Every time you fall ill, America gets a little richer, for we are a billion dollar market
By Mira Shiva
Public Health Activist
IN THE past year America has seen the most violent, nation-dividing debates about its healthcare system. India could do with some of that energy. We are short of approximately six lakh doctors, and there is a bigger shortage of nurses, auxiliary nurse midwives, lab technicians, anaesthetists, psychiatrists in our public health. Instead of addressing these shortages, our healthcare is being pushed blindly towards an American agenda. Budgetary allocation for healthcare is only 0.36 percent of India’s GDP and 80 percent of healthcare is privatised. This privatisation is leading to the pushing of expensive drugs, technology and vaccines. The current model is for bigger, costlier medical institutions and doctors who prescribe to rich patients. With our significantly high maternal, infant and neonatal mortality, India cannot switch to a privatised, hi-tech, curative care kind of model that emphasises funding and research.
US-style privatisation basically relies on the market to take care of everything. What this model forgets is comprehensive healthcare — not a new idea by any means. It was formulated in 1978 in Alma Ata, currently in Kazakhstan. India signed the Alma Ata Charter. The idea was to prioritise healthcare for the majority, irrespective of the patient’s ability to pay, with an appropriate referral system in place for secondary and tertiary care. One cannot focus on these while neglecting determinants of health — food, water and shelter. Curative healthcare alone will treat a person again and again for typhoid or amoebiasis, yet what is the point if your drinking water is contaminated by sewage? The aim was to prevent common health problems, without their becoming more serious, requiring hospitalisation, along with costly medicines and medical interventions.
But that was in 1978. Today, the areas of great concern for us should be biotechnology, Intellectual Property Rights (IPR), food and agriculture. There is a sustained attempt by the US (and the EU and Japan with whom we signed free trade agreements) to asphyxiate the generic drugs industry in India. These drugs are crucial to developing countries. When Nelson Mandela came to power in 1994 in South Africa, the cost of the antiretroviral AIDS drug was $15,000 a year. The African nation, with its high incidence of HIV/AIDS,wanted to give its patients cheaper, high-quality generic equivalents. The Indian pharma corporation Cipla took on the challenge and produced the generic antiretrovirals at $350 a year. India supplies 80 percent of AIDS medicines to developing countries. Obviously, a country using TRIPS (Trade-Related Aspects of Intellectual Property Rights) flexibility and supplying cheaper, quality drugs to its HIV positive patients was a commercial threat. In 2001, around 39 pharmaceutical MNCS took the South African government to court for violation of intellectual property rights. An outcry by public health groups, AIDS activists and governments of developing countries resulted in the Doha Declaration on IPRs and public health in the same year. The government of Thailand, too, has faced tremendous pressure from the US for using TRIPS and compulsory licensing to produce cheaper generic equivalents of antiretroviral and anti-cancer drugs.
Several patented drugs are going to be out of originator’s patent protection soon. Generic equivalents can then be manufactured making the stakes add up to billions of dollars. So, how do drug companies in the First World stall it? One way is mergers and acquisitions. In India, the MRTP (Monopolies and Restrictive Trade Practices) Act used to be a safeguard against such mergers. Not anymore. Mergers like Ranbaxy-Daiichi and Piramal-Abbott are going to seriously impact Indian access to many drugs, their prices, the nature of research and development and where public health priorities lie.
There are other ways. A coalition of stakeholders calling themselves the International Medical Products Anti-Counterfeiting Taskforce (IMPACT)was sneaked into the WHO — shifting the contours of the debate so that the word counterfeit would be used instead of generic drugs. (Today, Wikipedia’s entry on Anti-Counterfeiting Trade Agreement aligns generic drugs with counterfeit ones.) The stated intentions of IMPACT has been challenged at the World Health Assembly by the developing nations. The health ministries of India, Thailand, Brazil and civil society organisations like Health Action International (HAI), Third World Network (TWN), Knowledge Ecology Initiative (KEI), Peoples Health Movement (PHM) expressed their dissatisfaction with commercial interests guiding IMPACT. There is also the deceptively titled Partnership for Safe Medicine, an NGO from the US. Four out of five of its objectives are related to the counterfeit agenda.
The proposed Anti-Counterfeiting Trade Agreement (ACTA), which is supported by the US, is the civil and criminal enforcement of IPR. The issue of safe and unsafe medicines is an important one. Unsafe drugs like Thalidomide, prescribed during pregnancy, have resulted in the birth of thousands of babies without limbs. Diethylstilbestrol (DES), also prescribed during pregnancy, resulted in development of vaginal adenomas in girls once they grew up, and infertility in case of a boy child. Which is why there is a genuine concern about Rofecoxib (painkiller), Fluoxetine (anti-depressant) and Rosiglitazone (anti-diabetic), drugs associated with adverse cardiac effects and therefore withdrawn in the EU and US. However, perfectly functional drugs produced in India are acquiring the connotation of being spurious or substandard. This means the medicines you export can be destroyed on grounds of suspicion.
The US and EU are pushing for data exclusivity and patent linkage to enable market protection to originator pharmaceuticals by denying approval to generic equivalents. Take Gleevec, the Novartis drug for chronic myeloid leukaemia, which costs Rs. 1.2 lakh a month. The Indian generic drug costs Rs. 10,000 a month, which is still on the higher side. Novartis has changed the drug formulation slightly to try and get a new 20-year patent. There has also been pressure from the US to do away with section 3(d) of the Indian Patent Act, which prevents the evergreening or lengthening of patents.
The other area of great concern is food and agriculture. The US, with its genetically modified processed food, has massive health problems. The aggressive marketing of branded processed foods, considered junk food by nutritionists, are especially targeted at children. Processed foods are filled with chemicals like monosodium glutamate and are sweetened with genetically modified high fructose corn syrup. This is linked to several health problems and, if pushed in India, could worsen the increasing trend of diabetes and obesity in the young. We have a high disease burden of poverty, malnutrition and communicable diseases, water and vector-borne illnesses, STDs and chronic noncommunicable diseases like hypertension, diabetes, cancers and mental health problems such as stress and depression.
With pizzas, noodles and soft drinks, we are opening ourselves to a whole new set of health hazards. We risk standardising the varieties of food available in the country. There is huge pressure to distribute cola drinks and processed food with government mid-day meals. To make matters worse, the Indian Medical Association has endorsed Pepsi in the past. Have the medical associations ever taken on corporations for selling hazardous drugs or unethical marketing? If these are the people taking decisions on food and health on our behalf, then we are in big trouble.
When President Obama visits, there are some compromises we should not make because they will endanger our healthcare. ACTA should be protested because it is against the interests of public health. We should not cede to American demands of data exclusivity and patent linkage. Section 3(d) of the Indian Patent Act should not be repealed at any cost. We cannot allow potentially toxic or hazardous industries, even if it is considered a big carrot to attract foreign investment. We need to make sure we have more than adequate liability clauses related to vaccines and genetic engineering. The larger determinants of health — food, water and shelter — cannot be forgotten.
Besides being a national shame, the recent case of the denial of justice to the victims of the Bhopal gas tragedy raises another important question. Who is supposed to clean up the toxic effluents? The tragedy is a stark reminder of the healthcare implications of letting corporations run loose.
If they cannot keep their flashback responsibility, how will they retain a flash forward responsibility?