Solutions That Are Working -- Richard Tren, TechCentralStation, 2005-02-28
Solutions That Are Working
By Richard Tren Published 02/28/2005
Johannesburg, South Africa -- AIDS has been in the news a great deal lately, more than usual. The South African generic drugs company, Aspen Pharmacare has just announced that its generic versions of its AIDS drugs have been accepted by the US drug regulator, the Food and Drug Administration (FDA). At the same time, the WHO has announced that -- depressingly, and some might say predictably -- it has fallen far short of its target of treating 3 million people by 2005. Yet concurrently the Accelerating Access Initiative (AAI), a treatment access partnership between the research based drugs industry and various UN bodies has announced a sharp increase in people receiving medicines via its programs. These stories highlight some of the ongoing problems in delivering treatment and show a way forward.
The FDA approval of Aspen's drugs has not only boosted Aspen's share price, but also, potentially, boosts efforts to deliver safe and effective medicines to those in need. The FDA is a notoriously tough regulator, but with that approval, Aspen's drugs can now be bought with President Bush's emergency AIDS treatment funds, PEPFAR. The decision to require FDA approval was controversial, but it seems to have paid off. The unseemly episode where several Indian generics companies were forced to withdraw their drugs from the WHO list of pre-approved medicines jeopardised treatment for thousands in Africa that were using those drugs and reflected very badly on the WHO system that had approved them in the first place.
Aspen's drugs only have the potential to boost access to treatment because cheap medicines are only one element in ensuring better access to healthcare. There are numerous reasons for the fact that many Africans do not have access to Asprin, let alone antiretroviral therapy. Chief among these is sheer poverty and a complete lack of healthcare infrastructure.
Some governments, such as Botswana's, have for many years taken healthcare seriously and tried to improve this infrastructure, but many others have not. While Zimbabwe's health personnel are fleeing the country and its health infrastructure crumbles, the government has chosen to increase funding to Robert Mugabe's hated secret police six fold. Unfortunately Zimbabwe is among many other countries where the political will to fight disease of any sort is sorely lacking.
Some countries are actively building barriers to drug access. Kenya and Uganda have just announced that patients in those countries will now be forced to pay 10% more for medicines. Those countries have joined the East African Community's Customs Union which demands a 10%tariff on any imported medicine. Other countries, such as the ironically named Democratic Republic of Congo, have even higher tariffs at 30%. These outrageous taxes on the sick and dying show that much of Africa's leadership on AIDS is empty rhetoric.
Bizarrely at the World Economic Forum meeting in Davos, France's President Jacques Chirac has called for some sort of international tax on air travel or financial transactions to fund 'the war on AIDS'. This classic Gallic solution will only create some monstrous and corrupt international bureaucracy and is hardly likely to help any unfortunate AIDS patients.
Despite the many difficulties associated with improving treatment, AAI is attempting to find solutions. Among the principles of the AAI is that it will work with countries where there is political commitment, work with all sectors of society, acquire additional funding and continue investment in research and development.
The AAI has just announced that its partnership now secures treatment, around the world, for 333,000 people. Most of those are in Africa, where the number on treatment via AAI increased by more than 50% between September 2003 and September 2004 to 157,000. An example of an AAI initiative is Merck's collaboration with the Gates Foundation and the Botswana Government. This partnership has succeeded in building clinics, training medical staff and treating patients, while other initiatives, notably in South Africa have failed.
The spirit of cooperation in Botswana contrasts sharply with the acrimonious battles between the drugs industry, government and NGOs in South Africa. The unfortunate reality is that while the politics continues, thousands go without treatment and into an early grave.
Apart from the incalculable benefit of ensuring that patients have access to medicines right now, we have to ensure that those in the future also receive effective drugs. That is why the focus on continued research and development is so important. The worrying reality is that the number of firms conducting research into AIDS drugs is down by just under a third from 1997. Part of this drop is because AIDS has increasingly become a poor country problem, but the vilification of the research based industry by activists around the world has certainly also played a large part. Few CEOs are happy to have their photos daubed with blood at demonstrations.
AIDS medicine has come a long way since the early 1980s, but unfortunately the politics and grimy reality of medicine in Africa has not changed much. AIDS patients don't need more taxes nor do they need more demonstrations; they need their own governments to take their disease seriously and implement the solutions that are already working.
Tren is a director of the health advocacy group Africa Fighting Malaria and is based in Johannesburg, South Africa
Africa's AIDS policy a barrier to access -- Richard Tren, Business Day, 2005-02-17
17 February 2005
Africa’s AIDS policy a barrier to treatment
THERE has been mixed news on AIDS treatment recently. SA’s generics firm Aspen Pharmacare has had its generic AIDS drugs approved by the US drug regulator, the Food and Drug Administration (FDA). This could be good for poor countries trying to improve access to the essential medicines.
The Accelerated Access Initiative, a joint treatment access initiative between the research-based drugs industry and various United Nations (UN) organisations, has announced a sharp increase in the numbers of people receiving treatment through its programmes.
Yet the World Health Organisation (WHO) announced, perhaps predictably, that it was only about a quarter of the way towards treating 3-million people by this year. The announcements highlight intractable problems facing AIDS patients and all other patients in Africa.
Now that Aspen’s drug has been approved by the notoriously tough FDA, the US government can use some of President George Bush’s emergency AIDS funds to purchase the medicines.
The good news has boosted Aspen’s share price, but cheap medicines are one element in the battle to improve access to treatment. One could be forgiven for being cautious about the announcement.
While drug patents certainly have the potential to block access to essential medicines, in reality they play a small role. Research by Dr Amir Attaran of Ottawa University shows that only a tiny fraction of the WHO’s list of essential medicines are actually patented in poor countries.
Yet access to the medicines is low, mostly because of a range of fundamental barriers. Poverty and a lack of medical infrastructure are at the top of the list, and are the main reason many Africans lack access to aspirin, let alone antiretrovirals.
Such partnerships have led to a rise in the number of people getting medicines. The initiative secures treatment around the world for 333000 people. Most are in Africa, where treatment increased by more than 50% between September 2003 and September last year, to 157000.
One of the initiative’s principles is that it will work with countries that have political commitment, work with all sectors of society, acquire more funding, and continue investing in research and development.
But while some countries seek solutions to the treatment problem, others actively build barriers to drug access. Kenya and Uganda have just announced patients in those countries will be forced to pay 10% more for medicines. The East African Community’s Customs Union demands a 10% tariff on imported medicine.
At 30%, the Democratic Republic of Congo has higher tariffs. Outrageous taxes on the sick and dying show much of Africa’s leadership on AIDS is empty rhetoric. French President Jacques Chirac recently proposed a classically Gallic solution to AIDS treatment at the World Economic Forum meeting in Davos. His idea is for some form of international tax on air travel or financial transactions, or anything else to fund “the war on AIDS”.
Given revelations about the UN’s oil-for-food programme, prospects that his plan will turn into a monstrous and corrupt international bureaucracy are high. AIDS medicine has come a long way since the early 1980s, but politics and the grim reality of medicine in Africa have not changed. AIDS patients don’t need more taxes or protests; they need governments to implement solutions that already work.
ŹTren is a director of health advocacy group Africa Fighting Malaria.
India's Deadly Lies -- Amir Attaran & Roger Bate, TechCentralStation, 2005-02-15
India's Deadly Lies
By Amir Attaran and Roger Bate Published 02/15/2005
The World Trade Organization has long faced angry accusations that its patent rules deny patients in poor countries life-saving medicines by making them too expensive. But starting three years ago, two academic studies -- one in the Journal of the American Medical Association and the other in Health Affairs -- expressed doubts at the magnitude of the problem. Both argued that most of the medicines that WHO terms "essential" in developing countries are no longer patented -- fully 98% of them are off patent. As a result, efforts to assail and reform patent law would only affect health on the margins. Far more alarming, from a public health perspective, was the stingy government financing earmarked for population health (worldwide, no more than $200 million for malaria in 2003; a bit more for AIDS, less for tuberculosis), and the careless expenditure of foreign aid money on medically useless interventions, or on certain developing countries with a long record of treating their poor and sick citizens with contempt. The evidence, collated by one of us (Attaran), proved as much, and had to be reckoned with.
