INTRODUCTION
Populations in developing and least-developed countries still have little to no access to medicine.[1] Across the continent of Africa, This is a matter of global concern, given the sweeping health implications raised by inadequate treatment for neglected diseases such as tuberculosis, malaria, and AIDS, which together account for over 5 million deaths annually, “almost all of them in poor countries.”[2] The available statistics can be misleading due to inadequate reporting of infections and the increased risks involved with simultaneous tuberculosis and HIV infection, which together decrease life expectancy from several years to several months.[3] Existing drugs and treatments are becoming increasingly less effective because of resistance, which can be attributed to a lack of access to complete drug regiments and weak solutions for continued funding of research and development (R&D).[4] For instance, between 1975 and 1997, only 4 out of the 1,233 drugs licensed worldwide “were developed by commercial pharmaceutical firms specifically for tropical diseases [affecting] humans.”[5] Moreover, there is no research underway to find cures for a “small cluster of tropical diseases [which] lack any medicines at all.”[6] The health risks are very real and if sweeping reform is impractical, then perhaps some non-traditional approaches may supply some practical solutions.
SUMMARY
The irony is that people are not investing in deadly human diseases and this article opens with an overview of the two key market failures which partially explain this phenomenon and several approaches currently in place to remedy those failures.[7] Following are brief case studies of how the Coca-Cola Company overcame many of the same obstacles and difficulties Ethiopia’s Health Extension Program encountered in applying these same ground-up principles. Finally, this article concludes with the key lesson the international health care sector can take away from these endeavors: for development of the international health care sector to have any hope of sustainable progress, less-than-conventional methods must be adopted and implemented as part of an overall scheme of infrastructural growth.
KEY MARKET FAILURES INHIBITING MEDICAL RESEARCH & DEVELOPMENT
The first market failure is attributable to time-inconsistent incentives between vaccine producers and governments.[8] In addition to the tremendously expensive bureaucratic costs associated with the drug approval process, namely compliance with convoluted tax and regulatory schemes, producers take on enormous R&D, production, marketing, and distribution costs.[9] Consequently, they favor a free-market supply and demand model for pricing and stronger intellectual property rights to protect their cost-intensive technological advances. Governments, however, are the primary purchasers of vaccines and can use their dominant market positions, diplomatic pressure, and NGO relationships to circumvent intellectual property laws and artificially lower prices below a threshold which would adequately reimburse the producers, thus stymieing private firms’ ability to continue funding much needed R&D.[10]
The second market failure is the classic free rider problem; historically, no country was willing to unilaterally invest more than a token amount to publicly fund the R&D necessary to develop what will ultimately be freely disseminated as a global public good.[11] The primary causes of these two failures are a lack of money; minimal cooperation between governments, private industry, and NGOs; and a failure to incentivize innovation, ingenuity, and invention.[12] None of these factors can suffer weak or illusory treatment if a serious solution to developing and maintaining a robust, sustainable health care infrastructure for developing and least developed countries (LDCs) is to be achieved.
Promising solutions to these two impediments are gaining momentum within the international community. In June of 2009, under the Advanced Market Commitments model (AMC), wealthy donor countries and NGOs (Italy, the U.K., Canada, Russia, Norway, and the Bill and Melinda Gates Foundation) committed $1.5 billion to insure private firms against unreasonable prices for vaccines after development.[13] In exchange for this investment, firms made “legally binding commitments to supply the vaccines at lower and sustainable prices after the donor funds are spent.”[14] Additionally, a combination of research grants, designed to “push” the creative process with initial funding, and government prizes, designed to “pull” results more quickly from the R&D process (via a winner-take-all approach) is a leading approach to the Catch 22 of “Penniless-Demand” versus “Market-Driven Supply.” This paper concludes with a complementary approach, following a brief discussion of the role intellectual property rights play in the debate.[15]
TRIPS, DOHA, COMPULSORY LICENSING, & A WORD OF CAUTION
Countries with weak, non-existent, or strong, yet unenforced, intellectual property laws remove the incentives for private firms to conduct R&D by destabilizing the certainty of their ownership rights and their right to control their products.[16] The principle concern for development firms is the risk of outright theft of their patented property. But a major secondary concern is compulsory licensing, an exception to patent protection whereby a government sanctions the use of a “patented product or process without the consent of the patent owner.”[17] Compulsory licenses (or simply the threat of compulsory licensing) under the auspices of Article 31 of the World Trade Organization’s agreement on intellectual property, the Trade-Related Aspects of Intellectual Property Agreement (TRIPS), can be an extremely effective technique for poor and middle-income countries to exert diplomatic pressure on firms to lower the cost of medicines.[18]
The Doha Declaration on TRIPS and Public Health removed the ambiguities surrounding TRIPS, reaffirmed the acceptability of invoking the Article 31 compulsory licensing exception, and clarified the conditions under which it is appropriate to do so: once voluntary licensing negotiations on reasonable commercial terms have failed, pending legal review in the country granting itself the license, issuance of a compulsory license to produce generic copies of a patented product for domestic use only is appropriate, so long as the patent owner is paid adequate remuneration, with adequacy to be determined by the country invoking Article 31.[19] In other words, if you need it and they won’t sell it to you, just take it and pay them what you can, just don’t make more than you need or export it. “Development activists and developing nations see the right to compel a license as an aid to ensuring affordable health care.”[20] TRIPS and Doha provide the legal basis for them to do just that.
