Editorial: Do we negotiate human health?

The 156 member states of the World Trade Organization (WTO) are negotiating trade agreements during the Millennium Round in Seattle. The WTO applies a strategy based on the postulate that market liberalization and the free circulation of goods, capital and services create favourable conditions for economic development. The role of the WTO is not only to define the rules of international trade on goods and services and the rights of intellectual property, but also to enforce them and to pass judgement in case of dispute. To the crucial question of whether these negotiations are equitable for all countries, the answer is a clear ‘No!’. The votes of, for instance, Sudan, Nicaragua or Indonesia do not carry the same weight as the votes of the USA, the EU, Canada or Japan, since the weight of each country's vote is proportional to the extent of its participation in international trade. Several countries of the South are grouped together, and although they may not have the same interests, their national interests cannot be represented individually. At least two agreements concern human health ( Aventin 1999): the ‘General Agreement on Trade in Services’ (GATS) which covers 160 sectors, and the Agreement on ‘Trade Related Intellectual Property Right Systems’ (TRIPS). The GATS was signed on April 15, 1994 by WTO members during the Uruguay Round and will be revised during the Millennium Round. Developing countries, led by Brazil and India, refused to include trade in services during the Uruguay Round. As they trade few services, they feared being forced to open their market to the developed countries in exchange for preferential treatment for their exports of goods. Developing countries have no advantages at all in the health sector for example, where skills and technological know-how are especially developed in the industrialized countries. Free exchange of services would result in domination by American and European companies. In Seattle this issue is being discussed again. A document written in September 1998 by the ‘Council for Trade in Services’ of the WTO states that the liberalization of exchanges in the health sector ‘must enable the developing countries to reinforce their domestic services and to better use their comparative advantages’ ( WTO 1998), thus negating the objections brought forward by developing countries during the Uruguay Round. A proposition by the ‘Council for Trade in Services’ illustrates how the WTO interprets ‘reinforcement of domestic services and the better use of comparative advantages’: trade in health services is translated into trade in patients. ‘Trade may take the form of patients moving (a) from developing to developed countries, for example with better-off people seeking rapid access to high-quality services abroad; (b) from developed to developing countries, demanding “exotic” therapies or, simply, less expensive treatment in cases not covered by health insurers’ ( WTO 1998). These practices are clearly discriminatory and stigmatizing. But they are also contrary to the UN charter, which forms part of WHO's constitution: ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social conditions’ ( WHO 1999). Such transfer of patients will prevent developing countries from building their own ‘high-quality’ health services because wealthy patients will go abroad for care. The same willingness to create two health systems, one for the rich and one for the poor, is expressed in the proposition for the medical insurance sector, which is of concern for both developed and developing countries: ‘Private insurers competing for members may engage in some form of ’cream skimming', leaving the basic public system, often funded through the general budget, with low-income and high-risk members'. ( WTO 1998). Private companies benefit from premiums paid by healthy members, thus depriving the public sector of profits gained from social health contributions which it needs to subsidize care for the chronically ill, poor or unemployed. If no extra taxes are raised on profits made by private insurance companies, it is difficult to imagine how this mechanism will reduce the weight of health expenditure on national budgets. On several occasions the WTO report cites the increasing weight of health expenditures on national budgets, without however, mentioning, for example, the growing profits of the pharmaceutical industry. It states that ‘The health sector is considered to be counterproductive to the economical expansion of countries’ ( WTO 1998). It is true that the health sector does not contribute directly to the Gross National Product, but it does so indirectly, as good health of a population is a condition for good productivity and economical activity. Among other things, the TRIPS agreements regulate patents on pharmaceutical products and play an important role in the access to drugs in developing countries. Before the TRIPS agreements, drug patents were only applied to the industrial process, not to the pharmaceutical product itself. This process patent system promoted the local production of drugs through a different manufacturing process, created a competitive environment and acted as a strong check on prices. By switching to a product patent system, it became impossible to copy drugs. Moreover, TRIPS agreements impose a duration of 20 years for drug patents, whereas previously, this was determined by individual governments. TRIPS agreements have been in place since January 1995, with some exceptions for the poorest countries. By 2005, however, all member states must uniformly accept them. Application of the TRIPS together with the liberalization and deregulation of the national market will result in more expensive drugs. Between 1988 and 1992, real-terms drug prices increased by 16.6% in Argentina, by 24.2% in Brazil and by 44.5% in Mexico ( Benett et al. 1997 ). The ‘increase of competition’ moved the international multinationals into a dominant position, while local pharmaceutical producers were strangled. The official representation of several African countries realized that industrialized countries safeguard their position and declared officially that ‘the TRIPS agreements establish minimal conditions for protection and not for liberalization’ ( OMC 1999). In terms of value, the African share of the world pharmaceutical production decreased from 1.3% in 1975 to 0.7 in 1995 ( Maritoux 1999). The TRIPS agreements will only accentuate the deprivation of the domestic pharmaceutical industry; they will impede access to affordable drugs for poorer countries to the same degree that drug prices are exclusively set by the multinational pharmaceutical companies. Revision of the TRIPS agreements commences this month, when the application of compulsory licensing will also be reviewed. Compulsory licensing permits a national government to use the patent of an expensive drug of high public health importance without the agreement of the patent holder but by paying a royalty. This permits local production and marketing of the drug at affordable prices. It is important for poor countries to keep this privilege, but the conditions for application must be clarified because so far they have been kept vague and extremely complex (Article 31 of the TRIPS). If compulsory licensing is not safeguarded, it will be impossible for poor countries to have access to expensive but life-saving drugs such as antiretrovirals to treat people living with HIV/AIDS. Overall, developing countries have become poorer and the social climate in developed countries has deteriorated over the past 20 years ( UNDP 1999). It is impossible to prove a direct link between this deterioration and the effects of the Uruguay Round because not all clauses have yet been put into practice. But is it logical to start the Millennium Round, continuing in the same direction, without having analysed the consequences of applying them fully? Making health dependent on commercial agreements will exclude increasing numbers of people from health care in both developed and developing countries. Human health is not a commercial good or service and guarantees are needed to secure access to health care for each individual. As such the health sector must be excluded from the WTO negotiations. We did not reach the WHO target ‘Health for all by the Year 2000’, but there is little evidence that we will reach it by swapping H for T.

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