Meeting the Challenge: Canada's Foreign Policy on HIV/AIDS - With a Particular Focus on Africa

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Section 5.0 - Key Foreign Policy Directions

This section discusses the approaches that Canadian foreign policy should pursue with respect to some of the key global HIV/AIDS issues. It examines the need for scaling up the response to HIV/AIDS, particularly with respect to resource allocation; the need to promote a human rights-based approach to the epidemic; the central importance of efforts to promote access to HIV-related treatments; and the need to the support key role in the response played by civil society, people living with HIV/AIDS and vulnerable groups.

5.1 Scaling Up Canada's Response

As the world marks the twentieth anniversary of AIDS, it is time for the international community to go on a wartime footing in the fight against HIV/AIDS. In the face of the Y2K virus...at least US$200 billion was raised... And to contain and turn back Serbia's hold on Kosovo, more that US$46 billion was invested... AIDS is no less a global threat and the international community is paying an increasingly heavy price for failing to respond accordingly.

- International Crisis Group⁴⁸

Today we need a new "Marshall Plan" to scale up national responses in poor countries. Developed countries...finally need to assume their responsibility in changing this dramatic situation.

- Paulo R. Teixeira, Marco Antonio Vitoria, Johney Barcarolo⁴⁹

As indicated above at the end of Section 2.0 (The Impact of HIV/AIDS), a tragedy of the magnitude of HIV/AIDS requires a response that is commensurate in size and scope. The response to date has not been commensurate. The fundamental international development objectives, to which Canada is committed, such as the Millennium Declaration and Millennium Development Goals, the Johannesburg Declaration and Programme of Action, and the New Partnership for Africa's Development, will not be met unless the challenge of HIV/AIDS is adequately confronted. The goals contained in the UNGASS Declaration of Commitment on HIV/AIDS will not be achieved without a massive scaling up of the response.

The capacity exists to apply resources on the scale required. The estimated resources required for an effective response to HIV/AIDS in Africa are small when compared to the costs in 2003 alone of the war and post-war occupation in Iraq or current global expenditures on cosmetics.⁵⁰

Many governments are reinforcing commitments to scaled-up efforts, particularly in the most-affected areas. The Maputo Declaration of the African Union (July 2003) takes a comprehensive approach, committing the participating governments and seeking significant international support. Forty African countries have completed national strategic AIDS plans.⁵¹ New initiatives from developed countries, including the pledge of US$15 billion over five years from the United States (US) Administration, and new partnerships, like the Brazil-US joint initiative against HIV/AIDS in Portuguese-speaking Africa, are breaking new ground.⁵²

But the response is not yet full scale. For example:

• Full scale responses to the epidemic need full scale resources. Despite recent increases in pledges and funding, commitments are only one-half of what is needed by 2005.⁵³
• Moving to scale in treatment requires multiplying effort and investment . Despite new commitments to providing access to treatment, out of an estimated 30 million HIV-positive people in Africa only 27,000-50,000 benefit from antiretroviral treatment.⁵⁴
• Stopping the spread of infection requires investment in basic public health services. An estimated 29 million infections could be prevented this decade with an investment of US$10 billion,⁵⁵ yet in many countries and regions the majority of residents do not have easy access to the most basic of health services and treatments, essential for prevention, care or survival.⁵⁶

For responses to be brought to scale, leadership, particularly among donor countries, is urgently required. For Canada, scaling up means providing more resources, sharing best practices, and taking a leadership role in addressing global HIV/AIDS issues. It means giving HIV/AIDS a much higher profile than it currently has in the Department of Foreign Affairs and International Trade (DFAIT) and in the other federal departments and agencies that are involved in global issues. It means greater coordination of theactivities of these departments and agencies. It means developing and executing HIV/AIDS-specific strategies. Elsewhere in this paper, we have included recommendations concerning many of these strategies.

In order for DFAIT to fulfill its role with respect to the global response to the epidemic, HIV/AIDS needs to be mainstreamed throughout the department. HIV/AIDS activities need to be included in the workplans of all of the work units of DFAIT, not just in the HIV/AIDS Unit. As well, two work units should be strengthened. First, more resources should be allocated to the HIV/AIDS Unit, and it should be mandated to play a coordinating role within the department. Second, more resources should be allocated to the Human Rights, Humanitarian Affairs and International Women's Equality Division to allow it to address the human rights dimensions of HIV/AIDS and health. Linkage between these units and those engaged in trade and investment negotiations, pursuant to an overall right-based strategy, should be ensured. Finally, training programs on global HIV/AIDS issues, including the human rights dimensions, should be designed and widely delivered throughout the department.

Recommendations

13.	We recommend that DFAIT work with other governments, international agencies and NGOs to champion the development of an international strategy and action plan to massively scale up support to save and extend lives, reinforce health systems and halt and reverse the spread of HIV/AIDS in Africa, and use its experience in this initiative to inform actions in other regions confronting the epidemic.
14.	We recommend that the DFAIT develop and implement a plan for mainstreaming HIV/AIDS in its operations, and that DFAIT seek advice on the development of this plan from Canadian non-governmental organizations with experience in the area. The plan should:
	include measures to integrate HIV/AIDS into the work of all work units of DFAIT, including the foreign embassies, high commissions and consulates; call for the inclusion of HIV/AIDS activities in the workplans of all work units; increase the resources allocated to the HIV/AIDS Unit in DFAIT, and provide it with a mandate to play a coordinating role within the department; increase the resources allocated to the Human Rights, Humanitarian affairs and International Women's Equality Division in DFAIT, to enable it to respond to the human rights dimensions of HIV/AIDS and health; include measures to ensure effective linkage between HIV/AIDS, human rights and trade units, within a human rights-based policy framework; and include the development of training programs on global HIV/AIDS issues, and the human rights dimensions of HIV/AIDS, and the delivery of this training widely throughout DFAIT.

5.2 Promoting Human Rights

The AIDS paradox teaches that the most effective way of preventing the spread of the virus responsible for AIDS is by protecting the human rights of those most at risk.

- Justice Michael Kirby⁵⁷

As noted in Section 3.0 (Foundations), in Canada's domestic and international response to HIV/AIDS the supreme principle guiding policy should be human rights, with a focus on the human right to health. This flows from the "the fundamental principle that international human rights law, including the right to health, should be consistently and coherently applied across all relevant national and international policy-making processes," as embodied in the Vienna Declaration and Programme of Action (1993).⁵⁸ To this end, the International Guidelines on HIV/AIDS and Human Rights and more broadly the General Comment No. 14 of the Committee on Economic, Social and Cultural Rights offer highly relevant guidance.

The strategic importance of human rights to the response to HIV/AIDS has several dimensions. For one thing, a human rights-based approach supports sound public health practices. For another, principles of equity (including gender- and age-specific guarantees) and non-discrimination provide frameworks that assist the evaluation of the adequacy of responses to specific groups at risk, as well as access to services. Furthermore, as Justice Kirby points out, "given the absence of effective vaccines...the only means of reducing the spread of the epidemic is by sharing of information and ...behaviour modification in those principally at risk."⁵⁹ This requires paying particular attention to the rights of groups who engage in high-risk activities.

