Latin America: Research Can Drive Inclusion

By Judith Sutz and Rodrigo Arocena*

A woman points to a microscope while a man looks on.

Researchers from Uruguay’s Universidad de la República worked with partners from the World Health Organization on a project to prevent dengue fever in Salto, Uruguay. / PAHO / Flickr / Creative Commons

Research programs that address “invisible problems” in society – challenges that are generally overlooked – increase marginalized people’s inclusion far beyond solution of their immediate problems.  Problems lacking “agency” get little or no attention as competing demands for public funding crowd out resources for studying problems suffered by marginalized groups.  The solutions that arise from most research, moreover, are often too expensive and too elaborate for the less fortunate.

  • Many health problems denominated “neglected diseases” fall within what the World Health Organization calls “the 90/10 gap.” Some 90 percent of all the health research done around the world is devoted to the kind of health issues suffered by 10 percent of the world population, while the 90 percent get scant attention.

Money and political will are only part of the problem.  Research to identify a problem is in itself a challenge.  Our research indicates that some initial research is often all that is necessary to make an “invisible problem” explicit enough for policymakers to be forced to pay attention.

  • In Uruguay, a university research program in 2010 uncovered the link between rice workers’ health problems, including early death, and agrochemicals seeping into the water spread at plantations. The link was difficult to detect because their symptoms were all “normal” and had other common explanations, but an interdisciplinary team analyzed epidemiological data to confirm it, which prompted the Ministry of Public Health to take action.

A second challenge is developing new approaches to adapt existing solutions that work for the well off to sectors without resources.  Many times in the past, research stopped when a solution, albeit a costly one, was found – which has the consequence of excluding sectors of modest means.  But we know that new intellectual directions can break through even those technological barriers.

  • Once a vaccine was found for the bacterium Haemophilus influenzae type b (Hib), a dangerous pathogen that causes meningitis and other life-threatening diseases in children under five, the threat disappeared from developed countries. But it remained dangerous elsewhere in the world due to the high cost of the vaccine.  Researchers at the University of Havana explored a new approach and designed a synthetic vaccine with a very low cost of production – which many scientists have hailed as an important success.  Argentinean scientists’ development of a probiotic yogurt – called Yogurito – has provided an affordable solution to provide lactobacilli that children need for digestive health.  These “frugal innovations” yield huge benefits.

An inclusive research agenda – promoted by universities and other thought leaders throughout Latin America – can transform knowledge into a tool for social inclusion if the knowledge produced and diffused in the innovation system is focused on the broadest possible segment of society.  A Copernican shift of research agendas worldwide is unlikely in the short term, but a commitment to human sustainable development will necessarily open spaces for broader agendas over time.  Democratization of access to higher education is one important driver in building “inclusive innovation systems.”  In both developed and underdeveloped societies, “developmental universities” can play a big role in solving problems and, importantly, enfranchising broader segments of the population.  Inequality in knowledge – forgetting people with forgotten problems – is a source of broader inequality the reversal of which will be of benefit to all.  Seeing victims of illness who lack the cures that wealthier citizens have as agents, rather than just as patients, is an important first step.

September 20, 2018

* Judith Sutz is Professor and Academic Coordinator of the University Research Council of the Universidad de la República, Uruguay, and Rodrigo Arocena was the University’s rector.  Their recent book is Developmental Universities in Inclusive Innovation Systems: Alternatives for Knowledge Democratization in the Global South (Palgrave Macmillan, 2018).

Zika Challenges Mount

By Rachel Nadelman* and Fulton Armstrong

Scientists and Zika

Photo Credit: Pan American Health Organization / Creative Commons / Flickr

While scientists struggle to confirm their theories over the link between the Zika virus and the dread health conditions it apparently causes, national and regional leaders face the monumental task of addressing popular anxiety that’s spreading faster than the virus itself.  The Health Minister in Brazil – site of the largest outbreak of microcephaly – has said he is “absolutely sure” that the virus is causing women to give birth to babies with the condition, characterized by abnormally small heads and serious developmental deficits.  The head of the World Health Organization’s emergency response team said last week (2/19) that the “virus is considered guilty until proven innocent,” but that it will take four to six months to even potentially be sure.  In the meantime, other questions are emerging:

