secrets, taboos, private lives Bad Economy and Global health 22 Big pharma bets on emerging economies 06
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Issue 01 WINTER 2009 $4.95 U.S.
FOOD CRISIS www.globalhealthmagazine.com —
The region is at a crucial tipping point.
Access to services and information now could determine the future in Latin America and the Caribbean. Youth hold the key to making this a positive change. Visit www.ippfwhr.org to learn more about our innovative projects throughout the region.
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issue 01
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In this issue:
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06 secrets, taboos, private lives
09 Financial Meltdown and Global Health
22 Pharma Targets Emerging Economies
COVER STORY: Feeding the hungry —
14 Are U.S.$ Used Wisely? 18 Are there sustainable solutions to the nutritional crisis? C How Did We Get Here? C Will Africa’s Green Revolution Work?
screenshots —
04 How Do People Pay for Health? 05 Where Do Refugees Live? 05 Who Has No Toilets?
Cover Photo credit: Erin Lubin/CARE
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Issue 01
Global Health
letter
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from the editor
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Editor-in-Chief
Nils Daulaire
Executive Editor
Annmarie Christensen Managing Editor
Tina Flores
Web Manager
Winnie Mutch Graphic Design
The Times, They Are A Changing Welcome to this seminal issue of GLOBAL HEALTH, the Global Health Council’s new magazine. Change, while sometimes little more than lip-service, can, at its best, be transformative. So it is fitting that the launch of GLOBAL HEALTH is during a time of change, both for the world in which we work, as well as in the way in which we learn and interact. GLOBAL HEALTH is a bridge from the print format to the web, embracing both genres, and celebrating the advantages of each. The print version highlights the major stories that affect global health, and WWW.GLOBALHEALTHMAGAZINE.COM allows for engagement and further discussion with you, our readers. While this print issue’s main thrust is the food crisis, it also discusses the challenge of a flailing economy, and how pharma is exploring new markets. It shares the story of a poet who returns to the AIDS crisis in his native Jamaica. There are also screenshots, statistics from the field that are graphically designed to tell a story at a glance. Features currently appearing exclusively online include the GLOBAL HEALTH blog, focusing on the impact of the new U.S. administration on women’s health. The online Field Notes section highlights the work of our members, in this instance, JSI in Nepal. And on the lighter side, we include a travel section and Dim Sum – a cornucopia of books, movies and other items of interest, both of which will rely on your contributions. We welcome your feedback and look to you for suggestions. Above all, we want to hear your voices at WWW.GLOBALHEALTHMAGAZINE.COM. The Editors
ISSUE 01 winter 2009
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Design Army E-mail:
magazine@globalhealth.org Global Health Council Board of Directors
Susan Dentzer, chair, William Foege, MD, MPH, chair-emeritus Rogaia Mustafa Abusharaf, PhD Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Hon. Jim Kolbe, MBA Joel Lamstein, SM Joy Phumaphi Reeta Roy Nils Daulaire, MD, MPH Global Health is published by the Global Health Council, a 501(c)(3) non-profit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at www.globalhealth.org
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online exclusives
go to www.globalhealthmagazine.com for further reading
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C The Blog
Foreign Aid Reform Guest blogger Beth Fredrick, executive vice president of the International Women’s Health Coalition, discusses women’s health and foreign aid in the new administration.
C Hot Escapes
Lamu: Explore this other piece of Kenya – one filled with relaxation, donkeys and history.
C Dim Sum
A collection of film picks, book reviews, and other relevant fun stuff Journey of A Red Fridge The Translator Access to Life •
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C Field Notes
Nepal: Women Volunteering to Saving Children
Access to Life/Mali © Paolo Pellegrin/ Magnum Photos Access To Life/Russia © Alex Majoli/ Magnum Photos
C Going Viral Joseph J. Schatz
What’s the buzz on YouTube, Facebook, LinkedIn and other places online www.globalhealthmagazine.com
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Global health statistics
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How People Pay for Health Services
Fa so
zil
Bra
Ch
ina
AE
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ay
gu
Ura
Vietnam
B u rk ina
adesh
Bangl
other Current Income Health Insurance Borrow from Others Borrow from relatives Sold Items Savings
Sr
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ica
Czech
S. Afr
ia
Ethiop
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My anmar
Phillip
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World Bank with data from the World Health Organization’s World Health Surveys.
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Major refugee hosting countries, end-2007 Pakistan* 2,033,100 Syrian Arab Rep.** 1,503,800 Islamic Rep. of Iran 963,500 Germany 578,900 Jordan** 500,300 United Rep. of Tanzania 435,600 China 301,100 United Kingdom*** 299,700 Chad 294,000 United States***281,200
* Includes Afghans in a refugee-like situation. **Government estimate. ***UNHCR estimate based on 10 years of individual recognition asylum-seekers. Figure excludes resettled refugees.
2.6 billion: People who did not use improved sanitation facilities E. Asia/ Pacific S. Asia Sub- Saharan Africa Latin America/ Carribbean Middle East/ N. Africa CEE/CIS country
Rural (millions)
Urban Total (millions) (millions)
E. Asia/ Pacific S. Asia Sub- Saharan Africa Latin America/ Caribbean Middle East/ N. Africa CEE/CIS
722 768 322 64 74 45
222 153 118 60 22 18
944 921 440 124 96 63
Developing countries World
1,995 1,996
593 593
2,588 2,590
UNHCR 2007 Global Trends: Refugees, Asylum-seekers, Returnees, Internally Displaced and Stateless Persons.
Improved sanitation: public sewers, septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines. 2004 Data by region. UNICEF Progress For Children: A Child Survival Report Card, November 6, 2007.
Secrets, Taboos, Private Lives By Kwame Dawes
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Photo credit: Joshua Cogan
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A Poet’s Journey to Jamaica Becomes Deeply Personal HIV/AIDS is a disease contracted in the most private of spaces; one that comes with a sense of betrayal, failure and attendant anxiety because somehow, a social contract between two people, a contract that is supposed to give pleasure and security, has produced death or its specter. In a society like Jamaica, any talk about HIV/AIDS is going to be about secrets, about taboos, and about the private lives of people. I was talking to people about sex. I was talking to people about their mortality and its meaning. Many of them had lived with the disease for years, and others had learned they were infected a few months before. This crisis has shown us the challenges we face as a culture in Jamaica – the way people behave sexually: the penchant for multiple partners, the disregard for safe sex practices, the highly sexualized society rooted in a deeply conservative cultural ethos, the ubiquitous reminder of homophobia at all levels of society, and so much more.
