By Dr. Gregor Wolbring*

The Kyoto Protocol is an agreement made under the United Nations Framework Convention on Climate Change (UNFCCC). Countries that ratify this protocol commit to reduce their emissions of carbon dioxide and five other greenhouse gases, or engage in emissions trading if they maintain or increase emissions of these gases(1).”Carbon emissions trading is a market-based solution to act on climate change demanded by for example the G8 CLIMATE CHANGE ROUNDTABLE in 2005 (2) which involves the trading of permits to emit carbon dioxide and other greenhouse gases. Carbon trading is seen as one of the ways countries can meet their obligations under the Kyoto Protocol to reduce carbon emissions and thereby mitigate global warming (1; 3-6). Recently Kyoto style trading is also envisioned especially by people and organisations involved in a proposed Medical R&D treaty (7) - which I critiqued before (8) - as a solution to deal with the problems related to neglected diseases (9-12). In this case one does not trade carbons or emissions but diseases as such and ‘certain medical determinant intervention activities for diseases’ related to neglected diseases. This paper looks at the implication of the remedy discourse around neglected diseases and particular the impact of disease intervention credit trading.

Three types of diseases exist, if one looks at them from the funding and attention level, namely, not neglected diseases (type I), neglected diseases (type II), and very neglected diseases (type III). The following chart shows the correlation between the degree of neglect and the income levels of countries (HIC = high income country and LMIC = low to medium income countries: Click Here for chart.

(9) Roughly two billion people - one-third of the world’s population - still lack regular access to essential medicines at affordable price and assured quality. Irrational use of medicines, unfair financing, unreliable delivery systems, inadequate regulatory systems and high medicines prices are critical factors in this lack of access (10-12).

Of 1393 new drugs marketed between 1975 and 1999, only 16 were for tropical diseases and tuberculosis, which make up 99% of the global burden of disease in low income countries (13). There is a 13-fold greater chance of a drug being brought to market for central-nervous-system disorders or cancer than for a neglected disease;(13) Pneumonia, diarrheal diseases, tuberculosis and malaria, when combined, have been estimated to account for more than 20% of the disease burden in the world (mostly in developing countries), yet they receive less than 1% of the total public and private funds which are devoted to health research. (14)

“Between 1990 and 1998, per capita expenditures on health in African LDCs (least developed countries) actually fell in real terms, from $11 to $8, even as it increased in other developing countries from $100 to $180. Children in poor countries still suffer 1.6 million deaths every year due to measles, tetanus, and pertussis, even though these diseases have been substantially eliminated in the high-income countries. Only half of all developing nations, and only 6 of 47 LDCs, are able to provide essential medicine access to over 80% of its population.”(15)

There is no doubt that the situation around neglected diseases has to be rectified. The question is how. Numerous strategies to deal with neglected and very neglected diseases have been proposed from a variety of players, including NGO’s.

To quote Martin Khor (16) from the Third World Network

In many developing countries, NGOs and health professionals and researchers have also in recent years raised concerns that much of the research and innovation in health was being motivated by corporate objectives to obtain profits. As a result, most of the new medicines and other health care products being produced were catering to patients in developed countries, while little research was being done towards new medicines to meet the needs of developing countries. A movement developed to have the WHO look into new systems of incentives towards research and development for health care products needed by developing countries. Such systems could complement or be alternatives to the current patent system. The two streams (those concerned about innovation for new medicines, and those concerned about access to medicines) merged into the movement for a global framework or strategy that would lead to R&D appropriate for health needs in developing countries, and access to the results of the products.

NGOs and others believe that there are possibilities to rectify the problems related to neglected diseases within a New Health R&D Framework (17).

What does the global strategy, especially the one involving NGO’s, look like at the moment? What mechanisms are envisioned to increase the interest in finding solutions for the problems attached to neglected diseases? How are the problems of neglected diseases defined? What interventions are envisioned as solutions to the problems of neglected diseases?