While the R&D costs of development were paid by private firms, the primary criticism of their temporary patent monopoly on their products is the excessive prices being charged for their use.[21] For HIV/AIDS related illnesses, the yearly cost of treatment is $15,000, whereas the cost for developing countries to produce an identical regiment of generics is only $150 per year.[22] Similarly, treatment of psoriasis goes from $20,000 to $100.[23] Firms have a legitimate argument, given the enormous costs involved in both the development stage of production and the approval process, which requires navigating a labyrinth tax and regulatory schemes before final approval is granted to release the drug.[24]
Unfortunately, both sides have extremely compelling arguments supporting their antipodal positions. In view of the status quo of the global health crisis, developing countries facing imminent health emergencies can hardly be slighted for invoking Article 31 as a short-term solution, especially after the Doha Declaration reaffirmed their right to do so with the following proclamation: “[T]RIPS … does not and should not prevent Members from taking measures to protect public health … and should be interpreted in a manner supportive of WTO Members' right to protect public health and in particular, to promote access to medicines for all."[25] With so many people afflicted, any government would be remiss in not exercising every measure in its very limited arsenal to protect its population from the multiple epidemics which threaten the nation’s continued survival, especially when the sole reason against doing so centers around the diminishing profit margins of foreign corporations.
In 1980, the United States Supreme Court declared that the uncertainty surrounding patent protection “will not deter the scientific mind from probing into the unknown any more than Canute could command the tides.”[26] This, however, assumes that the few private firms capable of reliably generating the timely innovations at issue here care more about “probing into the unknown”[27] than about remaining financially solvent enough to fund future expeditions; it is clear that they do not. For example, the Bill and Melinda Gates Foundation’s 2005 pledge of $258.3 million for research into malaria brought the total amount spent annually on researching the disease to $375 million.[28] “That is a quarter of the sum that men in wealthy countries spend annually buying Viagra.”[29] Meanwhile, malaria “kills 2,000 African children every day.”[30] It is possible that private firms could channel those profits into R&D on less lucrative medicines for life-threatening diseases which affect the developing world, but expecting the private sector to pay for the solution by appealing to an imaginary, altruistic sense of moral obligation, is simply not realistic. From the private sector’s perspective, failure to innovate in these areas decreases the supply of medicines subject to Article 31 compulsory licensing. Moreover, it is important to remember that private sector pharmaceutical producers are neither humanitarian organizations nor 501(c)(3) non-profit organizations and it is a mistake to expect them to operate as if their continued existence did not depend entirely on profitability. These diametrically opposed, yet reasonable, positions do not appear to be reconcilable without outside funding from NGOs and humanitarian aid organizations.
