Critical Analyses, Musings and General Observations on Malaysian and International Health Law. All views are mine unless expressly stated otherwise.

Tuesday, 19 July 2016

MPP Consultation - Accelerating Access to New HIV/HCV Drugs Tuesday, 19 July 2016 - 21st International AIDS Conference, Durban, South Africa

Public basic healthcare is provided for free in Malaysia, with 84.7% of brand name medicine requests substituted with generics. While categorised as an upper middle income country based on World Bank GNI classification, average household income is USD$1334 per month, with populations we serve earning a fraction of this. Malaysia has a population of around 30 million people. First line HIV medications, including tenofovir, are fully subsidised by the government. Other medications like dolutegravir, are not subsidised whatsoever, and remain out of reach by Malaysian patients. 

Dolutegravir was launched at the price of USD$290 per month in October 2014 and it remains at this price to this day. This price is prohibitively high, and at present there are only 9 adult patients nationwide accessing dolutegravir. GSK has said that due to a Brazilian tender, this price may go down to $176 per month, but it remains to be seen when this could be. 

While Malaysia is included in MPPs voluntary license in terms of paediatric dolutegravir, there is a discrepancy between what the licence terms set out and actual practice on the ground in terms of procurement of these medications for paediatric use. That is, to this day there is no paediatric use of dolutegravir in Malaysia, and this is likely to international and domestic regulatory barriers. Dolutegravir for adult use is not on the government radar for a compulsory licence, and in such a case we think that a voluntary licence would be a step forward, but not the end game for access. 

In terms of HCV, it is estimated that 425,000 Malaysians live with HCV, however an upcoming cohort study may show more accurate figures on prevalence and this may be slightly lower. Malaysia is predominantly genotype 3 with genotype 1 as the second most occurring genotype. Treatment regimens in public healthcare facilities are composited of pegylated interferon-ribavirin, i.e. direct-acting antivirals are not available in these facilities as of yet. However, sofosbuvir, sofosbuvir/ledipasvir, dasabuvir, daclatasvir, boceprevir, and Abbvies Viekirax drug (ombitasvir, paritaprevir, and ritonavir) have all been registered and are available at innovator prices in private facilities. Malaysia does not presently have a national hepatitis strategy, but it is in draft stage. 

It should be noted that there is a very important trial for a pan-genotypic regimen underway in Malaysia and Thailand, driven by Drugs for Neglected Diseases initiative (DNDi), for sofosbuvir + ravidasvir with a target cost price of under USD$300 per cure. The decision of the government to treat with DAAs is likely to be hinged on the results of this study. At present, certain influential government officials are partial to a compulsory licence. 

It should be noted that Malaysia has signed the Trans-Pacific Partnership Agreement, and is modifying its patent law to include longer market exclusivity periods. These could potentially keep medicines out of HCV patients hands for longer. Im very keen on discussing the way forward today, whether in terms of VLs or CLs, and how we streamline the mechanism better so that we see patients accessing these medicines. 

Sunday, 24 April 2016

The Disappointment that was the UNGASS on Drugs

Last year, I said that the UNGASS on drugs would come and go and nothing would happen. A few people cringed. One scrunched up her face like I'd just told a poop story. One said I was defeatist.

Sure, some amazing messages came out of the meeting from a bunch of brilliant drug policy warriors that I admire and am proud to know. But we saw no real change to UN language around drugs. The outcome document was disappointing. No UN officials were seen on the ground in countries meeting with heads of Ministries of Home Affairs. I doubt more than 12 people in the Malaysian National Anti-Drugs Agency knew what the UNGASS on drugs was.

 I'm not saying I have the solutions. I don't. I just wish we'd gotten real about it a hell of a lot sooner.

Wednesday, 7 October 2015

The Illusion of a ‘Golden Balance’: Access to Medicines and the TPP

by Fifa Rahman and Fran Quigley

In an account of life in Malaysian Borneo in the 1930s, the author Agnes Newton Keith detailed a card game played in Sandakan involving a card box placed at the entrance to a married woman’s house. The game dictated the protocol to meet newcomers to the area. These rules proved to be a conundrum. The author elaborated: ‘Sometimes newcomers do not understand about this game, or play it with a different set of rules in the outer world from which they come. This creates an impasse in social relations, for not until the first round of cards can people meet in person. The impasse continues until someone quietly hands the newcomer a printed slip containing the laws of the Medes, the Persians, and the Game of Cards.’

