SPECIAL STUDY MODULE COVER SHEET

SPECIAL STUDY MODULE COVER SHEET
Convenor Name: Dr. O’ Neill and Dr. Dillon
Title of SSM: Brazil’s response to HIV/AIDS – a transferrable success?
Student Surname: Worthing
Student First Name: Kitty (formerly Katherine)
Student ID No.: 200648572
SSM Number: 1339
Year of Study: 2010/11
Academic Year: 1st
Word Count: 3175
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•
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1 Kitty Worthing SSM1 Medical Humanities 2011 Kitty Worthing Candidate Number: 1339 Convenors: Dr. O’ Neill and Dr. Dillon Word count: 3175 Brazil’s response to HIV/AIDS – a transferrable success? 2 Kitty Worthing Abstract
There has been a considerable amount of criticism directed toward the approaches
used to tackle the HIV/AIDS epidemic in the developing world. This review considers
the notion, expressed in many papers and reports, that the strategy adopted by Brazil
has been successful in helping manage the problem in that country and therefore
could provide a template that is transferrable to other developing countries.
This paper considers the factors that have contributed to Brazil’s success and
discusses some of the barriers to transferring this model.
The review also reveals the complex interaction between health programmes, disease
behaviour, social change and global markets in medicine.
Acknowledgements
I would like to thank Dr O’ Neill and Dr. Dillon for organising the interesting and
diverse range of experiences in this SSM period and for their encouragement in letting
us pursue our individual interests when choosing a topic. I would like to extend this
thanks to all those who ran the sessions for their inspirational insights into the world
of medical humanities and the fantastic community development projects they are
involved with. Also, thankyou to Siobhan Harkin for all her help in organising our
SSM.
3 Kitty Worthing Introduction
The 2009 AIDS UNAIDS1 report provides the latest reliable data on the AIDS
epidemic, stating that in 2008 there were 33.4 Million people living with HIV and 2.0
million AIDS related deaths. 22.4 million of the HIV cases in 2008 were in subSaharan Africa and if you total together the three regions with the highest rates of
infection worldwide (Sub-Saharan Africa, South and South East Asia and Latin
America) 28.2 million of the people living with HIV are accounted for. This is 84%
of the worldwide total of HIV cases in 2008. The International Monetary Fund
classifies economies into ‘advanced’ and ‘emerging and developing’ from this point
on to be referred to as ‘developed ‘and ‘developing’. (See Appendix A) All
economies within the three regions containing the highest rates of HIV infection are
classified as ‘developing’, with the two exceptions of Hong Kong and Taiwan.2 When
the distribution of these statistics is considered, the disparity of the epidemic between
the developed and the developing (See Appendix A) world becomes clear.
When considering countries in the developing world, Brazil is often referred to as an
example of a successful response to HIV/AIDS. This notion of ‘success’ has been
prompted by:
•
Brazil’s contribution to global health and trade policy, especially with regard
to the ability of countries to ‘essential’ (See Appendix B) medicines.3
•
The influence Brazil has had on the policies and practise of other developing
countries4
•
The extent to which Brazil’s ‘model’ can be effectively transferred to other
countries5
The effectiveness of Brazil’s programme to reduce levels of HIV infection is
portrayed starkly in UN data6 (p 2):
‘The United Nations predicted that Brazil would have 1.2 million people infected
with HIV by the year 2000. The reality was that 597 000 people were HIV-infected
by the turn of the millennium.’
4 Kitty Worthing Although the prevalence of HIV infected Adults (aged 15-49) in Brazil seems to have
stabilised since 2000 at around 0.6%7,8 the nature of the epidemic is changing, as
highlighted by international AIDS charity Avert9(p 1) : ‘The epidemic is evolving more
slowly among men who have sex with men and injecting drug users than before, but
its impact on the heterosexual population has increased dramatically. This increase
has brought with it an alarming rise in the percentage of women affected by HIV.’
In light of this and the high prevalence of the disease worldwide, some may contest
whether any country can be referred to as ‘succeeding’ against the epidemic. Would
‘success’ only come with the eradication of the disease globally? However when
looking for solutions in dealing with epidemics, it seems important to consider the
effects of a countries actions on others in order to attempt to make a positive
progression towards the eradication of the disease.
