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Critical reforms of IMF policies demanded

Bobby Ramakant — 2009-04-22T05:18:40Z

Earlier this month the Group of Twenty (G-20) leaders had announced a USD 1.1 trillion booster-dose into the world economy by the end of 2010 through multilateral institutions like the International Monetary Fund (IMF). Health advocates believe that critical reforms are needed for IMF policies to prevent disastrous fallouts like rising tuberculosis (TB) incidence in countries that might receive IMF funding.

In July 2008, analysts from Cambridge and Yale Universities had reported that tuberculosis (TB) in countries with IMF loans rose sharply. The strict conditions on IMF loans were blamed for thousands of extra TB deaths in Eastern Europe , and former Soviet republics. A UK TB charity backed the Public Library of Science (PLoS) study findings - but the IMF had firmly rejected them, as per a BBC news (July 2008).

David Stuckler from Cambridge University had said to BBC in July 2008 that "If we really want to create sustainable economic growth, we need first to ensure that we have taken care of people's most basic health needs."

The BBC news further said that "in recent years, it [IMF] has offered assistance to 21 countries in the region, in the form of loans offered in exchange for the meeting of strict economic targets. The researchers claimed it was efforts to meet these targets that were undermining the fight against TB by drawing funding away from public health."

Most striking was the analysis in BBC news that "without the IMF loans, they suggested, rates would have fallen by up to 10%, meaning at least 100,000 extra deaths. Countries which accepted IMF loans averaged an 8% fall in government spending, a 7% drop in the number of doctors per head of population, and a fall in a method of TB treatment called "directly observed therapy", which is recommended by the World Health Organisation."

The Treatment Action Group (TAG) is mobilizing civil society from around the world to endorse a letter before 23 April 2009 to demand that the final proposals must include critical reforms of IMF policies that will enable increased investments in health and education.

As an outcome of the G-20 meeting in London on 2 April 2009, the Declaration called on the IMF to come up with "concrete proposals" for the allocation of these additional resources during the Spring Meetings of the World Bank and IMF planned for 25-26 April 2009 in Washington DC , USA .

The civil society letter calls upon the IMF's International Monetary and Financial Committee and the World Bank-IMF Development Committee as well as any IMF committee tasked with developing proposals to fulfill on the G-20 commitment, to ensure the following reforms are incorporated in the final proposal:

– The IMF must phase out those activities outside its areas of core competence such as those of the Poverty Reduction and Growth Facility (PRGF). The IMF does not have a mandate for, or competence in, the long-term development of low-income countries. IMF resources channeled through the PRGF and from the proceeds of gold sales should support grant assistance or debt relief and be directed to an appropriate aid mechanism. The IMF's Policy Support Instrument (PSI) should also be phased out, in order to end the IMF's monopoly on 'signaling' to donors whether or not developing countries warrant support.

– The IMF must eliminate harmful conditions linked with its loan programs and other instruments. The IMF should end its tradition of requiring countries to implement contractionary policies in economic recessions. For instance, the IMF should ensure that expanded investment in health and education are not subjected to overall budget caps and that subsidies that cushion the impact of the crisis on poor people are not eliminated. The IMF has made progress toward eliminating wage bill ceilings as conditions for lending, but it should stop this practice entirely. In addition, the IMF should stop directing countries to engage in privatization of services or financial sector liberalization through its loans and other instruments.

Organizations from around the world are endorsing this civil society letter and let's hope that IMF will listen to these sane voices.

(The author is a World Health Organization (WHO) Director General's WNTD Awardee 2008 and writes extensively on health and development. He can be contacted at: bobbyramakant@yahoo.com)

Another blow to enforcement of tobacco control policies in India

Bobby Ramakant — 2008-12-01T09:55:28Z

Right after the strong and effective guidelines to stop tobacco industry interference in health policies were adopted by the government representatives of 160 countries including India, the pictorial warnings on all tobacco products that were supposed to become mandatory from 30 November 2008 in India, were, again delayed – reportedly due to hectic lobbying by the industry allies and other entities like the beedi growers' association.

Pictorial warnings on tobacco products have been delayed, at least, seven times. Before going to the 3rd Conference of Parties (COP3) to the global tobacco treaty (Framework Convention on Tobacco Control), the Indian Ministry of Health and Family Welfare had revealed before the Central Information Commission that tobacco industry is putting "pressure" to relax the tobacco control policies (source: The Hindu, 14 November 2008).

The Article 5.3 of the global tobacco treaty, if defined broadly, recognizes “the tobacco industry's fundamental and irreconcilable conflict with public health.”

