2004 World - CiteSeerX

2004World

OPENING STATEMENTHistory of the Committee

TOPIC AREA A:GLOBAL EPIDEMICSIntroductionHistory of the ProblemStatement of the ProblemCase Study: SARSQuestions a Resolution Must AnswerSuggestions for Further Research

TOPIC AREA B:PHARMACEUTICALS AND DEVELOPING COUNTRIESIntroductionHistory of the ProblemStatement of the ProblemCase Studies: HIV/AIDS and MalariaPast ActionsQuestions a Resolution Must AnswerSuggestions for Further Research

CONCLUSION

BIBLIOGRAPHY

APPENDIX

World Health OrganizationDirector:Yehoda [email protected]

Dear Delegates,

It is with great pleasure that I welcome you to the 2004 session of WorldMUN. I am also delighted to have you all on the World Health Organization Committee.

I am a junior at Harvard with a strong interest in healthcare and development, which partly accounts for my involvement in the WHO committee and my choice of topic areas. The topic areas address complex health issues that are nevertheless pertinent to the global health status today. I am confident that the conference is going to promote effective dialogue and mutual enrichment on the case of “Pharmaceuticals and Developing Countries”, and “Global Epidemics”.

I believe your diverse backgrounds will enrich our WorldMUN experience. I am eager to hear your perspectives on these topics and I am very much looking forward to meeting you all in Sharm El-Sheikh!

Sincerely,

Yehoda MarteiDirector, World Health OrganizationHarvard WorldMUN 2004

392 Eliot Mail CenterCambridge, MA [email protected]

HARVARD WORLDMUN 2004 SHARM EL-SHEIKH, EGYPT

World Health Organization

HISTORY OF THE WORLDHEALTH ORGANIZATION

The World Health Organization was born out of the “Health Organization” of the League of Nations. The WHO was established on 7 April 1948, as a United Nations specialized agency for health, with the aim of providing health for all. This concept of “health for all” is a reflection of the quest for health equity expressed in the Constitution of WHO. By definition, of the WHO Constitution, Health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.

The WHO is governed by the World Health Assembly, which is made up of 192 member states. The World Health Assembly is the decision-making body of the WHO. Its functions include appointing the Director-General of the WHO, supervising financial policies and reviewing and approving budgets proposed by the Organization.

The role of the WHO in the world to date includes, but is not limited to, facilitating cooperation among its member states—developed and developing countries. The WHO has also acted in the past to provide relief during health emergencies, such as epidemic outbreaks. The WHO is currently promoting research and development into under-explored diseases pertaining to the developing world. Its main objective is to make drugs more accessible to the world’s poorest, especially in the case of HIV/AIDS. The current Director-General of the World Health is Dr Lee Jong-wook. Today, the WHO still has at the core of its projects, the objective of “Health for All”.

TOPIC AREA A:GLOBAL EPIDEMICS - SURVEILLANCE AND CONTROL

IntroductionWith the speed of air travel and

increased global movement, it is almost

impossible to identify most cases of highly contractible infectious diseases a traveler might carry upon arrival into another country. Global epidemics are a complicated case of locally infectious diseases because they are usually more serious and require experts in epidemiology and surveillance and well-equipped laboratories, to identify and handle infected patients appropriately. Timely information in terms of rapid identification and reporting of cases is needed in order to track the chain of transmission and control these epidemics. The public health system in most countries is usually inadequately prepared, as the first line of defense, to diagnose infectious diseases. Early diagnosis coupled with extensive publicity can curb the severity of an epidemic. The implementation of centuries old control measures, such as isolation and quarantine in the event of an outbreak are also effective in epidemic control.

This topic area will focus primarily on the recent Severe Acute Respiratory Syndrome (SARS) outbreak to enhance the understanding of the annihilating effects of global epidemics and explore avenues by which efficient epidemiological surveillance can be carried out on a global scale. The committee will also look at ways in which affected countries, the international community and the World Health Organization intervened in order to prevent the SARS outbreak from developing into a pandemic. With these past interventions as guidelines, the committee will discuss possible ways by which future epidemics can be contained more efficiently.

History of the ProblemThe constant evolutionary arms

race between disease and humans suggests that epidemics have coexisted with humans for several millennia. Perhaps the biggest epidemic outbreak in recent history is the bubonic plague. The name bubonic plague originated

from the name of the swellings (buboes) that occurred in the lymph glands in the groin, underarms, upper neck and below the ears areas after contracting the infection. It came to be termed the “Black Death” in Europe because of its discoloration of the skin and the black tumors that formed after an individual was infected. The Black Death is most often associated with Europe, from 1346 to 1350 (other sources quote 1347 – 1351 (Watts 1)) and rightfully so, since the mortality rate of the Black Death in various parts of Europe rose to between two-thirds and three-quarters of the population (Wild, “The Black Death”). Reliable documentation of the major outbreak from 1346-1350 is scarce and therefore there are inconsistencies in some of the data presented by different medical historians. Watts declares the Black Death the worst epidemic disaster to hit Europe since the collapse of the Roman Empire (1).

There have been records of other infectious disease outbreaks on different scales around the globe, a summary of which is provided in Table 1. In addition to these is the relatively recent influenza epidemic in 1918 that killed 20 to 40 million people worldwide. The case of measles, can also be cited as a fatal incident in epidemic history (Bloom, “Lessons from SARS”).

Recently HIV/AIDS has become the most devastating health crisis in human history. It falls beyond the realms of epidemic and is now termed a global HIV/AIDS pandemic. The enormity of the HIV/AIDS pandemic is unprecedented, and records reveal that 22 million adults and children have died, while 36 million people currently live with HIV. If this progression of the pandemic is not halted, it has been estimated that by 2010, there will be 40 million AIDS orphans. In Asia, where infection rates are spiraling uncontrollably, extrapolations indicate that by 2010 the total annual deaths among people aged 15-49, will increase by 40 percent (Health Action AIDS).

HARVARD WORLDMUN 2004 PAGE 2

OPENING STATEMENT WORLD HEALTH ORGANIZATION


There are ongoing efforts by the global community to arrest the cause of HIV/AIDS, which has the potential of leaving the most horrendous mortality rate in human history.

Another class of epidemics includes sporadic infections, either virgin soil epidemics or resurgence of past epidemics. The case of the Ebola hemorrhagic fever (EHF) is a more localized example of this class. The Ebola virus causing EHF was first identified in 1976 in Sudan and the present-day Democratic Republic of Congo. The World Health Organization classes this as one of the most virulent diseases known to humans with a death rate of 50-90 percent in positively diagnosed patients.

Today, Severe Acute Respiratory Syndrome (SARS) presents an immediate and highly documented case study of global epidemics. Its eventual containment, which was coordinated by the World Health Organization, will

also provide lessons for the control and surveillance of future epidemics.

Statement of the P roblem

Definitions of Epidemics and Related Terms

The roots of the word epidemics lie in two Greek words: demos, which translates to “people” and epi meaning “upon” or “close to”. Its first usage was as a title of a major section of the Hippocratic corpus. Benenson’s definition of epidemics encapsulates the wider usage of the term today. He defines an epidemic as:

“The occurrence in a community or region of cases of an illness (or an outbreak) clearly in excess of expectancy. The number of cases indicating the presence of an epidemic will vary according to the infectious agent, size, and type of population exposed, previous experience or lack of exposure to

the diseases, and time and place of occurrence; epidemicity is thus relative to usual frequency of disease in the same area, among the specified population, at the same season of the year” (Cliff et al. 3).Severe Acute Respiratory Syndrome

(SARS), falls into a subdivision of epidemics known as propagated epidemics. These epidemics arise from a direct transmission via contact with infected individuals or indirectly through a vector (Cliff et al. 5). The initial outbreak of a disease in a non-immune population, which is a population that has never had any experience with the epidemic or for many generations, is termed a virgin soil epidemic (Achon 7). A closely related term to epidemics is pandemics. This term is sometimes used with reference to epidemics that cover a significant global area and affect a high percentage of a population (Achon 7). Increased Travel and Global Epidemics

GLOBAL EPIDEMICSWORLD HEALTH ORGANIZATION

Location Date Disease Mortality Source

Athens 430 BCE Smallpox One-quarter of the Athenian army and countless civilians died

Thucydides, 118

Roman Empire 165-180 CE Smallpox 25-33 percent of infected population died; 3.5-7 million died