This review aims to critically compare literature that considers why the Brazilian
experience in the fight against HIV/AIDS might be considered a success and whether
it can be transferred to other developing countries. To do so, it will consider the
reasons for Brazil’s success, then address whether it is advisable to use Brazil as a
model, and finally, the extent to which it could be transferred. Finally it will reflect on
the limitations of the literature and methods used in this review.
The value in reflecting on the notion of whether Brazil’s approach can be deemed a
success, if its implementation in other countries should be considered and, if so,
whether the approach might be an exportable, lies in the possibility that this could
prevent wasted funds and ineffective, or even detrimental, programmes being
developed.
Michel Sidibe,10 the Executive Director of UNAIDS, confirmed the continued need to
learn from successful models at the 2010 International AIDS conference:
‘… we are at a defining moment. Millions more will die if we keep offering only a
jumbled mix of uncoordinated, underfunded and underutilized services.’10 (p 2)
5 Kitty Worthing Reasons for Brazil’s ‘success’
The literature on HIV/AIDS in Brazil highlights several key factors:
•
The historical and sociopolitical context in which HIV/AIDS first emerged as
a health issue
•
The reduction of stigma and discrimination experienced by HIV/AIDS
patients
•
The creation of Brazil’s public health system, The Sistema Unico de Saude
(The SUS)
•
Access to healthcare as a human right
•
The provision of universal access to Anti-Retroviral (ARV) medication
The historical and sociopolitical context in which the HIV first emerged as a health
issue
Berkman et al 4 argue that ‘the Brazilian mobilization against HIV must be viewed in
the context of the larger social mobilization of Brazilians confronting the military
dictatorship and demanding democracy.’4 (p 1163) Berkman et al 4 and Nunn et al
(2009)3 observe that social mobilisation was successful in 1985 when the
democratization of Brazil began. Many civil society groups – such as Non
Governmental Organisations (NGOs) and human rights movements – had been
fiercely opposing the repressive military regime. Once democratization began, many
of these groups focused their efforts on ensuring that human rights issues such as
access to health care and social inclusion of groups previously discriminated against
were apart of the new constitution of 1988. This focus on human rights and inclusion
occurred simultaneously with the ‘emergence of the first reported cases of AIDS (in
1983)’4 (p 1164-1165) and explains why the response to AIDS was rapid, a crucial factor in
the success of policy.4
6 Kitty Worthing The reduction of stigma and discrimination experienced by HIV/AIDS patients
Levi and Vitoria11 agreed that ‘one of the keys to the successful Brazilian response to
AIDS was strong social mobilization.’11 (p 2377) They point out that the number of the
NGOs fighting HIV/AIDS and the diversity of the groups mobilizing these NGOs
(including those set up by homosexuals) grew as the epidemic developed. Scheffer12
states that (in 2000): ‘the number of NGO involved in the fight against AIDS in Brazil
was nearly 450.’ Okie13 adds that, this significantly helped reduce the stigma
surrounding HIV positive individuals, encouraging them to openly seek treatment and
for others to get tested. Lessening stigma around sexuality has been central to the
HIV/AIDS response through sexually ‘open’ media campaigns and extensive condom
distribution, which encouraged openness about sexual practices and HIV/AIDS
transmission. Berkman et al 4 (p 1168) comment: ‘Nowhere is the importance of sexual
culture in Brazil as clear as in the ways in which prevention programs have been able
to address sexuality, focusing on condom promotion while also combating stigma and
discrimination’
The creation of the Sistema Unico de Saude (The SUS)
With democracy, came pressure from civilians for the government to create an
effective public health system. El Sistema Unico de Saude was created through the
1988 constitution.14 The SUS offered free health care to the whole population,
enabling HIV/AIDS patients to firstly receive drugs for opportunistic infections and
then later ARV treatments. Galveo15 states that this access to HIV/AIDS treatment
was consolidated in 1996 when Law 9.313 made distribution of medicines guaranteed
to HIV/AIDS patients.
Access to healthcare as a human right
Berkman et al 4 observes that with Health Care redefined as a Human Right in 1988,
the government became responsible for the provision of healthcare not just from a
moral perspective, but also on legal grounds. This created a platform to challenge
health policy from a human rights perspective.