The advance price or purchase commitments (APPCs) system (18) and ideas of the International Policy Network (19) are just two models of how to deal with diseases in low income countries. One can think about many other mechanisms of disease intervention and prevention trading. I want to focus here on theMedical R&D treaty and the World Health Assembly resolution WHA59.24as these are related to each others and involve NGO’s to a great deal (20)

According to the webpage of the Medical R&D treaty , a number of economists, scientists, public health experts and others began work on an alternative trade framework for medical R&D in 2002. The Medical R&D treaty was to replace existing or planned trade agreements that focus on patents or drug prices leading to minimum national obligations for supporting medical R&D, with flexibility regarding the business models, intellectual property rules or other mechanisms (such as open source approaches). The Medical R&D treaty introduced the mechanism of tradable credits for investments in particular projects regarding neglected diseases.

On 24 February 2005, a letter was presented to the World Health Assembly Executive Board and the WHO Commission on Intellectual Property Rights, Innovation and Health, asking for an evaluation of the Medical R&D treaty that had been developed to deal with the problems of neglected diseases in low income countries. In response, the World Health Assembly adopted resolution WHA59.24(20) on 27 May 2006. This resolution established a Working Group that was assigned the mandate of coming up with a global strategy on intellectual property, health research and development, and new medicines for diseases that especially affect developing countries.

WHA59.24(20) does not talk about the mechanisms of how it would increase the R&D in neglected diseases but the mechanism envisioned by the Medical R&D treaty might be employed to make the WHA59.24(20) vision a reality as the push around theMedical R&D treaty led to WHA59.24(20).

How will the scope and vision evident in the Medical R&D treaty and WHA59.24(20) impact on the global strategy to deal with neglected diseases, on the mechanisms to increase the interest in finding solutions for the problems attached to neglected diseases, on the definition of the problems of neglected diseases, on the interventions envisioned as solutions to the problems of neglected diseases, on other areas beside neglected diseases, on global health and what are other social consequences? These are just some of the questions one has to answer.

So how does one increase interest in dealing with neglected diseases?

The original Medical R&D treaty envisions the usage of a Kyoto-type credit trading:

Similar to the Kyoto climate treaty, credits would be traded across borders – and countries that exceed the benchmark obligations can sell excess credits. The credits will be given for a variety of projects including:

-R&D for neglected diseases and other priority research projects,

-”Open public goods,” such as free and open source public databases,

-Projects that involve the transfer of technology and capacity to developing countries,

-The preservation and dissemination of traditional medical knowledge, and exceptionally useful public goods. (7)

The letter which was presented to the World Health Assembly Executive Board and the WHO Commission on Intellectual Property Rights, Innovation and Health, asking for an evaluation of a Medical R&D treaty (21) envisioned the following:

At the core of the proposed treaty is an obligation to finance Qualified Medical Research and Development (QMRD). This obligation is tied to country GDP. In Draft 4, two different methods of determining the fraction of GDP for QMRD are presented. Alternative 1 uses different rates for each of four income groups (high, high medium, low medium, and low). Alternative 2 is a graduated rate. QMRD would include (1) basic biomedical research, development of biomedical databases and research tools, (2) development of pharmaceutical drugs, vaccines, medical diagnostic tools, (3) medical evaluations of these products, and (4) preservation and dissemination of traditional medical knowledge. (21)

In other words the Medical treaty proposes the establishment of credit trading for “disease intervention” for neglected diseases. On the one hand this is hardly surprising, taking into account that the use of market forces to deal with medical health issues and diseases is a long established practice. Medicine and other medical health technologies have been commodities of disease intervention trading for a long time. A large part of economic activity in high income countries is based on selling “health products”. The whole discourse and dynamic of private and public health care and health insurance is based on trading medical health and disease interventions. Health economics is a flourishing field as are the development of measures needed for medical health economics.

On the other hand the recommendation of this kind of market solution is surprising as one could argue that disease trading and disease intervention and prevention trading are the two major reasons why neglected diseases exist in the first place. So what are disease trading and disease intervention and prevention trading?

