Water and Sanitation: Probably the Greatest Possible Benefit to Health that Exists

Great to read an article in the New England Journal of Medicine (NEJM) making it quite clear, if it wasn't clear enough already, that the cure for cholera is improving access to safe water and sanitation. The recent massive cholera epidemic in Haiti means that several years and billions of dollars of aid money have not resulted in the provision of safe water and sanitation. The epidemic in Zimbabwe means that provision of water and sanitation, which may have been adequate at one time, collapsed. (It is estimated that about half a million people were infected with some kind of diarrhea in Zimbabwe alone in 2012.)

The good news is that lots of diseases can be wrapped up along with cholera and eradicated; most water-borne diseases. The bad news is that no country has ever eradicated cholera or any other water-borne disease without providing clean water and sanitation. The mere development of a vaccine for cholera or any other single disease misses the point and misses a wonderful opportunity. Half a million cholera infections and thousands of deaths are reported every year, all for want of clean water and sanitation. But the true number of infections is likely to be several million and the number of deaths likely to be 100-200,000.

Institutions such as the Gates Foundation like to boast about how many billions they are putting into vaccines for individual diseases, such as rotavirus. That's admirable in its own way, but why line up a few diseases to be addressed and ignore the conditions that ensure these diseases will remain endemic for the foreseeable future? Especially considering how long lack of access to clean water and sanitation has been one of the most serious issues facing developing countries. If, as the NEJM article claims, the problem is related to rapid urbanization, we're a long time getting around to it; urbanization in many African countries began decades ago.

Access to clean water and sanitation for all may seem like a very long term goal. However, in conjunction with improved health services and education, better water and sanitation will also lead to better health and educational attainment indicators. Even maternal and child health, which are often said to be priorities, would be greatly improved. Rather than targeting various diseases and sectors of developing country populations, improved water and sanitation for all would result in benefits for all sectors. Indeed, progress in health and education provision will be a lot slower without improvements in water and sanitation provision.

In relation to the challenges of such an intervention, NEJM mentions expanded access to antiretroviral treatment to poor people in developing countries. But improved water and sanitation is not at all like antiretroviral treatment; everyone needs access to water and sanitation, not just pockets of people in certain parts of certain countries. Improved antiretroviral treatment does not aim to prevent HIV transmission, though big claims are now made about preventive benefits. Antiretroviral treatment is not like provision of water and sanitation because the former targets one disease, almost entirely ignoring other diseases, and even health, education and other development areas.

Indeed, the parallel is even weaker than that. Lack of access to water and sanitation affects all poor people, especially those living in rural areas and, arguably, affects women and children more, perhaps more directly, than adults and men. HIV is often more common among wealthier people with better education, and certainly among those who live in more urbanized areas. The article concludes that "the current state of development leaves more than a billion of the poorest and most marginalized people at risk of ingesting feces with their food and water". So let's not approach lack of water and sanitation as we did HIV and access to antiretroviral drugs. Access to clean water and sanitation is a basic human right, so why not approach it that way?

Syngenta Dumps Upriver, Sells Fertilizer Downriver

If you are one of the biggest seed and agrochemical multinationals in the world, you might have enough confidence in your products to launch them on the market without trying to get people 'hooked' on them, right? But if you know that the only way to get your merchandise 'accepted' is to create some kind of dependency before people even know what's going on, you might stoop to any trick.

Well, in the case of Syngenta and their genetically modified organisms (GMO), it is clearly not in the interest of poor farmers to buy seeds that are more expensive, give a similar or lower return and involve significant increases in more expensive agricultural inputs, in addition to degrading the environment and resulting in the loss of sales to countries that don't buy GMOs.

Syngenta is one of the biggest seed companies in the world. Along with Monsanto, DuPont and Limagrain, they control over 50% of the seed market. It is also one of the biggest agrochemical companies in the world. Along with DuPont, Monsanto, Dow, Bayer and BASF, they control 75% of the market.

So it's easy to see why Syngenta don't expect people to buy their seeds without some 'sweetners'. In Kenya the Syngenta Foundation, itself a non-profit, but wholly funded by the organisation that benefits directly from its dirty work, has found it expedient to sell seeds that come with built in insurance.

Officially, commercial GMO agriculture does not even exist in Kenya. But the Syngenta Foundation has, apparently, tricked 12,000 farmers into buying their seeds and they hope to recruit another 50,000 additional suckers. They have even given the scheme a nice Kiswahili name, Kilimo Salama (Safe Farming).

A good drug pusher would be proud of the scheme. When the farmer buys the seeds, they also get insurance, so if there is too much rain, too little rain, to many pests or conditions are otherwise inclement, the farmer is eligible for compensation. Conditions are monitored remotely in GMO contaminated areas so no money will be wasted on assessing individual circumstances.

Once a farmer buys GMO seeds, they need to buy the seed manufacturer's inputs, such as pesticides. As the pesticides cease to work, as they have done everywhere else, the farmer needs to purchase them in larger and larger quantities. These pesticides are already more expensive than other products, but other products don't work at all with GMOs. And once the manufacturer's pesticides are completely useless, they can sell you an 'improved' version, which is even more expensive, and you can start the vicious cycle all over again.

GM cotton, which is now common in India, was introduced by such trickery, before it was even legal to grow it. Having been introduced by the back door, the claim was that most of the country's crop was contaminated, so there was little point in opposing it. It was a done deal, supposedly. India has spent the years that have followed regretting that they went down the GMO path in the first place. But it is unlikely they will ever be able to reverse the process now.

GM contaminated maize has also been surreptiously brought into Kenya. Someone knew, of course, but it wasn't done legally. The maize was legitimately imported from South Africa, as far as the vendor was concerned. The shipment was not certified GMO free, but nor was such certification sought. Some of that maize may have remained in the port, it's hard to find out, but GM contaminated maize is apparently now common in Kenya. Is GMO now a done deal in Kenya, before most of the public have even been armed with impartial information about what they are getting themselves into?

This doesn't seem to be the behavior of a multinational that has confidence in its products or that has the interests of Kenyans at heart. The country may have gone through the motions of creating the legislative framework, but no one would claim that Kenya is in any position to monitor GMO contamination, let alone commercial production of GMOs. But that's the way multinationals like Syngenta operate. It's also unlikely that Kenya is the only African country to have suffered this fate.

It shouldn't take long before people in Kenya start to notice some of the disadvantages of taking the Syngenta shilling. Those who farm close to where GMOs are grown will soon be growing GMO contaminated crops. Contamination is inevitable, through wind, water, soil movement, crop proximity, seed swapping, etc. And even those who grow GMOs and then revert to conventional seeds will also end up with contaminated crops. And the seed owner, because the farmer is not the seed owner, will be entitled to make claims against the farmers for patent infringement. Notice, they are not selling insurance against patent infringement or contamination!

UNAIDS Now Open About Being Pharmaceutical Industry Mouthpiece

The English Guardian has suddenly noticed that "Beating copyright infringement in the third world could be as simple as making products affordable". I have argued this on several occasions in the last few years, including here and here, but I would not be the first person to make this point.

However, I'm happy to hear that Joe Karaganis and others have spent three years researching the issue and come up with the Media Piracy in Emerging Economies report. But I don't expect that to make much difference to the position of people in developing countries.

It is also worth stressing that intellectual property (IP) protection, one of the most popular forms of trade protection among those who ostensibly oppose trade protection, is not paid for by those who benefit from it; it is paid for by consumers, in rich and poor countries alike. It's like a kind of tax that we pay to protect the interests of the rich. And it can represent well over 90% of the revenue that IP owners receive.

The report is also important in being independent, unlike much of what we read about IP, copyright issues, piracy, counterfeiting, fakes and whatever else industry is currently whining about.

We might think that everyone can do without luxury goods, especially people who are also short of water, food and medicine. However, various multinationals are doing everything in their power to control water, somehow or other, they already control food to a large extent and the drug industry is almost entirely run on profits inflated by IP protection.

There may be a lot of talk from Bill Clinton, Bill Gates, the World Trade Organization (WTO), UNAIDS and others about generic medicines and making drugs affordable. But prices of vital drugs are also protected by the same means as other goods. Even drugs whose cost has 'dropped' from the astronomical thousands of dollars per year to not much more than 100 dollars, are protected. The ultimate price charged is 100% controlled by the rich and powerful.

Therefore, the 'South African Generic Medicines Association' may sound touchy-feely enough, what with the 'African' and the 'generic' bits. But it is as much part of the pharmaceutical industry as AVAC or any of these other front groups that claim to be trying to keep costs down and make pharmaceutical products more accessible.

A speech by Paul de Lay of UNAIDS makes it clear who his intended audience is and who stands to benefit from any agreements that are made when it comes to generic drug pricing. The prices discussed may seem affordable when compared to the ridiculous prices they are replacing. But in reality, they are only affordable to the aid industry, not to the people who need them.

