January 2014 – PEAH – Policies for Equitable Access to Health

Synergizing Roles: Experiences of Civil Society Working Towards Promoting Local Generic Pharmaceutical Manufacturing in the EAC Region

Due to a number of bottlenecks, the generic pharmaceutical manufacturers in the East African Community region produce at a cost disadvantage compared to their large-scale Asian counterparts. This article highlights some of the key areas where civil society has engaged and can still engage with local pharmaceutical industries to address these challenges

SYNERGIZING ROLES: EXPERIENCES OF CIVIL SOCIETY WORKING TOWARDS PROMOTING LOCAL GENERIC PHARMACEUTICAL MANUFACTURING IN THE EAC REGION

By Moses Mulumba

Executive Director, Center for Health, Human Rights and Development*(CEHURD), Kampala Uganda

Background & Introduction

Although civil society activists and local pharmaceutical manufacturers serve different objectives, the two groups have had to work together in the area of access to affordable quality medicines, which are much needed in the East African region. Indeed this is one of the unique working relationships where health-related civil society has had to move away from the traditional shelving away from private “profit oriented” pharmaceutical companies to combine efforts towards scaling up access to generic medicines in a region that is heavily burdened by diseases such as HIV, malaria tuberculosis and several other health challenges. I must quickly point out that the central reason that has led to this relationship is the realization that in order to deal with gaps of access to adequate basic medicines in the region, promoting local manufacturing is key. As UNAIDS, WHO and UNDP have advised, countries like those in the East African Community (EAC) need to invest in regional and national production capacities in the pharmaceutical sector and in the development of local expertise.

The pharmaceutical manufacturing sector in the EAC is largely dominated by generic manufacturing. In Uganda all existing local pharmaceutical companies are generic manufacturers. Generic medicines are pharmaceutical products usually intended to be interchangeable with an innovator product and manufactured without a license from the innovator company and marketed after the expiry date of the patent or other exclusive rights. It is significant to note that due to a number of issues including infrastructural challenges, tax policies, investment policies and others, the generic pharmaceutical producers in the EAC region produce at a cost disadvantage compared to their large-scale Asian counterparts. As such, even when local generic manufacturing offers such a huge opportunity for bridging the access to essential medicines gap, without addressing some of these tailbacks, the EAC region will be yet to realize the full benefits of local manufacturing.

As such, there are clear opportunities for health civil society to combine efforts with the local generic pharmaceutical manufacturers to address the bottlenecks to fully benefit from generic local manufacturing. The paragraphs below highlight some of the key areas where civil society has engaged and can still engage with local pharmaceutical industries to address these challenges.

Key Issues for Local Generic Manufacturers and Civil Society

Addressing the Legal and Policy Environment in the Region

The legal and policy environment for the production of local generic medicines still has a number of gaps that need to be addressed. There are a number of laws and policies that still need to be reviewed and others put in place both at the individual country level and at the EAC regional level. The legal environment touches a number of aspects including investment laws, tax laws and several commercial laws which cannot all be highlighted within the space for this paper. As an example, I will throw more light on the intellectual property regime, which is key for local generic pharmaceutical manufacturing. Except Kenya, all the other EAC countries are still listed as Least Development Countries and are therefore still exempted from Intellectual Property rights enforcement with respect to pharmaceuticals under the TRIPS agreement. This provides ample opportunities for these countries to maximize the benefits provided by the TRIPS flexibilities. The current legal reforms in the EAC countries indicate that countries are not fully utilizing these flexibilities. For instance, the TRIPS flexibilities have been only sparsely incorporated in Uganda’s process of enacting the Industrial Properties Bill. Similarly, Rwanda remains the only country in the region that has implemented the TRIPS Council’s August 30th decision which allows member states to grant compulsory licenses to import or manufacture urgently needed patented medicines.

Another disturbing development is the fact that countries in the EAC are at various stages of enacting laws to address counterfeiting and these laws have been defining counterfeiting so widely as to include generic medicines. This could hinder locally manufactured legitimate generic medicines from entering the channels of commerce, thereby undermining public health objectives in the region by obstructing access to essential generic medicines. These legal challenges exist regardless of continuous drug stock-outs occurring across the region. The current inability of governments in the region to wield the power conferred by the TRIPS flexibilities means that continuous health civil society engagement with the relevant stakeholders is required to protect the critical legal and policy space used by local generic pharmaceutical manufacturers.

Poor Infrastructure and Capacity Issues of Local Pharmaceutical Manufacturers

Another concern is that the technical and financial capacity of East African pharmaceutical manufacturers is compromised by a lacking technical labour force as well as low investment into the sector in the region. The private foreign investors who dominate the regional manufacturing sector inject limited financial resources into East Africa. Because of this, the regional governments still have a very vital role to play in facilitating the sustainability of pharmaceutical manufacturers. Quality Chemicals, which was initially a joint venture between the Government of Uganda and private actors, experienced a strong start following various forms of support provided by the Government of Uganda.

Low financial and technical capacity means that local manufacturers are unable to produce sufficient generic medicines to supply the high demand at affordable prices. This is further aggravated by challenges such as inadequate electricity supply and weak transport and communications infrastructures, increasing the cost of production of generics in the region. While regional governments should be commended for creating some tax incentives for investors and at times providing financial support, such support is usually not sufficient to enable companies to perform to capacity. This also affects other critical processes such as WHO prequalification, a prerequisite for successful local generic manufacturing.

Low Investments in R&D and Poor Signs of Technology Transfer

Directly related to the lack of capacity of local generic medicines manufacturers is the low level of technology transfer and investment in research and development. One of the cornerstones of the TRIPS Agreement as embodied in its principles and objectives is the adoption of measures (Article 7-9) that promote technological innovation, transfer and dissemination in the development of intellectual property laws. One way in which national technology innovation, transfer and dissemination can be achieved is by encouraging pharmaceutical companies, which are driven by foreign private investment, to train a local labour force and transfer advanced technology into the country. The continued importation of semi-processed raw materials made from raw materials already existent in the region and the perpetual importation of skilled labour creates a resource and labour dependence syndrome which significantly inhibits the development of the regional capacity to manufacture generic medicines. This is a critical area where civil society can engage with governments to promote local generic pharmaceutical manufacturing.

