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But a lot can happen in thirty minutes. Earlier, I had been looking over some 2009 UNAIDS statistics, and noting the numbers issued in the report. They are all very big, big enough certainly to require the pressing of buttons on calculators. More to the point, I learn that during my thirty minutes, approximately 70 people died from HIV/AIDS in Sub-Sahara Africa. That’s 1.3 million victims each year – in Sub-Sahara Africa alone. Many of these were parents leaving orphans, and many were young children just leaving. Most troubling, however, is the fact that all of them suffered their fate with a loss of dignity.

Why do I say this? I say this because people shouldn’t have to die from HIV/AIDS. There are good medicines out there, and they can control the disease. In fact, for those in the developed world, HIV/AIDS is now considered a chronic disorder, not a death sentence. If you are diagnosed, you are no longer forced to take a shortcut to demise. You can still have a long life, you can still be productive, and you can still live with dignity.

Unfortunately, this wasn’t an option for those who passed away. For them, the medicines were out of reach. They were simply too expensive. And from this, you come to realize a cold hard fact in this narrative: that the fate of a person living or dying from HIV/AIDS is determined by their income. This statement is fairly straightforward, with no mincing of words, or confused rhetoric. But for most, it feels fundamentally wrong, and yet, it is a simple reality of how the world works today. Why it works in this way, however, is complicated.

This, basically, is how the pharmaceutical industry works. They are inventors, and their product is medicine. Research and development costs are significant, both in terms of money and in terms of time, mostly because many of the things they invent do not work out in the end. They get patents, and are compensated and rewarded accordingly – relatively speaking, the pharmaceutical industry is rewarded very handsomely.

This is because there is a market for such things: whether we are talking about antiretroviral drugs for HIV or Viagra for life style needs, in the developed world, people want these drugs (and in some cases, need these drugs), and are willing to pay for them. They do this, because they can, often with help from health care providers and government. The supply and demand is there, and the pharmaceutical industry knows how to play this game. You, the reader in the developed world, make the market.
Because things are so handsome, the pharmaceutical industry has a vested interest in maintaining the status quo. They don’t want to lose any semblance of control, even if, apparently, lives are on the line. They are very good at protecting this control – their lobbying influence is very strong indeed, and they do this with zeal although sometimes by misrepresenting facts.

1. This market doesn’t count because they cannot afford the drugs.

2. This market doesn’t count because they are not part of the pharmaceutical industry’s bottom line.

Consequently, a lot of very clever people have suggested that a way to get around this challenge, this challenge of access to medicine, is to set up ways to produce generic drugs. This is essentially where outside companies can be granted the right to copy the drug and produce it at much lower costs. Just to clarify, the cost of drug production is generally a very small fraction of the final price tag. Anyway, the argument here, is that these rights would be very specific, in that generics could only be sold under strict circumstances such that the status quo is unaffected in wealthy markets. A good example of this, is to simply say that generics can only go to developing markets, can only go to places like Sub-Sahara Africa, since they already do not factor into the industry’s bottom line. Furthermore, the inventors can stipulate royalties, so that they still get compensated for opening up these markets. In fact, in the best situation, the inventors would even produce their own generics.

For a variety of reasons, the pharmaceutical industry has not been keen on this idea, and has done much to make generic production as laborious and slow as possible. Ideally, they would be a willing participant in discussions with generic producers, and bargain fair terms so that these cheaper drugs can be made. Unfortunately, this rarely happens and when it does, it tends to be on an older palette of medicines, things out of date for rich people like us, which may be less effective for a variety of reasons (side effects, efficacy, convenience).

Because the pharmaceutical industry generally does not want to play, the notion of “compulsory licenses” has been pushed to the forefront. I’ve written about these in the past, and they deserve a repeat mention.

To illustrate this, here are some hypothetical (and not so hypothetical examples):

1. You are a company that recently received your patent, so that now your drug is being sold for $1500 instead of the previous $10 pricetag.

2. Your country has experienced a series of anthrax scares. The company that holds the patent for the most effective drug against infection from the offending bacterium, sees an opportunity, and decides to jack up the price.

3. Someone has declared war on your country. To defend yourself, you would like to utilize a particular product. Unfortunately, it is under a cost prohibitive patent and therefore out of reach.

4. There is an impending nuclear power plant meltdown, and there is technology that would be incredibly useful to mitigate radiation contamination and poisoning. However, your resources are already stretched because of the utterly horrific effects of a 9.0 Richter Scale earthquake, and this technology is too expensive at the scale that is required in such an emergency.

5. There are markets where your life saving drug is not being sold because no-one can afford them anyway. However, the drug (which could be a matter of life and death for millions) could be made at a cost (i.e. a generic) that makes it accessible in these markets, but if and only if, the patent over them is adjusted.

Here is the point. In all of the above cases, you would like to live in a civil society where the government can step in and forcibly change the patent, because in every case, there is an element of morality involved. And guess what – governments can do this and they do! It’s called a “compulsory license,” and they exist for this very purpose.

In fact, even the WTO is on board with this idea. They recognize that in some circumstances, such as those pertaining to global health, there needs to be an understanding that using such compulsory licenses is both necessary and an obligation. In fact, if you have a hankering for the legalese that outlines this for patents over essential medicines, you need only look up info on the Doha Declaration.

Unfortunately, there is some serious push back from the Canadian pharmaceutical industry. They lobby government and do so with counter arguments that have already been addressed by this expert peer review, such that many have been calling the pharmaceutical industry unethical: that their reasons for fighting are based on misinformation. Most of their arguments appeal to those that value ownership, that their properties, inventions, and monopolies are in danger because of careless policy, but that could not be farther from the truth. They simply don’t want to lose any semblance of control. Despite these tweaks being carefully scripted to protect their business interests, the pharmaceutical industry still regards them as a starting point to a “possible” loss of control. Because of this excessive anxiety, they fight and they fight and they fight. For those interested in endings, this one is severe: Bill C-393 was killed.

Sometimes, they fight in other ways. In the case of Free Trade Agreements between the European Union and India, one of the battles over generic drugs concerns the issue of “data exclusivity.” This is a technical term that essentially says that even if a patent is not holding things back, a company still can halt the process. Here, a bulletin recently released by Doctors Without Borders describes it well:

Data exclusivity (DE) is a backdoor way for multinational pharmaceutical companies to get a monopoly and charge high drug prices, even when their drug has been found to not deserve a patent, or the patent has expired – DE would apply to all drugs.

If India accepts DE, the agency in charge of approving medicines for use in the country would not be allowed to register a generic version of a medicine for a period of time – usually 5 to 10 years. To register a generic, producers rely on the clinical trial data provided by the originator company to show the drug is safe and effective. All the generic has to prove is that it is identical to the originator product. But if DE were in place, the originator company’s clinical trial data would be protected by ‘exclusivity’ and generic producers would therefore have to submit their own safety & efficacy data to register the generic medicines. This would oblige them to repeat clinical trials—something that would take years and be incredibly expensive, not to mention unethical, as it would involve withholding a drug that has already proven to be effective from some of the participants in the trial.

And so things drag, time passes, and minutes, days, and years are wasted. To call this delay an act procrastination sounds too contrite. I can certainly think of stronger words.

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To get involved there are a number of places I can recommend. Firstly, an informal blog collective has been set up to discuss these issues in a more layman and easy to read manner. This blog is called “My Rights Versus Yours” and includes a cast of students and academics who are involved in various aspects of the Access to Medicine cause. We aim to have posts that deal with the various issues at stake including pieces about both the science and policy involved. This is a new blog, but we are hopeful that many will find it both useful and enjoyable to read. You can follow the blog on twitter or better yet, partake in its first Global Health Carnival. If you’re a Canadian reader, I strongly urge you to check out aidsaction.ca particularly the page which asks our candidates to endorse and support the reform of Canada’s Access to Medicines Regime. Timing is crucial here, as a Federal election looms. If nothing else, just make sure you vote.

The Second Coming, William Butler Yeats

“Scientists identify gene that influences quality of person’s empathy”… “Earth ‘heading for 6ºC’ of warming”… “From the lab, a New Weapon Against Cholesterol”. These three headlines were taken from three leading and reputable media outlets: the Times of London, the BBC and the New York Times. Apart from their provenance, these headlines share another, arguably less desirable, trait. All massively simplify the scientific primary sources they are reporting. But why would such erudite news sources feel the need to simplify so much? One oft offered answer is that this is a necessary step in making science comprehensible for the general public. Yet, as the British physician and writer Dr. Ben Goldacre points out, ‘Nobody dumbs down the finance pages…[but]…imagine the fuss if I tried to stick the word “biophoton” on a science page without explaining what it meant.’ In his many articles on this subject Ben Goldacre often points to the over-representation of Arts majors in editorial positions as a cause for the over-simplification of science in the media suggesting that they simplify science because they themselves are unable – or unwilling – to understand it. While this may be a slightly uncharitable view of our good friends with tweed and corduroy and Penguin paperbacks, the results of this over-simplification are undeniable. Rather than seeing an increased public understanding we see an increased public misunderstanding. The inaccuracies and simplifications of journalism science lead to pertinent pieces of information being left out. Also, overconfident language that does not allow for the possibility of incorrectness or incompleteness in the primary research leads to even more confusion and mistrust of science. While there are many positive aspects of science reporting, the negative aspects indicate that there is also much room for improvement.