And the aid money going towards overpriced generic drugs is effectively another subsidy for those who ostensibly despise subsidies. This is money that could be better spent on the care people need, beyond the mere distribution of drugs, nurses, doctors, other health personnel and much else. But it is not the needs of HIV positive people that are being served here.

Incidentally, de Lay's speech mentions what he considers to be three areas of discussion, HIV prevention, treatment and health delivery. In reality, all three of these refer to drugs, to be paid for by aid money. To date, a relatively small percentage of HIV spending has gone towards prevention, but the industry has agreed that putting more people, HIV positive and negative, on drugs will prevent HIV transmission. And health delivery may sound like more than drugs, but it isn't really. Just read the speech.

It's wonderful how the interests of UNAIDS and the HIV industry as a whole now matches the interests of the global pharmaceutical industry. In fact, UNAIDS' HIV strategy can be summed up in one word: drugs. You can waste a lot more words on it, and you can be sure that UNAIDS and others will, but in the end, drugs are it.

De Lay advocates TRIPS (Trade Related Intellectual Property Rights), TRIPS Plus, Economic Partnership Agreements (EPA) and all sorts of other institutions and instruments that only point to one thing: intellectual property and the protection of the very rich against the very needy. The consortium of partners includes the wHO, the World Bank, the Gates Foundation (financed by IP protection) and a few others.

So it's official: the entire HIV industry, fronted by UNAIDS, is run by and for big pharma, and much of the aid industry will continue to subsidise and represent the interests of other industry sectors. The whole pretense of humanitarian motives can now be abandoned, as no one was fooled anyway. But, more worryingly, few seem to object to this either.

What if HIV Drug Pricing Depended on 'the Market', Rather Than Subsidy?

Are HIV programs in developing countries really in danger of collapsing because donor funding is being cut? This would result in the HIV drug subsector suddenly having to do without public money, which has supported it almost entirely so far.

Antiretroviral drug (ARV) research and development was carried out by publicly funded institutions. And the bulk of the finished products have always been bought and paid for by public money, so called foreign aid.

The price of ARVs has so far stayed too high to rely on any 'market'. The majority of HIV positive people live in developing countries and would never be able to afford to pay for ARVs for the rest of their lives, even if they were a fraction of the current price.

I doubt if the ARV industry, that has been built up so carefully, will be allowed to collapse. Like the financial institutions around the world that have been propped up with public money, this industry is also 'too big to fail'.

The ARV market is also changing. Up to now, the drugs are usually given to HIV positive people who have reached a certain stage of disease progression. As part of a larger care program, ARVs can keep people alive and healthy for many years.

But more recently, there has been talk about putting people on ARVs regardless of what stage of disease progression they have reached. This could increase the number of potential customers by several hundred percent.

And there are plans to put as many HIV negative people as possible on ARVs of some kind. Of course, the potential recipients of these drugs for prophylactic uses are referred to as 'most at risk' or something similar. As if the HIV industry have any idea who is at risk; as if they give a damn.

If you ask UNAIDS who is most at risk of being infected in African countries, they will say that anyone who is sexually active is at risk, and those who are most sexually active are most at risk. But who is most sexually active, and are they really more at risk than those who are not particularly sexually active, or who are not sexually active at all?

Surprisingly, the answers to these rather obvious sounding questions is not so clear. Because UNAIDS then point to those who are most infected by HIV and conclude that it is because they are most sexually active. The circularity of this argument has very serious consequences.

So as the pharmaceutical lobbyists want more HIV positive people to be put on ARVs earlier, and also want more HIV negative people to be put on them as well, much of the work will be completely misdirected. Rates of drug resistance will be rife and death rates will probably also rise.

But a hell of a lot of drugs will be sold. And resistance will mean many tens, perhaps even hundreds of times more money per patient. Developing countries will be drowning in a sea of drugs, yet most of them will be of little benefit and many could be doing a lot of harm.

A recent IPS article asks when national governments of countries with serious HIV epidemics will become major funders in HIV treatment and prevention programs. But were they ever intended to become involved? What exactly could they do?

It would be interesting if these countries could have a say in how HIV positive people were treated and in how HIV prevention policies characterized risk. Would they reject the current racist and sexist assumptions about African sexuality, or would they simply play along?

There would certainly be no incentive to play along if they had to pay for treatment and prevention themselves, if any of these countries were even able to do so. But if they were allowed to play a part in HIV programming, perhaps they would do what no Western country or institution has yet done: question the assumption that all Africans are sex maniacs.

The article concludes with some rather trite nonsense about negotiating through the World Trade Organization (WTO) to get a better price, using the TRIPS (Trade Related Aspectes of Intellectual Property Rights) agreement, but these were never developed to benefit developing countries. On the contrary, they were developed to support the pharmaceutical industry and others based in rich countries.

If a reduction in donor funding means that people currently being kept alive by ARVs will just be allowed to die, this would be a humanitarian disaster. But if it means that countries with the worst epidemics, all African, get to decide what would really have an impact on HIV transmission, this might be the first step in turning around the pandemic. This could avert the even bigger disaster that is the status quo, which condemns millions of people to HIV infection, illness and premature death.

The Insatiable in Pursuit of the Uneatable

For all the blubbering Western powers, such as the EU and the US, do over aid and development, they show their true colours when it comes to trade. Western trade policies with developing countries are designed to increase their own markets, increase their supply of cheap raw materials and labour, destroy anything that may create even the smallest bit of competition and, in general, retain their position of dominance and exploitation.

The EU is currently trying to push India into signing a trade agreement that will threaten the supply of cheap and affordable antiretroviral (ARV) medications to developing countries. India is one of the few countries in a position to produce generic equivalents of branded versions that demand extortionate prices. The issue is, ostenibly, over whether India should be allowed continued access to the data they need to produce the drugs cheaply.

The EU is happy to spend enormous sums of money on this kind of pursuit, far more than they spend on 'aid'. And even though EU and US money is going towards the purchase of a lot of ARVs used in developing countries, they seem content to pay more for, presumably, a lot less of an identical product in the future. And this is at a time when all sorts of crazy policies are being discussed to increase the number of people on ARVs to several times present levels. (There is some discussion of these policies on my other blog, which deals with Pre-Exposure Prophylaxis and other technical 'fixes' for HIV.)

The apparent contradiction in vastly increasing the cost of products that their own funding will be used to purchase in ever increasing quantities is not really a contradiction at all. So called 'aid' money is mainly used as a subsidy for their own industries, especially the pharmaceutical industries. And compared to the amount of money that goes into promoting the interests of Big Pharma, aid money is little to write home about, anyway.

Despite claiming to have the interests of developing countries, including India, at heart, the EU seems intent on destroying the Indian generic drug industry. If developing countries, especially African countries, cease to be a market for these affordable drugs, there will be no other viable markets large enough to sustain the sector.

You might think that this would mean the EU is scoring an own goal but it is just what Big Pharma would like. They have never really wanted a supply of affordable generic drugs, why would they? They couldn't care less who buys their drugs as long as they pay a price that keeps their profit margins at levels they are accustomed to.

A few million Africans may die but that's just collateral damage to the pharmaceutical industry. And the thought of millions of Africans dying could make for a great publicity campaign to increase the amount of money the EU and the US are willing to pay for overpriced drugs. With competition out of the way, top prices are guaranteed. That's how the free market works, it appears.

Just in case you thought all that free market (for developing countries), anti-subsidy (except for wealthy countries) liberalism had been entirely discredited by recent global financial crises, think again. Those who gained from the policies of the past are doing very well, thank you, it's ordinary people who are, as always, paying the price. According to an article by War on Want, the deregulation that has caused so many problems is to continue. Clearly it didn't cause any problems for some people.

And talking of maintaining policies that have caused devastation up to now, the EU is busy pushing biofuels as a 'green' alternative to fossil fuels. Not only is biofuel production not a green alternative in any sense, production of biofuel in large quantities requires even greater exploitation of developing countries than is seen at present.

Vast tracts of land in developing are currently being used to produce food and raw materials for Westerners. But these tracts of land are nothing to what is being grabbed to supply Western cars with cheap fuel. The question of whether there will be land enough left over for developing countries to grow enough food to survive is not really being asked by the land grabbers. Water, in short supply in many countries, will become even scarcer in the pursuit of 'green' biofuels.

Production of biofuels will involve large scale destruction of environments to make way for factory production methods needed to produce 'cheap' fuel. The process of grabbing land is already underway, has been for several years. Perhaps the EU hopes that any increase in carbon emissions will occur in countries too poor to measure the pollution or to do anything about it.

The extent to which Western powers exploit developing countries should never be forgotten when the subject of 'charity beginning at home' comes up. Rich countries may be looking for ways to reduce spending but what they spend on development is a mere pittance, much of it never reaching the supposed recipients. The best thing rich countries could do is reduce their levels of exploitation. Then, whether they continue providing aid and how much they provide may cease to be relevant.