Civil Society Engagements In initiatives Promoting Local Generic Pharmaceutical Manufacturing

The EAC Partner State governments have relegated themselves to a mainly regulatory role in the pharmaceutical manufacturing sector. East African civil society organizations have often bridged the gap between governments and manufacturers, adding the voice of public interest into the sector. The following paragraphs highlight some of the instances in which civil society has engaged in initiatives that either directly or indirectly boost local pharmaceutical production in the EAC region.

– Intellectual Property Legal, Policy and Institutional Reforms: As the EAC Partner States worked on their legal reforms, health-related civil society has provided a critical eye to all the provisions suggested in the national legislation in the area of intellectual property to ensure that TRIPS flexibilities are fully utilized. Some of these flexibilities, such as compulsory licenses and the adoption of the August 30th Decision, are central to encouraging local generic pharmaceutical manufacturing. In addition to the legal reforms, health civil society organizations are undertaking a campaign to encourage national intellectual property offices to undertake the necessary reforms to do patent searches and registration at the country level as opposed to doing this at the regional level through ARIPO (African Regional Intellectual Property Organization), where patent pre- and post-grant opposition procedures are almost impossible. This will enable the opposition of possible patent grants for the benefit of local manufacturing of generic medicines.

– Influencing Policy Decisions: Health civil society organizations continue to play a critical role in defining the policy decisions both at the country and regional level. A clear example has been making a decision on the policy of legislating for the counterfeiting problem in the region. While the Government of Kenya had already embraced a law that broadly defines counterfeiting to include generic medicines, the civil society movement undertook several counteractive measures including a human rights court challenge on the possible implications of this approach on access to medicines in Kenya. With a successful court challenge, the law has been put on hold pending its revision to reflect the importance of access to generic medicines in Kenya.

– Promoting Public Trust in Locally Manufactured Medicines: There has been a lot of misconception about the quality of locally manufactured medicines within communities in the region. This has been partly due to current talk about counterfeits and substandard medicines. To clear this doubt in Uganda for instance, a group of civil society actors working towards access to medicines has fostered dialogues between the manufacturers and the public. Within these dialogues, the public has expressed some of the concerns and the manufacturers have addressed misconceptions. Civil society continues to play the role of bridging the gap between local pharmaceutical manufacturers and the public through sensitization and awareness campaigns to encourage the use of safe and efficacious generic medicines.

– Towards a Better Environment for Local Generic Pharmaceutical Manufacturers: Many of the challenges of pharmaceutical manufacturing in the region are related to the local infrastructural environment. For instance, commercial and taxing policies heavily affect the success of local generic pharmaceutical manufacturing. Health civil society organizations have engaged with the governments in the region to encourage them to address many of these challenges. For instance, Ugandan civil society organizations have campaigned for governments to waive taxes on health commodities including raw materials for local pharmaceutical manufacture.

– Delinking the Medicines Patent Status for Drug Registration: A further major challenge for locally manufactured medicines is registration with the national regulatory authorities to enable the medicines to enter the market. In the past there have been requirements by some EAC national regulatory authorities that in order for drugs to be registered they should not be on patents in other regions. This clearly bars the approval for marketing any locally manufactured generic medicines that may be on patent elsewhere even when the East African countries in question have no obligation to protect such patents. Health civil society has encouraged these governments through the drug regulatory agencies to delink drug registration from patent status in order to protect local generic pharmaceutical production.

– Regional and International Initiatives: Civil society organizations are currently involved in campaigns to mitigate possible consequences of regional and international trade negotiations that could affect local manufacturing of generic medicines. A key example is the Economic Partnership Agreement between the European Union and the EAC which introduced several provisions including intellectual property provisions that could deter local manufacturing of legitimate generic medicines. Health and trade civil society organizations in the region are working hard to get such provisions expunged from these initiatives.

Conclusions and Moving Forward

There is no doubt that successful local pharmaceutical manufacturing of generic medicines calls for some joint collaboration between local pharmaceutical manufactures and civil society organizations. While their general objectives seem different, the interests of the two sectors converge when it comes to bridging the gap in access to medicines in the region. The paragraphs above have indicated some challenges of local generic pharmaceutical production and how civil society efforts have tried to address some of these. The key message from this is the fact that while the local manufacturing sector can play an important role in increasing access to and promoting the affordability of medicines in the region, a lot of support is needed for them to not only increase their production capacity but also to make a greater contribution to healthcare in the EAC region. Health civil society now needs to get into wider campaigns for the development of regulatory guidelines stating requirements for manufacturers of generic medicines to develop local capacity and undertake increased technology transfer into the region while at the same time lobbying EAC partner states to create subsidies and concessions which can boost the local pharmaceutical manufacturers’ capacity to adequately provide the much needed legitimate, affordable and quality medicines. This should be in addition to scaling up wider campaigns necessary to sensitize the public on the safety of generic medicines and combat the current assumption that generic medicines are counterfeits.

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*The Center for Health, Human Rights and Development (CEHURD) is an indigenous, non-profit, research and advocacy organization which is pioneering the enforcement of human rights and the justiciability of the right to health in Eastern Africa. CEHURD was founded in 2007 and was registered under the laws of Uganda as a company limited by guarantee Certificate No. 114712. It was formed to contribute towards ensuring that laws and policies are used as principal tools for the promotion and protection of health and human rights of populations in Uganda and in the East African region. CEHURD realizes this through a set of programs: (1) Human Rights Advocacy; (2) Community Empowerment; and (3) Research and Documentation. CEHURD focuses its efforts on critical issues of human rights and health systems in East Africa such as sexual and reproductive health rights, trade and health, and medical ethics which affect the vulnerable and less-advantaged populations such as women, children, orphans, sexual minorities, people living with HIV/AIDS, persons with disabilities, internally-displaced persons, refugee populations and victims of violence, torture, disasters and conflict.

