Originally published in the National Post, June 5, 2013.

Worldwide, millions of people die each year because they cannot afford the medicines they need. These numbers could climb even higher, unless Canada and other Pacific Rim countries involved in the Trans-Pacific Partnership (TPP) trade negotiations take decisive action to protect global public health.

The latest round of TPP trade talks took place in Peru in May. All negotiations are conducted in secret, but leaked documents reveal that the United States is pushing for stringent intellectual property protections for drugs. These protections could give pharmaceutical companies longer monopolies over brand name drugs. This would allow them to charge high prices for longer periods of time and either stop or delay the generic competition from producing less expensive versions that are vital to global health. If the U.S. proposals are not deleted from the text before the deal is sealed this Fall, the TPP risks being the most harmful trade deal for access to medicines ever seen.

India 2013 © Siddharth Singh/MSF

We know that generic drugs help save lives. Take HIV: Affordable generic medicines dropped the price of treatment from over $10,000 per person per year in 2001, to just $120 today. This price reduction has made it possible for 9-million people to receive treatment in developing countries.

So how is the U.S. seeking to make generic competition more difficult and hurt access to medicines? Among its long list of demands, the U.S. is asking to lengthen patents beyond 20 years, lower the requirements for patentability, and allow companies to sue governments for patent infringements through unaccountable tribunals.

Barack Obama referred to the TPP as a “model not just for countries in the Pacific region, but for the world.” Yet the TPP as currently drafted will undermine the public health exceptions agreed in the Doha Declaration in 2001, which reaffirmed governments’ rights to use generic versions of patented drugs to respond to public health priorities.

Protectionist trade deals add huge burdens to already stretched healthcare budgets, which ultimately limits access to medicines for patients. We have already seen the impact of these harmful trade agreement provisions before. In Jordan, brand name drug prices increased 20 % in the five years after similar patent protections were implemented in the U.S.-Jordan Free Trade Agreement. In Costa Rica, public spending on HIV drugs is expected to increase by at least 50 % as a result of the U.S.-Central America Free Trade Agreement. Protectionist trade deals add huge burdens to already stretched healthcare budgets, which ultimately limits access to medicines for patients.

While the impact of the TPP agreement may seem far removed from Canada, it could also put a dent in Canadians’ pockets. In 2012, for example, spending increases on prescription drugs in Canada slowed down thanks, in part, to the expiration of patents on several brand-name drugs, thus allowing for less costly generic versions to enter the Canadian market.

Eli Lilly is now demanding $100 million in compensation from Canadian taxpayers for alleged lost profits. Canada is also experiencing firsthand the consequences of using unaccountable tribunals to resolve trade disputes. Eli Lilly recently initiated proceedings under the North American Free Trade Agreement, to sue the Canadian government for what they believe was their right to the patent of an ADHD drug. They are now demanding $100 million in compensation from Canadian taxpayers for alleged lost profits. To avoid future lawsuits, Canada should join Australia in refusing to include these so-called investor-state dispute resolution mechanisms in TPP negotiations.

Instead of prioritizing brand-name pharmaceutical interests, the TPP could be used to improve patient health and reduce drug expenditures, especially in poor countries. Rather than stunt innovation and discourage market competition with its excessive patent protections, the TPP could provide an opportunity for a new approach to drug development and medical innovation. This could be achieved through new models of drug research and development, including incentives that promote more open innovation and that break the link between the drug prices and the costs of research and development that is used to justify excessive patent protections.

As an international medical humanitarian organization working in more than 70 countries, Médecins Sans Frontières/Doctors Without Borders (MSF) relies on affordable quality generic medicines to treat hundreds of thousands of patients. We strongly urge Canada to take a bold stand and protect public health interests. Access to medicines is a matter of life and death. We can’t ignore the millions of lives that hang in the balance.

by Stephen Cornish

Executive director for Médecins Sans Frontières in Canada

First published online by The Globe and Mail on May 6, 2013

We are failing the Syrian people. Right now, women, men and children are suffering and dying needlessly. We can and must do more to help them.