Manufacturing Markets for Big Pharma

There’s a distinct tension between two articles I came across recently on generic antiretroviral drugs (ARV). The first, entitled ‘PEPFAR success critically dependent on use of generic ARVs, study shows’, claims that use of generic ARVs have allowed PEPFAR (the US President’s Emergency Plan for Aids Relief) to reach its target of getting 2 million people on treatment in low and middle-income countries. The article describes how use of generics has overcome various objections from some US politicians, who were well lobbied by the pharmaceutical industry and its cronies.

I would guess that what pharmaceutical companies settled for was to be in control of generics, rather than wishing their use to be banned. They would have wanted to control who produced generics, where and at what price. There’s no reason to lobby against them if they bring in a healthy profit. We are told that PEPFAR saved around 323 billion dollars by using generics. Regardless of whether they would really have spent that much money on overpriced pharmaceutical products, pharmaceutical companies still took in hundreds of millions of dollars. Anyone with shares in the industry need have no worries about that.

The article concludes that “Drugs are no longer the main driver of treatment costs”, which is good to hear. But it is interesting to note that drugs for sick people are potentially just a small part of the ARV market. A much hyped microbicide, a gel containing the ARV Tenofovir, is aimed at women who are HIV negative. And the same Tenofovir is behind the current pre-exposure prophylaxis trials (or ‘PrEP’, the process of taking antiretrovirals to reduce the likelihood of being infected with HIV), amply supported by Bill Gates’s Foundation. PrEP could potentially be used by any HIV negative person, though it may be targeted especially at men who have sex with men and perhaps commercial sex workers.

Current estimates are that in excess of 30, perhaps nearly 40 million people are HIV positive. That sounds like a vast market for ARVs when you consider that people will have to take them for the rest of their lives. But this is nothing compared to the number of people who could be customers for microbicides, PrEP and any other ways of selling ARVs that the pharmaceutical industry dream up. In Africa alone, the potential market could run into hundreds of millions of people. It is to be wondered if PEPFAR will still have the stomach for that. Gates needn’t worry, the Foundation stands to gain if microbicides and PrEP get off the ground.

In case hundreds of millions of customers doesn’t satisfy Big Pharma, and it won’t keep them happy for long, newer versions of ARVs are constantly being produced with improvements or claimed improvements. These are gradually replacing older versions. And those on ARVs, sooner or later, develop resistance to first line drugs. Second line drugs can cost many times more, but without them people will die. Third line drugs are still beyond the reach of developing countries, despite all the donor money available for treatment. It’s not clear where all the money will come from as it will exceed PEPFAR, the World Bank’s Global Fund and Bill Gate’s savings many times over. But things are going well for Big Pharma so far.

The second article is entitled ‘HIV generics under threat from tighter patenting rules’. This is about the pharmaceutical industry lobbying that is still going on to persuade governments, and anyone else who will listen, to create intellectual property laws that prevent generics from being produced. The US and the EU are the main culprits, as usual. Although generics can be produced once a ‘voluntary licence’ has been obtained, the original patent holder still gets a big say in how the drugs can be distributed, how they are priced and where they are sold.

Some object to this on the grounds that it leaves too much power in the hands of the patent holders. As I suggested above, the pharmaceutical industry likes to be able to control things and it seems unlikely that they would have conceded anything without getting their pound of flesh. Far from trying to relax intellectual property laws so that poor countries with high HIV prevalence can benefit, the US and the EU have been trying for some time to make it more difficult for countries like India, the biggest producer of generic ARVs, to produce these drugs. And there have been efforts, some of them successful, to prevent other countries from buying them. An example is Kenya, and other African countries are now trying to create similar laws.

Given the weight behind increasing the cost of ARVs, it seems very odd that PEPFAR should be fighting to reduce them. Are we supposed to believe that PEPFAR is in conflict with the government that allowed it so many billions of dollars? Could PEPFAR be a champion of fair intellectual property and trade laws that benefit poor people in poor countries? This is difficult to accept. The PEPFAR billions were unlikely to have been forthcoming in the first place unless they stood to benefit the US industry as a whole and Big Pharma in particular.

The World Trade Organization (WTO) has talked the talk of allowing developing countries access to ARVs by giving them a nominal right to produce generic ARVs under a compulsory licence. But this has had little impact in practice. And in case it should ever any impact, the US and EU are busy trying to get developing countries to sign up to Free Trade Agreements and Economic Partnership Agreements so that whatever the WTO has done is irrelevant.

Big Pharma seems to have used a classic bargaining trick; they have started the bidding at a price many times higher than would be reasonable. They have then been in a good position to accept a price a few times lower, probably set by parties who had an interest in maximizing pharmaceutical company profits. Giving the industry so much control means that they can add in the pretence that there is some level of competition, though there is unlikely to be any. A spokesperson for UNITAID, Ellen ‘t Hoen, said that “financing for HIV had to remain strong, as even the lowest-cost drugs needed an assured market”. So that’s the level of competition!

The pretence that the global pharmaceutical industry is just trying to make its way in a competitive business is sickening enough, when you consider how much effort goes into stacking the odds in their favour. But the expansion of the ARV market to include those thought to be at risk of being infected with HIV is outrageous. UNAIDS and various other commercial interests, academic institutions and the like, view almost all Africans as being at risk of infection with HIV. Yet this same group has failed adequately to describe serious HIV epidemics to the extent that they are in any position to make a useful assessment of risk.

Not only is the carefully crafted market for ARVs huge and expanding, it also enjoys the full protection of ‘global’ trade laws. And judging by the emphasis on microbicides and PrEP at the recent Vienna Aids Conference, the HIV industry appears to see its primary role as helping Big Pharma expand. The right to health has shrunk to a ‘right to treatment’ and those providing ‘the treatment’ have moved in to supply it to the healthy and the unhealthy alike. As for the HIV pandemic, Big Pharma says ‘don’t worry, we have the treatment’. But if health has been reduced to treatment, will there be any resources to ensure that healthy people stay healthy, even to reduce the spread of HIV and perhaps eventually eradicate it? Already, the HIV pandemic seems far too valuable to risk destroying.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Will a New HIV Boss at WHO Make a Difference?

The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.

There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.

But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.

There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.

People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.

Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.

So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?

First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.

Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.

Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?

Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.

Big Pharma Must Think We Are Idiots

A former British politician called Lynda Chalker who interferes with intellectual property (IP) issues in East Africa, says she is sure that East African IP legislation will not confuse generic and counterfeit drugs on the one hand and fake drugs on the other. But Kenya's Constitutional Court has already ruled that its own Anti-Counterfeit Act, only two years old, does confuse the three phenomena. And the court admits that this could result in people presently receiving affordable antiretroviral (ARV) therapy for HIV being denied the drugs the future. Chalker describes Kenya's decision as a 'drawback' to anti-counterfeiting efforts.

But Chalker herself simply makes the same confusion. She says that 'an anti-counterfeit law is essential in Uganda and east Africa as a whole; one only has to look at the number of deaths arising from counterfeit pharmaceutical products, electronic goods and auto spare parts'. If a drug or produce is causing death or injury, that is a health and safety problem. Branded goods can cause death and injury. Putting a brand name on a product illegally doesn't make it harmful, nor does doing so legally make it safe. The harm comes when the goods are substandard or when drugs are fake, not real drugs at all.

The distinction seems basic enough, but Chalker and the people who put together the original Kenyan bill appear unable to comprehend it. Worse still, Uganda and several other countries seem keen to follow Kenya's lead, despite the Kenyan's change of mind. Chalker and others who follow this tendency to conflate counterfeits, generics and fakes then go on to deny that their stance could jeopardize availability of affordable generic drugs, such as ARVs. But their denial sounds hollow when they go to so much trouble to confuse generics with counterfeits and fakes.

Someone who has been taken in by this deception pontificates about 'fake' drugs (and doctors) in Uganda in another article. Eleven Ugandan 'legislators' are querying the quality of drugs from India, which is the source of most of Uganda's affordable generic drugs. They note that the price of the same drugs from the UK is higher and wonder why. Perhaps that's a question for Chalker. But usually a huge difference in the price of drugs indicates that the expensive ones are branded versions and the cheap ones are generic versions.

Of course, there may also be counterfeit drugs and fake drugs in circulation. When drugs are priced so that no one in developing countries can afford them, in the hope that aid money will be used to purchase them, it's not surprising that some people will try to cash in on the market for cheap drugs. If the pharmaceutical industry is concerned about the fact that it is quite easy to make a good profit from counterfeit and fake drugs, they need to sort out their own pricing policies, perhaps by taking a look at what the 'market' can tolerate. Otherwise they might be accused of depending on subsidies and of rigging the market, which would be quite intolerable.

Chalker expresses her concern at the 'extra burden counterfeiting places on health services in developing countries'. If she is worried about health services being burdened, it is branded goods she should target. If she thinks that health services will be unable to afford the growing need for ARVs, she needs to champion the cause of those producing affordable generic versions of the grossly overpriced branded drugs that her friends in the pharmaceutical industry produce.