Global Health 2035 Report: Flawed Projections

Hopes that a comprehensive global health goal could be reached by 2035 are hardly credible with the load of unresolved issues still on the table. This article turns the spotlight on much-debated relevant questions that were left out or under-scrutinised in a recently published Lancet report

Global Health 2035 Report: Flawed Projections

by Daniele Dionisio*

Member, European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases

Published online on 3 December, a Lancet Report developed a forward-looking investment agenda to attain dramatic health gains by 2035. The Report emphasises public revenue generation and public financing to be allocated to and within public health budgets especially for the poor populations in the low- and middle-income countries. And it asks for measures including, among others: full exemption of out-of-pocket expenses for the poor; poor-friendly pathways towards universal health coverage; heavy taxation on tobacco and other harmful substances; and reduction or elimination of energy subsidies on air-polluting fuels.

Apart from undeniable merits, including a statement of methodological caveats, the Report gives up on tackling a number of conflicting issues whose resolution is crucial to allow global health targets to be achieved by 2035. Regrettably, since these issues are far from settlement from a mid- to long-term perspective, the feasibility of the optimistic projections laid down in the Report remains doubtful.

These projections are unlikely to come off in today’s world landscape, which is torn by disalignment, litigations and frictions among the involved parties. This context entails that unbiased solutions for global health only hinge on political will to improve equity, coherence, coordination, collaboration, transparency and accountability both at domestic and international level.

Unfortunately, the world leaders are not ready to converge on this, and plenty of evidence shows that policy and trade directions, largely from the most advanced countries, run exactly contrary to these principles.

These directions and their impact on health were left out or under-scrutinised in the Lancet Report. This article seeks to spotlight some much-debated questions.

Intellectual Property Policies

The concerns above are appropriate now that trade agreements and governments’ choices, largely by the European Union (EU) and the United States (US), are turning intellectual property (IP) agendas into policies which protect monopolistic interests at the expense of equitable access to care and lifesaving treatments in resource-limited settings.

In recent years, the EU has been pushing for exacerbated IP provisions in bilateral trade agreements with emerging economies such as India and Thailand. Meanwhile, a still underway US-led Trans-Pacific Partnership (TPP) deal has incurred criticism that without an infusion of standing power by TPP participating countries against US pressure, the US will force to consolidate monopoly control by big companies, hence undermining access to lifesaving medicines for millions of people in resource-constrained settings.

Relevantly, a June 2013 EU custom regulation has been blamed for allowing illicit seizing of in-transit goods (including legal generic medicines) “over a simple suspicion of IP infringement without checking beforehand whether these goods are headed to the European territory or just in transit” and without “clear and convincing evidence of a substantial risk of diversion.” These terms run against EU commitments regarding access to treatments without restrictions.

These cases just represent the tip of the iceberg for the underhanded tactics to ensure that developing countries adopt IP clauses that go beyond the full extension they had a right to under the World Trade Organization (WTO) Trade-Related Aspects of Intellectual Property Rights Agreement (TRIPS).

These strategies add to the current breakthrough of multinational drug corporations in the middle-income country markets including through takeovers and buyouts of local companies.

Overall, this is an indication that corporate profits now outweigh any commitment to the global human rights.

As regards health, this context means a threat to India and other emerging countries as providers of lifeline medicines to the poor’s world.

TRIPS-plus measures would include: making it easier to patent new forms of old medicines that offer no added therapeutic efficacy for patients (“evergreening”); restricting “pre-grant opposition,” which allows a patent to be challenged before it is being granted; enforcing intellectual property beyond what TRIPS requires; allowing customs officials to impound shipments of drugs on mere suspicion of IP infringement, including “in transit” products that are legal in origin and destination countries; expanding data exclusivity beyond WTO’s request for data protection against unfair commercial use only; extending patent lengths beyond 20-year TRIPS requirements; and preventing drug regulatory authorities from approving new drugs if they might infringe existing patents.

In the meantime, the government of Canada has killed a bill on access to medicines for developing countries. And there is more.

Concern is spreading that, as in the recently signed Canada-EU Trade Agreement, terms encompassing an “investor-state mechanism” could be approved inside other trade agreements that are underway or soon-to-be initiated. These include the EU-India deal, the Trans-Pacific Partnership Agreement (TPP), and the Transatlantic Trade and Investment Partnership (TTIP).

The impending threat of an investor-state system enforcement as regards access to medicines cannot be underestimated. In this regard, many forms of government regulations, including price cuts of medicines, could be argued not to conflict with the TRIPS agreement, yet to make pointless or erode the expectations of the patent owners.

Relevant risk sectors also include tariffs on medicines, as would be the case should a country that has agreed to reduce tariffs on an imported product later subsidise home manufacturing of the same medicine. A complaint against this country under an investor state system would be allowed to re-establish the conditions of competition in the original transaction.

Additionally, the sectors relevant to packaging and labelling requirements, and to IP protection enforcement measures, may also result as risk target areas, since they might affect the patent holders’ access to the market of medicines.

Under these circumstances, a claim could easily be lodged against a government for nullifying or eroding benefits by applying IP protection rules or packaging and labelling models that, despite full alignment with TRIPS requirements, are deemed to be insufficiently stringent or fraudulent.

World Bank, WTO, IMF Programmes

Public opinion is increasing pressure against WTO and World Bank controversial economic reform programmes deemed to have a negative impact on health and health infrastructures in the developing countries. Pressure involves the International Monetary Fund (IMF) programmes that are charged with indirectly stifling health spending, while being too conservative about what policies are needed to attain macroeconomic stability in the borrowing countries.