The Bad

One can say, without fear of contradiction or dissent, that Science (and I intend the capital ‘S’) is an altogether overwhelming topic. It comprises fields of study that range from the taxonomy of soil bacteria to the birth of the universe and its three traditional (within universities at least) subtopics of Biology, Chemistry and Physics are outdated and inadequate in the ever-deepening and evermore interconnected pursuit of scientific knowledge. Thus it expects too much of someone, even a trained scientist let alone a layperson, to possess an understanding of everything to do with Science. However it is not too much to ask that the layperson should understand the complexity and subtlety of Science. It is here that the way in which the media covers Science first lets us down. In the age of the Internet, 24-hour cable news and satellite TV there is more news space to be filled than ever before. Additionally, there is much more competition to attract viewers and readers. This leads to a pressure to sensationalize scientific discovery, to make it more ‘sexy’. While this may aid TV ratings or website visit counts, it does nothing for the quality of the reporting, turning carefully worded conclusions into short, inaccurate sentence fragments. Currently, one of the most important fields of scientific inquiry is climate science. However, it is also one of the most susceptible to over-simplification and inaccuracy. Hardly a day goes by without another study or report being announced that contains a prediction regarding global temperature changes, sea level or emission levels. In addition, each report arrives it usually contains slightly contradictory or different conclusions than those that preceded it. By simplifying the contents of these studies to a simple phrase about temperature increase, such as the headline of the BBC story at the beginning of this essay, the story seems to indicate that the study is sure of its claims. In actuality, just like any other scientific report, the authors make, state and defend a set of assumptions that they used in their model or calculation. These assumptions get no mention in the news story, leading to one of the most common causes of misunderstanding: contradiction. If two news reports appear about two separate studies, the first from a respected climate scientist and published in Nature Geoscience and the second from the United Nations, that respectively predict global temperature increases of 6ºC and of anywhere between 1.4 to 3.8ºC a hypothetical reader of both would conclude that either both are wrong (and that perhaps this whole climate change thingy is a load of hooey) or that one is wrong and the other right. This is a false choice as if presented with a full set of the facts, our reader would be in a position to conclude that both had elements of truth and be able to make a rational, informed decision about what to believe. However, this is rarely the case unless the reader makes a concerted effort to dig into the primary literature which unless they are either very rich or have access to a university library is very hard, though the issue of open source scientific literature is another story altogether.

One of the cornerstones of science and scientific thought is the acceptance of fallibility and the acknowledgement that one may be wrong. It is this acknowledgement of fallibility that allows for scientific progress. It allowed Nicolas Copernicus to question Ptolemy’s astronomical model of the Solar System, replacing the Earth with the Sun as the centre. It allowed for Albert Einstein to revolutionize Newtonian physics. Yet, more often than not, scientific discoveries are portrayed in the media as being absolute and infallible. This presentation of scientific results as being completely true gives readers the idea that if a scientist is reported says it is true than it must be. That other scientists might refute the presented ideas, while a perfectly normal occurrence in scientific circles, is reported as controversial. The upshot is generally a mistrust of science in general. A good example of this was the measles, mumps and rubella (MMR) vaccine scare in Britain in the late 1990s. A paper in the respected medical journal the Lancet that posited a link between the MMR vaccine and autism sparked the media frenzy. The article’s findings were highly controversial, but the media coverage made no mention of this and the public largely accepted the findings. When the rest of the scientific establishment countered the findings, the news coverage gave equal weight to both sides of the argument. While it is a generally laudable trait to be objective when writing the news, it is misleading when one side of the story is almost certainly incorrect. As with the previous example about climate science, the result was a confused public, left unsure of what to believe in by inaccurate media coverage.

The Good

Of course, not all reporting of science is bad and at the very least it is a necessary evil. While one may decry the over-simplification and blanket statements, the public has a right to know just what is going on behind the locked doors and safety glasses, it is after all their tax dollars that are being spent and it would be arrogant in the extreme to assume that the Average Joe doesn’t care about science. On balance, more good is done than harm and there are many excellent sources for excellently written science news. The Guardian website has very good coverage, as does the New York Times though it was criticized at the beginning of the essay. Nonetheless, the bulk of news stories that one reads about science are either incorrect or inaccurate. If media coverage of science is inaccurate due to a belief that science is too complicated for the general public to understand, that is an excusable but incorrect assumption that should be changed. However, in some cases, it seems as if the media coverage of science is intentionally perverted to make the story more controversial or exciting. This insidious altering of the facts is inexcusable and must be done away with.

The Future

We live in a surprisingly credulous age and it behooves those that write about science to be very careful with how the report the scientific advances of the day. They must be constantly aware that their reports are in media res: the readers are arriving at the story in the middle without any knowledge of what research came before this latest study. Thus, science stories must be placed in context, much like a book review references the author’s previous work and other contemporary writers of the same genre. In our example concerning differing projections for global temperature rise; it would have improved the BBC story greatly to include a mention of other studies and predictions. All to often it appears that these contextualizing facts and reservations are excluded in favour of the more dramatic elements of the story. It is also necessary that the reporters and editors that cover science have more faith in the intellectual ability of their readership. The idea that science must be simplified to be comprehensible demeans the reader and, as we have seen, can lead to confusion, mistrust and misunderstanding.

While it would be ludicrous to publish unadulterated scientific articles in major newspapers or news websites, the complex, subtle and fallible nature of science must be embraced and acknowledged in news stories about science. To return to Dr. Ben Goldacre’s contention, we should be putting words like biophoton into the news for while we may not live in an age where one can know everything, we do live in an age where – through the Internet – one can find out anything they wish to know.

References

“Don’t dumb me down”, Ben Goldacre, The Guardian: link [accessed 16 November]

“Earth ‘heading for 6C’ of warming”, Richard Black, BBC News: link [accessed 18 November, 2009]

“From the lab, a New Weapon Against Cholesterol”, Anne Eisenberg, The New York Times: link [accessed 21 November, 2009]

“MMR vaccine controversy”, Wikipedia: link, [last upated 23 October, 2009; accessed 19 November, 2009]

“Scientists identify gene that influences quality of person’s empathy”, Mark Henderson, The Times Online: link [accessed 17 November, 2009]

“The UN Global Warming Report: Facts and Predictions”, reviewed by Thilo Kunzemann for Allianz Knowledge: link [accessed 18 November, 2009]

Culture, our ability to pass information, artifacts, and other non-genetic material from one generation to the next, operates on much smaller time scales: millennia, centuries, even decades. The larger cultural landscape consists of religion, language, governments, laws, etc. and many of these change so quickly that they have only been in their present form for hundreds or (in a few cases) thousands of years. It is the blinding speed of culture that has allowed humans to break free of the ecological niche evolution alone would have forced upon them.

One of the subsets of culture is technology, which allows us greater control and understanding of our environment and provides us with new or expanded senses. Technological change occurs on the scale of years to months and is currently outpacing culture at large. The current fad in new technologies is to make these available to a large percentage of the population (literacy, vaccines, video recorders, telephones, etc.) and suddenly many people have the ability to do things for which we have no cultural “rules”.

Sexting is a grand example of the intersection of evolution, culture, and technology. Our prehistoric bodies evolved the desire (possibly need in a normal healthy person) to have sex from puberty on and not just for procreation but for recreation as well [1] (this is why sex is more fun than, say, wearing matching socks). The American sexual culture [2], heavily based on Iron Age religions (which tend to demonize sex, especially for women) and the Victorian era “Body Taboo,” has produced a culture that equates nudity with sex (our laws only barely distinguish between the two). The near instantaneous onset of the cell phone camera represents a technology that allows the “biological human” to do something that the “cultural human” abhors. The best examples come from minors sexting semi-nude photos of themselves to friends and later being charged as child pornographers.

This disjunct between rates of evolution, culture, and technology isn’t new. History shows us that our bodies are very bad at evolving to act the way culture tells us; circumcision and homosexuality being grand examples. But the modern drive to make technology available to the masses means that when human desires run counter to cultural rules (“values”, “morals”, laws, etc.) there will be a larger pressure placed on culture to change. Sexting was first reported in the mid 2000s and by 2009 laws were introduced to allow consensual sexting among minors. Presumably faster technological changes will drive faster and faster cultural changes until, someday, some aspects of our culture will be so futuristic they’ll be prehistoric.

