DEVELOPMENT AND COOPERATION

ENTWICKLUNG UND ZUSAMMENARBEIT

International Journal

ISSN 2366-7257

Monthly e-Paper November 2016

Mangaluru Self-help groups Human rights Urban development ’s collective EU trade policies X + in a mid-sized town saving schemes should reflect in make a difference European values

Infectious diseases Christian Guy/Lineair Title: South Sudanese nurse in 2011. Photo: Jörg Böthling/Photography

Focus: Editorial Infectious diseases Government responsibility At least 900 dead in 2015 Infectious diseases affect poor countries in particular. In advanced This year, the rainy season lasted longer than it normally economies, many diseases such as cholera or tuberculosis have been does in , allowing mosquitos to thrive. As a virtually eradicated. There are several reasons for this divergence, including consequence, the risk of dengue infections was higher the following: than it normally is. Freelance journalist Edith Koesoe- ■■ Inadequate nutrition makes people more vulnerable. mawiria assesses the situation. Page 14 ■■ Good water and sanitation infrastructure protects people from infections. ■■ Low levels of education result in poorer understanding of how to handle Diseases of the poor illnesses and, more generally, how to live in a healthy way. ■■ Pharmaceuticals tend to be expensive and inaccessible in developing coun- Neglected tropical diseases (NTDs) hardly affect advanced tries. economies with great purchasing power, so pharmaceuti- ■■ Many immunisation programmes can be taken for granted in rich nations, cal companies and academic research do not pay them but not in poor ones. much attention. In Africa, Asia and Latin America, however, one in seven people suffer from an NTD, reports The pharmaceutical industry is a multi-billion dollar business. Corporate D+C/E+Z’s Sheila Mysorekar. Page 16 research is primarily geared to making profits rather than to fighting the world’s worst diseases. Pharma companies do not invest heavily in finding Virus reveals shortcomings therapies for the illnesses that haunt poor people, and their approach is reasonable. That kind of investment would not be lucrative, since patients Brazil is fighting the zika virus, and the number of would not be able to afford the medication – unless it was sold at very low infections has been declining since summer. To tackle the prices with rather small profit margins. It is therefore no coincidence that serious consequences of the illness and prevent future pharma labs have developed pills against erectile dysfunction while human- epidemics, substantial reforms are needed nonetheless. kind still lacks therapies for Chagas or dengue. Sanitation must improve, and the health-care system must become stronger, writes Renata Buriti, an expert in Indeed, health care must not be left to market forces. Governments must water resources management. Page 19 assume responsibility. Because of systemic market failure in this sector, the state plays an important role in the highly regulated health systems of all Dangerous trend advanced economies. Accordingly, health needs are greatest in poor coun- tries where government capacities are weaker. Antibiotics have been a real blessing for humanity. However, more and more bacteria are becoming resistant. In principle, every human being must get competent health care. Making this Christian Wagner-Ahlfs of Buko Pharmakampagne, a vision come true is on the UN agenda of the Sustainable Development Goals. German non-governmental organisation, reports that tens Rich nations must contribute to the cause. After all, they are compounding of thousands of people are dying every year, and not only health problems internationally, for instance, by enticing doctors and nurses industrialised countries are affected. Page 21 to migrate from poor world regions to fill personnel gaps in more prosperous places. Obviously, the governments of developing countries must assume “Involve the local people” responsibility too. They must use their limited resources efficiently and effec- tively. Health centres with competent staff and sufficient pharma supply are Health care cannot be left to doctors and drug companies, needed everywhere. Otherwise, simple infections can plunge entire families argues Zafrullah Chowdhury of GK, a rural health NGO in into poverty. Experts know there are causal links between poverty and illness. . It is essential to raise awareness and build For obvious reasons, people’s productive potential depends on their health. capacities at the grass-roots level. Page 24 One way of assuming responsibility is not to shy away from disputes with Medicine for all pharma corporations, for instance regarding intellectual property rights. The rules of the World Trade Organization (WTO) allow governments to grant Gavi and the Global Fund to Fight AIDS, Tuberculosis and compulsory licences for manufacturing patent-protected medications if that have saved millions of lives. According to Karoline is needed to safeguard public health. As UN experts have recently pointed out Lerche of the advocacy organisation ONE Campaign, they once more, this right becomes worthless if the governments of developing have succeeded by encouraging recipient countries to countries do not make use of it. take the lead and involving civil society. Page 27 Fighting infectious diseases is a complex challenge. Many different partners Needs-based humanitarian aid – ranging from patients and medical staff to scientific research institutes and international organisations – must Natural disasters, hostilities and other catastrophes tend play their part. The good news, how- Sabine Balk to cause a surge in infectious diseases. Shushan Tedla ever, is that the international commu- is a member of the editorial team of and Irmgard Buchkremer-Ratzmann of action medeor, nity has been making progress – and D+C/E+Z. a German aid organisation, spell out what must be further progress is possible if all parties [email protected] done. Page 30 cooperate well.

2 D+C e-Paper November 2016 D+C November 2016 In German in E+Z Tribune Entwicklung und Zusammenarbeit. Both language versions at www.DandC.eu

Monitor 4 Results of Habitat III / Providing companies from developing countries with a foothold on German markets / Postgraduate Programme at the German Development Institute / Global Hunger Index 2016 / Nowadays: Many South Sudanese people are forced to flee again and

again / Imprint / How democratic governments should deal with Oikocredit authoritarian regimes / GIZ-organised photo competition in Flexible and disciplined

Focus: Infectious diseases In Africa, self-organised savings groups are common. Edith Koesoemawiria They are called “tontines” in Cote d’Ivoire. They Indonesia is looking for a dengue vaccine 14 improve members’ livelihoods, serve social inclusion and promote community cohesion. The majority of Sheila Mysorekar members are women. According to development Neglected tropical diseases affect poor people in particular 16 consultant Eva-Maria Bruchhaus, tontines thrive on mutual solidarity. Page 38 Renata Buriti Zika virus has revealed gaps in Brazilian health care 19 “Mental attitudes matter”

Christian Wagner-Ahlfs When a city changes, so does the everyday life of its How to tackle dangerous antibiotic resistances 21 female inhabitants. Infrastructure, education and awareness raising matter. Civil-society activists Hilda Interview with Zafrullah Chowdhury Rayappan from Mangaluru, a south Indian port town, Awareness raising and capacity development are needed at demands that the needs of women and the poor grassroots level 24 must not be neglected in urban development. Page 36 Karoline Lerche Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria have saved millions of lives 27 Debate Shushan Tedla and Irmgard Buchkremer-Ratzmann Medical emergency kits are required in disaster settings 30

Lea Diehl Review essay: relevant reading on who benefits from medical research 33

Tribune Interview with Hilda Rayappan How urban change impacts women in a South Indian town 36 John Bompengo/picture- alliance/AP Photo Eva-Maria Bruchhaus Self-organised savings groups make a difference in Africa 38 Looming chaos

Armin Paasch In the past 10 years, the Democratic Republic of the EU trade policies should be based on concern for human rights 40 Congo has made some progress towards demo- cratic stability. Recent developments, however, look scary. President Kabila is clinging to power, and Debate 42 some 50 persons have been killed in riots. Whether Comments on the DRC’s volatile politics, appropriate support for elections will be held according to schedule in smallholder farmers, Indonesia’s traumatic post-colonial history and December is not obvious. Lawyer Jonathan Bashi ’s involvement in building Pakistani infrastructure assesses the situation. Page 42

D+C e-Paper November 2016 3 United Nations Mixed results

In Quito in October, the UN conference The NUA includes proposals concern- Ahead of Habitat III, debate thus Habitat III adopted the New Urban ing suggestions for the decentralisation revolved around implementation and Agenda. The document emphasises all of administrative bodies, jurisdictions, procedural aspirations. Nonetheless, the people’s social inclusion and calls spatial planning and budgeting. It pro- Quito Implementation Plan, the only for- for good urban governance. However, motes participatory decision-making that mal implementation structure of Habitat it fails to recognise fully just how involves the people at large. Moreover, III as of today, is somewhat disappointing. relevant urban agglomerations are local governments are considered to be for humankind’s future. important partners for implementing and monitoring the proposed measures. How- Implementation plan All 193 UN member countries have unani- ever, the agenda is not legally binding and mously adopted the New Urban Agenda does not include tangible indicators for In the context of this plan, governments, (NUA). Their delegates had agreed the assessing success. It therefore remains municipalities, civil-society organisa- final text weeks before the conference an open question how impact monitoring tions, private-sector companies, scientific started. While many municipal leaders will be conducted. institutes and other players were invited were among the 30,000 to submit tangible measures to imple- Monitor participants in Quito, The NUA is linked to the 17 Sustain- ment the NUA. By the end of the confer- only few national-level able Development Goals (SDGs) that were ence, a mere 64 commitments were made. leaders attended the con- adopted by the UN last year. SDG 11, for This number is tiny. By comparison, some ference. example, is to “make cities and human 11,000 projects were announced at the settlements inclusive, safe, resilient and climate conference in Paris in December An important aspect of the NUA is sustainable”. Other SDGs have local-level 2015. that it acknowledges that all inhabitants implications as well. of an agglomeration enjoy a “right to One of Quito’s few national-level the city” in the sense of being entitled to While the NUA is thus rooted in the initiatives was launched by ’s use its infrastructure, shape its character SDGs, it does not move this discourse for- Federal Ministry for Economic Coopera- and make themselves at home. In view ward. The NUA’s first section states that tion and Development (BMZ). It is called of growing inequalities, this right is very the efforts contribute to achieving the Transformative Urban Mobility Initiative important. SDGs, but it does not spell out the implica- (TUMI). The BMZ has been promoting tions. The entire document only mentions urban infrastructure and good municipal Urban areas are the hubs of economic the climate agreement that was struck in governance as focus issues for some time. growth around the world as well as key Paris last year twice. In cooperation with KfW Development destination areas of migrants. Cities are Bank, it will make € 1 billion available marked by great social and economic Ultimately, the NUA does not recognise for building and expanding sustainable disparities, and they are exposed to con- in full the huge relevance that cities have transport options in developing countries flicts over resources, income, goods and for global sustainable development. This and emerging markets as early as next services. The NUA explicitly spells out relevance has, for example, been elabo­ year. One thousand experts and managers the rights of refugees and migrants in this rated by the WBGU, the German Federal involved in urban mobility will be trained. context. One of its goals is to achieve syn- Government’s Advisory Council on Global Moreover, innovative pilot projects in ergies between international migration Change (see interview with Dirk Messner small and mid-sized towns will get sup- and development. in D+C/E+Z e-Paper 2016/10, p. 29). The port. NUA fails to spell out the urgency of avoid- The NUA argues that municipal ing destructive lock-ins and developing All in all, however, national govern- authorities’ capacity to act must be alternative models for the design, plan- ments only announced four initiatives in boosted at national and local levels ning and management of cities. Quito. Municipal authorities announced for them to become able to rise to the seven. The majority of proposals were challenges. Unfortunately, however, Habitat conferences are held every small. They were made by grassroots the document does not appropriately 20 years. The results of Habitat II in Istan- organisations that focus on maintaining deal with the international level. It nei- bul in 1996 included the Habitat Agenda green spaces, generating employment ther refers to the lack of serious roles and a Global Plan of Action. Their tan­ or promoting the social inclusion of the for urban and local governments in gible impact remained rather limited how- youth. UN policy-making, nor to the interna- ever. At best, Habitat II only had a minor tional conditionalities that often limit impact on the dramatic urbanisation the The Quito Implementation Plan - the scope of local policy-making. That world has been witnessing in recent years. egorises all initiatives according to topics is the case, for instance, when munici- Today, more than half of the world popula- such as housing and infrastructure, social pal budgets are slashed in the course of tion lives in urban settings, and the share cohesion and justice et cetera. It does not structural adjustment. will rise to two thirds by 2050. state, however, how the various commit-

4 D+C e-Paper November 2016 picture-alliance/dpa

Light show in Quito’s historical centre on the occasion of Habitat III.

ments are supposed to add up to a holistic pal leaders have showed in Habitat III increasingly understood to be the focal urban development strategy at a global inspires some optimism. They matter centres where sustainable development level. very much, and their relevance will keep must happen. Eva Dick growing. When Habitat II took place in Success will thus depend on the Istanbul 20 years ago, urban develop- Link action of national and municipal govern- ment was something of a niche topic in The New Urban Agenda: ments. The strong interest that munici- global development debate, but cities are https://habitat3.org/the-new-urban-agenda/

D+C e-Paper November 2016 5 Business support Sustainable export promotion

Exporters in developing countries GLOBAL G.A.P. certification. This certifica- their competitiveness. The IPD promotes and emerging markets often struggle tion confirms safe and sustainable produc- sustainable approaches to business and to get a foothold in the German and tion. The IPD helps companies to improve ensures developing countries become bet- European market. The Import Promo- their quality management which is an ter integrated into international trade. tion Desk offers support. important step for becoming certified. When product quality improves, com- modities are processed domestically, and Colombian highlands tea, Indonesian The IPD also lends support to German goods are exported directly without mid- coco-flower sugar, sustainable tropical importers that are looking for new prod- dlemen, new job opportunities and addi- wood from Peru, walnuts from Kyrgyzstan, ucts or suppliers. IPD organises sourcing tional income are generated. Moreover, and cut flowers from Ethiopia – Germany’s missions to find competent exporters, partner countries’ share in added value Import Promotion Desk (IPD) brings high- diligently assessing their product quality, increases. quality products from developing coun- production capacities, certifications and tries and emerging markets to the Euro- compliance with international standards. The IPD focuses on goods that are pean market. The IPD is an initiative of the The IPD also does comprehensive match- in demand in Europe such as exotic Federation of German Wholesale, Foreign making at trade fairs and buying missions. fruit and organic products, and strictly Trade and Services (BGA) in cooperation excludes basic foodstuff and consumer with the non-profit company sequa, share- With IPD support, private-sector com- goods that people in developing country holders of which include business associa- panies in partner countries can boost depend on. Frank Maul tions and the GIZ. The IPD is funded by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) and is currently supporting exporters in eight partner countries: Colombia, Egypt, Ethio- pia, Indonesia, Kyrgyzstan, Nepal, Peru and Tunisia.

IPD marketing experts help foreign partners to draft appropriate strategies. The IPD provides market surveys and sector-specific information. It runs work- shops and training seminars on export- related issues. Important aspects include reliable supply, consistent product quality, exact pricing and the transparent commu- nication of delays or bottlenecks. The IPD, moreover, organises study tours to Ger- many, so export managers from partner countries can gather first hand insights by visiting trade fairs and private-sector companies.

For many exporters from developing countries, the most important challenges are the insufficient knowledge of European import regulations and the lack of neces- sary certifications. To improve matters, the IPD hosts workshops and seminars on legal requirements and quality standards of timber products, for example. In the partner countries, the IPD cooperates with suppliers, business associations and export promoting agencies in order to raise aware- ness of market opportunities in the EU.

An important precondition for market- IPD ing fruits and vegetables to the EU is the Visiting a banana plantation in Peru during a sourcing mission.