McNeill, 116; Hopkins, 22-23

Egypt 165-180 CE Smallpox 30-90 percent decline in number of male taxpayers in several communities

Duncan-Jones, 20-21

Constantinople 541-542 CE Bubonic plague 40 percent of total population; 10,000 deaths per day in the city

Hopkins, 23

Mediterranean region

6th and 7th centuries

Bubonic plague Population reduced by 40-60 percent Gottfried (1983), 11-12

Izumi Province, Japan

735-737 CE Smallpox 44 percent of adult population died; 25-35 percent of the total population died

Farris, 378-81

Japan 812-814 CE Smallpox “almost half ” of the population died Farris, 378-81Cairo 1347-1349 Black Death/

bubonic plagueBetween one-third and one-half of the population (200,000 people) died

Watts, 25-26

“some cities and villages” in England and Italy

1348-1400 Black Death/ bubonic plague

70-80 percent died Herlihy (1997), 17

Europe 1348-1420 Black Death/ bubonic plague

Total population reduced by 30-60 percent

Herlihy (1997), 17; Slack, 15

Table 1 (Alchon 21) – Mortality Associated with Epidemics in the Old World before 1500

Historians concur that with the invention of the steamship came an increase in the risk of disease importation. This served as the impetus for the United States to derive a means of disease surveillance around the world. The result was the establishment of the “Weekly Abstract”, compiled by US consulates in their respective stations in many parts of the world (Cliff et al. 50).

The problem of increased travel presents itself on a grander scale with air travel in the 21st century. The repercussion of increased travel is the exposure of travelers to infections not present in their home countries. Another implication arises from the increasing size of airplanes. In order to quantify the extent to which size plays a role in increasing the risk of travelers contracting an infection, D. J. Bradley (1988) considers a hypothetical case in which any given traveler has a 1 in 10,000 chance of being in the infectious stage of a communicable disease. In a 200-seater aircraft, the probability of having an infected person on board (x) is 0.02, and the number of potential contacts (y) is 199. This gives a combined risk (xy) of 3.98. If the size of the airplane is doubled, x=0.04, y=399, and xy=15.96 (Cliff et al. 358-359). The risk of infections increases exponentially with increase in the size of the aircraft, which clearly illustrates that, the size of an aircraft, coupled with its flying range and speed, present new means for transmission of infections.

Case Study: Severe Acute Respiratory Syndrome (SARS)

Severe Acute Respiratory Syndrome, commonly referred to as SARS is a respiratory disease with high incidences reported in some parts of Asia, North America and Europe. According to the recent findings of a team of investigators, which comprised 13 laboratories in 10 countries and the Center for Disease Control, the etiologic agent responsible for the syndrome is a previously unrecognized

coronavirus. This coronavirus is called the SARS coronavirus, or SARS-CoV. The first symptom exhibited by infected individuals is a high fever (>38oC). Individuals with SARS might also show respiratory symptoms such as cough, shortness of breath and difficulty breathing, which usually develops after two to seven days. In addition to these symptoms, infected persons may experience an overall feeling of discomfort, headaches and body aches.

SARS is a propagated epidemic, which means that it is transmitted via close person-to-person contact. This is evident in the cases of SARS, most of which developed from direct contact with an infected person, or infectious material from a person with SARS. In other words, touching the skin of other people or objects that are contaminated with infectious droplets and then touching one’s eye(s), nose or mouth can spread SARS. Coughs and sneezing are reliable modes of transmission of the coronavirus.

Origin of SARSIt is widely believed that the origin

of SARS is in the southern province of Guangdong, China, where the first purported cases of SARS appeared in November 2002. More documented information though, reveal that the spread of SARS on the international level was initiated by an infected medical doctor from Guangdong who spent the night of 21 February 2003 on the 9th floor of Metropole Hotel in Hong Kong. He infected at least 14 other persons visiting or staying on the same floor. Through this event SARS was transmitted internationally.

How Did SARS Develop into a Global Epidemic?

The 14 guests and visitors, who contracted the coronavirus from the infected medical doctor at Metropole Hotel, subsequently carried the virus with them to their home countries. They infected the hospital systems in Toronto,

Hong Kong, Vietnam and Singapore. The volume of international air travel catalyzed the spread of SARS around the world with unprecedented speed. Excluded from the data set are two guests from the United Kingdom, who did fall ill after contracting the coronavirus and were hospitalized in the Philippines. For inexplicable reasons though, upon their arrival to the United Kingdom, they failed to initiate an outbreak. Hence the United Kingdom, unlike Toronto, Hong Kong, Vietnam and Singapore, did not experience an outbreak seeded by visitors to the Metropole Hotel in Hong Kong.

These events preceded the Global Alert by WHO on SARS, therefore hospital medics in the home countries of the infected guests of Metropole Hotel were unaware of the highly contractible pneumonia-like disease, which was soon to be an epidemic. The information blackout in the early days of the epidemic is partly blamed for the global spread of SARS. Hospital staff were generally not well protected to treat the disease, and hence the first major explosions of the outbreak were in hospitals, infecting staff, other admitted patients and their guests. This initial outbreak sparked a chain of infections that extended to the larger community of family members and close contacts of infected individuals.

The roots of the global outbreak of SARS prompted the WHO to declare a Global Alert on 12 March 2003, for the first time in its history.

Figure 1 and Table 2 summarizes the cumulative number of SARS cases worldwide.

Country SpecificsChina

SARS is thought to have originated in Southern China, where the first purported cases appeared in November 2002. The coronavirus is then believed to have been carried to Hong Kong, Vietnam, Toronto and Singapore. At about the same time, a group of virologists at the Academy of Military Medical Sciences


GLOBAL EPIDEMICS WORLD HEALTH ORGANIZATION



CountryCumulative Number of

Cases2

Number of New Cases Since Last WHO Update2

Number of Deaths

Number Recovered

Date Last Probable Case Reported

Date for which Cumulative Number of

Cases is Current

Australia 5 0 0 5 12/May/2003 27/Jun/2003

Brazil 1 0 0 1 9/Jun/2003 1/Jul/2003

Canada4 250 0 38 194 9/Jul/2003 10/Jul/2003

China5 5327 0 348 4941 25/Jun/2003 11/Jul/2003

China, Hong Kong 1755 0 298 1433 11/Jun/2003 11/Jul/2003

China, Macao 1 0 0 1 21/May/2003 10/Jul/2003

China, Taiwan 671 0 84 507 19/Jun/2003 11/Jul/2003

Colombia 1 0 0 1 5/May/2003 5/May/2003

Finland 1 0 0 1 7/May/2003 20/May.2003

France 7 0 1 6 9/May/2003 11/Jul/2003

Germany 10 0 0 9 4/Jun/2003 23/Jun/2003

India 3 0 0 3 13/May/2003 14/May/2003

Indonesia 2 0 0 2 23/Apr/2003 19/Jun/2003

Italy 4 0 0 4 29/Apr/2003 8/Jul/2003

Kuwait 1 0 0 1 9/Apr/2003 20/Apr/2003

Malaysia 5 0 2 3 20/May/2003 4/Jul/2003

Mongolia 9 0 0 9 6/May/2003 2/Jun/2003

New Zealand 1 0 0 1 30/Apr/2003 25/Jun/2003

Philippines 14 0 2 12 15/May/2003 11/Jul/2003

Republic of Ireland 1 0 0 1 21/Mar/2003 12/Jun/2003

Republic of Korea 3 0 0 3 14/May/2003 2/Jul/2003

Romania 1 0 0 1 27/Mar/2003 22/Apr/2003

Russian Federation 1 0 0 0 31/May/2003 31/May/2003

Singapore 206 0 32 172 18/May/2003 7/Jul/2003

South Africa 1 0 1 0 9/Apr/2003 3/May/2003

Spain 1 0 0 1 2/Apr/2003 5/Jun/2003

Sweden 3 0 0 3 18/Apr/2003 13/May/2003

Switzerland 1 0 0 1 17/Mar/2003 16/May/2003

Thailand 9 0 2 7 7/Jun/2003 1/Jul/2003

United Kingdom 4 0 0 4 29/Apr/2003 30/Jun/2003

United States 75 0 0 67 23/Jun/2003 9/Jul/2003

Vietnam 63 0 5 58 14/Apr/2003 7/Jun/2003

Total 8437 0 813 7452

Table 2 – Cumulative Number of Reported Probable Cases of SARS (WHO), From 1 Nov 2002 to 11 July 2003

(AMMS), in a well-equipped lab in southern Beijing had discovered a new virus, the SARS coronavirus, in samples from some of the earliest patients. They had grown the coronavirus in cell cultures and suckling mice and taken snapshots with an electron microscope. They were then able to relate the virus to a family not known to cause death in humans, the coronaviruses. By the first week of March, the group of virologists, led by Yang Ruifu and Zhu Qingyu, had tentative evidence that the new virus might indeed be linked to the epidemic. The only problem is that the group failed to report their findings to the rest of the world. Even in China, almost nobody knew about their discovery.