Disease trading has two meanings:

1. The focus on a specific disease over another.

2. The generation of “new diseases with the purpose of selling products for the new disease.

Taking the first meaning one could indeed make the case that disease trading is what caused the very existence of neglected diseases. To develop products for diseases in low income countries where the monetary return is low would impact on the stock prize as it would be seen to impact on the profitability of the company in a negative way. Therefore companies often reject to work on diseases with low return and focus on diseases with high return. “Disease trading could also be seen at the root of the 10/90 gap where 90% of the global health research dollar is spent on 10% of the global medical health problems. (14)

Taking the second meaning, my recent columns on Ableism , Enhancement, and Transhumanism and a recent report by me (8) highlight the existence of the medicalization dynamic which is often called disease mongering (8) where the human body increasingly is becoming a commodity for “disease trading” and “disease intervention trading” (see also a new report by ETC Group Group).

We design new disease for the human body so a product can be sold as a medical product. This dynamic entices entrepreneurs (companies and individuals) to focus on selling new diseases to the ‘medical healthy’ in high income countries as the return for profit is better than dealing with neglected diseases in low income countries.

Disease trading is, of course, not the whole story. The other part relates to the envisioned interventions related to a neglected disease (disease intervention and prevention trading).This trading comes also in two types:

1. A given social environment decides to spend the money and infrastructure resources on other priorities. It trades disease interventions against other commodities such as military products. That drugs exist, but do not reach the people because of a country’s internal problems, is often used as an argument to claim that the 10/90 gap does not exist. (22-24). This argument is used to justify the withdrawl of money from disease interventions. It is true that often cheap drugs or vaccines do exist and that they do not reach the people in need due to problems within the countries political and social infrastructure. However this is really not an argument that a 10/90 gap does not exist but simply an argument that within a 10/90 gap solutions for neglected diseases are generated which are sometimes not put into effect because of adverse social and political factors within the counties needing the interventions.

2. A given social and political environment decides to spend the money on direct medical interventions for a disease such as drug development and ignores the benefits which can be gained by spending money on social determinants. Here we trade medical determinant interventions against social determinant interventions.

On the procedural level it is not clear at the moment what means will be implemented to fulfill WHA59.24(20).

Even from the wording of the original Medical R&D treaty it is not clear whether the trading will be market-based, whether it will be shaped by individual countries trading credits, whether companies themselves are involved in the trading and if yes, where and with whom, and whether the WHO or another trans-national agency is brokering and overseeing the trades.

The WHA59.24(20) document, which is the endpoint as of yet in the efforts towards dealing with neglected diseases also does not specify on the procedural level how the vision of dealing with neglected diseases would be resolved. In Carbon credit trading, numerous players are involved and numerous schemes are employed each with different consequences attached to them. In regards to the procedural level it remains to be seen where the Kyoto style disease intervention trading and the WHA59.24(20) might lead us.

With regard to what interventions would be dealt with, on a philosophical level the Medical R&D treaty and the WHA59.24(20) seem to be much clearer. Both seem to limit their scope to medical determinant interventions.

Although Carbon trading is seen as a valid option by many it is also seen as having problems. (3; 25; 26) Some see Carbon trading as a threat to social justice and vulnerable populations (27). Some see it as the Privatization of the Atmosphere (26). The Durban declaration on Carbon trading (28) outlines a variety of problems as does the book by Larry Lohmann published recently by the Dag Hammarskjöld foundation (3). It might be useful for the people promoting Kyoto style disease credit trading to look intensively at the problems cropping up in carbon credit trading in order to omit certain procedural mistakes. However beside procedural and general problems which might be attached to credit trading in general there are very specific problems which are attached to the language and scope of the Medical R&D treaty and WHA59.24(20).

