed $15.9 billion in 2009, the amount was $7.7 billion short of the estimated $23.6 billion needed to combat AIDS in low and middle-income countries.  Contributing governments included the U.S. (58%), United Kingdom (10.2%), Germany (5.2%), the Netherlands (5%), France (4.4%), and Denmark (2.5%).  The report noted that “without U.S. funding, international AIDS assistance from donor governments would have significantly declined between 2008 and 2009.”

Global Inequality & Access to Health Care

According to a recent study in The Lancet, “The world’s wealthiest two billion people get 75 percent of all the surgery done each year, while the poorest two billion get only 4 percent and often die or live in misery as a result.” It’s a striking fact; how are we to interpret it?

There are two metanarrative accounts of the relationship between inequality and health care. On a Whiggish, optimistic view, vast inequality can generate the capital necessary to fund investment in innovative health care technologies. Scholars like Richard Epstein have celebrated both general economic inequality and unequal access to health care particularly because, they claim, buying power at the top promotes investment in medical advances. On this view, innovations in the wealthy world can diffuse throughout lesser developed regions. Moreover, the rich can also subsidize the poor locally, paying for infrastructure that serves a broader community.

Interpreted less charitably, inequality enables the well-off to bid away resources and opportunities from the poor. Richer nations and persons may snap up limited resources; for instance, in 2009, Jeanne Whalen at the Wall Street Journal wrote an article entitled “Rich Nations Lock In Flu Vaccine as Poor Ones Fret:”

A scramble among wealthy nations to guard against a swine-flu pandemic is raising concerns that billions of people in poorer countries could be left without adequate supplies of vaccine. . . . The emerging battle between the haves and have-nots underscores a major weakness in the global health system: Pharmaceutical companies have severely limited capacity to produce flu vaccines in emergencies.

Inequalities can be even more stark at the R&D phase. If an anti-baldness cure can generate billions of dollars in revenue while a new therapy for tuberculosis only generates hundreds of millions, for-profit pharmaceutical companies may well have a fiduciary duty to invest scarce research dollars in the unhirsute rather than the truly unhealthy.

Lawrence Gostin’s recent article “Redressing the Unconscionable Global Health Gap” offers some practical ways of addressing these disparities:

The international community is deeply resistant to taking bold remedial action — more concerned with their geostrategic interests than the health of the poor. The scale of foreign aid is both insufficient and unsustainable and fails to address the key determinants of health. As a result, the world’s distribution of the “good” of human health remains fundamentally unfair, causing enormous physical and mental suffering by those who experience the compounding disadvantages of poverty and ill health.

Lest we dismiss such inequalities as “not our problem,” Thomas Pogge’s sobering new book elaborates on his earlier argument that wealthier nations are responsible for the plight of the poorest:

[P]olitical and economic inequalities are rising dramatically both intra-nationally and globally. The affluent states and the international organizations they control knowingly contribute greatly to these evils — selfishly promoting rules and policies harmful to the poor while hypocritically pretending to set and promote ambitious development goals.

Both Pogge and Gostin’s work should guide policy responses to the extraordinary disparities exemplified in the Lancet story. As I continue to study fractal inequality in access to medicine, I will be sure to consult their proposals for a more just world. I also hope to see proposals for taxation of “medical tourism” that would redirect at least some of the funds from overseas patients to infrastructure that would support underserved patients in the regions they visit.

Mirror, Mirror on the Wall–Who Has the Most Free Market Health Care System of them All?

At least since legal realist Robert Hale published his Freedom through Law, the question of what constitutes state “intervention” in the market has been complex. For example: at what point does licensing of doctors move from being a natural aspect of any competent health system to being termed a suspect “intervention”? If there is to be free trade in services, don’t we at least need some information about what constitutes genuine medical care? “Perfect information” is a cornerstone of idealized markets—isn’t some baseline of information necessary to any actual market?