Chalker says that IP laws should be 'well-drafted', which, presumably, all laws should. But well-drafted for whom? Intellectual property is for the benefit of industries like big pharma, not for the benefit of poor people who are sick and dying. IP laws are not, as Chalker seems to think, to protect people from harm, and I don't think anyone who knows about IP would claim something so stupid. That's why human rights activists had to fight for international law to protect people from IP laws and allow poor countries access to affordable generics. I don't believe Chalker is stupid, though. She just thinks that everyone else is.

Fake Aid to be Cut: Recipients May Benefit

It isn't often that government departments admit that they got something wrong but it's no less welcome when they do. The two Kenyan departments responsible for health (two because of the power sharing government) agree that they were wrong to pass the anti-counterfeiting bill in a form that failed to distinguish between counterfeit and fake. They accept that this could lead to people being unable to purchase affordable versions of vital drugs, including HIV drugs. India was particularly worried as they supply most of the generic drugs that Kenya and other African countries purchase.

The Kenyan health departments claim that the law in question was pushed by the Ministry for Industry, who didn't realise the implications of the wording of the law. Both these claims sound suspect and the whole issue of a bill which was so stacked in favour of the pharmaceutical industry and against the generic drug industry smelled of industry lobbying and arm twisting. And in practice, even without this law, enormous amounts of money are spent on non-generic, branded products, despite the availability of generics that cost a fraction of the brand price.

Most money spent on health in Sub-Saharan African countries comes from donors. This is one of the reasons that unnecessary amounts of money are spent on overpriced branded drugs. African countries certainly couldn't have afforded them. Some even suspect that a lot of foreign donor money is specifically made available for branded drugs in order to destroy the generic market. After all, branding, intellectual property, is a particularly egregious form of market protection. And there are few who like to protect their markets more than the pharmaceutical industry, regardless of how many people suffer or die from treatable and preventable illnesses as a result.

But this is not the end of the matter. The European Union, that bastion of free market talk and protectionist action, wants India to sign up to a 'Free Trade' Agreement which will effectively restrict the country's ability to produce generics and sell them to poor countries. Médecins Sans Frontières (MSF) is campaigning against this appalling threat to the health and lives of so many people, but most international health institutions are remaining silent.

Many other African countries followed Kenya's unwise decision to pass intellectual property law that only benefited pharmaceutical multinationals, so maybe some of them will reconsider this now. Perhaps they will also get behind MSF and any other organisations involved in campaigning for fair economic conditions for developing countries. Tanzania and others are wondering how they will fare now that so much donor funding has been cut, with the global economic crisis being used as an excuse. They will do a lot better when they exercise their right to purchase generic drugs, rather than wasting the ample HIV funding on extortionately priced brands.

Multinationals and other pushers are constantly bleating about how people in developing are suffering and all rich country governments need to do is pay for their products for things to be ok. But there just isn't enough money to buy branded products, nor is there any necessity to do so. Much of the current HIV transmission in developing countries is preventable, especially transmission from mother to child. But despite the relevant drugs being available for many years, an estimated 43,000 babies were infected by their mothers in Tanzania in 2008 alone. Of the 217,704 new infections, many more would have been the result of lack of proper equipment for ensuring proper levels of medical safety. Tanzania need to find affordable drugs and medical equipment so that they can get by with less money.

The issue of intellectual property protectionism goes far beyond essential drugs and medications. Most household product markets in Kenya and other African countries are dominated by one single brand or a handful of brands, for example, soap, sanitary pads, diapers, cleaning materials, etc. These brands are unnecessarily expensive but one disinfectant soap manufacturer even claims that using their soap makes you and your children 100% healthier. Such claims, leading people to believe that they are harming their families if they don't use these products, are widely advertised. That is where much of the money made by multinationals is spent; it's spent on marketing and advertising, not on research, as they would like us to believe.

Let multinationals do their own dirty work, they should not be entitled to donor money that is supposed to be spent on needy people. If these organisations are bothered by competition from generics, let them put their prices down and learn how to compete, for a change. They love talking about competition but they usually operate in completely protected environments. And if they think those producing fakes are worth fighting, they could just lower their prices enough so that it is no longer worth while producing fakes. Fakes are only economic when the cost of making the goods is low but the price charged is high. Multinationals should start abiding by some of the principles they seem to think are so important. They have priced themselves out of the market that they have worked so hard to rig in their favour.

Countries like Kenya and Tanzania are right to be worried about reduced funding but there are two things that may work in their favour. Firstly, if they are less dependent on donor funding, they may be better able to shop around for affordable drugs and other vital goods. At present, donors usually decide which drugs and goods to purchase and they favour their own markets. That's what being a donor is all about, isn't it! Secondly, they may find ways of achieving even more with less money once they are freed of all the restrictions that foreign loans and donations often carry. This is not an argument for reducing funding, which I think should be increased. But it is an argument for funding to become more transparent, more democratic, more like genuine funding than merely a tool for benefiting the donor far more than the recipient, as it appears now.

Big HIV Funding and Blatant Racism

Many people and organizations in the HIV world, especially those involved in HIV treatment, as opposed to prevention, are worried about the effects of global financial belt tightening on HIV budgets. They are right to worry. A lot of big funders are capping funding or reducing it. And the global financial situation may not be the only reason for this austerity.

For many years, HIV prevention has taken a back seat to HIV treatment. Those in favour of treating as many people as possible and ignoring the fact that more people are becoming infected than going on treatment, assure us that mass roll out of treatment also plays a part in 'health systems strengthening'. This is supposed to make those concerned about a high rate of new infections feel better, as if new infections are being taken care of because those infected for some time are being treated in great numbers.

Indeed, defenders of the status quo that involves treating those who are infected and almost completely ignoring new infections, explicitly argue that HIV treatment also prevents new infections. To an extent that is difficult to quantify, this is true. HIV positive people who are responding to treatment (which means they also need adequate levels of nutrition and general health, etc) tend to have a lower viral load. They are less infectious and, therefore, less likely to infect others.

But this still leaves others vulnerable to infection. If many were not currently vulnerable to infection, the rate of new infections would be negatively correlated with the number of people who are responding to treatment. Those in favour of treatment at the expense of prevention claim to be averting infections, but only by using a circular argument; that the number of new infections must be lower than it would have been if treatment hadn't been rolled out because treatment reduces the incidence of new infections. The fact is, widespread treatment hasn't yet reduced new infections very much.

Well, if these treatment fundamentalists are really concerned about the effect that cuts in funding will have on the lives and health of people in developing countries, there are a number of alternatives they could consider. For a start, they will have to make some effort to reduce new infections at some stage. No person or organization would be wise to keep spending money on outrageously expensive drugs for treatment when the numbers of infections continues to rise, more or less unabated.

So these concerned and worried parties (Michel Kazatchkine, Michel Sidibe and others) can start campaigning for the sole use of generic versions of antireteroviral drugs (ARV), at least in poor countries. At present, expensive, branded versions are used almost universally. There has been a lot of pleading about how much pharmaceutical companies have dropped their prices but these reductions are nothing compared to the savings that use of generics could bring. To argue for more or continued funding for overpriced medicine is stupid and downright deceitful.

With the money saved by switching to generics, some money could be spent on prevention. And I don't mean the ABC (abstain, be faithful, use a condom) rubbish that has been churned out for more than ten years. This 'behaviour change communication' and any prevention programmes based on the idea that Africans have lots more sex than anyone else, has never worked and it never will work. More money has probably gone into publicity to show how successful this disgraceful waste of money has been than into programmes that really do work.

Plenty of research has shown that most of the 'prevention' programmes that have been carried out so far have achieved little, especially as far as reducing HIV transmission is concerned. But there is also research that receives a lot less attention which shows that HIV transmission can be reduced significantly, but also cheaply. Larry Sawers and Eileen Stillwaggon have argued for this in several publications, including in an article entitled 'Understanding the Southern African 'Anomaly'; Poverty, Endemic Disease and HIV'.

In this article, Sawers and Stillwaggon demonstrate that HIV transmission can be influenced by inexpensive measures such as providing people with deworming, sanitation, STI (sexually transmitted infection) treatment, mosquito control and safe water. These, they argue, are all essential in controlling HIV. In addition, these measures all have benefits that go beyond their effects on HIV and will improve the lives and health of tens of millions, perhaps hundreds of millions, of people in developing countries.

There is a lot of good money to be made in the HIV industry, especially where expensive drugs are involved. Attention to these drugs has been far higher than the success of ARV rollout could explain. Yes, many people are alive now who would not be alive without the drugs. But this has been achieved at a cost that is far higher than necessary. And as a result, preventing new infections has been given short shrift, even though this can be effected at relatively low cost. One might almost think that HIV has been seen as an opportunity to sell vast amounts of drugs that have a very small market outside of developing countries.

To make it clear, in case people may think I'm advocating against spending money on drugs for people who are HIV positive: I believe everyone who is in need of HIV drugs should receive them, but I believe they should be purchased at the lowest cost possible. This is not currently the case. Costs are kept artificially high by intellectual property laws (In other words, market protectionism) that favour rich countries and multinationals, by behind the scenes deals, by lobbying and by fancy marketing and publicity. The big HIV funders are being robbed blind, or perhaps they are being robbed and happen to be blind as well. I also believe that HIV positive people should have all their other health needs attended to and that they should have access to an adequate diet without which the drugs and treatment they receive are useless.

