See also:
The Social Implications of Genetically Modified Food
Warlpiri Sign Language and Auslan - A Comparison

"Pharmaceuticals and the Political Economy of Health"

© 1998 Samantha Madell

Master of Arts (Applied Anthropology and Development)
Macquarie University, Sydney, Australia

Comments? Email me (Sam Madell)

Introduction

The modern pharmaceutical industry is extremely important on many levels, including economically and scientifically, as well as in its impact on the health of the world’s populations. As the trend towards globalisation continues, the pharmaceutical industry can be expected to become even more important. As this essay will endeavour to show, nowhere are politics, economics and health more closely interwoven than in relation to modern pharmaceuticals.

This essay aims to examine the basis of the pharmaceutical industry’s power. The often cynical, profit-oriented approach of the industry towards human health will be discussed, as will be the response of physicians to the tactics of the pharmaceutical industry. The actual worth of pharmaceutical products will also be examined.

The Authority of Pharmaceutical Transnational Corporations

“Claims of authority in our contemporary world rest increasingly on the possession of knowledge, of which scientific discourses are supreme” (Aronowitz, 1988)

Modern pharmaceutical drugs can be seen as authority in pill form. Effectively encapsulated in each pill is a long, expensive chain of scientific research and marketing. Each pill embodies the faith which doctors and patients place in Western medicine. Each pill promises a chance of better health. Each pill, in a way, symbolises power.

The symbolism of pills is debatable, but what is certain is that the modern pharmaceutical industry is a very lucrative one, as illustrated in Table 1, below. The table provides an overview of those pharmaceutical transnational corporations (TNCs) which are large enough, based on total revenues, to rank within the top five- hundred corporations in the world. In total, thirteen pharmaceutical manufacturers achieved a place within the top 500 global corporations of 1998. Of those thirteen transnationals, eight have headquarters based in the United States of America, two based in Switzerland, and three based in the United Kingdom.

Altogether, the world’s thirteen largest pharmaceutical manufacturers make an annual operating profit of over 54-billion Australian dollars. This level of profit is the result of very successful globalisation by the industry. As one example, Johnson and Johnson, the world’s second largest pharmaceutical TNC, employs over ninety-three thousand people, and has “more than 190 operating companies in 52 countries around the world, selling products to more than 175 countries” (Johnson and Johnson, 1999).

In view of the large profits made annually by pharmaceutical corporations, there is a clear implication that a very large global market exists for pharmaceutical products. But pharmaceutical products - as marketable commodities - are perhaps unique in their explicit links to health, and their implied links to authority and faith. While a certain amount (and type) of “faith” might be placed in a General Motors’ vehicle or a bottle of Coca-Cola (whose manufacturers are globally ranked 1st and 201st respectively), that faith seems trivial when compared to the faith placed in modern medicine by sufferers of, say, AIDS or tuberculosis.

The Importance of Essential Drugs Lists

Pharmaceuticals - like most products, including clothing - can be sold under two broad categories: either as a generic product, or as a brand named, proprietary product. Brand name medicines, just like brand name clothes, are invariably - and often significantly - more expensive than their generic counterparts. However, the generic name of a pharmaceutical drug is also, in fact, its chemical description. This means that generic drugs are chemically identical to their brand named equivalents.

The generic name of a drug tends to be “long and hard to remember while the brand name is often catchy and popular” (Bodenheimer, 1985:205). For example, the generic drug fluoxetine hydrochloride has been marketed extremely successfully by one of its manufacturers, Eli Lilly, as the brand name drug “Prozac”. Fluoxetine hydrochloride is, however, also marketed by other manufacturers as “Erocarp”, “Fluohexal”, “Lovan” and “Zactin” (MIMS, 1998).

Clearly, for any brand name drug to be more well known and popular than another chemically identical drug, marketing forces must be involved. Indeed, it has been argued that the price of brand name drugs has “virtually nothing” to do with production costs and industrial expenses, but rather is “based upon the maximum the public in its medical need can be induced to pay” (Bodenheimer 1985: 206). Price discrepancies vary from drug to drug, but brand name drugs commonly cost from three to thirty times the amount of their generic equivalents (ibid 1985:187). For a very large number of poor people in the world, a drug costing thirty times the amount of its generic equivalent would be an unaffordable - or even ridiculous - luxury. A luxury, that is, when a cheaper alternative is available.