Despite the overwhelming evidence that patents aren't an obstacle to essential medicines, India led a phalanx of developing countries and antiglobalization NGOs intent on doing away with the WTO's patent rules for medicines. They pushed so aggressively that at the WTO summit in Cancun in 2003, their interventions nearly scuppered the Doha Round of trade discussions and the future of the entire WTO. Only after a series of face-saving but ineffective compromises did India relent, and four days shy of a January 2005 deadline, it introduced pharmaceutical patenting.
But while India has been vacillating over patents, its health systems are crumbling, making it patently obvious that its government cares not a jot for its people. A prime example of its lack of attention to healthcare is that by some estimates it may have more HIV positive people (over 5 million) than any other nation, including South Africa.
But most amazing is this: the same Indian government that for years held the WTO to ransom never itself believed that medicine patents were a problem. Speaking at a medical conference in Bangalore two weeks ago, Indian Health Minister Anbumani Ramadoss confessed that "there is no need for any apprehension" over patents driving up the price of essential medicines in India, since 90 percent of them are not patented.
The health minister's rounding errors aside, this is basically the right answer, and Mr. Ramadoss is correctly, if belatedly, concluding that India will be only slightly affected by medicine patents.
But where was India's acknowledgement of that fact as recently as 2004, when it was leading the anti-patent voices at the WTO? At that time, India justified its tergiversation by insisting that it was concerned for its citizens' health. How very untrue. At the same conference in Bangalore, Indian Finance Minister Palaniappan Chidambaram explained why his fellow citizens are among the most diseased in the world. Calling his own government's efforts "inadequate for [the] health sector", he unveiled figures showing that India spends 4.5% of its GDP on health, of which only 0.9% is public expenditure. No government in South Asia spends less, making New Delhi dead last (tragic pun intended) in providing for its citizens' health. What's more, India stalled forward progress on trade liberalization at a time when other poor countries desperately required the benefits it would bring. India sold out Africa, one could say.
Far from being actuated by health concerns, in hindsight India's cynical diplomacy seems motivated by a desire that disputes over patents not interfere with India's now burgeoning pharmaceutical export trade ($460 million to the USA last year).
Meanwhile, seen from a slowly-propelled bicycle, the health of poor Indian villagers is shockingly worse than in much of Africa. Few medicines, whether patented or not, are available in public hospitals, principally because the government does not care to provide them. We are haunted by the sight of a man, crossing the road, dragging behind him a leg made lame and elephantine by lymphatic filariasis -- a disease for which Western pharmaceutical firms offer the medicines not just cheaply, but for free, if only the elites and Brahmins officiating in New Delhi cared to distribute them.
The international community should not forgive India's perfidy lightly. The next time Indians arrive at the WTO with a pressing demand, let it chill on the agenda. And the next time India seeks foreign aid for AIDS, malaria, tuberculosis, et cetera, donors such as USAID and the Global Fund should absolutely refuse. Any country having spent billions of dollars to acquire nuclear weapons, or on follies such as a lunar exploration probe (coming in 2008!) clearly has significant sums to spend on public health; frankly, India neglects its citizens' health out of choice rather than fiscal stringency.
This advice may sound harsh, but any government having India's aspirations must be taught that both globalization and human health are precious -- but desperately fragile -- things. To mock them as India has done is to destabilize the edifice upon which the welfare of billions of the world's least privileged people lies. Having knowingly deceived, India now belongs at the back of the queue for international respect and cooperation, for there are other poor countries far more deserving.
Amir Attaran is associate professor of both law and international population health at the University of Ottawa, associate fellow of the Royal Institute of International Affairs, London, and author of Delivering Essential Medicines: The Way Forward (Chatham House, 2004). Roger Bate is a fellow of the American Enterprise Institute.
Health agencies must stop demonising DDT - it saves lives -- Dr Roger Bate, Daily Telegraph, 2005-02-07
Personal view: Health agencies must stop demonising DDT – it saves lives
By Roger Bate in Galle, Sri Lanka (Filed: 07/02/2005)
Headache, high temperature, the shakes, an enlarged spleen and two billion parasites in my liver – that's the price of travelling to Sri Lanka to cover the aftermath of the tsunami.
It was all so different last time: England had just played a great cricket match against the Sri Lankans, the local economy was bustling, and the great threat – from the Tamil Tiger rebels – was waning. Today, the cricket pitch lacks a single blade of grass, the economy is in tatters, and there are more than 31,000 dead from the tidal wave. The only things that remain the same are the heat and humidity.
As I found out the hard way, malaria is back and poised to strike down still more of the children, many orphaned, of this wretched place. It can be stopped, but only if ill-informed prejudice against DDT, the insecticide, is dropped.
Thanks to their food drops and water provisions, a good proportion of Galle's inhabitants have survived the immediate results of the devastation. Nevertheless the malaria-control programme is being compromised.
In a paper entitled "Malaria Risk and Malaria Control in Asian Countries Affected by the Tsunami", the World Health Organisation (WHO) outlines its policy for the affected region. The mistakes in it are being copied by everyone else operating in Sri Lanka and the rest of Asia.
In Sri Lanka, malaria is transmitted by the female Anopheles culcifacies mosquito. The species breeds in rock pools and rice fields, and is a fairly efficient vector of the disease. Historically, the primary method of malaria control has been to spray indoor walls with DDT. It's an efficient way to kill the bugs, given their habit of resting on walls, and only tiny amounts are needed.
More importantly, studies show that mosquitoes are reluctant to enter a DDT-treated building, which means it offers a far cheaper alternative to prophylactic drugs or bed nets. Use of DDT in Sri Lanka cut malaria rates here from 3m cases a year in the 1940s to fewer than 50 in 1963.
Since then, environmental pressures against DDT have forced it to be abandoned, first in Western countries and then in most other parts of the world. Although it was obvious that it was the massive use of DDT in farming, not the small amounts used in public-health applications, that caused the environmental problems, the issue of scale was ignored by policymakers.
Aid agencies' failure to fund DDT was defended by studies that showed that Sri Lankan mosquitoes were developing resistance to DDT, an argument which ignores the chemical's main benefit. Treated houses repel mosquitoes better than any other insecticide yet tested but the WHO, adopting the anti-DDT environmentalist agenda, ignores it, instead advising the use of alternative insecticides.
The organisation spent the vast majority of its $980,000 Sri Lankan tsunami-related resources on bed nets (about $780,000), and about $100,000 on organophosphate insecticide spray, Malathion. Even this was not used in its most effective form of indoor spraying, which provides months of protection, but was instead used in clouds. Even the WHO admits that this is of limited use. It does, however, look good on television, and demonstrates something is being done.
The WHO is also supplying about $70,000 of old drugs, and pharmaceutical company Novartis has donated more than $40,000 worth of its new anti-malarial drug, Coartem. (The old drugs still just about work, although the oldest, chloroquine, is losing its efficacy here.)
WHO agents on the ground, along with other aid agency personnel, are doing the best they can, but they are hampered by an official policy that is harmful. Unfortunately, to speak out against it is to risk one's job. The cost can be measured in Sri Lankan lives lost.
Though Janaka Tillakeratne lost his café to the tsunami, he has kept his family safe and free from major disease. But he has no bed nets for them and would like his house to be sprayed to lower his children's risk of disease, but it's unlikely to happen.
As I left for the airport he smiled and told me to come back and watch some cricket here again. "Perhaps in a year when the pitch is repaired," he said. "And make sure you buy produce from my new shop," which he is already planning. I handed him my remaining supply of Coartem; it was the least I could do.
The tragedy of the tsunami is obvious and largely unavoidable. But malaria deaths could be significantly reduced if only health agencies would do the politically incorrect – but morally correct – thing and spray DDT and other long-term insecticides.
If this disaster doesn't persuade them to change, nothing will – except perhaps a major outbreak. It's no fun, I can tell you.
Roger Bate is a health economist with Africa Fighting Malaria and a fellow of the American Enterprise Institute and the Institute of Economic Affairs.
WHO's to Blame? -- Dr Roger Bate, National Review, 2005-02-02
WHO's to Blame?
By Roger Bate
Posted: Wednesday, February 2, 2005
Publication Date: February 14, 2005
Galle, Sri Lanka--The last time I was here in Galle, England had just played a great cricket match against the Sri Lankans, the local economy was bustling, and the great threat--from the Tamil Tiger rebels--was losing its force. But today, the cricket pitch lacks a single blade of grass, the economy is in tatters, and there are over 31,000 dead from the tsunami. The only things that remain the same in this southern port--75 miles southeast of Colombo--are the heat and humidity. One alarming new difference is that malaria is back, and is poised to strike down still more of the children, many orphaned, of this wretched place. It can be stopped, but only if ill-informed prejudice against DDT, the insecticide, is dropped.