Nevertheless, middle-income developing countries without (but which soon may have) the infrastructure necessary to conduct meaningful health care research and innovation should be hesitant to abuse this Article 31 exception during “less-than-emergency” periods if they value long-term development and production by established multinational producers. They too argue that they are only acting in the best interests of their afflicted populations and that unfair patent laws justify liberal application of Article 31 licensing. But for countries occupying this middle ground on the development scale, this approach is arguably a form of moral hazard. If exacerbating the negative externalities claimed by private firms ultimately precludes future private sector solutions entirely, then the collateral consequences of this behavior seemingly outweigh the short-term gains sought in the immediate present. Instead, it would behoove these countries to strengthen all sectors of their domestic infrastructures as much as possible so that when future emergencies inevitably occur, they will be empowered to avoid what they consider unfair pricing by multinational firms through domestically-generated innovation and solutions funded by internal commercial investment.[31]
COCA-COLA’s SOLUTION TO INADEQUATE INRASTRUCTURE:
TAPPING LOCAL TALENT
The second market failure is the classic free rider problem; historically, no country was willing to unilaterally invest more than a token amount to publicly fund the R&D necessary to develop what will ultimately be freely disseminated as a global public good.[11] The primary causes of these two failures are a lack of money; minimal cooperation between governments, private industry, and NGOs; and a failure to incentivize innovation, ingenuity, and invention.[12] None of these factors can suffer weak or illusory treatment if a serious solution to developing and maintaining a robust, sustainable health care infrastructure for developing and least developed countries (LDCs) is to be achieved.
Promising solutions to these two impediments are gaining momentum within the international community. In June of 2009, under the Advanced Market Commitments model (AMC), wealthy donor countries and NGOs (Italy, the U.K., Canada, Russia, Norway, and the Bill and Melinda Gates Foundation) committed $1.5 billion to insure private firms against unreasonable prices for vaccines after development.[13] In exchange for this investment, firms made “legally binding commitments to supply the vaccines at lower and sustainable prices after the donor funds are spent.”[14] Additionally, a combination of research grants, designed to “push” the creative process with initial funding, and government prizes, designed to “pull” results more quickly from the R&D process (via a winner-take-all approach) is a leading approach to the Catch 22 of “Penniless-Demand” versus “Market-Driven Supply.” This paper concludes with a complementary approach, following a brief discussion of the role intellectual property rights play in the debate.[15]
TRIPS, DOHA, COMPULSORY LICENSING, & A WORD OF CAUTION
Countries with weak, non-existent, or strong, yet unenforced, intellectual property laws remove the incentives for private firms to conduct R&D by destabilizing the certainty of their ownership rights and their right to control their products.[16] The principle concern for development firms is the risk of outright theft of their patented property. But a major secondary concern is compulsory licensing, an exception to patent protection whereby a government sanctions the use of a “patented product or process without the consent of the patent owner.”[17] Compulsory licenses (or simply the threat of compulsory licensing) under the auspices of Article 31 of the World Trade Organization’s agreement on intellectual property, the Trade-Related Aspects of Intellectual Property Agreement (TRIPS), can be an extremely effective technique for poor and middle-income countries to exert diplomatic pressure on firms to lower the cost of medicines.[18]
The Doha Declaration on TRIPS and Public Health removed the ambiguities surrounding TRIPS, reaffirmed the acceptability of invoking the Article 31 compulsory licensing exception, and clarified the conditions under which it is appropriate to do so: once voluntary licensing negotiations on reasonable commercial terms have failed, pending legal review in the country granting itself the license, issuance of a compulsory license to produce generic copies of a patented product for domestic use only is appropriate, so long as the patent owner is paid adequate remuneration, with adequacy to be determined by the country invoking Article 31.[19] In other words, if you need it and they won’t sell it to you, just take it and pay them what you can, just don’t make more than you need or export it. “Development activists and developing nations see the right to compel a license as an aid to ensuring affordable health care.”[20] TRIPS and Doha provide the legal basis for them to do just that.
While the R&D costs of development were paid by private firms, the primary criticism of their temporary patent monopoly on their products is the excessive prices being charged for their use.[21] For HIV/AIDS related illnesses, the yearly cost of treatment is $15,000, whereas the cost for developing countries to produce an identical regiment of generics is only $150 per year.[22] Similarly, treatment of psoriasis goes from $20,000 to $100.[23] Firms have a legitimate argument, given the enormous costs involved in both the development stage of production and the approval process, which requires navigating a labyrinth tax and regulatory schemes before final approval is granted to release the drug.[24]
Unfortunately, both sides have extremely compelling arguments supporting their antipodal positions. In view of the status quo of the global health crisis, developing countries facing imminent health emergencies can hardly be slighted for invoking Article 31 as a short-term solution, especially after the Doha Declaration reaffirmed their right to do so with the following proclamation: “[T]RIPS … does not and should not prevent Members from taking measures to protect public health … and should be interpreted in a manner supportive of WTO Members' right to protect public health and in particular, to promote access to medicines for all."[25] With so many people afflicted, any government would be remiss in not exercising every measure in its very limited arsenal to protect its population from the multiple epidemics which threaten the nation’s continued survival, especially when the sole reason against doing so centers around the diminishing profit margins of foreign corporations.