I recently returned from a two-week mission to Syria, Lebanon and Turkey. There I met with Syrians struggling to survive a brutal civil war that has so far killed more than 70,000 people and forced more than one and a half million to flee to neighbouring countries.

Syria 2013 © Brigitte Breuillac/MSF

I also met with aid workers providing lifesaving assistance – from my own organization, Médecins Sans Frontières/Doctors Without Borders (MSF), and from the few others present.

One thing became absolutely clear to me on this trip. We, the international community, are not living up to our responsibility to meet the escalating humanitarian needs of the people caught up in this intractable war.

Truly, we are failing the Syrian people. The medical needs are overwhelming – from shrapnel injuries that go untreated for lack of accessible care, to pregnant women who must risk their lives to deliver their babies, to sufferers of chronic illnesses like diabetes and cancer who can't obtain treatment, to the miserable and unsanitary conditions of the camps for displaced people.

I cannot overstate the scale and severity of the humanitarian emergency I witnessed. The Syrian conflict is already the world's largest refugee crisis. We can do more to save lives and reduce suffering, and we must do it now.

Click to listen to Stephen Cornish talk about the Syrian humanitarian catastrophe on CBC's Metro Morning.

What can we do? The crisis requires political will and leadership on the part of national governments to persuade Damascus, opposition groups and Syria’s neighbours to increase humanitarian access and reduce barriers to aid. It also requires more resources to meet the escalating needs.

Targeting of medical personnel and restrictions on crossing the constantly shifting frontlines are major impediments to providing lifesaving care where it is needed most. Syrians often have to risk their lives on long, circuitous journeys in order to get medical help. All parties to the conflict must be pressured to respect medical facilities, as well as the rights of aid workers and their patients.

In opposition-held territories in the north of the country, where MSF is operating three hospitals, there are too few aid organizations present to meet the needs. The increased security risks are also making it difficult to work.

Inside government-controlled areas, restrictions on the UN and Red Crescent hinder their abilities to respond in areas where needs are highest. Despite repeated requests, the government still refuses to give MSF and others permission to work, which further impedes the aid effort.

Iraq 2013 © Michael Goldfarb/MSF

Outside Syria, the UN expects the number of refugees to reach three million by year’s end. Lebanon, Turkey, Jordan and Iraq are doing what they can to care for the refugees. But these countries are stretched to the limit and need help, in the form of financing, technical assistance, and more aid organizations to help them respond to the unprecedented flow of refugees.

Resources have been promised, but now they need to be mobilized. In January of this year, 60 countries pledged more than $1.5 billion in aid for the Syrian people. So far, only a fraction of this money has materialized. Donor countries not only need to honour their existing commitments, they need to significantly increase them to keep pace with the escalating needs.

In many camps, conditions are woefully inadequate. Relief supplies and food are being stretched to cover the steady stream of new arrivals. Insufficient access to clean water and sanitation presents the risk of disease outbreaks as we move into the hot summer months.

For the refugees inside Lebanon, medical care is frequently poor or nonexistent ̶ about half are unable to access it. During my visit, I met a pregnant woman who was ready to risk returning to Syria to deliver her baby, because she couldn't afford to pay medical fees for a caesarean section.

Neighbouring countries should also be encouraged to do more to facilitate the delivery of aid for Syrian refugees – especially by removing bureaucratic hurdles. This includes faster registration of international aid organizations, reducing barriers to import relief supplies and easing visa restrictions for aid workers.

The conflict in Syria shows no sign of abating, and the needs of the Syrian people are increasing daily. There is no excuse for our continued humanitarian failure. We must act now.