It was 1989. A man in Kingston was very ill. He was a young man, a 25-year-old man. He lived in an apartment building with at least one good neighbor, Joseph Robinson, a dancer, a community activist, and a good soul. The good soul knew that the man was sick and dying of AIDS. The good soul knew this because he had seen the early devastation of HIV/AIDS in New York. He started to care for the sick man. Then he began to solicit help for this man from his friends. His friends were reluctant and afraid at first, but he picked good friends, people he knew would respond because he had asked. He taught them that they could touch people with AIDS by touching the man with AIDS, by washing him, massaging him, praying and meditating with him, feeding him. And his friends learned how to care for this man through their own doubts and anxieties. Soon, the good neighbor turned his friends into a committee of doers, people who would start organizations, establish care facilities, and start a movement of care that continues today. The sick man would die eventually. And so would many others. But this gathering of friends learned how to help people through their journey to death, how to care for them, how to stare at the broken bodies ravaged by this disease, yet still be tender and present.
These days, the language of death is a dialect of betrayals; the bodies broken, placid as saints, hobble along the tiled corridors, from room to room. Below the dormitories is a white squat bungalow, a chapel from which the handclaps and choruses rise and reach us like the scent of a more innocent time. I am trying to listen to the plump Palestinian man with his swaying rural middle-class patois, this jovial servant, his eyes watering at the memory of an eleven year old girl brought to die inside the white walls and cheap fabric of this place; her small body fading, her eyes fiercely flaming with light, with hunger for wide open spaces – decades of discovery. Her mind is still unable to calculate the treachery of rape, to grasp how a man can seek revenge on her tender body; why as he wept when hey took him away, she wept, too, like the day she wept when they took her mother’s empty body away, the disease leaving her with nothing but bones, thin skin, the scent of chickens. There is refuge, I know, in distraction, the chapel of charms down the hill, the pure sound of my youth, when cleansed by the perpetual blood my sins were never legion enough for despair; when the comfort of the Holy Spirit was green as this sloping escarpment, thick with trees, cool against the soft sunlight; these things she saw before her body could not cope anymore; her laughter, her laughter. The plump man brushes the gleam of tears from his cheeks. I think of the simple equations of compassion; I think of songs, the accordion, the strained harmonies, the bodies of the dying shuffling past, eyes still hoping; the van waiting in the shade to take me from all of this; the long ride through rain and dark to Kingston, to sleep and more sleep.
HOPE’S HOSPICE For John Marzouca, late co-director of Hope’s Hospice, Jamaica
At the same time, the crisis has brought out the resourcefulness of Jamaicans, their generosity of spirit to help and support those who are suffering, the strength of character and wonderful capacity for humor and stoic resolve in the face of serious challenges, and the power of community. The story of HIV/AIDS in Jamaica is as much about those who are living with the disease as it is those who care for them. At the end of the day, all the stories become deeply personal.
The Good Soul Ian McKnight, one of the founders of Jamaica AIDS Support for Life (JASL), would remember his own entree into this service that would come to consume his life for the next 20 or so years. Ian was taken into the world of death and suffering without really knowing where he was being led.
Poet Kwame Dawes was born in Ghana and grew up in Jamaica. He is professor of English at the University of South Carolina, reported on the impact of HIV/ AIDS on Jamaica as part of a multimedia project of
the Pulitzer Center on Crisis Reporting. An interactive presentation of the project, including Dawe’s poetry and music, composed by Kevin Simmonds, can be found at www.livehopelove.com
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These people would learn how to solicit money, how to get funding to care for the sick, how to manage all of this in a country in which many are hostile to even the very idea of homosexuality, in a country in which many people for a long time thought of HIV/AIDS as a gay disease and a white person’s disease, in a country where secrets have to be kept, in a country where at the time, the doctors and nurses did not want to care for people with this disease, in a country in which the paranoia about HIV/AIDS was palpable. They would continue in this work for years. These are the people who started JASL, they are the people who have kept it going for all these years. They are still doing this work. Some, like the good neighbor, would die, others would leave the country, and others would stay to continue the work.
own dinner. And, he knew I wore gloves. He had the information but he did not get the knowledge at that time, and then I realized information just wasn’t enough.”
Ian McKnight, after many years on staff and in leadership of JASL, now serves on its board, and remains an indefatigable recruiter of volunteers and helpers, he is always ready, with his quietly persuasive and upbeat manner to recruit someone – someone to adopt a child orphaned by AIDS, someone to offer work to people living with the disease, someone to provide food for prostitutes so they can take their medication, someone to become a full-time caregiver for the sick.
Hope and Concern In truth, this project has taken me to parts of Jamaica (and by here I don’t mean geographically) that I have either not been to in years or have never been engaged by. At the end of it all, I remain at once hopeful and deeply concerned.
A Changed Woman For Carla Bingham Ledgister, it was a woman, whom she had to care for, that turned her around. This woman lived in a community next to Carla. For the first time, AIDS was at her door. Carla went to see the situation with this woman, and what she saw changed her. “What really got to me was that her family lived next door to her and she was (HIV) positive and they wouldn’t assist her because she wasn’t well. They would put her water in a bucket at the fence, and she had to get there to get it. They would leave her food and other contents at the fence. Nobody would come in to assist her.” Carla Bingham Ledgister, who works for the Jamaica AIDS Support for Life, would care for this woman until she died. She would spend time washing this woman, washing her clothes, feeding her, and nursing her because no one else would do it. And even as she did this, she was facing the problems of stigma in her own home with her husband, also a health officer.
She explained her husband’s behavior as best she could. “At that time, a lot was not known about it, and persons were thinking a lot of the information they were getting is just fake stories. ‘They’re telling us this to make us comfortable,’ and so it takes persons a while before they get to that level to where they feel comfortable.” She said that this unlearning and learning has to happen again and again for workers in Jamaica. Eventually, they get there. She said that these days the learning period is shorter. There is greater awareness.