7 Kitty Worthing Nunn et al (2009) 3 observes that the centrality of human rights in Brazils policies has
exerted global influence; Brazil put forward the first human rights resolution that
directly addressed access to HIV/AIDS treatment in 2001, Brazil introduced the
resolution Access to Medication in the Context of Pandemics such as HIV/AIDS to
The United Nations commission on Human Rights (UNCHR) This was the first time
Human rights and the access to medicine have been so unequivocally linked. ‘…Brazil was able to link AIDS treatment to universal human rights. Brazil then used
human rights to justify changing other global essential medicines institutions.’ Nunn
(2011)16 (p 158)
Using human rights law to challenge the prices charged by international
pharmaceuticals companies placed Brazil at the centre of challenging global health
policies (arguing on the grounds of human rights violations proved more effective
than challenging patent laws from an economic perspective), and ultimately enabled
Brazil to reduce HIV/AIDS treatment prices.3 The provision of universal access to ARV medication
The SUS was where governmental responsibility for access to medication began, with
the system offering universal access to free health care for all. There was therefore
pressure on the government to supply HIV/AIDS treatments to all citizens.15
Access to treatment was reinforced by Sarney’s Law (1996), guaranteeing access to
modern HIV/AIDS treatments for all AIDS patients.15,17 Nunn (2011) 16 (p 91) explains
how this law: ‘formalized and helped centralize ARV drug policy at the federal
Health Ministry.’
To maintain an economically viable supply of ARV drugs, Brazil turned to domestic
manufacture of pharmaceuticals4: This protected against uncertainties caused by
currency fluctuations and allowed the government to issue compulsory licenses
(Appendix C) allowing a domestic company to produce the drug, regardless of its
patented status. This ‘strengthens the government’s hand in its negotiations with the
multinational pharmaceutical companies.’4 (p 1170) Bate and Tren18 note several
examples of global negotiations and disputes involving Brazil that contributed to the
governments attempt to keep prices low. In 2001 The U.S.A accused Brazil of not
being in line with the Trade-Related Aspects of Intellectual Property Rights (TRIPS)
8 Kitty Worthing agreement (Appendix D) in regard to Article 68 of Law 9.279/96 (Appendix E). The
U.S.A dropped the case later that year, enabling Brazil to give compulsory licenses to
domestic manufacturers allowing generic production of the drug, if the company does
not begin producing the drug in Brazil within three years of patent start date. They
suggest that reason the U.S.A withdrew it’s complaint was because it was being
portrayed as trying to prevent free and universal access to AIDS treatment in Brazil. 18
Also in 2001, at the World Trade Organization meeting in Doha, Brazil rallied other
developing nations in challenging the TRIPS agreement on the grounds that it could
affect public health, drawing global attention to the importance of not allowing
pharmaceutical companies to charge unaffordable prices for treatments.18
Through the local manufacturing of ARV drugs and the challenging of
pharmaceutical companies prices internationally, Brazil successfully managed to
lower the cost of HIV/AIDS treatments. It was calculated that between 2001 and 2005
Brazil saved USD$ 1.2 Billion through pharmaceutical companies lowering costs.19
Berkman et al 4 states several benefits of a free and universal system of drug
distribution:
•
Increased points of access to treatment allows more rapid and extensive
distribution
•
Black market in HIV/AIDS drugs is inhibited
•
Government’s ability to survey the epidemic is increased because guaranteed
treatment provides an ‘incentive for more at risk individuals to be tested.’4 (p
1170)
The literature above includes reference to the negative impacts of Brazil’s policy, this
will be discussed at a further point in the review.
The extent to which Brazil’s experience of HIV/AIDS has been/is currently being
used as a ‘model’
Two key examples of the use to Brazil’s approach as a model for other developing
countries, are outlined by Cohen and Lybecker,20 and indicate international
recognition that Brazilian practices could be successfully implemented elsewhere.
9 Kitty Worthing Firstly, Paulo Teixeria (then head of the Brazilian Health Ministry’s AIDS
programme) was asked by the World Health Organization to create a new global
policy based on the Brazilian response. Secondly, ‘Teixeira noted that in the past
three years, ‘31 developing countries have adopted Brazil’s guidelines [concerning
HIV/AIDS].’20 (p 225-226)
To what extent can the Brazilian model be successfully ‘transferred’ to other
Developing Countries?
The literature reveals a number of issues that may challenge the notion of a simple
transfer between countries.
