Medical Transmission of HIV May Be Widespread in African Countries

A couple of weeks ago I was taken to see a woman in a rural area who was very sick. She was terribly emaciated and the place she lived in had clearly not been looked after for a long time. The woman insisted that she did not have HIV, although she also claimed not to have been tested. After a few days, she was taken to the local health centre. There, it turned out that she had already been tested for HIV, was found to be HIV positive and was put on antiretroviral drugs (ARV). But she refused to take the drugs and agreed to be sent home, as the health centre was unable to do anything for her. She died about one week later.

All we could do was insist that she went to the health centre to be tested and take her drugs. She reluctantly went to the health centre but refused to take her drugs. It was as if that was all that was left to her to preserve her dignity. For some time, she had refused the advice of neighbours and health volunteers. And they were growing less willing to visit her, because they knew that she was going to die. On the day she went to the health centre, she looked humiliated and perhaps even angry.

The stigma that still attaches to HIV/Aids, and even TB because of its association with HIV, may seem like a sticking point that results in people wishing to deny that they have been infected, even when the cause of their illness is undeniable. But the stigma is real. People are ostracized and treated differently because they have a disease that is associated with illicit sexual activity, either on the part of the sick person or on the part of someone with whom they are intimately connected.

The 'behavioural paradigm' for explaining HIV transmission is widely adhered to and informs most HIV prevention programmes. From the extremely naive ABC (Abstinence, Be faithful, use a Condom) to the downright foolish mass male circumcision (MMC) campaigns, the assumption is that because HIV is mostly transmitted by sexual intercourse, all we need to do is get people to change their sexual behaviour.

So far, I have accepted the often published claim that most HIV is sexually transmitted. But I have argued that the circumstances in which people live and work, for example, may determine who they have sex with, when and under what conditions. Trying to influence their sexual behaviour without examining these circumstances too, will result in a lot of failed prevention programmes. Most prevention programmes to date have, indeed, failed.

But perhaps, while rejecting the behavioural paradigm, I have fallen into the trap of accepting something like a sexual paradigm, that most HIV transmission is sexual transmission. Perhaps this is not even true. I was aware that there were people arguing that non-sexual, particularly medical transmission, could be far higher than accepted by many theorists. But I had to exclude certain lines of enquiry in order to limit my dissertation to a manageable field. Now that I am no longer so constrained, I have time to revise this limitation.

If medical transmission of HIV is significantly more common than supposed by most HIV analyses, a lot of questions could be answered. For example, perhaps more women than men, especially women of childbearing age, are infected because they receive more medical treatment. Perhaps many children who have been infected, especially those whose mother is not infected, have been infected by medical treatment. Perhaps the reason those in Northern Kenya, who have least access to modern medicine, also have very low levels of HIV because they are not being infected by medical procedures.

I have been reading a book by Daivd Gisselquist called Points to Consider: Response to HIV/AIDS in Africa, Asia and the Caribbean, conveniently published on the internet. Some of the things revealed in this book are truly shocking. When I have finished, I have to go through everything I have written about HIV and reconsider my whole view of it. My view of development will probably remain the same, but the way I reached some of my conclusions will have to be revised, considerably.

If Gisselquist and others are right, and I have no reason to believe they are are wrong, the woman who refused to take her medication could have been a victim of stigma, not primarily emanating from her own neighbours, but from some of the most eminent health professionals in the world. That HIV is primarily sexually transmitted in African countries is a long held, received view. Because of this received view, people who say they have not had sex in the period in which they became infected have not been believed. Women who are infected when their husbands are not are assumed to have had extramarital sex. Where couples are infected with different strains of HIV, they are both assumed to have been promiscuous, rather than just one of them.

This received view is in need of thorough testing and it is incredible that it has been used to face down challenges for so long. The view has shaped most of the (highly unsuccessful) prevention campaigns, but also people's reaction to their being infected with HIV or the reaction of others when faced with someone who has been infected. How many innocent people may have died in shame, misery and isolation because the health profession has refused, for whatever reason, to investigate its poorly supported assumptions about frequency of transmission of HIV in medical contexts?

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.