Kyoto style credit trading and the recommendations of the Medical R&D treaty and the WHA59.24(20) are seen by many as the way forward to deal with neglected diseases. However the language and content of both the Medical R&D treaty and the WHA59.24(20) pose some problems.

A Table from a 2004 academic article highlights two quite different philosophies toward dealing with global health which includes neglected diseases. Will there be an increased focus for medical/techno fixes (Gates Foundation list) and a diminishing look at social determinants (Journal of Nursing Scholarship list) in the wake of the Medical R&D treaty and the WHA59.24(20)?

Click here to see the two lists. You will have to exit (press "X") twice from this file in order to return to this page.

The letter which was presented to the World Health Assembly Executive Board and the WHO Commission on Intellectual Property Rights, Innovation and Health, asking for an evaluation of a Medical R&D treaty (21) envisioned the following interventions:

At the core of the proposed treaty is an obligation to finance Qualified Medical Research and Development (QMRD). This obligation is tied to country GDP. In Draft 4, two different methods of determining the fraction of GDP for QMRD are presented. Alternative 1 uses different rates for each of four income groups (high, high medium, low medium, and low). Alternative 2 is a graduated rate. QMRD would include (1) basic biomedical research, development of biomedical databases and research tools, (2) development of pharmaceutical drugs, vaccines, medical diagnostic tools, (3) medical evaluations of these products, and (4) preservation and dissemination of traditional medical knowledge.(21)

The WHA59.24(20) document that established a working group to come up with a global strategy on intellectual property, health research and development, and new medicines for diseases that especially affect developing countries also has a medical focus in solving the problems. It talks about “the need to continue to develop safe and affordable new products”2 and specifies in footnote 2 that “the word ‘products’ hereafter should be understood to include vaccines, diagnostics and medicines”.

Problem: The Medical R&D treaty and the WHA59.24(20) both assume that the lack of medical products and medical R&D for neglected diseases is at the root of the problem with neglected diseases. However the Medical R&D treaty and the WHA59.24(20) not only seem to ignore social determinants problems attached to the dealing with neglected diseases but seem to further the problem of disease intervention trading outlined above. A few of the quotes from the WHA59.24(20) document highlight its one sided focus on medical determinants:

Considering the need to continue to develop safe and affordable new products2 for such communicable diseases as AIDS, malaria and tuberculosis, and for other diseases or illnesses disproportionately affecting developing countries;

Conscious of the opportunities opened up by advances in biomedical science, and the need to harness them more effectively to develop new products, particularly in order to meet public health needs in developing countries;

Aware of the considerable progress that has been made in recent years by governments, industry, charitable foundations, and nongovernmental organizations in funding initiatives to develop new products to fight diseases affecting developing countries, and to increase access to existing ones;

Aware of the need for additional funding for research and development for new vaccines, diagnostics and pharmaceuticals, including microbicides, for illnesses, including AIDS, that disproportionately affect developing countries;

Recognizing the importance of, and need for, public/private partnerships devoted to the development of new essential drugs and research tools, and aware of the need for governments to set a needs-based priority agenda for health, and to provide political support and sustainable sources of funding for such initiatives;

Recognizing the importance of public and private investment in the development of new medical technologies;

Considering that a number of developing countries have been strengthening their research and development capacity in new health technologies, and that their role will be increasingly critical, and recognizing the need for continued support for research in and by developing countries;

Noting that intellectual property rights are an important incentive for the development of new health-care products;

Noting, however, that this incentive alone does not meet the need for the development of new products to fight diseases where the potential paying market is small or uncertain;

2. URGES Member States:

(1) to make global health and medicines a priority sector, to take determined action to emphasize priorities in research and development addressed to the needs of patients, especially those in resource-poor settings, and to harness collaborative research and development initiatives involving disease-endemic countries;

(2) to consider the recommendations of the report and to contribute actively to the development of a global strategy and plan of action, and to take an active part, working with the secretariat and international partners, in providing support for essential medical research and development;