Modern pharmaceuticals are a very important aspect of the Western biomedical model of healthcare. In recognition of this fact, the World Health Organisation (WHO) published its first Model List of Essential Drugs in 1977. WHO considers essential drugs to be those which can provide “safe, effective treatment for the majority of communicable and non-communicable diseases” (WHO, 1998). In 1997, WHO prepared its 10th Model List of Essential Drugs. This current list names a total of 306 drugs, including 166 which have been added since 1977, as well as 68 drugs which are no longer deemed appropriate.

WHO views essential drugs as “one of the most cost-effective elements in modern health care”. According to WHO, each year 40 million people die in developing countries. One third of those people will be aged under five. One quarter of those 40 million people will die of acute respiratory infections, diarrhoea, tuberculosis or malaria - “all conditions for which safe, inexpensive, essential drugs can be life-saving”. WHO adds, however, that over one-third of the world’s population still lacks access to essential drugs (WHO 1998).

Essential drugs lists are widely regarded as an important tool in increasing access for the world’s populations to effective health care (Ekins 1992:113). One successful example of the production and promotion of high quality, low cost essential drugs has taken place in Bangladesh. “Gonoshasthaya Kendra” (GK - the People’s Health Centre) was established in Bangladesh in 1972 by Dr Zafrullah Chowdhury. As well as successfully training paramedics in preventative and simple curative medicine, GK was responsible for establishing Gono Pharmaceuticals (GP) in 1981. The essential drugs manufactured by GP supply 5% of Bangladesh’s total pharmaceutical market, but up to 60% of some categories. Furthermore, its prices are up to 60% below those of the TNCs, leading to a significant general decrease in pharmaceutical prices. Following the GP experiment, Chowdhury became a key adviser to the Bangladesh government in drawing up its Essential Drug Act of 1982. This act banned 1,700 dangerous or useless drugs, and set a unique precedent (Ekins 1992:113).

Essential drugs lists enjoy little popularity, however, in countries with strong pharmaceutical industries. For instance, neither the US nor any Western European country (including the UK) implements WHO’s essential dugs list. Indeed, essential drugs policies on a global level are constantly “threatened by increasingly liberal policies towards pharmaceutical companies” (Smith 1999).

The level of resistance against essential drugs policies is not altogether surprising given the “inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of the public”. Rather, “we would do well to remember that people who run drug companies are not bishops, they are businessmen” (Ong Beng Gaik).

As long ago as 1979, the US federal government was aware that the use of generic drugs could save US consumers US$400 million every year. In an attempt to reduce the costs of its Medicare program, the US government began urging doctors and pharmacists to use generic drugs. The government was, however, quickly prevented from further promoting generic drugs by legal action from the Pharmaceutical Manufacturers Association (Bodenheimer 1985:206).

The Development and Patenting of New Drugs

The story of penicillin’s discovery in 1928 by Dr Alexander Fleming is a famous one. The detection of this antibiotic mould, eating away at a staphylococcus colony, was made completely by chance. Research on penicillin continued for well over a decade until its production had been refined to the extent that it could be used on a wide scale. By 1943, penicillin was available for the treatment of wounded WWII soldiers (Hooper 1972:104-109). Fleming was a medical doctor trying to better understand staphylococcus, who happened upon arguably the most significant pharmaceutical drug in history.

Times have changed. The modern pharmaceutical industry is highly research intensive. By the mid 1960s, the pharmaceutical industry was recording the highest proportion of research expenditure to sales of all non-military industries in the US (Lall 1980:164). In keeping with its level of expenditure, and in contrast to the serendipitous circumstances which surrounded the discovery of penicillin, today’s pharmaceutical research tends to be strictly focused. And that focus is on creating profitable and patentable drugs.

The largest profits in the pharmaceutical industry come from the sale of brand name drugs in developed countries. With this in mind, it comes as no surprise that, for instance, tropical diseases affecting hundreds of millions of people in underdeveloped countries receive only two percent of the sum spent annually on cancer research (Bodenheimer 1985:209). The reason for this lack of support for tropical disease research is simple: “it could not pay for itself for a very long time” (Anon ?:99). Or, as one research director explains: “In five or ten years of research, we might hit on a useful new compound that could help a lot of people in Africa or South America. They would like to have it, but neither they nor their government could afford to pay much for it. They have the disease but not the money. My stockholders would have my scalp” (ibid ?:99). Hence, money is spent on the development of drugs for the control of “diseases of affluence”, that is, coronary disease, cancer and high blood pressure to name a few (Taylor 1979).