More than 80 years later, in July 2013, hundreds of negotiatiors and maybe 40 civil society actors descended upon the city of Kota Kinabalu in Malaysian Borneo for another game of a similarly confounding temperament. This time, the game involved disagreements on intellectual property and state-owned enterprises and technical barriers to trade creating geopolitical and social impasses between nations. This game, the 18th round of negotiations of the Trans-Pacific Partnership Agreement (hereinafter TPP), did not happen in the environment described in the above book, out in the open, obscured only, perhaps, by the glistening fronds of palm trees. The TPP negotiations had been – and continue to be – negotiated in secret, and Kota Kinabalu was no different. Held at the lavish Sutera Harbour Resort, negotiators from 11 countries convened daily discussing terms of this agreement, which negotiators say will be the ‘gold standard’ for generations to come, poring over pages of pages of documentation of provisions that had very little to do with traditional trade matters.

A token day was reserved for civil society engagement, during which a series of 7-minute presentations to negotiators were permitted, followed by a briefing from Chief Negotiators, after which civil society and other stakeholders were permitted questions. Locked out of the negotiations, frustrated civil society representatives asked about international litigation on tobacco control, food labelling requirements, restrictions on capital controls, state sovereignty to regulate in favour of health, and last but not least, the eternally controversial issue of stronger intellectual property provisions and access to generic medicines.

Reacting to civil society questions on access to medicines, U.S. Chief Negotiator Barbara Weisel stated:
We are looking for the golden balance on IP. We are thinking about a system that promotes generics. Balanced against that is the next generation of drugs. We all share an interest in making sure we find that balance. So we'll take that time. We have to all come to an agreement that satisfies all parties. And it is not an issue of patients versus companies, it is not.

The ‘golden balance’ in access to medicines in trade is rooted in the idea that stronger intellectual property is needed to promote innovation of future drugs, i.e. that if these IP provisions were not given, there would be no incentive for pharmaceutical companies to research new drugs. So in the TPP, the proposals seek extensive monopolies beyond the current 20-year patent period under WTO rules, including patents for minor modifications of medications, regardless of whether the modification improves therapeutic efficacy. It should be emphasised that this idea of a ‘golden balance’ was precipitated in the name of innovation. This emphasis is important because there is no evidence that stronger intellectual property has encouraged innovation of new drugs.

Cynthia Ho, Professor of Intellectual Property Law at Loyola described in her 2015 article the ‘innovation crisis’ affecting pharmaceutical companies, referring to the European Commission Director-General’s 2009 Pharmaceutical Sector Inquiry that found that pharmaceutical companies increasingly patent drugs that are ‘merely minor variations’ of existing drugs. India is another example – their flexible IP system has come under attack recently for being too weak, but this argument does not hold water. Medécins Sans Frontières’ Chase Perfect describes this, well, perfectly: ‘India’s current intellectual property model is under attack not because it has failed, but because it has succeeded.’ India’s system enables access to generic medications, while ensuring that real innovation occurs, not merely minor variations of old drugs.

The failures of unrestrained patent monopoly systems to develop new and needed drugs, especially compared to the success of systems like India, reveal the false premise in the narrative that stronger IP protection is needed for drug innovation.  Thereon, how do we expect to achieve a ‘golden balance’ if the base of that balance is fundamentally flawed?

Neither can we achieve a golden balance where there is radically unbalanced participation by civil society in these negotiations. Flynn et al. (2013) posit that if the intention is to find balance, the ‘interests of those excluded from the formal process must be amplified’, and that the process ‘is, in short, an incredibly unbalanced proposal emanating from an extraordinarily imbalanced process.’