As I fly over the port, I think the devastation does not look as bad as the pictures I’ve seen of Aceh, Indonesia, which Secretary of State Colin Powell described as resembling the effects of a nuclear explosion. But Galle is still a terrible mess. Though Aceh, as the worst-affected region, is rightly getting most of the attention, private-aid groups have acted swiftly in Galle as well. Thanks to their food drops and water provisions, an estimated 515,000 inhabitants have survived the immediate aftershocks of the tsunami’s devastations. But the malaria-control program is being compromised by outdated thinking, especially from the world’s leading health and government-aid agencies.
The prime example of their folly is found in a paper, “Malaria Risk and Malaria Control in Asian Countries Affected by the Tsunami,” in which the World Health Organization (WHO) outlines its policy for the affected region. While a relatively sound document, it does perpetuate mistakes, which are then copied by everyone else operating in Sri Lanka and the rest of Asia.
In Sri Lanka, malaria is transmitted by the female anopheles culcifacies mosquito. The species breeds in rock pools and rice fields, and is a fairly efficient vector of the disease. Historically, the primary method of malaria control has been Indoor Residual Spraying (IRS)--the spraying of house walls with tiny amounts of an insecticide, usually DDT. IRS often kills mosquitoes, but more important, it creates a barrier between man and mosquito. Studies show the vast majority of mosquitoes won’t enter a DDT-sprayed building, and this chemical barrier prevents transmission of the disease, much as prophylactic drugs or bed nets do, but more cheaply. Such an approach was highly successful in Sri Lanka. Owing to DDT, malaria rates fell from three million cases a year in the 1940s to fewer than 50 in 1963.
But then environmental pressures against DDT led to its abandonment, first in Western countries and then in most other parts of the world. Although it was obvious that it was the massive use of DDT in farming, not the small amounts used in public-health applications, that caused the environmental problems, the issue of scale was ignored by policymakers.
Aid agencies’ failure to fund DDT was not the only problem. Studies showed that Sri Lankan mosquitoes may be developing resistance to DDT, which meant that some of them would not be killed by the insecticide. Even the WHO report says Sri Lanka’s malaria vectors have been considered DDT-resistant for many years. But DDT’s main role is as a repellent, not as a toxic agent. Houses sprayed with DDT repel far more mosquitoes than any other insecticide tested and so remain effective even when resistance is substantial. This information, although known by health entomologists, is ignored by the WHO, which has adopted the anti-DDT environmentalist agenda. The WHO advises using alternative insecticides--although the organization buys precious few even of these.
The organization spent the vast majority of its $980,000 Sri Lankan tsunami-related resources on bed nets (about $780,000), and about $100,000 on spraying of the organophosphate insecticide, Malathion (often used to combat West Nile Virus-carrying mosquitoes). Unfortunately, this Malathion spraying is not the most effective indoor variety--the kind in which one spray provides months of protection--but rather the kind known as “fogging”: the external spraying of a cloud of insecticide to kill adult mosquitoes. Even the WHO admits that fogging is not a very useful approach. It does, however, look good on TV, and demonstrates that action is taking place.
The WHO is also supplying about $70,000 of old drugs, and pharmaceutical company Novartis has donated over $40,000 worth of its new anti-malarial drug, Coartem, which has zero failure rate in Sri Lanka. (The old drugs still just about work, although the oldest, chloroquine, is losing its efficacy in Sri Lanka, and should not really have been purchased by WHO.) WHO actors on the ground, along with other aid-agency personnel, are doing the best they can, but they are hampered by an official policy that is harmful. Unfortunately, to speak out against it is to risk one’s job, so criticisms rarely occur. The cost can be measured in Sri Lankan lives lost.
Though Janaka Tillakeratne lost his café to the tsunami, he has kept his family safe and free from major disease. But he has no bed nets for his family and would like his house to be sprayed to lower his children’s risk of disease, be it malaria or dengue or any other fevers spread by bugs thriving in the post-tsunami chaos; but extensive indoor spraying won’t be happening any time soon. As I left for the airport he smiled and told me to come back and watch some cricket here again. “Perhaps in a year when the pitch is repaired,” he said. “And make sure you buy produce from my new shop,” which he is already planning. I walked back and handed him my remaining supply of Coartem; it was the least I could do.
The tragedy of the tsunami is obvious and it was largely unavoidable. But malaria deaths could be significantly reduced if only health agencies would do the politically incorrect--but morally correct--thing and spray DDT and other long-term insecticides. If this disaster doesn’t persuade them to change, nothing will.
Roger Bate is a health economist with Africa Fighting Malaria and a visiting fellow at AEI.
The Fraud Dilemma -- Roger Bate & Ben Schwab, TechCentralStation, 2005-01-27
The Fraud Dilemma
By Roger Bate and Ben Schwab Published 01/27/2005
NATAL, South Africa -- In the wake of Asia's tsunami tragedy, many have called on the United States to substantially increase its aid budget. At the same time, many also want increased accountability from those agencies and governments getting the money to protect against fraud and abuse.
The tragedy is that while the goals of both are to help poor countries, together they could paradoxically make things worse.
What is going on in the world's battle against the AIDS pandemic illustrates the problem.
The dilemma in AIDS funding, as in many other types of aid, is ensuring sufficient oversight to maximally restrict fraud, while refraining from overloading recipients with cumbersome paperwork that restricts performance.
Limiting serious fraud is vitally important, especially now that the United States is embarking on a $15 billion worldwide AIDS program, and the Global Fund to Fight AIDS, Malaria and Tuberculosis also is increasing its efforts. In the next year, AIDS funding is expected to increase from $1 billion to $8 billion.
Further, there is evidence that better oversight is needed.
Previous HIV aid efforts have focused mainly on getting as much funding as possible to those most likely to be able to make a difference, with little regard for strict standards of accountability. The inevitable consequence has been poor oversight and fraud.
One of the early egregious abuses of funds for AIDS occurred in 1996 when then South African Health Minister, Nkosozana Dlamini-Zuma was reprimanded by the Auditor-General for spending $2 million on a play without coherently accounting for the expenditures. The current Auditor-General is investigating allegations made by the Sowetan newspaper, that a major AIDS group, the National Association of People Living with AIDS (NAPWA), has not paid staff and been forced to close several offices even though sufficient funds for these agreed allocations were previously released.
Kenya's National AIDS Control Council has witnessed several abuses and only investigative journalism has uncovered most of them. Nicole Itano, a South African writer, describes how 'the council's director, Margaret Gachara, was removed from her position after she used faked documents to garner a salary almost seven times above the norm for someone in her position.' In August 2003 the Kenyan Government, under pressure to act from its own finance officials, cut funding to four AIDS organizations alleging fraud and is investigating 10 others.
Fatima Hassan an attorney with the Johannesburg-based AIDS Law Project who filed requests with the SA Attorney-General requesting investigations into AIDS finances notes, "There are groups meeting their objectives and those that are not, but no one is holding them accountable.". According to Hassan, the South African Government simply does not have the appropriate systems in place to prevent fraud.
Hassan says current investigations may be touching just the tip of the iceberg. Indeed, disability grants in South Africa have increased by 32% in the past year, and while HIV maybe the cause of much of this, the South African Department of Social Welfare believes fraud is another.
But in confronting these cases of abuse, major government donors are engaging in reactionary practices that are massively wasteful.
Giant aid agencies, such as the U.S. Agency for International Development USAID, are so worried about bad publicity from small scale fraud that they are employing huge beltway contractors to do much of their "giving" instead of taking a chance on organizations based in affected countries.
These contractors may provide useful educational materials, and some educational workshops make sense. But how much is going for such activities rather than in country aid? Probably way too much. Figures are uncertain as U.S. AID is obsessively stingy with releasing any information relating to contract proposals, terms or budgets. When it was forced to reveal this information about its malarial control programs, though, allocations were found so appalling that Sens. Gregg and Feingold called for a General Accountability Office investigation.
Indeed, according to insiders and scholars who have studied this issue closely, only a few cents of every aid dollar ends up in the hands of the countries and people that need aid the most. The vast majority of USAID (taxpayer) funding never leaves the United States. One USAID employee, who prefers anonymity to losing his job, explains that the preference for big contractors results from a focus on "getting the job done, not getting the job done right."