(3) to work to ensure that progress in basic science and biomedicine is translated into improved, safe and affordable health products - drugs, vaccines and diagnostics - to respond to all patients’ and clients’ needs, especially those living in poverty, taking into account the critical role of gender, and to ensure that capacity is strengthened to support rapid delivery of essential medicines to people;

3. DECIDES:

(4) to continue to issue public health-based research and development reports, identifying from a public health perspective, gaps and needs related to pharmaceuticals, and to report on them periodically;

(5) to continue to monitor, from a public health perspective, in consultation as appropriate with other international organizations, the impact of intellectual property rights and other issues addressed in the Commission’s report, on the development of, and access to, health care products, and report thereon to the Health Assembly.

The only language in WHA59.24(20) which might open the door for social determinant work is the following section:

3. DECIDES: (1) to establish, in accordance with Rule 42 of the Rules of Procedure of the World Health Assembly, an intergovernmental working group open to all interested Member States to draw up a global strategy and plan of action in order to provide a medium-term framework based on the recommendations of the Commission. Such a strategy and plan of action aims at, inter alia, securing an enhanced and sustainable basis for needs-driven, essential health research and development relevant to diseases that disproportionately affect developing countries, proposing clear objectives and priorities for research and development, and estimating funding needs in this area;

One could interpret this to mean that needs driven health research has to include social determinants and a look how social actions lead to the increase in incident of neglected diseases. This would be in tune with the WHO Commission on social determinants (30). However it is less than clear whether it would open the scope or whether even this section would be interpreted with footnote 2 in mind which reads “2 The term “products” hereafter should be understood to include vaccines, diagnostics and medicines.”

The players in the Medical R&D treaty and the WHA59.24(20) have to rethink their strategies towards neglected diseases and their exclusive focus on medical determinants. It is true that to some extends R&D into neglected diseases is lacking. However there is more to the story. According to a recent report published by the International Policy Network (31):

Lower income countries have often not benefited from the full potential of modern drugs because of a number of self-generated policy failures that actively impede access to medicines. These include:

- Excessive tariffs and taxes on both imported and domestically produced drugs, which can inflate the cost of medicines by up to one-third. While these artificial price inflators raise little money for government treasuries, they are regressive taxes that price the poor and sick out of treatment.

- Weak healthcare systems that hinder the effective distribution of drugs. While this obviously includes such things as effective hospitals and nurses, it also extends to the wider infrastructural constraints on the delivery of drugs such as poor roads and unreliable electricity networks. Research shows that extra funding of public health services in lower-income countries rarely translates into improved services for the poor.

- Lack of health insurance. Governments in lower income countries also fail to provide the necessary institutional environment for functional risk pooling mechanisms (or health insurance) that would widen access to medicines by removing the need to make out of pocket payments for healthcare.

- The intervention of international public health authorities, such as the WHO, is no guarantee that medicines will be widely distributed. Both its ‘3 by 5’ and Roll Back Malaria programmes have failed to achieve their self-imposed targets, and may have made matters worse by increasing drug resistance.

One can dispute some of the claims, statements and cause-and-effect relationships outlined in the report (31). However to assume that everything will be fine with neglected diseases if more drugs are produced and more medical R&D is done is not warranted.

The exclusion of social determinants in the Medical R&D treaty and the WHA59.24(20) opens the door for disease trading in general and medical technology and medicine trading in particular as a market based remedy to medical health problems. Furthermore social well-being problems could be labelled as medical problems in low income countries with the accompanying focus on medical R&D which will not be able to deal with the social well being problem which is mostly based on social determinants and this would mark the end of meaningful and effective social interventions. Groups such as the people health movement and others have to demand the inclusion of social determinant aspects into the Medical R&D treaty and the WHA59.24(20) and a broad debate has to happen around the social determinant aspects of neglected diseases. There is more to the issue than the 10/90 gap. So far the social determinant aspect in regards to neglected diseases is covered by others it seems for example, the International Policy Network (31). The NGO’s involved in the Medical R&D treaty and the WHA59.24(20) have to cover the relationship of social determinants and neglected diseases much more.