To illustrate further, Ottersen et al. (2014) in the Lancet talk about ‘transnational activities that involve actors with different interests and degrees of power’ and how these global political determinants of health inequity are the result of 5 dysfunctions of global governance systems.  One of these dysfunctions is the democratic deficit i.e. lack of participation of civil society actors and marginalised groups in these processes. That is the very same democratic deficit which TPP negotiators tried to remedy via a one hour Chief Negotiator briefing on one day of an eleven day negotiation round.

Not surprisingly, given who has access to the process and who is locked out, the leaks of the IP chapter of the TPP show, as described by Rohit Malpani, Director of Policy for Doctors without Borders, “There’s very little distance between what Pharma wants and what the U.S. is demanding.”

This debate on the existence of a golden balance is exhausting. It’s exhausting not because there isn’t one to be found. There should be one to be found because the rights of right holders who create medicines that are truly new and involve an inventive step and have industrial application are legitimate.

Whether the patent system is the best system to reward them is an equally exhausting debate meant for another day. It is exhausting because these global political determinants are protecting the rights of companies that are not really innovating, on a premise that is structurally unsound. To protect this premise they are shutting out civil society voices, the voices that can help dysfunctional global governance systems and ensure that occurrences of health inequity are mitigated. It is exhausting because it is lucidly clear that the negotiations are pro-pharma, and that the golden balance is not what the U.S. Chief Negotiator is looking for, at least not as part of her professional mandate. So at the end of this article we are back to this discombobulated game, the TPP, played back then on the island of Borneo, continuing to create impasses throughout the world in lobbies and meeting rooms of luxury hotels, until that time when it’s simply is too late and the TPP has been signed.

*Fifa Rahman is Policy Manager at the Malaysian AIDS Council and has attended 4 rounds of the TPP negotiations as a stakeholder; and Fran Quigley is Clinical Professor of Law, Health and Human Rights Clinic at the Indiana University Robert H McKinney School of Law and has written extensively on the TPP and medicine prices.

*This post was written prior to the conclusion of the negotiations in Atlanta on 5 October 2015. For my comments regarding the conclusion and impact on Malaysian access to medicines, see this link: 

Tuesday, 30 June 2015


The International Visitor Leadership Program (IVLP) is the U.S. government’s premier professional exchange program, established in 1940 and designed to increase mutual understanding through communications and diplomacy. Participants are chosen in areas that the U.S. Embassy has deemed of bilateral interest to the host country and the US.[1]

Since 2010, the Malaysian AIDS Council has been involved in coordinating a national campaign on access to generic medication and the Trans-Pacific Partnership Agreement (TPP), opposing TRIPS-plus provisions including patent extensions, data exclusivity, data linkage, and investor-state dispute settlement (ISDS), among other provisions, on the grounds that they would reduce access to generic medication. The TPP, a 12-country multilateral trade agreement contains IP proposals that are ‘widely acknowledged as the latest manifestation of the US maximalist agenda in international intellectual property rulemaking.’[2] Malaysia, a country of 29 million people, is categorised as upper middle income, but has an average household income of USD$1614 per month. A study conducted in 2011 showed that Malaysian pharmacists recommend generic medicine substitution for 84.7% of all brand name medicine requests.[3] Due to these and other considerations, I represented the Malaysian AIDS Council at several stakeholder sessions at four TPP negotiation rounds: Auckland, Singapore, Kota Kinabalu, and Brunei, and through these rounds became acquainted with economic counsellors and other economic staffers at the US Embassy in Malaysia. I made several media appearances criticising TRIPS-plus provisions in the TPP on both Malay-language and English-language television and radio networks, and reached a certain level of visibility and prominence on the topic. I also participated in closed-door meetings with high-level trade officials. I was nominated for the IVLP in 2014 and after a vetting process, was notified in April 2015 of selection for a 3 week individualised program on HIV, pharmaceuticals and global governance to begin in May 2015, with target cities of Washington, D.C., New York City, Chicago, Indianapolis, and Los Angeles.