It is a perverse betrayal of HIV sufferers to spend most of an AIDS budget on these types of activities, mostly because the big contractors are easier to monitor and have sophisticated accounting techniques -- not to mention entrenched Washington interests.
The overzealous attack on abuse also does little to encourage accountability in those local organizations that can and are actually doing thins to fight the AIDS pandemic.
For example, the Treatment Action Campaign in South Africa, which tries to increase generic drug distribution to those with HIV, rarely discusses funding abuses in order "to avoid creating confusion or further disunity among people with HIV/AIDS and the organizations that represent them"
There is a balance between counterproductive accounting controls and resource draining fraud. A privately-funded South African organization has found it.
The South African Sibambisene AIDS Network, funded by drug company Bristol Myers Squibb and the Nelson Mandela Children's Fund, helps distribute money to 30 or so small organizations addressing the AIDS pandemic in South Africa.
PhaPhamini, an orphan support group in the beautiful location of Hluhluwe, is what most are like. It reportedly does a great job of protecting AIDS orphans and educating people about the dangers of AIDS. And it operates on only a few thousand dollars a year.
As Nicole Itano explains: 'PhaPhamini is run by a woman who speaks no English and has no computer skills"' The woman is typical of the people doing much of the essential compassionate caring work. They are not trained professionals and are unlikely to care about filing reports on time. Some have trouble appreciating the separation of work from home life, since they have never held a job before. Many used work cell phones for personal calls without apparently knowing that such a practice was inappropriate.
Unfortunately, three of the 16 other orphan networks Sibambisene supports couldn't account for how they had spent most their funds. Anthony Mkhabela, Sibambisene's network's project manager, suspects that the money was used privately by the organisation's leaders.
What to do? Demand more paperwork from operations such as PhaPhamini? It would make no sense.
Instead, Sibambise tacitly accepts that a small amount of abuse, such as using money for cell phones, may occur, but uses its own funding structure and distribution systems to ensure as little aid as possible is wasted. - less than a month's worth of money granted to any organization.
The losses from the embezzlement by the three guilty orphan agencies thus amounted to less than a thousand dollars. Furthermore, the guilty are now repaying the missing funds, and the local organization responsible does not receive monthly distributions any more.
Finally, learning from the past, Sibambisene helps small organizations account for money responsibly and provides basic training in banking and accounting.
This makes far more sense than what USAID is doing in hiring huge contractors to watch over its giving.
As one Beltway consultant who also declined to be named because of the risk of future contracts being withdrawn, said, "Paying USAID funded consultants, doing work of marginal value, more per week than was stolen in an entire year by the private Sibambisene groups is a poor allocation of resources."
Fraud will happen. Efforts need to be made to limit it. But overly zealous efforts to eliminate it will only waste more aid than is saved. USAID officials may be able to say that taxpayer funds are not embezzled, but they also won't likely be able to say that they did much good - except for contractors.
Dr Roger Bate is a fellow and Ben Schwab a researcher at the American Enterprise Institute.
Private route avoids the aid gap -- Richard Tren & Roger Bate, Business Day, 2005-01-24
Private route avoids the aid trap
BROWN'S MISGUIDED MISSION/Richard Tren & Roger Bate
GORDON Brown, Britain's chancellor of the exchequer, has finally gone home after his African trip, no doubt with a glowing feeling in his soul. His efforts to forgive debt, increase government-to-government aid transfers and increase trade will win him many friends at home and abroad. Increasing aid transfers pleases Big Government supporters who believe the west's wealth came at the expense of African development.
Bureaucrats in Africa and in developed countries will be pleased as they will have increased budgets and power.
However, the people that Brown thinks he is trying to help will rue the day he set foot on the continent. If history is anything to go by, increased aid transfers will only stifle economic growth, increase the size of government and hurt the poor even more.
Brown considers himself the new George C Marshall, coming to the rescue of Africa, as Marshall supposedly did for Europe after the Second World War. But Europe probably would have grown faster without the Marshall Plan, because the plan increased the size of government, thereby frustrating private enterprise. In any event, the new democracies of Europe had, by then, made firm commitments to protecting the institutions of a free society. These institutions, such as the rule of law, protection of private property rights and limited government, are the very foundation of economic growth. And it is economic growth, not handouts, that eradicates poverty.
It is a pity Brown didn't read a paper by economist Tomi Ovaska that lays bare the myths about the merits of government-to-government aid transfers. In his 2003 paper in the Cato Journal, Ovaska finds there is a negative relationship between aid and economic growth. Specifically, he says: "It was found that a 1% increase in aid as a percentage of gross domestic product (GDP) decreased annual real GDP per capita growth 3,65%."
So, far from helping poor countries, aid transfers actually slow economic growth and keep them mired in poverty. One reason for this is that aid transfers give all the wrong incentives to developing country governments. Governments can choose to adopt policies that increase growth and reduce poverty and thereby become less reliant on handouts. Or they can perpetuate policies that subvert the free market and undermine individual enterprise, from which the political elite is largely immune. So, the more a government can increase poverty and stifle growth, the more easy money, via aid transfers, might be made available.
Ultimately, more aid puts a country on a downward economic spiral. But pointing this out is hard to do World Bank economist William Easterly was encouraged to leave the institution after he continued to point out this truth.
Donor governments are trying to ensure that aid goes to responsible and democratic governments it is vitally important to stop the taxpayers of rich countries unwittingly funding torture and abuse in poor countries. Yet Ovaska finds that "aid given to countries with a better quality of governance was not found to improve the effectiveness of aid". So the harm aid does to work effort and in misallocating resources is present whether or not a government is responsible and democratic.
After decades of grandiose aid projects and one impressive-sounding rescue plan after another, Africa is poorer than ever and has an ever-diminishing life expectancy. Yet the problems of aid transfers should not mean that the citizens of rich countries should just sit back and watch African children die of preventable diseases. It merely means they should discourage their governments from giving their hard-earned taxes away to other governments that have clearly shown they cannot encourage growth and reduce poverty.
A far better solution is for the citizens of rich countries and investors to make private transfers. Private aid to poor countries is far more effective than state aid. When a US citizen makes a direct transfer to a specific cause or charity in a poor country, he or she is much more likely to ensure it is used properly. Investors, with an eye on the bottom line, will be motivated to ensure their money is well used and will transfer skills and technology to areas where poor countries actually need it .
Brown likes to speak of the morality of his cause. Yet there is ample evidence that his efforts are deeply immoral in that they are destined to keep Africa poor and ever more reliant on the hapless taxpayers of rich countries. If African governments really wanted to help the poor, they would have sent Brown packing and made a real effort to get their own houses in order.
Tren is director of the health advocacy group Africa Fighting Malaria; Bate is a visiting fellow of the American Enterprise Institute in Washington.
Jan 24 2005 08:20:48:000AM Business Day 1st Edition
A Deadly Cocktail in South Africa -- Richard Tren, TechCentralStation, 2005-01-10
A Deadly Cocktail in South Africa
By Richard Tren Published 01/10/2005
On Thursday Nelson Mandela's eldest son, Makgatho died tragically from an AIDS related disease. Mandela has been widely hailed for being open about the cause of his son's death. In a country where the stigma of AIDS forces people to lie every day about the disease, Mandela's move was indeed brave and is another example of his extraordinary moral courage and leadership. Right now, South Africa is in desperate need of more leadership of this nature. The same week that Makgatho Mandela died, controversy rages about the safety of the AIDS drug Nevirapine. The South African government, far from providing balance and reason, seems to be creating confusion and adding to stigma. The acrimonious relationship between the South African government, NGOs and the drug developers does untold harm to the effort to roll out essential treatment. All of this confirms the opinion that we have held for many years; that the simple message that drug patents block access to treatment is wrong.
Nevirapine is a non-nucleoside reverse transcriptase inhibitor, and is known to be highly effective at preventing mother-to-child transmission of HIV and is also used in triple therapy for people living with HIV/AIDS. When used to prevent mother to child transmission, a single dose is given to the mother when she begins labour and a single dose is given to the infant.