A recent UN News service article UN HEALTH AGENCY EXPANDS PROGRAMME TO FIGHT NEGLECTED TROPICAL DISEASES (32) stated

Buoyed by its success in saving an estimated 110,000 people who would otherwise have died from sleeping sickness over the past five years, the United Nations health agency today expanded its programme to fight some of the most neglected tropical diseases that destroy the lives and health of poor people.

This expansion is possible thanks to a renewed collaboration with sanofi-aventis, the world’s number 3 pharmaceutical company, which has agreed to donate medicines and financial support worth $25 million over five years to the UN World Health Organization (WHO).

This news item seems to fit with the intention of the Medical R&D treaty (21) and WHA59.24(20). However as great as this news is again this can’t be the whole story.

Foladori’s from the Universidad Autónoma de Zacatecas wrote a piece on “the Challenge of Infectious Diseases to the Biomedical Paradigm” in which he states:

The resurgence of infectious diseases and the emergence of infectious diseases raise questions on how to cope with the situation. The germ or clinical approach is the hegemonic biomedical paradigm. In this article, the author argues that the spread of infectious diseases has posted a challenge to the biomedical paradigm and shows how lock-in procedures maintain alternative and complementary medicine paradigms in the backyard. (33)

Foladori writes further:

The resurgence and emergence of infectious diseases questions public health policies. Alternatives to cope with epidemics are based on the different hypotheses of disease causality, but one of them, the germ or clinical approach, is hegemonic on world public health. The clinical approach considers that there is a micro-organism responsible for each disease. The World Health Organization (WHO) defends the idea that diseases are the main block to development in less developed countries, and if a vaccine or specific medicine can be developed for the main third-world diseases, such as malaria, and extensively applied in poor countries, socioeconomic development would be the outcome. On the contrary, the social determination of the health approach considers micro-organisms the agents and lack of development the final cause of a disease. (33) Chart deliniating the cuases of the resurgence of various diseases

(33)

Foladori’s writings highlights another reason why the Medical R&D treaty (21) and WHA59.24(20) both should be changed to include social determinants as both can’t deal with the problems outlined by Foladori in their current scope and language.

Even if one decides to look at social determinants and not just at medical fixes the problem arises how to qualify and quantify social determinant interventions versus medical determinant interventions.

Measurement and outcome tools such as the DALY (34-36) intentionally (37) (pp.709, 723) do not take into account social determinant but use only medical determinants. The DALY emerged as a measure of the “global burden of disease” to support the medical model/medical determinants combination of health and disease. DALYs are inadequate for measuring the global burden of disease because they do not evaluate and measure the roles played by environmental, societal, and other factors in determining the severity and cause of “non-normative functioning,” “impairments” and “diseases.” (8)

DALYs are inadequate for measuring the effectiveness of health interventions because they have not been designed to measure social determinants of medical health interventions and non-medical health interventions (social well being). No evidence gathering, evaluation, and measuring tools exist which allows for the comparison of medical determinants/interventions with social determinants/interventions in regards to cost effectiveness and other outcome measures. (8)

Evidence gathering, evaluation, and measuring tools need to be revamped because they cannot really trade medical determinants/interventions against social determinants/interventions.

If the above proposed system of credit trading for medical interventions is approved, the language of WHA59.24(20) would allow for the expansion of such systems to no communicable diseases. Unipolar disorder, for example, has been projected to be one of the major contributors to the burden of disease in low income countries by 2020(38). Would the current focus on medical interventions for neglected diseases – that ignores social determinants as both the cause and the remedy as evident in WHA59.24(20) and the Medical R&D treaty , be carried over into interventions for noncommunicable diseases? Would interventions be limited to medical interventions, ignoring the roots of many of these conditions and the needed interventions at the social and psychosocial levels?