The Pretence of Aid

Some of the issues this blog is particularly concerned with include unfair trade policies that aim to keep developing countries in their current state of underdevelopment, the use of developing countries to produce low value goods and raw materials, but not high value goods, which they have to import from rich countries, and the use of developing countries for growing monocultures and single resources that are often processed in rich countries, earning poorer countries very little.

Economic Partnership Agreements (EPA) are, to a large extent, behind these and other issues. Rich countries have been busy for a long time trying to persuade African countries to sign up to these EPAs, without much success, yet. But as the number of poor people in African continues to rise, mostly as a result of the 'pro-poor' policies of rich countries, it should be possible to persuade more countries to put the noose around their neck in return for some short term handouts that they need for an emergency.

Perhaps Kenyans think there is no alternative, perhaps there is no alternative for them, but they seem to be getting further and further into the noose of producing cheap primary goods for export. Huge areas of land are being diverted to use for biofuels and other things that people here are not in great need of. At the same time, small farmers, who produce the bulk of what Kenyans eat, are slowly losing access to land as they are pushed off by rich industrial scale agricultural interests and as the prices rise to levels they will never be able to afford.

Rich countries used trade tariffs to get to the position they are in today. Now they want poor countries to remove their tariffs so that the rich countries can expand their markets and compete, under completely skewed conditions, against the poor countries' markets. EPAs are dressed up as being advantageous to African countries but so far, most African leaders have not been fooled.

The East African press generally seem uninterested in non-national matters, so I was surprised to come across an article that discusses the difficult area of EPAs in simple language for a non-political economist like myself to understand. This article sees EPAs as the wrong kind of development model and discusses a number of key points. One of these concerns EPA provisions that are highly detrimental to African countries' development. The EU claims that dismantling tariffs will promote growth, despite the fact that this has never been the case, in any country, or at any time in history. On the contrary, tariff cuts have taken countries in the oppostie direction, leading to stagnation and de-industrialization.

Kenya is typical of the countries who will suffer if they sign up to an EPA. They depend on a handful of low value primary goods that are often produced by farmers at an extremely small profit, even at a loss: sugar, sisal, coffee, tea, fruit, vegetables and the like. It would be extremely advantageous to Kenya to use those primary goods to supply an industrial sector, if they had an industrial sector. But much of the industry they do have is owned by foreigners from rich countries, who are effectively subsidized to be here. They get tax breaks and other incentives so that Kenyan industrialists have no chance of competing with them.

Of course, the EU would not want Kenya to develop an industrial sector, not an indigenous one, anyhow. Their economies depend on cheap goods and cheap labour from developing countries. So they dress  up their policies and 'contributions' as 'aid' and they talk the talk of development. And for the EU and other rich parties, African countries are not just sources of cheap goods and labour, they are also important markets, where very expensive goods, often made with cheap African raw materials and labour, are either sold or dumped on the African market.

It's a disgusting thought, but all the land that has long been used to produce non-food or non-essential food products in developing countries could have been producing food for starving people here in Africa. Instead, starving Africans get a pat on the head and a hand-out from the rich world. Now that some rich countries are unable to produce enough food for themselves, they are buying up African land. Others are buying up African land to produce biofuels. Africans can expect more pats on the head and more hand-outs whenever enough Western attention is drawn to some drought, flood or other 'natural' disaster.

And don't be fooled into thinking that most of the disasters that strike poor countries are wholly natural. Many are not in any sense natural. People starve, become sick and die during what are referred to as disasters, usually, because they don't have access to the food or the water that is being extracted by foreign interests. The 'shortages' of food that Kenya has experienced recently and will continue to experience into the future have been manufactured. The bulk of land, and therefore water, in Kenya is devoted to producing goods for export. Even those goods that consist of food items are destined for Europeans who can afford it, not Kenyans, whose buying power is undermined by various agreements with the EU and other rich countries and zones.

Human Rights Are Not Just for the Rich World

According to Dr Marcos Espinal of the Stop TB Partnership, "TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation." And I applaud him for saying this. If developing countries are not allowed to develop (and I would argue that developed countries are doing all in their power to stop them from developing), diseases like TB will not successfully be treated by drugs alone. People in developing countries are poor, they suffer bad health, they receive little or no education, they live in terrible conditions and their human rights are being denied. It is no wonder that TB and many other diseases are rife and increasing.