6 D+C e-Paper November 2016 Post-grad studies Solving global problems

The UN 2030 Agenda of the Sus- a partner institute in the country where its for the research teams is to learn how tainable Development Goals (SDGs) field research will take place. The research to cooperate amongst eachother at per- defines huge challenges. Those who results must serve the interests of that sonal and professional levels so the field aspire to play a professional role in partner institute, for instance by providing research can become fruitful. rising to those challenges may bene- expert advice to German or other Euro- fit from the postgraduate programme pean policymakers – the very people the Applicants for the PGP must have (PGP) run by the German Development young professionals will work for after a master degree, for example in econom- Institute (GDI-DIE) in Bonn. graduation. ics, political science, global development studies, peace studies or related subjects. The PGP is based on academic knowledge The field research itself takes another Many students have shown an interest in and geared to providing policymakers with 10 to 11 weeks. Participants spend that issues of global justice and equity since expert advice. Applicants must be from an time at the partner institute as well as with their youth and spent time as volunteers EU member country and younger than 30. cooperation partners in other places of the or interns in countries of the global south They must also have an excellent grasp of country concerned. The teams conduct or nations transitioning from communist the German language. extended in-depth interviews and analyse rule. They must speak English fluently and the qualitative data thus generated. be able to converse in a second UN lan- All relevant kinds of professional work guage or Portuguese. are taken into account: ■■ leadership in a government department Personal growth By applying, postgrads indicate their (such as, for example, Germany’s Federal interest in working for development agen- Ministry for Economic Cooperation and To cooperate intensively in a small group cies and their willingness to work abroad. Development) or other state agencies; for an extended time requires good prepa- Employers appreciate that, so job oppor- ■■ management of projects (for example at ration and personal growth. Field research tunities are good after graduation, even the development bank KfW or the GIZ); is more challenging than internships for those without prior professional expe- as well as are. The team members, who have only rience in development affairs. Regine Mehl ■■ working for private-sector consultancies recently met, must cooperate on creating, such as GFA in Hamburg or GOPA in Bad improving and maintaining a framework Link Homburg. that allows them to achieve their goals. Training at the DIE: Accordingly, team-building seminars are http://www.die-gdi.de/en/training/postgraduate-training- All of these institutions need experts that part of the PGP. One of the major tasks programme/ are willing to think outside the box, tackle questions from other academic disciplines than their own and rise to complex man- agement challenges in multi-cultural set- tings.

Learning – debating – problem solving

The curriculum’s first phase lasts nine weeks, during which DIE scholars convey fundamental theory insights on the basis of empirical case studies. Debates with experienced policymakers and top-level civil servants complement these lessons, emphasising issues of practical relevance. This phase ends with a three-day simula- tion of intergovernmental talks, with staff from BMZ, GIZ and KfW serving as experts.

During the second phase, which lasts 11 to 12 weeks, the 18 students form three

research groups and prepare for empirical picture-alliance/obs research. Each group is guided by a DIE To be an aid worker takes intercultural competence as well as expertise: German development professional scholar and must cooperate closely with in Ghana.

D+C e-Paper November 2016 7 Food security Better figures

According to the data published in To judge by GHI numbers, Chad and 13 countries, including Burundi, the Dem- this year’s Global Hunger Index, the Central African Republic (CAR) are ocratic Republic of the Congo, and things have improved – but 795 mil- currently the two countries that hun- Eritrea. Dieckmann points out that these lion people still suffer hunger. The ger affects most. Many people have fled very countries are actually “the main chal- reasons include war, environmental to Chad from Sudan, and the CAR was lenge” since undernutrition and the other change and disease. Children are recently rocked by civil strife. GHI indicators are probably especially pro- affected in particular. nounced there. In the case of Eritrea, the The statistics also indicate that Namibia last time a GHI could be calculated was The Washington-based International Food and Sri Lanka have problems. These are the 2014. Back then, it turned out to be the Policy Research Institute (IFPRI) has com- two countries for which the GHI shows the world’s second worst GHI. piled the annual Global Hunger Index least progress since 2000. The IFPRI schol- (GHI) for the 11th time. Its calculations are ars report that Namibia has been exposed Ursula Hudson, a slow-food activist, based on four indicators that reflect peo- to draughts, floods and usual un­ patterns says that consumers in rich countries ple’s nutritional situation: undernutrition, of rainfall, so grain production and animal some responsibility for global food secu- child wasting (too little weight in rela- keeping have been hurt. In Sri Lanka dis- rity. Consumption patterns must change tion to body size), child stunting (reduced eases are currently preventing progress, in rich nations, she demands. Meat pro- growth) and child mortality. The current according to the GHI report. duction is a problem, for instance, because index for all developing countries and it requires grains that could also serve as emerging markets is 21,3. In 2000, it was Lack of data limits precision, more­ human food. Moreover, Hudson wants 30. Accordingly, the experts reckon that over. The IFPRI team admits that it more attention to be paid to rural workers’ hunger has been reduced by 29 %. IFPRI could not compile an up-to-date GHI for fair remuneration. Lea Diehl publishes the GHI every year in coopera- tion with two civil-society organisations: Concern Worldwide from and Welthungerhilfe from Germany.

At first glance, the new data look good. In 22 countries, the index has been halved – for example in Rwanda, Cambodia and Myanmar. Nonetheless, 795 million peo- ple around the world are still estimated to suffer hunger. Bärbel Dieckmann, the president of Welthungerhilfe, considers this number unacceptable, especially as children are most affected. According to the IFPRI scholars, the situation is „seri- ous“ or even „alarming“ in 50 of the 118 countries that they have assessed.

Dieckmann finds setbacks particu- larly frustrating, as she stated at a pub- lic event hosted by Welthungehilfe and KfW in Berlin in October. She said that the earthquake in 2010 had undone the progress that Haiti had made up to then. After Hurricane Matthew struck recently, her organisation­ pointed out that the likelihood of cholera had grown in Haiti because the storm had damaged water and sanitation infrastructure.

Violent conflict is another reason of need. When people flee from war, for example, food security is reduced in poor neighbouring countries, according to International Food Policy Research Institute, Concern Worldwide and Welthungerhilfe: Dieckmann. Global Hunger Index 2016. http://www.ifpri.org/publication/2016-global-hunger-index-getting-zero-hunger

8 D+C e-Paper November 2016 Nowadays: Displaced yet again

In July, Simon Wani fled the Depressingly, a struggle for leader- South Sudanese capital Juba and ship between President Salva Kiir headed for neighbouring and his deputy Riek Machar Uganda with his family. He thus turned ugly. In December 2013, became a refugee for the second fighting erupted in Juba. President South Sudan time in two years. Indeed, being Kiir accused Machar and several Juba a refugee is a recurrent feature senior members of the SPLM of in his life: Wani first sought shel- attempting a military coup. In ter in Uganda in 1993 as a teen- response, Machar organised what ager, during the independence he called “resistance”. Since then, war that the SPLM (Sudan’s Peo- violence has kept flaring. ple Liberation Movement) waged against Sudan. In December 2013, Wani sur- crossed the Ugandan border this second time. The first time was vived an attack on the com- summer after renewed violence in 1991, when she was still That war began in 1983, and it pound where he lived in Juba. in Juba. More than 300 soldiers a child. Back then the reason had only ended with the signing of Soon after, he took his young and civilians died in four days of been clashes of South Sudanese a comprehensive peace agree- family to Uganda. “I’m a serial street battles. A few weeks ear- rebels with Sudan’s armed ment (CPA) in 2005. Six years asylum seeker,” he says, sup- lier, a Transitional Government forces. later, South Sudan’s people porting his head with his hand. of National Unity (TGONU) had voted for independence from “Right now, I am a refugee for been formed, but it failed, and Wani’s and Poni’s fates are not Sudan in a referendum. The the third time in my life.” Machar, the former vice presi- unusual. Particularly in northern country became the world’s dent, fled the country. Uganda, many people have youngest sovereign state in Wani is one of hundreds of thou- crossed the border repeatedly, 2011. sands of South Sudanese who When fighting ended in Juba, it fleeing when fighting broke out spread to rural areas, forcing and returning to South Sudan thousands of civilians to flee. when the situation calmed According to UN figures, the down, only to flee again when In our column “Nowadays”, number of refugees from South armed conflict resumed. In such D+C/E+Z correspondents Sudan passed the 1 million mark circumstances, it is nearly write about daily life in in September. impossible to build a stable work developing countries. and family life. Mary Poni, a mother of four, says her husband was killed by armed Ayen Deng fled with three chil- men: “I don’t know who they dren across the border. “My Philip Thon Aleu were, but they killed my hus- youngest son is demanding to is a journalist and lives in Juba, South Sudan. band for refusing to join them.” return to Juba,” she recounts. Poni left her village for Uganda “But without assurance that the [email protected] in August. She has come to peace is holding, we cannot risk Uganda as a refugee for the to go back.”

Imprint

D+C Development and Cooperation and academia at an international level. Executive director: Translators: two voucher copies are sent to the editor Vol. 43, 2016 D+C is the identical twin of E+Z Oliver Rohloff M. Bell, C. Davis unless copyright is explicitly indicated. D+C is published together with Entwicklung und Zusammenarbeit, This does not apply to the photographs the German edition E+Z the German edition. Address of the publisher Disclaimer according to § 5,2 Hessian published in D+C Development and Coop- Internet: http://www.DandC.eu and editorial office: Law on the Freedom and Rights of the eration and E+Z Entwick­lung und Zusam­ ISSN 2366-7257 ENGAGEMENT GLOBAL gGmbH Frankenallee 71-81 Press: The shareholder of the company men­arbeit. The editors request that no Service für Entwicklungsinitiativen D-60327 Frankfurt am Main, Germany is Frankfurter Societät GmbH. unso­licitated manuscripts be sent. How­ Published on assignment from: Tulpenfeld 7 ever, they do welcome proposals along 53113 Bonn This is also the legally relevant address Advertising and subscription service: with abstracts that serve to outline Tel. (02 28) 2 07 17-0, of all indicated as responsible or entitled Klaus Hofmann (responsible) submissions. Fax (02 28) 2 07 17-150 to represent them in this imprint. Phone: +49 (0) 69 75 01-48 27 D+C Development and Cooperation is http://www.engagement-global.de Fax: +49 (0) 69 75 01-45 02 Prices for print edition (incl. mailing charges): funded by Germany’s Federal Ministry Editorial team: [email protected] single issue: € 2.20 for Economic Cooperation and Advisory board: Dr. Hans Dembowski (chief), Sabine Balk, annual subscription, Germany: € 14.00 Development and commissioned by Thomas Loster, Prof. Dr. Katharina Katja Dombrowski, Sheila Mysorekar, Opinions expressed by authors indicated annual subscription, world: € 18.00 ENGAGEMENT GLOBAL. D+C does not ­Michaelowa, Prof. Dr. Dirk Messner, Eva-Maria Verfürth, Dagmar (assistant) in bylines do not necessarily reflect the serve as a governmental mouthpiece. Petra Pinzler, Hugh Williamson Phone: +49 (0) 69 75 01-43 66 views of ENGAGEMENT GLOBAL, the Printing: Our mission is to provide a credible Fax: +49 (0) 69 75 01-48 55 publisher or the editor and his team. Westdeutsche Verlags- und Druckerei GmbH forum of debate, involving govern- Publisher: [email protected] Individual articles may be reprinted Kurhessenstraße 4–6 ments, civil society, the private sector Frankfurter Societäts-Medien GmbH Graphic design/Layout: Jan W. Hofmann provided the source is mentioned and 64546 Mörfelden-Walldorf, Germany

D+C e-Paper November 2016 9 International cooperation Dealing with authoritarian governments

International cooperation requires endorse participatory decision-making at sponsor formally independent organisa- sensitivity, and democratic change all levels. tions with radical leanings. The scholars takes time. Universal standards can want development agencies to pay atten- be helpful, even though application To what extent those standards are met tion to these matters. may be difficult. in practice is a different question. It is impor- tant to take into account local settings and The governance standards of the SDGs Autocratic governments are quite diverse. historical backgrounds. Ghanaian scholar are loosely defined so there is ample scope Some rely on ideology, others on reli- Emmanuel Gyimah-Boadi emphasises that for interpretation. However, ambiguous- gious faith or ethnic identity. Some are autocratic rule was the norm in Africa for ness is not necessarily bad, as Leiniger organised like monarchies and rooted in a long time, and that despotic leaders can and her GDI/DIE-colleague Kai Striebin- tradition, while others manage to stay in be reformers. Rwanda is an example, where ger argue in a recently published column. power thanks to economic success. Many economic progress is considered as evi- Ambiguousness is helpful to reconcile authoritarian rulers resort to repression, dence of a regime’s success. diverging democratic traditions, from limit civic liberties and restrict the scope municipal self-government to referendums. for popular participation in public affairs. The panelists agreed that dealing with autocratic governments requires a lot of Despotic regimes are a huge challenge sensitivity, beginning with the choice of Global challenge for donor governments, as became evident words: it is often unwise to point out that during a panel discussion, which focused a government is “autocratic”. Unlike the previous Millennium Develop- on the Sustainable Development Goals ment Goals (MDGs), the SDGs apply to all (SDGs) and was held at the German Devel- Scholars argue that international part- nations rather than only to developing opment Institute (GDI/DIE) in Septem- ners are well advised to engage in dialogue countries. Democratic culture, moreover, ber. Die SDG agenda itself can be read as with civil-society organisations in the has recently become a hot topic in Europe a response to autocratic rule, according to countries concerned. They warn, however, and North America. Governmental repres- GDI/DIE scholar Julia Leininger. The SDGs that fanatics and populists can also form sion and populist parties are the reason. can serve as yardsticks for assessing politi- independent organisations. For example, Recent developments in Turkey, for exam- cal processes internationally. For instance, this is currently the case in Tunisia, where ple, are worrisome. they promote the establishment of effec- autocratic rule has given way to a fragile tive and accountable institutions that are democracy after the Arab spring revolu- All too often, democratic governments geared to social inclusion. Moreover, they tion of 2011. Sometimes, governments support autocratic ones. For example, the USA is cooperating with authoritarian rul- ers in the Middle East. Robtel Neajai Pai- ley, a Liberian migration expert at Oxford University, demands that democracy- preaching leaders of high-income coun- tries must pay careful attention to whom they are supporting.

According to Pailey, political and busi- ness networks are complex. Transnational links matter, and so do diaspora commu- nities. She says one result of migration is that a country’s citizens do not all live within its borders. Policymaking should take that into account. Lea Diehl

Reference Striebinger, K., and Leininger, J., 2016: Umgang mit Autokratien: Helfen die globalen Nachhaltigkeitsziele? Aktuelle Kolumne vom 19.9.2016. Bonn: Deutsches Institut für Entwicklungspolitik (in German).