This context has critically impaired access to food. Over the last 20-30 years, the World Bank and the IMF, and more recently the WTO, have forced countries to decrease investment in food production and to reduce support for peasant and small farmers. Under neo-liberal policies, state-managed food reserves have been considered too expensive and governments have failed to protect farmers and consumers against sudden price fluctuations, while being forced to “liberalise” their agricultural markets through reducing import duties and accepting imports for at least 5% of their internal consumption even if they did not need it. As such, the critics argue that the neo-liberal policies have destroyed the capacities of countries to feed themselves.

And this occurs at a time when land grabbing and evictions as part of neo-colonialism policies, including for biofuel agribusiness, are on the rise in Africa and elsewhere under national governments complacency and a widespread corruption.

Undermined WHO Performance

The models the WHO has called for to finance R&D for diseases of the poor and ensure long-term access to medicines have been overlooked in the Lancet Report. This comes as no surprise now that WHO performances, including its Medicines Pre-qualification Programme, suffer from funding shortages and inadequate collaboration by member governments.

This is the case with the EU, whose global plan for health development cooperation lacks coordination with the WHO, while the EU looks like it would disregard WHO as the most accountable actor, and a number of its political choices run contrary to the WHO directions. As an example, while the latest WHO and EU plans to address medicine quality issues have raised criticism of inadequate coordination and collaboration with each other, the Directive 2011/62/EU against falsified medicinal products did not mention WHO as a partner body for field purposes, and did not align with WHO definitions of Substandard/Spurious/Falsely-labelled/Falsified/Counterfeit Medical Products (or SSFFCs).

In the meantime, disalignment by member governments accounts for the exceedingly slow pace of the WHO Member State Mechanism on SSFFCs since it was established in May 2012.

Medicines Quality Issues

The poor legislative and regulatory framework monitoring the quality, sale and transit of medicines in the developing countries, coupled with the scarcity of human and financial resources and a lack of political will, have allowed the trade in counterfeit and substandard medicines to boom.

Estimates of counterfeit medicines sold in developing countries range from 10% to 30%, including treatments for malaria, tuberculosis and AIDS.

Substandard medicines are an even larger threat to public health than counterfeit ones, comprising at least half of tested medicines. The spread of these drugs is facilitated by the fact that for-export medicines to developing countries are often poorly regulated, with quality evaluation a mere formality and efficacy and safety testing not undertaken at all. Diversified production chains can exist within the same facilities: top quality for wealthy markets; intermediate for middle-income countries; and much lower quality for least-developed countries.

The importance of poor-quality medicines cannot be underestimated, as they may disrupt all major complex interventions to ensure treatment efficacy. Not only treatment failure may ensue, but emergence of drug resistances can be favoured.

Unfortunately, the legislation against counterfeit and substandard medicines too often does not address quality issues, but instead is aimed at protecting the commercial interests of brand-name drug manufacturers.

And now that new relevant initiatives risk overlapping, the governments are seemingly not ready for signing agreements whereby international donors must strengthen WHO-aligned quality clauses in tender transactions with non-governmental organisations, while purchasers must insist that manufacturers and distributors supply medicines that meet WHO requirements, and governments must authorise export only of products meeting WHO quality, efficacy and safety standards.

“Brain Drain”, Health Worker Shortage

Scarce attention was paid by the Lancet Report to the critical shortage of health care professionals that limits the access to care to millions of individuals in resource-limited settings. This situation requires urgent action, such as a profound transformation of the present training approach, as to adapt curricula to local needs, promote strategies to retain expert faculty staff and reverse “brain drain”, expose trainees to community needs during training, promote multi-sector approach to education reforms, and strengthen links between the educational and health care delivery system. Western academic institutions’ role is to facilitate the process. The possible strategies for assistance should be in constant and balanced partnership.

Consensus Principles, Nothing Less

What expectations on these grounds? Hopes that a comprehensive global health goal could be reached by 2035 are hardly credible with the load of unresolved issues still on the table.

And the most advanced countries look like they wouldn’t be ready to embark on the gaps highlighted here as an opportunity for national security and profitable return on their disbursements rather than just a heavy burden in times of economic slump.

Yet, what shouldn’t be given up for this aim?

More money is obviously a key issue, but a coordinated, collaborative effort from all the parties is equally vital. Hence, a common agenda for shared health priorities is needed. And leading institutions and organisations must enhance working with health ministries to strengthen national systems, invest in infrastructures, improve transparency and accountability, and boost needs-driven rather than market-driven rules. This means giving up “closed doors” negotiations and adopting multi-sector participatory models for decisions affecting national health, growth, employment and budgets.

This entails linking together patent offices and legislators worldwide to develop evidence-based reforms of the patent regime of medicines. As reported “…[I]f countries set higher standards for incremental innovation patenting, and permit citizen or third-party review of patents before and after examination, then we will likely see increased generic competition in the …market, new combination therapies, and lower … prices. In the longer term, higher inventiveness standards will help clear the patent thicket to allow new products to develop, and push industry towards genuine innovations….”

Eventually, global level institutions should work to increase coordination and effectiveness of the UN system. They should seek synergies with WHO to address global health challenges and support stronger leadership by the WHO to improve global health. They should enhance dialogue and joint action with key players, including UN agencies involved in global health, international financing institutions, regional organisations, regional health networks, and countries, in order to identify synergies, coordinate actions, advance in the achievement of commitments, and avoid overlapping and fragmentation.