There is little doubt that the advent of the antiretroviral drugs in Jamaica has made a huge difference in the lives of so many in the country. Many of the people I met are surviving and thriving because of the drug. At the same time, it was hard to avoid the persistence of sexual habits that can only be described as highly dangerous and disturbing. Doctors and AIDS workers would express their frustration with men and women who continue to ignore what they know about the disease and engage in highly risky sexual practices. Men still told me that they would continue with multiple partners and could tell if their partner was sick by looking at them. The women reminded me about the economic bind they were in forcing them to accept sexual relationships that they knew to be risky largely because they needed the financial support that came from these relationships. My journey back to Jamaica has changed me a great deal. I can say one simple thing, HIV/AIDS is a present reality in my life today. My friends are living with it, and I want to see that others are able to survive it or find ways to live with the disease with dignity and grace. When I was in Jamaica, it seemed to rain a lot, and the landscape was riotously green – a quality of resilience and lush energy after the storm:
He was not taking well the fact that his wife spent her days caring for a woman dying of a very terrible disease. “He has knowledge, he has information. But when I go home from these visits, I had to strip off my clothes in the hall. I had to shower right away; and he cooked his
There is a substance in the green of rainy season, in the harvest of sweet mangoes in November. There is evidence in these songs we now sing Defying that tyranny of this disease in us.
HIV/Aids Statistics • Caribbean has 2nd highest per capita rate in world • Predominant transmission route: heterosexual sex
• Cuba has lowest rate; Haiti, the highest • 50% of Jamaican men have multiple partners
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By Lindsay Morgan
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What Does The Financial Crisis Mean For Global Health?
It’s hard to see your way through a storm when you’re in the middle of one. Such is the predicament of the global health community, as we sort out what the financial crisis will mean for the health of poor people in developing countries months – even years – from now. While nothing is known for certain, most agree the impact will be substantial and negative. “After wars, plagues and natural disasters, financial crises kill the poor the most,” said Liliana Rojas-Suarez, senior fellow at Center for Global Development (CGD) and an expert in financial markets. There are some measures that can be taken to mitigate the damage (such as expanding and developing safety nets), but the main task is to get more health for every dollar.
Let’s start with aid. Will politicians choose to offset a tiny fraction of the $700 billion bailout by reducing official development assistance (ODA) in general, and funding for health (which has grown disproportionately in recent years)? The evidence suggests the answer is yes. Research from CGD fellow David Roodman shows that after each previous financial crisis in a donor country since 1970 (which includes Japan, Finland, Norway and Sweden), the country’s aid declined. Foreign assistance tends to be pro-cyclical – that is, shortfalls in aid and domestic revenue tend to coincide. And as InterAmerican Development Bank health expert Amanda Glassman said, “Aid for health is no exception.” But don’t expect governments to announce cuts in foreign assistance; the contraction will be invisible, with disbursements quietly dragged out and contracting seeing a slowdown. A shortfall in ODA could have big repercussions. Poor countries rely on donor assistance to supplement domestic resources for essential services such as primary education and immunization – in many sub-Saharan African countries, close to half of all basic health sector funding comes from development assistance, and donors buy the vast majority of vaccines for many poor countries. If ODA Lindsay Morgan is a policy analyst at the Washington D.C.-based Center for Global Development.
decreases – especially during a period of global economic contraction – these services may be disrupted with an immediate negative effect on those in greatest need. What about other types of external support for health, such as the funding – some of it raised on the capital markets – for research and development and specific health programs? It may be more difficult to persuade private sector partners such as pharmaceutical companies that it’s worth their time and resources to participate in public-private partnerships now, when firms are likely to be strapped for credit and have an even greater need to show near-term returns to shareholders. The United States is by far the biggest player in R&D, spending more than $28 billion each year on biomedical research, and much of the private investment in R&D comes from U.S. sources. The financial crisis will mean increased competition for research dollars; funding for the National Institutes of Health is unlikely to increase. The financial crisis may also dampen enthusiasm for relying on capital markets more broadly, a model the International Finance Facility for Immunization follows, for example. So can we turn to philanthropy to fill the gap? Possibly. Against the backdrop of the crisis, $16 billion was pledged to fight poverty in late September at the United Nations summit of world leaders to review progress on achieving the Millennium Development Goals. But some foundations that depended on now-defunct hedge funds for contributions and/or which invested in the shakier parts of the stock market are likely to face a sharp decline in their assets. This makes it doubtful that they will embark on new initiatives that they otherwise might have considered. Grant making may also be reduced. Individuals who give to charities involved in overseas relief and development – whose collective giving is significant (according to the Hudson Institute, in 2006, the United www.globalhealthmagazine.com
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financial crisis
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States gave $34.8 billion in private philanthropy) – are also likely to have less to give away this year and next. What health programs are at risk? It will be difficult for donors to pull back from certain commitments, such as funding for HIV/AIDS, because cutting funding would most certainly force people off life-extending treatment. Legislation passed in July 2008 authorizes approximately $39 billion over the next five years for HIV/AIDS (as well as $5 billion for malaria and $4 billion for tuberculosis), but at least half of that must be spent on treatment and care. Resources for prevention have always been scarcer and it’s unlikely they will increase given the enormous (and expanding) cost of treatment, given that it is harder to measure prevention successes, and given the complicated U.S. domestic politics that surround the issue. There are other health priorities that will likely struggle for support in economic hard times (and for which little funding currently exists), such as building the capacity of health systems in developing countries, and preventing maternal mortality, which is the leading cause of mortality globally among adult women of reproductive age. And little can be expected in the area of chronic disease even though the toll of cardiovascular disease, hypertension, diabetes and cancer outweighs that of infectious disease in nearly every region of the world, according to CGD deputy director for global health, Rachel Nugent.
Far more important than whether aid dollars rise or fall is the potential impact of the financial crisis on the fiscal positions of developing countries. The forecast is not encouraging. Slowed growth in emerging economies may dampen demand for imports, contributing to a drop in the prices of commodities. Leading indicators of global economic activity, such as shipping rates, are
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already declining at alarming rates. Taxable activities, such as trade, will be diminished and investment in lowincome countries (LICs) may slow. Yet LICs have less ability to deal with the damage through counter-cyclical fiscal policies (such as issuing bonds). Private capital flows to emerging markets, which hit a record $1 trillion in 2007, are also expected to drop to around $800 billion by 2009, according to a World Bank report. Developing countries are generally seen as risky borrowers, so when markets are jittery and lending is cut back, they lose more than most. Developing country budgets, therefore, are likely to be strained. And in times of austerity, health spending will be especially vulnerable. Meanwhile, poor households will have to deal with inflation and high food prices. In poor countries, it is common for families to spend between 50-70 percent of their income on food, according to the International Food Policy Research Institute. As domestic banks face pressures, families may find it difficult to obtain credit or access financial services. And a slowdown in the U.S. is likely to affect demand for labor and may lead to a decrease in the flow of remittances, which could have major effects on poor households, especially in Mexico and Central America. Money sent home by Mexicans living in the United States fell to $1.9 billion for August 2008, according to the Bank of Mexico, a 12.2 percent drop from the same month last year. Changes in both public and private expenditures could have a significant negative impact on the health of the poor in developing countries. The effects of economic shocks on health vary and can be ambiguous, but a new study analyzing the effects of economic shocks on child schooling and health from the World Bank shows that, “recessions, droughts and other economic downturns tend to have negative effects on both health and education outcomes for children in poor countries.”