Despite the fact that the drug works and can save thousands of lives, the South African government had to be taken to the highest court in the land, the Constitutional Court by the AIDS activist group Treatment Action Campaign (TAC) before it would provide the therapy. Cost cannot have been an issue as Nevirapine's producers, Boehringer Ingelheim, offered the drug for free. The government's reluctance to provide treatment probably has more to do with its own AIDS denialism than sound medical or economic policy.
In September 1999 a study, known as HIVNET 012, was published on the use of Nevirapine in Uganda by, among others, the National Institutes of Health (NIH) and Johns Hopkins University. Subsequently some deficiencies in the documentation of the study were reported and even though the NIH has clarified the deficiencies, the ANC and South Africa's Minister of Health claim that the drug is unsafe. This is despite the overwhelming evidence that the drug is safe and effective. Thousands of pregnant women have been given Nevirapine without a single life threatening adverse effect being recorded.
Shortly before Christmas, an ANC newsletter accused TAC of "discounting the lives of Africans" and questioned the US government's motives in providing Nevirapine to Africans. For those South Africans that are taking Nevirapine as part of ongoing antiretroviral therapy and for those HIV positive pregnant women, the controversy has been confusing and frightening. There is a great deal of stigma attached to HIV/AIDS and so people are reluctant to be tested for the disease. The last thing that South Africa needs is for people to stop their treatment or to refuse to be tested for HIV in the first place because they think the treatment is harmful.
To add to the confusion a new body known as The Traditional Healers Organisation (THO) has added its somewhat dubious voice to the debate. In a large advertisement placed in South Africa's Mail and Guardian newspaper, the THO claims that it comprises more than 20,000 members and "reaches out to a total of almost 200,000 Traditional Health Practitioners" whatever that may mean.
Many South Africans consult traditional healers who treat them with the leaves, bark and roots of numerous plants, following generations of handed-down advice. Although many South Africans trust traditional healers implicitly, THO is attempting to promote its craft by making some ludicrous (and I would think libellous) claims. For instance it states that:
"The fatal side effects of prescription drugs have become the hallmark of modern pharmaceutical-based medicine. In the United States and the industrialised world the epidemic of deadly side effects from pharmaceutical drugs have become the third largest cause of death."
Without bothering to substantiate its claims, the THO goes on to state that:
"Currently the pharmaceutical industry is being exposed globally as an investment business that is responsible for the premature death of millions of people."
The THO states that Africans are being used as guinea pigs by the international drugs industry because they are taking Nevirapine -- a claim also made by South Africa's Minister of Health. Bizarrely, the traditional healers then accuse TAC of being a pharmaceutical interest group and of greedily trying to destroy humanity. The THO then appeals "to all Health loving individuals and institutions to further investigate the TAC's intentions to disturbalize the country's peace, justice and stability" (sic).
In a moment of nauseating sycophancy, the THO then commends the "efforts of OUR Government through the office of the Minister for putting up a committee that will further investigate this deadly deeds." (sic)
The THO doesn't seem to have a website (perhaps that wouldn't be traditional enough) and the number provided for their spokesman is never answered and so it hasn't been possible to get clarification on their many mysterious statements.
One thing we can be sure of however is that the TAC is not a pharmaceutical interest group. They have conducted a successful and often acrimonious campaign against the research based drugs industry for many years. Their chairman, Zacchie Achmat has accused the drugs industry of having blood on their hands for defending their drug patents. He even accused me of endorsing genocide for daring to suggest that patents were not the problem in AIDS drug access. While I consider the TAC to have got it wrong on drug patents, they have played an invaluable role in challenging the stigma of HIV/AIDS and in forcing the South African government to roll out desperately needed AIDS medicines.
The attacks on the drugs industry and TAC by government and the traditional healers show how far South Africa has to go in order to roll out a comprehensive AIDS treatment programme. South Africa could learn a great deal from its neighbour to the north, Botswana which has been running an excellent AIDS treatment programme for several based upon cooperation and partnership between government, the drugs industry, academia and NGOs. It is shameful that South Africans will die needlessly because the government prefers to play politics and ignore good science and medicine. Our sympathy goes out to the Mandela family and we hope that Nelson Mandela's leadership and courage will somehow rub off on the ANC government that he used to lead.
Tren is a director of the health advocacy group Africa Fighting Malaria and is based in Johannesburg, South Africa.
The Right Kind of Aid -- Roger Bate, TechCentralStation, 2005-01-04
The Right Kind of Aid
By Roger Bate Published 01/04/2005
As more aid pours in for the unfortunate victims of the Asian tsunami, there has been much hand-wringing that nations, notably the Untied States, have not done enough. But while the highly paid UN staff whips up, and the media avidly reports, big government aid competition, what is far less well monitored is whether the money is being well spent. If history is any guide, the short run aid, especially from the private sector, will probably be relatively well spent, but the loner term aid, especially from governments, will prop up failing systems and allow domestic funding for healthcare and social security to be diverted into arms purchases.
Lord Peter Bauer pointed out half a century ago that much of the so-called aid to developing countries was being used by recipient governments to subjugate their own people. Yet after five decades of failed aid, donor governments keep on undermining the very development they are attempting to promote.
Donor nations may attempt to ensure that aid is spent on health care, food delivery, poverty reduction or some other desired relief work. They may also receive solemn pledges from recipient governments on the proper utilization of aid money. But once the money is thrown into the budget pot of the recipient government, the aid frees other resources for spending on weaponry and other odious acts to support suppression.
Overcoming the 'diversion of funds' problem in government-to-government aid appears insuperable as long as developing-country governments regard oversight as interference in their internal affairs. However, people-to-people, non-governmental aid would solve the oversight problem and have many other additional benefits.
Donor nations could leverage earmarked aid funds by a multiple of three or four, depending on their tax rates, by allowing tax deductions to their own corporate and individual taxpayers for investments and philanthropy in designated developing countries. In other words, government-to-government aid could be converted into a larger amount of citizen-to-citizen aid.
Poverty relief would be real, identifiable and quantifiable if made by private organizations and individuals. Investments and donations in recipient countries would go directly to areas where they would make the most difference in providing jobs and relieving poverty. Bureaucrats would not absorb a large percentage of the funds in administration costs, and buying arms with donor money would be out of the question.
Private investors and donors have a personal interest in ensuring that their investments are productive and their donations used for their intended purposes. They consequently oversee the process more efficiently than their governments are capable of doing. Investors reduce poverty by investing their capital in the production of goods and services -- tax breaks and diplomatic support from their home countries could reduce the risk of investing in poor countries and provide incentives for them to do more of it.
Instead of having anonymous flows into the coffers of recipient governments, aid to developing countries would become personalized - the recipients of donations and employees of investing firms would be able to put faces to their benefactors. As a result of such personal contact, demands for aid now directed at governments would become invitations directed at investors and requests to private donors, completely changing the nature of the process. Most importantly, direct interaction between individual donors, investors and the citizens of developing countries would occur, contributing significantly to good relations between nations.
The UNs Millennium Development Goals (MDGs) aim to reduce poverty, malnutrition and ill health. A 'global partnership' is envisaged, coupled with the exhortation that 'while success depends on the actions of developing countries, which must direct their own development, there is also much that rich countries must do to help.'
But since most previous government-to-government aid has failed abysmally the MDGs are likely to be missed since despite past failure, the UN continues to expect governments to be the primary agents for ridding the world of poverty, disease and all the social ills that accompany them. There is no recognition that it is private firms and individuals that are, always have been, and always will be, responsible for reducing their own poverty and that of others. It should be of no surprise that it is the private sector in China that has driven poverty from millions, but the UN misses this point.
If governments were to concentrate on their legitimate core functions and leave the business of business to the people, economies would function more efficiently, consumer needs would be met more effectively, and poverty would be rapidly reduced.
The most effective way to address all the MDGs is therefore to leave the delivery of aid in the hands of private firms and individuals from developed countries, whose governments should refrain from taxing monies utilized by their citizens for investment and philanthropy in poor countries. Citizens of poor countries must develop institutions such as property rights, the rule of law, and freedom of exchange to sustain wealth-creation, which is the other side of the poverty-reduction coin.
Given the right conditions and incentives, the rich citizens of China, America and Europe will reach out to the less fortunate of Asia to help them create the necessary institutions needed to support poverty-reduction.
Band Aid for a Terminal Illness -- Richard Tren, Business Day, 2004-12-21
Band Aid for a terminal illness
TWO years ago I, along with public health experts, criticised the Nobel Prize-winning health-care organisation Doctors Without Borders for supporting the Zimbabwean government's decision to import generic AIDS drugs.