In 1980, the United States Supreme Court declared that the uncertainty surrounding patent protection “will not deter the scientific mind from probing into the unknown any more than Canute could command the tides.”[26] This, however, assumes that the few private firms capable of reliably generating the timely innovations at issue here care more about “probing into the unknown”[27] than about remaining financially solvent enough to fund future expeditions; it is clear that they do not. For example, the Bill and Melinda Gates Foundation’s 2005 pledge of $258.3 million for research into malaria brought the total amount spent annually on researching the disease to $375 million.[28] “That is a quarter of the sum that men in wealthy countries spend annually buying Viagra.”[29] Meanwhile, malaria “kills 2,000 African children every day.”[30] It is possible that private firms could channel those profits into R&D on less lucrative medicines for life-threatening diseases which affect the developing world, but expecting the private sector to pay for the solution by appealing to an imaginary, altruistic sense of moral obligation, is simply not realistic. From the private sector’s perspective, failure to innovate in these areas decreases the supply of medicines subject to Article 31 compulsory licensing. Moreover, it is important to remember that private sector pharmaceutical producers are neither humanitarian organizations nor 501(c)(3) non-profit organizations and it is a mistake to expect them to operate as if their continued existence did not depend entirely on profitability. These diametrically opposed, yet reasonable, positions do not appear to be reconcilable without outside funding from NGOs and humanitarian aid organizations.
Nevertheless, middle-income developing countries without (but which soon may have) the infrastructure necessary to conduct meaningful health care research and innovation should be hesitant to abuse this Article 31 exception during “less-than-emergency” periods if they value long-term development and production by established multinational producers. They too argue that they are only acting in the best interests of their afflicted populations and that unfair patent laws justify liberal application of Article 31 licensing. But for countries occupying this middle ground on the development scale, this approach is arguably a form of moral hazard. If exacerbating the negative externalities claimed by private firms ultimately precludes future private sector solutions entirely, then the collateral consequences of this behavior seemingly outweigh the short-term gains sought in the immediate present. Instead, it would behoove these countries to strengthen all sectors of their domestic infrastructures as much as possible so that when future emergencies inevitably occur, they will be empowered to avoid what they consider unfair pricing by multinational firms through domestically-generated innovation and solutions funded by internal commercial investment.[31]
COCA-COLA’s SOLUTION TO INADEQUATE INRASTRUCTURE:
TAPPING LOCAL TALENT
If we are to achieve things never before accomplished, we must employ methods never before attempted. – Sir Francis Bacon
The Coca-Cola Company is the largest beverage distribution system in the world and sells 1.7 billion servings per day in over 200 countries.[32] Short of taping medicine to the bottom of Coke bottles, what about this ubiquitous global presence and unrivaled access to international markets can be applied to streamlining inadequate distribution networks for condoms, medicine, healthcare, and access to information concerning preventive health measures, all of which are in short supply due to the aforementioned market failures?[33]
When Coke first entered the African markets in 1928, its conventional distribution methods failed due to a lack of infrastructure, namely for want of a viable system of roads.[34] Over time, however, the company noticed that locals were purchasing large quantities of the products and reselling them in rural constituencies where Coke’s regional distributors had not yet gained access.[35] So beginning in 1990, Coke started empowering these fledgling entrepreneurs by awarding them with small business loans and training them to be more effective “Micro-Distribution Centers” (MDCs), within their local region. Today, there are over 3,000 established MDCs, accounting for over 15,000 jobs across the continent.[36] By adapting its distribution model and utilizing the local entrepreneurial talent’s inherent mobility and internal motivation to distribute the product, Coke now derives 90% of its national sales in previously impenetrable markets like Tanzania and Uganda from these small-scale operations.[37] This is an extremely well-managed example of what anthropologist Gordon Matthews refers to as low-end globalization.[38]
“Low-end globalization is globalization not as practiced by the big multinationals with their batteries of lawyers and their billion-dollar budgets, [but rather] … globalization done by individual traders carrying goods in their suitcases back and forth from their home countries. That’s the dominant form of globalization here… and that’s how globalization works for 70 percent of the world’s people.”[39]
Using low-end globalization techniques, however, should be a temporary solution to the distribution problem because the practices involved necessarily increase the risk to the intellectual property rights of private firms. The risks incurred by establishing these less-formal networks are precisely the same as the advantages. Specifically, individual traders carrying patented products or generic replicas in their suitcases back and forth from their home countries, with no oversight by the patent owners’ battery of lawyers. This type of network is especially risky once a compulsory license has been issued because it creates the opportunity for domestic producers and smugglers to overproduce the generics and export them beyond their national borders, a makeshift black-market pharmaceutical superhighway, if you will.