In health policy circles, the United States health care system is often seen as the most “free market” system internationally. But even the US would appear to be more interventionist than China, on a cursory reading of Blumenthal and Hsiao’s 2005 article in the NEJM:,

in the early 1980s, China virtually dismantled its apparently successful health care and public health system overnight, putting nothing in its place. In retrospect, this startling and almost inexplicable event seems to have been collateral damage from a much more carefully planned and successful policy strike: the privatization of China’s economy and a general effort to reduce the role of Beijing’s central government in China’s regional and local affairs. Only recently have Chinese authorities recognized the pain and the massive disruption in health care that they have caused.

By contrast, by some calculations, “the current tax-financed share of health spending is . . . 59.8 percent.” Very recent Chinese stimulus spending may be reversing prior privatizations there. But it’s clear that Chinese savings rates are still high, largely because so many citizens are scared of being sick and broke in a market-driven health care system.

Of course, it’s hard to develop any clear metric of private/public here; Blumenthal & Hsiao’s piece may only speak to financing and not other practices. Nevertheless, if Americare fails, the US and Chinese health care systems may be en route to superfusion.

Ethical Marketing Measures in Access to Medicines Index: An Important First Step

Earlier this week, the Access to Medicine Foundation released its 2010 Access to Medicine Index, “a ranking of the world´s largest pharmaceutical companies on their efforts to increase access to medicine for societies in need.”

In a change from the 2008 Index, which was the first to be issued, the 2010 Index includes measures designed to assess companies’ commitment to, and practice of, ethical marketing behavior.  Per the report accompanying the Index, “[t]he marketing and promotion of drugs can have a significant influence on the type of medicines that patients receive.  Particularly in Index Countries [88 countries with low or medium levels of development] with less robust regulatory enforcement and consumer protection, the marketing behavior of pharmaceutical companies can shape access to both appropriate and affordable medicines.  Unethical marketing can lead to suboptimal clinical decisions, prescription of more expensive drugs and irrational use of medicines by consumers, which can result in reduced treatment efficacy and other complications, such as adverse drug reaction and drug resistance.”

The Index ranks pharmaceutical companies’ marketing behavior along three axes: (1) commitments, (2) transparency, and (3) performance.  In the commitments category, companies are assigned points for the marketing codes and standards they have adopted and that they require their local third party sales agents to adopt.  For example, “originators,” i.e., research-based pharmaceutical companies, receive 5 points on a scale of 1-5 for committing to the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) Code of Pharmaceutical Marketing Practices, the WHO Ethical Criteria for Medicinal Drug Promotion, “or an equivalent industry code.”  Originators that have not committed to any external codes but that have an internal code which covers the same core principles receive 2.5 points.  (The scoring is different for generics on this measure because they do not have a “viable up to date and auditable external code.”)  With regard to third party sales agents, both originator and generic companies can receive all 5 points if they make “specific ethical marketing demands” of their sales agents and then audit the agents’ practices to ensure compliance.

For transparency, the Index gives points to companies that “publicly disclose[] detailed information regarding [their] marketing and promotional programs in the Index Countries, such as payments to physicians or other key opinion leaders and also its promotional activities for other healthcare providers, distributors, etc.”  None of the companies earned any points in this category.  While some have started to disclose payments made in the United States, no company has disclosed payments made in any of the Index Countries.  According to the report, three companies — GlaxoSmithKline, Merck, and Roche — have pledged to disclose payments made in the Index Countries soon.  Companies can also earn disclosure points for revealing breaches of marketing codes and marketing-related litigation in the Index Countries.

For the third category, performance, companies lose points if they breach the IFPMA Code or if they are sued or subjected to fines for marketing behavior.  Companies can earn points for including binding ethical marketing requirements in their agreements with their sales agents and by establishing employee codes of conduct in the Index Countries equivalent to the codes they have in place in other markets.  Despite the fact that issues have been raised “about pharmaceutical marketing practices in the Index Countries, especially regarding clear mention of … adverse side effects,” none of the companies studied lost any points in this category.