Once the cost of treating HIV positive people has been set at a level that poor countries and poor people can afford, there should be a lot more money available for preventing new infections. The approaches mentioned by Sawers and Stillwaggon, above, are all vital. And they are compatible with others, such as identifying instances of HIV being transmitted non-sexually, whether by unsafe medical practices, cosmetic practices, unsafe traditional medical practices or whatever.

As long as the big earners in the HIV industry continue to spend billions on overpriced medicine when cheaper alternatives are available, their wailing about rights and justice are so much hypocrisy. They are long enough in the business now to know what is going on, a lot better than laypeople do. And it must be as clear to them as it is to anyone who bothers to check that HIV prevention has to accompany HIV treatment if the disease is to be eradicated. Equally, these big earners cannot continue to ignore the evidence that they are wrong about sexual behaviour in African countries. Levels of risky sexual behaviour are higher in America and Europe than they are in Africa (and Sawers and Stillwaggon are particularly clear on this point in all their publications). Claiming otherwise is blatant racism.

Excessive Drug Prices Promote Counterfeit Drug Industry

According to the WHO, lifesaving drugs are not exempt from the trade in counterfeit medicines. But nor are they exempt from the rights of powerful multinational pharmaceutical companies to make obscenely high profits, regardless of the cost in terms of sickness, suffering and death in developing countries. Organisations like WHO and Interpol (effectively, publicly funded) are busy trying to help these poor victims, the pharmaceutical companies, that is. Otherwise, their ability to extract higher and higher profits every year may be compromised.

Yes, the WHO is right, it is cynical to produce counterfeit drugs, some of which may not help the person taking them; some may make them worse or even kill them. But it is also cynical for Big Pharma to put such impossibly high prices on drugs, spend far more on marketing and lobbying than on research, compromise doctors and other health professionals to push their products, produce goods for the rich world while ignoring the poor majority, using people in poor countries as cheap research fodder for drugs intended for the rich world, preventing poor countries from producing and making generic equivalents of overpriced branded drugs, lobbying the WTO (World Trade Organisation) to make laws that protect Big Pharma at the expense of poor countries and generally frustrating any attempts to regulate them, even slightly.

I don't know how many people die from counterfeit drugs but I know that an estimated 14 million die every year from infectious diseases, many of them preventable or treatable. The policies of Big Pharma ensure that the majority of people who need drugs most will never be able to afford them. A notable exception is antiretroviral drugs (ARV) for HIV, which have only been reduced slightly in price and only because they are being paid for by aid money. And no one need worry that production of ARVs on a massive scale at slightly reduced prices causes Big Pharma to suffer in the least. If they didn't get the HIV industry to buy their drugs, the market for them would be miniscule in comparison to what it is now.

So the humbug WHO claim to be worried about ordinary people being exposed to counterfeit drugs. But this is just an excuse to use lots more public money to protect the interests of Big Pharma. Already, public money has gone into the research the pharmaceutical industry claims to do. But most of the costs of drug research are met by publicly funded bidies, such as research institutions, laboratories and universities. Then the drug companies slap a patent on the results and pocket all the profits. If the WHO was really concerned about endangering the public they would lobby Big Pharma to do one simple thing: lower their prices.

But that is one thing the industry will not do. Far from it, they will continue to lobby to be protected so that they can continue to make far bigger profits than most other industries. Lowering their prices, or even lowering their prices to affordable levels for drugs needed most by developing countries, would have little negative impact on their profits. In fact, like with HIV drugs, they may discover a market they have long been ignoring. But they would prefer to fight for their right to charge more than people in developing countries can afford, perhaps by lobbying for aid money to be spent on drugs other than just ARVs.

As long as patented drugs continue to be too expensive for people in developing countries, it will be worthwhile for counterfeiters to target them with their products. As long as Big Pharma lobbies against the production and distribution of generic versions of patented drugs, people in developing countries will have no option but to look for cheaper alternatives. Big Pharma, in its efforts to maximise its profits, is creating the ideal market for counterfeiters. Getting Interpol and the WHO to spend increasing amounts of money and creating more sophisticated law enforcement systems is pointless. Counterfeiters will also become more sopisticated, as they are amply demonstrating.

Why? Because there is good money to be made. Pharmaceutical products don't just include drugs, the number of products that are artificially overpriced because they are produced by this industry is enormous. Who wouldn't grasp the opportunity to take advantage of the opportunity to produce relatively cheap products that can be sold on at ridiculous prices, only slightly less ridiculous than the prices charged by Big Pharma?

It's because I sympathise with vulnerable people, mainly in developing countries, that I think that drug counterfeiting should be stopped. It's not because I think the pharmaceutical industry should be allowed to hold the world to ransom. But I think the industry itself is creating the problem. The cost of drugs needs to be reduced to make them affordable in developing countries and it needs to be possible for developing countries to produce and/or buy generic equivalents of life saving drugs because they will never be able to pay the prices currently demanded by the industry.

HIV Treatment is Necessary, But Not Sufficient, For Prevention

Medicins Sans Frontieres (MSF) has published a report on reduced funding for HIV treatment, from the World Bank's Global Fund and the US Government's President's Emergency Fund for Aids Relief (PEPFAR) in particular. MSF have good reason to be worried.

The pharmaceutical industry successfully lobbied governments and international institutions to pay huge amounts of money for antiretroviral (ARV) drugs that most of the people suffering from HIV/Aids would never be able to afford. In fact, the governments of countries with high rates of HIV/Aids would never be able to afford these drugs, either.

Countries like Kenya have the option to produce generic versions of ARV drugs at a fraction of the price that is currently being paid. But most countries, including Kenya, have chosen not to exercise this right, preferring to enact laws that make it unlikely that the country can produce or even purchase such cheap generic versions. Good relations with the pharmaceutical industry seems to be more important to them than saving the lives of their citizens.

MSF are right, huge ARV rollouts cannot now be stopped without endangering the lives of millions of people who are HIV positive and even people who are, as yet, HIV negative. But rather than arguing for the money to keep coming, in fast increasing amounts, they could concentrate on finding ways of reducing the cost of treatment so that it can continue and even expand.

How much of the billions of dollars of aid money have been spent on building factories to produce drugs that people need in Kenya? I haven't heard of any. Most of the money has been spent in ways that don't go on to produce anything or increase the country's sustainability or self reliance. The funds have mostly been spent as if HIV is just an emergency.

Well, it is something of an emergency, but there are underlying factors that are not part of an emergency. The country has a decaying health service, decaying education sector and a small and decaying infrastructure. People are poor, unhealthy, badly educated and unable to access vital services, such as clean water and proper sanitation. These are the things that face the majority of Kenyans every day, whether they are HIV positive or not.

Money spent on drugs, regardless of the overall condition of health systems is, to a large extent, wasted. Many drugs go out of date before being distributed, they get to people unprepared to take them properly, they are taken by people who are dying of other, easily prevented and treated illnesses, etc. My argument is not that ARVs should not be purchased and distributed and prescribed; it is that there needs to be a proper, accessible health service for all this to happen.

There is not a proper health infrastructure in Kenya, there hasn't been for a long time and increased HIV/Aids funding has not brought about a health infrastructure that serves people's needs. True, there are many clinics and institutions that were not here before HIV/Aids and wouldn't have even appeared. But these mostly deal with HIV/Aids, not other, basic health problems that people face.

My argument is also directed at the emphasis on HIV/Aids treatment over prevention. MSF's Goemaere is right to object to the prevention/treatment 'dichotomy'. Of course treatment has a positive effect on prevention efforts. But it is not enough to try to treat our way out of the epidemic. This is clearly not working and much more needs to be done to prevent new infections. Otherwise, the aim to treat everyone who requires treatment becomes even less attainable and less sustainable that it is right now.

People who are HIV positive need more than just drugs, or even treatment. There are a lot of threats to their health and welfare than HIV. They are dying because they are too far from the hospital, because the hospital is not up to the job of caring for them, because they are entitled to benefits they don't know about or that have been stolen by someone else, because they are poor and isolated and not considered important enough. But there just aren't the services needed to support chronically sick people and these will not just appear because the country is swamped by HIV/Aids (treatment) related institutions and programmes.

Those who are HIV negative need to stay that way and this won't happen by rolling out ARVs, alone. They have needs that are far more important and urgent that the possibility that they may become infected by something that won't kill them for many years. Most won't live for very long anyway, for a huge variety of reasons that are not being addressed right now.

Goemaere recognises the false dichotomy of treatment/prevention, but fails to see that increasing treatment while effectively ignoring prevention will not combat HIV/Aids in the long run. Assuming that HIV treatment will also prevent infections is not enough because it doesn't prevent enough infections and it never will. And treatment will never be as efficient as it should be if health, education, infrastructure and other social services continue to be ignored.