WTO and TRIPs

Capitalism could probably be viewed as a special “disease of affluence” whose main symptom might be compulsive commercialism. The World Trade Organisation (WTO), in turn, could be seen as a manifestation of capitalism. The WTO actually describes itself as “the only international organisation dealing with the global rules of trade between nations. Its main function is to ensure that trade flows as smoothly, predictably and freely as possible” (WTO 1999).

According to pharmaceutical manufacturers, the promise of property rights is a prime motivator in the development of new drugs. Trade related intellectual property rights (TRIPs) are the focus of a new international agreement administered by the WTO.

“Intellectual property” refers to a design, technology or product invented by a person or corporation. “Rights” to that property are conferred by awarding patents, copyright, or trademarks to the “owner” or inventor (Khor Kok Peng 1995:27).

According to its critics, “probably the worst single feature of the WTO was the decision to include pharmaceutical patents and apply them to developing countries”(James 1998). Under the TRIPs agreement, patents on new drugs will remain valid for twenty years. The implications of this patenting are significant. For instance, as mentioned earlier, brand name drugs are frequently sold for three to thirty times the price of their generic equivalent. Under the TRIPs agreement, generic “copies” of brand name, patented drugs will be outlawed for twenty years.

As was also mentioned earlier, more than half of the 306 drugs considered essential by WHO have been added to its list in the space of twenty years. Hence, if the development of new drugs continues over the next twenty years at a similar pace to the past, it is safe to assume that, in the future, drugs considered essential will not be available in generic forms. Furthermore, a Third World country agreeing to a TRIPs agreement but not adhering to it could, in future, suffer from official “cross-retaliation” and find trade sanctions imposed against its export goods (Khor Kok Peng 1995:27).

The World Trade Organisation is ostensibly the champion of market forces economics, free trade, and globalisation. However, it seems extremely ironic that the new world order of globalisation and privatisation (to which national protectionism in the form of government taxes and subsidies are anathema) can happily manipulate the introduction of such extreme protectionism for its star citizens, the transnational corporations.

Indeed, many of the activities of transnational corporations make a complete mockery of the concept of “free trade”. For example, the 40,000 transnational corporations of the world and their 250,000 foreign affiliate firms currently account for approximately two-thirds of the world trade in goods and services. One-third of these transactions take place within firms, while another third are inter-firm transactions. So, while many of these transactions are technically carried out across national borders, they stay within corporations, and accordingly remain free from normal taxes and restrictions. This means that about four-ninths, or very nearly a half of all world trade in goods and services is not carried out according to free-market-free-trade theories of arms-length transactions (Raghavan 1996).

The pharmaceutical industry is highly research intensive, but that research tends to be concentrated within the largest corporations. For example, in the US - home to most of the world’s largest pharmaceutical TNCs - the twenty largest pharmaceutical firms account for ninety-five percent of total research and development in the industry (Lall 1980:165). This situation would seem to indicate that the largest corporations will tend to become even larger under the impact of TRIPs. Also, because the“mobility of transnational corporations gives them an insuperable advantage over the immobility of national governments”, the transnationals truly may have “become the centre of power in today’s world” (Bodenheimer 1985:189).

The WTO is, at least outwardly, sensitive to criticism. It devotes several pages on its website to dispelling “10 common misunderstandings about the WTO”. Among these common misunderstandings is one that the WTO is “anti health”. “Not true” counters the WTO, for the simple reason that “The [unspecified] agreements were negotiated by WTO member governments, and therefore the agreements reflect their concerns”.

It seems erroneous to suggest that, purely because member governments negotiated the WTO agreements, these agreements are therefore automatically not “anti health”. This argument makes at least two important assumptions: firstly, that all WTO member governments enjoy equal status within negotiation processes; and secondly, that all governments are unquestionably pro-health. Reality would suggest that neither of these assumptions are accurate.

The WTO’s existence is based on its promotion and enforcement of trade laws and regulations. For the WTO, commercial interests are vitally important. Twenty-nine of the forty-eight least developed countries in the world (as defined by the United Nations) are members of the WTO. But, with the WTO’s commercial interests in mind, it seems unlikely that any of those twenty-nine countries would hold as much negotiating power as, say, the US. In fact:

“Many Third World governments involved in the negotiations have increasingly expressed unhappiness and frustration at the attempts of the major industrial countries to bulldoze through proposals to drastically alter the rules of international trade and economy. They have been severely hampered by the lack of technical and diplomatic clout and coordination amongst themselves” (Khor Kok Peng 1995:4)