The Coca-Cola Company incurs much less risk to its intellectual property rights than companies in the pharmaceutical sector. Despite the fact that both deal in the distribution of fungible goods, Coke is not analogous to a pharmaceutical firm for at least three reasons. First, no soft drink will ever be deemed the solution to a national emergency and subjected the Article 31 compulsory licensing. Second, whereas Coke requires little innovation in terms of its existing formulas, the health care industry is required to respond to market demand for different and improved medicines with innovative developments of the products themselves. This disposable income gives the company greater resources to expend on marketing and ground support for the MDCs. Third, Coke is famously difficult to duplicate and less expensive to produce, whereas duplicating medicine is much less difficult and, once duplicated, can be sold at 0.5%-1% of the market-driven price.[40] The lesson to derive from Coke’s use of local talent and innovative low-end globalization to provide access to hard-to-reach locations is one of creativity and proactive management. If an overall distribution scheme is poorly managed, the advantageous techniques of low-end globalization can quickly become systemic weaknesses which result in billion dollar losses; and non-existent budgets equate to non-existent future R&D.[41] The following example demonstrates a fairly well-managed, but problematic example of this concept in practice.
ETHIOPIA’s HEALTH EXTENSION PROGRAM:
HANGING THE PAINTING WITHOUT THE WALL
HANGING THE PAINTING WITHOUT THE WALL
In 2002 and 2003, Ethiopia's Health Extension Program employed a technique similar to that employed by Coca-Cola, tapping local talent to overcome local challenges.[42] The program is an expansion of Ethiopia’s health care infrastructure and seeks to “develop a cadre of Health Extension Workers (HEWs) to provide basic curative and preventive health services in every rural community.[43] As of 2008, the result of this initiative was 30,000 HEWs, trained in 34 training centers, in 7 regions, and deployed in pairs of two to over 8,500 villages to deliver health care directly to the people, with the idea being that dispatching HEWs to or near their hometowns would enable them to better understand local conditions and deal with local problems.[44] The twelve-fold increase in the number of available health care professionals led to an unprecedented result: a 25% drop in the child mortality rate by 2008.[45]
The Health Extension program focused on four principle areas: hygiene and environmental sanitation, disease prevention and control, family health services, and health education and communication.[46] Within those four areas, the Ministry emphasized 16 development goals which constitute an excellent summary of the African health care sectors most needed reforms.[47]
A. Hygiene and Environmental Sanitation (seven packages):
Proper and safe excreta disposal system;
Proper and safe solid and liquid waste management;
Water supply safety measures;
Food hygiene and safety measures;
Healthy home environment;
Arthropods and rodent control;
Personal hygiene;
B. Disease Prevention and Control (four packages):
HIV/AIDS prevention and control;
TB prevention and control;
Malaria prevention and control;
First AID;
C. Family Health Services (five packages):
Maternal and child health;
Family planning;
Immunization;
Adolescent reproductive health;
Nutrition;
D. Health Education and Communication (0 packages)[48]
This program represents a remarkable innovation by the Ethiopian Ministry of Health, considering the program was doomed from the start to encounter crippling challenges due to inadequate access to reliable transportation routes, communications facilities, basic medical supplies, drugs, and vaccines.[49] The institutional facilities were severely underfunded and contained no classrooms, libraries, water, or restroom facilities.[50] The pool of recruits turned out to hail from urban areas rather from the localities to which they would be assigned and the program facilitators were unable to orient them sufficiently well to cope with the complex health states they would encounter in the rural villages.[51] A significant portion of the trainees planned to leave the country and saw the program as a way to develop professional health care skills which would be useful outside of Ethiopia.[52] Salaries and worker stipends were unevenly distributed and the trainers were predominantly non-degree holding males, resulting in little to no practical training and very poor performance by the trainees.[53]
But despite all of the failures, “trainees expressed a high level of commitment to work in rural areas.” The people of Ethiopia are showing a commitment to solving their own problems and the government is cooperating with NGOs to fund these efforts. This type up ground-up innovation is necessary to access rural communities in places like Ethiopia, but once the cadre of health care workers is trained and deployed, an overall scheme of infrastructural development is required if the African community hopes to avoid the institutional setbacks encountered in Ethiopia and make sustainable leaps towards a healthy future.