Fakes, Counterfeits, Used Goods, Generics and Hazards

There was a confused and confusing article in Tanzania's Daily News on Thursday. It starts off with an account of how much tax revenue the government loses as a result of counterfeit and substandard goods. For a start, I don't think it is because goods are substandard that tax is withheld, but no matter; the country badly needs tax revenue and everyone should be protected from substandard goods.

But if the Tanzanian government is so worried about tax revenue, they should take a careful look at the foreign owned extractive industries. They make huge profits and they legitimately pay very little tax or duty. But many who don't even bother paying anything at all. In fact, indigenous industrialists cannot compete against the benefits that foreign owned businesses enjoy. I guess that's the 'free market', which penalises small businesses and rewards big, foreign multinationals. Indigenous businesses are asking for fairness, not protection.

In Kenya, the government could take a look at its cut flower and horticulture sector, much of it foreign owned. Many of the company owners neither pay tax in Kenya nor in any other country. In fact, both Kenya an dTanzania need advice on raising revenue. So perhaps they could ask leaders of the burgeoning Christian church industry, which extracts punitive levels of dues from the poorest people in East Africa. Just an idea.

The article purports to be about counterfeiting. However, it fails to distinguish between counterfeit products, used goods, generic products and fake products, even hazardous products. If I put a brand name on a product and try to pass it off as genuine, that's a counterfeit. If I produce an equivalent product with a different brand name, that's a generic. Goods that have already been used are used goods, of course. And if I produce something that doesn't do what it purports to do, that's a fake. Thus, the newspaper’s photo of a 'fake pair of shoes' really depicts shoes that may be counterfeit or they may be generic. I doubt if they are fake. A hazardous product would be something like the malaria pills that have been found to have no active ingredients.

The recently passed Kenya Counterfeit Bill also fails to distinguish between these basic concepts. It is legitimate to charge 100 dollars for a pair of shoes that have a particular logo on them if you are the owner of that piece of intellectual property. The fact that the shoes cost less than 5 dollars to make (in a sweatshop that pays peanuts to underage employees) and could profitably be sold for 10 dollars, is irrelevant. These overpriced shoes could also be substandard, but this affects the consumer, not government tax revenue.

If you have an income of between 30 and 60 dollars a month, you won't be buying the 'genuine' article. You may buy something second hand, a generic equivalent, a counterfeit version, whatever. People produce generics and counterfeits because there is a market for them. The market for cheap products is created by the existence of overpriced goods that can only charge these inflated prices because intellectual property laws protect intellectual property owners. They claim to protect consumers but, in fact, they only protect consumers who can afford the inflated prices.

Wealthy and very greedy multinationals create the market that results in the production of cheaper goods and that guarantees that they will often be bought in preference to 'genuine' goods. Ironically, the 'deregulation' insisted on by international financial institutions and by free market dogmatists also means that national governments have very little control over trade. But unfortunately, the same laws that were designed to protect people from dangerous goods, poor working conditions, exploitation, etc, also fell under the hatchet of 'deregulation'. Countries didn't suddenly become lawless, as this article would have us believe; they were rendered lawless by the growth of globalization and other ideologies.

Consumers need to be protected from fake products that don't do any good or ones that do harm. That's true whether they be branded products, generics, counterfeits or second hand goods. People also need to be protected from trade practices that favour rich multinationals over poor consumers. Labour forces need to be protected from unscrupulous employers who expose them to physical danger, exploitation, long hours, low pay and casualisation. Why single out a few objectionable practices and ignore others?

The deception involved in calling a radio Sqny or Phillips may really deceive, though I doubt it. The consumer gets a product they can afford and the owners of the intellectual property don't. Perhaps they could consider reducing their prices. They don't pay much in wages and they do very well but they seem to want to price themselves out of the market and, at the same time, penalise anyone else who tries to take up the business that they themselves don't seem to want.

But personally, I object to the deception of charging 100 dollars for a pair of shoes that could cost a lot less. The price, protected by international laws, hangs on people valuing a particular fashion. Great, if they can pay for it. If they can't, they just need shoes and there are people willing to supply them. There is more than one deception here and I’m out of sympathy with the owner of the ubiquitous smudge that happens to be their logo.

And on the subject of fakes, products purporting to be something they are not, there's an article in Kenya's Saturday Nation about genetically modified maize (GM) possibly making up 90% of the maize imported into the country every year. Maize is the country's staple food but, apparently, Kenyan's don't know they are eating GM maize. There is a deception here that seems far more significant than a mere name, brand or logo. People are entitled to make the choice as to whether they consume GM products and it sounds as if they are not being given that choice in Kenya at present.

Kenya has also just passed a Biosafety Act, to allow the safe use of GM crops. But it seems a bit late if the market is already swamped with contaminated foods. If regulations are such that it's not even certain how much of the country's imports are GM, there is already a serious problem. How much GM food has been distributed, to whom and what has it been used for? If people have used GM foods to try to grow crops, they will be in trouble when the owners of those technologies find out, they will have to pay for the 'privilege'. And many GM seeds will not germinate. Right now, crops are failing because of low levels of rainfall. In the future, will crops fail because they are 'terminator' crops, ones designed so that the seed cannot be collected and used for the next season?

It's a dangerous trick. GM products are hazardous in the sense that their safety has never been demonstrated but sneaking them in without people's knowledge, even if there is a low concentration of GM organisms, only increases the danger further.

There are many threats to our welfare and safety, often masquerading as 'genuine', 'approved' and 'legal'. Consumers need legislation that protects them, not legislation designed to allow certain producers to maximise and protect their profits at all costs.

Generic Drugs are Counterfeit, Say Kenyan Government

When pharmaceutical products first became available to treat HIV, they were far too expensive for most people to afford, especially in developing countries. Yet, the majority of people in need of treatment for HIV live in developing countries. So, how could pharmaceutical companies fix a price that would allow them a staggeringly high profit margin but also a large volume of sales?

HIV treatment (antiretroviral treatment or ART) is still very expensive, and that's just the drugs. It's still unaffordable to most people, but pharmaceutical companies have successfully lobbied donor governments to pay for the drugs. That gets rid of one problem, how to maximise profits for pharmaceutical companies.

But then there was another problem. Some countries who had the capacity to do the requisite research and planning and production are now producing generic equivalents of HIV drugs. These are much more affordable but this is a terrible headache for pharmaceutical companies. Of course, they are not too worried, most aid money for HIV goes to buying the branded, expensive drugs. Very little is allowed go to generics.

In Kenya, the pharmaceutical companies don't seem to have had much problem. The government produced a piece of legislation that doesn't distinguish between counterfeit products and generic equivalents. Perhaps the Kenyan government thought it was better to buy products that are tens or even hundreds of times more expensive. After all, they are not paying for them. Or perhaps someone nobbled the Kenyan government, it's hard to know. But the legislation makes sure that generics from any country can be considered counterfeit and this is very useful to the pharmaceutical companies.

There are hundreds of thousands of Kenyans in need of ART in order to stay alive and raise their families. Many of them are not on ART because the business of rolling out the drugs is slow. And because so little money is being spent on preventing new infections, the number of people requiring ART continues to increase. In fact, most of the money being spent on HIV prevention goes to programmes that have little influence on transmission of HIV or any other sexually transmitted infection.

I agree that treatment is part of prevention; people who are on treatment are less likely to transmit HIV if the treatment is working properly. But it's not good enough to spend, say, 50% of the 15 billion dollar President's Emergency Fund for Aids Relief (PEPFAR) on treatment when only 20% is going on prevention, especially as many prevention programmes have fairly dubious benefits.

It wouldn't be so bad if some of that 50% is going on something other than drugs. People on ART need more than just drugs, they need a lot of palliative care, a lot of monitoring, good health care, economic and moral support, good levels of nutrition, etc. Perhaps if pharmaceutical companies were to provide these things, donor money would be spent on them. As it is, many people get the free drugs but little else.

Those on ART who are not taking the drugs in the prescribed way, or who are not responding to the treatment for some reason, may turn out to be like the 80% of Kenyan's who don't know they are HIV positive; they could be continuing to have sex, not knowing that they are may be as infectious as people not on ART. Even worse, they may be spreading a resistant strain of HIV.

Resistance is most worrying in Kenya because it could take some time to identify people who are carrying resistant strains. Health and social facilities are not strong enough to monitor people adequately. Many get the drugs and disappear, for some reason or other. Others struggle to get the treatment they need but they don't know if they are or are not responding to the treatment until they become ill. By this time, their life and the life of their partner may already be at risk.

Resistance is a good thing, though, if you are a pharmaceutical company. People who are resistant to 'first line' drugs are usually put on 'second line' treatment. This is far more expensive, meaning higher profits. So if people fail to take their ART drugs properly, that could help the pharmaceutical companies greatly.