The move, I argued, would do nothing to improve access to medicines as it did not address the fundamental problems of a lack of infrastructure, corruption and the Zimbabwean government's failure when it comes to HIV and AIDS.
Recently I felt myself slipping from the moral high ground I had assumed when I found myself sitting near Zimbabwean Health Minister David Parirenyatwa .
Zimbabwe's government has decided to reintroduce DDT spraying to control malaria, which is a good thing. For decades DDT ensured that malaria was well under control in the country but when it was removed in the early 1990s, malaria cases and deaths began to rise. At the same time, Zimbabwe's economy began its decline under the tyrannical grip of President Robert Mugabe and as a consequence all medical care and public-health programmes began to suffer.
The Zimbabwean government invited me to a press conference in Harare to raise the profile of malaria and dispel any myths about DDT. I felt that I could possibly do some good and help save lives by assisting. I was probably wrong.
Yet there I was, sitting near a senior member of Mugabe's government. I have met many people who have been arrested and tortured by Mugabe's secret police, the Central Intelligence Organisation. Their horrific stories kept playing in my head as I listened to Parirenyatwa say that Zimbabwe was well prepared to deal with malaria.
Certainly, if the government were as effective in its battle against the Anopheles mosquitoes as it is against its opponents, there wouldn't be a malaria problem.
To be fair, Parirenyatwa is quite widely respected as a health minister. Yet he is a high-profile member of Mugabe's regime, and in Zimbabwe you can judge a man by the company he keeps.
In any event, his assurances rang hollow, as I had already spoken to several Zimbabwean doctors and read many reports that describe the almost complete breakdown of the country's health-care system. But it was curious that the minister felt he had to defend himself and his government's policies .
Since passing the Access to Information and Protection of Privacy Act , Mugabe's government has silenced most of the independent media. No independent journalists were invited to the malaria press conference, just the state broadcasters, journalists working for the state-backed newspaper and Zanu (PF)'s newspaper, the Voice. These socalled journalists think nothing of writing hate-filled stories designed to belittle Mugabe's opponents. Their favourite phrase is to call Mugabe's critics the "running dogs of imperialist Britain and the US".
Their writing often incites violence and is normally completely divorced from the truth. So when one of the journalists started to question me fairly aggressively about the use of DDT, the effrontery was too much . Was I expected to argue and explain myself to these disciples of Goebbels? What is the point in trying to impart truths to people only interested in lies?
However, within Zimbabwe's health department there are ordinary men and women who are trying their best to save lives and improve malaria control.
Unfortunately the main reason malaria cases have risen is that the malaria-control programme has been starved of funds. Only 3,4% of the houses that are supposed to be sprayed with insecticides were sprayed last year. Malaria-control officers had no budgets .
Zimbabwe is in a sort of truth twilight zone. One or two publichealth experts I spoke to would tell me of their hatred of Mugabe and the real health-care problems only in private. Publicly, of course, the government blames the "running dogs" for everything.
The decision to use DDT is a good one, but this is overshadowed by countless human rights outrages and ongoing state violence.
DDT may save the lives of some Zimbabweans, only for them to be denied food and starved, raped, tortured or murdered for the crime of not belonging to Zanu (PF). Until Mugabe's reign of terror ends and democracy is restored, this running dog is staying away.
Tren is a director of the South Africa-based health advocacy group Africa Fighting Malaria.
Dec 21 2004 09:09:42:000AM Business Day 1st Edition
China's Latest Health Scandal -- Richard Tren & Roger Bate, Apple Daily - Hong Kong, 2004-12-15
China's Latest Health Scandal
By Roger Bate, Richard Tren
Posted: Wednesday, December 15, 2004
Apple Daily (Hong Kong)
Publication Date: December 15, 2004
Is China denying African children a medicine that would save their lives? The evidence is growing that it is, and this policy must stop.
Public health officers and doctors have a tough time trying to control malaria. Not only do they have to deal with the Anopheles mosquitoes, which are wily beasts to say the least, they have to contend with the malaria parasite, which is constantly outwitting anti-malaria drugs. In recent years however a new and highly effective dual therapy based on an ancient Chinese herbal remedy, known as Artemesinin-based combination therapy (ACT) has changed the face of malaria treatment and holds out great hope for the control of malaria. Unfortunately for malaria control experts, in addition to mosquitoes and parasites, basic economics and politics now stand in the way of progress.
During the Vietnam War, the North Vietnamese appealed to their Chinese allies to find an effective drug against malaria, which was claiming far too many of their troops. The Chinese government obliged and after bio-prospecting a great number of substances hit upon Artemesinin (qinghaosu), which is an extract of an ordinary looking shrub, Artemesia annua. The new drug remained a secret for many years even though there was increasingly widespread resistance to the alternative therapies. During the 1990s some south east Asian countries began to adopt ACTs with great success.
Most African countries, where around 90 percent of the world’s malaria cases and deaths occur, were slower to adopt ACTs but have now started to change over to the new drug. Unfortunately funding bodies and the WHO were behind some of the delays in adopting ACTs and this no doubt cost lives. An article in the medical journal Lancet earlier this year accused these agencies of medical malpractice for dragging their feet over ACT adoption and approving the use of ineffectual medicines in Africa.
Since then the Global Fund for AIDS, TB and Malaria has supported the roll out of the new drugs. But since other agencies didn’t buy drugs effective demand was low, so supply wasn’t increased, and now that demand is high supply has not changed hence the price of artemesinin has gone up.
Apart from the problem of basic economics, according to sources in the WHO, it seems that the Chinese government, once secretive about its new malaria drugs, is actually trying to limit the export of artemesinin seeds. The plant Artemesia annua is not exclusive to China, but the high yielding varieties are and attempts by other countries, such as South Africa, to import seeds have so far been fruitless.
If indeed the Chinese government is attempting to restrict the export of the seeds, it would surely be breaking some fundamental World Trade Organization rules. Breaking WTO rules is unfortunate, but the real outrage is that their actions are condemning thousands of Africans to an early grave. Given the Chinese government’s unfortunate record over the SARS outbreak and over the sale of HIV tainted blood, many will not be surprised that they are implicated in yet another healthcare scandal.
This whole debacle highlights some important points about public health and access to medicines that is far too often overlooked. The popular view in the whole access to medicines debate is that drug patents and drug company profits are by and large responsible for the fact that poor Africans can’t get treatment. Yet the reality is that in most poor countries it is poverty, a lack of medical infrastructure and a lack of political will to deal with health problems that denies people treatment.
The Swiss pharmaceutical company, Novartis, pioneered ACTs with its single dose combination Coartem. The company is selling the medicine on a non-profit basis and has expended a great deal of time, effort and money to improve treatment in many African countries. Even though the company is large and powerful, it is still subject to the same laws of supply and demand as everyone else and is having difficulty sourcing Artemesinin. This reality however did not stop the medical charity, Medicines Sans Frontiers blaming Novartis for the ACT shortage.
Add to the activist politics the actions, or lack of them, of various UN agencies and malaria control seems a far off goal. Most UN bodies and donor agencies have failed Africa’s most vulnerable by ignoring interventions that work, such as effective drugs and indoor spraying of insecticides that protects households from the Anopheles mosquitoes. In 1998 the WHO, UNICEF, the World Bank and various donor agencies launched a new malaria control program, Roll Back Malaria (RBM). The goal was to halve the burden of malaria by 2010. Since then malaria cases have gone up not down and earlier this year the British Medical Journal editorial characterized RBM as “a failing health initiative.”
It is time for governments, UN agencies and activists stop blaming the easiest target, the drugs industry, and start to face up to the fundamental barriers to access and deal with the politics that denies people treatment. Tackling China over their apparent reluctance to boost the supply of Artemesinin would be a good first step.
Richard Tren is the director of the South Africa based health advocacy group Africa Fighting Malaria, and Roger Bate is a fellow at the American Enterprise Institute.
Europe Promotes Tragedy in Uganda -- Dr Roger Bate, TechCentralStation.com, 2004-12-14
Europe Promotes Tragedy in Uganda
By Roger Bate Published 12/14/2004
If Kansas Sen. Sam Brownback is correct, European scaremongering is delaying the re-introduction of DDT into Uganda. And this will have deadly consequences.