The economic, social and cultural rights of people are closely connected with the principal social determinants of health, including such essentials as nutritious food, clean water and housing. Further, an economic, social and cultural rights framework provides guarantees that protect the right to health, and that should inform policy more broadly. Guidance in this regard is provided in the Maastricht Guidelines on Violations of Economic, Social and Cultural Rights.⁶⁰ These guidelines note that violations of rights agreed to in the International Covenant on Economic, Social and Cultural Rights occur, for example, when states fail:

• to take into account their international obligations under the covenant when they enter into bilateral or multilateral agreements with other states, international organizations or corporations;
• to exercise due diligence in controlling the actions of third-parties - including multinational corporations - over which they exercise jurisdiction; or
• to use their influence to ensure that violations do not result from the programs or policies of international organizations of which they are members.

In concrete terms, the tendency to give legal priority to trade and investment commitments - by stating that other agreements must be compatible with them, by applying such measures as "necessity tests," by requiring that regulations applied in a given field be the least trade-negative in impact, or by requiring that evaluations thereof are made by trade bodies where commercial criteria are pre-eminent - should be resisted. Coherence with and compliance with the right to health should be the primary criteria, and evaluatory decisions should be made by domestic or international bodies responsible for human rights.

The importance of enforcing human rights obligations in the context of trade and investment agreements has been recognized by the Parliamentary Standing Committee on Foreign Affairs and International Trade. In a report released in June 2001, the Committee requested that the federal government study the question and report by April 2002.⁶¹ In its initial reply, the government said that it was committed to a "balanced and coherent political, economic and social agenda," and agreed to study and report on the issue. However, no report has yet been issued.

Human rights principles should inform and guide Canada's trade and investment negotiations. A number of informative reports have been made to the United Nations Commission for Human Rights⁶² regarding the human rights implications of trade agreements. In one of her reports to the Commission, the High Commissioner "stresses[d] the need to make commitments on the basis of sound empirical evidence," and encouraged "states to undertake public, independent and transparent human rights assessments of the impact" of trade policies and "progressive liberalization" under various World Trade Organization processes.⁶³

The development of a governmental position that is based on, and that recognizes, the primacy of human rights obligations has long been recommended by a number of Canadian human rights and non-governmental organizations. As a useful first step towards this end, DFAIT should review current trade and investment agreements, and negotiating positions in play, with regard to their human rights compatibility in general, and their possible impact on the government's policy objectives regarding HIV/AIDS.

DFAIT recently announced a process for undertaking environmental assessments of trade negotiations. The process involves the development of a framework, close collaboration with other relevant departments and agencies, and a three-phase assessment process involving public consultation and comment. A similar process should be used to assess the human rights implications of trade negotiations. The range of impacts of trade agreements - including the General Agreement on Trade in Services, the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), and the Free Trade Area of the Americas (FTAA), and the increasingly numerous bilateral trade and investment accords - on human rights in general, and on the right to health and various dimensions of HIV/AIDS in particular, make such a process an urgent necessity.

In order to ensure that the development of international policy regarding human rights and HIV/AIDS goes hand in hand with domestic policy in this regard, it may be useful for DFAIT to establish links with the expertise and experience of Canada's federal and provincial statutory human rights agencies, as well as with relevant NGOs, and human rights and development research agencies.

Recommendations

15.	We recommend that DFAIT, utilizing the expertise of its Human Rights, Humanitarian Affairs and International Women's Equality Division, take the lead in developing a process for public, independent and transparent human rights assessments of trade negotiations; that DFAIT invite other relevant departments and agencies, including the federal and provincial statutory human rights agencies, and non-governmental human rights, development, health and HIV/AIDS organizations, to participate in the design of appropriate frameworks and processes, and to contribute evidence and impact evaluations for this assessment; and that the criteria of human rights-compatibility and compliance be the guiding evaluatory principle of this assessment.
16.	We recommend that DFAIT, in cooperation with other relevant departments and agencies, strengthen its support for, and promotion of, human rights and promote the recognition by all states of their obligation to respect, protect and promote human rights in the response to HIV/AIDS, through international initiatives designed to:
	champion the International Guidelines on HIV/AIDS and Human Rights, their application and further development; encourage and support actions by national governments to respect, protect and promote human rights through such measures as: (a) developing national legal frameworks related to HIV/AIDS; (b) developing legislative and administrative measures to protect people living with HIV/AIDS from discrimination; (c) implementing measures to enhance gender-specific policies that reduce vulnerability and protect the human rights of women and girls; and (d) implementing measures to achieve greater human rights education and public mobilization; provide resources and expertise to agencies advancing such initiatives - agencies such as the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Fund for Technical Cooperation and Assistance (of the Office of the High Commissioner for Human Rights, and the United Nations Development Programme's Thematic Trust Fund on HIV/AIDS; enhance the enforcement mechanisms of the Covenant on Economic, Social and Cultural Rights, by championing and building support for the proposed Optional Protocol to the Covenant which, among other things, would open access for complaints by victims of violation of human rights; and enhance the work of the United Nations Commission on Human Rights, its Sub-Commission on the Promotion and Protection of Human Rights, and the United Nations Committee on Economic, Social and Cultural Rights, by advocating for these bodies to continue to monitor the ongoing challenge of HIV/AIDS; by supporting ongoing research regarding the implications of trade, investment and service agreements for the enjoyment of the right to health, and for access to medicines and services; and by supporting the work of the United Nations Special Rapporteur on the Right to Health.
17.	To help ensure that the exercise of Canadian policy is thoroughly informed by Canada's human rights obligations, we recommend that DFAIT ensure that the research reports of the Commission, Sub-Commission and other human rights mechanisms and bodies are brought to the attention of trade negotiators and their advisors; and form the basis for dialogue with NGOs in consultative processes related to the preparation or review of Canada's positions in global and regional trade and investment negotiations.

5.3 Saving Lives: Access to Treatment

As the dean of a US medical school put it recently, "In the next five years, either 5 million or 30 million will die: this will depend on access to drugs"

- Mary Robinson, United Nations High Commissioner for Human Rights⁶⁴

[T]he most striking inequity is our failure to provide the lifesaving treatment to the millions of people who need it most... [T]he single most important step we must now take is to provide access to treatment throughout the developing world. There is no excuse for delay .

- Nelson Mandela⁶⁵

[T]he imperative of treatment is spreading non-stop across the African continent.

- Stephen Lewis, United Nations Special Envoy on HIV/AIDS for Africa⁶⁶

There are no circumstances in which the most fundamental human rights should be subordinated to the requirements of IP protection.

- Commission on Intellectual Property Rights (United Kingdom)

The challenge of treatment

In the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS, UN member states undertook to "...in an urgent manner make every effort to provide progressively and in a sustainable manner the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections, and the effective use of quality-controlled anti-retroviral therapy."⁶⁷

The economic rationale concerning the cost-effectiveness of large-scale investment in treatment is increasingly clear. As highlighted in a recent presentation to the 2 nd International AIDS Society Conference on HIV Pathogenesis and Treatment (July 2003), Professor Jean-Paul Moatti, of the International AIDS Economics Network, stated that funding access to treatment is a rational economic choice. "We have systematically underestimated the impact of AIDS on the economy," Moatti argued. Noting that Brazil saved US$2 billion in four years and prevented more than 60,000 new cases of HIV infection, 90,000 deaths and 358,000 hospital admissions, Professor Moatti said it would be economic "stupidity" not to provide antiretroviral treatment to HIV/AIDS patients in developing countries.⁶⁸

One principal reason why the overwhelming majority of people living with HIV/AIDS in developing countries do not have affordable access today is that many of these drugs are too expensive. Although the prices of some of these drugs have come down significantly in some countries, the drugs still remain out of the reach of most people living with HIV/AIDS in developing countries. A number of authorities argue, however, that prices have now been reduced to a level where rapid extension of treatment is feasible.⁶⁹ A variety of strategies, appropriate to different circumstances of each country, may be required. An initial examination of short, medium and long-term institutional, clinical, resource and research strategies can be found in a study prepared for the Access to Essential Medicines Subgroup of the Millennium Project, supported by the United Nations Development Programme (UNDP). A pro-active examination of technical obstacles occurred at the July 2003 Amsterdam International Workshop on Strategies for Scaling-Up HIV/AIDS Treatment in Resource-Poor Settings.⁷⁰ This event sought to recommend creative means for scaling up to a global target of treating three million people in the developing world by 2005.