1. See Why is Sex Fun? by Jared Diamond and The Naked Ape by Desmond Morris

2. See Sex, Society and History by Vern L. Bullough

Maternal health refers to the health of women during pregnancy, childbirth and the period after delivering a child. Pregnancy can be a rewarding experience once adequate healthcare is available, however; pregnancy for many women is associated with suffering and often death. Efforts toward improving maternal health began a long time ago at a conference in Kenya, where attention was drawn to the poor maternal health in many developing countries, and the need for countries to address the high rate of maternal-associated deaths [4,5]. These efforts, arising from the launch of the Safe Motherhood Initiative in 1987, were met with grand support by governments and NGOs, and were somewhat successful. Yet maternal death rates did not decline as anticipated [4]. Efforts toward improving maternal health were strengthened again in 2000 when world leaders of 189 member states of the UN made a commitment, through the development of the Millennium Development Goals (MDG), to use stronger efforts to defend the vulnerable. The MDG consist of eight specific, measurable, time-bound goals which should result in a better, more equitable world once achieved [4,5]. There has been significant progress in many of the MDGs but nine years after their generation, and five years prior to the deadline, there has been virtually no progress in the critically important goal improving maternal health.

The grim picture painted in the recent MDG update released in December 2009 points to the existence of inequity that belies the social development and innovation that is so characteristic of this information age. That 536,000 women and girls die as a result of preventable complications during pregnancy, childbirth, or the six weeks following delivery every year is appalling [1]. Half of these deaths (265,000) occur in sub-Saharan Africa and another third (187,000) in Southern Asia, together accounting for 85 % of all maternal deaths [1,2,5]. Incidentally, the main direct causes of death in these regions are described by the UN as “preventable” [1]. More specifically, 34 % of deaths in sub-Saharan Africa result from hemorrhage, with infections, high blood pressure, and prolonged or obstructed labor accounting for the remainder of deaths. Anaemia, which is made worse by the prevalence of malaria, HIV and other conditions, greatly increases the risk of maternal death from haemorrhage [1].

If these deaths are preventable, why then has there not been a decline in the number of maternal deaths in these regions over the past decade? Upon further analysis, the key message being sent by the UN statistics clearly demonstrates that access to reproductive health is a privilege of the rich. That access to reproductive healthcare is directly related to economic status can be seen both between and within countries. This is especially clear when considering the number of maternal deaths per 100,000 live births, or maternal mortality ratio (MMR) between countries. Sub-Saharan Africa for example, suffers from the highest MMR at 920 maternal deaths per 100,000 live births, followed by South Asia, with an MMR of 500. This compares with an average MMR of 8 in industrialized countries [3]. More specifically, in Ireland, women have a 1 in 47,600 lifetime risk of dying during pregnancy or from a birth-related cause; while in Niger 1 in 7 women face lifetime risk [1]. With respect to within country disparities, the same pattern is evident [1,3]. In the United States of America (USA), there a link between economic status and racial background that impacts maternal health care access. For example, despite the fact that black women represent only 32 percent of women, they make up 51 percent of women that are less likely to have access to adequate maternal health care services [6]. They are more likely to die in pregnancy, childbirth, and in high-risk pregnancies than the rest of the population.

There is now “intensified” commitment to improving access to reproductive health. But how will the NGOs, governments, policy makers, and health care providers ensure that this problem is given the required political and financial attention that is necessary to reduce maternal mortality? How will they ensure that the failures of the past no longer haunt future progress? First, policy makers must tackle at least three key factors when addressing maternal health in these regions; accessibility of resources, equity, and financial commitment. According to the UN Children’s Fund (UNICEF) and the World Health Organization (WHO) recommendation, pregnant women should have a minimum of four antenatal visits [1]. These visits provide women with access to important services, such as tetanus vaccinations and screening and treatment for infections, as well as potentially life-saving information on warning signs during pregnancy. The statistics indicate that basic care is still unavailable to many. In Southern Asia and sub-Saharan Africa, more than half of all births still take place without the assistance of trained personnel, demonstrating that this need is unmet [1].

Secondly, global and local leaders, and governments must promote interest in these issues. Improvement of women’s heath is a basic human right, and is absolutely necessary for promoting development. In fact, addressing the issues plaguing pregnant women and their newborns is at the helm of such advancement. Indeed, I would argue that Millennium Development Goal number 5 “Improve maternal health”, should be used as the gauge for measuring overall progress and governments’ commitment to safe, equitable countries with growing economies.

Thirdly, and most importantly, there must be improved and sustained investment in this cause. Since an infant’s risk of dying in his or her first year of life is 60 per cent higher when the mother is under the age of 18 than when the mother is older, educational programs geared to young women can have a significant benefit which may lead to reductions in death [1]. Of utmost importance to improving maternal health in developing countries is high level commitment and sustained funding toward education and family planning. Given that pregnancy early in life contributes to an estimated 70,000 maternal deaths among girls aged 15 to 19; governments in affected countries should commit to family planning and education as the foundation of any successful maternal health program [1]. Interestingly, instead of increasing support in these areas over the past decade, the UN MDG update indicates that there has been diversion of resources from family planning and sex-education, citing funding gaps as the major obstacle accounting for the failure towards progress in this area. Specifically, there has been a greater than 50 percentage reduction in donor assistance for family planning programs per woman aged 15 to 49 between 1996 and 20061. Where the monies are being shifted to is not clear. What is clear is the low concern for women’s health in these societies, and the lack of commitment to improving maternal health.

Targeting these three areas would undoubtedly improve access to reproductive health. Therefore, failure to make progress in all of these areas over a nine year period points to many short-comings, most notably, a lack of political will. This is especially obvious in the Sub Saharan region, where the death toll has remained unchanged over the decades [2]. Granted, many of these countries rely on international aid programs which, when diminished or reneged, result in the closure of relevant programs. Nevertheless, given that most deaths are preventable (over 90%) small measures taken in affected areas are bound to have significant positive effects, which will ultimately lead to a significant decrease in the number of deaths. The lack of political will is also evident internationally, primarily when countries renege on their pledges, or when financial support for maternal programs is absent. This lack of will is at the crux of the battle for improved maternal health. Thus, substantial change will result only when foreign governments and agencies are held accountable and demanded to pay the monies they pledged, and when local governments in affected countries place maternal health at the top of their public health agendas. This will ensure that preventable death is not the outcome for giving life.

There are a few key questions that must be answered before MDG 5 gets off the ground. Firstly, how exactly does political will become strengthened? More importantly, who determines the political will of a government? There are likely many ways to increase political will. But the most remarkable change occurs when issues like universal access to maternal health are considered to be of common interest by “everyday people”. When people are interested they raise their voices, demand accountability, and engage their political leaders, teachers, and press. We must demand vigilance from our press. How often does maternal health appear in the headlines? Yet, every minute of every day, a woman will die because of poor care during or immediately after pregnancy. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities.

We must also demand vigilance from our educational institutions. What efforts do “world-renowned” institutions make towards addressing such issues? How is the scientific innovation generated at universities translated to influence policy and treatment for women? When relevant drugs are discovered, are they available to the neediest? We live the era of innovation, antibiotics, specific vaccines, pediatric intensive care, biotechnology, and globalization, but these new developments have had very little impact on maternal health, in developing countries. Instead, developed nations have efficiently reduced already low numbers of maternal associated deaths, while the numbers in developing nations remain largely unaltered. How do we disrupt this vicious cycle?

In MDG 5 countries have made commitments to improving maternal health and reduce the global maternal mortality ratio by three quarters between 1990 and 2015. However, very little progress has been made and the maternal mortality ratio declined by only 5% to date. Reaching this goal now requires accelerating progress. Developing countries have many challenges to overcome before their healthcare systems will directly mirror that of developed countries. However, since early pregnancy, insufficient prenatal care, and the unavailability of medicines are three important contributors to death, sustainable intervention on a country-to-country basis must include education, improved access to essential health care and medicines, and development of health care infrastructure. Most importantly, these efforts must be sustained to bear fruit. Science and innovation can improve access to relevant materials but researchers and educators in developed countries and at leading research institutions must commit strongly and entirely to knowledge translation and international development. This will enable policy makers in developing countries to develop more sustainable approaches to improving access to life-saving services. This will also ensure that governments of developing countries maximize their limited resources by focusing on the most efficient medicines and technology. Most significantly, the general public must be stimulated to act on behalf of the vulnerable. Increasing public interest in maternal health may have a strong effect and can ultimately result in faster improvements in reproductive health for all women.