Carbon became a new commodity to trade with the Kyoto Protocol. Carbon trading started on the level of countries and is expanding now to the level of companies and might end up on the individual level (39-43) (44)

Medical intervention and disease trading are not that new, although no one uses those terms for processes that are already common. However, performing a Kyoto style credit framework on a country level is certainly new even though the subsidies companies often receive for developing new ‘medical products’ could be seen as a Kyoto style credit framework related to companies. I outlined in detail elsewhere (8) that in high income countries an increasing amount of normal variations in body functioning and structure are labelled as deviations as “diseases”, as defects in need of fixing (the dynamic of medicalization) (45-47) to generate demand for “medical” products. A growing number of ‘medical technologies’ are employed to improve the looks, performance, and psychological well-being of people who are healthy. This dynamic might spill over to low income countries if the Kyoto style credit trading is applied to noncommunicable diseases and diseases in general. The language of WHA59.24(20) and the Medical R&D treaty opens the door for this dynamic. It would go beyond the scope of this paper to look at the global health scene in a thorough fashion. However, two issues are worth exploring. How will the appearance of a transhumanist/enhancement model of health and disease -the idea that human beings are by default medically ill till they have received the newest performance enhancement–(8), the increased phenomenon of medicalization, and the appearance of the transhumanization of medicalization(8;48) as seen in developed countries play itself out on the global health stage? Will one see an increasing the social construction of new diseases? Will one see an increasing use of drugs for “diseases,” ignoring social determinants leading to “diseases”? It is interesting that the increased use of drugs is one of the main cost related problems of many health care systems in high income countries (8)

The Transhumanization of Medicalization

Advances in sciences and technology increase the ability, demand for, and acceptance of improving and modifying the human body (structure, function, capabilities) beyond its species-typical boundaries. An increasing number of people believe that we can, will, and should try to overcome our biological limitations and that the move toward the enhancement of the Homo sapiens body is not preventable. (49-60)

The transhumanist model of health and disease defines the human body in general as defective, or as a work in progress(8), elevating the medicalization dynamic to its ultimate endpoint, namely, to see the enhancement beyond species-typical body structures and functioning as a therapeutic intervention (transhumanization of medicalization). The transhumanization of medicalization moves the dynamic of medicalization to its logical conclusion by adding the enhancement of body appearance and functioning above species-typical norms and boundaries to the mix.

If one links the possible inevitability of more enhancements becoming available with the increased popularity of the transhumanist model of health and disease, the dynamic of medicalization, and the transhumanization of medicalization, it comes as no surprise that the emerging field of enhancement medicine becomes an increasingly flourishing field of medicine providing the remedy through surgery, pharmaceuticals, implants and other means generating new jobs such as such as ‘body engineers’, ‘body designers’ and body techno-maintenance crews.. (8)

A transhumanized version of the DALY

To quote Murray and Acharaya (Murray being the father of the disability adjusted life years (37))

“? individuals prefer, after appropriate deliberation, to extend the life of healthy individuals rather than those in a health state worse than perfect health.”

The spirit of this quote allows for the justification of a hierarchy of treatment of people with poor medical health whereby the ones which are deviating the least from a “species typical medical health state are treated first. It furthermore allows for the following interpretation:

” individuals prefer, after appropriate deliberation, to ENHANCE the life of healthy individuals rather than those in a health state worse than perfect health,”

which allows for the justification of a societal development where one favors ‘enhancement medicine over ‘curative medicine’ seeing pure curative medicine as futile and as a waste of health care dollars.(8) This shift might also be lucrative from another economic standpoint as enhancement medicine provides the remedy through surgery, pharmaceuticals, implants and other means and could become the number one cash cow for many hospitals and medical practitioners such as ‘body engineers’, ‘body designers’ and body techno-maintenance crews. (8)

Transhumanized version of the burden of disease

The transhumanization model of health and disease prepares the groundwork for the acceptance of a view of health, which links the concept of the burden of disease not to a deviation from Homo sapiens-typical functioning but to the lack of enhanced functionalities and life extension and productivity modification of sentient beings. (transhumanist/ enhancement concept of disease) The question is, does the language of the WHA59.24(20) and the Medical R&D treaty allow for the transhumanized policy on diseases to be applied to low income countries and a transhumanized focus on global health? I would say that the medical focus of WHA59.24(20) and the Medical R&D treaty not only allows but even encourages such a development.