By Dr. Unni Karunakara, International President, Médecins Sans Frontières/Doctors Without Borders (MSF)

In February, during a visit to Bolivia, I had the opportunity to tour the Chagas diagnosis and treatment project that Médecins Sans Frontières/Doctors Without Borders (MSF) runs in Narciso Campero province, located in the rural area of Cochabamba, which has one of the highest prevalences of Chagas in the country. During my visit, I talked to both patients and MSF staff and they confirmed that, despite the challenges, diagnosis and treatment of people living in areas far from urban centers is possible.

Paraguay 2012 © Seamus Murphy/VII

Unfortunately, the experience in Narciso Campero is just a drop in the ocean when you consider the actual impact of Chagas disease: it is estimated that there are between eight and 10 million cases worldwide and that the disease causes the death of 12,500 people every year, making it one of the parasitic infections with the highest mortality rate in the American continent. In Bolivia, it is estimated that up to one million people are affected, and more than 3.2 million people are exposed to the disease in endemic areas. The situation is even more difficult for those patients who have developed heart or digestive complications due to the disease, since palliative care in these cases is expensive.

Changing this scenario is only possible if governments of endemic countries commit to closing the significant gap between the number of people living with Chagas and those who receive treatment. Latin American states are facing a historic opportunity, more than one hundred years after the discovery of the disease, to finally begin transforming the reality of Chagas patients.

In recent years there has been significant progress. The Drugs for Neglected Diseases Initiative (DNDi) has developed a pediatric formulation of the drug used for the disease, leading to improved treatment for children. The International Federation of Chagas Patients, which allows for those affected to have a platform from which to make their voices heard, and International Chagas Day, which we commemorate today, were recently created. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) have both adopted resolutions recommending the diagnosis and treatment of Chagas be integrated into primary healthcare centers (ie the clinics and hospitals that are closer to the community), and the supply of the existing treatments strengthened with the aim of making access universal in the future. But much remains to be done for these resolutions to be translated into concrete actions.

In this sense, Bolivia can play a key role as a regional leader in the fight against Chagas. Although it is the country with the highest Chagas endemicity, it is also the one treating the largest number of patients, and it has some of the strongest laws regarding the disease. Act 3374 of March 23, 2006, for example, declares as a national priority the fight against Chagas and its prevention in all departments. If, under the leadership of the President of the Republic, the Health Secretary and provincial governors, the country achieves to turn into a concrete reality what the decree proposes, Bolivia can become a role model for the continent.

The great barrier existing today for patients’ access to diagnosis and treatment is the lack of human resources and a sound primary healthcare infrastructure that includes raising awareness and educating both the population and medical staff in charge of providing treatment. Simpler diagnostic tools and better treatments, tailored to the contexts, are needed. New drugs have to be developed to accompany this process; meanwhile WHO and PAHO should support the efforts of governments, ensuring that the necessary drugs are available in all concerned countries. Since 1999, MSF has been working on Chagas, serving more than 7,000 patients in different countries of Latin America and proving that it is possible to provide treatment. Of course, it will take time, work and commitment from the authorities, but the moment to start transforming the lives of millions of patients with Chagas is now.

by Stephen Cornish

Executive director for Médecins Sans Frontières in Canada

Article originally published in the Ottawa Citizen.

This year’s World AIDS Day (December 1, 2012) has an ambitious theme: “Getting to zero.” This means: Zero new HIV infections, zero discrimination and zero AIDS-related deaths.

Significant progress has been made. AIDS is no longer an automatic death sentence. More than eight million people living with HIV in developing countries are currently on antiretroviral drugs (ARVs), which allow them to live healthy and productive lives. Scientific evidence ─ stemming from research done in Canada by Dr. Julio Montaner and his team at the B.C. Centre for Excellence in HIV/AIDS ─ shows that by getting people on treatment earlier, you can reduce the spread of HIV. And, on paper at least, the political commitment is there: the international community has committed to scaling up HIV treatment to millions more who are still in need.

India 2012 © Subodh Pakhare
Veena Panchal lives in Andheri East, a crowded suburb of Mumbai, along with her two children. She found out in 2002 that she was HIV positive, after the death of her husband from HIV/AIDS. Her two children are HIV negative.