The tobacco industry interference has times and again weakened and delayed the enforcement of the public health policies - for example, more than 70 court cases were filed against tobacco control policies in Indian courts in September 2008, and due to aggressive lobbying, the consultative Group of Ministers (GoM) formed to review the pictorial warnings on tobacco products, had diluted the pictorial warnings provision and postponed the implementation of pictorial warnings on tobacco products at least six-times earlier. This is the seventh time the pictorial warnings on tobacco products have been again postponed, as reliable sources revealed, to the end of May 2009.

The industry interference in public health policies certainly needs urgent attention to save lives otherwise it will continue to threaten to reverse the great advancements made in forging public health policies and implementing them. Meantime tobacco continues to kill more than a million people in India, and 5.4 million globally, every year.

Also when these pictorial warnings were finally approved by a GoM, why did the GoM met again in an emergency meeting a week before the pictorial warnings provision was about to become mandatory? GoM including the Union External Affairs Minister - Pranab Mukherjee, the Union Information and Broadcasting Minister - PR Dasmunsi, the Minister of State for Labour and Employment - Oscar Fernandes the Union Minister for Commerce and Industry -Kamal Nath, Union Minister for Culture and Urban Development -Jaipal Reddy and Union Health and Family Welfare Minister Anbumani Ramadoss,

The GOM in an earlier meeting this year headed by India's External Affairs Minister Mr Pranab Mukherjee had agreed for two mild images of a scorpion signal depicting cancer or an x-ray plate of a man suffering from lung cancer as pictorial warning to deter people from smoking.

These pictorial warnings provide smokers with helpful information on the health effects. Most smokers want this information, and certainly want their children to have this information too. The tobacco industry is continuing its decades-long strategy of trying to minimize the effectiveness of package warnings. The tobacco industry is no friend of smokers - and ironically it's true that 'the tobacco industry kills its best customers'.

Pictorial warnings on all tobacco products are a good public health strategy because the cost of package warnings is paid for by tobacco companies, not government. Also this should not be looked upon as an isolated initiative rather has to be supported by comprehensive healthcare, legislative and education programmes to attain long-run public health gains. Pictorial warnings may also be appropriate, particularly in countries with low literacy rates or where research shows that smokers are ignoring standard warning labels.

Several nations have implemented strong health warning label requirements. Examples include:
– Canada, whose health minister recently proposed enlarging the labels from 30% of the package face to 60%;
– Thailand, which has added the message "SMOKING CAUSES IMPOTENCE" to its list of required warnings; and
– Australia, which was the first nation to require that "how to quit" information be printed on every pack.
– South Africa, Singapore and Poland also require strong warning labels.

Over past years there were consistent efforts to water down the implementation of the tobacco control policies in India. India's Union Minister of Labour and Employment, Mr Oscar Fernandes, who is also a member of GoM, had earlier said while replying to a written querry in the Lok Sabha (parliament) on 21 April 2008: "Public health measures such as pictorial health warnings on tobacco products don't have any immediate economic impact on the industry due to the item's addictive nature and the time taken for demand reduction, according to various studies." Mr Fernandes also told the Parliament that 'his ministry was receiving representation from various organisations/central trade unions such as CITU, the Tobacco Institute of India, Federation of Farmers Association and others particularly relating to apprehension of loss of employment, arrangement of alternative jobs to the affected 'beedi' workers and adverse effect on health among others (Source: PTI, 21 April 2008).

On 15 December 2006, GK Sanghi had raised the question in Rajya Sabha about Government's response to the 'beedi' workers agitating against the proposed printing of skull and bones on 'beedi' packs. In May 2007, Gutkha (chewing tobacco) manufacturers in India were attempting to get a court injunction to delay the directive requiring all tobacco products to carry health warnings. Another interesting attempt was made in the same month (May 2007) when External Affairs Minister Pranab Mukherjee suggested in his letter that the sign will likely offend the Muslim community, who are employed in the beedi industry of Murshidabad, as they unlike Hindus bury their dead, and do not burn them.

Another major move to water down the Indian Cigarette and other tobacco products Act also happened in May 2007 when Tamil Nadu Chief Minister M Karunanidhi called on the central government to defer implementation of the legislation, saying that "the move has threatened the livelihood of 1.5 million beedi workers in the State." Karunanidhi said beedi manufacturers in the State have stopped production with some tobacco industry players threatening to go on an indefinite strike from 1 June 2007 if the Act is enforced. Also in May 2007, The Karnataka Beedi Association in India said that the directive to print skull and bones on beedi packs would result in a steep decline in beedi sales adversely affecting the welfare of beedi workers.

The All India Beedi Industry Federation had also written to Prime Minister Manmohan Singh that the 2 October 2008 smoking ban has made things tough for the beedi industry. Meanwhile, "we have told the Prime Minister ... that a forced printing of the pictoral (cancer) warning … will lead to a further decline in sales by 30%," had said Rajnikant Patel, president of the All India Beedi Industry Federation to the media.