CONCLUSION: REFORM, REFORM, REFORM
By strengthening domestic intellectual property legislation, enforcing those laws, and conservatively invoking Article 31 compulsory licenses, developing and least developed countries, NGOs, and private firms can begin to seek out new and better solutions to the health care debacles they currently face. At the same time, the extensive tax and regulatory schemes, which often account for as much as half of the cost of development, need to be streamlined as they constitute the most formidable barriers between the impoverished individuals most susceptible to these diseases and the essential medicines necessary for their treatment.[54]
If effective solutions, such as the Advanced Market Commitments, “push-pull” incentives, and low-end globalization techniques manage to stabilize the incongruous interests of firms and at-risk nations, ongoing foreign direct investment and domestic commercial investment will become more likely to improve the overall infrastructure of the developing world.[55] Idealistically, the ultimate goal is to develop LDCSs and developing countries into financially solvent states with the physical and institutional infrastructure necessary to maintain a self-sustaining domestic R&D industry.[56] While not every country needs to independently develop an R&D sector, an increase in the number of efficiently functioning sectors will certainly correspond to an increase in the opportunities available for local talent to develop customized approaches to problems which lack generic solutions, thus reducing the need for Article 31 compulsory licensing under the TRIPS Agreement.
Proactive developing countries such as Ethiopia, which enact domestic and regional programs to remedy the global health crisis by increasing access the health care and awareness of preventive health measure, deserve the respect and support of the international community. If adequately funded and properly managed at the start-up phase, these programs have the potential to fuel progress towards achieving the principle goals of each of the aforementioned parties. They seek to foster robust health care networks, provide widespread access to information and medicine, encourage overall economic stability and financial solvency, enable at-risk nations to better afford the market-driven prices of difficult to develop pharmaceuticals, and effectively pardon the death sentences of millions who would have otherwise been doomed to die of preventable and treatable diseases.
Within each of these at-risk countries, the goal should be to develop and maintain a viable system which provides the poorest demographics with needed information and medicine, and which is sufficiently advanced to report valuable data back to governments and producers to develop their disease profiles and guide their research prioritization.[57] The achievement of this goal, however, is entirely dependent on the simultaneous development of robust transportation networks, public utilities, and communication channels before anything resembling a sophisticated health care distribution network can flourish.[58] In other words, you can’t hang the painting without the wall.
WORD COUNT: 4101
[1] Morris, J.; Stevens, P.; and van Gelder, A.; Incentivising Research and Development for the Diseases of Poverty, International Policy Network Working Papers on Intellectual Property, Innovation and Health 5 (2005).
[2] Barder, O.; Kremer, M.; and Williams, H.; Advance Market Commitments: A Policy to Stimulate Investment in Vaccines for Neglected Diseases, Economists’ Voice, Feb. 2006.
[3] BBC News, Dual Epidemic threatens Africa, (Nov. 2, 2007) available at http://news.bbc.co.uk/2/hi/africa/7074298.stm last visited (Sept. 27, 2011).
[5] Barder, Kremer, and Williams, supra. citing Pécoul, B.; Chirac, P.; Trouiller, P.; and Pinel, J.; Access to Essential Drugs in Poor Countries: A Lost Battle? Journal of the American Medical Association, Vol. 281, No. 4, pp. 361-367, 1999.