The implicit goals were that I would be sensitised as to the American healthcare system, barriers and obstacles to quality healthcare in the US, and rationales as to intellectual property policy in international trade, and engage with persons who – for reasons of socioeconomic or sociocultural marginalisation – have difficulty accessing healthcare. These persons included undocumented persons, multi-ethnic populations, and young black and Latino LGBT populations, among others. The following are observations from visits and meetings and analyses of those meetings.

Sexual transmission of HIV among black and disadvantaged populations in Washington DC

DC has HIV rates that mirror rates in some African countries. [4] In 2009, the highest prevalence was disproportionate among black residents, at 4.3%.[5] While overall HIV prevalence has reduced, it remains at epidemic proportions, at 2.5% of the population.[6] In addition to HIV statistics, DC also has among the highest STD rates in the US.[7] 60% of District residents living with HIV are between the ages of 40-59[8] suggesting an aging population of people living with HIV. A 2014 study among 1553 black men-who-have-sex-with-men (MSM) in 6 US cities (including Washington DC) found that newly diagnosed HIV-infected black MSM were more likely to be unemployed, have bacterial STIs and engage in unprotected receptive anal intercourse than other black MSM, and concluded that there was a need for culturally-tailored programs addressing economic disenfranchisement and increased engagement in care, among others.[9]

On 7 May 2015, I met with Dr Celia Maxwell, Associate Dean for Research at Howard University Hospital, a historically black institution operating opt-out HIV testing. At the time of meeting, her project had tested 93,599 persons, out of which 93,298 had known insurance statuses. From this figure, 67% were covered by Medicaid.[10] Here I learnt that people living with HIV in the poorest DC wards (7 & 8) also faced a number of co-occurring diseases and comorbidities, complicating healthcare. These wards have the District’s highest obesity rates, and are home to large ‘food deserts’ i.e. a lack of access to full service grocery stores and farmers markets due to uneven distribution.[11] These poor wards also have been most recently associated with up to 10 times higher mortality rates for infants as compared to the richest wards.[12]

HIV epidemic in Scott County, Indiana

At the time of writing, Scott County, Indiana, is undergoing a HIV epidemic among injecting drug users. Governor Mike Pence recently declared it a public health emergency, and reluctantly approved needle-and-syringe exchange programs towards the end of the first quarter of 2015.[13] While there was a perception that the epidemic emerged out of nowhere, health professionals in Indiana soon negated this. Scott County for some time has been characterised by poverty, a lack of opportunity, and a culture of drug use.[14]

On 19 May 2015, I visited a Community Outreach Centre in Austin, Scott County. It was a standalone white building set in a patch of grass, and as we drove up at 9:45am we were amazed at the number of cars that were already there. Inside, the environment was bustling. They had some kind of support group or training going on that morning. The actual room where sterile injecting equipment was given out had a surgical screen running across it, behind which were two tables where staffers and clients sat for consultations and needle-and-syringe exchange. There I met with the Preparedness Coordinator, Patti Hall, who was a recent convert to needle and syringe exchange programs and explained with enthusiasm the services that were available there. She attested as to the lack of opportunity stimulating injecting use, stating that there was no motivation for kids to finish high school because even if they did, there was no guarantee that jobs would be available for them.

The day before, I had met with an infectious diseases physician who proudly related their upcoming treatment program for Hepatitis C with the new revolutionary direct-acting antiviral, Sovaldi. I enquired as to the price of the medication, given that it was registered in the US at the price of $84,000 for a 12-week regiment[15], and at varying prices in middle income ($5000-10000 for 12 weeks) and low-income countries. When she professed that they were providing it at the full price, I wondered as to (1) the apparent lack of negotiation power; (2) intellectual property barriers in place that would prohibit generic competition; and (3) the strength of the pharmaceutical lobby. It seemed amazing to me that given the HIV epidemic and that it was a given that Hepatitis C rates would be higher than the HIV rates, and given that it was clear that the demographic was low-income, that they would be offered sofosbuvir at the exorbitant price of $84,000. This price seems highly inappropriate given recent estimates that when produced at volume, treatment with DAAs could cost US$171-360 per person without genotyping for 12 weeks.[16]

