'Health is simply politics by other means'

James Orbinski was one of three doctors who began the Canadian branch of Medecins Sans Frontieres (MSF) (Doctors without Frontiers) in 1990. As President of the MSF International Council, Orbinski received the Nobel Peace Prize on behalf of the or ganisation in 1999. In Dhaka for PHA 2000, the veteran of humanitarian emergencies in Peru, Somalia, Afghanistan and Rwanda spoke to Sukumar Muralidharan about the MSF's programmes and operational philosophies. Excerpts:

Could you tell us something about the essential medicines programme of the MSF? Is there any particular order of priorities here in terms of diseases that require attention?

Basically what we see in our projects - we have 400 projects around the world - is that in many cases patients are dying not because there are not enough physicians but because they have no access to life-saving medicines. There could be three reasons. O ne is that drugs are too expensive, largely because of patent protection. The second is that drugs exist but are not produced because they are no longer commercially viable. And a third is that there is not enough research and development for new drugs t o overcome problems of resistance.

So in the first category, AIDS is a very good example. And in the second category, African sleeping sickness is a good example. And tuberculosis is a very good example in the third category. There has been no new drug for the disease for 22 years.

When you say that drugs are no longer produced for certain diseases, this would be a reflection on the public health system which is in a state of collapse in much of the developing world. A viable health delivery system would mean a ready market for these drugs, making their production commercially viable.

That is another element of the problem. There is no doubt that health care infrastructure is a key element in increasing access to medication. And there is no question that this is a part of the problem that needs to be addressed properly. There are many organisations and people doing that. We are, in partnership with other organisations, focussing on the production of the actual medicines. Because of the nature of our work and our capacity, one has to make a choice on how best to use the resources. An d our choice is to focus on the actual medicines, while supporting other groups that are focussing on infrastructure.

Is this a shift in focus for you since your experience so far has been in combat or humanitarian emergency situations?

The issue of access is an emergency. Look at what is happening with malaria. In many parts of Africa, 50 per cent of cases are proving resistant to all known treatments. It is not localised to one place but it is still an emergency and affects a large nu mber of people. And the reasons why there are no new drugs are in fact structural, and to address the emergency, we really have to look at the structural reasons.

So you would essentially be seeking to mobilise public pressure on the drug companies and the research laboratories to deal with this emergency...

Not only them, but also WHO and governments themselves. We would have to mobilise the large pharmaceutical companies, the small companies, the generic producers and researchers in academics. One has also to address the shortage of research capacity in th e developing world. And if you want to have really sustainable solutions to these issues, you would have to look at how to build capacity for R&D work in the South. How do we build capacity for drug production in the South? How do we stimulate the so-cal led "market forces" to ensure that this capacity exists? And on the other side of this coin, to look at those diseases for which market forces will never work. And again a very good example of that is African sleeping sickness. People in many parts of su b-Saharan African are exposed to the disease - there are at least 60,000 cases a year and millions at risk. These are extremely poor people who will never be able to afford treatment. Does that mean that there should never be any solution? We find that t otally unacceptable. And so that will require a different kind of solution. That would require public intervention at the local level, state level, national level, the international level.

Is your participation in the People's Health Assembly part of some kind of coalition building? What have you gained from being here?

We were asked to come here to talk about our campaign and also to share our experiences. And that is what I did - I shared our experiences in the MSF and I talked a little bit about the context that now exists - the neo-liberal regime that we all live in and what that means in terms of NGOs and their relationships. We do not have any pretensions about taking any sort of leadership role in a people's health movement. But we want to be a part of it.

Doctors of the MSF were once known as "medical hippies". How are you perceived now? In particular, have you had any kind of impact on the ethics of the profession? There are some concerns that doctors as a professional group are often catering to cons tituencies other than their patients.

Well I think in some ways, we challenge that ethic. We believe very much that it is the responsibility of the physician to be not merely technically competent, but to be committed to a universal medical ethic and to speak, to witness and to advocate on b ehalf of his patient. He should not simply stop treatment at the point that the technical act fails or ends. It is the role and the responsibility of the physician to put the dignity of the patient at the centre of his work and to see his work as more th an a technical act.

And would political activism be a part of the physician's work?

I believe in the approach of one of the fathers of public health, the 19th century German physician Rudolph Virchow, who said - and I paraphrase - that "health is simply politics by other means".