Nasri/picture alliance/AA https://www.die-gdi.de/uploads/media/Deutsches_Institut_ Protests in Tunisia in September 2016. fuer_Entwicklungspolitik_Striebinger_Leiniger_19.09.2016.pdf

10 D+C e-Paper November 2016 Civil Peace Service Dreams of a better life

Documenting one’s vision of a live- media professional. He says, he wants to ■■ a website for essays, documentations, able Lebanon: that was the objective create a “perspective of hope in regard to videos and debates and of a photo competition which was run everyday worries”, and his pictures reflect ■■ workshops that allow participants to by the GIZ’s Civil Peace Service (CPS). that intention. He took part in the photo share ideas and express visions crea- Sixty-five young photographers took competition to share his approach with tively. part. They illustrated the young gen- the local community. The competition was eration’s dreams in a country devas- organised by civil-society organisations in Ahead of the competition, the partner tated by civil war. cooperation with the CPS in the context of organisation defined four topics. The par- the Hayda Lubnan project. ticipants were thus asked to create pho- A Muslim family is sitting on the beach tos to show “good citizenship” or “human of Saida, a town south of Beirut, at dusk. Life in Lebanon is marked by the con- values”, for instance. A jury chose the best The old port is seen in the background. cerns of the here and now. Insecurity and pictures. Children are playing in the sand, and the the sense of distrust between religious family’s big umbrella is colourful. “The communities are the legacy of the civil war The dreams of Mohammad, Ali and the multitude of things reflects the multitude – and they make it hard to move ahead. other participants are now meant to serve of our human souls,” comments Moham- The Hayda Lubnan project is creating as a foundation for moving on towards mad Bassyouni, who is 25 years old and spaces in cooperation with local organi- a shared vision by providing a model of works as a graphic designer. The young sations for expressing ideas and sharing dialogue and community. This is needed in man from Saida is the winner of the Photo them with others. Topics include a more a country that has lost to consider the future Competition and his aspiration is to show promising future, a better society and in confidence because of a violent past and the “magic” that is driving the young gen- a healthy natural environment. a currently fraying political order. (giz) eration. Hayda Lubnan provides three plat- Link The jury similarly appreciates the forms for this kind of exchange: GIZ / Civil Peace Service in Lebanon: work of Ali Arkadhan, a 28 year-old social ■■ the photo competition, https://www.facebook.com/gizZFDlebanon/

Some of the best photos of the CPS-competition. GIZ/ Mohammad Bassyouni/ Ali Arkadhan

D+C e-Paper November 2016 11 Infectious diseases

Illnesses condemn people to poverty, hampering development. Health-care systems tend to be overburdened in developing countries. Compounding the problems, some diseases that haunt these countries hardly affect rich nations and have so far been neglected by the pharmaceutical industry. More research will help – and more research is also needed to stem the dangerous trend of bacteria becoming resist- ant to antibiotics. In the past decade, new international institutions have made a difference. To improve health care in poor countries, however, it is necessary to raise awareness among the people in general and build capacities at all levels. The humanitarian need is obviously greatest in war or when natural disasters strike. A doctorseesapatientinBangladesh.

Ron Giling/Lineair At least 900 dead in 2015

This year, the rainy season lasted longer than it normally does in Indonesia, allow- ing mosquitos to thrive. As a consequence, the risk of dengue infections was higher than it normally is. A vaccine would be welcome – but is not available so far. Indo- nesia’s Ministry of Health wants to change matters in cooperation with a pharma Indonesia company.

Jakarta By Edith Koesoemawiria

Mosquitos haunt the alleys and streets of Jakarta’s apartment blocks that are the homes of the better off. crowded informal neighbourhoods, where poor The more it rains, the worse the problem becomes. Mos- people live, as well as the normally sterile high-rise quitos are not only irritating, some are really dangerous.

Dengue research is advancing, including in The global threat of dengue Indonesia. The World Health ous complications – especially hemor- Organization (WHO) rhagic fever – rises with further dengue estimates that 390 infections. million people in more than 120 coun- Dengue mostly affects tropical regions tries were infected and is especially common in Southeast with dengue in 2014. Asia, South Asia, Central America and the Moreover, it argues Caribbean. Some African countries are at that dengue is risk too. becoming a and is already threatening half of the world population. The most common vector is Aedes aegypti, the mosquito that also transmits

Dengue is also called “break bone fever” yellow fever, zika and other diseases. Adhyasta Harimurti/picture alliance/dpa because of severe joint, muscle and back However, Aedes albopictus is also a den- pain. It can be deadly, not only for children gue vector, and this mosquito kind is com- governments should carefully assess and the weak. Symptoms include nausea mon in more moderate climates. As other whether its use makes sense in their coun- and vomiting, high fever, severe head- mosquitos can probably transmit the virus tries, according to the WHO, which aches, weakness and pain behind the too, dengue may spread in regions where recently published a position paper on the eyes. Improvement appears temporarily it is not prevalent so far. matter. Other vaccines are being devel- two to four days later, before high fever oped. Research is advancing, including in returns accompanied by dropping blood Global travel is increasing the risks Indonesia (see main article). pressure and heart rates. Recovery can because infected persons move around take up to four weeks even with medical the world. In some regions, where dengue To facilitate the development of dengue attention. The incubation time is up to 14 is uncommon, hospitals with special tropi- vaccines, the WHO makes several recom- days. cal medical sections put patients in quar- mendations, including the monitoring of antine to prevent local mosquitos from mosquito populations and dengue out- Four different virus strains (DENV-1 to biting them and thus spreading the virus. breaks and the identification of knowl- DENV-4) cause dengue. People who have edge gaps and research needs. suffered from one strain become immune Sanofi Pasteur, the French pharma multi- to that strain, but that immunity does not national, registered the first ever dengue Link protect them from the three other strains. vaccine in Mexico in 2015. The vaccine is WHO, 2016: Dengue vaccine position paper. Compounding matters, the risk of danger- called Dengvaxia (CYD-TDV). However, http://www.who.int/wer/2016/wer9130.pdf?ua=1

14 D+C e-Paper November 2016 Dengue is a flu-like, but severe illness with poten- tially lethal complications (see box p. 14). Mosquitos transmit it. This year, infections were reported in nearly all of Indonesia’s major cities. According to the Jakarta Post, some 100,000 cases were counted in the country last year, and the disease killed some 900 people.

There must have been many unreported cases however. Poor people often do not see a professional doctor, so they never get a scientific medical diagno- sis. Moreover, the health-care infrastructure is much poorer in villages, where dengue is prevalent too.

There is no specific treatment for the illness, though traditional medicine relies on plants and fruits like guava to help patients recover. The disease can be deadly, but most patients get well again after severe suffering.

The main way of preventing dengue is to reduce mosquitos’ breeding grounds. Obviously, doing so also reduces the risk of other mosquito-borne ill- nesses, including malaria, for example.

Mosquitos need only three millimetres of stag- nant water to lay eggs. In urban areas, water standing in puddles, car tracks or even empty tin cans can be Pesticides should only the problem. In rural areas, mosquitos breed in rice be used sparingly, but paddies, swamps, stagnant ponds and slow moving application can make streams, for example. sense where the dengue risk is evident: To limit mosquito populations, one should: government-sponsored fogging in Aceh ■■ clear the neighbourhood of ponds and water holes, Reza/picture-alliance/NurPhoto Fachrul Province in February. ■■ cover all water containers and remove objects that can trap rain water, ing the use of pesticides in infection-prone areas. It ■■ regularly drain and fill swimming and ornamental is following the proposals made by the World Health pools, keeping the water flowing, Organization on these matters. ■■ keep larvae-eating fish in rice paddies or ponds that cannot be drained, Unfortunately, Indonesia cannot benefit from the ■■ install mosquito screens on doors and windows, first dengue vaccine which was registered in Mexico in ■■ use mosquito nets over beds, and 2015. According to the Ministry of Health, the vaccine ■■ change water in vases and flowerpots at least once does not serve the nation’s health needs because it a week. does not prevent infection with the virus strains that are common in the country. The government is coop- Methods of personal protection, moreover, include the erating with Bio Farma, an Indonesian pharmaceuti- use of mosquito repellents and wearing clothes to limit cals company on developing a vaccine against the two skin exposure to mosquitos. Insecticides should only locally prevalent virus strains (DENV-3 and DENV-4). Edith be used sparingly because they have unwanted side Koesoemawiria effects both in terms of human health and the environ- According to media reports, Bio Farma has suc- is a freelance journalist. ment. If a specific mosquito-related health risk is evi- ceeded in isolating DENV-3, but will need at least [email protected] dent, however, it may make sense to use insecticides. three years before a safe vaccine for DENV-3 can be produced. People would still be exposed to DENV-4 Some people propose exterminating mosquitos, however. but that approach would be environmentally irre- sponsible. Mosquitos are important components of The Indonesian Health Ministry is expressing opti- eco systems. mism nonetheless. It hopes human testing can be car- ried out soon and sees an opportunity for providing an affordable solution of other Asian countries, which Vaccine hopes are plagued by the same dengue strains as Indonesia. Bio Farma has a strong track record. It has developed Indonesia is striving to get a grip on dengue. The gov- an anti- vaccine which it now markets through- ernment is promoting preventive measures, includ- out the ten ASEAN member countries.

D+C e-Paper November 2016 15 Diseases of the poor

Neglected tropical diseases (NTDs) hardly affect advanced economies with great purchasing power, so pharmaceutical companies and academic research do not pay them much attention. In Africa, Asia and Latin America, one in seven people suffer from an NTD. Not all NTDs kill infected patients fast. Some do so slowly or disable people long term.

By Sheila Mysorekar

Some 8 million people are estimated to be year”. According to the international organisation, infected with Chagas, and most of them live in they mainly affect people living “in poverty, without Latin America. About 25 % of Latin Americans are at adequate sanitation and in close contact with infec- risk of suffering from this NTD in their lifetime. tious vectors and domestic animals and ”. Animal health, veterinary medicine and safe water Chagas is caused by a parasite which is transmit- matter very much in terms of fighting NTDs. ted by a blood-sucking bug. The acute symptoms of a fresh infection are fever and sore eyes. A period As the WHO points out, NTDs diminish the quality of dormancy of about 10 to 20 years follows. When of life and productivity of the affected persons, even the disease finally breaks out, it affects the heart and if the patients don’t die. Moreover, the symptoms of other organs. these diseases are often unclear, which makes a self- diagnosis of the affected persons difficult, so they are Once the disease has reached this stage, no ther- unlikely to seek professional help. Typically, these dis- apy is effective anymore. Those patients who do not eases are transmitted or caused by worms or , die remain unable to work for the rest of their lives. so it would be helpful to improve hygienic conditions. Therapies would be available earlier, but the problem The WHO has prioritised the fight against 17 NTDs is that most infected people do not know that they (also note review essay by Lea Diehl on p. 33). have contracted Chagas. There are towns like Tarija in Bolivia, where 40 % of the people are infected. The quest for new Most Chagas-infected people live in Brazil and pharmaceuticals Argentina, but not everybody there is equally likely to contract Chagas. “It is a disease of the poor,” says Ade- “Neglected diseases continue to cause significant lina Riarte of the National Institute for Parasitology in morbidity and mortality in the developing world,” Buenos Aires. “A well-fed person who lives in a proper argues the Drugs for Neglected Diseases Initiative house with plastered walls and roofs, where the bugs (DNDi), a civil-society organisation based in Switzer- can’t breed, is unlikely to get the disease. The land. NTDs account for 11 % of the global disease bur- thrives in huts with thatched roofs and mud walls.” den, according to the DNDi, but only four percent of the 850 new therapeutic products approved between 2000 and 2011 were indicated for neglected diseases. The WHO perspective The DNDi is a non-profit organisation that does What Chagas has in common with other neglected research and development (R&D) according to tropical diseases is that the patients lack purchasing patients’ needs, emphasising collaboration. It aims to power. Accordingly, pharmaceutical companies do develop new medicines for NTDs. It has seven regional not take interest in developing vaccines and cures. offices in Asia, Africa and Latin America. Germany’s They focus on the health problems that afflict more Federal Government is among the donors. prosperous societies where affordability is not an issue because most people are covered by private or In 2012, the WHO published the Declara- government-run health insurances. tion on Neglected Tropical Diseases. In this context, several parties made important commitments. They The World Health Organization (WHO) defines included pharmaceutical multinationals like Pfizer NTDs as “a diverse group of communicable diseases and Novartis, charitable institutions like the Bill & that prevail in tropical and subtropical conditions in Melinda Gates Foundation, international organisa- 149 countries and affect more than one billion people, tions like the World Bank and civil-society initiatives costing developing economies billions of dollars every like the DNDi. By 2020, they promised:

16 D+C e-Paper November 2016 Life-saving rubber boots

In Thailand, farmers typically stand bare- disease is severely underreported in the 45 demic institution does specialise in it as foot in flooded fields, planting rice sap- countries in which it is known to be well as other NTDs however: the Mahidol lings. Most of them do not realise that endemic. Moreover, the report showed that Oxford Tropical Medicine Research Unit they are in danger of contracting a deadly melioidosis is likely to be endemic in a fur- (MORU), which is run by Bangkok’s disease. Thailand’s third most-deadly ther 34 countries where the disease has not Mahidol University in cooperation with infectious disease is called melioidosis. It been officially reported. Yet it kills around Oxford University in Britain. kills 40 % of the infected persons, but only 90,000 people each year. So far, melioidosis few have ever heard of it. is not one of the NTDs that the World Direk Limmathurotsakul heads the micro- Health Organization (WHO) prioritises. biology department at the Mahidol Faculty Mostly found in the country’s north-east, of Tropical Medicine. There is no vaccine, melioidosis is caused by Burkholderia There is a cure for melioidosis, but it is he says, but insists that people can protect pseudomallei, bacteria that live in soil and only applied if the disease is properly diag- themselves from melioidosis “simply by water in the world’s tropical regions. One nosed. To administer medication, doctors boiling water before drinking it and wear- can get infected by drinking water or need to identify the infection fast. The sad ing rubber boots when they work in the standing in water. The symptoms are high truth, however, is that the poor patients fields”. In his eyes, “awareness campaigns” fever and indistinct pains, which make who suffer from this disease tend to be are needed – and urgently so. melioidosis difficult to identify. The dis- just as neglected as the disease itself. ease is often not diagnosed correctly, and More must certainly happen. One problem many infected people die within 24 hours. Though melioidosis is the third most dan- is that boiling water is actually not that sim- gerous disease in Thailand, it does not get ple for poor, hard-working people in rural In January 2016, the science journal Nature much attention. After all, it mostly affects areas. It requires fire- published a report on melioidosis. It poor rural workers and people who lack wood, a resource that included global data and stated that this access to clean drinking water. One aca- tends to be scarce.