It is understandable that the drafters of the Medical R&D treaty and the WHA59.24(20) want to continue to involve the industry and the other players already involved in disease intervention trading and disease trading as they perceive it that the situation can not be solved without involving the players already involved in disease intervention trading and disease trading. However, strategies that are developed without input from all the people who are affected cannot be successful on a global level. What other players do we need to involve in the decision making process?

A variety of groups and individuals are moving the concept of Carbon Trading which was employed initially on the level of countries and companies toward the realm of the individual.(39-43) Personal Carbon trading allocates emissions credits to individuals on a per capita basis(41). One would become responsible for ones carbon usage. To quote the Guardian:

The environment minister, David Miliband, today unveiled a radical plan to cut greenhouse gas emissions by charging individuals for the amount of carbon they use. Under the proposals, consumers would carry bank cards that record their personal carbon usage. Those who use more energy - with big cars and foreign holidays - would have to buy more carbon points, while those who consume less - those without cars, or people with solar power - would be able to sell their carbon points. (42)

Although not covered so far within the discourse around the Medical R&D treaty and the WHA59.24(20) one can easily envision how the concept of personal carbon trading could be applied to personal disease prevention and intervention trading and the generation of new diseases. If one eats healthily, has a healthy lifestyle, is not involved in unsafe recreational activities, and takes as many disease prevention measures as possible – including prebirth genetic and non-genetic diagnostics with accompanying selection and deselection procedures – one could gain or at least not lose credits. In the same way that personal carbon trading seeks to encourage responsible energy usage, disease intervention trading could be seen as encouraging people to live responsibly with respect to their medical health. One might be able to trade something for this “responsible” style of living. Social determinants are taken out of the equation, however.

Intriguingly – extending the environmental analogy – one can envisage a disease generation footprint that is comparable to an ecological footprint - where the percentage of overweight people, for example, is a reflection of how active individuals are within a given social structure, what is advertised and sold, how we eat as individuals, and the activities we cherish. In other words, how a society is structured, and how it functions, leads to choices that create disease generating “footprints.”

Individual disease intervention and prevention trading might be used by countries to trade credits for global health.

The difference between carbon trading or emission trading and disease and disease intervention trading at this point has to do with the level at which the trading takes place. Disease intervention trading happened mostly on the level of companies and on the interaction between companies and government structures or companies and individuals within a country. We trade national health through the share prices of the companies who sell or develop medicine and share prices of health care companies and insurance companies.

So far, disease intervention trading is not triggered by government desires to trade the good or bad health of their population and the cause of and intervention in national health with other countries towards gaining credits for an improved global health. If that would be the case we would have global health as the outcome measure. Countries would then trade their national health status and the interventions and problems with other countries to not exceed the quota – e.g. like a % of overweight people or whatever one wants to look at. So far such trading does not exist between countries although we might move towards this.

Wherever the discourse around Medical R&D treaty and the WHA59.24(20) and other suggested remedies for neglected diseases takes us, several important guidelines must be kept in mind if we are to find the best solution:

The range players involved in the decision making has to be broadened.

Social determinants have to be taken seriously.

The impact of new and emerging technologies on health concepts and interventions has to be taken into account.

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* Dr Wolbring is based at the University of Calgary. He is a health researcher, a ability/disability studies scholar, a governance of science and technology researcher, a bioethicist, and a biochemist. His webpage is http://www.bioethicsanddisability.org. . His biweekly column “The Choice is Yours” can be found here http://www.innovationwatch.com/commentary_choiceisyours.htm His blog is at http://www.wolbring.wordpress.com