I would add that HIV, also, is not just a medical problem, nor is it just a matter of sexual behaviour. Parallel arguments could be used to show that, so far, both HIV and TB programmes have failed to prevent the spread of the diseases and will continue to do so. If you don't deal with the conditions that result in diseases spreading, all diseases, you will not eradicate the diseases. After using little more than expensive pharmaceutical products to treat TB for many years, an estimated 440,000 people are now resistant to commonly used TB drugs. I have not been able to find estimates for the number of people with HIV strains that are resistant to first line drugs commonly used in developing countries, but resistance is a very serious threat.

There's an interesting article on the website of the United Nations Development Programme (UNDP). They have been publishing the Human Development Report for many years now and they are about to reveal some of the main trends over the past four decades. The Human Development Report measures development by criteria other than just economic, such as health, gender, education and other things. This article notes that there has been significant progress in development, but this has come from improvements in education and health, not economics.

It also notes that these improvements have little or nothing to do with globalization. Rather, they have been achieved by expansion of "educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics." In other words, state intervention.

The research finds that there is no correlation between economic growth and changes in non-income components of human development. It concludes that "the oft-repeated dictum that growth is a necessary condition for increasing human development is simply not true."

So the approach to development and human rights related problem, such as HIV or TB, is to improve education, health, economic circumstances, gender imbalances, employment, infrastructure and many other things. The approach should not be to set up well financed vertical programmes that target single diseases or narrow issues at the expense of other, broader issues.

Throwing eye watering sums of money at a problem, such as HIV or TB, will not even solve the problems of HIV or TB. Especially if most of the money is spent on technologies that are produced in rich countries. That's just taking money out of one pocket and slipping most of it into another. It's time for new thinking on development. Development is not just one thing, it's many things. And if you don't know enough about any of them, just read the Universal Declaration of Human Rights and consider how many of those rights people in developing countries are currently being denied.

More Good News for Big Pharma: Resistant Gonorrhoea

Yesterday, I blogged about the fact that TB is on the rise worldwide. Funding for TB prevention, and even for treatment, are not commensurate with the threat to global health that this epidemic poses. And the rise of TB is often blamed on the current HIV pandemic. I would suggest that there is a TB epidemic of a level that can not wholly be explained by the HIV pandemic and that, like almost every disease and health issue aside from HIV, TB is being ignored.

Those heavily involved in the HIV industry, such as Michel Sidibe, the head of UNAIDS and Michel Kazatchkine, head of the UN Global Fund for HIV, TB and Malaria, deny that high levels of HIV funding have starved other diseases of cash. Kazatchkine claims that 'over a third of of overall funding of the Global Fund is actually going to strengthening health systems'. I don't know how he came up with this estimate but it seems to me that there are only certain aspects of health systems that are benefitting from HIV cash, and those aspects relate to HIV.

Kazatchkine says the money is not just going on condoms and drugs. I sometimes wonder if the money is even going on condoms, along with the logistics of ensuring that people use condoms all the time and properly. Even the claim that a lot of money is being spent on drugs can seem hollow when people supposed to be taking them often cannot do so because of lack of food. And 20% of the new HIV cases in Kenya every year come from vertical infection, from mothers transmitting HIV to their babies.

Treatment of people with HIV may well have exceeded expectations. And I would like to see every HIV positive person who needs treatment receiving the drugs and support they need. But since the recent expansion of HIV treatment, millions more have become infected. Prevention has been forgotten about. People like Kazatchkine and Sidibe like to argue that distinguishing between treatment and prevention is a false dichotomy, but this is not so. If treatment played such a huge role in preventing further infection, transmission rates would be much lower than they are. In fact, the majority of people in Kenya who are HIV positive do not know their status. Perhaps there shouldn't be a dichotomy between treatment and prevention, but there is.