The group of virologists did not disclose their findings due to fear of challenging a well-established hypothesis proposed by an esteemed senior microbiologist and member of the Chinese Academy of Engineering, Hong Tao. Hong promoted the hypothesis that atypical pneumonia, as SARS was referred to then, was caused by a Chlamydia bacterium. Yang Ruifu, a member of the team at AMMS said, “it would not have been respectful” to challenge Hong’s hypothesis. Further

still, others say that the Ministry of Health in China had effectively banned alternative views. Consequently the team of virologists neither sought media attention for its findings nor did they alert any of the labs in the WHO network working on deciphering the epidemic.

After the WHO issued the Global Alert on SARS on 12 March 2003, the international consensus about the coronavirus theory, still did not receive a warm welcome within China. With increased awareness of SARS on the global level, the group of virologists at AMMS finally reported their findings to the Ministry of Health. The department though stuck to the Chlamydia theory. The ministry went to the extent of rebuking a virologist, Bi Shengli who announced in a newspaper on 11 April 2003, that his research confirmed the implication of the relation of the coronavirus to the SARS epidemic. In order to control publicity the Ministry of Health set up a group to actively censor information about SARS-CoV studies.

The true extent of the crisis was downplayed to the people of China and the world, but on 20 April, China made a stunning turnaround. This began with the firing of the health minister

Zhang Wenkang and Beijing Major Meng Xuenong for their mishandling of information about the SARS epidemic. The Chinese president Hu Jintao subsequently pledged an all-out fight against the epidemic. Klaus Stohr, the WHO top scientist who is credited with orchestrating the 11 international laboratories that collaborated in the virologic studies that successfully identified the SARS coronavirus, holds that if the AMMS team of virologists in China had publicized their results, they might have accelerated the collective response by days, or possibly weeks.

The use of aggressive public health measures from fever clinics to road blocks to isolation and quarantine helped bring the SARS epidemic close to defeat. The virtual networks of researchers collaborated by the WHO also helped halt further spread of the epidemic. The control measures employed by the international community and the WHO will be discussed in-depth in a later section.

Hong KongFor Hong Kong, the SARS epidemic

was one of the worst crises the country has ever faced. The SARS coronavirus is reported to have been introduced into Hong Kong from Guangdong in China. The virus then infected 1,755 people and killed about 296 others in its stead. Hong Kong’s resident population of almost seven million and its high population density of nearly 6,500 people per square kilometer, made the country a hotspot for the outbreak of SARS. This facilitated some unique modes of transmission such as was witnessed in Amoy Gardens, the housing estate that suffered the worst outbreak when 329 residents were infected through faulty drainpipes. 42 of these residents died as a result of the infection. The SARS epidemic in Hong Kong was also amplified due to its fluid border with China, which experienced one of the worst outbreaks.

Hong Kong is finally off the blacklist of SARS-infected areas, but the region is



SARS: Number of Current Probably Cases as of 19 May 2003, 16:00 GMT+2


still suffering from repercussions other than that of morbidity and mortality. At the height of the outbreak, trading within Hong Kong was hardest hit because most people simply stayed at home. Reports show that nearly 1,300 people were confined to their homes during the outbreak, while experts fought to stop further transmission of the coronavirus. Economic analysts postulate that the extent of the economic damage due to the SARS epidemic, will cost the city billions of dollars in lost business, which will lead it into a possible recession, its third in six years. SARS also caused the escalation of the unemployment rate in Hong Kong to a record high of 8.3 percent. A vital source of income, tourism, was also adversely affected in the wake of the global epidemic.

VietnamThe outbreak of SARS and its

subsequent timely containment in Vietnam has served as an ideal illustration of how of how rapid detection, transparency shown by the government and immediate action can mitigate the annihilating effects of an epidemic. In Vietnam the outbreak began in February, from a single infected patient who was being hospitalized for treatment of a severe pneumonia-like syndrome. The infected patient is believed to have been a Chinese-American businessman who is thought to have contracted the coronavirus in Hong Kong. Following his admission, about 20 members of the hospital staff came down with similar symptoms of the pneumonia-like infection. A total of 63 SARS infections were recorded in Vietnam, including five deaths, all of which are thought to have originated from the index case.

Dr. Carlo Urbani, a WHO communicable diseases specialist in Vietnam, was one of the first clinicians to examine the index patient and subsequently alerted the international community on the potential threat posed by the virus. Dr Urbani later

died from contracting the infection, but his foresight prompted swift action in Vietnam and the international community, which led to heightened global awareness that ultimately saved many lives. The French-run private hospital where the index patient was hospitalized, was immediately isolated and closed to new admissions. This was a critical step in dampening the amplitude of the outbreak in Vietnam. The Vietnamese government was not complacent with its achievement, but went further to allocate $2.6 million towards protection against another wave of the epidemic in Vietnam.

WHO InterventionBecause of the enormous economic

and political ramifications posed by an epidemic, it takes a lot of courage for world leaders to declare to the global community that there is an epidemic within its borders. Following the death of Dr Carlo Urbani, the WHO infectious disease specialist in Hanoi, Vietnam, and similar cases in Hong Kong, along with rumors of the infection in China, the World Health Organization declared a Global Alert for the first time in its history. The alert gave all countries ample time to arm themselves against a potential global epidemic. The reaction to global alerts takes two forms.

In a country with a very competent public health system the health problem might be alleviated, leaving no evidence that something very grand was achieved. On the other hand, if a country has a weak public health infrastructure, the outbreaks could develop into epidemics. However, when officials warn about a probable case of an epidemic, that then fails to spread, billions of dollars may be lost due to sunk-in cost of building defenses against the epidemic.

The WHO employed expertise from around the world in finding the cause of the SARS epidemic. It created a network of 13 laboratories in 10 countries, including the United States’ Center for Disease Control and Prevention (CDC), which identified a virus associated with SARS in two weeks and had its entire genome sequenced in an additional two weeks. The power of electronic communication facilitated the establishment of this virtual network of researchers and promoted the sharing of knowledge in an unparalleled manner, to the benefit of everyone. Based on the timeliness of results obtained from the researchers around the world, it was possible to define the clinical features of the SARS infection and further investigate its mode of transmission.

The WHO simultaneously issued


Extensive public health measures facilitated the eradication of SARS in China.“China’s Missed Chance”. Science. Vol. 301.

an emergency travel advisory based on the preliminary information they had about the epidemic. Since air travel was the key factor in the spread of the infection, the WHO issued the emergency guidance, mainly to travelers and airlines. In the initial stages of the outbreak the WHO did not restrict travel to specific destinations, however it disclosed information to travelers and airline crew about the major symptoms and signs of SARS. These included a high fever (>38°C) and other respiratory symptoms, mentioned earlier. The WHO advised airlines to report any passengers who exhibited these symptoms to airport health authorities for assessment and management. It also recommended that patients with these symptoms be isolated with barrier nursing techniques and treated as clinically indicated.

As the understanding of the infection and its geography increased, the WHO asked travelers to postpone all but essential travel to places that were hardest hit by the SARS epidemic. This included Hong Kong Special

Administrative Region and Guangdong Province, China. Also international travelers from infected areas were screened for SARS before departure.

The initial cases of the SARS infection spread within hospitals, including staff, other patients and visitors. The WHO therefore felt the need to release hospital infection control guidance as a means of halting the spread of the coronavirus. They advised that suspect cases of SARS should be diverted by triage nurses to separate care to minimize transmission to others. Based on clinical and epidemiological data, the WHO defined a suspect case of SARS as an individual with a high fever and cough or breathing difficulty. The WHO asked that hospital medics dealing the infection should protect themselves by the use of facemasks, eye protection and gloves. The WHO also suggested the use of disposable equipment wherever possible in the treatment and care of patients with SARS.