We have seen this happen before. A study by Christina Paxon of Princeton University and Norbert Schady of the World Bank analyzed the impact of a crisis in Peru in the late 1980s on infant mortality. They show that there was an increase in the infant mortality rate of about 2.5 percentage points for children born during the crisis, implying that about 17,000 more children died than would have in the absence of the crisis. They suggest that the collapse in public and private expenditures on health played an important role.
So what is the global health community to do? In the short-term, we must consider the potential reorientation of aid dollars toward helping countries create viable safety nets in order to reach people who are made extremely vulnerable by shocks (e.g., populations who are most affected by high food prices, loss of remittances, and unemployment). According to the IMF, 56 countries reported targeted cash transfer programs for 2008, but only 39 had expanded their programs in response to fuel and food price increases.
A severe economic crisis in Argentina in 2001 led to drug shortages that prompted the government to import 21,000 doses of HIV drugs to be distributed in hospitals as an emergency measure, along with insulin from Brazil and over-the-counter drugs from Spain and Italy. At the same time, World Bank loans intended to support health sector reform were diverted to procure vaccines so that the country could maintain its immunization program. Health insurance and social security schemes faced severe financial difficulties while many bank accounts were frozen, leaving people with limited access to cash.
Over the long-term, more emphasis should be placed on monitoring donors’ financial contributions to global health and making it visible when they shirk earlier commitments. The field of global health is crowded with populist promises that often go unrealized, but good results depend on the predictability and reliability of resources. Strong advocacy for more sustained health assistance should also continue. The argument for investment in health is clear and compelling: good health improves labor productivity, facilities learning, and contributes to economic growth and poverty reduction. And most fundamentally, donors must ensure that aid dollars reach the poorest, and that money translates into improved health.
And the 1997 Asian currency crisis, which caused severe economic damage across much of East and Southeast Asia, had a negative impact on public health in Indonesia. Data from the World Health Organization show an almost 25 percent decline in immunization coverage rates between 1995 and 1999, the reduction being most striking in 1997-98. Expenditures by individuals on primary care from 1996/97 to 1999/2000 were reduced by 20 percent, and government spending was cut by 25 percent.
“Like a hurricane, a financial crisis reminds us of how vulnerable we are, and how the most vulnerable are the least well protected,” said Ruth Levine, CGD vice president and senior fellow. It’s time to think about development assistance, not as a luxury to pursue when times are good, but as a powerful stabilizer when times are tough. The poorest need our help now more than ever.
Between 1997 and 1999, the use of health care services by poor children dropped by about 17 percent, compared with 8 percent in children from wealthier settings.
www.globalhealthmagazine.com
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Photo Credit: Photographer Š Jacob Silberberg
Can We Feed the
Hungry? The world food crisis is undermining the promising trends in global health over the past decade. Malnutrition, according to the World Health Organization, is a major threat to public health worldwide, responsible for onethird of child deaths and 10 percent of all diseases. It has negative effects on education, economic growth, productivity and income. As food prices rise due to energy costs and increased population, families will be forced to spend even more than the 75 percent of their disposable income they currently spend on food. In the end, the global community may find it a challenge just to stay even.
Feeding the hungry
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BY Nellie Bristol
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Is the U.S. Using Its Money Wisely?
The longer the food price crisis continues, the more imperative it becomes that food is used in the most efficient form. On average, Congress appropriated $2 billion yearly for food aid since 2002. It allotted $2.5
billion a year in the recent Farm Bill and an additional $1.2 billion to address the food crisis. GAO estimates that even before the current crises, fuel and business costs reduced the total tonnage of food delivered with U.S. funds by 52 percent over five years. The stakes are high for the world’s vulnerable populations. The price of food more than doubled over the last several years in some places, causing additional stress for families and increasing political pressure for developing country leaders. The UN Food and Agriculture Organization estimates that more than 75 million people have been added to the roles of the hungry since prices began to climb in 2005. With the global financial crisis, growing markets in China and India, and added pressures from climate change, the situation is only expected to get worse. Some predict that the era of food surpluses may be over, indicating a drastic need for increased agricultural development in food insecure areas. Food security is key to the health both of economies and individuals, especially for particular populations. Research shows that lack of essential nutrients in the first two years of life can lead to irreversible damage including shorter adult stature, lower attainment in school and reduced earning capacity. Lack of food has a range of effects for HIV/AIDS positive individuals. Infected adults need 10 percent to 30 percent more calories than the noninfected while HIV positive children can require up to 100 percent more calories than other children. Poor nutritional status can speed progression of AIDS related illness and jeopardize drug adherence, said Stuart Gillespie, director of the Regional Network on AIDS, Livelihoods and Food Security. “Some people are actually scared to take the drugs because they know their appetite will increase and they know that they won’t be able to find the food for that increased appetite,” Gillespie adds. Adequate food availability can also have a preventive effect, keeping women in particular from engaging in risky transactional sex to feed themselves or their families.
ISSUE 01 winter 2009
Nellie Bristol is a freelance journalist specializing in health policy.
The food price crisis is spurring food aid policy reforms at institutions as varied as the World Bank and the Gates Foundation. But the largest food donor, the United States, which provides more than half of food aid globally, is largely maintaining what many feel is an antiquated and inadequate food delivery system. With the best chance for reform, the 2008 U.S. Farm Bill, already behind them and the crisis not likely to abate, food aid advocates are wondering what it will take to force U.S. policy to be more responsive to the hungry and vulnerable. Devised 50 years ago largely to offload farm surpluses and promote trade, U.S. food aid is delivered almost entirely in the form of grain and other commodities and transported mainly on more expensive U.S. ships. The Government Accountability Office (GAO) calculates that even in emergency situations, the shipments take four to six months to arrive in needy areas. Sometimes they arrive after the harvest has come in and the crisis has abated, which leaves shipments to flood the now functioning local market. Those pushing for reform are asking the U.S. to provide more cash for local and regional food purchases both to make aid quicker and to bolster local markets. They also are advocating for more resources to support long neglected developing world agriculture sectors. “This is really all about a flexible approach,” said Phillip Thomas, GAO assistant director for international affairs and trade. “If you’re really about feeding hungry people in an emergency situation or in a development situation, you want to have all the tools.”