References

1. The United Nations. The Millennium Development Goals Report 2009. Pages 26-32.
Accessed on: 11/12/2009. Last Updated: June 2009
Url: link

2. Lieve Fransen. 2003. The impact of inequality on the health of mothers. Midwifery, 19: (2), 79-81.

3. UNICEF. Child info: Monitoring the Situation of Children and Women.
Accessed on: 28th March, 2010. Last Updated: September 2008
Url: http://www.childinfo.org/maternal_mortality.html

4. Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M, Suzuki E; Maternal Mortality Working Group. 2007. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet, 370(9595):1311-9.

5. O’Heir, J. 2004. Pregnancy and Childbirth Care Following Conflict and Displacement: Care for Refugee Women in Low-Resource Settings. Journal of Midwifery Womens Health,
49(4 Supplement 1):14-18.

6. Amnesty International. 2010. Deadly delivery, The Maternal Health Care Crisis in the USA: Summary. Accessed on: 28th March, 2010. Last Updated: 12th March, 2010
Url: http://www.amnesty.org/en/library/info/AMR51/019/2010/en

7. Levine MM, Robins-Browne R. 2009. Vaccines, global health and social equity. Immunol Cell Biol. 87(4):274-8.

(If you want to leave a comment about the talk, please do so here).

Topic: Alex discusses the influence of gender in his own life in this TEDx talk, describing both medical and social perspectives of gender in our daily lives and the impact and consequences these perspectives bring to every individual.

Links:
Transgender Health Program, VCH, TEDxTt09

Filmed by Craig Ross at TEDx Terry talks 2009 (October 3rd, 2009). Video edited by David Ng.

This inevitably raises the question if water is a “human right”: Should everyone have access to clean water? But how should water supply and consumption be regulated to guarantee both universal access to and sustainable use of this precious resource? Arguably, less water would be wasted if it were priced at market value. Would this scarce resource be better managed if water were treated as a commodity, and traded and priced accordingly?

Canada has been blessed with large freshwater resources and is often termed one of the “water-richest” countries in the world. So, why can’t we just lean back and enjoy nature’s plentiful supply? With increasing water shortage in other regions of the world, water-rich countries are brought into play as possible sources and suppliers of the Blue Gold. This raises the question if we should share our abundant supply with those who are desperately in need of water. It is not so much a question of engineering pipelines but – first and foremost – of putting adequate and sustainable governance and management systems in place to regulate water supply with all environmental foresight necessary.

What makes water so special?

We tend to think of water as something consumed, but water does not actually “get used up” – and understanding the issue of water shortage requires some counterintuitive thinking. The amount of water on our planet does not change – only its distribution. In a continuous cycle, the same water molecules evaporate from the oceans and the land surface into the atmosphere, drop onto the land as precipitation and transfer back to the sea (hydrologic cycle). Groundwater occurs in the tiny spaces between soil particles (silt, sand, and gravel) or in cracks in bedrock. In many cases, groundwater is interconnected with lakes and rivers and often resurfaces as springs. The underground areas of soil or rock where substantial quantities of water are found are called “aquifers” and provide most of the water supply in regions where the surface water is scarce or polluted. Aquifers are important sources of irrigation water and are used extensively for municipal, domestic, and industrial water supplies.

Groundwater resources may, however, become depleted when the rate of recharge does not match the amount of water withdrawn – either a result of overpumping, the extraction of groundwater in excess of supply, or decreasing recharge, e.g. caused by droughts. Due to their inaccessibility, most aquifers cannot be “cleaned up” once they have been subjected to contaminants. Moreover, as aquifers can be buried hundreds of meters below the earth surface, it may require decades or even hundreds of years for them to replenish. Deeper aquifers, in particular, may not recharge because the weight of overlying sediments causes the aquifer to compress as the water is pumped out, i.e. it may not recharge for generations, if at all.

An additional degree of complexity is added by the intimate relation between the water cycle and the climate: The climate of a region largely determines the evaporation, precipitation and ultimately the local water supply. The average annual water flow, its seasonal distribution and its variability can be directly affected by climatic changes resulting in an increase in the frequency of extreme weather events and may further put the availability of fresh water at risk. Water supplies may ultimately become scarcer as a combined effect of extreme weather patterns, an increase of water evaporation and a reduction of stored fresh water resources in glaciers and snowpacks.

The world’s water: human right or commodity?

The World Bank considers access to clean water a “human need” rather than a “human right” [3]. What seems a subtle difference at first glance, actually allows for two fundamentally different interpretations: a human need can be supplied by the market – in other words, water becomes a trade good, a commodity which is subject to principles of profit. Human rights, on the other hand, cannot be traded. Up to this date, however, the right to access to drinking water has not been added explicitly to the Universal Declaration of Human Rights [4]. It is argued that access to water is included in the right to an adequate standard of living [5] leaving substantial room for interpretation.

The issue of water privatization is fairly recent. Historically, private companies showed little interest in owning or managing water utilities as there was little or no profit to be made. Water and sanitation have traditionally been supplied by public utilities. Limited public budgets are, however, increasingly driving governments to foster the privatization of water supplies, mainly centred on two reasons: apart from securing additional revenue by selling water licences to private companies, many governments regard it as means of improving public infrastructure and service delivery without tremendous public investments. Furthermore, multinational corporations such as Suez, Veolia Environment and Monsanto see lucrative business opportunities as freshwater resources become rare [6].

Traditionally, water management was limited to safeguarding public water supply by maintaining infrastructure for water storage and distribution but did not focus on reducing water demand. In many municipalities in developed countries, and in North America in particular, water pricing does not encourage water conservation as it rarely reflects the true cost of water. Hence, pricing water at market value has the potential to prevent overconsumption, as long as financial assistance for low-income households still guarantees universal access to drinking water. In addition, environmental laws should require private corporations bear the environmental costs of their operations.

The World Bank, in particular, actively fosters the privatization of water services in developing countries [7,8]. This raises the question, if market-oriented policies that may hold for market economies in “developed” countries can be transferred to countries with a thin domestic capital market or severe debt problems [9]. For instance, Tanzania [10] and Guinea-Bissau [11] have recently received funding under the condition to promote water privatization in their countries. The profit-orientation of private corporations often results in poor water quality as investments in costly equipment and qualified workers are kept low. Depending on the degree of privatization and monopoly – the company’s power to control the water market – one particular company may receive the exclusive right to control the price. An estimated number of one billion people worldwide lack access to safe, potable, and affordable water [12] and increasing water prices may make this essential resource unaffordable for even more low-income families.

On the flipside, it is important to note that water privatization is not necessarily “bad” per se: Many economists argue that private businesses are more cost-efficient and effective in providing services than the public sector. Even if a particular private corporation failed to provide adequate service, one needs to consider the quality and availability of water and the state of the supply system before this company entered the market. Understandably, private corporations will only consider capital investments in infrastructure to expand water delivery systems to poor urban communities, if they can expect a reasonable profit. Yet the profit motive on its own is not enough to condemn privatization as a bad idea or a particular company as exploitative.

Privatization can take various forms with local governments having different degrees of control over water distribution, the infrastructure investments or water pricing. Public tenders, where local government request bids from private contractors to design, construct, operate, and maintain public facilities are a common form of privatization. It allows for competition while giving the local government opportunity to intervene should the company fail to provide adequate service. Privatization, however, becomes more controversial when pumping plants and distribution systems or even water as resource (in form of aquifers or surface water) are sold or transferred to private corporations, allowing a particular company to dictate the price. In developing countries, privatization makes most sense where governments lack the capacities to provide basic public services to their people. However, privatization promotes exploitation in countries where weak or corrupt governments fail to adequately control and regulate the private sector.

On Guard for Thee?

Canada has 20% of the earth’s freshwater, but only 7% of the world’s renewable freshwater supply – the rest is fossil water, water left over from the ice ages trapped in ice, snow and glaciers [13]. Water for profit, however, may take a number of other forms which bring the worldwide water crisis home to Canada: international free trade agreements such as the North American Free Trade Agreement (NAFTA) and World Trade Organization (WTO) have the potential to create international markets for water – be it in bottles, by shipping or building canals and pipelines. Canadian legislation currently prohibits the bulk removal of water from major watersheds. But how will the federal and provincial governments position themselves in a world where more and more countries are running short of water? It is expected that by the middle of the century, up to 6 billion people may live in countries where water is in short supply [14]. This will ultimately not only impose a tremendous pressure on Canadian water export regulations, but also holds the promise of big profits. Given that the removal of large quantities of water will most likely have irreversible effects on the ecosystem, it is of utmost importance not to place short-term profit over environmental sustainability. On top of that, an international water market would be beneficial to only those places in the world that can afford the high water prices rather than to those who are in most urgent need of water.