International discussion of scaled-up provision of treatment has advanced as far as finding practical solutions to technical obstacles. However, significant fundamental challenges remain and must be taken into account in any successful strategy: inadequacy of health systems, faulty clinical procedures, cultural factors, inadequate or inappropriate research related to diseases prevalent in developing countries and, not least, inadequate resources.⁷¹

People working to improve access to medicines have identified the World Trade Organization's (WTO) TRIPS Agreement as contributing to barriers to affordable access, by requiring enhanced protection for intellectual property in medicines and thereby increasing costs to governments and consumers. The TRIPS Agreement does contain provisions that would, at least in theory, provide flexibility for countries to qualify or limit intellectual property protections in order to balance them against other policy objectives, including those related to public health - including measures such as compulsory licensing to permit the manufacture of lower-cost generic versions of patented medicines, and the parallel importation of patented medicines sold less expensively in another country. However, the reality has been rather different. In practice, countries considering using those measures have faced considerable opposition from industrialized WTO members, with the result that no developing country has yet mustered the political will to actually take such a step in order to secure lower cost medicines.

The Fourth Ministerial Conference of the WTO in Doha, Qatar was the occasion of public pressure and pointed debate on the issue of access to medicines. A declaration was issued (14 November 2001) which recognized the "gravity" of the public health problems afflicting many developing countries, "especially those resulting from HIV/AIDS, tuberculosis, malaria and other epidemics." The Doha Declaration on the TRIPS Agreement and Public Health recognized the importance of intellectual property protection for development of new medicines, but affirmed that the TRIPS Agreement "does not and should not prevent members from taking measures to protect public health." It said that TRIPS should be "interpreted and implemented in a manner supportive of WTO members' right to protect public health and, in particular, to promote access to medicines for all."⁷² The Declaration also expressly affirmed: (a) that the TRIPS Agreement contains "flexibilities" that countries were entitled to use, including compulsory licensing; and (b) that countries were entitled to determine for themselves the grounds upon which they would allow the issuing of compulsory licensing in their jurisdiction.

However, the Doha Declaration left an important issue unresolved. The TRIPS Agreement states that countries can only issue compulsory licences "predominantly" for the purposes of supplying their domestic market, restricting the possibility and scope of production of generic drugs under compulsory licence in one country for export to another. However, many developing countries do not have the manufacturing capacity that would allow local production of generic medicines. Consequently, the Doha Declaration recognized that such countries face difficulty in "making effective use" of compulsory licensing, because of their own limitations in manufacturing generic medicines and the restrictions imposed by the TRIPS Agreement on the rights of potential supplier countries to produce generic medicines for export.

The Doha Declaration committed the WTO Council for TRIPS to find an "expeditious solution" to the problem of countries with insufficient or no manufacturing capacity in the pharmaceutical sector. The WTO set itself a deadline of the end of 2002 for arriving at a solution. However, WTO countries were unable to meet this deadline. Developing countries made several proposals, the last of which, in December 2002, was approved by all countries except the US. Despite the advice of Trade Minister Pettigrew⁷³ that the issue should be resolved before the Cancún, Mexico WTO Ministerial Conference (in September 2003), the Montreal Mini-Ministerial preparatory meeting (July 2003) ended without such a result.⁷⁴

Only on 28 August 2003 in Geneva was a "deal" confirmed. It took 21 months of post-Doha negotiations before this compromise (with its attendant flaws) could be agreed.⁷⁵ In that interval, more than 8.3 million people died of HIV/AIDS.⁷⁶ During the first twelve months of negotiations, resistance to agreement on the outstanding issues was considerable, involving, according to observers "powerhouses such as the US, the European Union, Japan and Canada."⁷⁷

Since the deadlock in December 2002, Canada has made assurances that it would not initiate a formal complaint to the WTO's Dispute Settlement Body against developing countries that seek to buy cheaper generics, subject to a number of significant qualifications. However, this is no substitute for multilateral action in achieving a solution that truly addresses the health needs of developing countries.

The late August agreement reached by the Council for TRIPS on the implementation of the Doha Declaration permits WTO member countries with exporting capacity to accept a compulsory licence to manufacture and export particular drugs to an eligible importing country. An eligible importing country is defined as any least-developed country and any other country that has made a notification to the Council for TRIPS of its intention to import. Notification must be made to the Council for TRIPS confirming a number of details, and must meet a number of conditions which the Council for TRIPS will monitor and supervise. Products exported for these purposes must be specially packaged or labelled. Member countries must prevent re-export to third countries, and any WTO member can ask the Council to review an issue if it contends that this provision is not being adequately enforced.⁷⁸

This agreement, reached on the eve of the Cancún Ministerial Conference, is a positive development in that it finally opens a door which was promised at the last such conference. The Director-General of the WTO stated that it shows that the WTO "fully respects and protects humanitarian concerns."⁷⁹ The agreement is an advance over earlier proposals in one key area: It is not restricted to a list of specific diseases or to public health crises.

It must be recognized however, that the agreement is only an "interim waiver" regarding TRIPS provisions, pending an agreement to amend the current TRIPS agreement itself. Furthermore, the agreement, in the view of long-term treatment advocates, is seriously flawed. It places the Council for TRIPS and the WTO Secretariat in the position of reviewing the issuance of individual licenses, an intimate and potentially intrusive role that has the potential to complicate processes and to be used in a negative or delaying fashion. The WTO could have adopted a simpler and more straightforward approach as suggested, for example, by EU Parliament Amendment 196, which would have put non-manufacturing import-dependent countries more or less on an level playing field with industrialized countries.⁸⁰

What is the primary purpose of the much more complicated arrangement arrived at in the Geneva agreement? Is it to speed and ease the provision of access to HIV/AIDS patients in least developed and developing countries? Or is it, as claimed by Ellen t'Hoen of Médicins Sans Frontières, "to offer comfort to the US and the Western pharmaceutical industry."⁸¹

In light of this agreement, several actions need to be taken immediately:

• Governments and advocates must undertake efforts to ensure that developing countries can use these provisions with a view of expeditiously maximizing access to cheaper medicines.
• Developing country governments undertaking these efforts must be supported in the face of inevitable pressure that will be brought to bear against their doing so.
• Efforts must be continued to simplify and expedite provisions for access to generic supplies.

What about Canada's role? Canada's official position is that "balance" must be sought "between the need for innovation-spurring incentives and the benefits derived by society from maximum access to new creations."⁸² The question must be put as to the appropriateness of maintaining a policy of "balance", thus defined, in the face of massive death and suffering. Canada is one of the parents of the TRIPS agreement, and is one of the powerful "Quad" of nations with considerable influence and power in the WTO. Canada therefore bears a considerable responsibility for the results of negotiations. This leads to the following important questions:

• Was Canada, as charged by observers, one of the key centres of resistance to change before and after the Doha Declaration.
• Has Canada acted forcefully to place the right to health and access to treatment as the dominant concern in finding a solution?