Success “in getting to zero” could be within our reach if countries, including Canada, fulfill their pledges to do more. But progress is continually threatened by inconsistent government policies. Canada, for example, has pledged almost $1.3 billion to support the Global Fund for AIDS, Tuberculosis and Malaria; yet, on the other hand, Canada is also entering into trade talks that threaten the availability of affordable generic medications for HIV and other diseases.

Affordable ARVs are the cornerstone of the world’s response to AIDS. Thanks to generic competition from India, the price of HIV drugs has dropped by a staggering 99% in the past decade. More than 80 per cent of all HIV medicines bought by donors come from Indian generics, and Médecins Sans Frontières / Doctors Without Borders (MSF) also sources from India most of the ARVs it uses to treat 220,000 people across the developing world.

Yet inconsistent government policies make it harder to succeed in the fight against AIDS and threaten this lifeline of generic medications. We at MSF are particularly concerned about the Trans-Pacific Partnership agreement (TPP), a U.S.-led regional agreement under negotiation that currently involves Canada, the United States and nine other countries, including developing countries like Peru and Vietnam. Canada is a latecomer to the TPP but will participate at the next round of negotiations in December.

The TPP talks are being conducted in secret, but leaked drafts of the text show that the U.S. is demanding aggressive provisions that would stifle the production of less expensive generic drugs. The U.S. is pushing for longer and harsher rules that will keep generic competitors out of the market and keep prices high. The U.S. also wants to make it easier for pharmaceutical companies to get new patents on variations of old drugs even if these bring no additional therapeutic benefit for patients.

These policies threaten the affordability of and access to medicines for AIDS and other diseases. This can mean the difference between life and death for people in the developing world.

This trade pact also has implications for Canada’s own foreign aid and development policies. The Global Fund’s ability to scale up treatment to the almost seven million people who need it is critically dependent on a sustainable flow of affordable generic drugs, for example. By signing up to the provisions being proposed in the TPP today, Canada would be undermining the very global health programs that we support. It would be reneging on previous promises to ensure that trade does not trump public health.

The importance of protecting access to generic medicines is not a new issue for Canada. The country pioneered a bill in 2004 ─ Canada’s Access to Medicines Regime (CAMR) ─ that aimed to ensure we did our part to help developing countries access affordable medicines even when patents stood in the way of generic production. Yet eight years later, only one license has been issued under CAMR, and only one Canadian drug manufacturer has shipped generic HIV drugs to a developing country. CAMR is virtually unusable unless the political will to reform it is found. This week saw a massive setback when the revised CAMR bill C-398 failed to pass. Without this reform, it is unlikely that Canada will ever be able to make another shipment of lifesaving generic drugs to the world’s poorest.

Now, it is more important than ever for Canada to actively ensure the commercial negotiations it participates in do not trade away health. Getting to zero means drugs need to be kept affordable, and Canada must play its part.

by Stephen Cornish

Executive director for Médecins Sans Frontières in Canada

Earlier this month, Minister of International Cooperation Julian Fantino visited Burkina Faso. The visit dovetails with the government’s current matching funds program to raise aid money for the Sahel region of Africa. These efforts, laudable for their aim of helping people in need, unfortunately give an emergency-style focus on what in reality is a chronic crisis that needs long-term solutions.

This year, across the Sahel, one million severely malnourished children are expected to receive lifesaving nutritional and medical treatment. This is the largest number in the history of humanitarian interventions. Malnutrition in the Sahel, however, has not simply spiked overnight resulting in a nutritional emergency. What we are witnessing is the recurrence of a usually silent and recurring annual crisis.

Chad 2012 © Catherine Robinson/MSF

Countries in the region such as Burkina Faso, Niger and Chad, face a yearly hunger gap, a period in which last year’s grain stores are spent and this year’s harvest is still a few months away. This situation compromises the nutritional and health status for millions of people across the region. What is different now is that for the first time all concerned governments reacted early, calling for cooperation and international assistance. This has allowed donors and aid organizations to roll out relief efforts in time to maximize their lifesaving impact. In Niger alone, more than 229,000 severely malnourished children have been treated through these efforts.