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Article republished from Intellectual Property Watch January 23, 2014 http://www.ip-watch.org/2014/01/23/global-health-2035-report-flawed-projections/

*Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is an advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). He may be reached at d.dionisio@tiscali.it https://twitter.com/DanieleDionisio

News Link n. 79

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

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Per uno Stato Laico e Democratico nella Palestina Storica, la Medicina per la Pace

La collaborazione tra personale sanitario israeliano e palestinese acquisisce  un significato simbolico e concreto, non solo nel campo medico, ma anche nello sforzo di ottenere pace e giustizia in quest'area di conflitto. Per la prima volta nella storia, nel 2013 un ministro palestinese ha visitato il complesso ospedaliero di Hadassah, eccellenza della sanità  a Gerusalemme, accompagnato da una delegazione di funzionari palestinesi. Nel 2012 oltre 210 mila palestinesi sono entrati in Israele per trattamenti sanitari e medici. Il dato è vistosamente cresciuto anche soltanto rispetto al 2008, quando i palestinesi del West Bank e della Striscia di Gaza che hanno beneficiato di cure mediche gratuite nello stato ebraico sono stati 172 mila

Per uno Stato Laico e Democratico nella Palestina Storica, la Medicina per la Pace

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by Cinzia Chighine*

Regione Toscana, Attività Internazionali

Venti anni fa, esattamente il 13 settembre 1993, sono stati firmati gli accordi di Oslo all’interno dell’autorevole cornice della Casa Bianca: una stretta di mano simbolica tra il Primo Ministro israeliano Yitzhak Rabin e il Presidente dell’OLP, Yasser Arafat ha siglato lo straordinario momento, segnando il processo di Pace in Medioriente.

Dopo un ventennio, il processo politico, così entusiasticamente lanciato – perchè di Pace si trattava – appare oggi nel corso della Storia recente solo un obiettivo intermedio in un percorso iniziato il 29 novembre 1947, con la Risoluzione delle Nazioni Unite che sancì la spartizione della Terra d’ Israele con la Palestina.

Molti fattori hanno contribuito al collasso del processo di Oslo, ma la radice del suo crollo e i semi della catastrofe, che seguì, furono piantati dai tre leader Arafat, Rabin e Peres. Tutti e tre ricordati nella storia “Uomini di Pace” ma con forti responsabilità fin dall’inizio del processo nel fallimento degli Accordi stessi [1].

Arafat non ha saputo o voluto agire come uomo della transizione palestinese, dimostrando limiti sia in termini di mentalità che di leadership, non svolgendo a pieno il ruolo da Statista che l’era diplomatica gli richiedeva. L’esempio più evidente è l’immagine del suo arrivo alla cerimonia della Casa Bianca per la firma, indossando una divisa militare. La scelta di non cambiare l’uniforme in un vestito di affari, ha sancito per sempre nel ricordo storico di tutti il ruolo da combattente più che da grande statista.

Da parte israeliana, Peres e Rabin hanno fatto un grosso errore a non comunicare alle opinioni pubbliche israeliane e palestinesi, subito dopo la firma degli Accordi di Oslo, il fatto che questa nuova fase rappresentasse una profonda trasformazione della politica israeliana, che mirasse finalmente a conseguire un’inequivocabile soluzione di due Stati per due Popoli sulla base dei confini del 1967 – condizionati, naturalmente, al corretto rispetto delle misure di sicurezza per entrambi i territori.

Di conseguenza, gli apparati della burocrazia israeliana non hanno mai regolato un nuovo approccio “di buon vicinato” con i palestinesi: i vari attori delle Forze di Difesa israeliane, la Polizia e Ministeri non hanno mai trasformato il loro atteggiamento psicologico e pratico per una nuova realtà in evoluzione.

In pratica, Rabin e Peres hanno intenzionalmente lasciato vaga la visione dei negoziati, così facendo hanno generato una dissonanza tra visione diplomatica internazionale e gravi conflittualità interne.

La mancanza di una strategia israeliana chiara e condivisa ha creato un problema che ben presto è divenuto ancora più ruggente con l’accordo del 1995: quando la squadra negoziale israeliana scoprì che le istruzioni erano di raggiungere un esito nella trattativa che avrebbe lasciato aperte tutte le opzioni – “forse ci sarà uno Stato palestinese, o forse no, forse Israele si ritirerà , o forse no, forse ai palestinesi si sarebbe accordata solo l’autonomia, o forse no” – l’assenza di qualsiasi strategia ha portato ad un accordo minimo con il solo esito concreto di imporre superficiali “successi” israeliani ai palestinesi con l’obiettivo generale di negare loro i necessari passi per la creazione di uno stato emergente in Palestina. Questa situazione ha contribuito sostanzialmente al fallimento della realizzazione degli accordi di Oslo.

Allo stesso tempo, Israele ha continuato – fino ad oggi- la costruzione e l’espansione degli insediamenti, lanciando un messaggio interpretato da molti palestinesi, e non solo, come un segnale evidente che Israele non potrà mai ritirarsi da queste zone. Inoltre, l’umiliante trattamento sul terreno di tutti i palestinesi come nemici potenziali continua in maniera e frequenza sempre più cruenta, anche se la maggior parte dell’opinione pubblica israeliana è convinta che “la popolazione vicina” ormai non costituisca più una minaccia per Israele.

Le relazioni tra Israele e i palestinesi sono deteriorate a un ritmo sempre più veloce sotto la prima amministrazione Netanyahu (1996-1999) e con la sucessiva amministrazione 1999-2001 di Ehud Barak, che ha contribuito sostanzialmente al deterioramento della situazione. Lo stesso fallimento del vertice di Camp David, che per alcuni opinionisti [1] è in gran parte attribuibile alla strategia sbagliata di Barak sui negoziati – ha scatenato l’ Intifada , che a sua volta ha portato alla violenza reciproca e la perdita di fiducia nella possibilità di realizzare la Pace in Terra Santa.

Oggi, a vent’anni da Oslo, è giunto il tempo di fare tutto il possibile al fine di portare il conflitto israelo-palestinese a termine e di intraprendere un viaggio nuovo, scardinando e andando oltre l’attuale visione diplomatica internazionale, ponendo nuovi obiettivi alle società israeliana e palestinese, affrontando le ingiustizie e la reale condizione dei cittadini arabi di Israele nel corso degli anni.