One sign that Canada is fully behind efforts to expedite supplies of generics to non-producing countries would be an immediate commitment that Canada would, if asked by a Canadian generic manufacturer, approve a compulsory license for exporting drugs to Africa. A further important step would be the revision of the Canadian Patent Act to reintroduce compulsory licensing to authorize the production of generic versions of on-patent drugs for export to countries where medicines are not patented or where countries are invoking the agreement reached in Geneva. Canada should also make it clear that it will do nothing further to retard the implementation of the agreement and the granting of the relevant licenses.

Because the Geneva agreement is interim, opportunities remain for further advances with respect to the provision of drugs in the interest of public health. In this regard, Canadian policy should clearly prioritize the right to health and should ensure that trade and intellectual property provisions serve the right to health.

The United Kingdom (UK) Commission on Intellectual Property Rights has put forward three principles on which any further advance on the agreements at Doha should be based:

• "First, it should be quickly and easily implementable with a view to a long term solution.
• Second, the solution should ensure that the needs of poor people in developing countries without manufacturing capacity are given priority.
• Third, it should seek to ensure that conditions are established to provide potential suppliers the necessary incentive to export medicines that are needed."⁸³

The Commission further noted that t here are no circumstances in which the most fundamental human rights should be subordinated to the requirements of intellectual property protection.

The debate over TRIPS and access to essential medicines is not restricted to the WTO. Pressure to include TRIPS-like or TRIPS-plus provisions in regional and bilateral agreements is growing. As a recent study by the Quaker United Nations Office documented, "developing countries are concerned about so-called TRIPS-plus agreements, especially at the regional and bilateral level. These types of agreements include commitments that go beyond what is already included in the minimum standards of the TRIPS Agreement."⁸⁴ The study expresses concern that regional and bilateral agreements could undermine the limited but important flexibilities in the multilateral TRIPS agreement, which are of considerable importance to developing countries. Not least among the regional agreements causing concern is the FTAA, currently under negotiation. The study's assessment is blunt: "Proposals in the FTAA draft could undermine the capacity of governments to take measures to protect public health." The study says that the draft contains "various proposals that could limit existing flexibilities in the TRIPS Agreement and the Doha Declaration, including the principle of international exhaustion of rights, the use of compulsory licensing, and the availability of information on the safety and efficacy of a protected pharmaceutical or agricultural/chemical product."⁸⁵

Canadian policy, intellectual property, and health

Serious questions have been raised about the benefit to development and the public good of the global application of intellectual property protection. As the UK Commission on Intellectual Property Rights has stated: "Today, the main beneficiaries of intellectual property protection are largely trans-national corporations, which can use intellectual property laws to own and control research and development, while the world's poorest people face higher prices and restrictions on access to new technologies and products."⁸⁶

The Commission has cautioned that because of the power and resource inequalities between developed and developing countries engaged in negotiations like those regarding intellectual property, a significant imbalance exists and "intellectual property systems may, if we are not careful, introduce distortions that are detrimental to the interests of developing countries." The Commission commented that "there is sustained pressure on developing countries to increase the levels of intellectual property protection in their own regimes, based on standards in developed countries" and that bilateral and regional trade agreements often include commitments to implement intellectual property regimes that go beyond TRIPS minimum standards.⁸⁷ The Chair of the Commission also pointed out that pressures to harmonize patent provisions within the World Intellectual Property Organization "may remove the present flexibilities in TRIPS."⁸⁸ The Commission cautioned that "policy makers need to consider the available evidence, imperfect as it may be, before further extending IP rights."⁸⁹

In its recent review of TRIPS, the UNDP states that "the relevance of TRIPS is highly questionable for large parts of the developing world. Its asymmetric nature makes it unsuitable to be included in a trade-bargaining and negotiation context." The UNDP report concludes that TRIPS should be replaced with more development and health-friendly approaches.⁹⁰

DFAIT continues to be committed to a policy of encouraging "that developing and least developed countries should, as far as possible, fully implement current levels of international intellectual property obligations."⁹¹ This stance is not consistent with human rights principles. As the UK Commission reminded us in its final report: "There are no circumstances in which the most fundamental human rights should be subordinated to the requirements of IP protection."⁹²

Since Doha, discussions have not succeeded in arriving at a solution to TRIPS-related barriers faced by developing countries in making effective use of compulsory licensing to access more affordable medicines. Canada was one of the parents of the TRIPS agreement, and it has considerable influence and power in the WTO. Has Canada been, as charged by some non-governmental observers, one of the key centres of resistance to change before and after the Doha Declaration? Has Canada forcefully challenged the roadblock at the WTO and truly put the health needs of poor people in developing countries at the centre of its policy objectives, or has it struck a "balance" that prioritizes private patent rights over the human rights of people in need of life-extending and life-saving medicines? As part of a foreign policy approach to HIV/AIDS that is committed to respecting, protecting and fulfilling human rights, Canada can and should play the role of strong champion of access to medicines for poor people and developing countries.

With regard to regional and bilateral agreements, the question arises as to why Canada is promoting or condoning the advancement of TRIPS-plus provisions, and why the provision of protection of public health as well as the right to health has yet to be given priority in Canadian trade negotiation policy.

The future: Pharmaceutical research and provision in the global public interest

After Doha, it is clear that if drugs are considered as goods, health will remain an extension of the market, with remedies and treatments available only to those with enough purchasing power.

- German Velasquez, Coordinator, Drug Action Program, World Health Organization⁹³

This AIDS drug thing is simple. It's a chance to dip our well-fed toes in the water, by actually using our collective discoveries and inventions to benefit humanity. Maybe we shall find that it isn't so dangerous and that our economic system doesn't collapse. And the health benefits will be immediate and spectacular.

- John Sulston, Recipient of the 2002 Nobel Prize for Medicine⁹⁴

The UK Commission on Intellectual Property Rights examined the development policy impact of current intellectual property approaches, raising useful issues for further research, debate and policy development. The Commission noted that too little research on the relationship between intellectual property and development exists, particularly with reference to low-income countries.⁹⁵ If essential drugs are considered a global public good - i.e., something with benefits that extend to all countries, people, and generations⁹⁶ - several key questions must be addressed:

• "Can a global public good be patentable, so that a few have a monopoly over it to the disadvantage of millions?
• Can the drug that makes it possible to exercise a fundamental right be bound by rules that thwart access for 20 years?
• How can research and development of new drugs be organized to ensure that they are immediately accessible to those who need them?
• How can the pharmaceutical industry be reoriented towards goals compatible with improving health and the quality of life rather than economic expansion and profit?
• How can tomorrow's society secure the manufacture of those drugs at a global level?"⁹⁷

Many of these questions have been examined in reports to the United Nations Commission for Human Rights and related bodies. The Commission and the World Health Organization (WHO) are logical bodies for the aggressive development of answers to these questions and the development of a strategy to implement the answers. Humanitarian NGOs, such as Médecins Sans Frontières, have done extensive research in this area and have made very practical proposals for the funding of international research and development of pharmaceuticals in the global public interest. However, Canada could make a useful contribution by advancing consideration of questions like those raised as a result of the work of the UK Commission, through the appointment of a body to examine long-term approaches.