Wearing boots can be a matter of live and death: Thai farmer. Bleyer/Lineair

D+C e-Paper November 2016 17 Examining river blindness vectors in the context of a WHO programme in Côte d’Ivoire. Mark Edwards/Lineair

■■ to eradicate (reduce to zero the prevalence in the The WHO currently expects to eradicate Guinea host population) Guinea worm disease, worm disease and blinding by 2020. ■■ to eliminate (reduce global prevalence to minimal Regarding some diseases, for instance , some amount) , leprosy (see essay on countries are ahead of the WHO ambitions. In 2013, awareness rasing and treatment in Uganda in D+C/ Bangladesh had managed to reduce the incidence E+Z e-Paper 2016/08 p. 26 / print edition 2016/09- of human rabies being deathly by 50 %, for exam- 10, p. 15), sleeping sickness and blinding trachoma ple, through a combination of mass and and increased availability of vaccines free of charge. ■■ to control schistosomiasis, soil-transmitted hel- In May 2016, the World Health Assembly recognised minthes, Chagas, visceral leishmaniasis and river that there are “still many tropical, poverty-related blindness (). diseases or conditions that remain neglected and for Sheila Mysorekar which advocacy, awareness and research are required is a member of D+C/E+Z’s In order to achieve these goals, the parties pledged: to develop better diagnostic methods, treatments and editorial team. control strategies.” Two such NTDs, which are not on [email protected] ■■ to promote R&D for next-generation drugs, the WHO’s priority list, are melioidosis (see page 17), ■■ to provide tropical countries with adequate funding zika (see page 19) and ebola (see D+C/E+Z e-Paper for implementing NTD programmes, and 2016/08, p. 23). ■■ to enhance collaboration and coordination on NTDs at national and international levels. Links Drugs for Neglected Diseases Initiative: Internationally, there are success stories. In October http://www.dndi.org/ 2015, Mexico became the third country, along with World Health Organization (WHO): Neglected Tropical Diseases. Colombia and Ecuador, to be declared free of river http://www.who.int/neglected_diseases/diseases/en/ blindness by the WHO. This success is proof that WHO: London Declaration on Neglected Tropical Diseases. international collaboration is working. However, 120 http://www.who.int/neglected_diseases/London_Declaration_NTDs.pdf?ua=1 million people worldwide are still at risk of contract- Uniting to Combat Neglected Tropical Diseases (4th Report): ing this disease. http://unitingtocombatntds.org/report/fourth-report-reaching-unreached

18 D+C e-Paper November 2016 Virus shines light on structural problems

Brazil has declared war on the zika virus (ZIKV). There already has been some success: the number of new infections has been falling since the middle of the year. But in order to address the disease’s serious impact and prevent future epidemics, health care needs fundamental reforms. Public health services and basic sanitation must improve in particular.

By Renata Buriti

Brazil has the most cases of ZIKV in Latin emergency. According to estimates, over 1.5 million Ameri­ca. The impacts of the virus have been so people have been infected with ZIKV in Brazil. The bad that the government declared a national state of Ministry of Health has reported that at least

Brazilian baby with microcephaly. Fabres/picture-alliance/dpa

D+C e-Paper November 2016 19 205 babies have been born with ZIKV-related micro- ment. Many mothers of new-born are required to cephaly, more than twice as many as usual. The inci- travel hours to the nearest hospital and, once there, dence of Guillain-Barré syndrome, a nervous system wait hours more for their babies to be seen. That’s disorder, has also increased by 19 % since the out- after waiting months to get an appointment at all. break of the virus. Hardest hit by are Brazil’s poorer ZIKV has plainly overwhelmed the public health regions in the north and north-east, and in those services, which had already been underfunded for regions, poor and disadvantaged families have been years. Inadequate infrastructure, a lack of staff, drug disproportionately affected. shortages and underpaid doctors: Brazil had been struggling with these problems before the outbreak, Just two months after the microcephaly outbreak and they have not suddenly disappeared. The conse- in October 2015, the Brazilian government published quences have been especially serious for the children a national plan to tackle the crisis on three main and families affected by microcephaly. Depending on brazil fronts: fighting mosquitoes, providing care to affected the severity of the case, a child may need treatment families and devoting resources to technological from multiple specialists. development, education and research. To fight ZIKV this year, the government pledged 500 million reais The full impact of the epidemic will only become Brasilia (€ 141 million), and the largest share was earmarked clear over time. Until last year’s large-scale out- for the national health fund which finances the break, little international attention was paid to the national health service (SUS). virus. That was so even though studies showed that the previous zika outbreaks in French Polynesia also In order to fight the virus, the government coincided with a rise in cases of microcephaly and focused first and foremost on eliminating the Aedes Guillain-Barré syndrome. It isn’t yet known why ZIKV aegypti mosquito species, which spreads the virus. spread the way it did in Brazil and why there were It deployed over 200,000 soldiers in the hardest-hit such major regional differences. regions. Their job was to distribute informational bulletins, destroy mosquito-breeding grounds and kill mosquitoes and their larvae with insecticides. Infrastructure At least 400,000 pregnant women were given mos- quito repellent. Moreover, the government conducted The most important issues that have a bearing on awareness-raising in schools and in the media across how viral infections spread are the local ecology, the nation. population immunity and plain chance. Genetic factors, nutrition and environmental pollution also Reports of ZIKV cases have indeed fallen. In June play a role, according to scientists. A region’s level the number was 80 % lower than in the months of development matters too. It is no coincidence February to May. Brazilian health officials say the that Brazil’s least-developed areas were hardest hit decline results from the “national mobilisation” by ZIKV. Poor water supply and inadequate sanita- against mosquitoes. Some experts think that the tion contribute to the virus spreading. According epidemic will soon have run its course in Brazil, to the UN, improving relevant infrastructure is the since people who have been infected once become most effective way to prevent future ZIKV epidem- immune to the virus. Others believe that the drop in ics. cases is linked to the beginning of the cold season. They argue that there will be more infections start- Almost 40 % of Brazilians have no access to a pub- ing in spring, though there may ultimately be fewer lic water supply or clean drinking water. Improvised than this year. cisterns are ideal breeding grounds for mosquitoes. Infrastructure is particularly weak in the north-east- ern parts of the country. Dengue has the highest inci- Renata Buriti Impact dence there too. Eighty percent of people there have is a postgraduate researcher at already had that disease, which is also transmitted by the Technical University of In Brazil, the consequences of zika have been dra- Aedes aegypti. Cologne and specialises in matic. The skull deformities caused by microcephaly water resource management. tend to harm babies’ intellectual and physical devel- Another problem is that some areas lack sewage [email protected] opment. They will require constant care for the rest of disposal. According to the latest data from Brazil’s their lives, which places an enormous emotional and National Sanitary Surveillance Agency, wastewater financial strain on many families. In Pernambuco, was being collected for only 48 % of households in the state in north-eastern Brazil that had the high- 2013, and only 39 % of that waste was being treated. est number of cases, 77 % of affected families live in Researchers in Brazil have discovered that Aedes extreme poverty. Many families face a significant loss aegypti can also breed in dirty water, which further of income because one parent will probably have to increases the risk that mosquito-borne illnesses will stay home and take care of the child full-time. spread. The CNI, the national confederation of indus- tries, has estimated that the country will not be able It has proved difficult to obtain the medical treat- to provide comprehensive sanitation until the year ment and financial support promised by the govern- 2054.

20 D+C e-Paper November 2016 The problem of antibiotic resistance

Antibiotics have been a real blessing for humanity. Since their discovery in the 1920s, they have been used to treat infections that once caused great suffering and many deaths. The situation is changing dramatically, however, as more and more bacteria are becoming resistant to an increasing number of antibiotic agents. Tens of thousands of people are dying every year due to multi-resistant microbes. Not only industrialised countries are affected.

By Christian Wagner-Ahlfs

The causes of the spread of antibiotic resistance just sound good on paper without leading to real are very complex and thus require equally com- change? plex countermeasures. The World Health Organiza- tion (WHO) published an action plan on antimicrobial Experts from a variety of disciplines discussed resistance in 2016. The European Commission devel- these questions at a conference co-hosted by BUKO oped a strategy of its own in 2011, and Germany’s fed- Pharma-Kampagne, a German non-governmental eral government has concentrated its efforts in a pro- network, and Bielefeld University. The guiding prin- gramme called DART 2020 (Deutsche ciple was the concept of rational drug use. It means Antibiotika-Resistenzstrategie – German strategy on that antibiotics should only be used if they are really A blessing and a curse: antibiotics resistance). Do these plans adequately necessary and that they should be used properly. antibiotics cure serious address the complexity of the problem? Or do they Accordingly, change is needed in five general areas: diseases, but resistances eventually develop, rendering the drugs useless. Deloche/GODONG/Lineair

D+C e-Paper November 2016 21 doctor-patient relation, hospital care, livestock farm- only by doctors with additional expertise in infectiol- ing, international cooperation and research and ogy. Though it may be difficult to make such a system development. a legal requirement, it would still promote exchange among doctors.

Doctor-patient relation Livestock farming Antibiotics are being misused on a massive scale worldwide. Doctors frequently prescribe them when Farm animals are given antibiotics on a massive scale. it is not necessary and even when it does not make It is against the law to use antibiotics as a fattening sense. Colds and flu are caused by viruses and cannot aid in the EU, but doing so is still common around be treated with antibiotics, but doctors continue to the world. Moreover, enforcement could be better in prescribe them. Moreover, broad-spectrum antibiot- Europe. The measures that have been taken to docu- ics are often prescribed in situations where a targeted ment, control and limit the use of antibiotics do not treatment with a specific antibiotic would make more go nearly far enough. Many countries – including the sense. Reserve antibiotics have also become a stand- and , for instance – have made ard form of treatment all over the world, even though enormous progress in recent years, but the situation they should only be used in particularly serious cases. remains unsatisfactory in Germany. The sad truth is that many doctors are breaching med- ical guidelines against their better knowledge. One problem is the so-called right to dispense. German veterinarians both prescribe and sell drugs. Antibiotics require a prescription in Germany. But As a result of this double role, many vets earn most of since many patients do not receive enough informa- their income from pharma sales. Discounts from man- tion on how to use them properly, they often stop tak- ufacturers for buying in bulk have also contributed to ing them too soon and keep remaining pills and use the vast over-prescription of antibiotics. them to self-medicate at a later date – for instance to treat a viral infection. Users therefore need to be bet- High levels of antibiotic use are closely correlated ter educated. with certain types of agriculture. In industrialised farming, many animals are bred with an eye only Physicians’ conduct might improve if they got to increasing weight fast, maximising certain pre- feedback concerning their prescribing habits. The mium cuts of meat (chicken breasts, for instance) or Scandinavian countries have taken this approach, milk output. Such a narrow focus negatively impacts collecting and evaluating prescription data in cen- the animals’ health and their ability to fight off dis- tralised government-run databases. The strategy has ease. Mass application of antibiotics is not the right been successful: the Scandinavian countries prescribe response however. Things tend to be particularly bad the lowest volume of antibiotics and have the lowest in the poultry sector due to high stocking densities. levels of antibiotic resistance anywhere in Europe. Lots of animals share a small space, which causes stress and allows infections to spread fast. Birds are routinely fed antibiotics because farmers want to pre- Hospital care vent infections from killing entire flocks.

All too often, guidelines for appropriate antibiotic use Instead of keeping animals in a way that is as are disregarded in hospitals. The reason is that the healthy as possible, producers use medication to facili- specific pathogens and their resistance profiles are not tate cheap mass production. This phenomenon is not common knowledge. Time pressure adds to the prob- limited to Europe and North America, but has also lems when it makes staff fail to comply with necessary become common practice in Asia, Africa and Latin hygiene rules. In German hospitals, multi-resistant America. Adding to the problem, a few high-performing pathogens are mostly transmitted through direct per- breeds that are not adapted to a wide variety of climates, son-to-person contact. Proper hygiene and additional dominate the market. This situation must be remedied. staff are the best options for solving this problem. The main goal is to improve animal health in order to reduce the need for antibiotics – in other words, raise Hospitals must encourage the targeted use of the fewer, more robust animals. Breeds that are adapted to right antibiotic moreover. Diagnostics must also be different regions and climates are needed. Vaccines can improved and accelerated. Diagnostic measures are also lower the risk of infection. Finally, fewer transports often not taken at all in many countries, and even would mean less stress for the animals and would also in Germany, what is done in real life falls far short of prevent the spread of pathogens. what should happen ideally.

One interesting approach is a traffic light system International cooperation that divides antibiotic agents into three groups: drugs in the “green” group could be prescribed by all doc- A lot needs to be done from a development perspec- tors, “yellow” drugs by specialists and “red” drugs tive. Conditions in many countries tend to promote

22 D+C e-Paper November 2016 Heine/Lineair

rather than limit the development of antibiotic resist- restraint; they want to sell as much as they can at the ance. In many places, antibiotics are easily available highest possible price. Hospitals all over the without prescription. Pharmaceutical markets tend world have to combat to be unregulated, and self-medication is practiced Therefore alternative funding models are needed. multi-resistant freely. Proposed solutions include an international research microbes: an operation fund that would finance drug development. Research in Brazzaville, Congo. Many countries do not systematically document prizes have also been discussed. In any case, public antibiotic use and resistance. Necessary diagnostics funding is absolutely indispensable. are often neglected. The WHO action plan addresses such challenges and focuses in particular on helping The first step has already been taken. In coopera- poor countries develop the appropriate structures. tion with the non-governmental Drugs for Neglected But success depends on the existence of basic health Diseases initiative (DNDi), the WHO has launched the systems and will require long-term support. Global Antibiotic Research and Development Partner- ship (GARDP). The aim is to develop antibiotics to meet the requirements described above. In order to be suc- Research and development cessful, it needs long-term financial commitments from as many countries as possible. Germany’s federal gov- Almost all antibiotic agents currently in use date ernment has for instance pledged € 500,000 in start-up back to discoveries made in the 1940s to the 1960s, funds, but much more is needed to allow GARDP to tap so today, some kind of resistance affects more or less its full potential. It could become a research platform all known agents. For many years, hardly any new that compiles information, data and ideas and makes classes of agents were developed. The pharmaceuti- them available around the world through its network. Christian Wagner- cal industry had no interest in researching antibiotics Ahlfs because it does not consider them profitable enough. No doubt: antibiotic resistance is a complex chal- works for BUKO Pharma- lenge. Existing programmes have typically not taken Kampagne, a civil-society The research gap urgently needs to be closed. into account all issues discussed above so far. Improved organisation. First, since the private sector will not act on its own, international coordination will allow them to better [email protected] the research and development of new classes of agents complement each other. Lacking policy coherence has must be publicly funded. Second, new products must often been noted as well. In Germany, for example, become available and affordable all over the world. health-policy experts are striving to stem resistances Third, they must be applied as sparingly as possible while agricultural policies continue to favour mass in order to delay the inevitable development of new production and the export of milk and meat. resistances. Link Commercially-oriented research cannot meet List of proposed measures from the conference and further information these requirements. Private-sector companies have on antibiotic resistance: very different goals. They do not want to practice http://www.bukopharma.de

D+C e-Paper November 2016 23 “Involve the local people”

Health care is not something that must be left to doctors and drug companies, argues Zafrullah Chowdhury, the founder of a rural health-care organisation that serves several million people. As he told Hans Dembowski, awareness raising and capacity building at the grass-roots level is essential.