  • Argentine scientists calling themselves “Physicians in the Crop-Sprayed Villages” suspect that the outbreak has been caused by pesticides. They note that thousands of Zika-infected pregnant women in Colombia – where the larvicide pyriproxyfen has not been added to drinking water as in Brazil – have delivered normal babies.  El Salvador, also hard hit by Zika, has not reported Zika-related microcephaly cases.  Other scientific authorities, including the U.S. National Academy of Sciences, question the evidence for this theory, and the later arrival of the disease in these countries means the consequences for infected expectant mothers cannot be fully determined.  Research is ongoing.
  • In lowland Colombia, along the Caribbean Coast, the virus is being blamed for an outbreak of Guillain-Barre syndrome, when victims’ immune systems damage nerve cells and cause pain, weakness, sometimes paralysis, and even death. Scientists are investigating.
  • Mental health experts say the Zika virus closely resembles some infectious agents that have been linked to autism, bipolar disorder, and schizophrenia. They can’t confirm their suspicions.
  • Entomologists and climatologists are warning that global warming will accelerate the spread of Zika and other diseases transmitted by the mosquito Aedes aegypti, which thrives in warmer, more humid environments. They caution that the number of people currently exposed to the mosquito, roughly 4 billion, will grow steadily.  Evidence is inconclusive.
  • Other theories include that the birth defects are caused by genetically modified mosquitoes released by a British company in Brazil to combat dengue; and by vaccinations given to pregnant women to prevent rubella and pertussis. But doctors and scientists have so far rejected each one.

Regional organizations and governments are taking whatever actions they can while awaiting more conclusive science.  Briefing the OAS, the Assistant Director of the Pan American Health Organization called on countries to “to mobilize to eliminate mosquito breeding sites in every corner where they may be” and pledged PAHO’s support to do so.  Brazil has formed special teams to travel around the country to rigorously quantify cases of Zika and possible links with microcephaly.  U.S. President Obama has asked Congress for US$1.9 billion and approval to reprogram funds left over from Ebola eradication efforts to deal with Zika in Latin America and the United States.  Cuban President Raúl Castro has mobilized 9,000 troops and police to spray neighborhoods and eliminate standing water in which the mosquitoes breed.

The “epidemic,” as some leaders are calling it, will be difficult to respond to even after scientists certify the mosquito-virus link.  Solving the mystery of the higher concentration of microcephaly cases in Brazil, or linked to Brazil, will also be essential to developing an effective public health response.  Eradicating all mosquitos would be a monumental undertaking – further complicated by the fact that the history of pesticides shows equal or even greater risks to citizen health when used widely.  The Aedes mosquito sucks the blood of both rich and poor, but population density and weak infrastructure — allowing for stagnant water – makes lower-income communities much more vulnerable.  Focusing on the mosquito may not be enough, moreover, because there are early indications that Zika can be sexually transmitted.  Traces of Zika have been found in breast milk, but the implications remain unclear.  Such questions fuel popular panic, increasing the risk that governments will make rash decisions that could have  profound costs.

February 26, 2016

* Rachel Nadelman is a PhD candidate in International Relations at the School of International Service.  Her dissertation research focuses on El Salvador’s decision to leave its gold resources unmined.

Ignoring MERCOSUR and UNASUR at Your Peril

By Thomas Andrew O’Keefe*

Mercosur map

Participating countries in MERCOSUR. Image Credit: Immanuel Giel (modified) / Wikimedia / Creative Commons

Pundits who dismiss MERCOSUR and the Union of South American Nations (UNASUR) as failed attempts at Latin American economic integration should look again.  MERCOSUR has presided over an explosion in intra-regional trade among its four original member states (Argentina, Brazil, Paraguay, and Uruguay) from just over US$ 5 billion at its launch in 1991 to US$ 43 billion by 2014.  UNASUR, for its part, is credited with thwarting a coup attempt against Evo Morales in 2008 and putting a damper on continental arms races.

  • MERCOSUR and UNASUR member countries have taken additional important steps toward convergence since 2014, when MERCOSUR’s highest governing body adopted “CMC Decision 32,” which allows initiatives pursued by either collective to be binding on both if they arise from a set of goals and objectives common to both. The document reaffirms the UNASUR founding treaty stipulation that “South American integration shall be achieved through an innovative process that includes all of the achievements and advances by the processes of MERCOSUR and CAN [Andean Community].”  Chile has spearheaded this effort as a means of reducing duplication of efforts, and is also attempting to bridge ideological differences between the Pacific Alliance (Chile, Colombia, Mexico, and Peru) and MERCOSUR to further build Latin American unity.

Given the relentless negative assessment of both integration projects, multinational pharmaceutical companies were caught off guard when MERCOSUR and UNASUR forced them late last year to make substantial price cuts for public-sector purchases of Darunavir, an antiretroviral to combat HIV-AIDS, as well as Sofosbuvir, used with other medications to treat Hepatitis C.  Both drugs are on the World Health Organization’s List of Essential Medicines.  As a result of CMC Decision 32/14, the Ministers of Health of all the South American nations met in Montevideo on September 11, 2015, and launched a joint MERCOSUR/UNASUR committee to negotiate with multinational pharmaceutical companies on the prices for bulk purchases of certain high-priced drugs.  The committee, made up of representatives from each government’s agency responsible for purchasing medicines, won major price cuts last November – a steep reduction for Darunavir from Hetero Labs as well as lower prices with Gilead for Sofosbuvir.  The new costs were premised on the lowest amount charged to any one of the member governments, and enabled Chile’s Ministry of Health to pay 90 percent less than what it previously paid for Darunavir.  The South American governments as a whole are expected to save US$ 20 million in 2016 on purchases of this anti-retroviral.  A proposed 14 percent reduction in the cost of the combination Sofosbuvir-Ledispaver drug for Hepatitis C – if accepted by the MERCOSUR/UNASUR committee – would enable further savings.