Historical and political context
A particular countries history, political situation (and culture) is considered by
Berkman et al 4 to be a key factor in determining which aspects of the Brazilian
experience can be transferred. The social mobilisation that developed in response to
military regime facilitated the development of The SUS and capacity of human rights
groups to influence political leadership. These specific historical events cannot be
replicated and therefore it is difficult to transfer the above results to other countries.
This is further illustrated by considering how colonialism specifically stunted the
development of effective health care systems in much of Africa, partly due to a
concentration of delivery in areas where most Europeans resided.4 Nunn(2011)16
observes:
‘Brazil’s institutions are unlikely to be directly replicable in other developing
countries. Some of the most important building blocks of Brazil’s contemporary
AIDS treatment institutions are unique to Brazil.’16 (p 160)
However, the literature above identifies that political leadership/events is a factor that
has a critical effect on a countries response to HIV/AIDS.4
Differences in level of development
There are stark differences between middle-income countries such as Brazil and lower
10 Kitty Worthing income countries such as those countries in Sub-Saharan Africa; even though all of
the economies of these countries are referred to under the branch ‘developing.’ Some
comment that this makes comparison between Brazil and less developed countries
meaningless.4 Galveo15 suggests that the success of Brazil’s ARV treatment
programme could be a result of its relative development and lower rate of HIV
infection. For example, the number of people living with HIV in 2008 in Latin
America was 2.0 Million and in Sub-Saharan Africa was 22.4 Million. (The 2009
AIDS UNAIDS report.)1 In contrast, Ford et al suggests that countries with ‘middleincome’ economic status actually may find it harder:
‘They are viewed as emerging economies with rich elites representing lucrative
markets, and so are excluded from differential pricing policies offered to leastdeveloped countries.’21 (p S27)
Universal and free access to HIV/AIDS treatment
Berkman et al 4 argue that undertaking extensive negotiation with pharmaceutical
companies may be pointless if poor infrastructure and lack of medical professionals
restrict administration, distribution and access.
Oliveira-Cruz et al 5 suggests that low levels of surveillance and inadequate
administration due to lack of resources decreases the likelihood of the sustainability
of a treatment programme, but adds that a diverse combination of factors need to be
co-coordinated for universal access to be achieved. In conclusion, a positive aspect of
the Brazilian experiment has been the growing confidence of other countries to begin
to expand access to aids treatment programmes through similar strategies, however it
is clear that individual countries need to adapt Brazil’s template to their particular
situation.3,20
Should transferability even be considered?
It is important to consider the flaws in the Brazilian model and their possible
implications in other countries.
White 22 representing pharmaceutical companies argued that the provision of generic
drugs under compulsory license discourages innovation due to lack of investment by
11 Kitty Worthing shareholders (because of profit reduction), reducing the likelihood of progressive
treatments being developed. Development of progressive treatment is vital to every
country in the fight against HIV/AIDS. Bate and Tren18 support White’s argument
that Brazil’s contentious actions against pharmaceutical companies may have
discouraged investment in the development of HIV/AIDS treatments.
Another concern stated by Bate and Tren18 is that the domestic manufacturing of
generic drugs in Brazil may have lead to a reduction in the quality of HIV/AIDS
treatments in some cases. They refer to an incident in 2005 when the sale of generic
copies of one ARV treatment was suspended by the Agência Nacional de Vigilância
Sanitária (Brazil’s National surveillance agency) because it didn’t comply with
manufacturing guidelines. This problem could be exacerbated in less developed
countries due to poorly developed or funded regulatory agencies.
With increasing success of treatment programmes, comes an increasing number of
patients taking ARV drugs. This is due to patients increased life expectancy and an
increased level of testing as a result of increased awareness and a reduction in stigma.
This will increase the likelihood of the HIV virus becoming resistant to certain ARV
drugs. This results in the need for more second and third line ARV drugs which
increase treatment costs, lessening the sustainability of treatment provision. As this
presents a threat for the sustainability of Brazils access to HIV/AIDS medicine policy,
it is crucial that this is considered when attempting to implement similar policies in
less developed countries.5,7,18
Discussion
What has become clear from this literature review is the influence of Brazil’s strategy
for HIV/AIDS both as a model of good practise but also as an agent of global change.
In the former case, a number of key elements have been identified that supported this
strategy: the political background, civil society, the level of economic development,
the use of media and infrastructure alongside less tangible social shifts in the
stigmatization of sexual minorities. From this it becomes clear that a direct transfer to
other countries at different developmental stages and with very different cultures is
problematic and so, transfer would need to be selective.