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While millions of struggling people worldwide benefit each year from U.S. donated food, critics of the system advocate for a more efficient, development-oriented food assistance program. photo Courtesy of GAIN
The most effective form of aid is highly context oriented and sometimes even specific to the type of person receiving the aid, said Agnes Quisumbing, senior research fellow at the International Food Policy Research Institute. While all forms of food aid show increases in weight to height, work by Quisumbing and her colleagues shows differences in aid effectiveness depending on whether the food was distributed for free or used in a food-forwork situation. It also shows variations in effectiveness depending on the gender of the recipient. Research continues on whether food or cash is more effective for long-term results. While nutritional status may improve more rapidly in the short term with direct commodity distribution, cash may encourage sustainable markets, which could improve health outcomes more in the long term, she noted. “The donors were hoping we would come up with one blanket recommendation,” for the most effective food aid, Quisumbing said, but the results were not that clear. Overall, she said, research findings argue for greater investment in long-term agricultural development over provision of emergency aid after nutritional status already has been compromised. But emergency relief has grown in recent years and now comprises the bulk of U.S. food aid. In addition, funding for agricultural development has dropped steadily over the years from all donors. Agriculture made up 18 percent of official development assistance in 1979, but fell to 3.5 percent in 2004. Many are pushing for greater attention to increased crop yields and diversification and market improvements to reduce the number of food emergencies. “I think there’s general recognition that just focusing on the short term, we’re chasing our tail and we’re getting further and further behind,” said Thomas Melito, GAO director for international affairs and trade. To better address short-term concerns and support longer range market issues, food aid reformers advocate a range of interventions that respond to local market and
nutritional needs rather than just choosing one donation method for all situations. Cash is often quicker and more efficient but may cause more problems than straight food donation in some cases. “The problem is that cash works really well if markets work well,” said Christopher Barrett, international professor of agriculture at Cornell University and co-author of Food Aid After 50 Years: Recasting its Role. In other circumstances, “just pumping cash into the system can be purely inflationary,” he added. Food also is the better choice in situations where commodities are not available in a broad regional area. Barrett and co-author Daniel Maxwell, associate professor at Tufts University, developed a food aid decision tree that analyzes local markets and food availability to determine whether aid should come in the form of food or cash and whether food should be purchased locally, regionally or come from abroad. They and other advocates warn against locking into any specific donation method, but urge looking at the specific situation. Food, in fact, may become the more valuable commodity if prices remain high. “In-kind food aid is suddenly in very short supply and very high demand,” Maxwell noted. While recipients had been asking for cash, “Now they are saying, ‘please, we want the food and not the cash.’” Many also are arguing that the nutritional value of food, both that obtained locally and donated, needs to be considered more carefully. “We may need to bring in something that is trying to address the nutrition issue a bit more directly. That’s a big issue,” said Bob Bell, director of the food resources technical team for CARE. The recent Farm Bill, approved in June by Congress, calls for increased nutritional analysis of U.S. food and establishes a pilot project that provides cash for local food purchases. But many were disappointed that
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The food crisis is arguably felt the strongest in refugee camps, such as the three Dadaab Refugee Camps in northern Kenya. Frederic Courber/CARE
the bill didn’t go further. Bill sponsors rejected a Bush Administration proposal allotting 25 percent of food aid funding for local purchase instead of buying commodities in the U.S. The pilot program set aside $60 million over four years for local purchase, less than 1 percent of total U.S. food aid. An additional $50 million was added in supplemental appropriations, but advocates still find it lacking. “If you like the status quo then [the Farm Bill] is not so bad. If you’re interested in improving and reforming our food aid program, then it was a disappointment,” said Gawain Kripke, senior policy advisor on international trade issues for Oxfam America. Pushing against more sweeping reform is what is known as the “iron triangle” of agribusiness, maritime interests and NGOs that use funding generated from selling food aid to support their programs. Those interests “all have a major stake in seeing to it that the status quo is not upset because they all stand to lose if that coalition of interests falls apart,” said Tufts’ Maxwell. Some NGOs sell U.S. food that is donated to them in low-income countries. They then use the cash to support development programs and operations in a practice known as “monetization.”
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GAO calls monetization “inherently inefficient” and some estimate that for every $1 used to buy the food initially, 50 cents or less actually ends up in program budgets. The funding method is highly controversial and has divided the NGO community. One of the largest monetizers, CARE, instituted a four-year phase-out of the practice, which becomes fully effective in September 2009. “We stopped doing it because it was wasteful and because it has unintended harmful consequences,” including commercial displacement of local products and undermining local development, said David Kauck, senior program technical advisor with CARE. Bell adds, “Imported food aid is probably best when used in times of emergency or to support certain kinds of safety nets. Monetization, while important as a source of cash, was not the right use of the resource.” While CARE’s move is described as “bold” by several observers, the group says it expects to lose as much as $45 million a year in U.S. funding as a result of the decision. While it is working to raise the funds from other donors, CARE officials said the move will affect their
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operations in certain countries. That money was used for precisely the types of long-term programs most needed to ensure sustainable agriculture in developing countries. While some groups have expressed support for CARE’s move, including Catholic Relief Services and Mercy Corps, none has joined it yet.
food aid from farm-state representatives in Congress and others and potentially generates good will for the U.S. as the needy receive bags of grain emblazoned with U.S. symbols. “There certainly are valid political reasons for why the status quo has been maintained, there’s no question about that,” Maxwell said.
Pro-monetization forces, including World Vision, Feed the Children and Land O’Lakes, all members of the Alliance for Food Aid, argue that monetization provides important food resources in certain countries and supports key programs. “The proceeds generated from sales are used to support delivery of donated food or for projects that improve local food security, including decreasing childhood malnutrition, increasing agricultural productivity, and increasing household incomes in poor areas,” Alliance documents say. Sixteen NGOs received donated non-emergency food through the U.S. Agency for International Development’s Food for Peace program in 2007 valued at $348 million. USAID staff said about two-thirds of non-emergency food is monetized yearly.
