Pharmaceutical patents on antiretrovirals (ARVs) are to some extent responsible for the lack of or inadequate access to treatment for HIV & AIDS in African countries that are unable to make the drugs freely available in their public health systems. Globalisation and the resultant concentration of these patents and new health technologies such as ARVs in wealthier countries make these poorer, globally less integrated governments and their populations particularly vulnerable. In this way such countries come to depend on non-government organisations (NGOs), foreign funding, and other outside organisations as sources for treatment of HIV & AIDS in their populations.

This paper outlines issues of globalisation and the inequalities it brings about in global healthcare, particularly with regard to accessing new health technologies such as ARVs. It goes on to explore the intricacies of managing disease in populations when governments fail or are only partially able to meet the health needs of its population. Lastly, the paper explores how inadequate healthcare may affect the experience of individuals as they grapple with HIV & AIDS and its treatment.

Global health and inequality

In recent decades, global interconnectedness and the resultant free flow of peoples, goods, information, capital and ideologies⁽²⁾ have become a taken-for-granted fact. With twentieth and twenty-first-century innovations in technology there is almost no place in the world too remote to have remained untouched by globalisation or to consider itself separate from the global community. Despite this interconnectedness, there are places which are less globally integrated than others – places which are, as Inda and Rosaldo put it, “only tangentially tied into the webs of interconnection that encompass the globe.”⁽³⁾ As such, global flows are anything but even and reciprocal. Rather, they are uneven and to a large extent, unidirectional – some places having more global impetus than others.

The United States and other Western industrialised nations are considered to be the most powerful influencers of world culture – the disseminators of ideas, ideologies, and capital. But, while some countries ride the wave of prosperity (enjoying connection and mobility; making technological advances), they often do so at the expense of others. We need take only a brief glimpse of colonial history to give context to the remnants of today. These inconsistent global flows and the inequalities in our global world order mean that those who are not well enough connected or integrated on a global scale, are hardest hit by natural disasters and disease, and may often become the targets for exploitative capitalism (amongst others, sources for human trafficking, cheap labour, and medical tourism).

Today’s burgeoning interconnectedness comes at a price – and a higher price is paid by some. Specifically, the impact of globalisation on public and global healthcare is a serious concern, as it involves the lives of people who often have little or no resources for negotiating their health.

Global interconnectedness means that infectious diseases travel alongside and enter the more porous national borders on which globalisation flourishes. As we recently saw with the H1N1 virus, which reared its head early in 2009 and subsequently became a worldwide pandemic,⁽⁴⁾ it is no longer possible to ignore the implications of globalisation for both public and global health. In such a state of interconnectedness, a government’s concern for the national health and safety of its population cannot stand in isolation from global affairs. The threat of disease breaking out in an area of the globe thousands of kilometres away, soon becomes a threat to all areas of the globe. The global and the local become intertwined – the local reflecting global changes – and so concern for public health undeniably becomes concern for global health.

Nicholas King addresses some of these issues particularly as they relate to “colonial-era ideologies of medicine and public health.”⁽⁵⁾ He argues that the United States and other Western industrialised nations’ concern for global health is closely tied to the interests of national security and international commerce, albeit in the guise of humanitarian concern.⁽⁶⁾ Public health is thus no longer an issue of managing disease in a population that is tied to one geographical location, especially as interest and involvement abroad increase. Rather, it involves the management of disease on a global scale – identifying “problem” areas and groups around the globe so as to protect citizens from external health threats. In this way, fears over contamination automatically create a “diseased ‘Other’”/“healthy ‘Self’” binary. This contaminated “Other” is found today, as it was during colonial times, in the “postcolonial economic periphery of ‘developing nations.’”⁽⁷⁾ These nations are believed to be the harbourers of “potential and actual global pandemics such as HIV & AIDS, tuberculosis, West Nile Virus, Ebola and dengue.”⁽⁸⁾

The ever-present threat of emerging infectious diseases caused countries such as the United States to adopt the “emerging diseases worldview”, which borrows largely from colonial-era ideologies of public health. According to this worldview, “American institutions would be both the natural leaders and the most prominent beneficiaries of the creation of a global surveillance network.”⁽⁹⁾ The idea is to survey, identify and control areas deemed threats to public and global health (a kind of epidemiological survey of the globe) whilst developing technologies which can prevent and treat these emerging diseases. The development of vaccines and new drugs would be supervised by the United States’ Centres for Disease Control and Prevention (CDC) and in this way a global monopoly on health technologies would arise, concentrated in the United States and its European counterparts.⁽¹⁰⁾ The World Bank and the World Health Organisation (WHO) would also be key role-players on issues of global health. In this way, national or local responses to issues of health would always remain subservient to international or global responses.