[6] Id. (Interestingly, these authors attribute the principles causes of these diseases to circumstances incident to poverty, such as “poor nutrition, indoor air pollution, and lack of access to clean water, proper sanitation and health education,” rather than to a lack of medicine.)
[13] The Bill & Melinda Gates Foundation Website, Press Releases, Ministers of Finance and Global Health Leaders Fulfill Promise to Combat World’s Greatest Vaccine-Preventable Killer of Children, June 12, 2009 (last visited Sept. 14, 2011).
[16] Rozek, R., The effects of compulsory licensing on innovation and access to healthcare, NERA, September 2000.
[17] The WTO website, Trade Topics, TRIPS FAQ, available at http://www.wto.org/english/tratop_e/trips_e/tripfq_e.htm.
[18] Morris, Stevens, and van Gelder, supra. (“Brazil threatened to issue compulsory licenses on the key drugs that combine to form anti-retro viral treatments. http://news.bbc.co.uk/1/hi/health/4059147.stm” (last visited Sept. 14, 2011).)
[19] The Doha Declaration on the TRIPS Agreement and Public Health, available at http://www.wto.org/english/thewto_e/minist_e/min05_e/final_text_e.htm#public_health.
[20] Mark F. Schultz and David B. Walker, How Intellectual Property Became Controversial: NGOs and the New International IP Agenda, 6 Engage 82 (2005).
[21] Kohr, M., Patents, Compulsory Licence and Access to Medicines: Some Recent Experiences, Third World Network, Feb. 2007.
[22] Kohr, M., Patents, Compulsory Licence and Access to Medicines: Some Recent Experiences, Third World Network, Feb. 2007.
[23] Video tape: RA Mashkelkar, Breakthrough Designs for Ultra-Low-Cost Products, available at http://www.ted.com/talks/r_a_mashelkar_breakthrough_designs_for_ultra_low_cost_products.htm
[28] Gillis, J., Gates Foundation Pledges More Towards Malaria Research, The Washington Post (Oct. 31 2005) available at http://www.washingtonpost.com/wp-dyn/content/article/2005/10/30/AR2005103000700.html
[32] The Coca-Cola Company Fact Sheet: http://www.thecoca-colacompany.com/ourcompany/pdf/Company_Fact_Sheet.pdf (last visited Sept. 14, 2011).
[33] Video tape: Melinda French Gates, What Governments, NGOs, & Non-Profits can learn from Coke, available at http://www.youtube.com/watch?v=GlUS6KE67Vs.
[38] Matthews, G., Chungking Mansions: A Center of ‘Low-End Globalization, Ethnology XLVI (2), 169-183 (2008).
[39] Beerman, J., Inside Chungking Mansions with expert Gordon Mathews: Author of "Ghetto at the Center of the World: Chungking Mansions, 15 August, 2011 available at http://www.cnngo.com/hong-kong/life/inside-chungking-mansions-expert-gordon-mathews-098440. (Matthews maintains that the building, which is widely believed to be the epicenter of cosmopolitanism and multiculturalism, is the epitome of Hong Kong. The author of this paper had been a guest of the mansion and concurs. This claim is further elucidated and supported by Surajit Chakravarty who analyzes the ecology of the mansion in relation to international globalization and institutions of state-based and cosmopolitan citizenship. Chakravarty, S., Spaces of Market-Culturalism: The Case of Chungking Mansions, Hong Kong, A Dissertation Presented to the Faculty of the University of Southern California Graduate School, Aug. 2010.)
[43] The Earth Institute at Columbia University: Center for National Health Development in Ethiopia, The Health Extension Program, available at http://cnhde.ei.columbia.edu/programs/hep/ (last visited Sept. 14, 2011).
[46] Sebhatu, A., The implementation of Ethiopia's Health Extension Program: An overview, Addis Ababa (Sept. 2008).
[50] Kitaw, Y.; Ye-Ebiyo1, Y.; Said, A.; Desta1, H.; and Teklehaimanot A.; TGE Assessment of the Training of the First Intake of Health Extension Workers, Ethiop.J.Health Dev, 21:3 (2007).
[55] Park, W. & Lippoldt, Technology Transfer and the Economic Implications of the Strengthening if Intellectual Property Rights in Developing Countries, OECD Trade Policy Working Papers, No. 62 (2008).