Interview with Zafrullah Chowdhury

What kind of infectious diseases is Bangladesh diseases. More research is needed, and research struggling with? is expensive, so resources must be mobilised and Well, about 60 % of the disease load is infectious. pooled globally. Drug companies must be involved, Pneumonia and other infections of the chest and universities must play their part, and medicines respiratory system are a serious issue. Sexually trans- must be used rationally, or otherwise resistances mitted diseases cause a lot of suffering, and gastro- will develop fast. These things must be dealt with intestinal illnesses matter too. at the global level. ■■ Second, not all treatments are simple. Our health- What about diseases that affect tropical care infrastructure is weak, especially in rural areas. countries but tend to be neglected by pharma It needs to become stronger to deal with all health research? issues competently. And to make it stronger, we Bangladesh has actually made good progress in need to invest in the system, and some foreign sup- reducing the prevalence of rabies by providing free port is certainly useful. We mustn’t forget, moreo- vaccines. There is an effective national immunisa- ver, that chronic diseases are becoming ever more tion programme. Kala-azar, which is internationally important: hypertension, kidney failure, cancer, known as Leishmaniosis, remains a problem in some diabetes, mental illnesses et cetera. Poor countries’ parts of Bangladesh although it has been eradicated health-care systems must rise to these challenges, in most countries, primarily through public health but all too often, they are simply overwhelmed. measures. The incidence and spread of dengue is on the increase. Are rich nations’ aid agencies and global institutions such as the World Health Organi- When I first came to your world region in the zation (WHO), Gavi (the Vaccine Alliance) and early 1990s, I was told that diarrhoea was the Global Fund to fight AIDS, Tuberculosis and a killer. Malaria doing a good job in terms of promot- That is no longer so today. To survive diarrhoea, the ing research and supporting the expansion of essential thing is to avoid dehydration. Especially health infrastructure? young children lose a lot of fluid, and that fluid has The problem is that they focus too narrowly on scien- to be replaced. It really only takes safe water, some tific solutions. Ultimately, they are leaving everything salt and a bit of sugar (glucose). Even poor parents in the hands of doctors and drug companies. But that can handle that, provided they know what to do. In is not the right approach in low-income countries. Bangladesh, the knowledge has spread, not least We need to reach masses of people fast, and we do thanks to awareness raising, so the number of deaths not have enough doctors – not least, because so due to diarrhoea has decreased considerably. many are migrating to rich countries where they can earn more money. We need to focus on achieving the Does that show that a low-income country like greatest impact at the grass roots level. Bangladesh can cope with the challenges of infectious diseases on its own? What do you propose? It depends. If the treatment is well understood and The trick is to involve the local people, and the simple, we can cope on our own. But that is not people who traditionally take care of their health. always the case. Traditional birth attendants can make a huge differ- ■■ First of all, not all diseases are well understood, ence, as I elaborated in your paper a few years ago. and for many, there still is a lack of treatments. You It makes sense to train them, to update their skills just mentioned the so-called neglected tropical regularly and to expose them to modern knowledge.

24 D+C e-Paper November 2016 Harrison/Lineair

The people must know what serves health and what basic economic issues are not taught in medical A tetanus patient is does not. Doctors must be made accountable for school. Aspiring young doctors should learn about treated at a GK facility their service quality and behaviour with patients. keeping health-care costs low. They should learn in the 1990s. Prescriptions must be subject to audits. Every death to pay attention to the affordability of drug prices. in a health facility must be subject to public scru- These things are essential if we want to make health tiny, more so in the case of private hospitals and care more effective in developing countries. Generic clinics. It has been reported that some private hos- drugs are important, because they are cheaper. In pitals have prolonged patients’ stay long after their Bangladesh, we have built a strong generics industry, demise with the excuse that the patient was still which helps to reduce health-care costs. The WHO clinically alive i.e. not yet brain dead. A dedicated could do even more to promote these causes than it ombudsman for health services can introduce neces- has done so far. Not only medical research is impor- sary reforms. tant, research into making health care affordable is just as important. Do you want to raise awareness among the peo- ple in general, or are you focussing on tradi- Is there scope for south-south cooperation? tional healers? Countries should definitely share experience on low- Both must be done. If the people in general have no cost solutions that work. Currently, dialysis costs less idea of what is healthy, they will be hard to convince in India than in Bangladesh and is even free in Paki- of doing the right things. And those who are in the stan. Obviously, our country can learn from those best position to convince them are the people they examples. That said, some things cannot be easily turn to for help and trust. Nurses matter, paramed- replicated elsewhere. Consider sparsely populated Zafrullah Chowdhury ics matter, they all deserve our attention and require regions in Africa for example. They cannot copy our is a doctor who returned to Bangladesh capacity development. In developing countries, model of rural health centres in a densely populated from Britain during the liberation war in health centres tend to be under-staffed, and the lives country. Every GK centre is within reach for many 1971 and started the rural health-care and welfare of patients depend on everyone who thousands of villagers. They would not be viable if organisation Gonoshasthaya Kendra works there. Our vision at Gonoshasthaya Kendra they could only serve a few hundred. (People’s Health Centre). He is currently (GK) is that people at the grass roots level should be setting up a dialysis centre at GK’s hospital able to handle standard problems and know when Links in Dhaka. The plan is to provide dialysis to turn to a referral doctor or hospital. We are not Zafrullah Chowdhury on: for 400 patients every day at an opposed to scientific medicine, not at all, but we the history of Gonoshasthaya Kendra: affordable price for the poor ($ 14 per have to put things in context. http://www.dandc.eu/en/article/health-universal-right-argues-gonoshasthaya- session). GK is looking for a transplant kendra-bangladesh surgeon and nephrologists to help run the Should that not be part of medical school cur- generic pharma production in developing countries: centre. GK would welcome support for ricula? http://www.dandc.eu/en/article/bangladesh-self-sufficient-pharma-production this initiative. For further information Well, they should consider social-science studies traditional birth attendants: please contact Dr. Mohib Ullah Khondoker concerning health, but so far they hardly do so. Even http://www.dandc.eu/en/article/praise-traditional-birth-attendants-bangladesh [email protected]

D+C e-Paper November 2016 25 Follow us on Twitter! To stay in touch with what is happening on our website, follow us on twitter.

X + www.twitter.com/forumdc Medicine for all

Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria have helped save millions of lives. They have succeeded in part by encour- aging recipient countries to take the lead and by involving civil society in their efforts.

By Karoline Lerche

In 2000, the UN adopted eight Millennium fighting HIV/AIDS and malaria. Any measure nec- Development Goals, one of which aimed to essary to stem the spread of these diseases was reduce child mortality by two-thirds between 1991 welcome. and 2015. At the time, almost 10 million children around the world were dying before their fifth In order to achieve these goals, Gavi, the Vaccine birthday. Southern Africa was the worst affected Alliance, was founded in 2000. Two years later, the world region. In the same year, the UN Security Global Fund to Fight AIDS, Tuberculosis and Malaria Council identified HIV/AIDS as a threat to global was set up. Gavi’s objective is to overcome global in- security for the first time. Millions of people were equalities in terms of vaccine access, making vaccines dying of AIDS. Of the 28.6 million people infected available in order to reduce child mortality. The Global with HIV, only about 700,000 were receiving life- Fund focuses on financing prevention and treatment prolonging antiretroviral medication. Another programmes in the fight against AIDS, tuberculosis Polio vaccination in Millennium Development Goal thus focused on and malaria. . Sunday Alamba/picture-alliance/AP Photo

D+C e-Paper November 2016 27 Discrimination against women reduces immunisation rates

In the world’s poorest countries, women and girls are now get antiretroviral medication. Programmes that disproportionately affected by poverty. Several issues receive support from the Global Fund are ensuring – including child marriage, unstable and dysfunc- medication to 440,000 of the patients. tional families, exploitation, limited education and sexualised violence – make their risk of contracting Gavi has not found differences in immunisation rates HIV particularly great. for girls and boys. But social and economic discrimi- nation against women has a direct impact on child In sub-Saharan Africa, some 700 young women are vaccination. Women may not be allowed to use the newly infected with HIV every day. They account for family’s money to pay for a trip to the nearest clinic, 74 % of new transmissions. In the past six years, the or they may not have the time because of other tradi- Global Fund has therefore boosted its spending on tional chores. Women living in remote areas are par- programmes that serve women and girls. These ticularly affected. In many countries, women are not investments now make up 60 % of the Fund’s total permitted to travel to a clinic without being accompa- financial commitments. nied by a man.

Kenya is one of the countries where young women Literacy rates matter too. In countries like Chad, only are at a much higher risk of contracting HIV than half as many women can read and write as men. Par- men. From 2008 to 2015, deaths caused by HIV/AIDS ents’ willingness to have their children immunised declined by 58 %. The absolute number fell from typically increases with their level of education. Gavi about 85,000 to 35,754. In the same time span, new is addressing these challenges head-on, encouraging HIV infections were reduced by 32 %. Of the 1.5 mil- local partners to raise awareness for what makes lion people living with HIV/AIDS in Kenya, 800,000 immunisation coverage diverge.

In Kenya, the risk of contracting HIV is much higher for women than it is for men. Daniel Irungu/picture-alliance/dpa

28 D+C e-Paper November 2016 Both organisations target the poorest and Pooling demand lowers costs worst-affected countries in the world. They strive to improve national and international funding, anchor Gavi’s goal is to provide every child with the vaccines their programmes in the communities concerned, he or she needs at an affordable price. Gavi pools the make vaccines and medications more accessible and demand for vaccines from developing countries and affordable and make pharmaceutical supplies more can make long-term planning safe for pharma produc- reliable. ers thanks to donor funding. Therefore, more pharma companies are now offering lower-cost vaccines. In Developing countries define their own needs and 2001, Gavi cooperated with five vaccine manufactur- objectives. Aid is not distributed according to bilateral ers in five countries; today, the organisation works agreements between a government and a large num- with 16 manufacturers in 11 countries. Many of the ber of donor countries and aid organisations, as this companies are located in developing countries and approach often overwhelms developing countries. emerging markets, including Senegal, India and Indo- Instead, funds are collected by a specialised agency nesia. and allocated according to commonly agreed goals. This approach reduces transaction costs and leads to Because of Gavi, competition has become tougher greater efficiency. in the vaccines market. As a result, prices have dropped. In 2010, it cost $ 35 to fully vaccinate a child in accordance with the recommendations of the Involving civil society World Health Organization (WHO). By 2015, the cost had gone down to only $ 20. Above all, this reduction To get support from the Global Fund, a developing is due to the reduced price of the rotavirus vaccine, country must set up a partnership called “Coun- which protects children from a disease that causes try Coordinating Mechanism”. These partnerships severe diarrhoea. The price for this vaccine went down ensure the appropriate involvements of govern- by 70 % in five years. The cost of the pentavalent vac- ments as well as non-governmental organisa- cine, which provides protection against diphtheria, tions, academic institutions, private-sector busi- tetanus, pertussis, polio and Haemophilus influenzae nesses and grassroots people who are affected by type b (Hib), has declined by 43 %. the three diseases. Civil society is thus directly involved in decision making. The partnerships are Since it was launched, the Global Fund has also tasked with overseeing the projects’ imple- become the most important financial instrument in mentation. the fight against AIDS, tuberculosis and malaria. It has helped save the lives of 20 million people since Gavi provides vaccines to developing countries, 2002. Live-saving medications were delivered to supporting those countries’ objectives and strate- 9.2 million people living with HIV and AIDS. Moreo- gies rather than competing with them. Gavi cooper- ver, treatments were administered to 3.6 million preg- ates with state agencies as well as with civil-society nant women, so they did not transmit the virus to organisations. It is often necessary to provide essen- their unborn children. tial infrastructure like refrigerated trucks, refrigerators and solar equipment for power generation. Training The Global Fund also finances half of all malaria local medical staff and educating people about the programmes. Around the world, the number of deaths importance of vaccination are similarly important. caused by malaria declined by 48 % from 2000 to 2015. Moreover, Gavi works hard to win the support of poli- cymakers. The Global Fund’s latest replenishment confer- ence was held in in mid-September. Donors Both the Global Fund and Gavi encourage recipi- pledged almost $ 13 billion to finance the Fund’s work ent countries to take the lead. When accepting invest- from 2017 to 2019. The additional financing will help Karoline Lerche ments from the Global Fund, countries are required save 8 million lives, prevent 300 million new cases of is senior media manager for to commit some of their own money as well. Accord- the three diseases and mobilise $ 41 billion of recipi- ONE in Germany. ingly, countries’ share of funding for relevant meas- ent countries’ own funds. [email protected] ures has risen considerably. The countries themselves now bare more than half of all the costs associated Gavi is a similar success story. Since its founding, with fighting HIV. In the fight against tuberculosis, 580 million children have been vaccinated, which the share is three-fourths and in combatting malaria means that over 8 million lives were saved. The world one quarter. According to Gavi’s approach, all coun- has witnessed a 50 % decline in child mortality since tries should eventually fund their immunisation pro- the 1990s, and Gavi contributed to making that hap- grammes entirely on their own. Today, 14 countries pen. In the countries where the vaccine alliance oper- are already financing at least one immunisation pro- ates, child mortality declined significantly. The num- gramme themselves, while four countries that earlier ber of deaths per 1,000 live births fell from 76 in 2010 received Gavi support are now able to fund all of their to 63 in 2015. Gavi hopes to immunise 300 million immunisation efforts: Bhutan, Honduras, Mongolia children from 2016 to 2020, thus potentially saving and Sri Lanka. 5 to 6 million lives.

D+C e-Paper November 2016 29 Needs-based care in disaster situations

Natural disasters, hostilities and other events that cause mass displacement and migration tend to cause a surge in infectious diseases. Medical relief teams must tackle a range of communicable diseases that do not occur on such a scale in normal times. Emergency kits help relief workers respond effectively in various scenarios.