When governments fail: accessing treatment

In the above section it was argued that the United States and its counterparts’ concern for global health is not an entirely humanitarian act. These countries take it upon themselves to intervene in the health of other countries and populations so as to reduce the risk of contamination of their own populations. That economic growth is intricately tied to the protection of global health is also noteworthy. Conversely, new drugs and vaccines are largely unavailable where they are most needed – i.e. areas which have “few circuits connecting them to anywhere, only routes of communication and transportation that skip over or bypass them.”⁽¹¹⁾ Pharmaceutical companies operate mainly in the United States and other Western industrialised nations and seek customer bases which appeal to their capitalistic interests. As King notes, “[pharmaceutical] companies have few incentives to develop commodities for markets whose relative purchasing power in the global economy is negligible.”⁽¹²⁾ But what does this mean for countries in Africa? Areas on the globe which are less connected to or largely absent from the global arena are often in the same geographical vicinity. Africa, our second largest and often considered richest continent, is one such geographical location. With many states having weak governments and only barely functioning public health systems, how can African nations protect themselves against and treat infectious diseases?

We need look no farther than the HIV & AIDS pandemic for an example of the merger between the local and the global and of the inequalities which pervade our global world order. The biomedicalisation of global health means that the control of infectious diseases is reliant on the availability of pharmaceuticals and thus rests on distribution by pharmaceutical companies. The existence of ARV drugs paired with unequal access thus qualifies the lives of some, whilst disqualifying the lives of others. One example is the South African government's struggle for the right to produce generic ARVs to provide essential treatment to an otherwise dying population of HIV-positive individuals.⁽¹³⁾ This case suggests that the interests of pharmaceutical companies far outweigh the interests of public health. Bond explains that:

the case [of post-apartheid health policy, US government and pharmaceutical industry interests] raises concerns about contemporary imperialism ("globalisation"), the role of the profit motive as an incentive in vital pharmaceutical products, and indeed the depth of "democracy" in a country where high-bidding and international drug firms have sufficient clout to embarrass [former] Vice President Al Gore by pitting him against the life-and-death interests of millions of consumers of essential drugs in South Africa and other developing countries.⁽¹⁴⁾

This case, like so many others, has highlighted the fact that the power of pharmaceutical companies to influence both national and global health is becoming ever more pervasive, and that it has become powerful enough to have gained a monopoly on global health. The United States and other Western industrialised nations’ strong sense of responsibility for global health demonstrate their commitment to manage national safety against disease (through managing global health). Nevertheless, these countries’ acquiescence to pharmaceutical companies’ patents and strict guidelines negatively affect global health. Pharmaceutical companies are often reluctant and even outright refuse to adjust their patents or prices because it would decrease their already large profits. This phenomenon thus points to a tension between the interests of government and those of pharmaceutical companies, the former interested in both national and public health, and the latter interested only in increasing profits. Choosing between the interests of health and the interests of profits seems as simple a matter as choosing between good and evil, life and death. Even so, the profit motive has shown itself to be a strong competitor and a difficult one to outwit. As King explains, “participation in global public health is conducted upon a terrain already colonised by market relations and the logic of exchange.”⁽¹⁵⁾

But, if pharmaceutical industries are reluctant or unwilling to provide medicines to markets other than rich, Western markets, those who do not have access to or the means to pay for medicines are inevitably excluded from new health technologies and also global health. Those excluded fall, as we have seen, primarily into the category of developing, third-world countries. This fact warrants ethical questions regarding new technologies of health and global health – whose health is more important? Does the profit motive usurp human rights?

HIV & AIDS activists have been successful in lowering the price of ARVs, although a standardised price is hard to come by. Instead, each African country “must negotiate the price of each AIDS-cocktail component with each [pharmaceutical] company.”⁽¹⁶⁾ Although these negotiations may sometimes prove fruitful, the drugs are still unaffordable for most African countries. Enter: NGOs, foreign funding and other humanitarian organisations. Bodibe posits that “the majority of countries in sub-Saharan Africa rely on foreign funding to run their national AIDS programmes.”⁽¹⁷⁾ Countries receive funding for HIV & AIDS programmes primarily through donor governments, multilateral organisations such as the World Bank, and private-sector funding which includes organisations such as NGOs.⁽¹⁸⁾