As turmoil continues both in the food and financial markets, donors will be looking for ways to improve their aid efficiency. “The longer the food crisis goes on, the more flexible the U.S. is likely to become,” said Lisa Kuennan, director of the public resource group at Catholic Relief Services (CRS). She said USAID already shifting some of its contract with CRS from food to cash to mitigate the high costs of shipping.
Reform supporters say most NGOs, at least privately, admit that monetization is inefficient, but they are loath to give up the practice without a guarantee that equivalent funds would be made available to support their programs. “The challenge for NGOs is if you’re seeing investments in agriculture going down, why would you say stop food aid on an assumption that it would somehow go up?” said Sam Worthington, president and CEO of InterAction, an NGO umbrella organization. The European Union switched from a largely commodity based food aid system to a cash program, but some say the total amount of aid available has decreased. Also, they argue the current U.S. system generates political support for
Other proposals also are being developed. Sen. Richard Lugar, R-IN, ranking Republican on the Senate Foreign Relations Committee, introduced legislation in September that would authorize $5 billion over five years to develop an integrated U.S. global food security plan and support agricultural development in high-risk countries. It also would provide funding for local and regional purchase of food aid separate from current food aid programs. Despite entrenched interests in current U.S. food aid policy, some are optimistic there will be a move toward greater efficiency in the future. The food price crisis, said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies, “changes the whole context” of food aid policy. “It gives a whole different rationale and sense of urgency and allows us to lift the debate out of where it’s been stuck for a very long time.”
As of September 2009, CARE will halt the controversial practice of monetization, which is estimated to create a $45 million loss in U.S. funding each year. Left: Erin Lubin/CARE Right: Frederic Courber/CARE
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By Bobbi Nodell
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Are there Sustainable Solutions to the Nutritional Crisis? Plumpy’nut, a fortified peanut butter with milk and vitamins, has been hailed as a lifesaver for starving people. But for nutritionists like Dr. Susan Shepherd, who works in nutritional emergencies for Médecins sans Frontières (Doctors Without Borders), Plumpy’nut is far from a magic bullet. Not only is it expensive, but there is simply not enough of it. She estimates just 5 percent of the acutely malnourished people, who desperately need therapeutic foods like Plumpy’nut, are getting it.
nutrition. According to the Lancet nutrition series, $300 million a year is spent on nutrition while $6 billion is spent on HIV/AIDS.
And while such nutrition-dense foods are lifesavers, they are not a long-term solution.
“Nutrition can only be sustainable if people ultimately pay for it,” said Dr. Alfred Sommer, dean emeritus of the Johns Hopkins Bloomberg School of Public Health. “Nutrition could stop being a program when governments change priorities.”
“If you really want to focus on under-nutrition, you need to work in prevention, targeting the golden window of opportunity – conception through the first 24 months,” said Katharine Kreis, a senior program officer with the Bill & Melinda Gates Foundation. According to the Lancet nutrition series (January 2008), 178 million children under 5 suffer from nutritional deficiencies – 55 million acute and 19.3 million severely acute (wasting). Unlike many diseases, malnutrition has a cure – a balanced diet, regular consumption of fortified foods, supplements when local foods don’t have the nutrients needed, and animal-based products like milk, fish, eggs and cheese. As Shepherd notes, “Plumpy’nut is the equivalent of a glass of milk and a multivitamin.” But for millions of people, essential vitamins and minerals are a luxury they simply cannot afford. One solution is to dramatically increase spending on
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But increasing public funding is not sustainable, say nutritionists. Making nutrition available and affordable requires a partnership with businesses, governments and non-governmental organizations to increase both the supply and demand for affordable products.
Today, unlike any time before however, several partnerships are galvanizing efforts to solve the nutritional crisis with sustainable solutions. GAIN One of the biggest drivers in forging public-private partnerships is the Global Alliance for Improved Nutrition or GAIN, an alliance of key institutions founded in a United Nations session in 2002. GAIN now has partnerships in 18 countries as well as a project with UNICEF on iodization of salt in 13 countries. GAIN’s current main effort is in mass food fortification – the addition of micronutrients to commercially processed staple foods such as maize, rice and wheat flour, condiments like salt, sugar, fish sauce and soy sauce, and milk and oil. “GAIN uses different program implementation approaches according to the country’s specific circumstances,” said Regina Moench-Pfanner, senior manager of the Food
Bobbi Nodell, a veteran journalist, is the communications specialist for the University of Washington Department of Global Health.
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Fortified foods, distributed through food aid, is a lifesaving mechanisms for many, providing much-needed nutritional supplementation. Above: Courtesy of H.J. Heinz Company Foundation Right: Courtesy of Valid International
Fortification Program. For example, in Egypt, GAIN is working with the United Nation’s World Food Programme (WFP) in partnership with the government to fortify the wheat flour used in baladi bread, the staple food consumed by low-income populations throughout the country and subsidized by the government. GAIN is providing $3 million to the WFP to assist the government in strengthening and upgrading the quality system of the fortification of flour and in implementing a social marketing campaign to raise awareness of the health benefits of fortification, while the Egyptian government is investing $20 million for premix, equipment, manpower and quality control over five years. In Pakistan, where food products are not subsidized, GAIN is working with the government and millers to support fortification activities, including buying the premix. For long-term sustainability, GAIN and its partners advocate for mandatory food fortification laws, said Moench-Pfanner. “I really think that organizations like GAIN are making a huge difference in this field,” said Dr. Martin Bloem, chief of nutrition and HIV/AIDS policy for WFP and a board member of GAIN. “Ten years ago, I would be talking only
about the public sector and I would say we need more money. But that’s only part of the solution.” Sprinkles Meanwhile, in rural Tanzania, the Boston-based NGO Global Action is fighting malnutrition with Sprinkles, a micronutrient powder of essential vitamins and minerals, such as vitamin A, the B vitamins, iron, iodine and zinc. These are essential to boosting the immune system and preventing millions of childhood deaths a year. Global Action is launching a program in Tanzania in two regions where iron anemia is 88 percent and 79 percent respectively. The packets will be distributed at community health centers when children receive their free immunizations and through community health workers to reach a larger number of children in rural villages, said Michelle Lyden, the CEO. Dr. Stanley Zlotkin, a senior scientist with the Hospital for Sick Children in Toronto, invented Sprinkles just 10 years ago and now it’s being used in 15 countries, according to the Sprinkles Global Health Initiative. The H.J. Heinz Co. and DSM are the biggest producers of micronutrient powders like Sprinkles, which they provide to NGOs for low-cost or through donations.