Sen. Brownback (R-Ks) has just returned from a Ugandan health fact-finding mission. He told me that EU trade policies "will lead to an increase of deaths among pregnant women and children in Africa. DDT was used to rid Europe and the US of malaria. Now it can't even be sprayed indoors in limited settings to save vulnerable lives in Africa. God help us."
Ugandan farmers are being told that they could lose millions of dollars in fruits and vegetable exports into the European Union (EU) market when the Ugandan government imports DDT for the prevention of malaria. European protectionism is odious at the best of times, but this alleged EU threat borders is particularly egregious, and should be pre-emptively challenged by Ugandans through the WTO. There is no evidence that any of the DDT, which could be used to save thousands of babies from malaria, would ever reach any agricultural products; and even if it did, there is no evidence of any harm from DDT in produce, even at relatively high doses.
Robert Karyeija, the principal health inspector in the Ugandan agriculture ministry, said the EU -- the largest importer of Uganda's agricultural products -- was considering suspending buying its produce for fear of DDT intoxication. In an interview with the New Vision newspaper last Thursday in Kampala, the capital of Uganda, he said:
"The European Retailers Produce working group for Good Agricultural Practice is considering suspending exportation of our agricultural products as soon as the government imports DDT."
Mr. Karyeija explained that this would be catastrophic not only to the private sector, but also to government revenues. Apparently Uganda could lose up to US$23 million annually if EUREP-GAP, an EU exporters body, suspends buying local products because the consumers in Europe and America want organic products. EU importers claim to be concerned that DDT would spill over to agricultural fields, especially in rural areas, due to poor application of indoor spraying, making the eventual harvests inorganic. This is ridiculous.
First, the notion of organically produced food is misleading, since much European organically produced food uses inorganic pesticides, such as copper sulfate (and technically DDT is an organic chemical anyway). Second, there is no evidence that anything but tiny trace amounts (possibly not measurable) of DDT could ever reach crop production (the concern about DDT was when it was used in tons in farming, not ounces in malaria control, where most of that already small amount ends up absorbed into walls). Third, and most importantly for any WTO challenge, there is no evidence of any harm from trace amounts of DDT in crops, so boycotting Ugandan produce because of DDT contamination is untenable under WTO rules.
But the concern about DDT is being tacitly re-inforced by lack of unity in the Ugandan health department over using DDT. A decision was made over the summer by the Ugandan Ministry of Health to use DDT procured by the Global Fund to Fight AIDS, Tuberculosis and Malaria. But insiders I spoke with, who wish not to be named, say that overseas pressure to drop DDT use means the decision is on hold. Most aid agencies, whose historic actions have largely been ineffectual and often counterproductive, tend to want to stay under the radar. Therefore, the advice they give is predicated on annoying the fewest people, so they shy away from advising the use of insecticides since it upsets green groups who vociferously oppose nearly all man-made chemicals.
After complaints about the Global Fund's early actions by Senators Judd Gregg (R-N.H.) and Russell Feingold (D-Wisc.), the Fund has improved. As long as this continues and the Congressional oversight remains, especially the Senators' calls for outcome measurements, then it should continue to expand its work in Africa. Governments could increase funding to deliver what Africans want (drugs, insecticides and other resources), rather than what western aid agencies want to give them (mainly seminars, educational programs and consultants). If they do the former then we might start to see a reduction in the worst tropical diseases.
Unfortunately, the greens and Europeans with their well-oiled media machine are likely to win this battle. Ugandan agricultural officials will point out that alternative insecticides and bed nets are an option, (even though they don't work as well), and that Uganda cannot afford to lose exports. The health department, which is so reliant on aid, will only push its donors so far, and given the resistance from USAID, WHO and others on the use of insecticides, they will likely crumble.
For the thousands of Ugandan children whose lives could be saved, but who have no voice in this debate, it will be a tragedy. But just another tragedy on top of so many others perpetuated by European greens and the farm lobby.
Roger Bate is a fellow at the American Enterprise Institute and a Director of Health advocacy group Africa Fighting Malaria.
Unsound generic AIDS vaccines have caused untold misery to millions -- Dr Roger Bate, The Daily Telegraph, 2004-12-06
Personal view: Unsound generic Aids vaccines have caused untold misery to millions
By Roger Bate (Filed: 06/12/2004)
Last week an Indian generic drug company delivered a body-blow to millions of Africans. Hetero withdrew six of its anti-Aids drugs, compounds which were supposed to be generic copies of those which are used to treat the disease in the developed world.
The company was following another Indian manufacturer, Ranbaxy Laboratories. As a result, out of the 28 generics Aids drugs produced by Indian companies prequalified by the World Health Organisation in May, 18 have now been withdrawn.
Pro-generics pressure groups have downplayed this alarming development. Médecins Sans Frontičres responded: \"We are not worried for the safety of our patients. We are confident in the drugs we are using. We can\'t make an equation that if a drug is removed that it\'s not a good drug.\"
Yet this decision betrays thousands of desperately poor and sick Africans who were told by the WHO, generics manufacturers, pressure groups and \"experts\" ranging from nearly all EU politicians to US Senators Kennedy and McCain that Indian copycat drugs would save them. Now nobody knows whether the drugs work.
The WHO \"prequalification\" process is in tatters. It had claimed it could treat 3m Africans by the end of next year (the \"3 by 5\" campaign), but it has had to resort to using drugs that had not been properly tested for bio-equivalence to brand name medicines (produced by the likes of GlaxoSmithKline and Merck). Indian drug companies provided most of these drugs and now three quarters of them have been withdrawn.
In August the WHO rejected three anti-retrovirals that it had been buying from Ranbaxy, as well as two drugs made by Cipla, another Indian generics manufacturer, on the grounds that they were substandard.
Although the two Cipla drugs have now been reinstated, after the WHO received fresh information on bio-equivalence, since then seven more Ranbaxy drugs have been withdrawn, effectively meaning that all that company\'s Aids drugs have now been pulled.
Nobody from the WHO or the companies involved has offered any substantial assistance in managing the recall of these drugs or even providing briefings to African doctors as to the state of their clinical management. These drug recalls may have calamitous effects, a fact which is well-recognised by health professionals.
Resistance is already a problem in many African countries, such as Zimbabwe and South Africa, because drugs are not consistently available, and clinical practice is not always good. If, as seems likely, the recalled drugs were less effective than the branded originals, resistance will have developed even faster, in the same way that failing to complete a course of antibiotics helps the bacteria to develop resistance.
Clinical trials using the withdrawn drugs are now worthless because it cannot be known with any certainty whether a patient who fails to respond to treatment has suffered from some clinical or procedural mistake, or because he was given a bad batch of drugs. The effect of the recalls leaves patients with an invidious choice: use a possibly substandard product; use a brand original drug, which will work, but may cost much more; or use nothing.
Take the case of Lucy, a young mother of two children, living in extreme poverty in Zimbabwe. She was very frail, moving slowly to shake my hand, which she did with the support of her left arm. She is on a triple drug therapy, as part of a trial by the Mpilo Hospital in Bulawayo. She was able to walk for the first time in months, and although I didn\'t realise it at the time, I was seeing her at her best.
A few weeks earlier, she had been put on the children\'s dose of a branded drug because the doctors thought failure might have been the result of undernourishment. Previously she had been on the adult dose of a different drug and it overpowered her, actually making it harder for her to eat, creating a vicious circle. But now it seems the original drug may not have worked since it was a Ranbaxy cocktail.
Will Ranbaxy offer Lucy compensation, or even an apology? And what of the doctors trying to treat her, hoping that changes of diet and drugs might help? They were making decisions based on false information about the efficacy of the drug. Lucy told me she couldn\'t afford the drugs so she felt lucky to be part of the trial. Nevertheless, she was having to buy drugs for asthma and other opportunistic infections.
Meanwhile she is raising two children in two rooms of a small house. Lucy only found out her husband had HIV from his death certificate, which is when she was tested and found out she too, was infected. Still, Lucy may yet turn out to be lucky if she is switched to a reliable drug and given a guaranteed supply.
For all the Lucys of Africa it is essential that the US administration sticks to its guns and only buys drugs that are proven to work. And Britain must follow its lead. The WHO drive to treat 3m Africans by the end of next year is now sure to fail. WHO should accept defeat, acknowledge blame for its policy of approving untested drugs and apologise to the patients.
Then it must work with, rather than against, the US administration to deliver useful drugs in a controlled and responsible way to ensure that patients really do get better.