Regarding the assumption that governments are unquestionably pro-health, it might be useful to examine the issue of corruption. Government level corruption and conflict of interest is a frequently recurring theme in literature scrutinising the pharmaceutical industry. Glucksberg and Singer, for instance, cite the “high level corruption” (1982:386) of government officials by pharmaceutical TNCs as a significant factor in the inappropriate drug purchases by the governments of underdeveloped countries, using Zaire as an example. A Dateline report (SBS 1999) on AIDS in Zambia regarded government-level corruption (in relation to the purchase and distribution of AIDS therapies) as having risen to the level of an art form. It seems that “throughout the Third World, bribery and corruption represent an accepted way of life and a part of normal business practice”, but “such behaviour is not limited to the Third World” (Anon ?:119). Many examples of high level conflict of interest also exist in the US. For instance, before he became the US Vice-President (and subsequently President), George Bush was a director of Eli Lilly (Bodenheimer 1985:211).

The widespread existence of corruption suggests that at least some members of some governments are more protective of their own interests than those of the people they officially represent.

Aggressive Marketing

There is often a rather fine line between the aggressive marketing of pharmaceutical products, and outright bribery. Medicinal drugs - and particularly brand name drugs sold mostly in developed countries - are fairly unique amongst consumer products in that their actual consumers tend to have little ultimate choice regarding the drug they purchase. That is, patients purchase what their doctors prescribe for them. So, what choice does exist generally lies with the doctor. The pharmaceutical industry, accordingly, heavily targets doctors with their marketing.

Australian drug companies have been spending A$200 million every year just on marketing. This sum “represents almost A$10,000 a year spent on attempting to win each of Australia’s 21,000 GPs”. Alarmingly, this amount is also fifty percent more than allowed by law in the UK for marketing (Ong Beng Gaik).

Interestingly, the relatively high levels of education and easy access to information enjoyed by physicians do not, apparently, provide any kind of effective barrier against the persuasive powers of pharmaceutical TNCs. This is evidenced by the fact that “physicians all over the world prescribe brand name drugs that cost patients from three to thirty times as much as identical generic drugs” (Bodenheimer 1985:187). This is less than surprising given that:

“from the moment prospective doctors enter medical school, they are bribed and brainwashed to become lifelong servants (at no small reward to themselves) of the pharmaceutical industry....To insure that medical education is dominated by the pharmaceutical model, prominent medical educators are placed on pharmaceutical boards of directors” (Bodenheimer 1985:201).

Apart from being generous with free samples of brand name drugs, pharmaceutical TNCs invest heavily in glossy advertising in medical journals, as well as in brand familiarisation by means of widespread distribution to physicians of everyday items - pens, writing pads, calendars, mugs and so on - inscribed with company and brand names.

Large drug companies, though, set aside most of their marketing budgets for “drug detailing”, in the form of frequent visits to physicians in their offices. These drug detailers are commonly known as “detail men”. The ratio of detail men to physicians varies between countries, and ranges from one detail man for every ten or more doctors in the US, to one for every two or three doctors in Mexico, Brazil, Indonesia and the Philippines (Anon ?:107).

At best, detail men, by dint of their persistence, familiarise physicians with new drugs. At worst, they offer bribes, peddle drugs past their expiration dates, and provide dangerously inaccurate information (Anon ?:107).

Nevertheless, for physicians to fall victim to “brain washing” seems like a less than adequate excuse for potentially compromising the quality of patient care.

Inappropriate Uses of Drugs

As their susceptibility to blatant marketing techniques would indicate, physicians are not infallible. This is further evidenced by the fact that “up to 75% of antibiotics are prescribed inappropriately, even in teaching hospitals” (WHO 1998). Furthermore, in the mid 1980s, it was estimated that 78,000 people in the US died every year as a result of adverse reactions to “entirely unnecessary” medications (Bodenheimer, 1985:187).

In a world where scientific discourse and knowledge is said to be supremely authoritative, the supremely scientific pharmaceutical industry holds enormous authority. However, it is important to realise that pharmaceutical products are not the only answer to the world’s health problems. For an illustration of this idea, we can turn to history.

History tells us that, in developed countries, the most significant declines in the incidence and impact of infectious diseases such as tuberculosis, scarlet fever and diphtheria, occurred in the nineteenth century, clearly preceding the advent of antibiotics and vaccination (May 1994:157).This decline is clearly illustrated in Figure 1, using tuberculosis in England as an example. The root cause of this decrease in morbidity and mortality is, however, disputed. One school of thought attributes the decline to a general increase in nutritional standards (McKeown 1979), while another suggests that the credit for better health belongs to higher standards of public and private hygiene (May 1994:157). Population density is generally accepted as an important factor in the transmission of infectious diseases. Crowding promotes the easy transmission of disease.