As per the World Health Organization (WHO)'s MPOWER Report (2008), despite conclusive evidence, relatively few tobacco users understand the full extent of their health risk. Graphic warnings on tobacco packaging deter tobacco use, yet only 15 countries, representing 6% of the world's population, mandate pictorial warnings (covering at least 30% of the principal surface area) and just five countries with a little over 4% of the world's people, meet the highest standards for pack warnings.

“The bidi workers, majority of whom are bidi smokers, are in favour of pictorial health warnings on bidi packets. About 73 percent of the workers agreed that bidis are harmful to health and 79 percent felt that picture based warnings are important on bidi packets, at least to protect the younger generation,' according to the study conducted by the Voluntary Health Association of India (Source: IANS, 3 November 2008).

The fight to enforce public health policies, and put a check on industry interference, is clearly a long uphill battle indeed.

Bobby Ramakant
(The author is a World Health Organization (WHO)'s WNTD Awardee 2008 and can be contacted at: bobbyramakant@yahoo.com)

Will Afghanistan reaffirm commitment to TB/HIV in New York?

Bobby Ramakant — 2008-06-04T06:29:34Z

On June 9, for the first-time government, public health and business leaders, heads of UN agencies and advocates are coming together at United Nations (UN) Headquarters to acknowledge HIV/TB as an urgent priority. This first HIV/TB Global Leaders' Forum, convened by Dr Jorge Sampaio, the UN Secretary-General's Special Envoy to Stop TB, seeks to galvanize leadership at all levels.

The 2008 Anti-Tuberculosis Drug Resistance in the World report and the 2008 Global Tuberculosis Epidemic report of the World Health Organization (WHO) clearly mandates much heightened urgency in responding to TB-HIV co-infection.

Afghanistan continues to have the 22nd highest TB burden in the world. TB is the leading cause of death among people living with HIV (PLHIV). Approximately one third of the nearly 40 million PLHIV are also infected with TB. In high TB and HIV burden settings, up to 80% of TB patients may be co-infected with HIV and half of AIDS-related deaths are caused by TB.

Without proper treatment with anti-TB drugs, approximately 90% of people living with HIV die within two to three months of becoming sick with TB, even if they are receiving anti-retroviral treatment. Worldwide, nearly a quarter of a million people die from HIV/TB co-infection each year. This dual threat is a barrier to keeping people healthy and productive, and impacts poverty reduction plans and the broader development agenda. However, adequate treatment of TB in PLHIV has shown to prolong their life by at least two years.

HIV weakens the immune system and makes it more likely that latent TB infection progresses to active TB disease. PLHIV are up to 50 times more likely to develop TB disease over their lifetime.

Photo by Gianluca Liuzzi

Even where DOTS [directly-observed treatment short-course] programmes are available, current diagnostic tests fail to detect active TB in 60-80% of PLHIV due to the predominantly smear-negative nature of TB in this group.

Studies suggest that transmission of TB, especially the drug-resistant strains is more likely to take place where PLHIV congregate. Healthcare settings, for example anti-retroviral (ARV) clinics, are one such place where improper infection control can put PLHIV at risk of contracting TB. Improving infection control in healthcare settings is clearly vital, doable and potentially life saving.

In many countries insufficient laboratory capacity to test drug-resistance is a serious impediment in scaling up TB programmes. Developing laboratories to provide rapid diagnosis of anti-TB drug-resistance, particularly for PLHIV, is of utmost importance to improve TB responses.

Many countries including Afghanistan are making impressive gains in treating people living with HIV, but this investment and progress is squandered by a preventable and curable disease: TB.

A number of studies, including one released by the World Bank last month, have found that the direct and indirect costs of inaction on HIV are far greater than the costs of treatment. As for TB, a 2007 World Bank research report clearly demonstrated that countries heavily affected by TB could collect at least 9 times their investments in TB control.

There are well-established approaches for preventing deaths from HIV/TB. PLHIV need to be screened regularly for TB. Those who are sick with TB need effective TB treatment and those without TB disease should receive TB preventive therapy. These treatments are not expensive. A six-month course of TB treatment costs US$ 20; and preventive drug therapy costs US$ 2.

But progress remains slow on the more challenging front of detecting and treating TB among people cared for in HIV treatment settings. In 2006, only 1% of people living with HIV were screened for TB worldwide, according to WHO estimates.

New strategies and tools are urgently needed to tackle the challenge of TB/HIV co-infection. WHO-recommended collaborative TB/HIV activities must be accelerated, and research stepped up to deliver a new generation of effective anti-TB drugs and diagnostics to keep co-infected people alive. Closer coordination between national TB and HIV programmes and services is vital.

— Bobby Ramakant

(Bobby Ramakant is working as a regional correspondent to HDN, is recepient of World Health Organization (WHO)'s Award for the year 2008 and can be contacted at: bobbyramakant@yahoo.com