By Shushan Tedla and Irmgard Buchkremer-Ratzmann

In a disaster, four dreaded infectious diseases The outbreak of an infectious disease needs to can break out and become life-threatening be identified and addressed swiftly to prevent an epi- problems, especially for children. They are respira- demic. SPHERE offers guidance on an early warning tory infections, diarrhoea, and malaria. In system (EWARN) for outbreak detection; in the case many conflict areas, they cause 60 % to 90 % of fatal- of some highly infectious diseases such as cholera, ities. measles and meningitis, provision is made for weekly surveillance with the immediate reporting of new The SPHERE project is a voluntary alliance of cases. Once an outbreak has been confirmed, meas- organisations committed to improving humanitar- ures must be taken: ian aid and helping practitioners to become reliable ■■ to contain the infection (by isolating patients, for partners for donors and affected communities. The example), SPHERE handbook “Humanitarian Charter and Mini- ■■ to break the chain of infection (by implementing mum Standards in Humanitarian Response” is a use- vaccination campaigns, for example, or providing ful tool for disaster relief workers. Now in its 11th edi- safe drinking water) and tion and published in many languages, it is a widely ■■ to deliver diagnosis and treatment fast and compre- known and internationally recognised set of general hensively. principles and universal minimum standards for dis- aster relief operations. In addition to preventing the spread of communica- ble diseases by vaccination campaigns and hygiene Measures to prevent infectious disease and facili- measures such as provision of clean water, washing tate treatment are a core concern for SPHERE. They hands and building toilets, medical workers need suf- are described in the chapter Minimum Standards in ficient access to appropriate, high-quality medicines Health Action. Relevant issues include the choice for treating patients. of appropriate accommodation at appropriate loca- tions, sufficient water supply, good water quality, appropriate sewage disposal, adequate sanitation, WHO kits for rapid relief prophylactic vaccination, vector control and health education. In emergency and catastrophe situations, medical teams use a standardised kit that was developed by the WHO and major international NGOs. Known as Quality standards in the Interagency Emergency Health Kit, it contains humanitarian aid medicines, supplies and other items required to meet the needs of affected communities. The kit is designed As soon as a disease outbreak occurs, everyone to cater for 10,000 displaced persons for a period of affected must get access to diagnosis and treatment. three months. It comes at a reasonable price and can Certain programmes run by the World Health Organi- be purchased from commercial and non-profit pharma zation (WHO) – such as Integrated Management of wholesalers. Delivery is possible within hours. Childhood Illnesses (IMCI) and Integrated Manage- ment of Adult Illnesses (IMAI) – have developed The kit consists of ten basic units and a so-called important procedures to help ensure correct diagnosis supplementary unit. Each basic unit caters for a thou- at an early stage, thereby reducing mortalities from sand children and adults and is designed for use by communicable diseases. health workers without formal training. The supple-

30 D+C e-Paper November 2016 Action medeor supplied medicines to the in the wake of the 2013 Typhoon Haiyan: Albino M. Duran Memorial Hospital in Balangiga. action medeor

mentary kit contains medicines and medical devices needed for fluid replacement: oral rehydration solu- (equipment and renewables) that allow surgical pro- tion, infusions, cannulas, scalp vein sets, et cetera. cedures to be performed. It is intended for use by phy- Recommended antibiotics include doxycycline, eryth- sicians and senior health-care workers with profes- romycin and ciprofloxacin. sional skills. During initial relief efforts, the SPHERE stand- The basic kit contains disinfectants and the ard recommends checking which medicines are on antibiotic amoxicillin tablets for the prevention and the national list of essential medicines. In coop- treatment of communicable diseases. Where com- eration with national health authorities, it should plex infections are present or resistance is suspected, be assessed whether that list is appropriate for the patients should be referred to hospitals at the next case at hand. If so, international aid should ensure higher level. Because eye infections tend to be com- all listed medications are available – if necessary, by mon where hygiene conditions are poor, the basic kit donating drugs. also contains an antibiotic eye ointment (1 % tetra- cycline). A supplementary module can be ordered for treating malaria. Needs-based aid

The supplementary kit contains water-treatment Pre-packed standardised kits are part of a “push sys- tablets and various antibiotics for the oral and intra- tem”. For the sake of speed, they do not consider indi- venous treatment of infections. Where a cholera out- vidual recipients’ needs. Asymmetrical consumption break is feared – or an epidemic of diarrhoeal disease patterns quickly result in over- or understocking. caused by other organisms – the WHO Interagency Diarrhoeal Disease Kit is useful. Apart from large Some aid organisations that specialise in phar- quantities of disinfectants, it also contains everything maceutical support such as action medeor, Apotheker

D+C e-Paper November 2016 31 Shushan Tedla is an Eritrean pharmacist with a master’s degree in international health from a German university. She works for action medeor and has acted as pharmaceutical manager for temporary medical distribution centres in the Philippines and Nepal. [email protected] https://medeor.de/en/

Temporary medical dis- tribution centre in Kathmandu, Nepal. action medeor

helfen and Apotheker ohne Grenzen, can provide are resistant or less susceptible to certain pharmaceu- professional support that takes account of patients’ ticals. needs. After Typhoon Haiyan struck the Philippines in 2013, for instance, or after the earthquake in Nepal Medical aid organisations need a medicine man- in 2015, action medeor set up temporary medi- agement system that is not just effective and cost-effi- cal distribution centres in the countries concerned. cient, but also addresses issues such as correct storage, Irmgard Buchkremer- National specifics and requirements were considered rational use and disposal. This applies to small medi- Ratzmann in constant consultation with government agencies cal teams as well as to the organisation and adminis- is a pharmacist with experience in as well as medical workers active on the ground. The tration of drug donations at regional or national levels. research and industry. She heads distribution centres helped to ensure that health sta- the pharmacy department at action tions, hospitals as well as national and international Aid organisations specialised in pharmaceutical medeor and coordinates medical teams had stocks of appropriate high-quality support can offer support and backup in this context pharmaceutical advisory services. medicines and medical supplies. This kind of system – for example, by organising preparatory training pro- [email protected] is called a “pull system” because the users have an grammes for medical teams in Germany or providing impact on what is delivered. In the course of disaster support, supplies and medicine management services management, there is generally a switch from push to for teams active on the ground. pull systems. Links To permit effective, targeted treatment of infec- SPHERE Handbook, 2011: tious diseases, medical workers need access to a suf- http://www.sphereproject.org/ ficiently large selection of medicines. Above all, they WHO Interagency Emergency Health Kit: may need antibiotics to fight pathogen strains that http://www.who.int/medicines/publications/emergencyhealthkit2011/en/

32 D+C e-Paper November 2016 Global health challenge

Poor people in tropical countries are not benefiting enough from advances in medical technology. International experts are calling for change.

By Lea Diehl

Many infectious diseases can be treated better the human right to health clashes with the rights of today than even a few years ago. Moreover, the investors, the experts argue. High-Level Panel on Access to Medicines (2016), which was convened by UN Secretary General Ban Ki- The UN Panel does not challenge the fundamental moon, notes in its recently published final report interest of investors to make profit, nor does it ques- (September 2016) that preventative measures against tion the right to intellectual property. However, it calls bacteria, viruses or parasites have become more reli- for a sensible balance with the human right to health able. Macrotechnology and nanotechnology are care, which is in line with the UN’s Sustainable Devel- advancing as well. opment Goals (SDGs).

However, the UN authors criticise that not eve- In order to reach the SDGs, the UN report wants ryone is benefiting from such progress. According to governments to act at several levels. Governments them, many people – especially in countries with low should assume responsibility and ensure transparency and medium incomes – do not have access to medical in the health sector. It is necessary to monitor services treatment and medicines. High prices for medicines to ensure that they fulfil human rights. Results should The mosquito species plunge many people into poverty. Again and again, be published, according to the report. Furthermore, Aedes albopictus can transmit yellow fever and dengue as well as other diseases. Roger Eritja/Lineair

D+C e-Paper November 2016 33 Filipino slum: the poor are particularly at risk from infectious diseases.

governments should establish databases on patents research and calls for it to be expanded. It points so research results are made available to the public. out that scientists should pay more attention to dis- eases that have up to now been neglected because According to the UN document, intellectual prop- treatments do not look lucrative to pharmaceutical erty deserves protection. The authors point out how- companies. So far, many tropical diseases are virtu- ever, that according to the rules of the World Trade ally irrelevant for market-orientated research. Accord- Organization (WTO), governments can grant compul- ingly, an appropriate incentive system cannot only sory licenses for the production of patent-protected rely on patents which secure high profits for innova- substances if that is necessary to safeguard public tors, provided that patients have enough purchasing health. They should use this right. power or are covered by health insurances.

The experts appreciate private-sector corpora- For example, one-off premiums for successful tions engaging in voluntary license agreements to research results could be an alternative to intellec- make medicines affordable in developing countries. In tual property rights. “Milestones” could be defined, doing so, however, the corporations set certain condi- and those who reach them, would be paid a certain tions for particular countries or regions of the world. amount of money. As a push-mechanism, the UN It is obvious, moreover, that the negotiating power of Panel suggests that governments should disburse businesses increases when governments do not make research grants in advance. The experts identify inter- use of their right to grant compulsory licenses. esting options for cooperation with investment funds, public-private partnerships and other forms of net- The UN authors recommend investing more in working. research and development (R&D). However, this task should not be left to industry alone. The UN Panel Another central concern of the report is the staff- emphasises the significance of publically financed ing of the health-care sector. Doctors and nurses are

34 D+C e-Paper November 2016 needed so patients receive care according to up-to helminthiases, taeniasis/cysticercosis, trachoma and date knowledge. (endemic treponematoses).

The WHO views these diseases as a global chal- Antibiotics resistance lenge because, due to urbanisation, migration and environmental change, they are spreading to areas On behalf of the British government, scientists have where they were not present so far. They are transmit- been considering options to tackle antibiotics resist- ted by arthropods such as insects, spiders or crabs. ance which is increasing worldwide (also note essay These vectors should be controlled, and to achieve by Christian Wagner-Ahlfs on p. 21). The economist that, human beings, animals and the environment Jim O’Neill led the Review on Antimicrobial Resistance must be taken into consideration holistically. (AMR). The final report was published in May 2016. In order to fight tropical diseases, the WHO is It views resistances as a global problem. The pushing for key interventions: effects are evident worldwide – and they threaten ■■ innovative and intensified disease management, future generations. As O’Neill points out, the poorer ■■ more preventative treatment (including, for exam- countries are the most affected ones. ple, chemotherapy), ■■ vector management in line with environmental The AMR report bemoans that antibiotics are often principles, given out unnecessarily in industrialised countries ■■ veterinary public health (VPH) services and while they are unavailable in other places. Unneces- ■■ provision of appropriate water and sanitation infra- sary use of antibiotics by humans and animals should structure. be avoided, it states, and more precise diagnoses would help to achieve this. Too many antibiotics are Like the High-Level Panel of the UN and the British used in animal keeping, and this trend accelerates the AMR Review, the WHO emphasises the links between development of resistant bacteria. Global campaigns poverty and disease. Neglected diseases occur mainly should raise awareness of the issue, according to the in tropical countries, which generally are not among AMR Review. the highly developed ones. Market dynamics alone will not solve the problems. By 2030, the WHO wants In any case, new antibiotics must be developed to to create the conditions in cooperation with the World replace old drugs to which bacteria have become resist- Bank to ensure that: ant. The report argues that investment should not only ■■ at least 80 % of required essential health care is be made in the development of new antibiotics, but guaranteed all over the world, and also in research into ongoing treatments. Like the UN ■■ those who provide the services can be sure that they Panel, this group of experts expresses itself in favour will be paid out of pocket. of creating new incentives for investors than only rely-

Mark Edwards/Lineair ing on patents. Relevant options include international The WHO is in favour of international investors coop- consortia, public-private partnerships and establish- erating more closely with people at the grassroots ing a global fund for non-commercial research. level. Tropical diseases should become an integral issue for national health policies. Moreover, local The researchers praise existing programmes that investors should be mobilised. counteract antibiotics resistance – for example the ’s Fleming Fund or the Global Inno- The WHO report does not only mention problems, vation Fund. Governments must rise to the challenge, but also successes. More than 70 countries have and global funds must be mobilised, according to the adopted strategies to contain tropical diseases. More AMR report. than 800 million people were healed from such dis- eases in 2012 and 2013. A network of African coun- Lea Diehl tries have reduced the occurrence of African trypano- is a freelance author and Neglected tropical diseases somiasis by up to 90 %. studies cultural anthropology at Marburg University. It has long been recognised that more must be done Sources [email protected] to fight tropical diseases (see also article by Sheila Review on Antimicrobial Resistance, 2016: Tackling drug-resistant infections Mysorekar on p. 16). In 2015, the WHO published globally – Final report and recommendations. a status report on the issue and listed 17 neglected http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf tropical diseases: WHO, 2015: Investing to overcome the global impact of neglected tropical diseases – Third WHO report on neglected tropical diseases. buruli ulcer, chagas, dengue, http://apps.who.int/iris/bitstream/10665/152781/1/9789241564861_eng.pdf (Guinea-worm disease), echinococcosis, foodborne United Nations Secretary-General’s High-Level Panel on Access to trematodiases, human African trypanosomiasis Medicines, 2016: Report - Promoting innovation and access to health (sleeping sickness), leishmaniasis, leprosy (Hansen’s technologies. disease), lymphatic filariasis, onchocerciasis (river http://www.ip-watch.org/weblog/wp-content/uploads/2016/09/HLP-Access-to- blindness), rabies, schistosomiasis, soil-transmitted Medicines-Final-Report-Sept-2016.pdf

D+C e-Paper November 2016 35 Urban development “Mental attitudes matter”

The industrial development of Mangaluru, a harbour town in the the smart-city committee. Civil-society south Indian state of Karnataka, has recently been strong, and organisations and the government work together. I speak for the marginalised government agencies want to attract additional investors. Hilda women and the poor. Their needs must Rayappan is the leader of a local non-governmental organisation not be forgotten when urban infrastruc- which fights for the interests of the women and the poor. She ture is planned and expanded. I am discussed Mangaluru’s recent development in an interview with confident that the smart-city programme can bring change, if the plans are imple- Lea Diehl. mented

Interview with Hilda Rayappan Do you doubt they will? Well, all too often promising things are How did the infrastructure of Man- called Swachh Bharat Abhiyan (“Clean planned, and then nothing happens. galuru develop in recent years? India Mission”). It is being implemented Implementation is a huge challenge. Over the last few years, the infrastruc- in Mangaluru. Formal workers now pick ture has improved. You definitely feel up garbage from every household. The What challenges do poor and margin- the transformation of the city. Especially programme is successful, and our city alised women face? the traffic conditions have changed. The now looks much cleaner. Another current More and more women leave their homes central government built highways, so central-government programme is called and go to work. Women need a better driving distances have become much “smart cities”. It is meant to boost indus- transportation system to get to work shorter. The arterial roads are wide. But trial development, but it also provides safely. Leaving the house is still dan- traffic has become a big problem. There better infrastructure and facilities for civil gerous because many women in India are ever more vehicles on the roads. More society. Right now, they have listed 98 become victims of sexual harassment. It and more people, even women, drive their cities in India which they want to develop is a problem even in public places. Infra- own cars. In the rush hours, the highways as “smart cities”. Mangaluru is one of structural development could improve are congested. Crossing the streets or the first 20 cities where the programme the situation a bit. Illuminated streets are walking along them is dangerous. There has already started. I am a member of safer than dark ones. If buses run often is a need to build more sidewalks, espe- cially for older people. It’s important to find solutions for organising the traffic.

Tribune What else has to change? Actually, water supply is a serious problem. This year, the monsoon did not bring enough rain, and the impact on drinking water supply was bad. So far, people are not focusing on water harvest- ing. Other Indian cities, like Chennai, for example, have a harvesting system, but in Mangaluru, it has not been established yet. Greenpeace and local non-govern- mental organisations, that focus on environmental issues, are campaigning for change. But the official urban-devel- opment plans only focus on industry. They are felling trees to build highways without respecting nature. Something has to happen because these problems affect society as a whole.

What are different levels of govern- ment doing to improve urban life?

The central government has started Diehl a programme to increase cleanness. It is In Mangaluru, many people depend on fishing.