SARS was effectively curbed worldwide through the implementation

of centuries old control measures of isolation, quarantine and travel restrictions. Isolation and quarantine remain, for many, a viable method for the prevention and containment of epidemic diseases. They may either be undertaken voluntarily or compelled by public health authorities. According to the Center for Disease Control and Prevention, both strategies differ in that isolation applies to people who are known to have an illness and quarantine applies to those who have been exposed to an illness but who may or may not become infected. Isolation is usually imposed by governments in the event of an outbreak to protect healthy people from contracting a potentially dangerous infection. Quarantine on the other hand is enforced to prevent the movements of people likely to be infected, in order to break the transmission cycle of an infection. Quarantine has proved medically effective in the control of the SARS epidemic.

In about four months the World Health Organization in collaboration with the global community had managed to arrest the ascent of the SARS epidemic. As early as 28 April 2003, Vietnam was declared SARS-free, as were the Philippines and Singapore on 20 and 31 May 2003 respectively. The last areas to break the transmission of SARS were China and Hong Kong on 24 June 2003.

SARS: Will it be Back?With the emergence of a series of cases

of SARS in areas declared SARS-free, the question haunting most scientists is whether the epidemic will return. In order to answer this question, it is crucial to find out where the virus came from and how it came to infect humans.

Virologists suspect that there is an animal reservoir, an ecological niche, in which the virus evolved and possibly continues to thrive. So far two different species on sale at a Dongmen market were found to contain the virus: civets and raccoon dogs. A fairly high proportion of the early SARS patients


School kids in Hong Kong celebrate aer WHO declared Hong Kong a SARS-free region.http://news.bbc.co.uk/2/hi/asia-pacific/3013042.stm



were found to be “food handlers”, which includes animal wholesalers. This affirms their hypothesis that the coronavirus may have roots in an animal. There are plans by an international network of scientists to perform extensive laboratory experiments to check the susceptibility of different species to SARS-CoV. Hume Field, a veterinary epidemiologist noted that tracing the route of infection back to the animal reservoir could take years. If the natural host of the virus is in animals, then the probability of reemergence is quite high.

In his article, Martin Enserink explores other means by which the SARS epidemic can make a comeback. He explained that the virus may still be spreading at low levels among people who have virtually no symptoms, although such cases, he added, are yet to be found. Researchers suspect that lower temperature, humidity and ultraviolet light during the winter may increase viral stability, and people huddling indoors may facilitate the spread as well. Another possibility is that the coronavirus may be released inadvertently from a hospital or laboratory into the outside environment.

With these uncertainties still lurking, the WHO feels the need for at least a year of surveillance to determine whether the disease has become endemic and to ensure that no new cases go undetected. In the event that the disease is not endemic, the most pressing concerns lie in the possible animal reservoir of the virus. Until the questions about the actual roots of the SARS coronavirus are answered, scientists cannot rule out the possibility that the virus hides somewhere in nature, and like the Ebola virus, will wait for ripe conditions to make its comeback.

WHO: What Next?The immediate action the WHO

hopes to undertake in relation to the SARS epidemic is to revise a 52-year-old international treaty aimed at controlling global health threats. The need to revise this document is stimulated by the

Chinese authorities’ initial dissembling over SARS. Under the proposed new treaty, countries would be forced to notify the WHO immediately of any dangers emerging within their borders. This will put countries under legal obligation to report future public health emergencies of international concern to the World Health Organization, which was demonstrated in the case of Vietnam, and will inevitably help curb epidemics to a greater extent and with more speed.

Questions a Resolution Must AnswerUnanticipated outbreaks will continue

to be a reality. What lessons from the SARS outbreak will increase the capacity of countries to identify and react quickly to public health threats of a similar kind?

What role can the WHO play in strengthening the public health systems of developing countries to increase their preparedness and actions in the case of a global epidemic outbreak?

It took approximately four months for the WHO to successfully contain the epidemic. Are there any steps during its control that the WHO could have eliminated or added to accelerate the time in which the cycle of transmission of the epidemic was broken?

The newest WHO resolution is to pass a treaty that requires countries to report any incidence of potential epidemics. This requires a high level of surveillance within individual countries as well as knowledge of protective measures. How can the WHO reconcile its objectives with the socioeconomic level of most developing countries?

A BBC news report says that following the containment of the epidemic, China threatened to execute or jail for life anyone who breaks SARS quarantine orders and spreads the virus intentionally. Are these measures appropriate, or do they have the potential of being counterproductive? What other measures can governments employ to ensure that individuals do not cover up information about an epidemic?

There is still the pressing question of the reemergence of the SARS virus. With the latest news reports, are we any clearer about these prospects?

Suggestions for Further ResearchThe WHO, despite some hitches,

managed to contain the SARS epidemic. In order to evaluate the impact global surveillance on containing epidemics, you might want to refer to the WHO daily records (www.who.int) of SARS infected individuals in a country of your choice. Try to record any trends and use this information to draw appropriate conclusions on the usefulness of such records. If possible link it to the success rate of SARS eradication in this country.

In order to enrich our experience as a committee, be sure to analyze the practicality of global surveillance of epidemics and the preparedness of public healthcare infrastructure to deal with epidemics, in the individual countries you are representing. Periodicals and periodical search engines like LexisNexis are usually very useful in getting up to date information and often have subcategories that allow you to search medical periodicals as well.

TOPIC AREA B:PHARMACEUTICALSAND DEVELOPING COUNTRIES

Millions have died from AIDS due to lack of access to treatment.

PHARMACEUTICALS AND DEVELOPING COUNTRIESWORLD HEALTH ORGANIZATION

IntroductionAccess to healthcare remains as

the fundamental basis of survival for the human race, yet it is in the healthcare sector that the gravest inequities exist, between nations and even between the different socioeconomic classes within a nation. With the initiation of the “Health for All” strategy in 1981 by the World Health Organization, health is now recognized as a fundamental human right. For the majority of the world’s population living in developing countries though, this basic right is far

from being fulfilled (Patel.The major problem faced by

many developing countries, is the lack of research into diseases prevalent in these countries. Investment into research of this kind is generally unattractive to profit-making pharmaceutical companies because of political and economic instability in most developing countries. Another sphere of this problem, which most pharmaceuticals are facing on the supply side of HIV antiretroviral drugs is that, even in cases where the drugs are available for combating certain illnesses, there is not a sustainable demand

market for these drugs. This makes the attempted provision of drugs futile. It is a no-win situation where both developing countries and pharmaceuticals lose. This topic area will consider malaria in sub-Saharan Africa, to study how the gap between pharmaceutical supply and demand of developing countries can be bridged. In order to expound on the developing countries-pharmaceuticals predicament, this study guide will also take a look at different means by which HIV antiretroviral drugs are currently being made more accessible to HIV/AIDS infected patients in sub-Saharan


Figure 1: Global Summary of the HIV/AIDS Epidemic (UNAIDS). is figure gives a regional distribution of HIV/AIDS around the world.

PHARMACEUTICALS AND DEVELOPING COUNTRIES WORLD HEALTH ORGANIZATION


Africa. The committee will propose ways by which the World Health Organization can collaborate with individual governments of developing countries, Public and Private pharmaceuticals and organizations, in order to make drugs accessible to developing countries at an optimal cost to all parties involved. We will also discuss incentives that could be initiated by WHO to encourage disease research in developing countries.

History of the Problem

Global HIV/AIDS PandemicThe HIV/AIDS epidemic has been

around for nearly 30 years now and the world is not getting any closer to winning its battle against it. Instead, the annihilating effects are spiraling out of control, with some areas being hit harder than others. The number of infected individuals has skyrocketed. To date the AIDS epidemic has claimed the lives of 18 million people and another 42 million people globally are living with the virus (UNAIDS).

In Africa, the epicenter of the AIDS

crisis, the epidemic has and is continuing to strip most sub-Saharan African countries of their human, economic and financial resources and capacities on which development and political stability depend. Life expectancy in the worst hit countries has reduced enormously and the number of HIV/AIDS orphans in the

continent is ever increasing. According to reports by UNAIDS and the WHO, about 70 percent of newly-infected HIV cases reside in sub-Saharan Africa, while children in sub-Saharan Africa form 90 percent of newly-infected cases in persons under the age of 15 (UNAIDS).