As the title of this post suggests, I think that the Index’s attempt to rank companies’ commitment to and practice of ethical marketing practices is important.  Anyone who works in a law school knows how influential rankings can be — for better or for worse.  It is easy to imagine the Access to Medicine rankings providing an additional nudge to companies to begin disclosing payments to healthcare providers around the world not just here in the United States.  At the same time, there is ample room for refinement.  In the performance category, for example, measures, in addition to breaching the IFPMA Code/being sued/ being fined, are needed to expose differences that surely exist in companies’ approaches to marketing in the Index Countries.

New Jersey-based group digs wells to fight disease and malnutrition in Malawi

Today’s post comes from Seton Hall Law LL.M candidate and former long time Newark Star Ledger reporter, Robert Schwaneberg, J.D.

Health Reform Watch is truly pleased to welcome a reporter of such great renown to our blog.

By ROBERT SCHWANEBERG

The road to Euthini in northern Malawi is a narrow dirt path through fields of gourds, maize and peanuts, known locally as groundnuts. The delegation from WorldHope Corps arrives, by four-wheel-drive vehicle, to find the village leaders waiting under a tree. They are sitting in straight-backed wooden chairs with velveteen cushions that seem strangely elegant in this poor African community that lacks electricity, modern sanitation and any source of clean water.

According to the World Health Organization, 38 percent of rural Malawi lacks access to improved water sources.[i] Along with high rates of HIV infection, lack of clean water is a leading reason “Malawi’s health indicators are among the worst in the world.”[ii] Water-borne diseases such as diarrhea and cholera are “common in Malawi”[iii] and are among the top three killers of children under five.[iv] A survey done in 2000 found 18% of children under five had experienced diarrhea in the preceding two weeks.[v]

WorldHope Corps is trying to change that. Working with other non-governmental organizations, churches and private donors, it has arranged the installation of six hand-pumped wells in Malawi in the past two years and has plans for more.

“Wells are the water of life,” said the Rev. Michael Christensen, who teaches at Drew University in Madison, N.J., and founded WorldHope Corps in 2007. “If we can provide clean water to villages without water, we can save hundreds of lives because one out of five children dies under the age of five of water-borne diseases like cholera, dysentery and malaria.”

Drilling wells in northern Malawi is expensive. Holes have to be bored deep — 50 to 100 meters — to get below the groundwater contamination that pollutes shallow wells. Heavy rigs must be brought in from the southern part of the country, where the only drilling companies are located, and transported over primitive “roads” like the dirt path to Euthini. There are additional costs for having a government official inspect the work and certify the well is deep enough to provide safe water.

“All in all, it’s about $10,000, give or take $500,” Christensen said. He hopes to cut the cost by helping one of WorldHope Corp’s partners, CitiHope International, form a well-drilling business in northern Malawi.

“The prospects are very good,” Christensen said. “I think by this time next year we’ll have the beginnings of a well business that will cut the cost of a well in half.”

Last month, Christensen led a team of 10 volunteers on a 12-day mission to inspect existing well sites in Malawi and scout locations for new ones. Michael Bond of Basking Ridge, N.J., did not go with the idea of funding a well. He decided to do so after observing the stark differences between Euthini, where women haul water from a stream about a kilometer away, and Zowe, which got a deep well through WorldHope Corps in 2007.

“The life of a village, the life of a people changes dramatically once they get fresh, clean water,” Bond said. At Zowe, which also has a part-time medical clinic, Bond learned from the health surveillance officer that a remarkable thing happened after it got its well: No child died during 2008.

“The ah-hah moment for me was the difference a 20-minute drive down that trail (from Zowe to Euthini) made,” Bond said. “The difference was night and day. The kids were in dirty clothes; they were dirty because they weren’t bathed. Some showed signs of malnutrition.”

