When complexity challenges public opinion and democracy. Part 1—access to medicines

When complexity challenges public opinion and democracy. Part 1—access to medicines

Peter Ungphakorn

Still freezing outside: Brundtland
Still freezing outside: Brundtland (in the yellow top, immediately behind the banner) and the Høsbjør workshop participants


Seventeen years ago this month, 80 experts gathered at Høsbjør in the middle of nowhere, in the middle of Norway. Their secluded hotel was far enough north to still be surrounded by snow even though spring had already arrived in much of Europe.

The group wanted to be out of the limelight so they could discuss openly and frankly a particularly controversial subject: how to make medicines available and affordable in poor countries. They were not being particularly secretive. Details of what was said would be (and were) published afterwards.

Still, it did not take long for around 20–30 activists to track them down. The protesters gathered in the cold outside the hotel.

“WTO runs and hides!” they chanted. “The WTO kills!” their banners said. Their message was simple and clear.

At one level this was a clash of ideas: whether the international system of trade and intellectual property can serve the public health needs of everyone, rich and poor, or whether it should be overthrown. The protestors also objected to the presence of representatives of “Big pharma”, the multinational drug companies.

But there was another clash at a different level: between simplicity and real-world complications.

This is the first of a three-part series on the challenge of complexity in public policy-making. This part looks at patents and access to medicines. The next two turn to Trump’s trade war and Brexit.


The three-day workshop was organised by the World Health Organization (WHO) and World Trade Organization (WTO), who approached the topic from different directions, together with the Norwegian government and some other partners.

It was held in Norway partly because at that time the head of the WHO was Gro Harlem Brundtland, a former Norwegian prime minister. The Norwegian Foreign Ministry was a co-sponsor.

The participants were wide-ranging. They included: officials from a number of rich and poor countries; representatives of pharmaceutical multinationals producing patented medicines, and other companies manufacturing cheaper generic version in Asia, Africa and Latin America; activists from non-governmental organisations and consumer and treatment groups; academics; and officials from the WHO, WTO and aid agencies.

They were discussing the dilemma of how to encourage expensive research into new medicines that are essential for tackling diseases such as HIV-AIDS, malaria and tuberculosis, and to supply them at affordable prices in poor countries.

Central questions in the workshop included whether patent protection for new medicines — designed to encourage research — put the prices out of reach of the poor; and whether the pharmaceutical companies could cut their prices specially in poorer countries under a method known as “differential pricing”.

The pros and cons are complex, as summarised in this press release, and detailed in the presentations and final report, including the fact that “the price of drugs alone does not determine who gets access to health care.”

For the protesters outside, it was all very simple. Dialogue meant conspiracy rather than understanding. Multinational drug companies are greedy and evil. The WTO system allows them to exploit the monopoly created by patents internationally, by charging exorbitant prices which the poor cannot afford. “The WTO kills!”

Complex reality stands little chance against a dramatic three-word slogan. The WTO has an 8-page, densely typed “fact sheet” summarising the policy options available to governments. For example, they can bypass patent rights if they think it’s necessary to protect public health. The fact sheet is designed for non-specialists, but it’s still not an easy read.

Making new medicines available to all: the debate continues but it’s now better informed
Making new medicines available to all: the debate continues but it’s now better informed | CC0

Since then

Almost two decades later, the world understands the issue much better. We do still hear “the WTO kills” and accusations of secrecy, but much less than before.

It turns out that the Høsbjør dialogue was a beginning. Only a few months later, WTO trade ministers agreed by consensus to issue an important political statement: the November 2001 Doha Ministerial Declaration on the TRIPS Agreement and Public Health — TRIPS is “trade-related aspects of intellectual property rights”, the name of the WTO’s agreement.

The declaration affirmed that protecting patents and other forms of intellectual property “is important for the development of new medicines”. But crucially, it also said: “We agree that the TRIPS Agreement does not and should not prevent [governments] from taking measures to protect public health.”

It did not change the agreement itself. It was a political statement. The ministers were highlighting the fact that the agreement contains flexibilities allowing governments to bypass some intellectual property rights in the interests of public health.

It was designed to reassure governments, particularly in developing countries, that they could not be challenged legally in the WTO if they chose to use the flexibilities.

The declaration also kicked off some reforms. Two years later, the TRIPS Agreement was tweaked to remove a legal obstacle preventing poorer countries from obtaining some types of generic medicines.

And the dialogue initiated in Høsbjør turned into years of useful collaboration between the WTO and WHO and, soon after, the World Intellectual Property Organization (WIPO). Together with experts from all sides of the discussion, the collaboration produced numerous events and a number of reports that have expanded our understanding of access to medicines and intellectual property.

This 2013 joint study is a unique and valuable handbook for policy-makers and anyone else who’s interested in access to medicines. The range of topics it covers is vast: intellectual property systems, innovation, government policies such as on competition, public health, and regulation of medical technologies, market failure, access to healthcare, human rights, traditional knowledge, and much more.

The debate continues, but a lot has also been learnt.

Part of the credit has to go to the non-governmental organisations that been prepared to talk to Big Pharma, together with academics and other experts. They have worked with delegates and the three international organisations to clarify the issues and produce workable solutions.

Critics are now targeting the big pharmaceutical companies’ efforts to tighten intellectual property rules through regional and bilateral trade agreements, going beyond WTO obligations and therefore called “TRIPS-plus”. That makes the WTO agreement the target benchmark for them rather than the source of all evil.

There is still an element of simple slogans versus complex reality, but generally the debate is better informed. Expertise on all sides has been crucial.

That is not the case with some other public policy issues. Two current examples are US trade policy and Brexit — Britain exiting the European Union. In both cases the clash between the simple untruth and complex reality is a real challenge for decision-making, while input from experts is often simply dismissed. We’ll look at them in the next two parts.

Up next: Trump’s fixation with trade deficits, and his trade war.
Find out more
: This article by the “Undercover Economist”, Tim Harford, examines in detail why facts often lose out

Peter Ungphakorn is based on the shores of Lake Léman in Switzerland. He spent almost two decades with the WTO Secretariat, Geneva. Before that he worked for The Nation and the Bangkok Post. He now writes for IEG Policy on agricultural trade issues and blogs on trade, Brexit and other issues at https://tradebetablog.wordpress.com/



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