What is certain is that few comparisons can be drawn between nineteenth century Europe and north America, and the late twentieth century Third World. In Europe and the US, populations and prosperity grew hand in hand. Conversely, populations currently “burgeon” in the Third World, unaccompanied by comparable economic growth (May 1994:158). And, in the developing world, tuberculosis (TB) is still rife. Although the now developed nations conquered TB by environmental, economic and social advances “their prescription for the Third World is a disease-specific technological assault on the disease, utilizing vaccination, case detection and drug treatment” (Taylor 1979:10). This seems to be a clear case of treating the “symptoms” rather than the real problem.

Apart from being part of a “band-aid” solution to a much deeper problem, the excessive use of antibiotics - both in developed and underdeveloped countries - can have far reaching consequences. Indeed, “the currently accelerating appearance of resistance to the present generation of antimicrobial drugs by more and more infectious diseases is the greatest threat that looms under the heading of changing diseases in changing environments” (May 1994:170). This is not an isolated or fringe concern. WHO itself also explains that, until recently the “global war against infectious diseases appeared to be on the road to victory”. However, “the advent of new infectious diseases and the re-emergence of old ones in areas of the world avowedly free of such diseases, have precipitated a new health crisis which threatens to overwhelm the gains so far made” (WHO 1996).

What had been viewed as optimism regarding the control of infectious diseases can now be seen as fatal complacency. Indeed, infectious diseases remain the world’s leading cause of death, accounting for about 33% of the 52 million people who die each year (WHO 1998).

Infectious diseases, though, are not the only recipients of questionable biomedical “solutions”. For example, the most recent WHO essential drugs list has seen the addition of the pharmaceutical compound iron-folate. Iron-folate was added to the list specifically for its ability to prevent anaemia in pregnant women (WHO 1998). But a similar compound - with the same anaemia-preventing effect - is also found in normal foods, such as leafy green vegetables.

In developed countries, a failure to derive adequate nutrition from food is likely to be the result of either laziness, or a misguided attempt to minimise the consumption of calories, usually in the pursuit of weight loss. Last year, Australians spent about $357million on vitamin and mineral supplements (Goodyer 1999). This seems rather silly in the context of Australians’ easy access to a wide variety of fresh foods. In underdeveloped countries, though, where chronic malnutrition is a major problem, the promotion of vitamin supplements seems to be cruelly short-sighted. For pregnant women without access to adequate food for the prevention of anaemia, vitamin supplements are unlikely to be of real long term benefit.

Life and Death in the Time of AIDS

AIDS is a relatively new disease where all the ethical issues regarding the pharmaceutical industry seem to have collided. The race to find a cure for AIDS has acted as a catalyst to the appearance of many ethically questionable actions, relating to areas ranging from drug testing to drug distribution - with profit-motive tending to be the common denominator.

Pharmaceutical drugs have a long and ongoing history of being tested on people in underdeveloped countries, and in underprivileged minority groups (such as prisoners and public patients of teaching hospitals) in the US. This continues to be the case even though, as discussed earlier, the vast majority of drug research is focused on producing pharmaceuticals for the consumption of the relatively wealthy (Bodenheimer 1985:209). AIDS research is certainly no exception.

One notable new addition to the current WHO essential drugs list was zidovudane, the antiretroviral drug more commonly known as AZT, which is recommended for the treatment of HIV infected pregnant women in order to reduce mother-to-child transmission of the virus (WHO 1998). But AZT has a controversial testing history.

AZT has been found (in US studies) to reduce by two-thirds the incidence of HIV infection from pregnant, HIV-positive women to their babies. The particular regimen of drug use which achieved this result - labelled “ACTG 076” - has become the standard of care in the US (Lurie and Wolfe 1997:853).

In Asia and sub-Saharan Africa, it is estimated that by the year 2000, 6 million pregnant women will be infected with HIV. However, the “potential of the ACTG 076 regimen remains unrealized primarily because of the drug’s exorbitant cost in most countries” (Lurie and Wolfe 1997:853). As if this isn’t bad enough, some researchers have further exploited the dire situation of HIV infected people in underdeveloped countries by taking advantage of local (Third World) standards of care to undertake research which would simply not be allowed in the West.