It may be that the power of the Brazil model in the global arena has overshadowed
12 Kitty Worthing other successful models e.g Botswana16 (Nunn 2009), Thailand21 and these need equal
promotion.
In terms of global change the debate in literature suggests that even given Brazil’s
challenging and creative approach the powers of global capitalism and viral
mutability will challenge the sustainability of a free and universal access to
HIV/AIDS treatments across the developing countries throughout the world.
Critical appraisal
The review revealed a reasonably broad range of academically valid papers and books
and well as a number of reports from authoritative international bodies. There were
however some weaknesses:
•
Although much of the literature made references to the possibility of transferring
Brazil’s model to other countries only four authors (Nunn et al 20093, Berkman et
al4, Ford et al 21 and Okie 13) analysed these issues in any depth. Also these papers
focused mainly on HIV/AIDS treatment and Brazil’s interaction with
pharmaceutical companies and global actors. There is therefore a gap in the
literature reviewed relating to issues such as how Brazil’s experience of the work
of civil groups and the reduction of stigmas might be successfully transferred.
•
Although the literature is reasonably recent some of the statistics may be out of
date. It also needs to be acknowledged that recent medical advances and perhaps
social change are not necessarily captured.
•
The review relied heavily on the work of Nunn3,16,19 and Berkman4. However, this
can be justified, as they were the most comprehensive and analytical papers
available. •
It was clear from the literature that social, political and historic contexts are key
issues. However it was not possible to fully undertake an analysis of this within
the context of the review, either in terms of understanding the Brazilian
experience or that of other developing countries. •
Authors citing other works made some important points and in some cases it was
not possible to locate the original source and therefore secondary referencing had
to be used. •
The benefits of the review are that it provides a brief overview of the main
considerations surrounding the topic and brings together the various opinions
13 Kitty Worthing about the use of Brazil as a ‘model’ for the developing world, so a reader can get a
broader idea of the issues involved. References:
1 UNAIDS. AIDS epidemic update. 9. Geneva: UNAIDS; 2009,
http://www.unaids.org/en/media/unaids/contentassets/dataimport/pub/report/2009/jc1
700_epi_update_2009_en.pdf (accessed 8 February 2011)
2
International Monetary fund, Country composition of WEO groups, April 2010,
http://www.imf.org/external/pubs/ft/weo/2010/01/weodata/groups.htm#oem (accessed
8 February 2011)
3
Nunn A, Da Fonesca E and Gruskin S. Changing global essential medicines norms to
improve access to AIDS treatment: Lessons from Brazil. Global Public Health 2009;
4(2): 131-149.
4
Berkman A, MD, Garcia J, BA, Muñoz-Laboy M, DrPH, Paiva V, PhD and Parker
R, PhD. A Critical Analysis of the Brazilian Response to HIV/AIDS: Lessons
Learned for Controlling and Mitigating the Epidemic in Developing Countries.
American Journal of Public Health 2005; 95(7): 1162-1172.
5
Oliveira-Cruz V, Kowalski J and McPake B. Viewpoint: The Brazilian HIV/AIDS
‘success story’ – can others do it?. Tropical Medicine and International Health 2004;
9(2): 292-297.
6
Joint United Nations Programme on HIV/AIDS (UNAIDS). Join the fight against
AIDS in Brazil. 2002. http://data.unaids.org/Topics/PartnershipMenus/PDF/brazilfolder_en.pdf (accessed 9 Feb 2011).
7
Dirceu G B and Simao M. Brazilian policy of universal access to AIDS treatment:
sustainability challenges and perspectives. AIDS 2007; 21(4): S38.
8
United Nations Children’s Fund (UNICEF). Brazil Statistics. 2010.
http://www.unicef.org/infobycountry/brazil_statistics.html#66 (accessed 8 February
2011)
9
Szwarcwald C. L, Barbosa-Junior A. et al. (2005), "Knowledge, practices and
behaviours related to HIV transmission among the Brazilian population in the 15-54
years age group, 2004" AIDS; 19(4): S51-S58. Cited in: AVERT. The future of
Brazil’s AIDS epidemic. 2011. http://www.avert.org/aids-brazil.htm (accessed 8
February 2011)
10
Sidibé M. AIDS 2010: UNAIDS Executive Director's speech at opening session.