The Indian government is protesting because similar legislation is planned in other African countries, one of their biggest markets. And it's not just HIV drugs that are threatened, also cholera, malaria, hepatitis and malnutrition. This is not what Kenya or any other African country needs.

Bill Gates to Face Trial by Intestinal Worms

It has long been recognized that poor health results in people being more susceptible to anything going. That's why many people aim for good overall health by watching what they eat, taking enough exercise, getting enough sleep, etc.

It was also established some time ago that poor health and a high disease burden results in populations being more susceptible to major diseases like cholera, malaria, acute respiratory infections, TB, HIV and many other things.

The connection between high rates of intestinal parasite infestation and HIV was made more than a decade ago and soon after, it was pointed out that the search for a HIV vaccine would be hampered by the high disease burden suffered by populations most affected by HIV.

Anyone seeing a connection yet? People in areas with high rates of HIV are the same people who suffer from numerous diseases, many of which are treatable or curable, they suffer from poor water and sanitation supplies, poor nutrition, etc. Oh, and low levels of education, minimal infrastructure and many other things.

On the other hand, if water and sanitation were improved, many of the most common diseases would be prevented or seriously reduced. Cholera, for a start, also intestinal parasites, also hepatitis E, the list is long. 20% of young people in developing countries die of diarrhea alone, most of the other things that kill young and old are either preventable or curable. Many relate to water and sanitation.

So why does Bill Gates want to find a vaccine for cholera. He seems to like to find a 'big one' and hack away at that. HIV, TB and malaria are three others (the third of which is also directly related to water and sanitation). He wants to create a completely unsustainable and expensive solution to cholera when the best prevention for this is good water and sanitation.

Cholera vaccine research has come up against a problem. The vaccines work well in developed countries, where water and sanitation are not such a problem, but they work badly in countries where water and sanitation are a problem.

Have I spelled it out clearly enough for Bill and his defenders? I'm not saying he shouldn't spend his money on research that could save the lives of millions of people. I'm suggesting that he could spend his money on saving the lives of billions of people. Think of the number of diseases that would be reduced if he spent his money on water and sanitation.

But he seems to like intellectual property, drugs for cholera, drugs for malaria, drugs for HIV, drugs to prevent HIV among those who are not yet infected, pharmaceutical products for the starving, in the form of genetically modified organisms, a 'green revolution' driven by locking poor famers into an agreement to be slaves for the biggest multinationals in the world.

Because Bill knows intellectual property, he made his money out of it. What is software but intellectual property, low costs but high sale price? He has been manipulating intellectual property for most of his working life and now that he has become a philanthropist, he is depending on it still.

I'm not suggesting that he has anything personal to gain, in the sense that he has shares in all these pharmaceutical companies and all the others that will make billions. Perhaps he doesn’t have shares or any kind of interest. I'm just suggesting that there are immediate things that could be done that would obviate the need for all this research into more drugs when the solution is far more basic.

People in developing countries need, in addition to water and sanitation, good education, access to health care, good nutrition and food security, infrastructure, rights, equality. Drugs come and go, that's the problem, that's one of the reasons that they are not sustainable (also the ridiculously high prices and the corruption that keeps the prices high). And why put so much money into this technology when there are solutions that will have far greater benefits?

As many as 2 billion people in the world may have intestinal worms, this will affect their health, their welfare, their intellectual and physical growth. Bill, think of what good water and sanitation could do for people, never mind the pharmaceutical companies. Beating the worms would be a far bigger reward.

Intellectual Oppression

If you were a subsistence farmer in Kenya and you were in desperate need of money, would you consider mortgaging your future? After all, if you don't risk your future, you may not even have one.

Here's what you can do:

The Rockerfeller Foundation and the Bill and Melinda Gates Foundation think that the 'Green Revolution' in other developing countries was so good, they want to see another one and this time they want it to include Kenya and other African countries. Never mind that countries who experienced the first green revolution now realise what a terrible mistake it was.

These philanthropic parties are spending millions of dollars to ensure that poor farmers can purchase genetically modified (GB) seeds so that they can plant a green revolution in their own fields.

Don't get caught up in the argument about how GM crops could damage your health. People who oppose those arguments only want to catch you out by asking what evidence there is for health risks. Of course, there may be health risks, GM organisms have not been shown to be safe for human consumption. But that is not even the most important concern about GM.

If you buy GM seeds, you must buy the appropriate herbicides, pesticides and fertilizers to ensure the 'benefits' promised by the manufacturers. Yes, they manufacture the seeds, the pesticides, the fertilizers and the stories about how GM is good for your health, the environment and just about everything else.

In fact Agra (Alliance for a Green Revolution in Africa) also claim to be aiming specifically at small farmers. GM crops and 'improved' agricultural methods are primarily aimed at big farmers, but hey, what's a little white lie here and there?

The only people that stand to benefit from GM are the manufacturers of GM products. Oh, and those who have a financial interest in GM companies. Maybe these esteemed philanthropic parties have such a financial interest, maybe they don't. But it's big, powerful, rich people and companies that make a lot of money; you, I and small farmers only stand to lose. By the time said parties have made themselves even richer, most land will be depleted and contaminated, it will lack diversity, it will be as far from organic as it can possibly be and we will find it very difficult to reverse what they have got us into.

Farms surrounding those growing GM crops will also be contaminated. This contamination will come from cross pollination and run-off that carries toxic substances to other farms and into the water supply. Farmers who buy into GM are not just mortgaging their own future, they also mortgage the futures of their neighbours.

Does it sound dramatic to say 'mortgage your future'? Well, if you are a farmer, you are probably used to the process of growing crops and taking advantage of the way you can keep some seed each year. This can be used to grow the next years crops and you can even be selective, to preserve the best qualities in your crops.

Sorry, but you are not permitted to collect seed and grow more GM crops next year. Some GM crops are not even appropriate for this process. You will owe the GM manufacturer money because the seeds are a piece of intellectual property, you must pay for it. Even your neighbours could be found guilty of infringing GM companies’ copyright, even though they didn't take the king's ransom!

Ok, you can, slowly, get rid of some of the GM contamination. You can start afresh, growing wholesome non-GM crops. Well, maybe you can. You will already have played a part in reducing the biodiversity on your land and on surrounding lands. In fact, herbicides and pesticides used on GM crops kill everything, plant and animal, but that GM crop. This is one of the things that GM producers like to boast about.

But if you replace the GM soya with non-GM soya because you find it is not as productive as it says on the packet, you may be in for a nasty surprise. If the 'non-GM' crop is found to contain some of the GM manufacturer's intellectual property you are still liable to pay for it. Which is fantastic…if you’re a GM company.

The Rockerfeller and Gates Foundations may well do some great work, they may well fund many laudable projects but that shouldn't stop people from scrutinising what they fund. GM crops are not in any sense laudable and the fact that so much money is being spent on trying to get people to grow them should sound alarm bells.

As a rule of thumb, where intellectual property is involved, the interests of the rich are being served. If someone tries to tell you that poor people will benefit, check their credentials very carefully.

This is another example of Development by Omission, where developing countries would be a lot better off if they didn't receive this 'donation' from the rich and powerful. It's a lot more subtle, but also far more damaging than stealing maize intended for starving Kenyans. And it's not even considered to be a crime. Not yet, anyhow.

Protecting Minorities

Multinationals will spend a lot more money defending themselves against people they have exploited than they will in granting their workers better conditions or compensating victims of their greed. Remember Union-Carbide in Bhopal, India? Huge amounts of money were spent on defence and publicity, very small amounts on compensation. In the end, they denied responsibility for the thousands of deaths and the tens of thousands of people affected.

Many people are involved in the production of branded pharmaceuticals, foods, machinery, computers, clothing and various other things. But only a minority reap the benefits of intellectual property. In fact, it is mainly wealthy people and multinationals in rich countries who benefit from international intellectual property (IP) laws. The many people involved in their production are usually less well off and usually from developing countries.

So when you see an article called 'Rapid Rise In African Anti-Counterfeiting Efforts Led By Developed Nations', you might think, 'great, we consumers are going to be protected from people who produce fake drugs, fake brand name products, etc'. Using words like 'fear' and 'threat' and listing the beneficiaries of their efforts as hospital patients, pharmacists and farmers, perhaps we are suppose to think that they are doing it for us.

Are we supposed to breathe a sigh of relief and thank them for protecting us, for being the true guardian angels of enlightened self interest? Make no mistake, multinationals are protecting no one but themselves.

Fake pills and other products can kill people, true. But so-called legitimate products and services can also kill. Think of baby milk formula products and the much publicised Roundup pesticide, privatised water companies, extractive industries operating in countries where regulation is conveniently lax and many others.

The question is, why is it OK to compromise the health and safety of people if you are a multinational or a powerful corporation, but not if you are a 'criminal' operation, manufacturing counterfeit goods? I can see why the latter could be a crime, but I can't see why the former is legitimate.

More importantly, it seems to me that the latter is a product of the former. If it is possible to make enormous amounts of money to produce something at low cost and sell it for lots of money because of its brand name, I can see the attraction of getting in on the act. It is, in part, because such huge amounts of money can be made that it is worth while making fake versions of products.