Nonetheless, it would be fatal to ignore other countries’ demands for water while most parts of Canada seem to be blessed with freshwater resources. It is rather time to conserve our own resources, for example by installing more water meters to move away from flat-rate contracts. Pricing water according to consumption rate has proven to promote water conservation. In order to minimize international tension, sustainable water management calls for the implementation of local alternative water supplies, be it the efficient use of rain water, water desalination plants or water recovery systems. In regions that heavily rely on irrigation, developing alternative agricultural crops and techniques may be part of a solution toward sustainable water use and management. Concerted international efforts are necessary to conserve this precious resource but also provide access to clean water for all – so that water does not become a new source of conflict.

References

[1] United Nations Expert Meeting On World Population in 2300, New York, December 2003.
Accessed November 17, 2008 (link).

[2] World Population Prospects: The 2006 Revision Population Database, United Nations.
Accessed November 17, 2008 (link)

[3] Comprehensive Assessment of the Freshwater Resources of the World, Preparation coordinated by Stockholm Environment Institute (SEI), 1997. Accessed November 17, 2008 (link)

[4] Universal Declaration of Human Rights, UN Office of the High Commissioner for Human Rights. Accessed November 17, 2008 (link)

[5] General Comment 15: The Right to Water (Articles 11 and 12), UN Office of the High Commissioner for Human Right – Committee on Economic, Social and Cultural Rights, 2002. Accessed November 17, 2008 (link)

[6] V. Shiva, Water Wars: Privatization, Pollution and Profit, South End Press, p.88, 2002.

[7] Policy Paper, World Bank – Water Resource Management, p.15, 1993. Accessed November 17, 2008 (link)

[8] Ibid. p.42.

[9] J. Vickers, G. Yarrow., Economic Perspectives on Privatization, Journal of Economic Perspectives, vol. 5, no 2., p.111, 1991.

[10] Press Release No:2003/384/AFR: Tanzania Receives US$250 Million To Support Government’s Efforts To Reduce Poverty, World Bank, 2003. Accessed November 17, 2008 (link)

[11] Press Release No:2006/468/AFR: World Bank Supports a Program to Rehabilitate National Infrastructure, World Bank, 2006. Accessed November 17, 2008 (link)

[12] V. Thorne, W. Thomas, Issues of Water Scarcity and Multinational Corporations, 18 Nat. Resources & Env’t, 13, 2003.

[13] A Primer on Fresh Water, Environment Canada, 2006. Accessed November 17, 2008 (link)

[14] The United Nations World Water Development Report – Executive Summary, 2003. Accessed November 17, 2008 (link)

(If you want to leave a comment about the talk, please do so here).

Topic: Dr. Jennifer Gardy, an alumnus speaker at the event, is co-leading the new genome research lab at the BC Centre for Disease Control (BCCDC). She is also known as Nerd Girl from her Globe and Mail blog of the same name. In her talk, Gardy shared how advances in technology have provided increased collaboration on scientific research and scholarly publications — what she labelled as public health 2.0.

For example, she showed how one publication had 36 authors. After leading the audience through the origins of H1N1, she stated how it only took five days from the sequencing of the virus to the first open-source paper. Gardy ended her talk emphasizing how students should be willing to explore the benefits of Open Access publications, collaborative research, and emerging technologies. (From Phillip Jeffrey’s Macleans’ oncampus blog)

Links:
BCCDC, Nerd Girl, Phillip Jeffrey, TEDxTt09

Filmed by Craig Ross at TEDx Terry talks 2009 (October 3rd, 2009). Video edited by David Ng.

Presented on March 10th, 2009 at the Second Annual Most Exceptional Escapades in Science (This Time Also Darwinian) High School Student Conference, Michael Smith Laboratories, University of British Columbia.

Although bananas may only look like a fruit, they represent a wide variety of environmental, economic, social, and political problems. The banana trade symbolizes economic imperialism, injustices in the global trade market, and the globalization of the agricultural economy [1]. Bananas are also number four on the list of staple crops in the world and one of the biggest profit makers in supermarkets, making them critical for economic and global food security [2]. As one of the first tropical fruits to be exported, bananas were a cheap way to bring “the tropics” to North America and Europe [3]. Bananas have become such a common, inexpensive grocery item that we often forget where they come from and how they got here.

Bananas are cheap for a reason, having adopted unfair work trends (such as low wages and long hours) which are found in many global industries. Consequently, the lives of workers in developing countries have been sacrificed in order to keep bananas affordable [4]. Employees face shocking working conditions and extremely low wages. Furthermore, the large transnational banana companies that control wages, prices in the global banana trade, represent a real threat to small farmers [5]. In fact, economic wars have been fought over bananas, and they are the continuing cause of economic and political problems. They are also one of the most environmentally harmful agricultural industries [6]. Produced on multiple continents and consumed around the world, who knew that this popular, healthy fruit could cause such massive destruction?

How did bananas become such massive problem?

The history of the banana industry is long, dark, and complex. Economic and political problems and the mistreatment of workers date back to the late 1800s in Honduras, when the first railway system that connected Central America with North America was built. Bananas are a very difficult fruit to transport and keep fresh, and the railways allowed the export of bananas [7]. American businessmen very quickly bought large plots of land and shipped bananas to the United States, and a very prominent American corporation called the United Fruit Company (UFC) controlled the trade. UFC soon owned much of the best agricultural land in countries such as Guatemala, Honduras, and Nicaragua, and the banana industry grew exponentially between 1900 and 1930 [8].

At this time the term “banana empire” or “banana republic” emerged, appropriately named because UFC held incredible economic and political power in these countries [9]. For example, in 1930 UFC owned 63 percent of the 103 million bunches of bananas exported from Latin America [10]. The extent of their power and control was possible because Central America, a continent which historically had been economically weak and politically divided, was powerless against the large corporation. UFC thrived on the lack of unity, poverty, and corrupt governments [11]. Businessmen were able to manipulate governments to get the best land, and vertically integrate the industry to control all aspects of production and keep prices low [12] . Over the next few decades, Ecuador and many Caribbean islands joined the banana trade, while other transnational corporations emerged. Although these new producing countries greatly profited from the enormous amounts of exports, production of other industries declined, leading to an unhealthy dependance on the banana.

The banana industry in Latin America peaked in 1930; thereafter, the transnational corporations slowly lost much of their political influence in the banana republics, due to a number of factors such as plant disease, the great depression, and labor issues [13]. However they were still keen to keep a presence in Latin America, and in the 1950s, these transnational fruit corporations intervened when the Guatemalan government attempted to take back land from the corporations to distribute it among the peasants. The American government, backed by the transnational fruit corporations, overthrew the democratically elected government, and helped elect a president who favored their economic interests [14].

Later, in the 1990s, economic wars began between Britain, the United States, Latin America, and the Caribbean [15]. These “wars” which were fought over tariffs, import licenses, and the question of free trade, continue until today. Many complicated agreements exist, and determine which countries may export bananas to which markets. This is a major topic of debate within the World Trade Organization [16]. However, the biggest problem is that developed countries are continually searching for the cheapest bananas, and are willing to ignore the abominable treatment of workers and the worst environmental practices. Many countries around the world are now involved in this trade, and responsible for its political, economic, social, and environmental problems.

Where and how are bananas produced?

Bananas are produced in tropical climates around the world, from Mexico to Brazil, from to the Philippines to Madagascar. For the most part, bananas that are grown for export are grown in large scale plantations up to 100 square kilometers [17]. There are over 300 species of bananas, yet only one is grown for international trade: the Cavendish [18].

Banana plants take ten months to grow from a sapling to a fruit bearing tree [19]. The fruit is harvested four to five months later, while they are still green, in large bunches that can weigh up to 80 kilograms [20]. They are then taken to a packing site where they are separated, washed, wrapped and boxed. High esthetic standards must be met, and only “perfect” looking bananas are considered acceptable; any that are blemished are thrown away. The United Nations Agriculture Organization estimates that 30 to 40 percent of bananas are discarded based solely on appearance [21].

The enormous boxes containing the bananas are shipped around the world on freighters with intensive refrigerated units where the bananas are stored in order to prevent pre-mature ripening. It is estimated that this type of shipping accounts of five percent of world carbon dioxide emissions [22]. Once the fruit arrives in the country of destination, they are artificially ripened in warehouses by spraying them with a chemical called ethylene in carefully controlled temperatures. They are then transferred (usually by road or rail transportation) to retailers and wholesalers [23] . In all, the entire process produces large amounts of carbon dioxide emissions and waste.

Which companies export bananas?