Roger Bate is a fellow of the American Enterprise Institute in Washington DC, a fellow of the Institute of Economic Affairs and a Director of Africa Fighting Malaria.
Biting the Hand That Feeds You -- Roger Bate, National Review, 2004-11-29
To confirm the massive international bias (especially within the media) against the United States, one has only to examine the headlines about the recent major AIDS meeting in Tanzania. Most nations have failed to live up to their international obligations, whereas the U.S. has delivered on them. Yet, by some odd twist, the U.S. is criticized and the rest are not. It's time for Americans to consider ignoring international forums (such as the Global Fund), partner with those who want to work with the U.S. (as they did in Iraq), and just save lives.
The Global Fund to Fight AIDS, Tuberculosis and Malaria was established by the U.N. in 2001 to provide drugs, insecticides, and other interventions to the poor countries of the world. Most of the money has been spent on HIV/AIDS, although increasingly a greater percentage is going to malaria control. Malaria has a high death rate — especially among children in Africa — but is curable, so the returns in terms of lives saved are much higher than for AIDS. Even so, there is controversy about prevention and treatment. Debates over whether bed nets or DDT are better for stopping mosquitoes from biting kids are as divisive for malaria control as the debates pitting abstinence against condoms, and brand-name drugs against generics, are for AIDS prevention.
The fund finished its board meeting in Tanzania just before Thanksgiving. Attended by four African presidents, with abundant smiles and large begging bowls, the meeting was supposed to announce a $3 billion anti-AIDS program for 2005. Instead, it has received pledges of only $900 million, and the fifth round of funding may be delayed by several months until the rest of the money is procured. Additionally, under congressionally imposed rules, the U.S. cannot commit more funds until the other parties also pledge more.
The current chairman of the Global Fund board is the U.S. Secretary of Health and Human Services, Tommy Thompson. When he announced that the fifth round of funding might be delayed by “five months,” the U.S. was immediately attacked by pressure groups for not doing enough. The Global AIDS Alliance accused President George W. Bush of crippling the fund by harboring “an irrational hatred toward all things U.N.-related.” European newspapers reported these attacks gleefully.
The U.S. has been the harshest critic of the fund’s failings. First, it has criticized other donors for not doing their part; more important, it has complained that the fund was failing to manage projects efficiently. But apparently good-faith, accurate criticism is not allowed in the world of do-goodery.
Add to this the fact that others’ criticism of the United States is certainly not in good faith. It is disingenuous of the media and activists to berate the one party that does not renege on an international agreement (i.e., the United States). The G-8 group of nations declared last year that the fund should get $3 billion a year, with French President Jacques Chirac proposing $1 billion from Europe, $1 billion from the United States, and $1 billion from other countries.
But since European nations have not donated their share, the U.S. has so far paid more than its share — its support has been as high as 37 percent and is currently at 35 percent, exceeding the originally proposed 33 percent. When Congress agreed to the funding, it capped U.S. support at a third of the total level, not wanting to end up funding the vast majority of a supposedly global effort. As Thompson says: “If other countries were as generous as [the U.S.], we would not be in the situation we are in right now.”
Europeans have defended their stinginess mainly by complaining about America’s faith-based approach. U.S. policymakers insist that abstinence and education are as important a part of disease control as condom delivery, and the evidence shows this to be true. But the truth has not stopped European activists from excusing their governments’ refusals to grant funding on the grounds that they object to American policies.
Such carping at American largesse and annoyance at U.S. demands for accountability demonstrate that the rest of the world is happy to pay lip service to AIDS relief, but is neither serious about funding it nor about making sure that the funded interventions work. If the U.S. pulled out of these joint ventures, U.S. policy administrators could get on with saving AIDS patients pursuant to their own standards of accountability — and saving themselves the hassle of answering to the hostile European media. U.S. non-participation would also show up the rest of the world for doing so little.
No Aid for AIDS -- Roger Bate, National Review, 2004-11-19
No Aid for AIDS
Disease-prevention groups are still failing Africans.
By Roger Bate
Arusha, Tanzania — The great and the good of the health world, along with at least four African presidents, have descended on Tanzania for the United Nations' Global Fund meeting. The fund, established in 2000 to combat AIDS, tuberculosis, and malaria, has so far received over $3 billion from the wealthy nations. But presidents Yoweri Museveni of Uganda, Paul Kagame of Rwanda, and Mwai Kibaki of Kenya have joined the Tanzanian president, Benjamin Mkapa, in saying that more funds are required.
But the greatest problem in Africa is the lack of political will to both combat disease and — equally important — provide the institutional conditions for growth. Without the former, disease will never be controlled; without the latter, it will always return.
Sub-Saharan Africa has always suffered under the blight of war, famine, and disease. But — with some notable exceptions — there are more democracies and fewer wars today than in the 1980s. Indeed, since 1990 many countries have had peaceful transitions of power — a welcome novelty for the region. Food supply is generally more secure than ever before, such that a particularly bad drought in Southern Africa has led to no more than food shortages in most locations. (Except, of course, for despotic Zimbabwe — where politically driven food allocation is causing widespread starvation.)
Unfortunately, many health indicators are still moving in the wrong direction. The most dangerous diseases are less controlled today than at any time in the past 50 years. Malaria and AIDS are rampant; tuberculosis is increasing from an already high rate. Much of the blame for this lies with the inadequate attention paid to health by African leaders, some of whom have continued to deny that HIV causes AIDS, and many of whom have preferred to bolster their armies against non-existent enemies. A fair bit of the blame can also be heaped on aid and health agencies that have promoted the wrong policies: notably, advocating bed nets for malaria control at the expense of the more effective indoor DDT-spraying. As a result, over the past five years, malaria rates have increased by more than 10 percent at a time when funding for malaria has increased by over 200 percent.
Most of the fund's money is spent on AIDS prevention and treatment, and a lot of this money may be well spent. Unfortunately, we just don't know. If, in the first round of disbursements in 2002, significant health outcome statistics (morbidity and mortality changes in particular) had been collected, then we could know. But unfortunately they weren't, and so we don't. Add to this the fact that the fund was procuring anti-malarial drugs that were useless — and Indian generic AIDS drugs that may be useless and have now been recalled — and its track record is rather a mess. To its credit, however, the fund has listened to criticism, and appears to be building in outcome measurements and buying the right drugs.
And when it comes to malaria, in fact, the fund is doing the best job of all aid agencies. It is actually procuring DDT for countries that ask for it, such as Zambia. Other agencies continue to promote only bed nets and are doing everything they can to obstruct the use of DDT in Uganda. A decision was made over the summer by the Ugandan Ministry of Health to use DDT procured by the fund. But insiders I spoke with, who wish not to be named, say that overseas pressure to drop DDT use means the decision is on hold.
After complaints about the fund's early actions by U.S. Senators Gregg and Feingold, it has improved. As long as this continues and the congressional oversight remains (especially the senators' calls for outcome measurements), then it should continue to expand its work in Africa. Governments could increase funding to deliver what Africans want (drugs, insecticides, and other resources), rather than what Western aid agencies want to give them (mainly seminars and funding of "educational" programs and consultants). If they opt for the former, then we might start to see a reduction in the worst tropical diseases.
The international community has been critical of the Bush administration's decisions to buy only tested AIDS drugs and to promote abstinence for AIDS prevention, but the former certainly — and probably the latter, too — have been shown to be correct. Some critics will continue to press the administration to give more money with no strings attached, but it must keep trying to promote democratic reform — particularly property-rights reform — because without secure entitlement for ordinary people, economic growth is unsustainable.
The links between economic liberty, individual property-rights protection, and health — as demonstrated by the Wall Street Journal-Heritage Freedom Indices — are too strong to be ignored. The historic lessons of malarial control are clear, and are of direct relevance to combating HIV today. Those countries that kept malaria away after eradicating it with DDT were those that either had or developed strong property-rights systems (e.g., the U.S., Italy, Singapore). Eradication was not sustained in those without these institutions (e.g., Guyana, Malaysia).
The economic ministries of African countries know this to be the case. But the health specialists dominate the turf war to receive aid, and they naively believe that wealth will miraculously appear if disease is combated. The lesson of history is that they are wrong, but those in Arusha are not listening.
— Roger Bate is a fellow at the American Enterprise Institute and a director of the health-advocacy group Africa Fighting Malaria.