There is a difference, of course, between fake drugs and generic drugs. It is not a crime to produce generic drugs, in certain circumstances. But wouldn't it be convenient if a bill, proposed in the Kenyan Parliament, were to fail to distinguish between fake drugs and generic drugs?

However, my argument is that the process of increasing profits every year through selling brands gives rise to the 'crime' of copying those products and selling them at lower cost. There may be less incentive to produce generic versions because the costs involved could be similar to, perhaps higher than those faced by multinationals, yet the profits would be lower. But producing generic versions is often worthwhile and one can readily buy, say, sports shoes with a brand name and/or logo similar to well known ones. The customer gets the shoes at an affordable price, but this can be a crime in many cases.

I have little sympathy for those who produce ridiculously overpriced goods on the grounds that they are of a particular brand. That still doesn’t mean that I would condone those who produce fake malaria drugs which, aside from resulting in deaths, also build up resistance to the active ingredient. But I would also condemn the producers of drugs who keep the price high because they know the product is going to be paid for by donor money, that there is no real 'market' that is controlling the prices.

The kind of drugs I'm talking about are those for diseases that only or mainly affect those in developing countries. Anti retroviral (ARVs) are a particular example, used for those suffering from Aids. There are now generic versions of ARVs but some Western countries spend most of their ‘aid’ money on branded versions. After all, they are produced in Western countries, so it's a convenient way of spending money at home while pretending that it is foreign aid.

In reality, this is a de facto subsidy for Western pharmaceutical industries; a subsidy being something the International Monetary Fund, the World Bank, the EU, the US and various other Western interests have spent years claiming is a barrier to free trade.

Similar remarks apply to condoms supplied by donors, despite the fact that condoms could be bought by donors in the recipient countries. Condom producers in recipient countries then find it hard to compete against the 'free' ones from America, Europe, China and other countries. These processes also increase dependency, but maybe that's the intention.

Fake drugs can kill people, but so can fake aid. If I really thought these defenders of intellectual property were looking out for the rights of people in developing countries, I'd be in favour. So I find it especially repulsive that these defenders talk about 'the wellbeing of people'; who are they trying to fool?

They go on to talk about corruption in developing countries. I guess it is not considered corrupt to skew international intellectual property law so that it exploits the many for the benefit of the few. It's not corrupt, but it is still exploitation.

Developing countries are not just big markets, they are populated by the majority of people on the planet. If a large percentage of products sold in African countries are fake, this could be because little alternative remains. People just can't afford to buy the branded version of many things. What do the producers of branded products expect them to do?

In a sense, the ‘market’, so beloved by the West, actually gives rise to the production of goods that people can afford, be they generic or fake. At best, the price of ARVs is determined by the Western market, in conjunction with punitive intellectual property laws (punitive for the buyer, that is). Rather than allowing a price to be determined by any market in the majority world, pharmaceutical companies only have to lobby their democratically elected friends to ensure that money for aid and development is spent on them.

If the protectors of intellectual property need to, as is claimed, 'educate people' about the dangers of counterfeiting, whether it's in agrochemicals, medicines or anything else, perhaps they would also care to 'educate people' about how multinationals can justify international agreements that seem merely to protect their own narrow interests. I'd certainly like to know.

Aid is for the poor? Really?

One of the most interesting people I met last week works for Solar Cookers International. I have long been interested in solar cookers because they appear to have numerous advantages. In the field of international development this is very significant. Some people see development as being just one thing, population control, globalisation, political circumstances, corruption or whatever. I don't wish to define development but rather to say that, if the problem is malnutrition, food security is an issue, if the problem is a health risk factor such as acute respiratory infections, health is an issue, etc. They all relate to development; development is not just one thing.

Solar Cookers International make cheap solar cookers and other 'intermediate' technologies. More importantly, they give demonstrations and courses on using these technologies. This could play a part in development because it addresses nutrition, health, the environment and many other things. Using a solar oven, then, is not just a matter of cooking; it has implications for the nutritional value of the food, the environment, the economic circumstances of the user, the health of the user, the amount of time spent on domestic tasks, water and sanitation, using recycled materials and a whole lot more. Here's a partial list:

1) They don't require expensive fuel (that means time saved and less environmental degradation)
2) Reduced levels of smoke inhalation, experienced by women cooking and other occupants of kitchen
3) They preserve nutrients in the food because the food cooks more slowly
4) They can be used to pasteurise water and other utensils in areas where water may be contaminated
5) They can be used to heat water for cleaning and washing
6) Training in their use gives people knowledge about many other practical health and social issues
7) Recycled and cheap materials can be used to construct solar ovens, creating employment
8) They are light, portable and take up very little space when stored, compared to other cookers
9) They contribute to increased self reliance and self sufficiency

Another organisation I visited was called SHOFCO, based in Kibera, Nairobi. They carry out a number of activities relating to HIV, education and poverty reduction. I found their details when I was researching the use of income generation schemes as a way of allowing women to reduce and even eliminate their need to resort to commercial sex work.

Kibera is not an ideal place for solar cookers. There is not much space and Nairobi has less sun than many areas. However, there are communal areas in Kibera and there is enough sun to cook on many days of the year. Given the costs and advantages, the cost of a solar cooker would be recouped in a couple of months, perhaps less.

In addition to reducing household costs, it is possible that solar cookers could be produced by people in Kibera as a way of raising income. That's what I'm hoping, anyway. The problem is that many people adopting income generation schemes are undercutting each other's market. In Kibera, some women make and sell bead jewellery. However, there are so many people making and selling bead jewellery that it's getting harder and harder to make any money from it.

If you can't make enough money from your job, whatever it happens to be, you still need to resort to commercial sex work. If times get hard, and they are getting harder in Kibera, each woman needs to have more clients and to engage in more dangerous kinds of sexual intercourse, for example, agreeing not to use a condom. Bad economic conditions increase the vulnerability of people who are already poor, exposing them to HIV and other risks.

I look forward to meeting and hearing from others who have tried out income generation schemes of various kinds, and those who have successfully adopted intermediate technologies.
Renewable energy, of course, is not the only type of intermediate technology. Solar Cookers International also sell cheap and easy to use water testing kits. Many diseases in a country like Kenya are water borne, eg. cholera, E Coli and the many diseases caused by various intestinal parasites. Water and sanitation also play a part in the spread of malaria as mosquitoes breed in stagnant water.

If I seem to hop from one subject to another, I apologise, but these matters are all connected, really!

Cholera and Malaria relate to one of the largest sources of funding for the search to eliminate these problems; I'm referring to the Bill and Melinda Gates Foundation. Far from wishing to criticize an organisation that contributes so much to good causes, I'd like to look at disease a different way. The Gates Foundation is putting a lot of money into finding a vaccine for cholera. Yet cholera only exists where there is little or no water and sanitation infrastructure, where people don't have access to clean water.

The cure for cholera is clean water. Dying from cholera means dying of dehydration, perhaps after repeatedly drinking contaminated water. Countries who once had a problem with cholera no longer have that problem because they have addressed water and sanitation issues. A vaccine would be brilliant, except that it would not solve all the other water borne diseases, and there are many. What is the point in surviving cholera only to die of E Coli or hepetitis E?

Malaria is not so simple but again, countries that now have good water and sanitation no longer have malaria. The Gates Foundation has, quite rightly IMHO, been criticized for taking human resources from other projects, overlapping with existing health projects and distorting health funding. The Foundation has prioritised a few diseases when it's not the diseases that are the main problem. It's the risk factors, such as water and sanitation or acute respiratory infections that we should be concentrating on.

There are two other concerns that receive a lot of the Foundation's money: HIV and genetically modified crops (GM). The foundation is interested in finding a cure for HIV or treating HIV positive people and 'feeding the starving', allegedly. But only if these solutions involve intellectual property, it seems, intellectual property being something very close to the Gates heart.

Anti retroviral drugs (ARVs) and GM technologies are pieces of intellectual property. There are very cheaply produced drugs that do the same thing, but US money goes into expensive ARVs, produced by Americans in America. Does this make you think of the free condoms distributed in Mumias?

GM corn is a modified version of the corn that you see hundreds of hectares of between Mumias and Eldoret. But it costs a lot of money and it belongs to the company that produces it, not the person who grows it. A farmer can grow one crop with GM corn before buying more seed, from the GM producer, of course. Using the non GM version, they can save seed and grow corn every year.

Where was I? Oh yes, intermediate technology, such as renewable sources of energy. This technology is owned by whoever uses it. This can be contrasted with high technology, which belongs to very rich multinationals. So, would you choose a cheap technology that eradicates cholera and most other water borne diseases and has many other advantages, or would you choose a very expensive one that only eradicates cholera for those who can afford it? It only works for as long resistance to it is not developed. But then, a new version can be found, at a cost.

Finally, for those working with HIV and AIDS, I hope you have a productive World Aids Day! I'll post the news from Mumias later today or tomorrow.