The banana plantations and the banana trade are owned and controlled by transnational companies. In fact, only five transnational companies, Chiquita, Dole (both American based), Del Monte (Chilean based), Fyffes (Ireland based), and Noboa, known as the “Bonita” brand, (Ecuadorian based) own over 90 percent of internationally traded bananas [24]. In Latin America the main exporters are (in descending order): Ecuador, Costa Rica, Colombia, Guatemala, Honduras, Panama, Brazil, Mexico, Nicaragua, Venezuela, and Peru. Bananas from these countries are called “dollar bananas” because they are exported to North America and produced by American companies. The Ivory Coast, Cameroon, St. Lucia, Jamaica, Belize, St. Vincent and the Grenadines, Dominica, Suriname, Grenada, Somalia, Cape Verde, and Madagascar are called ACP bananas (African Caribbean and Pacific). These countries produce the bananas which are exported to Europe [25].

Colonial histories influence trade agreements and partly determine who exports to whom. For example, in North America we do not consume bananas from Belize or Suriname, which were former European colonies. Transnational companies will export from where it is cheapest and easiest. Although certain countries produce just as many bananas as others, for example Brazil produces just as many or more bananas than Ecuador, due to government policies and trade agreements, production and export of Brazilian bananas is more costly. Therefore, most Brazilian bananas are not exported and we consume bananas from Ecuador, a country where it is cheap to produce.

What are these so called “banana wars”?

The banana wars were a series of trade disputes between the USA and the European Union. The origins of the debate date back to the 1940s, although the most heated wars took place between 1993 and 2001 [26]. The US and the EU were the biggest players, although many other countries were also affected [27]. Free trade and tariffs were some of the fundamental reasons on which the banana wars were fought. The EU favors trade preferences, higher tariffs, and import licenses, where as the US prefers lower tariffs and free trade to encourage competitiveness and the constant search for lower prices [28].

The American approach leads to large scale plantations such as those in Latin America. Caribbean bananas, for example, are grown on very small plantations, and it is difficult to produce them cheaply in large quantities. Several important debate issues were as follows: the UK, who was then president of the European Union, were very much interested in protecting the banana industry in the Caribbean and wanted to foster trade with their former colonies [29].

Furthermore, in the early 1990s a banana import policy (the Lomé Convention) was created, which restricted the amount of Latin American bananas imported to Europe. This infuriated the United States because they led the banana trade in Latin America and were afraid of losing their market [30]. The World Trade Organization got involved in the disputes after the EU finalized and signed the Lomé Convention with its banana trade partners in 1993. This convention allowed European Union members to import from all ACP exporters (previously European countries only imported from former colonies). This accord also allowed European countries to favor ACP bananas. This greatly concerned the WTO, who favored more free trade [31]. The disputes cooled off in November 2001 when negotiations began in order to find a new trade regime that would please both parties and these negotiations continue until today [32].

These wars demonstrated the globalization of the agricultural industry, the importance that a single trade item holds, and most notably, it showed the power of the American corporation and its ability to influence trade policies [33].

What are some of the social issues associated with banana production?

The biggest problem with the banana trade is that there is currently a “race to the bottom”. This competition for the lowest prices is led by supermarkets, who are constantly looking to buy the cheapest bananas [34]. This comes at a great cost to plantation workers because they, in turn, are paid lower wages. For every dollar spent on bananas at the supermarket, eleven cents or less goes to the plantation. More often than not plantations receive only five cents from every dollar, which is then divided up, and as a result, workers are being paid shockingly low wages [35]. The actual wage workers receive depends on the country; for example, in Nicaragua workers are paid roughly one and a half US dollars for a day’s work. In Ecuador they may receive as much as five to eight US dollars; however, even this is not enough to pay for basic necessities [36].

Workers are forced to stay ten to twelve hours, even though they are only paid for eight. Transnational fruit corporations often do not respect labour codes nor workers rights, but workers have little way to protest because they are often prohibited for joining trade unions [37]. The work itself is physically demanding and workers may have to carry extremely heavy loads or stand for ten hours straight with their unprotected hands dipped in a bath of chemicals (in order to wash the bananas) [38]. Bananas are grown using large amounts of toxic pesticides, and cancer or even death from exposure is a concern. Indeed, many of these chemicals are prohibited in North America and Europe, but are still used on banana plantations [39].

Accidents are also a common occurrence and there is no medical treatment or compensation for workers [40]. Furthermore, plantation work offers very little job security. Laborers often migrate to find work, and then are only given a three to six month contract [41]. Although housing is provided on the plantation, conditions are usually appalling. Child labor is common place, and a non governmental organization in Ecuador found that children as young as eight were being recruited to work [42]. Gender discrimination also exists: women face sexual harassment, and men often make three to four times more for similar work. Lastly, indigenous populations are driven out from their land in order to create space for the plantations [43].

The worst problem, however, is that the banana republics have become so dependent on the banana trade that if all of a sudden importers stop buying, these countries will immediately face severe economic shock, and the entire country will suffer. This was seen with the case of Jamaica, who traditionally exported to the United Kingdom. When disease and other conditions harmed Jamaican banana production and made it more costly, the UK turned to Central America (where it was cheaper) for its banana imports, and the Jamaican economy greatly suffered [44].

How is the banana industry affecting the environment?

The banana is a very ecologically demanding species. It pollutes the air, water, and land. Land is cleared in order to make space for banana plantations, but because banana trees shed no natural leaf litter to feed the soil, it depletes very quickly. Plantations are therefore forced to expand, and the problems associated with banana production grow. Deforestation and unhealthy soil cause erosion, and the runoff causes frequent flooding and damage from sedimentation [45]. In a 1997 study done off the coast of Costa Rica, it was discovered that 60 percent of the coral reefs in Cahuita National Park had been severely damaged due to runoff from coastal banana plantations [46].

Heavy pesticide use also causes problems. In an attempt to meet the demand for aesthetically perfect bananas, over 400 types of agrochemicals are used. In fact, more chemicals are used during banana production than any other crop with the exception of cotton [47]. These chemicals can lead to sterility, cancer, and death. Insects become resistant to many of these pesticides, therefore stronger, more toxic chemicals are needed. These chemicals affect mammals, birds, and plants, and the bio-diversity of the area quickly disappears. Pesticides also destroy the possibility for pioneer plant species to grow, and the area dies.

Furthermore, bananas are grown as a mono-culture, meaning that all the bananas on a plantation are genetically identical. Although this makes crops easy to manage, these bananas face an increased risk of being wiped out by a single type of pest, fungi or disease [48]. In order to prevent this from happening even more chemicals are used. It is estimated that 30 kilograms of pesticides are used per hectare per year on a banana plantation, whereas only 2.7 kilograms are used for the average European cereal crop [49].

Lastly, according to the World Wildlife Fund the banana industry produces more waste than any other agricultural sector in the developing world [50]. It is estimated that for every one ton of bananas produced, there are two tons of waste [51]. This waste includes industrial plastic bags that cover the bananas during growing stages, the string that ties up these bags, and the containers the bananas are carried in. Banana trees only bear fruit once in their lifetime, therefore once bananas are cultivated, the tree is no longer useful, and goes to waste [52]. Also, those 30 to 40 percent of bananas that do not meet aesthetic standards are thrown away. Most of this waste is poisoned with toxic pesticides and harms the environment [53]. Although international environmental standards have been created in order to reduce these problems, many companies fail to follow them [54].

What is being done to change banana practices?

Although Chiquita and other companies have been making efforts to improve practices, there are still many problems with the banana industry [55] . As a result, there are a number of NGOs working towards improving the banana industry. An important British NGO called Banana Link (www.bananalink.org.uk) is a great source of information on the industry. With their partners, they are looking to reverse the “race to the bottom” [56].

With the help of a number of different NGOs, international banana conferences have been held between producing and exporting countries in order to acknowledge and analyze the problems with the banana trade and to look for feasible solutions [57]. These conferences brought together governments, companies, stake holders, and researchers. So far there have been two conferences in Brussels, one in 1998 and the other in 2005 [58]. After the first conference, an international banana charter was created, which outlined an action plan for improving social conditions.

Unfortunately, the charter was not observed, and if anything, working conditions actually worsened on account of the power recently acquired by large global retailers, who refused to cooperate and follow the charter. They actually lowered banana prices, which in turn, forced smaller retailers to lower their prices as well, and less money reached the plantations. A participant declaration was created after the second banana conference. Most importantly, this declaration attempted to regulate supermarket prices and enforce health, safety and environmental practices on the plantations themselves [59].

One of the important NGOs involved in these conferences (and the banana trade in general) is COLISBA (Coordinadora Latinoamericano de Sindicatos Bananeros). This group coordinates trade unions across eight Latin American countries. In general, workers are not permitted to join trade unions, and this organization fights for the creation of unions and workers’ rights. Other important organizations include EUROBAN, IUF (International Union of Food, Agriculture, Hotel, Restaurant, Catering, Tobacco, and Allied Workers’ Association), and US/LEAP (US labor and education in the Americas project). These three organizations also fight for workers’ rights, as well as rally against unsustainable environmental practices, and demand fair trade. The International Network for the Improvement of the Banana and Plantain (INIBAP) is one of the few organizations that does scientific research in order to improve banana production for small farmers [60].