The South American governments have their eyes set on several additional high-priced medications, with a particular focus on drugs used to treat cancer.  In order to aid the committee’s work, UNASUR is creating a data bank of the prices charged by the multinationals for specified medicines purchased by the public health sector in each member state.  The fact that the purchases are made jointly through the Pan American Health Organization’s already existing Strategic Fund opens the possibility that countries in Central America and the Caribbean can benefit as well.  It also means that all these countries can access the Fund’s capital account and do not need to have the cash in hand to acquire medications required to address public health emergencies.  MERCOSUR and UNASUR – often dismissed as ineffective – are demonstrating that integration produces tangible results.

February 11, 2016

* Thomas Andrew O’Keefe is President of San Francisco-based Mercosur Consulting Group, Ltd. and is former chair of Western Hemisphere Area Studies at the U.S. State Department’s Foreign Service Institute (2011-15).

Correction: Due to an editing error, an earlier version of this post mistakenly stated that “a 14 percent reduction in the cost of its combination Sofosbuvir-Ledispaver drug for Hepatitis C will enable Chile’s Ministry of Health to pay 90 percent less than what it previously paid for Darunavir.”  The outcomes of the cost negotiations for the two medications are unconnected.

Health Reforms in Latin America: Lessons for the U.S.?

Photo credit: World Bank Photo Collection / Foter / CC BY-NC-ND

Photo credit: World Bank Photo Collection / Foter / CC BY-NC-ND

While Washington struggles to implement modest health care reforms, a number of Latin American countries over the past decade have been changing their health systems in ways that may offer encouragement to advocates of progressive change in the United States.  Reforms in Brazil, Chile, Colombia, Mexico and others strive to provide universal care in circumstances that are, in some cases, much tougher than those facing proponents of Obamacare.  Some challenges and accomplishments include:

  • In Chile, after years of investment, about 73 percent of the population now uses the public health care system.  A Family Health Plan in Brazil, which accounts for US$2 billion of the US$3.5 billion of the government’s health budget each year, has contributed to expansion of health care participation to 70 percent of the population.  When Colombia passed a health care law in 1993, only 24 percent of its citizens had coverage; in 2007, it had reached 80 percent.  Mexico has gone from 40 percent in 2004 to about 70 percent.  (In the U.S., about 83 percent had access to health insurance as of 2010.)
  • Latin American elites, like their U.S. counterparts, have long resisted providing the resources needed to cover health care costs, either through workplace insurance or through paying taxes to support state provision of health services.  But Latin American experience shows that this reticence can be overcome.  Substantial taxes have been levied in recent years – such as a 7 percent health care tax in Chile – and, according to various databases, health-related spending has grown to almost 7 percent of GDP in Mexico, about 7 percent in Colombia, about 7.5 percent of GDP in Chile, and around 8 or 9 percent in Brazil.  (Health care spending accounts for about 18 percent of the U.S. GDP – about half from public spending.)

These Latin American governments have demonstrated that, Sí, se puede when it comes to reforming health care and challenging entrenched interests wary of change.  Spending is rising as a percentage of GDP, but expenditures remain a fraction of those in the U.S. – and the gap in quality of care is narrowing.  Latin Americans have expanded coverage at a time that access to good care in the United States remains a challenge for tens of millions of people.  The U.S. economy generates more than sufficient resources to guarantee health care for the entire population, but the Obama administration seems too weak to implement its tepid reforms on schedule – recently postponing an important mandate that large employers provide insurance coverage.  Health care providers in Latin America appear to be adapting to the new playing field, but their U.S. counterparts are lagging.  If Latin American leaders had advice for their U.S. counterparts on how to slay this dragon, it would probably involve taking note that reforms in the region invariably emerged from decisive leadership from the executive branch and, with the exception of Mexico, a willingness to increase tax burdens to expand coverage.  They would also note that, much like is evident in public opinion polling of Latino populations in the U.S., citizens of Latin American countries are overwhelmingly in favor of public guarantees of health services for all.