Malnutrition results not just from poor agricultural yields, but also from dirty water. About half the cases of underweight children are due to repeated bouts of diarrhea and intestinal infections from unsafe water and substandard sanitation and hygiene, according to W.H.O.’s 2008 report, “Safer Water, Better Health.”[vi] Globally, W.H.O. estimates that each year 860,000 children under five die from malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene.[vii]

The visit to Euthini ended with Christensen calling for a village youngster to fetch a shovel to break ground for its new well. But first, as he does with all his projects, Christensen enlisted the villagers in a partnership. He asked what they would contribute; they replied they would supply bricks, rocks and labor to construct the spillway and sinks for washing clothes. He asked how they would use overflow water; they said they would divert it to a community garden. He asked how they would pay for spare parts and repairs; they promised to take up a collection from all the villages drawing water from the new well.

“It’s not just about a bore hole,” Christensen said. “It’s about promotion of human rights, gender equality, community action, power of the people to make change.”

More information about WorldHope Corps is online at http://www.worldhopecorps.com/index.htm

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[i] World Health Organization, Country System Fact Sheet 2006 - Malawi. Online at http://www.afro.who.int/home/countries/fact_sheets/malawi.pdf

[ii] WHO Country Cooperation Strategy, Malawi, 2005-2009 at page15. Online at

http://www.who.int/countryfocus/cooperation_strategy/ccs_mwi_en.pdf

[iii] Id. at page 12.

[iv] The others are pneumonia and all neonatal causes, including diarrhea. World Health Organization, Country System Fact Sheet 2006 - Malawi.

[v] WHO Country Cooperation Strategy, Malawi, 2005-2009 at page 12.

[vi] World Health Organization, “Safer Water, Better Health: Costs, benefits and sustainability of interventions to protect and promote health,” at page 7. Available online at http://www.who.int/water_sanitation_health/publications/safer_water/en/print.html

[vii] Id.

Health Care, “Common Sense” and a Global Health Blogging Experiment

Today, Health Reform Watch is participating in a “Global Health Blogging experiment” coordinated by Christine Gorman of Global Health Report. Health Bloggers from around the world will all be converging to discuss a topic: for today, “prevention v. treatment,” and, to some extent-the underlying realities in which this experiment in synchronized dissemination is being conducted as they relate to global health concerns. I thought I’d take a look at the “to some extent.”

Ms. Gorman proposed this idea as a means of assembling something of a critical mass to explore issues regarding “Global Health” and as a means of gauging the mass of that mass. In addition to organizing the assemblage, Ms. Gorman also asked some prescient questions about the nature of the medium and the endeavor itself. It is here that I will focus.

She asks,

Is a social network around global health news starting to emerge organically on the web? What can we do to nurture it? Do economic realities dictate that this will have to be a volunteer led endeavor, at least for a while?

Or, another way of putting that last question: Is news about global health subject to the same market failures that afflict products for global health (e.g. free-market forces alone will not lead to new tuberculosis medications and other drugs that affect mostly the poorest people in the world)?

These are good questions. And as I think about the economic forces and the affect of such upon the dissemination of information, I find myself thinking that even with the emergence of a somewhat new journalistic paradigm–the blog– the dissemination of information is still largely governed by the older rule: zero sum. And this goes for time and money–as well as focus.

In many ways the blog is merely the modern progeny of its paper ancestor-the pamphlet, a time honored medium purveyed by amateur and psuedo-professional journalists and would be statesmen with some design on shaping policy and the contours of their fellow citizens’ minds. But it is perhaps important to remember that Thomas Paine’s revolutionary Common Sense, perhaps the most famous and influential American pamphlet of all time, was sold for a price-and it sold very well (it should be noted though that Paine donated his royalties to George Washington’s Continental Army for the procurement of mittens). It did not hurt sales that the first printing appeared at a time when King George had just denounced the Colonies to Parliament. Common Sense was of the moment; “Global Health” is not. Read more