36 D+C e-Paper November 2016 and regularly, waiting women are less at galuru does not have many slum areas. risk. But we need more than infrastruc- In megacities like Bangalore or Mumbai, ture change. People’s mental attitudes many areas are declared to be slums. In matter. If women go to work, for example, Mangaluru, we have some smaller areas there is a need to educate men to do that are like slums, but officially they are some of the household work and assume not registered. For example, there is an responsibility for the children. In regard open space close to the railway station, to sexual abuse, people have to become and many people live there under plastic empowered to report rape cases. Police sheets. Governmental action should do India officers often disregard what poor women something for them. These problems Mangaluru say. We are working hard to make change should be recognised as challenges of happen. Our NGO is running many pro- urban development. The people need grammes for creating awareness of gen- a place to live, and municipal services der equality and supporting marginalised should be available to them. women. Urban development has to focus on such How has the population of the city changes also. Do poor people in Mangaluru live in changed in recent years? special neighbourhoods? Many migrants come to Mangaluru from Link There are separate quarters for low-caste villages to find jobs. But there aren’t Prajna Counselling Centre: people and migrants. The government enough jobs for all. Unemployment has http://www.prajnacounsel.in wants to promote inclusive develop- become a big problem. On the other ment, however, so today people are hand, young people go abroad. They Hilda Rayappan legally entitled to choose where they study and work in different countries, is the director of the non-governmental Prajna want to live. Many governmental and for example, they move to or Counselling Centre in Mangaluru. The Centre civil-society organisations like us are run- the . Their families are left runs various social programmes with a focus on ning programmes to lift poor people up. behind. Among upper-class families, women’s and children’s welfare. Compared with other Indian cities, Man- many older people are now living alone. [email protected]

A fast growing city

Mangaluru is a south Indian city with around half a million inhabitants. It is the main port of the state of Karnataka and about 350 kilometres west of Bangalore (now officially called Bangaluru), the state capital. The city is the capital of Karna- taka’s Dakshina Kannada District.

Mangaluru is one of India’s fastest growing cities. It is not a megacity, but many sec- tors are already highly developed. The city is well-known for its industrial base. Impor- tant petrochemical and chemical compa- nies, including the German multinational BASF, and technology companies, such as

the Indian software firm Infosys, have Diehl production sites and offices here. Because of its industrial opportunities, people are moving to Mangaluru from the rural areas. Fishing boats and tourists in Mangaluru. Unfortunately the local government isn’t doing enough to adapt the infrastructure The climate is tropical. The port handles neering. Its population is diverse. The to the current development of the city. Like 75 % of the Indian coffee and cashew-nuts inhabitants have different cultural and their counterparts in many other Indian exports. Thousands of inhabitants depend religious backgrounds: most of them are cities, many citizens feel that the local on fishing for their livelihoods. The literacy Hindus, but there are also substantial Urban Development Authority has not rate of the city is high (94 %). Mangaluru is Muslim and Christian communities. In achieved much in recent years. To a large a college town: many Indian as well as South India, the share of Christians tends extent, urban development depends on foreign students are moving to the city for to be higher than the national average. initiatives taken by the central government. higher education, especially to study engi- Lea Diehl

D+C e-Paper November 2016 37 Microfinance Flexible and disciplined

As self-organised little savings communities, “tontines” are an as well as business people join hands in example of economic, social and cultural solidarity. Solidarity is tontines. their great strength. Collective savings provide financial and social security to tontine members. By Eva-Maria Bruchhaus Tontines matter especially in situations of precariousness and economic insecurity. Collective savings can be very suc- tive of female street merchants who joined Reciprocal solidarity is essential. Money is cessful. A group of market trader up in order to create better commer- pooled and shared fairly. women from Abidjan, the economic capi- cial conditions. With the rental incomes tal of the Côte d’Ivoire, are an example. As COCOVICO services the Oikocredit loans Communal saving is popular in many a cooperative, they have built up a market that were needed for establishing the mar- African countries, and it has a long tradi- with about 200 shops and 700 stalls. They ket (see box below). tion: from to Senegal, Sudan were supported by the international to Uganda. In Cameroon also, many Afri- microcredit provider Oikocredit. At its core, COCOVICO is based on an cans manage savings together. There are old method of economical cooperation many different models. In other countries The cooperative is called COCOVICO that is called “tontine” in francophone tontines are known by local names like (Coopérative de Commercialisation de West Africa. Tontines are associations “esusu” (Nigeria), “ekub” (Sudan, Eritrea Produits Vivriers de Cocody). By now it has of relatives, neighbours, friends or work and Cameroon) or ”jangi” (Cameroon). 600 members. They are market women of colleagues. There are tontines in all sec- different ages – between 16 and 65 years tions of society, both in urban environ- The French neologism tontine is derived old. The cooperative is based on an initia- ments and in rural areas. Farm women from the name of an Italian banker, Lor-

Successful self-help

Cocody is a comparably wealthy part of Zegbé Lou Ange Charlène has conducted Abidjan, a city of 5 million people. In a study on this extremely successful coop- a roofed market hall, food is sold, and so erative. According to her, COCOVICO gives are clothing and other items of daily its members a high degree of financial ivory coast necessity. The market is equipped with autonomy but, at the same time, consist- electric power, sanitary facilities, a health ently enforces the obligation to pay accru- station and a children’s daycare. als on time. Furthermore, the members Abidjan understand the structure of the organisa- The cooperative COCOVICO (Coopérative de tion and its procedures well. All this is in Commercialisation de Produits Vivriers de accordance with the tontine tradition. Cocody) runs the market. It was started by women who had lost their old market site Tontine principles shape COCOVICO in and joined forces in accordance with the another way too. The women are organ- tontine principle (see main text) in order to ised in groups that share experiences and create a new future for themselves. ideas and meet for meals and dance. They African market women, practice a savings are not formally registered, but all have system called “garde monnaie” (money Loans from the welfare-orientated inter- elected leaders, management, treasurers keeper). A person of trust (at the national microcredit organisation Oiko- and so on. ­COCOVICO market it is a pastor) visits his credit were decisive. All in all, the market customers once daily and collects a prede- women took out loans worth € 1.5 million A group’s members often come from the fined sum. The amount is recorded in euros and could thus acquire suitable same village or belong to the same ethnic a notebook with boxes for every day. After land. At present, the market provides group. Men can join and are even given 31 days the customer gets back the pay- livelihoods to about 1,000 market women. leadership roles. Group life offers the ments of 30 days, and the “garde mon- Servicing the loans is no problem because women social security. The members sup- naie” keeps the sum of the 31st day as the market is running well. The food sup- port each other in times of bereavement, payment for his services. Typically, the plies are mostly sourced from two regional for example. At the same time, the market women use the money to replenish their agricultural cooperatives. women of COCOVICO, like almost all West supplies.

38 D+C e-Paper November 2016 Oikocredit Market hall of COCOVICO.

enzo Tonti, who in the 17th century is said Papa Sow emphasises the socio-cul- Tontines have only received interna- to have suggested a mutual insurance sys- tural aspects of tontines. They strengthen tional attention since the second half of tem to Cardinal Mazarin, the finance minis- members’ sense of community and their the 20th century. Since then, anthropologi- ter of Louis XIV. African tontines are based cultural identity. However, tontines are cal and sociological research has been car- on different traditional forms of reciprocal more common among West African ried out. For about 25 years now, the huge collective help. After the introduction of the women than among men. Especially in “underground” savings have also attracted money economy they formed into recip- rural areas, tontines consist mostly of the attention of governments and global rocally founded associations to finance women. financial institutions. exceptional expenses such as funerals, baptisms or pilgrimages. Tontines are proof At regular meetings, the members Since then the formal financial sec- of African societies’ ability to form flexible, pay in a predetermined sum of money. tor has been pondering how to integrate but disciplined associations. Migration has The sum of the payments-in is then paid tontines into its business. Doing so makes brought tontines to Europe too. out at a previously determined date to sense if it boosts tontines’ capacities a previously determined member of the and facilitates major income-generating group. The next member benefits in the investments, as was obviously the case Clear rules cycle. There are many models that can be with the market of COCOVICO in Abidjan. changed according to the wishes or needs Caution is needed, however. All too often, Tontines mostly have clear and simple rules, of the respective members. commercial micro-finance schemes have which are observed with great discipline. led to over-indebtedness of poor people. Those who miss meetings without a valid The money is used by the members Moreover, tontine savings must not be lost excuse or disobey rules have to pay a fine, for different purposes. They spend it on in speculation, since that would thwart for example. Those who repeatedly stand special occasions such as festivals or pil- the core purpose of providing social and out as being disruptive are excluded. Contri- grimages, for example. Regular expenses financial security. butions are paid at fixed times, either weekly such as school fees can also be paid in this or monthly. These associations have strict way. Moreover, the money is sometimes Eva-Maria Bruchhaus systems of rules, the term “informal” does invested in long-term purchases such is a development consultant. She contributed to not describe them well. Papa Sow, a Senega- as cars or properties. Such investments the preparations for a conference on tontines lese sociologist who did research on the ton- are often relevant for business activities and microfinance that was hosted by the Goethe tines of West African migrant communities and generate additional earnings in the Institute in Abidjan in spring. in Catalonia, prefers the adjective “popular”. medium-term. [email protected]

D+C e-Paper November 2016 39 World trade The fig-leaf approach to human rights replace the private panels that have been The EU is facing a serious crisis of legitimacy concerning its dealing with disputes between foreign trade policies. To resolve the issues, the EU must refocus on basic investors and states to date. It insists, however, that foreign investors deserve European values. Unfortunately, such refocusing has hardly led to a special right to sue state agencies. Cor- tangible results yet. porations perceiving unfairness or indirect expropriation can thus claim billions of By Armin Paasch euros as compensation. They are empow- ered to take legal action even against Protests are arising all over the EU ■■ stronger protection of intellectual prop- reforms that affect land ownership, water against two planned trade agree- erty rights. supply or health care or serve the protec- ments: CETA (Comprehensive Economic tion of social human rights. and Trade Agreement) with and With an eye to increasing exports, it is TTIP (Transatlantic Trade and Investment still a core concern of the commission to Just like the previous strategy, the Partnership) with the USA. In response to abolish trade barriers. It praises its agree- new one does not foresee any exceptions the protests, Cecilia Malmström, the trade ment with South Korea as a model case. that serve to protect human rights. It fails commissioner, adopted a new strategy This agreement did away with 99 % of all to spell out that measures to ensure the called „Trade for all” in 2015. Among other import duties within five years on both rights to food, health or social protection things, it expresses renewed concern for sides and helped to boost EU exports by serve „legitimate policy goals“. The right European values as well as democracy. 55 % in three years. to regulate, however, must be rooted in legitimate goals, according to the EU. Malmström’s promises include effec- It is remarkable that the new EU strat- tiveness, transparency and a focus on val- egy stresses the relevance of the agriculture ues. She pledges to protect Europe’s social and food sector. According to the commis- Human rights at risk and regulatory model and to promote sion, the EU is the world’s greatest exporter human rights, sustainability and the fight in this sector, but it cannot rise to the top of In recent years, agricultural exports from against corruption all over the world. its potential because of trade barriers. the EU have put considerable downward pressure on food prices in developing However, the new strategy hardly In the multilateral context of the countries. Many smallholder farmers mentions tangible reform steps that would World Trade Organization (WTO), the have been plunged into poverty or even be necessary to initiate real change. And it EU has accepted preferential treatment crowded out of markets. Relevant products is not as innovative as the commissioner for developing countries, but in bilateral include milk powder in Bangladesh and would have us believe. The EU has offi- negotiations, it insists on reciprocity, Burkina Faso, pork in Cote d’Ivoire and cially been committed to the promotion only agreeing to a very limited measure tomato paste and poultry meat in Ghana. of human rights in trade relations since of preferential treatment. In its Economic Such exports have led to infringements of the early 1990s. In the Treaty of Lisbon Partnership Agreements, it even ensured the human right to food and other social of 2009, it pledged to respect and pro- that least developed countries such as rights. In this context, the EU announce- mote human rights in all dimensions of its Burkina Faso abolish 75 % of tariffs. The ment to keep supporting agricultural external affairs. What really matters, how- commission has not heeded – and is still exports via trade agreements sounds like ever, is what action the EU and its mem- not heeding – civil-society campaigns that a threat (see F. Mari in D+C/E+Z e-Paper bers actually take. have been criticising the EU for decades in 2015/9, p. 38 f., and D+C/E+Z print issue regard to dumping strategies, the crowd- 2015/6-8, p. 30 f.). In terms of substance, the new trade ing out of small-holder farmers and the aspirations hardly differ from the old ones. developing countries’ increasing depend- A second controversial issue is the The top priority is to enhance competi- ence on food imports. stronger protection of intellectual prop- tiveness and profitability of private-sector erty. The agreements the EU has struck companies based in Europe. For this pur- With respect to investor protection, with Colombia and Peru, for example, state pose, the EU demands: the commission emphasises what it calls that the 1991 convention of the Union for ■■ unrestricted market access for European a fundamental right to regulate. This the Protection of Organic Varieties (UPOV) goods, services and investments in all stance is a response to the vibrant anti- applies. According to this international partner countries, CETA and anti-TTIP movement. The com- convention, farmers, whenever they use ■■ unrestricted access to resources and mission now wants to introduce a kind of protected varieties, are neither allowed public-procurement tenders and international investment court system to to use what they harvest as seed, nor to

40 D+C e-Paper November 2016 Lissac/Lineair Excessively cheap EU exports destroy local markets: chicken farm in Senegal.

sell or trade parts of their harvest as seed. difficult to change course. To have an would make recurring human-rights These practices are quite common in the impact, SIAs would have to be carried impact assessments mandatory, in order Andes however. These rules are likely to out before negotiations start. In that case, for problems to be detected systemati- raise farms’ production costs and ulti- they could have a bearing on defining the cally. Finally, the clause would establish mately undermine farmers’ right to food. negotiation mandate. Moreover, it would a complaint mechanism for civil society make sense to involve civil society and the and give scope for rewriting the problem- EU trade policies threaten human European Parliament in making that defi- atical clauses of trade agreements. It is rights in other regards as well. Exagger- nition too. If that was done, the SIAs could a pity that the EU’s trade strategy does not ated IP rights limit people’s access to indeed have a meaningful impact and con- include any of these points. pharmaceuticals and thus affect their tribute to redrafting trade policies. right to health. Pressure to privatise pub- lic services can compromise the rights to It is well known, however, that not all Conclusion education, health and water. The fear of human-rights impacts are easily identi- foreign investors’ suing them can make fied before a trade agreement takes force. The EU has the legal duty to respect and governments shy away from indispensa- Accordingly, clauses concerning excep- promote human rights, including in ble efforts that would safeguard human tions that serve to protect human rights are trade matters. To fulfil this duty, it must rights. The EU demand to abolish export needed. Such clauses would ensure that reform and strengthen taxes, moreover, can spawn additional governments have the policy space they its human-rights instru- Tribune mining. In this sector, environmental need to protect human rights even if the ments. Unfortunately, damage and human-rights infringements necessary measures do not conform with such a reform is not on are all too common. a trade agreement. In this regard, existing the agenda – neither in human-rights clauses are insufficient. Brussels, nor in the capi- A pertinent question is thus: how does tal cities of the member nations. the EU intend to fulfil its obligation, which Last year, human-rights organisations is enshrined in the Lisbon Treaty, to respect tried to convince Commissioner Malm- So far, talk of human rights serves as and promote human rights abroad, includ- ström of a new model clause that was a mere fig leaf. The EU’s current crisis of ing in trade affairs? The commission points drafted by Lorand Bartels, a law expert, on legitimacy provides an opportunity to out that its strategy includes trade sustaina- behalf of Misereor and the German Insti- change course. Unless that happens, an bility impact assessments (SIAs) as a routine tute for Human Rights. The effort failed end to the crisis is not in sight. matter. It is indeed most welcome that the unfortunately. commission has begun to consider human Armin Paasch rights a relevant criterion in this context. The model clause would rule out that is an adviser on business and human rights for a trade agreement can be read in a way MISEREOR, the Catholic charity. The downside, however, is that SIAs that keeps signatory countries from ful- are only concluded once trade talks have filling their human-rights duties domes- advanced considerably and it has become tically or abroad. Moreover, the clause [email protected]