Saving lives: The road to increased immune capacity and prevention

[T]he long-term solution lies only in developing a safe, effective and equitable delivery system and not merely flooding the market with drugs.

- Canadian Public Health Association⁹⁸

[I]t is clear that a comprehensive approach to care, treatment and support of people living with and affected by HIV/AIDS is essential.

- Canadian International Development Agency Discussion Paper⁹⁹

Effective and sustainable treatment is not conceivable without the provision of information, counselling, monitoring and support. Effective prevention and care require many of the same elements. Both require innovative forms of outreach. Both require significantly increased resources for resource-poor countries.

The WHO's Commission on Macroeconomics and Health notes that treatment and prevention can move ahead together. The Canadian International Development Agency notes that in the immediate "battle" the following elements must be kept in view: "...battling the HIV virus with barriers to its transmission, drugs to limit its replication in people's bodies (ARVs), medications to treat the infections and conditions it causes, and measures to alleviate the pain and suffering of those who succumb to the disease and the loved ones they leave behind."

In the longer term, there must be "fundamental changes in the political, economic and social structures that foster HIV transmission and that exacerbate its impact among those marginalized by poverty, gender, race and/or sexual orientation."¹⁰⁰

Reversing the erosion of public health systems and strengthening their capacity to meet growing challenges is essential. Health systems must be expanded and strengthened. This will require interconnected investments in physical plant and equipment, training, personnel, drug supply, logistics, management services, information technology, oversight and monitoring.¹⁰¹ Policy provision and the allocation of resources for community-based primary health care, maternal and child health programs, immunization programs along with information and education, are essential to the success of an overall strategy against HIV/AIDS. Ongoing training of volunteers as well as staff is also essential. The unknowns about long-term effects of antiretroviral treatment require careful monitoring and analysis.

A significant share of increased resources for HIV/AIDS must be invested in health systems. Resistance must be overcome. As one recent study argues, "the central argument against aid - limited 'absorptive capacity' - must be viewed as a fundamental argument for aid. Moreover, devising more effective strategies for using donor funds and technical assistance to build capacity should be a central priority of developing and donor nations alike."¹⁰²

A further requirement is investment in antiretroviral drug research to develop drugs that are more appropriate for use in resource-poor settings.¹⁰³

Recommendations

18.	We recommend that DFAIT, in collaboration with Health Canada, the Canadian International Development Agency and other relevant agencies and departments, champion an international agreement on defined targets and timelines for provision of access to essential medicines, including antiretroviral therapy, for the treatment of HIV/AIDS, with specific attention to sub-Saharan Africa.
19.	We recommend that DFAIT support the target of the World Health Organization (WHO) of three million people receiving treatment with antiretroviral therapies by 2005, and support the definition and adoption of more comprehensive, ambitious and realistic targets beyond this initial WHO target.
20.	We recommend that Canada commit significant resources to the achievement of international targets for the provision of access to essential medicines; and that DFAIT advocate for this to happen.
21.	We recommend that DFAIT support, and where necessary initiate, international cooperation to ensure the provision of affordable quality supplies of medicines by encouraging regional generic production facilities, where possible; that DFAIT encourage the formation of an international consortium of generic-producing countries to scale-up production, distribution and sustainable supply, with appropriate changes in Canadian patent law to facilitate Canadian production of generics for export; and that DFAIT secure public commitments by World Trade Organization (WTO) Members at the Fifth WTO Ministerial Conference (Cancún, September 2003) that will facilitate and support this strategy.
22.	We recommend that Canada support an amendment to the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) that will ensure a simple and non-restrictive system for enabling countries with limited or no pharmaceutical manufacturing capacity to make effective use of compulsory licensing, including the removal of any remaining impediments in TRIPS that prevent such use; and that Canada support developing countries in their efforts to avail themselves of this solution, and oppose efforts to pressure them into not using it.
23.	We recommend that DFAIT, in collaboration with other federal government departments and agencies, work with developing countries to implement ways to significantly lower the prices of antiretroviral therapies and other HIV-related drugs, including the establishment of workable laws that give full effect to compulsory licensing.
24.	We recommend that a full evaluation of the implications of a more stringent intellectual property regime for the right to health and for development be undertaken on an urgent basis as part of human rights assessment of trade negotiations (see Recommendation 15).
25.	We recommend that DFAIT's current policy of encouraging further implementation of intellectual property obligations by developing countries be suspended pending the human rights assessment of trade negotiations; and that the policy be amended, if appropriate, in light of the findings of that assessment.
26.	We recommend that DFAIT oppose provisions such as the TRIPS-plus proposals in the Free Trade Area of the Americas negotiations, and similar provisions in any bilateral trade negotiations, that would extend intellectual property rights and limit states' policy options in balancing intellectual property protection against other policy objectives, such as protecting and promoting human rights, including the right to health. Instead, DFAIT should undertake to secure a development-friendly model for governance of intellectual property that does not mandate minimum length and scope of intellectual property protections and that increases national decision-making authority, allowing states to set public policy according to domestic considerations such as levels of development and health needs.104
27.	We recommend that in further development of Canadian strategies, initiatives and leadership in confronting HIV/AIDS internationally, DFAIT and collaborating departments and agencies give priority to a comprehensive approach to strengthening public health systems.

5.4 Mobilizing Resources

Whatever else, the war in Iraq and the aftermath is going to cost this world in excess of US $100 billion and I want someone to explain to me why there is always so much money for conflict and pennies for the human condition.

- Stephen Lewis, United Nations Special Envoy on HIV/AIDS for Africa¹⁰⁵

Resource provision for combating HIV/AIDS and the conditions that exacerbate it derive from a number of sources: domestic expenditure, funds freed by debt relief, bilateral official development assistance (ODA), multilateral lending and grants, and the initiatives of private foundations and NGOs.

Prior to the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, annual expenditures on HIV/AIDS in low and middle income countries was approximatelyUS$2.8 billion.¹⁰⁶ The Global Fund was designed to raise and spend new money, not replace existing spending. In its first two rounds of funding, in the period 2002-2004, the Global Fund has spent US$1.5 billion, of which 65 percent has gone to HIV/AIDS, and has committed an additional US$1.5 billion.

However, the needs are far greater than this. Significant new resources are required to combat HIV/AIDS effectively. Estimates of what is required range from US$7-10.5 billion a year by 2005 to US$22 billion a year by 2015. For example:

• The UNGASS Declaration of Commitment on HIV/AIDS called for annual expenditures in low and middle income countries to reach US$7-10 billion by 2005.¹⁰⁷
• The Commission on Macroeconomics and Health estimated in 2001 that the total costs of responding to HIV/AIDS would reach US$14 billion by 2007 and US$22 billion by 2015. It considered that annual expenditures might be distributed one third to prevention, one third to treatment of opportunistic infections and one-third to antiretroviral therapy. The Commission based its projections on very conservative statistics, assuming that only five percent of Africans living with HIV/AIDS are currently aware of their status, and are thus in a position to know whether or not treatment is appropriate.¹⁰⁸
• At the end of June 2003, UNAIDS estimated that US$10.5 billion will be needed by 2005 (an estimate it termed "bare bones"), of which only $4.7 billion has been committed. Even with intended increases recently announced by European nations and the US, commitments are about US$5 billion short of the 2005 target.¹⁰⁹

 

The Global Fund

The Global Fund is desperately in need of additional resources. The Fund is having difficulty raising the dollars it needs for the third and fourth rounds of funding (scheduled for October 2003 and April 2004) In all, for the three calendar years 2003-2005, the Global Fund estimates that it needs US$9.7 billion, of which only US$1.5 billion has been pledged.