The World Trade Organization rules currently state that importing countries may not refuse to buy bananas based on the way exporters treat their workers or oversee environmental practices [61]. The biggest challenge these NGOs face is changing the WTO’s rules so that importing countries can no longer buy from countries that do not follow international standards which were declared at the banana conferences.

What can I, as an individual, do to help?

The power to change the banana trade is truly in the hands of the consumer. One can purchase fair trade bananas, which are grown on plantations where workers are treated in a just manner and are paid higher wages. If consumers buy these fair trade bananas, demand for them will increase. Theoretically demand for other, non fair trade bananas will decrease and working conditions will improve.

Organic bananas are another feasible solution. Although workers on organic plantations may still face injustices, the environmental practices are considerably more sustainable, the crops are not always grown as a mono-culture, and less environmental damage is being done [62]. Unfortunately, organics currently only account for one to two percent of global banana exports [63].

It is important to remember that the banana trade affects the entire world, and it is up to us, as banana consumers in developed world, to help the lives of workers in the developing world, to end environmental damage, and to encourage fair trade.

FOOTNOTES
1. “The Banana Trade,” Banana Link, link.
2. “The Banana Trade,” Banana Link and Chapman, Peter, Bananas: How the United Fruit Company Shaped the World, (Great Britain: Canongate Books Ltd. 2007) 20.
3. Hamer, Ed. “Bananas.” The Ecologist, September 2007, 24.
4. “The Banana Trade,” Banana Link.
5. Hamer 24.
6. Shah, Anup. “Bananas,” Global Issues, link
7. Wiley, James, The Banana: Empires, Trade Wars, and Globalization (Lincoln: University of Nebraska Press, 2008) 6.
8. Wiley 29
9. Chapman 68
10. Scott Jenkins, Virgina, Bananas: an American History (Washington DC: Smithsonian Institution Press, 2000) 20.
11. Wiley 31
12. Wiley 18
13. Wiley 35
14. Chapman 123
15. Myers 23
16. Myers x
17. “Trade Policy,” Banana Link, link.
18. Hamer 24
19. Scott Jenkins 5
20. Hamer 27
21. Hamer 27
22. Hamer 27
23. Hamer 27
24. “Trade Policy,” Banana Link.
25. “Trade Policy,” Banana Link.
26. Wiley 164
27. Myers 1.
28. Wiley 181
29. Myers 3
30. Wiley xix
31. Alter, Karen J. and Sophie Meunier “Nested and overlapping regimes in the
transatlantic banana trade dispute” Journal of European Public Policy. April 2006. 368
32. Myers 178
33. Myers 1 and Wiley xix
34. “Social and Environmental Impacts,” Banana Link, link
35. Hamer 26
36. Hamer 26
37. “Social and Environmental Impacts,” Banana Link.
38. “Social and Environmental Impacts,” Banana Link.
39. Hamer 26
40. “Social and Environmental Impacts,” Banana Link.
41. “Social and Environmental Impacts,” Banana Link.
42. “Social and Environmental Impacts,” Banana Link.
43. “Social and Environmental Impacts,” Banana Link.
44. Myers 24
45. Hamer 25
46. Hamer 25
47. “Social and Environmental Impacts,” Banana Link.
48. “Banana Republics take up ecotourism,” Earth Explorer, 1995 eLibrary, Proquest CSA. Vancouver Public Library, link. (March 15 2009).
49. Hamer 26
50. Hamer 26
51. Hamer 26
52. Scott Jenkins 5
53. Hamer 26
54. “Social and Environmental Impacts,” Banana Link.
55. Jackson, Rachel, “Green Bananas,” E Magazine, January/February 2007, eLibrary. Proquest CSA. Vancouver Public Library. link. March 31 2009.
56. “The Banana Trade,” Banana Link.
57. “Alternatives for the Future,” Banana Link, link.
58. “Alternatives for the Future,” Banana Link.
59. “Alternatives for the Future,” Banana Link.
60. “Alternatives for the Future,” Banana Link.
61. “Alternatives for the Future,” Banana Link.
62. “Alternatives for the Future,” Banana Link.
63. “Alternatives for the Future,” Banana Link.

Care Consultant Jones: Good morning grandfather. I have washed my hands in the cleansing pod [1]. The entry button should be flashing so you can let me in.

Dr Jones: (searches around frantically) Found it! (Care Consultant Jones enters the room) I sometimes despair at all this new technology, I’ll never get used to it Roger. In my day, we just trusted people would have the common sense to wash their hands. Last week, I heard there was a gentleman in ward 15 whose cleansing pod broke. He was stuck in his room for days!

Care Consultant Jones: That’s just a malicious rumour. The engineers from Biotech corp [2] would never let that happen. Who would want to book into this hospital if that were true? [3]

Dr Jones: When I was a doctor, nobody was able to choose which hospital they went to. We all foolishly assumed that all hospitals tried their best! All this talk about the Biotech corp engineers just reminded me about my broken plasma screen. Could you ask the health care assistants to report it to them for me?

Care Consultant Jones: There will probably be several forms to fill in. Biotech corp is notorious for their
paperwork. In one ward round, I have to file at least 100 different electronic forms on my PDA. It is all because Biotech corp is so afraid of litigation. The amount of time I spend on documentation for a patient is ridiculous.

Dr Jones: Remember that you are very fortunate to be able to use PDAs [4] . We had to write down everything by hand!

Care Consultant Jones: I don’t understand how you can practice medicine without a PDA. How would you know a patient’s history when they came into the hospital?

Dr Jones: We used to take the history from the beginning every time a patient came into the hospital. The whole process was a good learning exercise for the medical students.

Care Consultant Jones: My medical students would definitely not be happy if I asked them to take everyone’s histories without a PDA. They would probably sue me for not providing a proper education [5].

Dr Jones: The amount of litigation has spiralled out of control! First the patients are suing their doctors and now the medical students are doing the same. Your insurance premiums must be extremely high [6].

Care Consultant Jones: I am just lucky that Angela is a lawyer. We would not be able to survive on my wage alone especially after I have paid the medical insurance premium.

Dr Jones: How are Angela and the children?

Care Consultant Jones: They are all fine. Johnny is now in his final year of medical school.

Dr Jones: Has it been 4 years already?

Care Consultant Jones: Medicine only takes two years now. Only graduates from the new pre-med courses can apply and they just do the clinical clerkships [7].

Dr Jones: Do they not learn about anatomy?

Care Consultant Jones: I think they only do virtual surgical anatomy. I was asked to teach it but I already had enough teaching points to fulfil my contract [8].

Dr Jones: Will Johnny be starting as a resident soon?

Care Consultant Jones: I think his official title is a F.C.A. It stands for Foundation Care Assistant.

Dr Jones: He will be very busy. I remember when I was a resident, I never had enough time for lunch.

Care Consultant Jones: He told me his shifts are scheduled for 9am to 3pm everyday for the first two months of the rotation. There are so many students graduating from medical school now that they have too many FCAs [9]. They all only work a few hours each day.

Dr Jones: How can they possibly attain the experience needed to be a doctor in that short time?

Care Consultant Jones: It’s generally expected that they can’t get the necessary experience. However, the rest of the time is set aside for formal teaching and other methods of training.

Dr Jones: Do they get paid for that?

Care Consultant Jones: No, it is terrible that they do not get paid but they have to take part. They have an obligation to teach the medical students. Otherwise, Biotech corp will terminate their contracts. They also have an obligation to receive a certain number of training points otherwise, their insurance premium is invalid.

Dr Jones: How will he survive?

Care Consultant Jones: We said we could help him out financially but he might have to get a part time job.

Dr Jones: Who would have thought that one day doctors would need to take a second job? We always used to moan about our pay as a resident! At least he’ll become an attending quicker under the new system. Does the pay go up then?

Care Consultant Jones: Yes it does but then so do the insurance premiums!

Dr Jones: What does he want to specialise in?

Care Consultant Jones: He doesn’t have to choose at the moment. He automatically becomes a general attending physician after five years, providing he passes all his competency assessments. After that, he is expected to work as a general attending physician in the hospital at night scheme for at least two years until he can specialise to become a care consultant.

Dr Jones: They make him work night shifts for 2 years?

Care Consultant Jones: It’s the only way that the hospitals can stay open for 24 hours a day. Patients won’t be kept waiting for anything nowadays, especially since they all pay the health tax [10].

Dr Jones: It was lucky that I retired before the health tax came into effect.