D+C e-Paper November 2016 41 Comment More turmoil to come? The Democratic Republic of the Congo (DRC) has made some pro- government manage new elections. gress towards democracy and stability in the past decade. In 2006 When this comment was finalised in mid- October, it looked unlikely that the the and 2011, democratic elections were held for the first time, and national dialogue would lead to a definite governance improved across the country. However, recent deve- solution, not least because the majority lopments indicate that troubled times are not over yet. of opposition leaders boycotted it. They see it as yet another attempt to delay the By Jonathan Bashi elections. They insist that Kabila, who has been in power since January 2001, should About 50 people were killed in vio- postpone the elections and allow Kabila step down at the official end of his term, lent clashes between protesters and to extend his mandate beyond the con- on 19 December, and let someone else security forces in Kinshasa on 19 and 20 stitutional limit of two terms. However, become president. 19 September, the first September. Opposition leaders had called after political unrest, which killed four day of the bloody protests, was the official for mass demonstrations to force Presi- people, the initiative was aborted. date on which the electoral process was dent Joseph Kabila to abide by the consti- ■■ In May 2016, representatives from the supposed to begin. tution and call for presidential elections in ruling party asked the Constitutional November. Violent outbursts led to the Court to clarify article 70 of the consti- Several commentators and foreign chan- celleries have warned of continued inse- Riot police on the streets curity in the coming months, some even of Kinshasa during going as far as talking of a looming civil protests in September. war. Indeed, recent events portend a poli- tical deadlock and more turmoil by the end of the year. On the one hand, it looks very unlikely that the elections will take place in November, as originally planned. On the other hand, opposition leaders have called for more demonstrations and set an ultimatum for Kabila to step down by 19 December. Otherwise they would use force. In addition, ordinary people feel frustrated and left out. They live in misery, and the gap between the rich and the poor continues to widen, while political leaders

John Bompengo/picture-alliance/AP Photo and their relatives seem to be privileged. Debate death of a few police offi- tution, which defines the number and All these factors are fuelling tensions cers and dozens of prote- length of presidential terms as well as the and make the future look grim in the DRC. sters. There was looting, modalities for the installation of a new Perhaps the international community and the headquarters of president. The Court ruled that the incum- could contribute to peace and stability political parties (from bent is expected to remain in office until by giving a special mandate to the UN both the majority and the opposition) a newly-elected president is installed. This mission in the country. Thus, MONUSCO were destroyed. implies that Kabila would stay in power in could help to ensure the safety of the peo- the case of a delay of the elections. ple in the coming months and to maintain This year’s elections will consti- ■■ In September 2016, the president cal- pressure not only on the ruling party but tute a key test for the country – if they led a “national dialogue” in an attempt also on opposition leaders. Both must take place. They should mark the end of to gather all political leaders. His goal abide by the constitution and other fun- Kabila’s second and last constitutional was to reach a consensus to ensure the damental laws and act responsibly to term. They are supposed to cement genu- organisation of peaceful elections within advance democracy and avoid chaos and ine change and democratic alternance at a realistic time frame. The government more bloodshed in the DRC. the head of the state. But opposition lea- and the electoral commission said that ders accuse Kabila and the ruling party of elections could not take place this year Jonathan Bashi delaying the elections in order to cling to because of a lack of resources, and com- is a PhD graduate from the SOAS, University of power. Several recent events corroborate mentators hoped that the national dia- London’s School of Law. He now works as a these allegations: logue would agree on a way to manage consultant and a law professor in the DRC. ■■ In January 2015, the ruling party tried the transition after Kabila’s term expires. to pass a new electoral bill which would One option would be to let an interim [email protected]

42 D+C e-Paper November 2016 Comment Conservative innovators On the basis of new data, a clear picture emerges on what innova- sting extension services differs not only tion potential can be expected of smallholder farmers. What they between countries, but between value chains too. need most is better financial services and competent advice. To make innovations more attrac- By Lukas Borkowski, Tobias Stöhr and Linda Kleemann tive to smallholders and reduce the risks they perceive, it is important to test inno- GIZ is running a programme called as the gains an innovation is expected to vations locally and minimise the failure “Green Innovation Centres for the deliver. If poor farmers adopt an innova- rates. This applies particularly to new or Agriculture and Food Sector” (Grüne Inno- tion, it is therefore likely to not cost much improved seeds, the most common kind of vationszentren in der Agrar- und Ernäh- and be implementable small-scale. innovation. rungswirtschaft) on behalf of Germany’s Federal Ministry for Economic Coopera- Farmers showed interest in more More generally speaking, the evidence tion and Development. The centres are sophisticated and expensive innovations suggests that it makes sense to put more designed to drive rural change in 13 deve- with potentially greater impacts, but they emphasis on knowledge-based change loping countries. clearly indicated their inability to finance than merely focus on technology-based such measures from cash-flow, borrow- innovations. What smallholders need In a baseline study for this programme, ing or savings. One in five farmers said most of all, is better financial services and we surveyed more than 5,300 smallhol- inadequate access to credit was a reason professional advice. der farmers. We collected data in Burkina they could not innovate. Relevant issues Faso, Cameroon, Ethiopia, Ghana, India, included prohibitively high interest rates, Lukas Borkowski Malawi, Nigeria, Togo, Tunisia and Zam- excessive collateral requirements and works for the GFA Consulting Group. bia. Focus group discussions served to administrative burdens. put the survey data in context. The goal was to understand what makes farmers Moreover, the farmers wanted better take a new approach. For our purposes, information on the risks of an innovation. “innovation” means that something is new They were likely to refrain even from low- to the farmer, not to the world. Our data risk innovations if they heard of those Tobias Stöhr confirm the conventional wisdom that approaches having failed somewhere. is postdoctoral researcher at the Kiel Institute smallholder farmers tend to be conserva- for the World Economy. tive. Only one third of the interviewed had The data suggest that the best way to introduced at least one innovation in the boost smallholders’ innovativeness is to past 12 months, while 45 % planned to do ensure they have access to sufficient fun- so in the next 12 months. The most popu- ding so they can handle the innovation lar kinds of innovations, both implemen- itself as well as its potential downsides. Linda Kleemann ted and planned, were: Moreover, they need reliable advice to works for GFA Consulting Group and is also ■■ opting for new or improved seeds or ani- take informed decisions. The data show a postdoctoral researcher at the Kiel Institute for mal breeds (31%), that many farmers accuse existing services the World Economy. The three co-authors ran ■■ switching to new planting methods of being biased and not paying enough the baseline study for GIZ, but all views (23%) and attention to risks. However, our data show expressed here are their own. ■■ starting crop rotation (16%). that the farmers’ satisfaction with the exi- [email protected]

The respondents thus appreciated low- Innovation types introduced in the past year cost innovations that are implementable on a small scale. This pattern is particu- Seed or breed larly evident among poor farmers who live Planting technique close to the subsistence level. A possible reason is that they can hardly risk failure Crop rotation since they lack savings and safety nets to Inputs cope with losses. Machinery Focus group discussions showed that Harvesting technique participants carefully weighed the risk of Other an innovation failing against the status quo. Staying able to cope with short-term Storage shocks mattered at least as much to them

D+C e-Paper November 2016 43 Comment Rehabilitate the victims Five decades ago, Indonesia experienced one of its worst traumas. On the other hand, civil society has A military coup toppled President Sukarno, the post-independence made inroads concerning the review of Indonesia’s darkest times. Mass graves leader, and the new regime started to hunt down followers of the have been documented across the coun- Indonesian Communist Party (PKI). The trauma still haunts the try. Small community tribunals have cre- nation. ated spaces for truth and reconciliation. The National Commission of Human By Edith Koesoemawiria Rights even prepared an investigation report in 2012, but its recommendations The clampdown in 1965/66 probably formed the Yayasan Penelitian Korban were put on ice. claimed more than 1 million lives. Pembunuhan 1965/1966 (Investigation This number is an estimate. There are no Foundation for Victims of the 1965/1966 To move matters ahead, Indonesian exact figures. General Suharto, the mili- Massacre). It ran into violent opposition and international human-rights organi- tary dictator, made sure the violence was when it sponsored the exhumation of sations hosted what they called the Inter- never properly investigated or researched. corpses from mass graves in Central Java national People’s Tribunal 1965 in The He stayed in power for three decades, in 2000. Hague. Its final report was published in spreading fear in a nation that had stood July and found the Suharto regime guilty united against Dutch and Japanese impe- Bones of local people who had been of gross human-rights violations. Its pro- rialism. Being related to or associated with buried in the Kaliworo forest after being posals include: anyone considered a communist could killed as alleged communists were found. ■■ The current government of Indonesia mean incarceration, torture and death or Local villagers watched the unearthing of should acknowledge the atrocities. the loss of one’s job. several mass graves. The skeletons were ■■ It should apologise to victims and reha- brought to a hospital in Jogjakarta for fur- bilitate them. Since 1965, two new generations have ther forensic investigation, which confir- ■■ Those responsible for crimes should be grown up in Indonesia. The country now med the crimes. tried in a court of law. enjoys freedom of speech, a free media and open internet access. However, the history News of this systematic attempt to Similar proposals had been considered of Suharto’s power has not been dealt deal with the traumatic past spread like by the National Commission of Human with in public in a systematic and cohe- bushfire. Emotions ran high, and some Rights. rent manner. What happened is still not political forces felt offended. A group of common knowledge, and aversion against self-declared Muslim patriots attacked A lot remains to be done. School anything that might be considered “leftist” the multi-faith reburial of the bones that history books must be revised, for ex- remains strong. was planned on 24 March 2001. They beat ample. So far, what people know, is based people, broke urns and cast bones around. almost exclusively on the individual testi- In 1998, a popular uprising ended The reburial had to be cancelled. The monies of victims and perpetrators, many Suharto’s regime. Abdurrahman Wahid, event showed that whoever tackled past of which have been documented in books who was elected president in 1999 and events was risking trouble. and films. To help Indonesia come to terms served for two years, actually apologised with the past, such knowledge should be to victims in public, but his stance unfor- That is still the case. From January backed up with systematic historical ana- tunately remained exceptional. 2015 to May 2016, government agencies lysis. So far, rumours and anecdotes sup- and non-government agitators prevented port too many diverging interpretations of Historical research became possi- at least 40 events at which civil-society what really happened. ble, however. Jakarta-based intellectuals activists had wanted to discuss 1965/66. Government agencies should heed Making a statement in the recommendations of the Internati- Jakarta: the writing on onal People’s Tribunal. Understanding the umbrella means: what happened 50 years ago will make “Resolve the Indonesia a stronger and more responsi- 1965/1966 case.” ble nation.

Edith Koesoemawiria is a freelance journalist.

Donal Husni/picture-alliance/NurPhoto [email protected]

44 D+C e-Paper November 2016 Comment Much needed injection of capital The China- Economic Corridor (CPEC) is a huge and cannot be fully assessed yet. According to ambitious infrastructure project. If it works out well, it could him, Chinese work culture and speed are amazing. jumpstart Pakistan’s economy. The CPEC has serious geopolitical By Afshan Subohi implications. Pakistan has long been allied to the USA, but the mood has soured, not The CPEC’s guiding idea is to link strong (see D+C/E+Z e-Paper 2016/09, only because of the war in Afghanistan. China’s western regions to the Ara- p. 26 – print edition 2016/09-10, p. 34). Moreover the IMF, which is dominated by bian Sea. The plan is to build an up-to-date The country has a long history of poor western powers, imposed austerity on the commercial port in Gwadar and modernise governance. Moreover, it is located in country, hampering its economic deve- road, rail and other infrastructure projects a volatile neighbourhood, with Afgha- lopment. In this context, Chinese trust in from there to the Chinese border in nistan and Iran in the west, India in the Pakistan’s potential looks inspiring. Pakistan’s northeast. The approach is east and China in the northeast. The wars quite comprehensive and includes power in Afghanistan and militant violence have Pakistan’s leaders are enthusiastic, stations, airport facilities, a metro line in severely affected Pakistan. and the Chinese patrons are unwavering. Karachi and even primary schools. Whether that is sufficient for ensuring Many Pakistani business houses pre- timely completion remains to be seen. The CPEC is getting massive funding. fer investing abroad to building produc- Several CPEC-related energy projects have So far, $ 51 billion of foreign money has tive capacities at home. To many of them, already hit snags, primarily because they been committed to investments in Paki- it looks less risky to invest in Bangladesh, were prepared in haste. Private-sector stan. This sum includes yet another Vietnam, Singapore or Malaysia, for exam- partners now want to renegotiate deals or $ 5.5 billion loan that China’s govern- ple. When the real-estate bubble burst in drop out entirely. ment pledged in September on top of its Dubai and other places in the Gulf states prior commitments. The Asian Develop- a few years ago, massive investments from Some setbacks are to be expected in ment Bank (ADB) had earlier increased its Pakistan were uncovered. any major infrastructure project. If there pledges by $ 2.5 billion, and the new Asian are too many of them, however, projects Infrastructure Investment Bank, which is The CPEC could well make a diffe- get derailed. A big question is thus whether based in , will contribute $ 300 rence. According to Finance Minister Ishaq Pakistan’s institutions prove strong million, partially in a cofinancing scheme Dar, Pakistan desperately needed a major enough to implement the CPEC effectively. with the ADB (see D+C/E+Z e-Paper investment push to escape its “low-invest- If they do, they may actually turn around 2016/06, p. 4). ment, low-growth cycle”. In his eyes, CPEC the country’s economy in the long run. is providing that thrust. Construction work has begun in Paki- Afshan Subohi stan and is apparently progressing well Zahir Shah, who is in charge of the is a business journalist on several sites. The CPEC is a showcase CPEC at Pakistan’s Ministry for Plan- and works for Dawn, Debate model for what China wants to achieve ning, Development and Reform, says: “We a national newspaper with its One Road One Belt policy. This expect a million jobs to be created in Paki- in Pakistan. policy is designed to facilitate growth by stan in the short run.” He adds that the improving transport and business options “long-run impact will be tremendous”, but [email protected] outside the People’s Republic.

The massive capital injection may jumpstart Pakistan’s economy, which desperately needs investments. In the past china financial year, the ratio of investments to afghanistan GDP was a mere 15 %. In 2006/07 it had iran been 20 %. Under- and unemployment are serious problems, especially in view of Pakistan’s huge youth bulge. Pakistan

Pakistan’s investment climate is adver- Gwadar india sely affected by several issues. Pakistan only returned to democracy in 2008. Insti- tutions tend to be weak, policies incohe- rent and mistrust between provinces is

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