And if you think the programmes to teach people about safe sex and to persuade them to use condoms have been successful, consider the figures for preventable and treatable sexually transmitted infections (STI). There are an estimated 340 million new cases of curable STIs every year. This is after over 20 years of preaching about safe sex in every country in the world. If people were practicing safe sex, transmission of most STIs would also be reduced. Prevention involves taking steps to ensure the infection is not transmitted. In the case of STIs, that could involve the correct use of condoms, minimally.

HIV treatment and care has received much of the money available for the disease. Kenya's official strategy papers make this quite clear. Prevention has received very little money and has been pretty unsuccessful, with 5 new infections for every two put on HIV treatment, globally. And HIV has been treated as if it's just an easy matter to round up people and give them some drugs. As a result, there is growing resistance to the few HIV drugs available in developing countries. This can be compared to TB, where it has long been recognised that you can't just send people away with some drugs and expect them to take them religiously for 9 months and never see them again.

If health solely involves treating sick people, how will you ensure the continuing health of those who are not (yet) sick? In the field of sexually transmitted diseases, gonorrhoea is now also developing resistance to the most commonly available drugs. There has been little recent research into alternative treatments for gonorrhoea (or TB) because, I would suggest, most of the money has been spent on other 'priorities' (Oh, and big pharma are waiting for public funding for their research, a very important component for these (private) companies). One of those priorities is HIV and despite ploughing a lot of money into condoms and safe sex campaigns, prevention has not received the level of funding it needs.

Yet more evidence of the lack of success of HIV prevention work is the level of pregnancies among women receiving HIV treatment. Women with untreated HIV have far lower fertility levels, so treatment should increase fertility. But women on HIV treatment should also be receiving advice about having unprotected sex and about unplanned pregnancies. I don't believe that all these HIV positive women are choosing to have more children, though some of them may be. Because other research has shown that the vast majority of pregnancies among women who are HIV positive were not planned.

Sidibe even seems to think that the global recession and climate change are distractions to the industry's fight against Aids. I would be hard pressed to find an attitude to which I am more opposed. He even has the cheek to suggest that HIV funding has not led to the neglect of other diseases because it has increased attention for TB, the two diseases being 'integrated', and that HIV prevention should take on a 'holistic approach'. Damn right, but I don't think his use of 'holistic' is the same as mine. But when is all this HIV money going to be spent on the many health issues that I and many others would claim have been ignored? Apparently, Sidibe and Kazatchkine think that's already taking place, and Sidibe feels that support from the big pharmaceutical companies is essential. Very funny.

TB on the Rise: Big Pharma Delighted

Although TB is often mentioned along with HIV, it doesn't get nearly as much attention, certainly not as much attention as it deserves. And it gets a fraction of the funding. It happens to be in the news now because World TB Day was just last week. Unlike HIV, TB is easier to catch but also easier to prevent. It's also curable. But like HIV, TB spreads rapidly in populations which face serious and long term economic challenges, have poor and inaccessible health systems, low educational standards and an inadequate infrastructure.

Like HIV, TB will not be eradicated until the determinants of health are tackled. Like HIV, you can spend as much as you like on the disease but as long as people live in terrible living conditions without even basic water supply and sanitation, suffer from poor health and nutrition and face many other stresses that allow any diseases going to spread rapidly, neither will be eradicated. The huge amounts of money spent on HIV over the last three decades has done little to reduce its spread and the far smaller amounts spent on TB have been equally unsuccessful.

Kenya ranks 13th in the 22 high burden TB countries and fifth in Africa, although it is notable that they are only rank 9th for HIV. There were 132,000 new cases last year. It is estimated that there were 2000 multiple drug resistant cases but only 4.1% of these were diagnosed. And only 48% of new TB patients were coinfected with HIV. New cases of TB are declining but the number requiring retreatment, those who either weren't treated successfully or who didn't finish their treatment, is increasing.

I think it is important to note that just over half of the new TB cases were not people who also have HIV. TB is an epidemic in its own right. While high HIV prevalence will increase the spread, TB is spreading independently of HIV too. And why wouldn't it? Most people in Kenya live in the sort of conditions where all diseases spread rapidly. Just as HIV has been treated as if it is exceptional and as if it is possible to eradicate a disease without also dealing with the determinants of health, TB is being treated as if people's living conditions don't matter. But they do matter, very much.