Una nuova strategia capace di affrontare, ad esempio, la definizione dello Stato non più solo come quella del popolo ebraico – una formulazione adeguata nel periodo post seconda guerra mondiale – ma di uno Stato laico e democratico nella Palestina storica [2], di tutti i suoi cittadini [3]. Una nuova strategia capace di essere dinamica e ricettiva al cambiamento.

Nel rinnovamento, la società dovrà necessariamente formulare un nuovo denominatore comune il più ampio possibile tra le sue diverse componenti, al fine di facilitare l’integrazione di tutti, riconoscendo sostanzialmente l’effettiva natura della società israeliana e nel contempo permettendo agli arabi di sentirsi cittadini a pieno titolo, con pari diritti e doveri.

Nella realtà attuale sembra che Israele non abbia una politica di Pace. Le continue dichiarazioni a sostegno della Pace e di due Stati non costituiscono una strategia, soprattutto quando si scontrano con la realtà drammatica degli insediamenti in espansione, gli avamposti illegali che fioriscono settimanalmente, l’assoluto immobilismo dello sviluppo economico e sociale palestinese in Area C (il 60 per cento della Cisgiordania) bloccato a causa della costante minaccia di annessione israeliana, l’aumento delle by pass roads, riservate agli israeliani, le zone militari chiuse, attorno alle città e ai villaggi palestinesi, che hanno cancellato ogni possibilità di uno stato contiguo, la conseguente cantonizzazione della Cisgiordania che ha prodotto delle enclave palestinesi, circondate da insediamenti israeliani, simili a bantustan del Sudafrica.

La sensazione generale per i palestinesi è quella di umiliazione, con nessun cambiamento all’orizzonte, nonostante che le recenti risoluzioni europee in materia di controllo israeliano sulla Cisgiordania sembrano aver aperto una campagna anti-israeliana che pone una minaccia economica per il Paese.

La mancanza di progressi politici indebolisce anche la parte palestinese moderata, la quale continua a sostenere l’ approccio di “Due Stati” sulla base dei confini del 1967 [4].

L’ attuale iniziativa guidata dal Segretario di Stato americano John Kerry sembra offrire l’opportunità di avanzare nel processo sempre più complesso e intricato. Ma la realtà ci offre attualmente una combinazione particolarmente sfavorevole: un governo israeliano che non è disposto a portare avanti l’agenda di Pace, un’opinione pubblica israeliana apatica e scettica, gli sconvolgimenti nel mondo arabo, che molti in Israele percepiscono come una minaccia, la debolezza politica della leadership palestinese, che soffre di una grave divisione sostanziale tra Fatah e Hamas, così come tra la Cisgiordania e Gaza, limitando ulteriormente la manovrabilità politica palestinese.

Negli ultimi tre decenni i progetti negoziali falliti hanno disseminato di carcasse la diplomazia mediorientale. Per più di 30 anni, esperti e politici hanno avvertito un “punto di non ritorno”. Il Segretario di Stato John Kerry è solo l’ultimo di una lunga serie di diplomatici americani sposati ad un’idea il cui tempo è ormai passato.

Entrambi le parti hanno motivi per aggrapparsi all’ illusione della “Two States Solution“. L’Autorità palestinese ha bisogno che la sua gente continui a credere che si stiano compiendo progressi verso una soluzione a due Stati in modo che possa continuare a ottenere gli aiuti economici e sostegno diplomatico utili a sovvenzionare gli stili di vita dei suoi leader, i posti di lavoro di decine di migliaia di soldati, spie, agenti di polizia e funzionari pubblici e la prominenza del potere in una società palestinese che lo vede come corrotto e incompetente.

Il Governo israeliano si aggrappa alla nozione dei due Stati , perchè sembra riflettere i sentimenti della maggioranza ebraica israeliana e mimetizza sforzi incessanti per espandere il territorio di Israele nella West Bank.

I politici americani hanno bisogno dello slogan “due Stati” per mostrare che stanno lavorando per una soluzione diplomatica, per mantenere la lobby pro-Israele e per mascherare la loro incapacità umiliante di una strategia diplomatica alternativa.

Infine, l’industria del “Processo di Pace” – con le sue legioni di consulenti, esperti, accademici e giornalisti ha bisogno di un rifornimento costante di lettori, ascoltatori e finanziatori. Il tutto produce un terribile congelamento [5].

Di fronte l’esigenza ruggente di quotidianità e sopravvivenza delle due popolazioni.

La situazione è similare alla Spagna del 1975, quando il dittatore Francisco Franco è entrato in coma: i mezzi di informazione hanno iniziato una lunga veglia di morte, annunciando ogni notte che il Generalissimo Franco non era ancora morto. Questa disperata fedeltà accomuna le speranze nel viatico della soluzione dei due stati oggi.

E’ vero che alcuni coma miracolosamente finiscono e grandi sorprese a volte capitano. Il vero problema è che i cambiamenti necessari per realizzare la visione della realizzazione dei due robusti Stati, israeliano e palestinese, richiederebbero oggi più che mai un alto livello di attenzione diplomatica, che ad oggi è carente e scadente.

Notizia di questi giorni è che in cambio di un accordo fra le parti, Bruxelles offre buoni affari in Europa. La proposta “Partnership Privilegiata Speciale”, giunta nel dicembre 2013 da Bruxelles – che con una mano ferma critica le colonie israeliane, ma con l’altra torna a proporre una pace economica tra le parti – si basa su un pacchetto senza precedenti da parte dell’Unione Europea di supporto politico, economico, cooperazione sanitaria e sicurezza ad entrambe le parti, israeliana e palestinese, se saranno in grado di finalizzare la Pace [6]. La proposta dei 28 è cristallina: la UE offrirà a Israele e al futuro Stato di Palestina l’ingresso facilitato nel mercato europeo, rapporti di natura culturale e scientifica, sostegno nell’investimento e nel commercio con partner europei. Precondizione al super-pacchetto europeo (oltre, ovviamente, ad un accordo di Pace definitivo) è il congelamento dell’espansione coloniale israeliana nei Territori Occupati.