Most of the shortfall will have to be made up by industrialized nations. Logically, the amount that each nation contributes should be based on its ability to pay, as calculated by the size of its economy - i.e., its gross national product. Canada has contributed only US$25 million a year to the Global Fund (for a four-year period). Based on an equitable contribution framework in which Canada contributes in relation to its percentage of world gross national product, to meet the fund's needs for the period 2003-2005 Canada's annual contribution should be in the neighbourhood of US$100 million, which is four times its current contribution.¹¹⁰

The Standing Committee on Foreign Affairs and International Trade has recommended that Canada triple its contribution to the Global Fund.¹¹¹

Official development assistance

Per capita amounts of aid in sub-Saharan Africa dropped from US$34 in 1990 to US$21 in 2001. In developing countries generally, over that same period, per capita assistance fell by one third from US$15 to US$10. The World Bank estimates that to meet the Millennium Development Goals by 2015 would cost an additional US$50 billion per year, which would double current levels of ODA from the industrialized countries. If the long-standing ODA target of 0.7 percent of gross national product¹¹² were met by the world's 23 largest donors (including Canada), this would generate US$165 billion a year, an amount that is more than three times the current ODA.¹¹³

The Prime Minister's commitment at Monterrey (2002) to increase Canada's ODA by eight percent per year is a very welcome announcement, but it only takes us gradually back to Canadian levels of a decade ago.¹¹⁴ Meanwhile, a number of countries are pledging significant new levels of ODA expenditure, including:

• Ireland, which has pledged to reach 0.7 percent of gross national product by 2007;
• Belgium, which has pledged to reach 0.7 percent of gross national product by 2010; and
• the Netherlands and Sweden which have pledged to reach 1.0 percent of gross national product by 2005 and 2006 respectively.¹¹⁵

Canada should follow the lead of such countries and establish a target and timeline for reaching 0.7 percent of gross national product no later than 2007.

Debt and the policies of the World Bank and the International Monetary Fund

Debt burdens, despite increased attention to their effects and their relief, continue to bedevil development initiatives in many developing countries. Canada has taken steps to reduce bilateral debt, and should be commended for having done so. However, significant debt is still held by multilateral organizations of which Canada is a member.

Debt relief for budget support at the national level in developing countries is a highly desirable objective. Both debt relief and the use of resources thus freed should be assessed in relationship to a country's needs in reaching the Millennium Development Goals, including the HIV/AIDS goals. Jubilee Research has proposed an independent mechanism for resolving debt issues in an open, accountable and transparent process, placing onus on both creditors and debtors.¹¹⁶ Until such an innovative solution gains approval, Canada, as a key member of both the World Bank and the International Monetary Fund (IMF), as well as of regional development banks, is in a position to influence debt relief and debt cancellation.

As long as multilateral debt remains a significant factor for any developing country government, the conditions on which borrowing or modifications in debt arrangements are based will play an influential role in domestic economic planning and policy. Conditionality has been energetically debated for some time. As public criticism of conditionalities has increased, the tendency has developed to transform them into preliminary requirements in advance of consideration or confirmation of funding. In terms of strategies to confront HIV/AIDS, the most sensitive areas are overall limitations on public sector spending, pressure to privatize public services - particularly health services - and pressure to conform to WTO agreements such as TRIPS, whereas special and differential arrangements might be more appropriate to national needs.

The basis for World Bank and IMF concessional lending, debt relief under the Heavily Indebted Poor Countries (HIPC) initiative and donor coordination is embodied in the Poverty Reduction Strategy Paper (PRSP) approach. These three-year national plans are supposed to be prepared in a participatory manner, focusing on public policy development that will most effectively address poverty and setting specific targets.

The United Nations Population Fund has recently published a study which, in part, examines the extent to which the potential of the PRSP process has been utilized to present opportunities to design strategies to deal with poverty and HIV/AIDS in an integrated fashion. The evaluation revealed that experience is extremely uneven; a great deal can be done to improve matters. Weaknesses identified include: the failure to address the structural causes of impoverishment, static approaches, the failure to critically examine policy, a lack of precision, new economistic frames of reference, and limited focus. The report concludes "most PRSPs completed have generally missed the opportunity for effectively assessing the links between poverty, population and HIV/AIDS." The report provides a checklist to assist the mainstreaming of HIV/AIDS considerations into poverty reduction strategies.¹¹⁷

The advisability of specific bank policies, including privatization, has come under increasing scrutiny. On the governmental side, the Commonwealth Foundation sponsored a consultative process on privatization of utilities and services preparatory to the 2003 Commonwealth Finance Minister Meeting (Brunei, Sept. 2003). The international NGO network, the Social Watch, has included in its 2003 annual report information on the experience of privatization in more than 40 countries. The negative effects of privatization, de-regulation and market pricing on services upon the poor and vulnerable in many situations is one of the key findings of such studies.¹¹⁸

Effective mobilization against HIV/AIDS requires strengthened government capacity, renewed public service delivery and a framework of service provision and access that honours human rights principles of equality and non-discrimination. Conditionalities which contradict or undermine these objectives should be eradicated.

Recommendations

28.	We recommend that DFAIT advocate among the industrialized nations for the adoption of an equitable contributions framework for contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria.
29.	We recommend that, based on this equitable contributions framework, Canada significantly increase its contributions to the Global Fund; and that DFAIT advocate for such an increase. Canada's contribution to the fund should be over and above established levels of official development assistance.
30.	We recommend that Canada establish and publicly announce a series of incremental targets (with timelines) that will enable it to quickly meet the goal of 0.7 percent of gross national product for official development assistance; and that DFAIT advocate for such targets.
31.	We recommend that DFAIT initiate consultations with Finance Canada, Health Canada, the Canadian International Development Agency and relevant NGOs to review the impact of current World Bank and International Monetary Fund conditionalities on the ability of developing countries to mobilize resources for an effective response to HIV/AIDS.
32.	We recommend that DFAIT work with the Finance Canada and the Canadian International Development Agency to encourage the rapid mainstreaming of HIV/AIDS considerations into poverty reduction strategies administered by the World Bank, utilizing such tools as the Checklist for Mainstreaming HIV/AIDS in Poverty Reduction Strategies, developed by the United Nations Population Fund.

5.5 Engaging Civil Society: Participation of People Living with HIV/AIDS, Vulnerable Groups and NGOs

Africa... is a continent where at the grassroots and community level, there is tremendous knowledge, tremendous resilience, tremendous solidarity at community and family level, particularly amongst the women who are still alive and active.... And what must happen is that we take the responses to scale. We must generalize the community responses throughout the country. And if we were able to do that, millions of lives would be saved. 

- Stephen Lewis, United Nations Special Envoy on HIV/AIDS for Africa

One of the characteristics of the global response to HIV/AIDS has been the engagement of the people most seriously affected as well as community groups, faith groups and social movements working with those most-seriously affected - not only in providing education, prevention and care, but also in planning and in developing policy. Not least among those involved have been people living with HIV/AIDS.