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While there is a growing selection of nutritional supplements, distribution and long-term sustainability remains a challenge. Courtesy of Valid International
Heinz now has manufacturing plants for Sprinkles in India and Indonesia and could open more if there was demand, said Tammy Aupperle, the director of the H.J. Heinz Company Foundation, the philanthropic arm of Pittsburgh-based Heinz. “We are completely dedicated to this project,” she said. Demand is created in many ways. Lyden said one way is for governments to take ownership and adopt Sprinkles in the national agenda similar to vitamin A and immunization. Another model being evaluated in Kenya and India is selling Sprinkles to women so they can sell it for a small profit (a penny or two). “Mothers want to have healthy children,” said Lyden, and many can afford to pay 20 cents to 30 cents a month. In Guyana, the government received a loan from the Inter-Development Bank to improve its micronutrient status and now is paying a local manufacturer to produce Sprinkles, said Zlotkin. He said the packets are distributed through public health clinics, which reach many of the poor but not everyone who wants it. “One has to be creative in distribution,” Zlotkin said. “You need multiple models of distribution – public sector, government sector, NGO sector and social marketing.” Population Service International in Washington, D.C, for example, has sold Sprinkles in Bostwana, Haiti, Bangladesh and Pakistan as part of its social marketing efforts.
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Other Products Many other solutions to the world’s nutritional needs are under way, such as efforts to create a lower cost version of nutrient-dense ready-to-eat products like Plumpy’nut. Valid Nutrition, an Irish-based charity for example, is active in developing local production capacities in a number of countries – Kenya, Ethiopia, Malawi and Zambia – each one based upon recipes that use locally available ingredients. And Project Peanut Butter operates a factory in Malawi dedicated to the production of a lifesaving lipid/vitamin paste. Meanwhile, new partnerships are forming between commercial food companies and microcredit companies. Jonathan Gorstein is a University of Washington associate professor whose business, Sagilo Solutions, is working together with GAIN to help forge these partnerships. In Bangladesh, he said, the Grameen Group is providing microcredit to dairy farmers so they can purchase hybrid cows, which produce significantly more milk than local cows. French-based Danone Foods then buys the milk from the farmers and makes yogurt fortified with essential vitamins and minerals. The yogurt is sold to consumers for a small profit by local women who then use the proceeds to improve their lives. “It’s very exciting for us to have all these new products to prevent and treat malnutrition,” said Ellen Piwoz, a senior program officer with the Gates Foundation, which is backing GAIN and several other organizations. “We think of nutrition as a neglected global health problem that has a solution.”
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Feeding the hungry
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online exclusives
By C. Peter Timmer
By Lillian Aluanga
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C How Did We Get Here?
C The African
Prices of basic foods have increased sharply since mid-2007. The causes and impact of higher prices are the subject of much analytical and policy debate, with little agreement except on the tragic consequences for the nutritional and health status of poor consumers. Fortunately, the price panics seen early in 2008 have reversed. But price levels remain well above long-run trends and significant micro and macro adjustments are in the works. How did we get here? Go to www.globalhealthmagazine.com to read full story.
Green Revolution
Dinah Wetaba has always loved the sound of raindrops pattering down her iron-roofed house in Western Kenya’s Butere District. For Wetaba, a farmer and mother of five, rain completes a cycle of long days toiling on her half acre plot, tilling, planting and tending her maize, beans, sweet potato, soyabean, spinach and collard greens. Lately though, delayed and unpredictable rains have threatened the promise of harvest. But Wetaba has other worries as well. This season she could not apply fertilizer to her crops. Since 2005, the cost of fertilizer has tripled from Sh1,600, (about US$20) to Sh4,000 (US$60) for a 50kg bag. As the world grapples with a global crisis that has seen food prices skyrocket and production shrink, Africa is looking to a new project – the African Green Revolution – as its last hope in easing suffering from hunger and malnutrition of one-third its population. Go to www.globalhealthmagazine.com to read full story.
Peter Timmer is a Fellow at the Center for Global Development and a visiting professor in the Program on Food Security and Environment at Stanford University.
Lillian Aluanga is a journalist with the Standard Newspapers in Nairobi, Kenya.
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By Andrew Jack
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Big Pharma Bets on Emerging Economies
On the shelves of pharmacies across India, a new form of competition is taking hold. Patients long neglected by multinational drug groups are beginning to gain access to a wider variety of innovative medicines at more affordable prices.
For many years, much of their action around “access to medicines” was essentially philanthropic. It focused on drug donations to treat the world’s neglected diseases, such as Merck’s provision of Mectizan for onchocerciasis, Pfizer’s Zithromax for trachoma, and GSK’s Albendazole for lymphatic filariasis.
In the past, even when newer drugs were physically available, they were typically charged at Western prices, too costly for most to buy. Now Merck is offering its diabetes drug Januvia at a fifth of the U.S. price, and GlaxoSmithKline (GSK) is charging different prices even within India to reach more of the population.
Since the turn of the millennium, growing demands from AIDS activists – backed by political pressure and legal challenges – offered a new approach spearheaded by wider access to costly new antiretrovirals for HIV in the developing world.
Such nuanced approaches to drug pricing that more closely reflect the ability to pay represent an attractive new trade-off for pharmaceutical companies: they provide greater sales to please their shareholders, while improving access to medicines for patients on lower incomes in the developing world.
A corporate desire to head off criticism, underwritten by fresh funding from donors and competition from generic drug manufacturers, helped reduce prices. Several began to experiment with differential or tiered pricing, through programs such as the industry-backed Accelerating Access Initiative.
“The pharma industry has realized that the vanilla solutions that were effective in the past now require significant differentiation,” says Todd Evans, director of the healthcare advisory group at PricewaterhouseCoopers, the accountancy and advisory firm. “Pricing is going to be highly varied.”
Drawing on the principle of “Ramsey pricing” developed by an economist of the same name in the 1920s, the idea behind the initiative is to charge prices that only just cover marginal production costs in poorer countries, so long as higher prices in richer ones cover research and development costs and provide an adequate overall rate of return.
While the U.S. remains by far the world’s largest single market for pharmaceuticals, GSK and a number of its rivals are increasingly betting on the fast-growing “emerging economies” of Asia, Latin America and Eastern Europe to compensate for increasingly sluggish growth in the developed world.