Il piano europeo rientra perfettamente in quella “pace economica” che l’amministrazione di Washington tenta da tempo di far passare come il miglior strumento per un accordo che ponga fine a sei decenni di conflitto. Un’opzione che lo stesso premier Netanyahu ha più volte ribadito e che ha trovato la sua massima espressione, il maggio scorso, nell’iniziativa “Breaking the Impasse” di 200 businessman israeliani e palestinesi: parlare di affari e fare affari per risolvere le questioni politiche [7].

Dal punto di vista oggettivo, l’attuale prospettiva è che l’opzione dei due Stati è svanita, e ciò che rimane è quello di agire attraverso mezzi non violenti per stabilire uno “Stato Unico” indipendente e democratico tra il fiume Giordano e il Mar Mediterraneo. Al di là della trappola della normalizzazione e oltre le politiche israeliane di destra, tra cui l’estremismo religioso, che si basano su una promessa divina e una equazione che pone la Terra al di sopra del Popolo e dello Stato, sempre più esponenti della politica isreliana e palestinese [8] recentemente propongono formule su uno Stato Unico come soluzione al conflitto, sostenendo un singolo stato egualitario [9].

Ghada Karmi – medico, scrittrice e docente universitaria di origine palestinese [10] – nel suo recente libro dal titolo “Sposata a un altro uomo. Israele e la questione palestinese”, ripercorre le tappe più importanti del conflitto mediorientale da quando l’idea di costituire uno Stato ebraico in Palestina fu per la prima volta discussa, e porta avanti la tesi del “One-state solution“: quella di uno Stato unico, laico e democratico, nel territorio della Palestina storica, che assicuri a tutti i cittadini, arabi, ebrei e di altre culture e religioni, uguali diritti di cittadinanza.

La sua analisi nasce dal tentativo di offrire nella complessità del conflitto un contributo alla sua soluzione, proponendo, con approfondite analisi storiche e psicologiche, una tesi ritenuta impopolare: “Uno Stato laico e democratico” dove i diritti non derivano dall’appartenenza a un gruppo etnico o religioso, ma dalla legge che ne stabilisce l’uguaglianza e che riflette la situazione attuale di multiculturalità della popolazione in quell’area a causa anche delle migrazioni di persone ebree da tutto il mondo, che Israele ha favorito.

D’altra parte, le società arabe hanno avuto storicamente una connotazione di pluralismo e tolleranza religiosa e l’analisi mostra come quelle terre siano state rifugio degli stessi ebrei dalle persecuzioni nei secoli.

Un percorso lungo, un futuro lontano, attivando e ricostruendo un’identità che inizi il suo cammino verso un senso reciproco di appartenenza e coesione sociale. Soluzione in prospettiva migliore di quella attuale, in cui il senso di supremazia, di discriminazione, di proprietà esclusiva comincia, anche se molto gradualmente, a modificarsi attraverso lotte difficili, democratiche, un lento processo dello sviluppo della consapevolezza. Una sfida formidabile che col tempo soprattutto le nuove generazioni si sentiranno di costruire per la Pace e la convivenza, orientate verso la creazione comune di una nuova società .

La speranza è supportata dall’esempio del Sud Africa anche nelle forme del pentimento e della riconciliazione con i riconoscimenti delle ingiustizie commesse e le pratiche di riparazione verso le vittime. Una lotta che, oltre a rendere desiderabile la soluzione di uno stato unico e democratico, è ora solo quella concretamente fattibile e preferibile in assoluto, salvaguardando le necessità di sicurezza d’Israele, le sue umane paure e i bisogni di giustizia dei palestinesi.

Proprio come un palloncino riempito gradualmente con raffiche d’aria, quando è passato il limite della sua resistenza alla trazione, scoppia, così ci sono soglie di radicali squarci in determinati momenti storici a cui far fronte con un cambiamento dirompente in politica [11]. Quando più inclinature si incrociano, l’impossibile diventa improvvisamente probabile, con implicazioni rivoluzionarie per i governi e le nazioni. Come si vede vividamente in tutto il Medio Oriente, quando le forze di cambiamento e di nuove idee sono soffocate da tutto e per troppo tempo come la popolazione palestinese è stata ed è nel conflitto israelo-palestinese, il cambiamento improvviso, inaspettato nelle strategie diplomatiche, diventa sempre più probabile [12].

A livello pratico, giorno per giorno, un singolo Stato appare oggi più che mai un concetto che sembra oggettivamente possibile da attuare e sostenere nella pratica quotidiana, parlando di affari economici, di occupazione giovanile ma soprattutto di salute e gestione delle cure mediche, dove la priorità della vita scavalca i rigidi confini e allaccia legami. Le differenze e le divisioni tra Israele e Palestina sono immense: due culture, due religioni, due nazionalità , due racconti, due identità . Tutto è diverso ma di fronte all’emergenza della salute per se stessi o un proprio caro compare un denominatore comune per colmare l’enorme divario. In quell’istante, in quel luogo, in quello spazio entrambe le parti raggiungono il punto in cui si è in grado di condividere e superare i propri simboli, ricordi e paure.

Nella West Bank, a causa dell’aggravarsi della situazione socio-politica e umanitaria, degli effetti di più di 40 anni di occupazione israeliana e dell’aumentata dipendenza dagli aiuti esterni, l’accesso a servizi medici sostenibili per i residenti palestinesi è stato fortemente compromesso e le possibilità di sviluppo di un sistema sanitario palestinese indipendente sono, allo stato attuale, difficilmente realizzabili.

