Global Health and Foreign Policy Blog

This frightening image is from Lael Brainard’s “Security by Other Means: Foreign
Assistance, Global Poverty and American Leadership.” Brainard and Steve Radelet from the Center for Global Development testified at the Senate Foreign Relations Committee last week on the need to reform U.S. foreign aid. While the above picture should be sufficient to convey their main message, the testimonies are also worth reading. Both call for major reforms including the creation of one integrated agency to manage U.S. foreign aid (akin to the UK’s DFID), and a complete overhaul of the 1961 Foreign Assistance Act. Interestingly, both cite preventing and managing infectious disease epidemics as a key part of advancing U.S. national security and national values. This is a good sign that the links between global health and foreign policy are recognized and accepted, at least within Washington DC. Their testimonies, available here, are a good overview of the problems and potential reforms to our foreign aid system.

This just in: White House interferes with public health and science. In case there is anyone reading who doubts that public health is a political activity, and I assume there are not many among our readers, this Washington Post article on White House interference with the Surgeon General is required reading. And it’s not just this administration; politicizing public health is a bipartisan sport. Note that all three previous Surgeons General, under Regan, Clinton and G.W. Bush, reported political pressure to modify or stop their speaking out on important public health issues.

Rather than issuing lamentations pleading for the political independence of public health, (see Waxman’s quote in the article,) we might try accepting that public health policies that determine whether or not people become sick and die are inherently political. Maybe then the public health community will be more successful in designing political strategies that build support for needle exchange programs, sex education, and other controversial interventions for which there is abundant scientific evidence but little political support.

The good news about the HIV epidemic among India’s general population, most recently reported here, was accompanied with bad news about the epidemic for India’s armed forces and their families. In an unusual announcement, Yogendra Singh, director general of the Armed Forces Medical Services, is urging wives of military personnel to protect themselves from HIV as the epidemic spreads among the armed forces. The government is “alarmed” at the spread of HIV in the military and Singh says “the youthful, exuberant and aggressive attitude of our troops, combined with the long separation from families and high mobility has compounded the risks faced by [wives].” One might add to this list of causes the rapid growth of brothels surrounding military bases in areas where soldiers often have higher incomes than the local population. The spread of HIV in India’s huge armed forces, (with 1.3 million active military personnel, 535,000 reserve force members, and another 1.3 million in paramilitary forces,) is occurring despite force-wide HIV screening introduced in 2006.

A major driver of this problem is the large number of Indian troops stationed in the insurgency-plagued Northeast, where heroin trafficking and use has contributed to high HIV prevalence in the area, especially in Nagaland and Manipur. Lieutenant General Bhopinder Singh, Director General of Assam Rifles (one of the paramilitary forces involved in counterinsurgency in the Northeast) recently said: “Now we find more soldiers dying to HIV-AIDS than to bullets fired by militants.” I have written here about how the overlap of insurgencies, sex workers, and heroin trafficking will create black holes in India, Russia and China’s efforts to fight HIV/AIDS. India’s Northeast, China’s Xinjiang and Yunnan provinces, and Russia’s North Caucasus region (which is also seeing a rapid rise in HIV prevalence) are major internal security issues for these states, and host large numbers of government troops. These troops are at high risk for infection, and will spread the disease when they are redeployed elsewhere or demobilized. I fear these troubled regions will become drivers of the epidemic in Russia, India and China, exporting HIV, TB and narcotics to neighboring areas and undermining efforts to fight the disease in these critical states.

The better news here is the recognition that HIV/AIDS can be a greater threat to troops than combat will push militaries to expand and improve their efforts to prevent transmission of the disease. The Assam Rifles seem to have realized this, as has the Indonesian military, which saw more of its peacekeepers in the UNTAC mission dying of AIDS than combat. The U.S. Navy runs an excellent military to military HIV/AIDS training program that addresses this issue by helping foreign militaries prevent and treat HIV/AIDS in their armed forces. These military efforts should be welcomed and might help limit the spread of HIV in the troubled areas where insurgencies, drug trafficking and commercial sex overlap.

Richard Holbrooke, former U.S. Ambassador to the UN and CEO of the Global Business Coalition on HIV/AIDS, suggests in the Washington Post that we may be seeing a change in Chinese foreign policy towards greater cooperation with the U.S. on issues of mutual concern. He cites as evidence increased Chinese diplomatic pressure on the governments of North Korea, Sudan and Burma (Myanmar) that has shown some small (but still insufficient) impact in negotiations with these states.

The ends toward which China directs its increasing foreign policy clout will have a major impact on global affairs, but it’s not just traditional foreign policy that interests China. The Chinese Ministry of Science and Technology announced yesterday “efforts to establish a biological security system in 20 years to fight against bio-terrorism and prevent serious epidemic diseases.” This raises big questions about the scope of this system, its linkage with other global surveillance efforts, the sharing of data on disease outbreaks, and the ends toward which the proposed Chinese biological security system is directed. While these questions play out, I think we can expect China to play an increasingly important and assertive role in global health security efforts.

The big health news out of India this month is that a new Gates-funded study puts the total number of people infected with HIV/AIDS in India at between 2 – 3 million people. That is half previous estimates of the Indian epidemic, which was considered by some to be the world’s worst in terms of total number of people infected. (South Africa, with an estimated 5.5 million cases, will retain this dubious title.) The study suggests that the virus is mostly prevalent in high risk groups, and has not spread widely in the general population. The combination of concurrent sexual relationships and transactional sex that have so greatly exacerbated the epidemic in Sub-Saharan Africa does not seem to be operating in India.