Jeffrey Sachs points out that if Africa had better health systems, HIV would have been identified a decade earlier. This is quite true, the symptoms that were later recognised as those of Aids were not recognised as being out of the ordinary. They were consistent with very poor health, poverty and malnutrition. It was only when people in more developed countries started to be infected that HIV and Aids were identified. By then, it was too late to avert a massive epidemic. Then, as now, the conditions in which people lived were appalling. 

Nigeria has an even more serious TB epidemic, third in the world, with 100,000 new cases last year, although they only rank 21st in the world for HIV (despite being estimated to have the second highest number of people living with HIV, after South Africa). Rwanda and Malawi have the highest rates of TB in the world but Rwanda, at number 14 and Malawi, at number 8, certainly don't have the highest rates of HIV. The point I'm trying to make is that in developing countries, conditions are poor and declining but also, are not being remedied by the pouring of funds into programmes that merely treat sick people (ok, a small amount goes into prevention, but not much).

Aside from neglecting the determinants of health in general, programmes for TB and HIV are mainly targeted at people who are already sick. Most of the money goes to treating people who are already infected. Preventing both HIV and TB has a lot in common, indeed, preventing all diseases has a lot in common. People need good living conditions, water and sanitation, education, health, employment, economic well being, good nutrition, food security and many other things. Instead, most of the aid money going into these diseases is spent on drugs and other technologies.

PRWeb has a cringe-making release about a report on TB theraputics (which costs $3450, in case you are interested. This release enthuses about the "excellent commercial opportunity for existing as well as new companies in this marketplace." The "marketplace" is certainly growing, because if the only solution to TB is to wait until people become infected and then treat them with drugs, resistance is only a matter of sitting back and waiting. People in developing countries with TB are given the drugs and sent home to continue spreading it in their inadequte housing and with their poor nutrition and lack of education and water and sanitation.

These pharmaceutical companies have been humming and hawing because public funding hasn't been forthcoming but now that it looks like that will be made available, they can start raking in the cash. Remember, that's public funding, because the profits certainly won't be public.

All the conditions for the rapid spread of TB are in place and many of them are the same conditions for the spread of HIV. Little has been done to alleviate these conditions and in countries like Kenya, they have been steadily disimproving for several decades. It may be popular to blame the HIV epidemic, for TB and just about everything else that's happened since the 1980s, but this excuse won't wash. Winding down public services and public spending started before HIV was even identified. TB was around before HIV was identified. The opportunity to eradicate TB is still there, but throwing a lot of drugs and money at it will continue to fail.

Developing countries need to be enabled to develop. Diseases are not just inconvenient pathogens that can be eradicated with some extremely expensive drugs. They require an appropriate environment and suitably weakened hosts. Current and past approaches to TB and HIV ignore the existence of appropriate environments and weakened hosts aplenty. That's why HIV and TB are spreading, despite the billions spent on them.

Stop These 24 Crimes Against Humanity

Perhaps people in rich countries like to believe that some of their country’s wealth supports people in developing countries. They may think too much money or too little money goes to developing countries and they may approve of development aid or they may disapprove. But they are less likely to realise that rich countries extract exponentially larger amounts of wealth from developing countries than they give in aid.

So instead of arguing for more aid money or less aid money or different ways of distributing it, people who feel strongly about development could lobby their governments to consider how rich countries could reduce the extent to which they impoverish poor countries. Below, I’ve compiled a list of 24 ways this could be done. This is what I call ‘development by omission’ and it will be noticed that every item in this list represents highly unethical behaviour, perhaps even criminal behaviour.