Le restrizioni alla libertà di movimento imposte dalle forze di occupazione israeliane alla popolazione palestinese creano gravi problemi sia per quanto riguarda l’accesso dei pazienti ai servizi sanitari sia per quanto concerne la formazione e l’aggiornamento di personale medico e la costruzione di un efficace sistema sanitario. Gli indicatori di salute evidenziano la critica situazione in cui si trova il sistema sanitario palestinese: la mortalità infantile è sei volte superiore a quella di Israele mentre la mortalità materna è addirittura 20 volte più alta [13].

Per la prima volta nella storia, nel maggio 2013 un ministro palestinese ha visitato il complesso ospedaliero di Hadassah, eccellenza della sanità a Gerusalemme, accompagnato da una delegazione di funzionari palestinesi. L’incontro con i vertici dell’ospedale israeliano era finalizzato ad accrescere il numero di medici palestinesi che prestano servizio presso la struttura sanitaria (attualmente non meno di 60) eccellenza nell’area mediorientale, e a favorire la cooperazione fra l’Hadassah Medical Center e l’ANP. La visita dei vertici della sanità palestinese rientra nel quadro di una quotidiana collaborazione in ambito di cooperazione sanitaria intercorrente.

Nel 2012 oltre 210 mila palestinesi sono entrati in Israele per trattamenti sanitari e medici. Il dato è vistosamente cresciuto anche soltanto rispetto al 2008, quando i palestinesi del West Bank e della Striscia di Gaza che hanno beneficiato di cure mediche gratuite nello stato ebraico sono stati 172 mila [14].

L’obiettivo generale degli interventi di cooperazione sanitaria tra Israele e Palestina, spesso sostenuti in un quadro di accordo trilaterale con un partner europeo, è quello di promuovere e tutelare il diritto alla salute della popolazione palestinese che risiede nei Territori occupati, nonchè di favorire un processo di collaborazione e dialogo fra operatori sanitari israeliani e palestinesi.

Attraverso il sistema sanitario palestinese e, nel contempo, la riduzione delle barriere tra popolazione israeliana e palestinese, si esprime la solidarietà concreta, la denuncia delle politiche che limitano il corretto funzionamento del sistema sanitario e l’accesso alle cure, coinvolgendo i cittadini israeliani ad agire per il cambiamento.

In questo senso la collaborazione tra personale sanitario israeliano e palestinese acquisisce un significato simbolico e concreto, non solo nel campo medico, ma anche nello sforzo di ottenere pace e giustizia in quest’area di conflitto. La sostenibilità dell’azione è quindi anche intesa nel rendere possibile il proseguimento del dialogo e della collaborazione israelo-palestinese.

Il problema non sta nella divisione fisica della terra ma piuttosto nella volontà e il coraggio politico di farlo.

Dialogare è difficile e complicato e richiede pazienza e tempo, ma è sicuramente un investimento. Bisogna mantenere aperti tutti gli spiragli e non spegnere il lucignolo che fumiga. Nel dialogo professionale del sistema sanitario palestinese ed israeliano in termini di capacity building e di formazione professionale ad esempio sembra che ciò sia già possibile.

RIFERIMENTI

1- Ron Pundak, “20 years on, Oslo architect has plan B” (articolo pubblicato il 21 Settembre 2013 in Haaretz).

2- Ghada Karmi, “Sposata a un altro uomo. Per uno Stato laico e democratico nella Palestina storica”, DeriveApprodi, Roma 2010.

3- E’ giusto ricordare che circa il 20% dei cittadini dello Stato d’Israele sono arabi e almeno altri 200.000 sono cristiani immigrati in Israele da Stati dell’ex Unione Sovietica nel quadro della “Legge del Ritorno”.

4- Ron Pundak , “Secret Channel - Oslo” pubblicato da Fondazione Konrad Adenauer 2013.

5- Yossi Beilin, “Beware the extremists: lesson from Oslo, twenty years on”, pubblicato in Haartez il 9 settembre 2013.

6- Comunicato emesso il 16 dicembre 2013 dai Ministeri degli Esteri europei.

7- Ian S. Lustick, “Illusione di due Stati” pubblicato in Haartez il 14 settembre 2013.

8- Heinrich Boll Stiftung, “20 Years since Oslo: Palestinian Perspectives in Perspectives. Political Analyses and Commentary from the Middle East & North Africa”, Issue n. 5 pubblicato in Dicembre 2013.

9- Danny Danon, “Israel’s Deputy Defense Minister calls for the annulment of Oslo Accords”, pubblicato in Haartez il 21 settembre 2013.

10- Ghada Karmi, docente all’università di Exter è una donna palestinese, vissuta in Inghilterra, diventata la sua patria di adozione. Situazione condivisa da milioni di profughi dopo il 1948, anno del riconoscimento della creazione dello stato di Israele, che diede origine alla più vasta diaspora di un popolo nel Medio Oriente.

11- Yossi Sarid, “Confessions of an Oslo Criminal“ pubblicato in Haartez il 19 luglio 2013.

12- La storia offre molte di queste lezioni. In Gran Bretagna, ad esempio, l’intera classe politica britannica considerava l’incorporazione permanente dell’Irlanda come un fatto politico inequivocabile fino al diciannovesimo secolo. Dal 1880, la questione irlandese ha rappresentato per la politica britannica la questione più importante, comportando l’ammutinamento nell’esercito e una guerra civile. Una volta finita la guerra, ci sono voluti un paio di anni per la nascita di un’Irlanda indipendente. Cosa era inconcepibile prima è diventato un dato di fatto poi.

13- Fonte “WHO monthly reports on Gaza and WestBank“ reperibili in Local Development forum (www.lacs.ps).

14- Adiv Sterman, “PA health minister in first visit to Hadassah hospital” pubblicato in The Times of Israel, 6 maggio 2012.

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 *Cinzia Chighine, nata a Viareggio nel 1974 e cooperante di professione per dieci anni in Africa e Medioriente, oggi vive  a Firenze dove lavora nel Settore Attività  Internazionali della Regione Toscana.