JAMA / May 2007

Health, Trade and Human Rights
By Theodore MacDonald, 138 pp
Radcliffe Publishing, 2006.

ISBN-13 978-1-8461-9050-6.

JAMA. 2007;297:2288-2289.

In recently concluded, but still undisclosed, trade agreement
negotiations with the United States, the South Korean government
demanded the capacity to establish a positive-list
cost-effectiveness and reference pricing system (as exists in
Australia) that values "innovation" in health care technology,
for all citizens, rich and poor alike, by expert evaluation of
its "objectively demonstrated therapeutic significance." Yet US
negotiators, contrary to resolutions of the Democrat-controlled
Congress, resisted this Korean approach and instead imposed a
mechanism for "evergreening" pharmaceutical patent royalties
likely to impede access by the poor to "essential" generic
medicines. Such developments are symptomatic of those carefully
highlighted by Theodore MacDonald in Health, Trade and Human
Rights.
MacDonald's is a fluidly expressed, well-researched book,
deserving the attention of those health professionals and policy
makers engaged in the important but Sisyphean task of making the
rules of international trade conform to the norms of
international human rights and the global burden of disease. It
also will assist those seeking a greater balance in the US
health care system between public (taxpayer funded) and private
goods.
MacDonald is a senior physician who has worked clinically in the
developing world. Health, Trade and Human Rights is dedicated to
Ken Saro Wiwa, activist for the human rights of the Ogoni Delta
people, who was hanged by the Nigerian government in 1995 for
criticizing the way international companies were exploiting that
nation's oil reserves. Yet, though infused with a similar
passion, the text makes its case with considerable moderation
and without departing from factually well-supported arguments.
It is less enmeshed in technical details and more infused with
human sympathy than a comparable text such as Health Policy in a
Globalising World (Kelley Lee, Kent Buse, and Suzanne Fustukian,
eds).
In chapter 1, "What Are the Problems?" MacDonald discusses how
improperly regulated international trade can subvert domestic
governance structures. He writes that "a US-based trans-national
corporation can effectively subvert the entire economy of a
third-world country by sending an e-mail between two banks." The
World Trade Organization has an explicit agenda (through
closed-door "liberalization" negotiations permitted by the
General Agreement on Trade in Services) in privatizing global
health care. That the World Health Organization has only a
nonvoting "observer" status in the World Trade Organization
council is merely symptomatic, MacDonald maintains, of the
extent to which an oligarchy of private interest groups has
succeeded in creating international governance structures that,
regardless of increased mortality and morbidity among the poor,
market health merely as a commodity that can traded, contrary to
the United Nations Charter.
Chapter 2, "First World Finance: Third World Debt," discusses
how the need of US banks to rapidly lend OPEC (Organization of
the Petroleum Exporting Countries) petro-dollars to finance
interest repayments encouraged the World Bank and the
International Monetary Fund to loan vast sums to developing
nations. To meet loan repayments, these countries were then
required by structural readjustment programs to compete with
each other in trades of sugar, cotton, tobacco, forest timber,
or coffee. The monies obtained often went to pay for armaments
rather than education or public health services. Since 1987, the
result has been that the International Monetary Fund received
$2.4 billion more from Africa than it provided in finance.
Likewise, by the end of 2002, the poorest nations in Africa had
transferred $167 billion to service First World creditors. This
had allowed those banks to make up to 3 times what was
originally lent, as well as to finance private takeovers of
Third World public infrastructure such as telecommunications
systems and health care facilities. Over this time,
developing-nation childhood and perinatal mortality increased as
health systems collapsed and necessary professionals migrated.
"We are talking," says MacDonald, "about people paying with
their lives for debts incurred before they were born and for the
benefit of others."
Chapter 3, "The Environment: Our Ultimate Arbitrator," develops
the thesis that resultant degradation of the environment is
placing a time limit on the capacity of international trade
arrangements to adversely influence world health. MacDonald
details the difficulties in regulating aviation as the
fastest-growing source of carbon dioxide emissions and
diminution of the aquifers that contain 97% of the world's water
supply. He details the environmental problems caused by tourist
developments in the developing world. He describes how the Bush
administration since the September 11, 2001, attacks has
abrogated legislation intended to reduce sulfur dioxide
emissions from US petroleum refineries and withdrawn pledges to
reduce carbon dioxide emissions.
"Mothers, Milk and Honey" (chapter 4) describes the now familiar
story of the dangerous misrepresentations made by the
multinational corporation Nestlé in selling its breast milk
substitutes in developing nations. MacDonald details how the
attempts by that company to resurrect its image involve more
public relations spin than substance.
"The Third-World Face of HIV/AIDS" (chapter 5) details how trade
agreement restrictions on access to inexpensive generic
medications has turned the human immunodeficiency virus/AIDS
epidemic in the third world into a "scourge maintained and
enhanced by the globalisation of trade under the aegis of
capitalism."
Chapter 6, "What Are the Solutions?" makes a valuable
contribution to reforms proposed by Joseph Stiglitz in Making
Globalization Work, to a lesser extent by myself in Who Owns Our
Health: Medical Professionalism, Law and Leadership Beyond the
Age of the Market State, and implicit in the UNESCO (United
Nations Educational, Scientific and Cultural Organization)
Universal Declaration on Bioethics and Human Rights "social
responsibility" principle (article 14.2.[a]).
MacDonald concludes with a plea for a system of expert Health
Impacts Assessments preceding any multinational corporate
enterprise. He encourages policy planning for the
postglobalization, "posteconomic development at all costs" era.
Such policies should reflect the understanding that once an
acceptable level of economic prosperity has been obtained, a
sustainable future for society resides not in ever-increasing
wealth but in moderating expenditure and production to limits
that permit environmental stability and regeneration. Such
policies, he claims, would ensure that lobbyists for
vested-interest groups such as the automobile and petrochemical
industries are more regulated in their capacity to prevent
states from providing adequate investment in new technologies
already capable of harnessing biomass, wind, wave and tide, and
solar power.
Financial Disclosures: None reported.
Disclaimer: Dr Faunce is project director of an Australian
Research Council (ARC) grant investigating the impact of
international trade agreements on medicines policy in Australia.
Thomas A. Faunce, LLB, BMed, PhD, Reviewer
Australian National University
Medical School and College of Law
Canberra, Australia
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Published on May 23, 2007

John L. Zeller, MD, PhD, Fishbein Fellow
Books and Media Reviews Section Editor, JAMA
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