Footnotes

• ↵* Balance of payments refers to the difference between the amount of foreign currency coming into a country (including from sales of exports) and the amount leaving (including payments for imports). A large deficit can create serious economic instabilities.

• ↵† As with any multilateral political process, groups have formed at the WTO embodying different economic, development, and regional interests. The most powerful of these is the Quad (Quadrilateral Group).

• ↵‡ The Africa group comprises all African nations, and has taken the lead on TRIPS agreement amendments.

• ↵§ Indeed, the focus on drug patents could be a public health distraction. Attaran points out that poverty in developing countries is a bigger reason for lack of access to essential medicines than drug patents protected under TRIPS.¹² Most essential drugs on the WHO’s Model List of Essential Medicines are not patent protected in developing countries, and drug companies often do not pursue such protection in low income countries because of their small market size and lack of ability to pay. Improvements in global health, including curbing of the HIV/AIDS and other infectious disease pandemics, are more likely to arise through reforms in other WTO agreements, such as those covering agricultural subsidies or special and differential treatment, than through reforms in drug patent protection, at least until poorer countries become wealthy enough to matter to the bottom-lines of multinational drug companies.

• ↵¶ The GATS defines four possible ways of providing services, or modes of supply. Each of these can apply to public health services: (1) cross-border delivery of services (such as shipment of laboratory samples or provision of telehealth services); (2) consumption of services abroad (called “health or medical tourism”); (3) commercial presence (foreign investors provide private hospitals, clinics, treatment centres, insurance or facilities management); (4) presence of natural persons (the temporary movement of health professionals from one country to another).

• ↵** Or, in the case of many developing countries, services that were publicly financed and provided before structural adjustments imposed by the World Bank and IMF led to their full or partial privatisation.

• ↵†† We set aside an examination of whether increased private financing or provision in health care and other important health determining services is a good or bad thing for the public’s health. What such privatisation does do, however, is limit or remove the ability to cross subsidise the costs of such services from healthy to sick and from rich to poor, rendering whatever mixed system results less fair.

• ↵‡‡ We emphasise that this an assumption only; evidence suggests that FDI follows economic growth at least as much as leads it. Nor does economic growth invariably reduce poverty.³¹

• ↵§§ How eventual conflicts between the Convention’s terms and WTO treaty obligations will be resolved remains uncertain.