If this new study is accurate, previous estimates of HIV in India were 50% higher than actual rates. There can be reasonable reasons for such a revision of estimates. The methods used in studies are different, and results can be greatly affected by which populations are sampled and how representative they are of the general population. But Daniel Halperin at the Harvard School of Public Health suggests in the New York Times article that there is a more nefarious reason behind the revision of estimates: “that that AIDS-fighting agencies had such a stake in portraying the epidemic as an approaching Armageddon that they were hesitant to make revisions.” If the downward revision of HIV prevalence in India, and similar revisions in Kenya, Mali and Zambia, are due to improved sampling or actual reductions in HIV prevalence, great. If public health agencies are hyping the scope of the epidemic by delaying the reporting of estimates that are lower than previously thought, they stand to lose one of public health’s only advantages in global politics: scientific credibility.

The new set of International Health Regulations (IHR), an update of the only international agreement on infectious disease control that is binding on WHO member states, will take effect on June 15, 2007. The arrival of the new set of rules has been heralded by some as a revolution in the fight against communicable disease and a high point for international health cooperation. While there is every reason to believe the new IHR represent an important step forward, it is also clear that they will not (and cannot) fix long-standing weaknesses in the international public health system. Until deeper problems are addressed, the IHR will remain a well-intentioned, but incomplete, instrument of global public health.

There are two key improvements in the new version of the IHR. First, it greatly expands the scope of internationally notifiable diseases. While only three diseases were reportable to WHO in the previous IHR (cholera, yellow fever, and plague), the revised version requires reporting on any event that constitutes a “Public Health Emergency of International Concern.” This theoretically requires countries to notify WHO of all existing and any new infectious diseases with a potential to spread internationally. Second, it allows for the inclusion of non-state information in notifications of disease outbreaks. Previously, WHO was constrained to reporting only disease outbreaks that had been officially recognized by the country experiencing the outbreak. The new IHR allow WHO to use third-party information (such as reports from other countries or from non-governmental sources) to publicly identify outbreaks even without official verification from the affected country.

While these changes are needed and are very welcome, there are two major problems contributing to global disease insecurity that the new IHR do not remedy.

First, disease surveillance capacity in many countries is poor to non-existent. The security provided by a global public health system is dependent on the effectiveness of its component domestic systems to provide timely and effective epidemiologic information, and many countries struggle to identify and track diseases. The new IHR acknowledge this weakness and urge rich countries to “provide support to developing countries…if they so request, in the building, strengthening and maintenance of the public health capacities required under the IHR”, but no solid, enforceable mechanisms for coordinating such a development program is outlined.

Second, the global health system is still comprised of sovereign states that place their own interests above all else. Mistrust and concealment is still a problem among countries and between countries and the WHO. For example, despite the looming threat of a devastating worldwide avian influenza pandemic, human and animal cases of the disease regularly go unreported, and some countries have been reluctant to share samples of the virus. Often, the reason for the lack of transparency is a fear of the negative economic repercussions from reporting a disease outbreak, which could lead to travel restrictions or a ban on exports. No effective measures currently exist to provide a counterweight to these often legitimate national concerns, and therefore secrecy will continue to hamper global disease control.

The IHR may represent an important health diplomacy tool, but the solution to the problem of international infectious diseases lies in addressing the global goods problem of funding the development of a true global capacity to identify and track diseases, as well as creating a responsible framework for incentives for countries to communicate quickly and openly about disease outbreaks. These solutions will not come from one international treaty, but from an extended multilateral effort with leadership coming from rich countries who realize that the best way to protect themselves from infectious diseases is to create a truly global disease control system.

The story of Andrew Speaker, the handsome newlywed who put the public’s health at risk by traveling to Europe to attend his wedding, has been headline news. Speaker has Extensively Drug-Resistant Tuberculosis (XDR TB), a form of TB resistant to nearly all drugs used to treat TB.

In traveling, Speaker put other people at risk. That an educated person could do this—a person whose father-in-law is a TB expert—only adds to the vulnerability people feel now.

The situation is not unique. Remember the SARS epidemic of 2002-2003? That disease was spread outside of China by a doctor who had been treating SARS patients in Guangdong province. He probably infected others by coughing. It is known that he infected at least 16 other people, all of whom spent at least some time on the ninth floor on the Metropole Hotel in Hong Kong.

People are right to be worried about spread. As one passenger on board the same flight as Mr. Speaker put it, “How many other people can do this or will do this? It’s hard to think about what this means for the future of air travel.” See full article here.

Policy, however, has to think about much more than border controls, travel restrictions, and quarantine. How did Mr. Speaker get infected? How did the person who infected Mr. Speaker get infected? How, especially, did the first person to acquire XDR TB get the disease? This person is especially important. Epidemiologists call this person the “index case.”

Newly emerging diseases can be prevented—or at least their chance of emerging can be reduced. The exotic wildlife markets in China played a role in the emergence of SARS. Similarly, a mutation of the avian flu virus H5N1 capable of human-to-human transmission is more likely to emerge where large numbers of people come into contact with large numbers of birds. In the case of XDR TB, emergence is likely to have been made more likely because of inappropriate drug use. The index case for XDR TB has not been identified, but this disease is almost certain to have emerged outside the United States.

There is a tendency for policy to respond to a situation like this by focusing on the need to throw up border controls. Such controls are needed, but so are other measures. In particular, we need better surveillance worldwide for emerging diseases like XDR TB. We also need policies that make emergence much less likely. Global standards for TB exist. Lacking are the carrots and sticks that create the incentives for countries worldwide to abide by these standards.

To protect the U.S. population, United States policy needs to look outwards and not only inwards (border controls). The U.S. cannot address risks like this unilaterally. A global approach is needed, but that will not be forthcoming without U.S. leadership—a reason why the intriguing case of Mr. Speaker should be a priority for U.S. foreign policy.

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.