From a public health perspective, the strength of these community and civil society links are integral to risk reduction. Investing in public health, with a strong emphasis on strengthening networks of mutual support and providing increased support for community responses, is essential.¹¹⁹ This is particularly important in the case of HIV/AIDS where the most vulnerable groups may be neglected by the existing system, where behaviour modification requires active personal involvement, and where civil society networks are the only means to reach people at risk.¹²⁰

In the UNGASS Declaration of Commitment on HIV/AIDS, United Nations member states acknowledged the "strong role played by communities"¹²¹ and "the particular role and significant contribution of people living with HIV/AIDS...and civil society actors"¹²² in the response to HIV/AIDS. The Declaration also committed member states to:

• developing and implementing national strategies that involve partnerships with civil society and the full participation of people living with HIV/AIDS and vulnerable groups;¹²³
• establishing mechanisms at the global level that involve civil society partners, people living with HIV/AIDS and vulnerable groups;¹²⁴ and
• involving civil society, people living with HIV/AIDS and vulnerable groups in periodic national reviews of the progress achieved in implementing the Declaration.¹²⁵

Health Canada has a good track record of involving civil society and people living with HIV/AIDS in the domestic response to the epidemic. As well, the International Affairs Directorate of Health Canada has established a working group of representatives of NGOs involved in global HIV/AIDS issues to provide advice to the Directorate.

At the UNGASS session in June 2001, DFAIT added two civil society representatives, including a person living with HIV/AIDS, to the Canadian delegation. DFAIT should continue this practice at the annual General Assembly UNGASS debates on progress in implementing the Declaration of Commitment.

Unfortunately, as the UNGASS debate itself showed, not all countries have a history of involving civil society, people living with HIV/AIDS and vulnerable groups in the planning and delivery of HIV/AIDS programming or in policy development. Canada can play a leadership role by championing the involvement of these stakeholders whenever opportunities present themselves on the global stage.

There are concerns in the international NGO community about how the implementation of the commitments in the Declaration of Commitment will be monitored, at both the national and global levels. UNAIDS is trying to promote the involvement of civil society in assessing the annual UNGASS progress report prepared by the Secretary-General. DFAIT should support the UNAIDS efforts.

Recommendations

33.	We recommend that DFAIT, in its bilateral relations with the governments of most-seriously affected countries, encourage and support the engagement of community-based organizations, NGOs, persons living with HIV/AIDS, and vulnerable groups in the development and design of HIV/AIDS policies and programs, and in their implementation and evaluation.
34.	We recommend that in multilateral fora, DFAIT champion the involvement of community-based organizations, NGOs, persons living with HIV/AIDS, and vulnerable groups in all aspects of the response to the epidemic.
35.	We recommend that representatives of civil society and persons living with HIV/AIDS be included in the Canadian delegations that attend the annual United Nations General Assembly UNGASS debates.
36.	We recommend that DFAIT support the Joint United Nations Programme on HIV/AIDS (UNAIDS) in its efforts to involve civil society in assessing the United Nations Secretary-General's annual progress report on the UNGASS Declaration of Commitment; and that in its bilateral relationships and in multilateral fora, DFAIT promote the involvement of civil society in critiquing the reports that individual states prepare on progress in implementing the commitments contained in the Declaration.