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Emerging Markets Become Significant Interest in extending such flexible pricing to other therapy areas and some of the larger emerging markets has been slow. In a report at the end of 2007, Oxfam, the British anti-poverty group, criticized pharmaceutical companies for “a failure to implement systematic and transparent
Andrew Jack is a journalist for the Financial Times of London since 1990, specializing in health and pharmaceuticals.
tiered-pricing mechanisms for medicines of therapeutic value to poor people in developing countries, where prices are set according to a standard formula which reflects ability to pay.” Novo Nordisk, the Danish pharmaceutical company, has been present for a decade in China, investing in research and manufacture as well as marketing and distribution. But it sells its new generation of insulin products to diabetics at Western prices. That is not simply a policy that suits the company. The Chinese authorities have imposed the system in order to stimulate innovation, investment and the creation of a domestic pharmaceutical industry. They have negotiated drug prices close to those paid by its far richer regional neighbors, such as Japan and South Korea. Following a similar pattern in other industrial sectors, the situation may change once China’s domestic drug industry becomes stronger. The fact that so many of its citizens are uninsured and unable to pay such high prices may also provide pressure for change. Elsewhere in the developing world, cancer medicines – by some estimates already the largest therapeutic category in the world and consuming a significant share of the pharmaceutical industry’s research funding – are generally allocated a single, high global price by their manufacturers. Companies such as Novartis of Switzerland, developer of Gleevec, a pioneering treatment for leukemia, have kept prices high and fiercely defended their patents
against generic copies, while operating patient assistance programs to offer the drug free to those on low incomes who need it. Some executives argue that demand for their medicines is relatively inelastic, with no price low enough to significantly boost access. A small, wealthy population in poor countries can afford to pay Western prices out of pocket or through health insurance. Most of the rest are so poor and left uncovered by rudimentary state health care that even a very substantial discount would not allow them to buy innovative medicines. Another reason more companies have not extended differential pricing widely in the developing world is fear that discounts may undermine the higher prices they charge in the West. Re-importation is one way this occurs. Intermediaries buy drugs in countries where they are cheap, for resale with a mark-up in higher priced regions. The practice is illegal in the U.S., but difficult to control, and takes place from Canada. Within the European Union, such “parallel trade” has been upheld as legal in several recent court rulings. Simply observing the lower prices charged elsewhere via the Internet may also trigger demands by middle-income and richer countries for similar discounts, undermining the prospects of subsidized sales for the poorest. “We price globally,” says Angus Russell, chief executive of Shire, an Irish-based company, which sells drugs to treat very small groups of patients with extremely rare diseases who may pay as much as $300,000 a year
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per person. “Otherwise you would get parallel imports. These are tight-knit communities.” But renewed commercial interest in emerging economies led by Brazil, Russia, India and China is also sparking a broader reflection on differential pricing. Among 50 top pharmaceutical executives polled last June by Roland Berger, the management consultancy, the single most significant commercial opportunity they cited was the “rising importance of emerging markets.” As IMS, a global health-care consultancy, highlighted in its “Harbingers of Change” for 2008, “Asian (excluding Japan), Latin America and European markets (apart from the five major developed markets) grew collectively by more than 10 percent and are now the largest source of growth in the global market.” As the World Health Organization has argued, with rising wealth and changing lifestyles, emerging markets are increasingly characterized by populations with the same health problems as more developed countries. Chronic diseases are becoming more important than infectious ones. While the Bill & Melinda Gates Foundation, from its U.S. base, has focused on tackling infectious disease in the developing world, Carlos Slim, the Mexican billionaire who by some accounts has become the world’s richest man, has established a foundation in his home country which concentrates on chronic disease. Pharmaceutical executives also recognize that if they do not act, others may take the initiative. Thailand and Brazil have in recent months issued “compulsory licences” permitted under World Trade Organization rules, which allow them to waive patent protection on costly drugs and buy alternative versions from generic companies of the same quality but far cheaper. Public pressure is also rising. Wim Leereveld, a Dutch former pharmaceuticals marketing consultant, this year unveiled his Access to Medicines Index, which rates companies according to criteria including affordable pricing. It has already provoked an indignant response, notably from those companies that scored poorly.
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Andrew Witty, the recently appointed chief executive at GSK, says: “We need to start thinking about new game rules for the emerging economies.” He has headhunted Abbas Hussein from Eli Lilly to a newly-created senior job in charge of emerging markets. “We already had the footprint. With Abbas, we have someone capable of creating the strategy.” One of the projects that helped Witty win the top job at GSK was to develop experimental ways to sell medicines, with tests in India, South Africa and Morocco. He oversaw “internal tiered pricing” to sell at relatively high prices to richer patients who were insured or paid for themselves; and discounts to those on lower incomes with little or no coverage. He is not alone. Allan Gabor, regional vice president for Asia at Pfizer, says: “Our objective is to make products more widely available, and be much more flexible than we have been on pricing.” Some generic companies such as Cipla in India continue to fight against patents, arguing that competition is the only way to bring down drugs to affordable levels. They are backed by groups such as Doctors without Borders, which wants further easing of intellectual property rules to keep innovative drugs cheap. Yet a report from the United Nations released just ahead of a special session on the Millennium Development Goals in September highlighted that one of the biggest gaps in access to medicines did not relate to patented medicines at all, but rather generic drugs with often very high prices. That reflects factors, including import duties, taxes, networks of intermediaries and wholesalers with high margins, and small and inconsistent volumes which push up prices. It also highlights poor health systems and reluctance by many governments to sufficiently invest in medical care, including the purchase of pharmaceuticals. Yet it may be commercial forces and the lure of emerging markets that ultimately do most to drive differential pricing, and boost access to many patients whose incomes still exclude them from so much care available to those in the world’s richer nations.
Global health
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We hope you are eager, as we are, about the launch of GLOBAL HEALTH, a magazine published by the Global Health Council. As mentioned in the editors’ letter, this magazine is a practical and symbolic note of change at the Council. The main stories are being offered in the print format, giving our readers the same look and feel as any other news publication. However, the magazine, in its entirety, is only available online at WWW.GLOBALHEALTHMAGAZINE.COM. As we all know, the economics of print publications have changed dramatically and with the advances in web communications, they are, to some extent, a luxury. Moreover, people have begun to read more magazines online. As such, the Council made a very conscious decision to create an online magazine with a print accompaniment to serve our members better. This allows you, our members, to access information faster and, likewise, to engage with us in a more immediate fashion. Also, it is an opportunity for your membership dollars to go further and allows us to allocate muchneeded unrestricted funds to other programs within the Council. Most importantly, we can now reach so many more of you online in a faster, eco-friendly, more efficient, and cost-effective manner.
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