OAS Drug Report: Let’s Get Serious

The OAS Preparing their Report on the Drug Problem in the Americas | Photo credit: OEA - OAS | Foter.com | CC BY-NC-ND

The OAS Preparing their Report on the Drug Problem in the Americas | Photo credit: OEA – OAS | Foter.com | CC BY-NC-ND

The Organization of American States’ most recent report on the drug problem in the Americas – released last week in Bogotá – takes a fresh, analytical look at the issue and, by advocating discussion of new approaches, subtly signals the “war on drugs” so far has failed.  The report was mandated by hemispheric leaders last year at the Summit of the Americas in Cartagena, who “agreed on the need to analyze the results of the current policy in the Americas and to explore new approaches to strengthen this struggle and to become more effective.”  It takes an analytical approach toward drug-related problems in the hemisphere and includes a discussion of both the supply and demand factors of the drug trade.  (Click here to view the OAS documents.)

The report does not make bold policy recommendations.  It calls for greater attention to the public-health implications of the drug problem, but generally avoids advocating particular strategic solutions to the production, transportation and consumption of illegal narcotics, instead providing different scenarios for the evolution of the drug problem in the Americas.  It envisions the legalization of certain drugs, such as marijuana, in various countries, but makes clear that the OAS is not advocating legalization or decriminalization.  Instead, the report emphasizes the need for countries in the Western Hemisphere to work together to combat the drug problem and discuss new approaches.

The OAS’s unique status in the hemisphere – demands on its performance are high but support for its efforts  from key governments in the region is inconsistent – may not make it the best organization to take the lead on an issue as thorny as the “war on drugs.”  The increasingly clear consensus south of the Rio Grande is that the past couple decades of effort have been not been worth the cost in dollars and lost lives, and many Central Americans, in particular, believe the militarized approach has been disastrous.  Often criticized by U.S. politicians and bureaucrats, Secretary General Insulza was probably wise not to use the report to formalize the hemisphere’s rejection of Washington’s policies.  But moving the discussion to the analytical level – rather than parroting support for another Plan Colombia or Mérida Initiative – is a significant accomplishment in itself.  Rolling out the report in Bogotá, where talk of “new approaches” is also growing, probably helped strike the right balance between old and new.  In addition to platitudinous calls for regional cooperation, the OAS can demonstrate its leadership and relevance by channeling the criticism, the lessons learned, frustration with U.S. consumption, and regional governments’ prescriptions on the way ahead into a serious, constructive strategy for the hemisphere.  With this report, the OAS has indicated that it’s time to get serious about viable alternative solutions to this multi-faceted issue – and that clinging to old models and rejecting new ideas is no longer an acceptable response to calls for rethinking the “war on drugs.”

Brazil’s Counternarcotics Policy Challenges

By Tom Long

Minister Alexandre Padilha meeting to discuss policies against crack | Photo by: Ministério da Saúde | Flickr | Creative Commons

Long a significant market for cocaine – the second or third largest in the world according to estimates – Brazil is suffering a major increase in crack cocaine use.  Visible in the centers of major cities, drug abuse has become a more serious national concern as Brazil prepares to mount the world stage as host of the 2014 World Cup and the 2016 Rio Olympics.  Brazil was slow to recognize the problem as it grew to epidemic levels, surpassing the United States as the largest consumer of crack cocaine, according to a recent report from the Federal University of São Paulo.  While national and local authorities have emphasized their recent approach to drugs as focused on public health – in contrast with the U.S.-led, supply-oriented policies – Brazil also has increased control and interdiction efforts.  According to the UN, cocaine seizures by Brazilian security tripled between 2004 and 2010.

The effort to control the flow of cocaine into and through Brazil will test both the country’s diplomacy and state capacity.  Its long, undefended and sparsely populated borders touch every major narcotics-producing and ­transiting country in South America, and cooperation in addressing the problem varies widely for political reasons and disparities in capabilities.  For example, the government of President Evo Morales in Bolivia has declined Brazilian requests for crossborder eradication, InSight Crime reported.  Other countries’ counternarcotics focus is almost completely internal, such as in Colombia and Peru.  As a result, Brazil is increasing action on its own.  President Dilma Rousseff supports plans to spend some $400 million on an expanded fleet of unmanned aerial vehicles, or drones, to provide surveillance of its borders.  Military patrols have increased, albeit in necessarily limited areas.

Experts have long warned that the “balloon effect” of counter-narcotics policies – when successful drug operations push the trade into less-defended countries and regions – was going to worsen the flow and use of narcotics in Brazil, and Brazil has long sought ways, within its resources, to collaborate.  When U.S.-Bolivia cooperation deteriorated in 2009-2010, for example, Brasilia tried to fill some of the void.  Brazilian diplomats have usually tried to lead quietly, build consensus, and avoid obvious pressure on neighbors.  However, as concerns grow, domestic politics could push Brazilian leaders to be more assertive, with the potential benefits and risks that would entail.  The challenge will be for them to find ways to collaborate on a common drug strategy with often skeptical neighbors while making gains to reduce internal demand.  Four decades of U.S. experience provide a cautionary tale.