In Southern Africa, the impact of AIDS is compounded by the food crisis that swept through the region, driving most countries to destitution. It has been estimated that in Southern African countries such as Botswana, Namibia, Swaziland and Zimbabwe, more than one out of five persons between the ages of 15-49 is living with the HIV/AIDS virus. At the turn of the century, Zimbabwe and Botswana had an exceedingly high rate of HIV/AIDS infection in pregnant women, where between one fifth and one half of all pregnant women were found to have contracted the virus. Health estimates indicate that, of these women, at least one third pass the infection on to their babies (UNAIDS).

As shown in Fig. 3, population estimates indicate that were it not for the inception of HIV/AIDS, the number of people dying at the age of 15-34 in South Africa would be gradually decreasing. Instead, the mortality rate in

Figure 2: ere has been an exponential increase in the number of people living with HIV/AIDS in sub-Saharan Africa.

Figure 3: e mortality rate of South Africa has shot up as a result of the inception of HIV/AIDS.


this region has shot up, and is expected to reach a devastating level of nine times what it was in 1980. For all the tangible consequences of AIDS, a silence born of shame and blame continues to obscure the epidemic in many of even the hardest-hit countries, which inevitably fuels the disease’s ability to thrive. A WHO survey notes that in many sub-Saharan countries with high infection rates, women refused to be tested if they were at a high risk of being infected, or even when tested very few returned for their results. The first step in reversing the course of the HIV/AIDS epidemic lies within the means of affected countries and that is to break the silence in order to expose the epidemic. To quote the South African president Thabo Mbeki, “ For too long we have closed our eyes as a nation, hoping the truth was not so real” (UNAIDS). Evidence of the positive impact of destigmatizing and demystifying AIDS has been observed in Uganda where a giant leap has been made in controlling the AIDS epidemic (UNAIDS). The other means of curbing the upward trend of the HIV/AIDS epidemic is by increasing access to the HIV antiretroviral drug. This requires a concerted effort of affected countries, the international community and public and private organizations. The role of pharmaceuticals or lack thereof in combating HIV/AIDS will be dealt with critically in a later session (UNAIDS).

Malaria in AfricaMalaria is another deadly disease,

which unlike HIV/AIDS has been around for much longer and is very preventable and treatable, yet continues to claim the lives of a good fraction of people in Africa. According to a WHO report, malaria remains the number one killer of young children in Africa (WHO). Detailed reports released by the WHO show that about 90 percent of all malaria-related deaths in the world today occur in sub-Saharan Africa. Fig. 4 shows the relative proportions of mortality due to malaria in Africa

compared to the rest of the world. This extremely disproportionate number of malaria patients in sub-Saharan Africa can be attributed to the causative agent Plasmodium falciparum, the most dangerous of the four human pathogens causing malaria, coupled with an equally hard-to-contain vector (or carrier), the Anopheles gambiae mosquito. A closer look at the affected age groups reveals that about one million people in Africa die from malaria each year and most of these are children under five years old (WHO). The high mortality rate due to malaria is partly a result of the multiple

dimensions by which death from malaria can occur. The three principal ways by which malaria can contribute to death in young children are:

· the progression of a simple malaria infection into cerebral malaria, which manifests itself as seizures and coma that may result in death;

· severe anemia (and ultimately death) resulting from repeated malaria infections.

· the high chance of pregnant women with malaria giving birth to children with low birth weights,


Figure 4: e relative ratio of deaths due to malaria in Africa and the rest of the world.



which in several cases increases the risk of death in the first month after birth (WHO).

the progression of a simple malaria infection into cerebral malaria, which manifests itself as seizures and coma that may result in death;

The case of malaria in Africa underscores the fact that, even in the case of very preventable diseases, access to drugs in many developing countries is below the optimum amount that is needed to arrest the ever-increasing mortality rates.

Statement of the Problem“Imagine you walk for a half-day to the only clinic within 100 km. You are diagnosed with diabetes. Drugs are available to treat you, but imagine their monthly cost is equivalent to your yearly salary. What if there was only one Drug Company making insulin and they stopped production because it was not profitable to treat you? - “Turn rhetoric into reality” (Medecins san Frontieres).

Case StudiesHIV Antiretroviral Treatment Too Costly for the Developing World

The AIDS epidemic is not an impossible hurdle to overcome in today’s highly resourceful and technological world, but having the necessary resources available in the right places at the right time is crucial to handling the AIDS crisis. At present, there is only one form of HIV/AIDS treatment, which helps in slowing down the spread of HIV virus. The development of this drug, the HIV antiretroviral drug, was the result of a concerted effort of public and private research groups. The molecular basis by which the HIV antiretroviral works relies on a set of drugs called protease inhibitors. This presents a problem in the usage of the HIV antiretroviral drugs, since the treatment can only work effectively when taken in large quantities. Even a small quantity of HIV protein unbound by the antiretroviral drug can easily spread the virus. The usage of this

form of treatment therefore requires close supervision in monitoring the dosages and its effectiveness (Day).

The antiretroviral drugs are available to HIV/AIDS infected individuals in developed countries at a high price. In certain parts of Europe and the United States, treatment is available for US $10,000-US $15,000 per patient per year. This cost inflation can be partly attributed to the added financial cost introduced by the acquisition of patents by western pharmaceutical companies (Day, 2001). Economic and health analysts concur that making antiretroviral drugs available to HIV/AIDS infected individuals in developing countries, especially in sub-Saharan Africa can successfully contain HIV/AIDS there. In South Africa where the government has strived to make drugs available to patients at a much lower cost of US $500 per year, most households are still unable to afford these drugs. Clearly, even though developing countries are most in need of HIV antiretroviral drugs, they do not have the financial capacity to provide an adequate demand market to match pharmaceutical supply of the drugs. Pharmaceutical companies on the other hand, cannot single-handedly deliver drugs to developing countries at a price that will be affordable to the majority of impoverished households residing in the developing world. This is because pharmaceuticals are kept in business by investors who expect some return on their investments. In order to stay in business, drug companies are therefore more inclined to focus their research and development on more profitable ventures. An additional deterrent is that pharmaceutical companies are not guaranteed sustained patents on HIV antiretroviral drugs and hence the likelihood that they might be undercut by cheaper generics makes the market of drug supply to the developing world less appealing.

It will evidently take multiple parties to address the problem of minimal access to drugs in developing countries.

The governments of developed countries are equipped with the technological and financial resources to fight AIDS, an economic self-interest and an ethical imperative to do so. To date though, the developed world has intervened very little in curbing this crisis. Having said that, the fight against HIV/AIDS does not rest on the arms of the developed world alone, but demands input from governments of developing countries and public and private pharmaceuticals and organizations (Day).

Access to Malaria Treatment in Developing Countries

In comparison with the cost of HIV/AIDS treatment, the cost incurred in malaria treatment is considerably less. Insecticide Treated Nets (ITN’s) are a low-cost and highly effective way of reducing the incidence of malaria in people. Recently the WHO has prompted the development of a more cost-effective net—the Long-Lasting Insecticidal Net, which requires no further treatment during its expected lifespan of four to five years. On average these mosquito nets cost US $5, yet the majority of impoverished African households cannot afford them. The cost of Insecticide Treated Nets has therefore been recognized as a barrier to their widespread use. The production, development and marketing of other forms of malaria drugs is not a highly patented industry, which suggests that the inability of most developing countries to afford the necessary treatment to combat malaria and other ailments is multifaceted. The reasons for which drugs are inaccessible to the majority of the developing world may therefore include the abject poverty level of many African countries, the relatively high cost of treatment, tariffs and sales taxes, and above all, a lack of sufficient international financial aid for the treatment of illnesses most commonly associated with the developing world


(11).

Pharmaceutical PatentsThis section will take an in-depth

look into the operation of pharmaceuticals and also the role of intellectual property rights; we will consider the specific case of patents, and how they impede access to drugs in developing countries. There is still ongoing debate surrounding the relevance of patents. Governmental and non-governmental organizations argue that patents induce a significant increase in the basic cost of drugs, thereby impeding access to these drugs in the majority of the developing world. Pharmaceutical firms on the other hand, are of the notion that patents create a necessary incentive for expensive research in areas that are under-explored such as HIV/AIDS and malaria in the developing world.

