Historicising state-NGO relations in global drug access campaigns: the case of the Bangladesh drug policy of 1982

What role do states, international organisations and NGOs play in disrupting the profit-driven logic of the global pharmaceutical marketplace? It seems a pertinent time to reflect historically on this question, following the restructuring by Médecins Sans Frontières of its long-running Access Campaign in 2024. Borne of struggles to lower the cost of HIV/AIDS treatment drugs, the campaign expanded over the years to confront the power of large pharmaceutical companies in a number of areas, including the lack of Research and Development of new treatments for Neglected Tropical Diseases like malaria, and the expense of treating multi-drug resistant TB. I spent some time in the War on Want and Christian Aid archives, located in SOAS in London last summer, and came across a wealth of documentation on the NGOs’ support of a Encountering archival traces of the Bangladesh programme prompted me to reflect on this past moment of idealistic global solidarity, and what it might tell us about the persistent obstacles to challenging power in global health.

Advertisement in support of Bangladesh drug policy

War on Want archive, box 76.

The World Health Organisation created a model list of the approximately 225 medicines deemed ‘essential’ for the treatment of the most common and fatal diseases in 1977, and, drawing on this, the government of Bangladesh produced a list of 150 essential and 100 specialised drugs in 1982. The Bangladeshi programme also introduced price controls and curbed the power of multinational corporations by banning the import of drugs which could be produced locally. Most importantly, the policy sought to ban drugs classified as non-essential and potentially harmful to the population. The marketing of the anabolic steroid Orabolin by the Dutch company Organon to children suffering from malnutrition in Bangladesh was a case in point (see Image 2  below). By exerting control over the market in this way, the idea was that resources could be redirected towards medicines truly needed by the majority of the population. The following passage from the report by the Expert Committee appointed to advise on the national drug policy (quoted in Pills, Policies and Profits) reflects this goal:

‘Recognising the right of every citizen to enjoy the highest possible level of health care, there is an urgent need to mobilise and make economic and effective use of all available resources for improving the state of health of our people. Drugs being most essential tools for health care, these cannot be treated just as any other commercial product. At present not more than 20% of the population have access to even the most essential drugs for their health care and yet the market is flooded with hundreds of useless or non-essential products.’

Despite clearly taking inspiration from the radicalism of the WHO’s Alma Ata Declaration on primary health care and Action Programmme on Essential Drugs,  it seems from archival records that the Bangladesh policy received at best a lukewarm response from the international organisation.Furthermore, in addition to predictable attacks from multinationals, there were attempts to discredit it by local interest groups, including GPs and drug sellers, who recognised that they could lose income with increased regulation of the market.

It was in this fraught environment that several Anglophone NGOs – including Health Action International, War on Want, Oxfam and Christian Aid – pledged their support to the Bangladesh drug policy, participating in a campaign of global solidarity. These international actors established a close relationship with the Bangladeshi NGO Gonoshasthaya Kendra, a ‘comprehensive primary health care’ organisation initially set up as the ‘Bangladesh Field Hospital’ for freedom fighters in the national liberation war. Its leader, Zafarullah Chowdhury, was a member of the Expert Committee that helped government to formulate the drug policy in 1982, and the organization later became a drug producer itself in line with the aims of the policy. Indicating the importance with which War on Want viewed the Bangladesh programme, the British NGO published a comprehensive exploration of the situation for its supporters in a booklet entitled Pills, Policies and Profits in  1985,

Cover of War on Want publication Pills, Policies and Profits by Francis Rolt (1985)

Cover of War on Want publication Pills, Policies and Profits by Francis Rolt (1985)

chronicling the various attempts to frustrate the policy’s implementation over the three years since its announcement. Transnational campaigns and alliances like this raise interesting questions about the relationship between non-governmental organisations in the Global North, and states and civil society in the Global South. Bangladesh was under the rule of a military regime at the time, and War on Want was under no illusions that its leadership represented a true voice of the poor. Nevertheless, reviewing another War on Want publication on Bangladesh, one commentator quipped that the country represented the ‘pearl in the mythology of “Third Worldism”’, hinting at the romantic lens through which Western actors still viewed the potential of the programme.

How do the political debates around access to healthcare and regulating the global pharmaceutical market in the 1980s relate to the present day, and what can we learn from returning to moments of contestation such as this? Present-day Bangladesh is a drug producer and emerging drug exporter, albeit in the shadow of large-scale generics production in India (referred to as ‘the pharmacy of the developing world’ by MSF Access in 2015). Gonoshasthaya Kendra is still an active organisation, with a presence in the Cox Bazar refugee camps that cater to the needs of the Rohingya community that fled Myanmar to Bangladesh. MSF too is a major actor there, and its efforts to secure a cost-effective way to treat the high levels of Hepatitis C among refugees indicate the complex impacts of Bangladesh’s contemporary market regulations on the most vulnerable people residing within its borders today. From the late 1990s, the MSF Access Campaign took up the mantle of critiquing the global power structures that determine the cost and availability of life-saving drugs. Echoing the Third-Wordlist language of global solidarity that animated the Bangladesh campaign in the 1980s, the movement highlighted the persistence of a fundamentally inequitable, commercially driven system for the research and production of essential medicines. Historicising such campaigns should prompt us to reflect on the role of both states and non-state actors in critiquing the power of multinationals, and to join the dots between present-day challenges and the idealistic ambitions of the post-Alma Ata decade.

 

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