Recently, with the economic recession of 2008/2009, there has been a significant reduction in international funding for HIV & AIDS in low and middle-income countries.⁽¹⁹⁾ This is proving detrimental to many African countries’ HIV & AIDS programmes since they are unable to sustain these programmes without financial support. Countries such as Kenya rely on foreign funds for approximately 95% of their HIV programmes and ARVs.⁽²⁰⁾ This overreliance on international funding translates into highly irregular funds and programmes that are not necessarily sustainable in the long run. Accompanying this is the threat that political instability will cause donors to withdraw funds completely, causing the entire collapse of a country’s HIV programmes and the deaths of many of its citizens. “UNITAID, the World Bank and PEPFAR plan to withdraw from the war-ravaged state of the Democratic Republic of Congo in 2011,”⁽²¹⁾ leaving already marginalised civilians to fend for themselves. Donor funds are thus not consistent but susceptible to political and ethical strife, and operate according to a global market logic in which global flows of resources are channelled to some countries and not to others.

In order to curb this overreliance on donor funds there have been calls for African countries to increase spending on health to 15% of their Gross Domestic Product (GDP). Most countries currently spend about 8 or 9% of their GDP.⁽²²⁾ Even if such an increase were possible, Bodibe maintains that it would still not be sufficient to address the need for HIV & AIDS treatment in these countries.⁽²³⁾

Concluding remarks

Decreasing international funding for HIV & AIDS, and the inability of African governments to maintain their own HIV & AIDS programmes without support, paints a bleak picture for the future of HIV & AIDS in Africa and global health in general. That is not to say that a great influx of foreign funding may be the answer to most African nations’ health needs, as some of them may be poorly resourced and lack the proper infrastructure to allocate and use the funds.⁽²⁴⁾ Even so, if financial support continues to be withdrawn, the continent may be all the more hard-pressed to fatalistically take on that already looming label of the diseased “Other” – a label bestowed upon it during colonial times and which would surely become a self-fulfilling prophecy under these circumstances. This however is not a productive outcome for a continent so harangued. Capitalism and the current global world order which it favours should be questioned for further marginalising those who need help, and lifting up those who are already uplifted.

NOTES:

(1) Contact Hanlie Myburgh through Consultancy Africa Intelligence's HIV & AIDS Unit (hiv.aids@consultancyafrica.com).
(2) Inda, J.X.&Rosaldo, R. 2008. Tracing global flows. In, Inda, J.X. & Rosaldo, R. (eds.), The Anthropology of Globalization(2nd edition). London: Blackwell. pp. 3-36.
(3) Ibid.
(4) ‘2009 H1N1 Flu Virus Outbreak’, American Veterinary Medical Association, 27 October 2010, http://www.avma.org.
(5) King, N.B. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science, 32(5-6): 763-789.
(6) Ibid.
(7) Ibid.
(8) Ibid.
(9) Ibid.
(10) Ibid.
(11) Inda, J.X.&Rosaldo, R. 2008. Tracking global flows. In, Inda, J.X. & Rosaldo, R. (eds.), The Anthropology of Globalization(2nd edition). London: Blackwell. pp. 3-36.
(12) King, N.B. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science, 32(5-6): 763-789.
(13) Bond, P. 1999. Globalization, Pharmaceutical Pricing, and South African Health Policy: Managing Confrontation with US Firms and Politicians. International Journal of Health Services, 29 (4): 765 – 792.
(14) Ibid.
(15) King, N.B. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science, 32(5-6): 763-789.
(16) McGeary, J., ‘Paying for AIDS cocktails’, Time Magazine, 12 February 2001,http://www.time.com.
(17) Bodibe, K., ‘African governments urged to save their own’, Living with AIDS#435, 6 June 2010,http://www.health-e.org.za.
(18) ‘Funding for the HIV and AIDS epidemic’, AVERT, http://www.avert.org.
(19) Ibid.
(20) Bodibe, K., ‘African governments urged to save their own’, Living with AIDS#435, 6 June 2010,http://www.health-e.org.za.
(21) ‘Funding for the HIV and AIDS epidemic’, AVERT, http://www.avert.org.
(22) Bodibe, K., ‘African governments urged to save their own’, Living with AIDS#435, 6 June 2010, http://www.health-e.org.za.
(23) Ibid.
(24) ‘Funding for the HIV and AIDS epidemic’, AVERT, http://www.avert.org.

Written by Hanlie Myburgh ⁽¹⁾