Presented at the XVIII International AIDS Conference(AIDS 2010). Vienna. 2010.
http://www.unaids.org/en/media/unaids/contentassets/dataimport/pub/speechexd/2010
/20100718_sp_exd_aids2010_en.pdf (accessed on 9th Feb 2011).
11
Levi, G. C. and Vitória, M. A. Fighting against AIDS: the Brazilian experience.
AIDS 2002; 16(18): 2373 – 2383.
12
Scheffer M. The AIDS epidemic in Brazil: public health and community responses.
South African Journal of International Affairs 2000; 7:81-88.
13
Okie S. Fighting HIV – Lessons from Brazil. New England Journal of Medicine
2006. 354: 1977-1981
14
World Health Organisation. Brazil's march towards universal coverage. Bulletin of
The World Health Organisation 2010; 88(9): 641-716.
14 Kitty Worthing http://www.who.int/bulletin/volumes/88/9/10-020910/en/index.html (accessed 8
February 2011)
15
Jane Galvão. Brazil and Access to HIV/AIDS Drugs: A Question of Human Rights
and Public Health. American Journal of public health 2005; 95(7): 1110-1116.
16
Nunn, A. The Politics and History of AIDS Treatment in Brazil. 1st Edition. New
York. Springer Science + Business Media; 2009
http://www.springerlink.com.ezproxy.liv.ac.uk/content/u50103/#section=18267&pag
e=3&locus=62 (accessed 9 February 2011)
17
Mesquita F, Doneda D, Gandolfi D, Battistella Nemes M I, Andrade T, Bueno R et
al. Brazilian Response to the Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome Epidemic among Injection Drug Users. Clinical
Infectious Diseases: An Official Publication Of The Infectious Diseases Society Of
America [serial on the Internet] 2003; 37(5): S382-S385.
http://web.ebscohost.com.ezproxy.liv.ac.uk/ehost/detail?hid=112&sid=5a428347d234-4f5a-b20fdd2b5be73ad4%40sessionmgr112&vid=1&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY
29wZT1zaXRl#db=mnh&AN=14648452 (accessed 9 February 2011)
18
Bate R and Tren R. Brazil’s AIDS programme: A costly success. American
Enterprise Institute for Public Policy research, Health Policy Outlook (From the
Health Policy outlook series) 2006.
http://www.fightingmalaria.org/pdfs/HPO_Brazil_AIDS.pdf (accessed 9 February
2011)
19
Nunn A, Fonseca M E, Bastos F I, Gruskin S, Salomon J A. Evolution of
Antiretroviral Drug Costs in Brazil in the Context of Free and Universal Access to
AIDS Treatment. PLoS Medicine 2007; 4(11): e305.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2071936/?tool=pubmed (accessed on
9 February 2011)
20
Pharmaceutical Research and Manufacturers of America (PhRMA) (2003), ‘WHO
to Adopt Brazilian Model to Fight AIDS/HIV’, BBC Monitoring International
Reports via NewsEdge Corporation, World Wide Web Posting ( accessed 21 May
2003) Cited in: Cohen J C, Lybecker K M. AIDS Policy and Pharmaceutical Patents:
Brazil’s Strategy to Safeguard Public Health. The World Economy 2005; 28(2): 211 230. DOI: 10.1111/j.1467-9701.2005.00668.x
21
Ford N, Wilson D, Chaves G C, Lotrowska M and Kijtiwatchakul K. Sustaining
access to antiretroviral therapy in the less-developed world: lessons from Brazil and
Thailand. AIDS 2007; 21(4): S21-S29
15 Kitty Worthing Appendices
Appendix A: ‘The country classification in the World Economic Outlook divides the
world into two major groups: advanced economies and emerging and developing
economies.’ These groups can be found on the website of the International Monetary
Fund: http://www.imf.org/external/pubs/ft/weo/2010/01/weodata/groups.htm#oem
(accessed 8 February 2011)
Whether a country is considered ‘developed’ or ‘developing’ varies according to
source. For the purposes of this essay the term ‘developed’ countries will refer to
‘advanced’ economies and ‘developing’ to ‘emerging and developing’ countries.