Significant challenges remain. With the onset of the rainy season, several areas have become inaccessible and recent floods have increased the incidence of malaria, affecting many people in a context where vulnerability is already at its peak. Political instability and insecurity in parts of Mali, Niger, Chad and Nigeria further complicate the delivery of assistance.

In Niger, the government, humanitarian organizations and donors developed preventative programs to ensure community supported nutritional care for infant children before their family’s resources dried up and the children’s weight plummeted to the point where they would require urgent and expensive medical treatment just to save their lives.

Lack of access to health care is a key component of this recurring crisis. Cost-recovery strategies long pushed on developing countries by the World Bank as part of structural adjustments to decrease social spending by developing nations governments mean that families with even the most modest incomes have to pay to access health care. During the lean period, people’s scarce resources are used to feed their family. There is nothing left to pay for medical care. This leaves children more exposed to opportunistic infections and seasonal malaria. Ensuring access to free health care and including ready-to-use food supplements containing proteins and micronutrients as part of the health package provided to mothers and children is essential to treat and prevent diseases. It will reduce the burden of malnutrition.

Burkina Faso 2012 © Aurelie Baumel/MSF

It is difficult to compare the impact of malnutrition from year to year, and particularly difficult when the comparison involves such a diverse group of countries, as well as external contributing factors. But we do know that hundreds of thousands of children are at risk of death every year, caught against their will in this predictable cycle of recurring starvation.

We must rethink the meaning of “normal” and “crisis” in the Sahel.

The good news is that the scale of the problem of malnutrition — which was previously under-estimated and even hidden — is finally visible. Developing nations, donor countries and humanitarian organizations are ensuring this year that more and more children are accessing lifesaving care.

Médecins Sans Frontières/Doctors Without Borders (MSF) has expanded its ongoing long-term programs across the region and stepped up its emergency response efforts. Between January and June, more than 56,000 severely malnourished children were treated by MSF in the Sahel region – more than 36,000 in Niger alone. MSF teams are also currently working in northern Mali, Niger, Chad, Burkina Faso and Mauritania to assist people displaced by the conflict in Mali.

While the emergency response underway in the Sahel is vital to help people in the region bridge the hunger gap until this year’s harvests come in, it cannot alone solve the “permanent emergency” of malnutrition in the Sahel. We must enact long-term solutions to change this chronic situation. Donor governments and developing nations must help to expand access to free preventative nutritional and medical assistance via local health ministries and aid programs. Such an approach will be more cost effective in the long run. It will save countless lives and will also help to pull families out of the vicious cycle of hunger and dependence on emergency aid once and for all.

by Fasil Tezera
Head of mission for Médecins Sans Frontières in Zimbabwe

June 6, 2012

In Zimbabwe, there are at least 66,000 people living with HIV who face the prospect of losing their current access to lifesaving antiretroviral (ARV) treatment because of a dangerous shortfall of international funding for local treatment programs.

To make up the shortfall, various segments of the Zimbabwean health sector proposed that certain HIV patients pay for their ARVs themselves. But what might initially appear as a cost saving measure will actually carry far greater costs – both in money and in lives – because it will undermine treatment adherence, quality and outcomes, as well as efforts to prevent more people from contracting the virus.

2011 Zimbabwe © Brendan Bannon
Seven-year-old Brian Tom, pictured above, is patient in the HIV/AIDS program run by MSF in Epworth, Zimbabwe.

Médecins Sans Frontières (MSF), which supports treatment for more than 228,750 HIV patients in more than 20 countries, is deeply concerned by these and similar proposals that involve shifting the financial burden of buying ARVs from state budgets and donor funds to HIV patients themselves. This idea is being aired as international donors continue to retreat from previous funding commitments on ARVs, thus cutting off access to lifesaving treatment for patients in resource poor settings.