Treatment access for undocumented immigrants in California

California has more immigrants than any other US state.[17] While the majority are documented, 7% of the state’s total population, or 2.6 million people, are undocumented.[18] Language and cultural differences continue to constitute barriers to health delivery and registration for coverage under the Affordable Care Act. On 21 May 2015 I met with Gerald Kominski, Professor of Public Health and Management, and Director of the UCLA Centre for Health Policy Research. Under the latter designation, Kominski’s centre conducts and coordinates the California Health Interview Survey (CHIS), a statewide survey examining, among other things, uptake of health insurance schemes, and compiles Californian health status information. Data from CHIS shows that 3.5 million persons in California remain uninsured, and that tremendous disparities exist between white and latino populations, among others.

Access to healthcare in California for undocumented immigrants is significantly worse when compared to other populations. They have the highest rate of no usual access to care (35%) when compared to lawful permanent residents (LPRs), naturalized citizen immigrants, and U.S.-born nonelderly adults.[19] In a 2013 report, the UCLA Center for Health Policy Research found that healthcare reform law was unlikely to improve the situation for undocumented immigrants given that they would be excluded from Medicaid expansions, among other reasons.[20]

During my time in California I became aware of non-profit organisations providing affordable HIV care to undocumented immigrants under a program called 340B, which mandates discounts on medications.

Analysis and Thoughts Pertaining to IP, TPP and the IVLP

As time passed and I got closer to finishing my 3-week program, it was clear that my sensitisation to US healthcare policy had not made me any less against the TPP. If anything, it had made me realise that there are many disadvantaged and disenfranchised Americans that deserve access to affordable generics, and that the strength of the pharmaceutical lobby that is so much more strongly entrenched compared to elsewhere around the world contributes greatly to health disparity. I also became acutely aware of the diversity of health issues across the US, but also that poverty was often a common denominator.

Americans pay far more for healthcare than people in any other developed country, even though US life expectancy falls below the average for developed countries.[21] Patent abuse is common, and this year Senators Chuck Grassley and Patrick Leahy, among others, introduced legislation to end abusive patent trolling.[22] Given that the percentage of new drugs that are ‘highly innovative’ continue to be decreasing over time[23], and many pharmaceutical companies rely on incremental innovations to maintain or continue patents[24], the risk of patent abuse from TRIPS-plus provisions are high. Patent extensions i.e. evergreening and patents for new uses and forms of medication are part of the IP provisions in the TPP, and would create an environment for patent abuse in TPP countries.

In regard to health centres providing more affordable drugs under the 340B program, the transparency annex of the TPP would require the US government to allow the pharmaceutical corporations to appeal drug pricing decisions such as the rebate amounts set under the 340B program.[25] This would affect medicines prices provided by migrant health centres, homeless health centres, and family planning clinics.[26]

Arguments for the TPP in the US have revolved around the creation of jobs – the Obama administration claims that 650,000 jobs will be created as a result of the TPP but this figure comes from calculations from the heavily criticised Peterson Institute study. Glenn Kessler of the Washington Post elaborates: ‘Essentially, the book suggests that an income gain of $121,000 would be “roughly equivalent to creating an extra job”. So the Obama administration took the figure of $77.5 billion (the estimated gain in income) and divided by $121,000, which yields 640,000. Rounded up, that becomes 650,000.’[27] And even on the off chance that it would create jobs, arbitrary medicines provisions in the TPP would keep healthcare costs high, raising real doubts as to the net benefit.

Proponents of the strong IP provisions in the TPP repeatedly say that the rules are to recoup R&D costs – but there is increasingly more evidence that R&D costs are overestimated.[28] Gagnon and Lexchin’s (2008) study estimating pharmaceutical promotion costs interestingly quotes the late Democratic Senator Estes Kefauver, Chairman of the United States Senate's Anti-Trust and Monopoly Subcommittee, who said that costs and prices were extravagantly increased by large expenditures in marketing. The authors in this study found that pharmaceutical companies spend almost twice as much on promotion as they do on R&D[29], and that while this isn’t confirmatory of Kefauver’s arguments, they certainly generate cause to reexamine prices of medications in relation to pharmaceutical marketing costs.