Appendix B: Reference to medicines as ‘essential’ refers to the WHO’s list of
essential medicines. Medicines included on this list will vary between the literature
reviewed because the list is updated biannually. The list can be found at:
http://www.who.int/medicines/publications/essentialmedicines/en/index.html
(accessed 9 February 2011)
Appendix C: An explanation of compulsory licensing from the World Trade
Organization: ‘compulsory licensing is when a government allows someone else to
produce the patented product or process without the consent of the patent owner. It is
one of the flexibilities on patent protection included in the WTO’s agreement on
intellectual property – the TRIPS (trade related aspects of intellectual property rights)
agreement.’ There is further information regarding more specific aspects of TRIPS on
the World Trade Organisation’s official website:
http://www.wto.org/english/tratop_e/trips_e/public_health_faq_e.htm
(accessed 9 February 2011)
Appendix D: This is taken from the World Trade Organizations website ‘The WTO’s
Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS),
negotiated in the 1986-94 Uruguay Round, introduced intellectual property rules into
the multilateral trading system for the first time’
There is a basic explanation of TRIPS and links to in depth explanations about its
implications (including its implications on public health and access to medicines) on
the WTO website: http://www.wto.org/english/thewto_e/whatis_e/tif_e/agrm7_e.htm
(accessed 10 February 2011)
Appendix E: Below is Article 68 of Law 9.279/96, taken from the World Intellectual
Property Organisations website:
http://www.oapi.wipo.net/wipolex/en/text.jsp?file_id=125397
(accessed 10 February 2011)
‘68. The titleholder shall be subject to having the patent licensed on a compulsory
basis if he exercises his rights derived therefrom in an abusive manner, or by means
thereof engages in abuse of economic power, proven pursuant to law in an
administrative or judicial decision.
16 Kitty Worthing (1) The following also occasion a compulsory license:
I. non-exploitation of the object of the patent within the Brazilian territory for failure
to manufacture or incomplete manufacture of the product, or also failure to make full
use of the patented process, except cases where this is not economically feasible,
when importation shall be permitted; or
II. commercialization that does not satisfy the needs of the market.
(2) A license may be requested only by a person having a legitimate interest and
having technical and economic capacity to effectively exploit the object of the patent,
that shall be destined predominantly for the domestic market, in which case the
exception contained in Item I of the previous Paragraph shall be extinguished.
(3) In the case that a compulsory license is granted on the grounds of abuse of
economic power, the licensee who proposes local manufacture shall be assured a
period, limited to the provisions of Article 74, to import the object of the license,
provided that it was introduced onto the market directly by the titleholder or with his
consent.
(4) In the case of importation to exploit a patent and in the case of importation as
provided for in the preceding Paragraph, third parties shall also be allowed to import a
product manufactured according to a process or product patent, provided that it has
been introduced onto the market by the titleholder or with his consent.
(5) The compulsory license that is the subject of Paragraph 1 shall only be required
when 3 (three) years have elapsed since the patent was granted.’
17 Kitty Worthing Bibliograpy
Biehl J. Will to live: AIDS Therapies and the politics of survival. 1st edition.
Princeton. Princeton University Press; 2007
Dourado I, Veras M A de S M, Barreira D, Brito A M de. AIDS epidemic trends after
the introduction of antiretroviral therapy in Brazil. Rev. Saúde Pública 2006 [serial on
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18 Kitty Worthing SSM1 Timetable
SSM1 Medical Humanities Course: 24th January 2011 Week 1 24th 25th 26th 27th January 28th January January January January Meeting Visit Neuro Fade Breadmaking Reasearch possible AM with convenor Support Centre library Read first 8 chapters of Mary Barton PM Induction Meeting with convenor Kathy James Talk on Motor Neuron Disease Library Talk on the history of Art with Reverend Ian Hu SSM topics Read material on public health in Liverpool Dr Dillon Talk on Health and Literature Kieran Lamb Teaching session on literature session 19 St Bride’s Church Talk on spirituality and health David Lawrence Talk about Anthropology/history Kitty Worthing SSM1 Medical Humanities Course: 24th January 2011 Week 2 AM PM 31st January Healthy Health Centres Dr Katy Gardner 1st February 2nd February 3rd February LMI Library Adrienne Mayers Evolutionary medicine/psychiatry Keith Morgan Gardening therapy + mental health Jennie Geddes Room 3:03 Dr Maggie Hammond Ian Williams Talk on medical illustration Research SSM topics 4th February Write up SSM 20 Convenor review and SSM presentation Fade Library Write up SSM