Countries are struggling more than ever to find additional alternative sources of funding in order to avoid a return to rationing treatment and undoing much of the progress that has been made in HIV care over the past two decades. Interrupting treatment will also contribute to the growth of resistant strains of the virus.  

In Zimbabwe, ARVs are not currently covered by the Health Transition Fund (HTF), which creates serious problems. Until the end of 2011, a pool of funds financed by the UK, Sweden, Norway, Ireland and Canada paid for ARVs. This year, the HTF, absorbed this pool, but purchasing ARVs was no longer part of its mandate.

This means that some 66,000 patients already on treatment do not know where their ARVs will come from, to say nothing about people waiting to begin treatment. If  donors such as the United States, European member states or the European Commission through the HTF, do not mobilize to cover the gap, the next opportunity for additional funding would be a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. The earliest that would happen, however, if it happened at all, would likely be in 2014.

The funding shortfalls have sparked much debate and calls from UNAIDS and others for countries gripped by the HIV crisis to step up domestic efforts. It is certainly true that national governments and ministries of health must make both political and monetary commitments to treating HIV. But passing the burden on to the patients themselves is not the answer. That would mean expecting people who are already vulnerable to pay for treatment that should be free; it also jeopardizes the gains and results treatment programs have made.

2011 Zimbabwe © Brendan Bannon
The pharmacy at the MSF clinic in Epworth, Zimbabwe. MSF provides patients in the HIV program medication and care free of charge at the clinic.

The World Health Organization – backed by medical evidence – holds that guaranteeing ARVs free of charge is crucial to maintaining good treatment outcomes and to slowing the spread of HIV. Most people accessing ARVs in high-burden countries through government healthcare, as in Zimbabwe, are already impoverished because they have lost income due to the disease and are shouldering ancillary healthcare costs. The majority of patients in Zimbabwe and similar low-income countries often live below the poverty line and already struggle to pay costs related to care, be it for drugs to treat opportunistic infections, registration and hospitalization fees, X-rays, laboratory tests, or transport to clinics or hospitals. A study carried out by MSF in Kenya in 2007 compared retention in care among HIV patients with access to free ARVs, to patients who had to pay a fee of approximately $7 per month, while all other elements of care were the same. The result was that offering ARVs free of charge reduced the risk of loss to follow up by more than 56.6 per cent.

To make vulnerable patients in poor resource settings pay for ARVs goes far beyond reasonable expectations. What’s more, fees collected from patients in a country where 80 to 90 per cent of the population is not formally employed will not amount to much. And we know from experience that patients with unpredictable incomes may start rationing their ARV intake, taking less than the recommended dosages of pills in order to make drug supplies last longer. This leads to added complications, drug resistance and interrupted virus suppression – all of which would further increase the cost of care, wiping out any savings generated by the imposition of fees. In turn, it would increasingly burden health services, discourage health workers, and, worst of all, deter people from coming forward for testing and treatment.

A great deal of progress has been made in the fight against HIV/AIDS in Africa, but the emergency is far from over and the successes to date are far from assured. Any domestic funds that can realistically be raised in low resource settings now will not be sufficient to cover treatment for all people in need –  the number of people infected is still too high. . Zimbabwe alone has one million people living with HIV.

Economists estimate that most low-income countries will have to remain reliant on external support for the next 20 years if they are going to ensure an effective HIV response that meets the needs of their populations. Zimbabwe’s national HIV and AIDS levy, which channels  domestic resources to the HIV response, is an effective model that shows the country’s increasing commitment to generating domestic financing for HIV, but international funding still is and will remain critical. The funds raised at home should be used to put more patients on treatment, rather than to fill gaps left by retreating donors.

Therefore, MSF urges donors to make sufficient funding available for free and effective HIV treatment to all who need it. Domestic resources must be augmented with consistent and continued international involvement. Only then can we curb the HIV epidemic in Zimbabwe and similar high-burden, low-income contexts.