WTO TRIPS AgreementPatents were introduced in the 18th

century, and have spurred arguments about their effectiveness and necessity ever since. A patent is a document granted by a government to an inventor, which protects the inventor from imitations, thus giving the innovator a monopoly in the market for a period of up to 20 years. During this period, the inventor is the sole owner of the invention, making this a hotly-debated issue, especially when it comes to trade and access across borders (”Patents”).

The World Trade Organization (WTO) Trade Related Intellectual Property Rights (TRIPS) agreement, was negotiated with other international trade agreements during the Uruguay Round trade negotiations of the GATT (General Agreement on Tariffs and Trade) from 1986 to 1994. As applies to all World Trade Organization agreements, TRIPS is totally binding for all WTO Member States. The TRIPS Agreement sets minimum standards in the field of intellectual property (IP—such as patents) protection that all WTO Member countries have to comply with. To be in line with the set requirements,

WTO Members have to modify their IP laws to make them agreeable with the new WTO standards. For instance, the TRIPS Agreement states that all patents shall be available for at least 20 years from the filing date, whereas before the inception of TRIPS, the patent term varied from country to country. All WTO members are therefore required to incorporate this standard 20-year patent term in their own national patent law.

It is important to note that, before the Uruguay Round and TRIPS, pharmaceutical patents and other IP rights on drugs, were extensively used in major industrialized countries but not in many developing countries. Under the new TRIPS Agreement though, all WTO Members have to make patents available for pharmaceutical inventions in their countries. The WTO acknowledges that the inclusion of pharmaceutical patents in the new WTO/GATT rules could potentially aggravate the already existing problem of access to drugs in developing countries, by disabling the use of generic drugs until the patents on new medicines expire (WHO). The TRIPS Agreement has made provision for compulsory licensing as a check on monopoly. The agreement gives countries the right to include in national legislation safeguards against patent monopolies that might obstruct access to basic healthcare. In relation to HIV/AIDS, a UN report argues that developing countries that choose to produce AIDS drugs under the TRIPS compulsory licensing to fight the epidemic have a strong case against pharmaceutical companies intent on protecting their patents (Macan-Markar).

Arguments Surrounding the Use of Patents in Research

The most commonly cited argument for the use of patents is that it has the potential to attract expensive and groundbreaking research in areas that are currently underexplored. Another school of thought admits that this argument only holds in developed countries where

the incentive to innovate is mainly driven by those markets with a strong demand. Most developing countries do not fall into this category, hence the argument of increased research and innovation does not hold. An analytical report on pharmaceuticals and developing countries further nullifies this argument by revealing that developing countries make up less than 20 percent of the global drug market due to the low purchasing power in these countries. A further breakdown shows that Africa as a whole, accounts for a meager 1.1 percent of global sales of pharmaceuticals. These figures signify that the markets in developing countries, especially in Africa, do not affect the polarity of research and development in the industrialized world (Combe et. al.).

The following conclusions can be drawn from this analysis: the HIV antiretroviral drug market in developing countries has a negligible effect on research and development of new drugs in developed countries; and secondly, generics sold in developing countries are unlikely to find a sustainable market among industrialized countries because local firms cannot match the technological capital of industrialized companies, so that imitation does not represent a significant threat to the innovator’s profit (Combe et. al.).

Related studies on pharmaceuticals and patents conducted by two Harvard University affiliates and UNAIDS on the patent status of HIV antiretroviral drugs revealed that patents are not systematically applied for in developing countries. They carried out a survey on the patent statuses of 15 HIV antiretroviral drugs in 53 African countries. Their results showed that antiretroviral drugs are patented in very few African countries, including South Africa. This observation could not be attributed to a lack of patent laws, since the two researches also noted that, there were provisions for patent protection in most of these countries. Their studies did not uncover any correlation between




patent coverage and access to HIV antiretroviral drug treatment in Africa, suggesting that patent laws contrary to popular believe, do not present a barrier to access to HIV/AIDS treatment. The research therefore concluded that other factors such as poverty and the high cost of treatment could be some of the barriers to treatment access. Tariffs, sales taxes, and the lack of international monetary aid, also present another dimension of inhibitors to HIV antiretroviral drug access. (Attaran et. al.)

Past ActionsThe inequities in research and

development and access to drugs especially in the developing world are mainly due to the non-profitability of these markets coupled with some economic and institutional barriers. Most of the attempted solutions to this problem have been based on the economics of the supply side (”push” policy) and the demand side (”pull” policy) of the market.

As already mentioned push mechanisms only affect the supply side of the market. These policies take the form of providing subsidies for research input,

Research and Development tax credits or grants to researchers. Push policies have an overall effect of reducing the costs of investments by facilitating regulatory processes for the new pharmaceuticals, an example of which is fast regulatory approval for HIV antiretrovirals. Some economists have argued that since the malfunctioning of the drug market in developing countries is more a failure of the demand side rather than the supply side, push mechanisms do not necessarily alleviate the barriers to treatment access in developing countries. They have therefore proposed the pull mechanism as being more effective in spurring HIV/AIDS and malaria research in developing countries.

Pull programs generally influence the demand side of the market. Pull mechanisms such as purchase pre-commitment, which requires the buyer to commit to a given quantity of products, definitely offer more attractive incentives to pharmaceuticals over the traditional push-type incentive. An added advantage of the pull system is that it does not involve the “traditional moral hazard and information asymmetry problems” that usually reduce the

effectiveness of push policies. The pull mechanism in effect rewards the actual outputs of research and development. They therefore serve as a better incentive for research work focused on developing more marketable forms of treatment, especially in developing countries (Combe et. al.).

Most of the systems set up to resolve the lack of access to treatment in developing countries integrate the push or pull mechanisms into organizational networks of public and private institutions. Public and private partnerships pull in the resources offered by public and private organizations, along with individual governments, in dealing with the health problems faced by the world’s poorest. The major problem with these partnerships is how efficiency and full potential can be reached without necessarily encountering a conflict of interest for the each, involved groups. Reich, in his paper on Public-Private partnerships, notes that reaping the potential benefits of these partnerships requires more than a charitable donation of a drug or vaccine. Fundamental to the success of such partnerships is an efficient organizational framework that

Global activists worldwide advocate for a bridging of the global gap between developing and developed countries


gets the treatment from producers to the consumers (Combe et. al., 2003).

The next section will take an analytical look at existing solutions to help us structure a balanced and effective method to increase access to drugs in the developing world.

Roll Back Malaria PartnershipRoll Back Malaria is a multiple party

partnership marshaled by the WHO and UNICEF. Other partners in this initiative include governments of malaria-endemic regions, donor governments, international organizations, the private sector, and civil society bodies. The Roll Back Malaria initiative was launched in 1998 with the goal of halving the burden of Malaria in Africa by 2010. It also set midway targets for certain intervention strategies at the Abuja Malaria Summit in April 2000. These strategies included the provision of timely access to treatment, the use of ITNs and the prevention and control of malaria in pregnant women (WHO).

The partners in this venture realized that the effective combat of malaria required an extensive monetary input. At the Abuja Malaria Summit it was estimated that at least US $1 billion is needed to tackle malaria. In line with this target, the international spending on malaria has doubled to approximately US $200 million per year, since the launch of Roll Back Malaria. It is also hoped that more financial resources can be tapped through the initiation of debt relief strategies.

The Roll Back Malaria initiative identified the cost of ITN’s, which is estimated at US $5, as a barrier to its usage in developing countries. Hence, at the close of the Abuja Malaria Summit, governments of countries with a high incidence of malaria agreed to either waive or reduce tariffs and sales taxes on anti-malaria treatment and related goods and services. Another means of reducing the cost of nets is by facilitating technology transfer so that ITN’s can be produced locally in many African

countries. This project is currently underway under the supervision of the WHO and the Roll Back Malaria Partnership. It has been projected that these measures will reduce the burden of malaria treatment on most households in Africa (WHO).

African Comprehensive HIV/AIDS Partnerships (ACHAP)

The African Comprehensive HIV/AIDS Partnerships is a public/private sector initiative jointly developed by the government of the Republic of Botswana, the Bill and Melinda Gates Foundation, and the Merck Company Foundation/Merck & Co., Inc. ACHAP, even though independent of the WHO, is an ideal case study since it integrates the resources and potential of the key players needed to address the HIV/AIDS pandemic. The principal focus of the partnership is to improve the national response to the HIV/AIDS epidemic in Botswana, in four strategic intervention areas. These include areas of prevention, care, support, and treatment. The long-term goals of the partnership are to optimize research and develop tools that could be emulated by other public/private partnerships with similar objectives in developing countries. The fundamental challenge faced by such a public-private partnership is linking both national and grass-root level projects and organizations to create a unified and effective effort, rather than dissociated working components.