1. Stop grabbing land in developing countries for food, resources, biofuels, etc, and return the huge tracts of land that have been grabbed during previous imperialist regimes.
2. Stop growing biofuels, which only benefit rich countries (if they benefit anyone at all) and effectively steal water, land and other resources from developing countries. Biofuels mainly use food crops, so this also drives up the prices that people in developing countries have to pay for vital goods.
3. Stop using developing countries as sources of raw materials and natural resources. Monocultures such as coffee, tea, cotton, sisal, cocoa and others keep people in developing countries in penury. They also waste land that should be used for food production.
4. Stop trying to palm off genetically modified (GM) crops on developing countries, especially under the pretext that this will make them more food secure and will solve food shortages. GM crops represent higher costs and lower profits for farmers, even in the rich countries for which they were originally developed. They also make farmers less self reliant and more vulnerable to various hazards, natural and otherwise.
5. Stop using developing countries as sources of cheap labour, especially in the growing of monoculture crops, non-food crops and crops intended for export. Export Processing Zones (EPZ) have been set up so that foreign companies can avoid meeting even minimum labour regulations, as well as avoiding paying tax.
6. Stop allowing foreign companies tax holidays and other benefits that are not available to people in the developing country in question. Tanzanian companies that wish to exploit the country's rich reserves of gold, for example, cannot compete with foreign companies.
7. Stop dumping cheap, subsidised goods, such as sugar and cotton, on developing country markets. Rich countries need to remove subsidies and allow developing countries to compete.
8. Reverse unfair trade agreements, especially bilateral agreements, that allow rich countries to extract goods and services from developing countries so cheaply that the developing countries lose out.
9. Stop aggressively recruiting skilled employees, such as doctors and nurses, which are in very short supply. Compensate adequately the countries who have lost most of their skilled employees over the years.
10. Repeal the various structural adjustment policies and similar World Bank and IMF (International Monetary Fund) strictures that reduce developing countries' ability to develop. Get rid of conditional aid, especially where those conditions are purely for the benefit of rich countries and are harmful to developing countries.
11. Change the terms and conditions for loans so that repayment does not mean that the borrowers are barely able to service the debt each year and will not be free of debt for the foreseeable future.
12. Get rid of ghost aid in its various forms. Much aid never reaches developing countries, some is a de facto subsidy for rich country products and services and some is debt cancellation or some other kind of expedient that makes it look as if aid is much higher than it really is. Get rid of purely supply led aid and interventions that are designed to benefit wealthy companies and NGOs.
13. Stop huge capital projects, such as hydroelectric dams, which cause more damage than good and usually only benefit some western companies who build the structures.
14. Where foreign companies are operating in developing countries, ensure that they pay proper wages and develop good working conditions. Also, ensure that they pay tax, at least at levels paid by people and companies from that company.
15. Stop aid programmes that simply increase dependency and do nothing to improve conditions. Also, aid that destroys local markets, such as food aid that consists of donations in kind from rich countries.
16. Stop selling unnecessary weaponry and other technologies, especially out of date technologies that are no longer of any use. Far from protecting developing countries from this kind of exploitation, many Western governments have been party to the exploitation. Also see ControlArms.org.
17. Stop setting up and supporting puppet regimes and undemocratic, corrupt governments. Stop interfering in the running of countries purely for the benefit of rich countries.
18. Stop encouraging developing countries to privatise public services and public utilities, especially where that involves those services and utilities being taken over by foreign companies.
19. Stop exporting pollution by producing the most polluting products in developing countries, for example, force growing fruit and vegetables in Kenya and flying them to Europe.
20. Stop dumping toxic waste and any other kind of wastes in developing countries, where they are unlikely to be treated responsibly. Stop dumping computers and other used goods where there is no demand for them and no capacity for processing the resulting waste.
21. Stop stealing indigenous knowledge and indigenous crops, genes and plants. Stop putting patents on things that have been stolen from developing countries.
22. Stop using developing countries as military and geopolitical pawns and pretending that this is a form of development.
23. Stop using developing countries as markets for products that are difficult or impossible to sell elsewhere. Stop forcing products on people who can't afford the consequences, such as GM crops, baby milk formula, etc.
24. Stop rich 'philanthropists' from using developing countries and their people for their experiments and their expansionist aspirations.

If rich countries stopped doing all or even some of the above, developing countries would be a lot better off. The paltry amounts of money spent on ‘aid’ would probably no longer be necessary. The number of people who live in poverty, suffer disease and other harm and who die unnecessarily as a result of rich countries’ practices of extracting wealth from developing countries could even seem like genocide. The list is by no means exhaustive.