Care Consultant Jones: It should have been reduced when the Biotech companies started to run the hospitals [11]. However, the government claimed that costs had risen so much that a health tax cut would have been the end of Medicare.

Dr Jones: That argument is an old excuse. It’s not really a government funded Medicare system anyway. As far as I can see, we pay for the privilege of going into the hospitals and the Biotech companies take away all the profit from running them.

Care Consultant Jones: All these extra taxes will be the cause of my financial ruin!

Dr Jones: I suppose that I should count myself lucky that I still receive a government pension [12].

Care Consultant Jones: Biotech corp has decided that they couldn’t possibly provide a pension for their Medicare employees. All the money that they have made from their new drugs must be used to pay for their extensive research and development programs.

Dr Jones: That argument is also an old excuse. I hope you are not put under any influence to prescribe these new drugs. Are you?

Care Consultant Jones: I can prescribe any medication available. However, the hospital only stocks Biotech corp drugs. So if I wanted to get something from a rival firm, it would take 5 days, and I would have to fill out about 5 forms.

Dr Jones: That’s disgraceful! I’m surprised that no one saw the conflict of interest.

Care Consultant Jones: The Biotech lobbies are so large in this country that nobody can argue with them. Anyhow, I hardly have to prescribe anything nowadays.

Dr Jones: I believe the new term is nursing prescribing power! [13] What precisely do you do at work Roger?

Care Consultant Jones: As far as I can figure out, we basically just keep an eye on things. The nurses prescribe and follow the care pathways. We are just there to check that everything is running smoothly.

Dr Jones: That means that no independent thought goes into the process! These care pathways are a menace. My doctor refuses to deviate from it even though I show him evidence from the latest clinical trials.

Care Consultant Jones: Patients are always showing us their internet derived evidence. It’s an unfortunate situation but we open ourselves to litigation if we deviate from the care pathway. Our insurance also becomes invalid. They are theoretically evidence based and updated automatically onto our PDAs.

Dr Jones: Theoretically is the correct descriptive term. What if I don’t agree with the interpretation of the evidence? Also, we all know that the Biotech lobby influence the people who review this evidence [14].

Care Consultant Jones: The nurses claim that the care pathways help them provide a standardised care to all the patients. We all know how powerful the nursing unions have become.

Dr Jones: As far as I can see the nurses do all the things that I used to do as a doctor. They prescribe drugs and look after the patient from a medical point of view. My nurse has called for the doctor’s advice only once since I have been here.

Care Consultant Jones: That doesn’t surprise me. We are just there as a final check on the process. They see the patient, bring up the history, follow the care pathway and institute the evidence-based management. The nurses hardly call me.

Dr Jones: I heard a rumour that the nurses get paid more than the junior residents now.

Care Consultant Jones: That’s not technically true. They get paid a slightly lower hourly rate than the FCAs, but they do more hours and so get paid a larger annual income.

Dr Jones: That’s how the idea was sold to the Canadian Medical Association!

Care Consultant Jones: The CMA has very little power compared to the nursing unions. If the doctors went on strike the hospitals would still be able to function but if the nurses did the same then the whole place would grind to a halt [15].

Dr Jones: I suppose if the nurses do all the work they should get paid more.

Care Consultant Jones: The nurses and the Family Practitioners get all the money.

Dr Jones: My Family Practitioner just bought a new Porche. Is it true they get paid per procedure and not by patient now?

Care Consultant Jones: There would not be much point in paying them per patient. They all have these super-clinics with thousands of patients in them. They get paid standard fees for the annual check-up, minor operations and specialist health checks.

Dr Jones: There is a big difference between what you would call a minor operation and what I used to call a minor operation. In my day, the general surgeons still did hernia repairs.

Care Consultant Jones: The Family Practitioners do almost all the operations now. Our attending general surgeons in the hospital only do organ transplants. Any pathology is treated with an organ transplant.

Dr Jones: We used to have a shortage of organs.

Care Consultant Jones: Donation was always a terrible way to obtain organs. We are fortunate that the government decided to ignore the protestors and grant the Stem Cell Research Bill [16] and now we can grow any organ we need in the laboratory.

Dr Jones: I am sure that Biotech corp would have used any means necessary to be able to grow organs in their laboratories. They must sell the organs to their own hospitals for a significant profit.

Care Consultant Jones: We should try to be a little less cynical next time I visit. I should go home. I have to get ready for my re-registration exam with the Provincial Medical Licensing Board [17].

Dr Jones: Has it been three years already?

Care Consultant Jones: Yes. I have to prepare my patient portfolio and revise for the exam. I shouldn’t have left it all to the last minute!

Dr Jones: Enjoy yourself! Goodbye Dr Jones. I hope you visit me again soon.

Care Consultant Jones: Grandfather, you know that the nursing unions put a stop to the term ‘doctor ‘a long time ago.

Dr Jones: Yes I do know. The term supposedly increased the divide between health care professionals. It was all politically correct non-sense. I just like calling you ‘doctor’. However, if you insist, Goodbye Care Consultant Jones.

Footnotes

1. All patient rooms have a cleansing pod outside which automatically sprays your hands with anti-microbial. This was in response to the great MRSA and C.difficile epidemics of 2010 and 2020.

2. The hospitals of the future are all run jointly by Biotech companies and the government.

3. Patients are able to book into any hospital they wish for care.

4. All doctors in 2050 were issued with a PDA. It would allow them to continuously monitor a patient’s history, investigations and management plan from anywhere in the hospital.

5. In 2039 a medical student successfully sued his medical school for not providing a good enough education. His argument was that if he was to be held accountable for his actions as a doctor then he should be trained to a high standard in core competency. As a result of his action all medical schools were required to provide every medical student with a supervising doctor who would follow their progress and assure they received training in core competencies. An obligation to teach was written into every doctor’s contract with their employer.

6. Insurance premiums rose to over half a doctor’s salary following a spate of litigation from patients complaining about their care.

7. In 2012 a major review of medical school education suggested students could complete the course in two years if the pre-med undergraduate included all necessary pre-clinical credits.

8. All doctors receive points for teaching medical students. They must earn 100 points a year to fulfil their contracts with their employers.

9. Medical student places were vastly increased by the year 2050. The entry requirements dropped to allow most people to be eligible to become medical students. This was a reaction to a problem of under-recruitment in the late 2030s. This was thought to be because of medicine becoming a very low paying profession due to reduced working hours and very high insurance premiums.

10. The health tax was introduced in 2020. It was a specific tax paid by all to enable a free health service. It was raised every year subsequently until the Biotech companies agreed to buy and run hospitals. It was never repealed.

11. To save money the government agreed to allow Biotech companies to run the hospitals as private ventures whilst still receiving government funding to provide free health care.

12. The government pension for healthcare professionals was abolished for all new employees in 2020.

13. Nurses were given the right to prescribe medication in 2030.

14. The Government Minister for Health was made head of a new committee designed to issue evidence based practice guidelines to all medicare health professionals. Thus no guideline was issued without express government approval.

15. There were several Nursing strikes in the 2010s. These had a large influence in making the nursing unions a major government lobby.

16. The Stem Cell Research Bill of 2015 allowed any research to be carried out on Stem Cells from any origin including fetal stem cells. This was met with large protests in the country but eventually allowed Biotech corp to grow new human organs in the laboratory from a patient’s own genetically modified cells.

17. Doctors are required to re-register with the Provincial Medical Board every 3 years. They must review in a portfolio all the patients they have treated since their last registration and must take an exam to demonstrate core competencies appropriate for their level.

Bibliography:

1. Nurse prescribing: Politics to Practice by Mark Jones. Published by Elsevier Health Sciences, 1999 ISBN 0702023140

2. Malpractice litigation as a factor in choosing a medical specialty. West J Med. 1990 March; 152(3): 309–312

3. Perceptions on the standardization of psychiatric work: development of a care pathway. Psychtr Ment Health Nurs. 2004, Dec(11):705-13

4. Private finance initiative: Partnership between private and NHS is not necessarily wrong. BMJ. 2000 January; 320(7229): 250.

5. Medicare advantage: The Case for Protecting Patient Choice. Heritage foundation. link

6. Medical Education is it time for change? President’s address, American Association of Medical Colleges. May 8, 2007. link

7. B.C. nurses give an overwhelming Strike mandate/ UNA Stat.2001, april Vol 8(8) link

8. The ethics of Stem Cell Research: link

9. ‘Super surgery plan condemned’ link

10. Nurse-led clinic: 10 essential steps to setting up a service. Nursingtimes.net link

11. ‘Alberta considers private hospitals’ -Canada.com. link

12. Ontario health tax: link

13. The private hospitals act: Manitoba: (link)

14. General Medical Council (United Kingdom) – re-validation of medical license. link