The Bill and Melinda Gates Foundation have dedicated US $50 million over a five-year period. Merck matched the Gates Foundation’s contribution with US $50 million and have offered their own research of HIV/AIDS treatment. Merck will donate two antiretroviral medicines for the duration of the ACHAP program. Since its launching in July 2000, ACHAP has undertaken a wide range of projects in Botswana to alleviate the HIV/AIDS crisis. The rapid uptake of programs by the people of Botswana signifies the

will and commitment on the part of the Government to attain Botswana’s stated goal of an AIDS-free generation. Some of ACHAP’s projects include capacity building in human resources and infrastructure and the provision of technical advice and support. ACHAP has also facilitated programs such as condom research and distribution, coping and counseling centers for people living with HIV/AIDS, an antiretroviral therapy program and the establishment of a state-of-the-art Botswana-Harvard AIDS Institute HIV Reference Laboratory (ACHAP).

The Global Fund to Fight AIDS, Tuberculosis and Malaria

The idea of an international fund to fight HIV/AIDS, tuberculosis, and malaria was first presented at the July 2000 G-8 Summit in Okinawa. Following that, in June 2001, at the urging of UN Secretary-General Kofi Annan and several national leaders, the UN General Assembly Special Session on HIV/AIDS unanimously approved the concept of a Global Fund. By the time of their next, G-8 leaders had pledged US $1.3 billion in support of the fund (globalfundatm.org).

The Global Fund to fight AIDS, Tuberculosis and Malaria was officially founded in 2002 as a charitable Swiss foundation, to pool and disburse substantial new resources to fight the world’s most killer diseases. As of July 2003, the fund had attracted US $4.7 billion in pledges over eight years from 40 countries, major foundations and private donors. The Global Fund is currently running under a performance-based system of grant-making, in which grants are disbursed based on a review of the feasibility and possible success of locally-developed proposals (theglobalfund.org).

Pharmaceutical companies have already expressed an interest in selling HIV/AIDS treatment to the fund at a much lower cost, to be used in poor countries (Sykes, 2002). Proponents of




this form of purchase fund argue that it would provide the necessary incentives to persuade the pharmaceutical industry to expand its research efforts to the world’s poor (Reich).

Proposed SolutionsMany of the programs and efforts mentioned above look towards long-lasting solutions. Along with the expansion of such programs, the Global Fund seems like a giant step in the right direction to bring to the world’s attention the deplorable state of health in many developing countries. Even in its nascent stage, the Global Fund has great potential in joining nations from all over the world in a moral quest to save the world’s poorest from HIV/AIDS, Tuberculosis and Malaria. The potential of the Global Fund to have an enormous impact lies in its global coverage. Yet, its grand scale of operation could equally introduce administrative and organizational problems that could counteract the efficiency of the Global Fund. The committee will discuss this and other possible loopholes that might handicap the Global Fund. We will then propose ways by which the effectiveness of the Global Fund can be optimized.

Questions A Resolution Must AnswerIn what ways can the World

Health Organization intervene in large public/private partnerships, such as the Global Fund, to ensure that there is a concentrated and coordinated effort among the parties concerned?

Who should the decision-making parties of the Global Fund partnership be—the WHO, donor countries, pharmaceuticals or Governments of developing countries?

Aid reports show that most developed countries as of 1999 (Table 1), had given much less than the United Nations targeted aid amount. Based on this, how can the WHO create a buffer system to guarantee that programs sponsored by the Global Fund can be sustained, especially since the major

source of funding for the Fund is dependent on the generosity of the international community?

Recently, the United States president, George Bush, pledged US $15 billion over a five-year period to fight HIV/AIDS in Africa. While this is a major increase on previous aid amounts, the funds were not channeled through the Global Fund. Will such unilateral donations hamper the progress of the fund? Is the WHO obliged to encourage a unified effort among nations via the Global Fund, and how will the WHO achieve this?

After considering the case studies, we can appreciate that lack of treatment access is a complex issue, which requires an integrated approach. Access to drugs basically involves supply and distribution. What institutional framework in developing countries can be advocated by the Global Fund to ensure that the people in need of treatment receive it?

In 2001, the director of the United States Agency for International Development said that AIDS drugs “wouldn’t work” because of the inability of many Africans to tell “western” time. Recent surveys in certain parts of Africa have shown that 90 percent of patients follow their treatment, as compared to 70 percent in the United States (New York Times). It will be helpful to read the article (included in the appendix) to understand why the fear of patients not complying with the treatment is valid: Doctors and other medics dread that the misuse of the drugs will result in drug-resistant strains. Are these fears valid enough to not supply drugs to developing countries? What better

solutions can you propose?

Suggestions for Further ResearchThe topic area does not provide

much in-depth information on the monetary endowment and organization of the partners involved in the Global Health Fund for AIDS, Tuberculosis and Malaria. www.theglobalfund.org is a good resource for exploring these

items. This will facilitate discussion and suggestions on how the Global Health Fund should be managed and also its sustainability. The UNAIDS site is useful for information on HIV/AIDS, as well.

By the time of the conference, Nelson Mandela (former president of South Africa), would have launched his anti-AIDS music-led campaign, “46664” to raise funds for antiretroviral drugs and increase awareness of the AIDS pandemic in South Africa. Drawing from the international participation, the involvement of song artists and the overall success of the campaign, come up with ideas on how the media and pop culture can increase awareness of the deplorable state of healthcare in developing countries and advocate for more aid for drugs. Once again, LexisNexis and other such search engines will be invaluable. If you are stuck in your research, please do not hesitate to e-mail me. Good luck!

CONCLUSION

Due to the sporadic occurrence of epidemics, its potentially devastating impact is often undermined; hence by focusing on the recent SARS outbreak, I advocate the need for sensitization on epidemics and global alertness. The topic area on pharmaceuticals and developing countries is a reflection of lack of access to drugs in the developing world today. I hope you enjoyed reading it, as much as I enjoyed researching and putting it together. I believe that at the end of the conference we will be able to formulate resolutions that would potentially ameliorate healthcare on a global scale.

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Topic Area B

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Presse-Agentur, Deutsche. “Pharmaceutical Companies Back UN on AIDS Drugs”http://www.globalpolicy.org/socecon/develop/aids/2001/0405unsg.htm

Reich, Michael R. “Public-Private Partnerships for Public Health”

Reich, Michael R. “The Global Drug Gap”. Science, 287 (5460), 1979-1981. March 2000.

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Shann, Frank. “Few Rich Countries Attain UN’s Aid Target for Poor Countries”. British Medical Journal 323(7313). September 2001.

Schoofs Mark and Michael Waldholz. “Price War Breaks Out Over AIDS Drugs in Africa as Generics Present Challenge”. Wall Street Journal. March 6, 2001.

Smith, Richard. “Vaccines and Medicines for the World’s Poorest: Public-Private Partnerships Seem to be Essential”. British Medical Journal, 320(7240). April 2000.

Sykes, Richard. “Commentary; The

Reality of Treating HIV and AIDS in Poor Countries”. British Medical Journal. Vol. 324(7331). January 2002.

The Global Fund to Fight AIDS, Tuberculosis and Malaria: An International Meeting To Support the Global Fund. http://www.theglobalfund.org

UN Studies AIDS Impact on Africa. http://news.bbc.co.uk/2/hi/afr ica/3115208.htm

World Health Organization. Report; International Seminar on ‘Global Public-Private partnerships for Health and Equity’. Rome, Italy, 2003.