For example, in an attempt to discover a less expensive regimen for the prevention of vertical transmission of HIV, researchers have been carrying out trials in the Third World where the control groups were placebo-treated, or, in other words, given no active substances. This is considered highly unethical given that a proven effective treatment actually already exists. The justifications for these trials is simple:

“Women in the Third World would not receive antiretroviral treatment anyway, so the investigators are simply observing what would happen to the subjects’ infants if there were no study” (Angell 1997:847)

Because placebo-controlled study is in fact the “fastest, most efficient way to obtain unambiguous information” (Angell 1997:847), it might be possible to see the advantages of documenting the health of placebo-treated research subjects. Sadly, though, placebo-controlled trials seem to be only the thin edge of the wedge. For example, Lurie and Wolfe (1997:854) document one horrifying case where researchers injected “live malaria parasites in HIV-positive subjects in China in order to study the effect on the progression of HIV infection”.

For all the academic debate regarding various aspects of AIDS-related pharmaceuticals, it remains the opinion of at least one AIDS worker in Zambia that what the people really need first is food (Dateline 1999).

Conclusion

In conclusion, it can be seen that, both literally and metaphorically, the modern pharmaceutical industry is larger than life. There is little doubt that the industry is primarily concerned with making profits and keeping shareholders happy. When it is allowed to do so, the pharmaceutical industry will exploit human life. However, this is not to suggest that important, positive changes in relation to human health and pharmaceuticals cannot be made.

Governments, doctors and consumers need to remain (or perhaps become) vigilant in their protection of human welfare as it relates to medicinal drugs. One method of doing this would be through the implementation of essential drugs strategies, following the example of Bangladesh.

It is also vitally important that pharmaceutical products are treated with the respect they deserve. That is, it should be realised that medicinal drugs are powerful and potentially dangerous, but they do not provide a simple solution to all of the world’s illnesses.

REFERENCES

Angell, M (1997) “The ethics of clinical research in the Third World” in New England Journal of Medicine vol.337 pp847-49

Anon (19??) “The drug industry” - sorry about this one Cynthia... this reference is one that you gave me, but there’s no clue as to what it is or who it’s by...??? It’s in the pile I returned to you.

Aronowitz, S (1988) Science as Power: Discourse and Ideology in Modern Society University of Minnesota Press, Minneapolis

Bodenheimer, T.S (1985) “The transnational pharmaceutical industry and the health of the world’s people” in Issues in the political economy of health care ed: McKinlay, J.B Tavistock Publications, New York.

Dateline (29 Sept1999) “AIDS in Africa - A Bitter Pill?” SBS Australia

Ekins, P (1992) Wealth Beyond Measure Gaia, London.

Fortune (1999) “1999 Fortune 500” Internet www.pathfinder.com/fortune

Glucksberg, H and Singer, J (1982) “The multinational drug companies in Zaire: their adverse effect on cost and availability of essential drugs” in International Journal of Health Services vol.12, no.3 Baywood Publishing.

Goodyer, P (Nov 11 1999) “Real Food Revival” in The Sydney Morning Herald ppFit 8-9

Hooper, M (1972) Everyday Inventions Pan Books, Sydney.

James, J.S (1998) “GATT and the Gap: How to Save Lives” from AIDS treatment news archive Internet www.immunet.org/immunet/

Johnson and Johnson (1999) “Johnson and Johnson Homepage” Internet www.jnj.com/home

Khor Kok Peng, M (1995) The Uruguay Round and Third World Sovereignty Third World Network, Penang Malaysia.

Lall, S (1980) The Multinational Corporation - Nine Essays Macmillan, London

Lurie, P and Wolfe, S.M (1997) “Unethical trials of interventions to reduce perinatal transmissions of HIV in developing countries” in New England Journal of Medicine

May, R (1994) “Changing diseases in changing environments” in Health and the Environment ed: Cartledge, B. Oxford University Press, Oxford.

MIMS (1998) MIMS Issue No.4, MIMS Australia.

Ong Beng Gaik (undated) “Misuse and overuse of antibiotics: Who is to blame?” Internet www.twnside.org.sg/souths/

Raghavan, C (1996) “Health: Assembly adopts new revised drug strategy” Internet www.hartford-hwp.com/archives

Taylor, R (1979) Medicine Out of Control Sund Books, Melbourne.

WHO (1996) World Health Report 1996 WHO Geneva

WHO (1998) “The Essential Drugs Strategy” Internet www.who.int/dap

WTO (1999) “World Trade Organisation” Internet www.wto.int