Notes

48. ICG. HIV/AIDS. 2001. p. 25
49. Teixeira, Paulo R, Marco Antonio Vitoria and Johney Barcarolo. "The Brazilian Experience in Providing Universal Access to Anti-retroviral Therapy." ARNS, Economics of AIDS and Access to HIV/AIDS Care in Developing Countries, Issues and Challenges p. 85. http://www.iaen.org./papers/anrs.php. Accessed 13 August 2003.
50. The cost to 5 August 2003 of the war on and occupation of Iraq is estimated at $67,223,742.642, based on estimates from the U.S. Congressional Budget Office. www.costofwar.com. Accessed 6 August 2003.
51. African Union. Maputo Declaration on HIV/AIDS, Tuberculosis, Malaria and other related infectious diseases. AU Declarations. Assembly/AU/Decl.1-5. (Addis Ababa, African Union, July, 2002).
52. U.S. Department of State. U.S.-Brazil Joint Venture on HIV/AIDS in Lusophone Africa. Fact Sheet. 10 June 2003. (Washington, D.C., The White House, Office of the Press Secretary, 20 June 20 2003). www.state.gov/p/wha/rls/21817.htm. Accessed 29 July 2003.
53. UNAIDS. Despite Substantial Increases, AIDS Funding is Still Only Half of What Will be Needed by 2005. Press release. (Geneva, UNAIDS, 26 June 2003). www.unaids.org/whatsnew/press/eng/PCB14Funding_260603_en-eng.php. Accessed 27 July 27 2003.
54. The figures are from a forthcoming study that the WHO has commissioned from Cheri Grace, Geneva, as reported by Velasquez, German. Drugs Should be a Common Good: Unhealthy profits. Translated by Julie Stoker. Le Monde Diplomatique, English edition, July 2003.
55. ActionAid. Defeating AIDS: The Global Fund is the best chance we have. Press Release. (London, ActionAid, 16 July 2003). www.actionaid.org/newsandmedia/globalfund.shtml. Accessed 1 August 2003.
56. Canadian Public Health Association. The Opportunities and Challenges of Introducing Anti-Retroviral Therapy (ART) in Resource-Poor Settings. (Ottawa, CPH, 31 January 312002): p. 10.
57. Kirby, Michael. The Right to Health Fifty Years On: Still Skeptical? Health and Human Rights: An International Journal, 4:1. (Harvard School of Public Health, 1999): p. 17.
58. United Nations. Economic and Social Council. Commission on Human Rights. Report of the UN Special Rapporteur on the Right to Health. CN.4/2003/58. (Geneva, Commission on Human Rights, 2003).
59. Kirby. The Right. 1999: p.17.
60. The Maastricht Guidelines on Violations of Economic, Social and Cultural Rights. Human Rights Quarterly, 20 (1998): 691-705.
61. Recommendation 1 of the June 2001 report of the House of Commons. Standing Committee on Foreign Affairs and International Trade (SCFAIT). Balance, Transparency and Engagement after the Quebec Summit. (Ottawa, SCFAIT, June, 2001).
62. See, for example: United Nations, Economic and Social Council. Commission on Human Rights. Economic, Social and Cultural Rights: Liberalization of trade in services and human rights. Report of the High Commissioner. E/CN.4/Sub.2/2002/9. 25 June 2002.
63. United Nations. ECOSOC. Commission on Human Rights. Economic. 2002.
64. Robinson, Mary. "Making Globalization Work for All the World's People." Speech. Aspen Institute Summer Speakers Series. 22 July 2003. www.eginitative.org/documents/summerseries-eng.php.
65. Mandela, Nelson. Speech to the Conference on HIV Pathogenesis and Treatment. Paris, France, 15 July 2003.
66. Speech by Stephen Lewis, UN Special Envoy on HIV/AIDS in Africa, at the Conference of the Centre for the AIDS Programme of Research in South Africa. Durban, South Africa, 3 August 2003.
67. UNGASS. Declaration. 2001.
68. "Paris AIDS Conference Opens." Amgott Mitchell. IAS Conference on HIV Pathogenesis and Treatment. Paris. 13 July 2003. Also, "Researcher, Advocates Call for Antiretroviral Drug Access for Developing Countries at Opening of IAS Conference in Paris." HIV/AIDS Newsroom, 14 July 2003. www.thebody.com/newsroom/2003/jul14_03/ias2003-eng.php. Accessed 20 August 2003. Professor Moatti is author of studies on HIV/AIDS in Europe and the South. See also: Rosenberg, Tina. Look at Brazil. The New York Times Magazine, 28 January 2001. www.nytimes.com/library/magazine/home/20020228mag-aids-eng.php.
69. See, for example: Irwin. Background Paper. 2003: section 3.3.
70. Ibid; and Consensus Recommendations from the International Workshop on Strategies for Scaling-Up HIV-AIDS Treatment in Resource-Poor Settings. 9-ll July 2003. Amsterdam, The Netherlands. Draft.
71. Irwin. Background. 2003; p. 17 ff.
72. World Trade Organization (hereafter WTO). Declaration on the TRIPS agreement and public health. Adopted on 14 November 2001. WT/MIN (01)/DEC/2. www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm. Accessed 20 August 2003.
73. Chase, Stephen. WTO drug deal "crucial." The Globe and Mail. 9 May 9 2003: p. B4. See also: DFAIT. Montreal Informal Mini-Ministerial. "Trade Ministers make Progress in Montreal, But Much Work Remains, says Pettigrew." 30 July 2003. No. 107. www.dfait-maeci.gc.ca/trade/mimm/menu-en.asp.
74. WTO. Declaration on the TRIPS Agreement. 2001.
75. WTO. Council for Trade-Related Aspects of Intellectual Property Rights. Implementation of paragraph 6 of the Doha Declaration on the TRIPS agreement and public health. IP/C/W/405 28 August 2003.
76. The number of estimated daily deaths from HIV/AIDS topped 14,500 in 2000. Utilizing this conservative estimate and multiplying by approximately 575 days since the Doha Declaration, the figure of 8,337,500 is reached.
77. Hormeku, Tetteh.. WTO Negotiations: Failures signal harder battles ahead. Africa Trade Agenda. TWN Africa, No. 5, December 2002. See also: Love, James. WTO Reneges on Drug Patents: Prescription for Pain. March, 2003
78. WTO. Council. Implementation. 28 August 2003.
79. Waddington, Richard. WTO Seals Deal on Cheap Drugs for Poorer Countries. Reuters. 30 August 2003. 9:30 AM ET.
80. The EU Parliament proposal read: "Manufacturing shall be allowed if the medicinal product is intended for export to a third country that has issued a compulsory licence for that product, or where a patent is not in force and if there is a request to that effect of the competent public authorities of that third country."
81. Médecins Sans Frontières. Flawed WTO drugs deal will do little to secure future access to medicines in developing countries. 30 August 2003. www.msf.org/content/page.cfm? articleid.
82. DFAIT. Trade Negotiations and Agreements. Further Opportunities. Intellectual Property Rights. Canada's Position in WTO and FTAA Negotiations. www.dfait-maeci.gc.ca/tna-nac/other/intellect-en.asp. Accessed 29 July 2003.
83. Commission on Intellectual Property Rights. Integrating Intellectual Property Rights and Development Policy, Report of the Commission on Intellectual Property Rights. (London, Commission on Intellectual Property Rights, September 2002): p. 48.
84. Vivas-Eugui, David. Regional and bilateral agreements in a TRIPS-plus world: the Free Trade Area of the Americas (FTAA). TRIPS Issues Papers 1. Quaker United Nations Office (QUNO). Geneva and Quaker International Affairs Programme (QIAP). Ottawa and International Centre for Trade and Sustainable Development (ICTSD). Geneva. August 2003: p.2.
85. Ibid: p. 18.
86. Commission on Intellectual. Integrating Intellectual. 2002.
87. Ibid.
88. Chakravarthi Raghavan. IPRS costly for Third World, don't help reduce poverty. Third World Economics, No. 289. 16-30 September 2002: p. 12.
89. Ibid.
90. UNDP, Human. 2003: Chapter 11.
91. Canada. DFAIT, Further Opportunities: Canada's Position in WTO and FTAA Negotiation: Intellectual Property Rights. www.dfait-maeci.gc.ca/tna-nac/other/intellect-en.asp.
92. Commission on Intellectual. Integrating Intellectual. September 2002.
93. Velasquez. Drugs. 2003.
94. Sulston, John. The Rich World's Patents...abandon the poor to die. Social Development Review, December 2002/March 2003; 7:1.
95. Commission on Intellectual. Integrating Intellectual. p. 164-165.
96. Inge Kaul, Pedro Conceicao, Katell le Goulven, Ronald U. Mendoza, eds. Executive Summary: Providing Global Public Goods: Managing Globalization. (New York and Oxford, UNDP/Oxford University Press, 2003): p. 26.
97. Velasquez. Drugs. 2003.
98. Canadian Public Health Association (CPHA). The Opportunities and Challenges of Introducing Anti-Retroviral Therapy (ART) in Resource-Poor Settings. Ottawa. CPHA. 31 January 2002: p.10.
99. Mulvihill, Mary Ann. CIDA Discussion Paper: Building Comprehensive Approaches to HIV/AIDS Care, Treatment & Support in Resource Limited Settings, CIDA, 30 May 2003: p. 23.
100. Ibid: p. 30.
101. Wilson, Paul et al. Background Paper of the Task Force on Major Diseases and Access to Medicine, Subgroup on HIV/AIDS. (New York, The Millennium Project. 18 April 2003): p. 14.
102. Ibid: p. 14.
103. CPHA. The Opportunities. 2002: p. 18 .
104. This approach is suggested by UNDP. Human. 2003: p. 221.
105. HIV/AIDS Global Fund. Report of a panel discussion sponsored by ActionAid. 16 June 2003. www.actionaid.org/ourpriorities/hiv/globalfund.shtml. Accessed 20 August 2003.
106. UNAIDS. Fact Sheet 2002: Meeting the need.
107. UNGASS. Declaration. 2001: Paragraph 80.
108. WHO. Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. (Geneva, WHO, 20 December 2001): p.53.
109. UNAIDS. Despite Substantial Increases, AIDS Funding is still only half of what will be needed by 2005. Press release 2003. 26 June 2003. www.unaids.org/whatsnew/press/eng/PCB14Funding_260603_en-eng.php.
110. This would represent about two percent of the total Global Fund contributions (using an equitable contributions framework).
111. SCFAIT. Report. 2003: Recommendation 1.1, pp. 1-2.
112. This target was established by an international commission headed by Canadian Prime Minister Lester Pearson three decades ago and has been re-affirmed repeatedly at global conferences.
113. WFUNA. We the peoples...2003.
114. SCFAIT. Report. 2003: p. 2.
115. UNDP. Human. 2003: p. 147.
116. Ibid: p.153-4.
117. UNFPA. The impact. 2003: pp. 85-92.
118. Commonwealth Foundation. Civil Society Statement on The Provision of Essential Services. Prepared for the Commonwealth Finance Ministers Meeting. 16-18 September 2003. (London. The Commonwealth Foundation. August 2003); and Social Watch. The Poor and the Market. Social Watch Report 2003. Montevideo, 2003.
119. Barnett , Tony. "What We Can Learn from the HIV/AIDS Epidemic?" Paper presented at the Von Hugel Institute, University of Cambridge, 26 February 2002.
120. Manetti, A. and C. Cassabalian. Inventory of "Health as a Bridge for Peace" interventions in WHO: survey conducted in WHO Headquarters in December-February 2003. Department of Emergency and Humanitarian Action. WHO. March 2003: p. 8.
121. UNGASS. Declaration. 2001: Paragraph 31.
122. Ibid: Paragraph 33.
123. Ibid: Paragraph 37.
124. Ibid: Paragraph 46.
125. Ibid: Paragraph 94.

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