APPENDIX

NB. The United Nations target is 0.7% of GDP

September 3, 2003, Wednesday

FOREIGN DESK

Africans Outdo U.S. Patients In Following AIDS Therapy By DONALD G. McNEIL Jr. (NYT) 1530 words

Contradicting long-held prejudices that have clouded the campaign to bring AIDS drugs to millions of people in Africa, evidence is emerging that AIDS patients there are better at following their pill regimens than Americans are. Some doctors, politicians and pharmaceutical executives have argued that it is unsafe to send millions of doses of antiretroviral drugs to Africa, for fear that incomplete pill-taking will speed the mutation of drug-resistant strains that could spread around the world. The danger already exists: nearly 10 percent of all new H.I.V. infections in Europe are resistant to at least one drug. For Africa, the issue is particularly touchy because it is tinged with racism. In 2001, for example there was an outcry

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when the director of the United States Agency for International Development said that AIDS drugs ‘’wouldn’t work’’ in Africa because many Africans don’t use clocks and ‘’don’t know what Western time is.’’ Now surveys done in Botswana, Uganda, Senegal and South Africa have found that on average, AIDS patients take about 90 percent of their medicine. The average figure in the United States is 70 percent, and it is worse among subgroups like the homeless and drug abusers. Compliance has become easier because drugmakers from India and elsewhere are beginning to make triple-therapy cocktails that come in as few as two


pills a day. (These are not available in the United States yet because of patent problems -- no Western company makes all three drugs for an ideal cocktail.) After nearly a decade of watching Africans die because AIDS drugs cost $10,000 or more a year per patient, rich nations began pledging aid after generic competition in 2001 drove prices down to about $300 a year. Last week the World Trade Organization agreed to alter its rules to give poor nations more access to life saving medicines. But as with any epidemic moving through a poor and ill-educated populace, the threat of disaster clings like a shroud. Patients in badly supervised programs

have been caught selling pills or sharing with desperate relatives -- acts of greed or mercy that could lead to doomsday strains of the virus. Anti-retroviral therapy ‘’is the No. 1 priority for the developing world,’’ said Robert C. Gallo, director of the Institute for Human Virology and a pioneer in researching H.I.V., the virus that causes AIDS. ‘’But it will be a tragic mistake if it’s not done right. You’ll have ‘Eureka!’ and ‘Thank you, America!’ for two or three years -- but then you’ll get multi-drug resistance, and whoops. . . .’’ Drug-resistant strains are inevitable, doctors say, and turn up in every illness from malaria in Africa to children’s ear infections in Manhattan. Hard-to-cure variants evolve spontaneously in response to drugs. But they are more likely to grow and be passed on if patients skip doses, because triple therapy often suppresses even mutant strains. To avoid an epidemic of incurable AIDS, new drugs must be discovered faster than old ones become useless. Africa can still do better than the West, they say, by avoiding old mistakes. Today’s drugs are more potent and no one will spend years on one drug, thereby breeding resistance, as many Westerners did on AZT before triple therapy emerged in 1996. Moreover, doctors say, most African patients are zealous about their regimens. They are also more truthful when estimating their adherence, said Dr. David Bangsberg, a professor of medicine at the University of California in San Francisco who has studied compliance patterns here and abroad. On average, he said, American patients tell their doctors that they are doing 20 percentage points better than they really are -- that is, a patient who says he takes 90 percent of his pills will, when tested with unannounced home pill counts or electronic pill-bottle caps, turn out to be taking 70 percent. A study of 29 Ugandan patients found that, on average, they estimated that they were taking 93 percent of pills and

Country % of GDP $Billions

United States 0.10 9.15

Italy 0.15 1.81

Greece 0.15 0.19

Spain 0.23 1.36

United Kingdom 0.23 3.40

Australia 0.26 0.98

Portugal 0.26 0.28

Austria 0.26 0.53

Germany 0.26 5.52

New Zealand 0.26 0.13

Canada 0.28 1.70

Belgium 0.30 0.76

Ireland 0.31 0.25

Finland 0.33 0.42

Japan 0.35 15.32

Switzerland 0.35 0.97

France 0.39 5.64

Luxembourg 0.66 0.12

Sweden 0.70 1.63

Netherlands 0.79 3.13

Norway 0.91 1.37

Denmark 1.01 1.73

Table 1 (Shann, 2001) – Net Overseas Development Aid Given by Countries in the Organization for Economic Development Cooperationand Development as a Percentage of GDP in 1999

Source: http://www.oecd.org/dac/images/ODA99amo.jpg.

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proved to be taking 91 percent. Though poor, more than 80 percent of the Ugandans had jobs, though most earned less than $50 a month. Most were women in their 30’s, and paying $27 a month for their twice-a-day, three-drugs-in-one pill called Triomune, made by Cipla Ltd. of Bombay. In many such cases, explained Dr. Merle A. Sande, a University of Utah medical school professor who also works in Uganda, the whole extended family, possibly with several infected members, will chip in so that one member will be saved to care for the children. ‘’If the whole family is pooling its resources to pay for you,’’ he said, ‘’you damn well better take your drugs. ‘’That’s a whole different scenario from the U.S., where patients get free medicine, and if they change therapy, will let a month’s worth go to waste.’’ Several doctors in Africa said their patients were highly motivated because they had seen friends or family die. Most come in only when deathly ill, so the drugs seem to perform a miracle, making them well enough to go back to work. And even $1 a day is a lot, so they treat it as ‘’an investment,’’ said Dr. Elly Katabira of Makerere University Medical School in Uganda. In Botswana, with the world’s highest infection rate, pill counts on 400 of the 10,000 patients on therapy showed that 85 percent were taking their pills flawlessly, said Dr. Ernest Darkoh, the national program manager. ‘’If you loosen the criteria a little -- missing a dose by two hours, for example -- you get about 90 percent,’’ he added. There are a few exceptions, he admitted: ‘’Some people bring back their pill containers saying, ‘Thank you, but my traditional healer told me not to take these.’ ‘’ However, some programs are not as good as others. In Nigeria, Africa’s most populous country, an ambitious, widely praised plan to get generic drugs to 15,000 citizens has been hampered by

bureaucracy, corruption and a scarcity of laboratories. Dr. Ernest Ekong, an AIDS specialist at the Military Reference Hospital in Lagos who has made Nigeria’s case at international conferences, at first said adherence so far has been ‘’no problem.’’ Then he began to qualify that. Some patients, he said, have felt so well that they shared pills with friends who could afford the $10 monthly charge. Some who developed ‘’nevirapine rash,’’ or nerve tingling, cut back. ‘’And,’’ he admitted, ‘’a very small percentage are selling their drugs.’’ Non-adherence, he said, is worst among patients with co-infections that require more pills -- tuberculosis patients, for example, must also take four antibiotics. No formal resistance study has been done, but Nigerian doctors are worried about a few patients who are taking all their pills but not getting better -- a sign that they might have resistant strains. The best adherence seems to come under tight supervision. A recent study in Cape Town found that older patients, patients who took pills twice a day instead of three times, and patients who spoke the same language as clinic staff members tended to do best. In May 2001, Africa’s best-known pilot project was opened by Doctors Without Borders in a crowded, dirt-poor black township near Cape Town called Khayelitsha. Because the drugs were then scarce, the charity set high hurdles for patients, so high that only 550 of the clinic’s 5,000 visitors are taking medication now. It reports extraordinarily high levels of compliance. Pill counts by social workers show that, after six months on treatment, 96 percent of the patients are still taking 95 percent of their pills. As a surer but more expensive backup, blood tests see how many have minuscule levels of virus, an indication that they have faithfully taken their pills. After six months, 91 percent do; at 18

months, 83 percent do. ‘’That’s pretty good,’’ said Dr. Eric Goemaere, the program’s director. ‘’Certainly better than what you see in most North American studies.’’ To qualify for treatment, patients must give up all alcohol and drugs; complete three months of taking a simple antibiotic; be on time for four clinic appointments in a row; reveal to their families that they are H.I.V. positive; and choose a friend who must come to counseling, make sure all pills are taken and report problems to a nurse. Dr. Bangsberg expressed surprise at how demanding the clinic was. ‘’Imagine trying to impose the no-drinking rule in San Francisco,’’ he said. Such standards are tough but necessary, Dr. Goemaere said. Binge drinking is the norm in South African townships, he said, and studies show that patients with histories of alcohol abuse or depression are the worst at taking their pills. ‘’There are certainly parts of Africa where you wouldn’t want to try this -- in Congo, for example,’’ he said. ‘’But 65 percent of South Africa is urbanized. People know how to take a taxi and get to an appointment -- and how to take their pills.’’ Correction: September 4, 2003, Thursday Because of an editing error, a front-page article on Wednesday comparing Africans’ and Americans’ ability to take AIDS drugs on time misattributed a comment about American patients. The researcher who said that when those patients change their pill regimens, they often ‘’let a month’s worth go to waste,’’ was Dr. David Bangsberg of the University of California, San Francisco, not Dr. Merle A. Sande of the University of Utah.

Copyright 2003 The New York Times Company


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