Global Health and Foreign Policy Blog

The Muslim world has largely avoided the HIV/AIDS pandemic that is impacting virtually every other area of the globe. Explanations range from the protective role of Islamic values, to the idea that there is growing risk of an epidemic but it is “hidden behind the veil.” A recent BMJ article is a good summary of the evidence and suggests that the low alcohol consumption and male circumcision typical of Muslim populations likely decreases the risk of HIV transmission. On the other hand, the article argues that Muslim societies may have a difficult time speaking openly of sexual practices to educate populations and prevent the spread of the disease. Gender inequality may also increase women’s susceptibility to becoming infected.

Two recent developments, both results of the wars in Afghanistan and Iraq, may contribute to ending the Muslim world’s isolation from HIV/AIDS. The first is the record breaking growth of opium cultivation in Afghanistan in the years since the fall of the Taliban (which had banned cultivation). The country now produces 90% of the world’s opium, which is manufactured into heroin and smoked or injected by users. This glut of opium tends to decrease the price of heroin while increasing the purity, both of which encourage drug use and addiction. There are reports of increasing numbers of injecting drug users in Afghanistan, Pakistan, Iran and a number of Central Asian states. Beyrer et al. has clearly documented how the spread of HIV follows heroin trafficking routes, and injection drug users often provide an efficient mechanism for introducing HIV into a previously unaffected country. Second, an article in today’s New York Times details how Iraqi refugees in Syria are having to turn to prostitution to support their families: “If they go back to Iraq they’ll be slaughtered, and this is the only work available.” The article estimates that 70%-80% of prostitutes working in Damascus are Iraqi and that “inexpensive Iraqi prostitutes” are making Syria a destination for sex tourists from wealthier Middle East nations, especially Saudi Arabia. 

These developments indicate that parts of the Muslim world are facing increasing drug and sexual risk factors for the development of a larger HIV epidemic than has been seen to date. I’ll repeat the often stated plea for early action before the epidemic takes hold, we really do know enough to limit the spread of this disease. And on a geostrategic level, it would be sad to see the Bush administration’s generally praiseworthy efforts to fight HIV/AIDS undermined by the unintended consequences of the wars in Afghanistan and Iraq.

A great summary of Scott’s talk at Harvard on working through the “final inch” of eradication programs. Read it here.

In late 2006, Thailand issued a “compulsory license” order for efavirenz, an HIV treatment drug. In January 2007, Thailand issued a similar order for lopinavir/ritonavir, another anti-HIV drug. Earlier this month, Brazil followed Thailand’s lead, issuing a compulsory license order for efavirenz. Does this mean we on the verge of a cascade of compulsory licensing orders? And, if we are, is that a trend to be welcomed?

First, some facts. A compulsory licensing order allows a country to make or import a generic version of a drug. It is essentially a huge bargaining chip in negotiations over price with patent holders. It is also legal. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) allows countries to issue such orders. Normally, they should do so only after negotiations with the patent holder have failed. However, in the event of a national emergency, the state can issue the order directly. Either way, the patent holder needs to be paid “adequate remuneration.”

So, will there be a cascade of such orders? The answer depends less on multilateral trade law than on the bargaining power of the parties. Though compulsory licensing is allowed, the option need not be exercised. Bilateral trade agreements provide an opportunity for rich countries to arm-twist poor countries into accepting tougher intellectual property arrangements, including stricter restrictions on compulsory licensing. “TRIPS-plus,” such provisions are called.

Are compulsory licenses a good or bad thing? Patents provide an incentive for innovation by awarding a monopoly to the patent holder. Monopoly pricing, however, can mean that some countries are priced out of the market, even when they are willing to pay more to obtain a drug than that drug costs to produce. So, there is a tradeoff between dynamic efficiency (innovation) and static efficiency (distribution). However, this tradeoff is partially false for two reasons.

First, only “enough” of an economic surplus is needed to spur innovation. The Thai market may have no bearing on the decision of a pharmaceutical company to invest in R&D when the market in North America, Japan, and Europe is sufficiently big. Second, pharmaceutical company profits can actually increase when poor countries are charged less than rich countries. The difficulty is that this can only work if rich countries agree to pay more.

Ideally, the poorest countries willing and able to pay the least for a drug should be able to procure it for a small fraction of the price paid by rich countries. Since compulsory licensing orders give poor countries the ability to negotiate such low prices, they are thus to be welcomed. But the incentive for pharmaceutical companies to innovate will then depend on rich countries paying a high enough price to stimulate R&D. This is the rub. A cascade of compulsory license orders will materialize only if the rich countries do not take away with the one hand (the hand that negotiates bilateral agreements) the authority they gave poor countries previously (in multilateral talks) with the other.

Chen Shui-bian, the President of Taiwan, wrote a very interesting piece in the Washington Post this morning. To maintain diplomatic relations with China, most countries of the world uphold the pretense that Taiwan is a renegade providence of mainland

China. Because of this diplomatic status,

Taiwan is neither a member of World Health Organization (WHO) nor an observer at the World Health Assembly. In this article, Shui-bian renews calls for

Taiwan to be admitted as a full member of WHO based on two main arguments. First, Shui-bian argues that it is immoral for an international humanitarian organization to allow power politics to obstruct the participation of a willing nation in the work of global health. Second and more ominously is the subtle suggestion that keeping

Taiwan out of WHO will impede global efforts to limit the spread of avian influenza and other acute disease outbreaks.

What a great microcosm of some of the links between global health and foreign policy. Would including Taiwan’s 23 million people in WHO help improve health in

Taiwan and global efforts to respond to infectious disease outbreaks? Sure. Is China opposing Taiwan’s entry to the WHO to maintain its “One China Principle” and keep international institutions from recognizing Taiwan? Undoubtedly. Is Shui-bain using the threat of disease outbreaks and China’s cover-up of SARS to leverage his country’s diplomatic position regarding independence from

China? Absolutely. That other countries will use “health diplomacy” to further their own ends shouldn’t surprise us, but I fear

U.S. policymakers haven’t grasped this dimension yet. See Under Secretary of State for Democracy and Global Affairs Paula Dobrianky’s article on science diplomacy here (warning, big PDF file): http://www.state.gov/documents/organization/67518.pdf

What disappointing news about the resignation of Randall Tobais due to his admitted use of Deborah Palfrey’s escort service for “massages.” See the Washington Post here.  Most commentators have focused on the clear and angering hypocrisy of Tobias pushing (or implementing Congressional earmarks for) abstinence programs and anti-prostitution pledges for PEPFAR funding while using an escort service himself. However few have discussed the larger implication that reform of US foreign aid and discussion of its relation to

US foreign policy objectives may be dead until the next administration. With the reorganization of foreign aid just getting started, and Secretary Rice feeling that Tobais was essential to these efforts, it seems unlikely in a crowded political season that this issue will get the attention it deserves. What ever you thought of his policies, Tobais was successful in getting PEPFAR off the ground and in bending recalcitrant bureaucracies into action. With Tobais gone, questions of how

US health and development funding can be improved and their relation to US foreign policy goals will likely be set aside for the next administration. This is a shame as these are critical questions on how the

US will engage with world that we should be discussing now. If Tobais’s resignation caused the White House to further delay and abdicate leadership in starting the discussion on PEPFAR reauthorization, it would further worsen the fallout from these events.