The defeat of Fast Track/key prerequisites for Fast Track for the TPP twice in the US was demonstrative of increasing unease with this secretive trade agreement and its dubious benefits. In June 2015, Nancy Pelosi did not back Obama on Trade Adjustment Assistance, a prerequisite for Fast Track. Sherman, Bresnahan and French in Politico elaborated: ‘By Friday morning, it was clear that a crucial piece of Barack Obama’s trade initiative was barreling toward defeat. Democrats were disjointed, dispirited, even angry in some cases… On Friday morning, before she spoke to Boehner, Pelosi told Obama — sitting in her office during a last-ditch visit to the Capitol — that she probably wouldn’t back TAA, a necessary precursor to the fast-track vote he worked hard to pass. But when Pelosi’s decision was final that she would split with the president, one of her aides – not the California Democrat herself – delivered the news to the White House.’[30]

This political divisiveness on the TPP was welcome to many civil society groups in TPP countries, but many were acutely aware that the defeats could be temporary. Their suspicions were well founded. On 24 June 2015, Senate gave Obama fast-track authority with a 60-38 vote[31], and on 29 June 2015, President Obama signed into law the bill that would give him fast track power.[32]

While this in itself does not mean the fight is over, my worry is that we are of course much closer to the conclusion of the TPP. The silver lining, of course, is that the White House is on the defensive and rightly so. The medicines issue is colossal, Malaysia as a major currency manipulator might be, actual impact on US jobs, and the secrecy element could still throw a wrench into the finalisation of the TPP. Our task is to up the opposition to it before it goes to Congress for that up or down vote. Livelihoods across the world depend on it.

[1] Embassy of the United States of America, Kuala Lumpur, International Visitor Leadership Program (IVLP)
[2] Sean Flynn et al. The US Proposal for an Intellectual Property Chapter in the Trans-Pacific Partnership Agreement. 28 Am. U. Intl. L. Rev. 105, 108 (2013), quoted in Burcu Kilic, Defending the Spirit of the DOHA Declaration in Free Trade Agreements: Trans-Pacific Partnership and Access to Affordable Medicines (2014) 12(1) Loyola University Chicago International Law Review 23-57
[3] Chong CP, Hassali MA, Bahari MB and Shafie AA. Generic medicine substitution practices among community pharmacists: a nationwide study from Malaysia. Journal of Public Health 2011; 19(1): 81-90.
[4] Janice Hopkins Tanne, HIV Prevalence in US capital is at Epidemic Level (2009) 338(1205) BMJ
[5] Ibid.
[6] Government of the District of Columbia, Department of Health, HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA), Interim HIV/AIDS Surveillance Report: Preliminary 2013 Data (December 2014)
[7] Matt Cohen, Report: D.C. Has One Of The Highest STD Rates In The Country (25 March 2015) DCist <> Accessed 14 June 2015
[8] DC Department of Health (DOH) HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA) 2013 HAHSTA Annual Report. Released June 2014.
[9] Kenneth H Mayer, Lei Wang, Beryl Koblin, et al. Concomitant Socioeconomic, Behavioral, and Biological Factors Associated with the Disproportionate HIV Infection Burden among Black Men Who Have Sex with Men in 6 U.S. Cities. (2014) 9(1) PLOSOne e87298
[10] Dr Celia Maxwell (2015) unpublished data.
[11] DC Hunger Solutions. When Healthy Food is out of Reach: an Analysis of the Grocery Gap in the District of Columbia (2010)
[12] Save the Children. The Urban Disadvantage: State of the World’s Mothers 2015 (2015) <> Accessed 14 June 2015
[13] Sarah Kaplan, Indiana is battling the worst HIV outbreak in its history (26 March 2015) The Washington Post <> Accessed 14 June 2015
[14] Danielle Lama, Why Scott County? An in-dept look at the HIV epidemic that’s hit so close to home (12 May 2015) <> Accessed 14 June 2015
[15] Drew Armstrong, At $84,000 Gilead hepatitis C drug sets of payer revolt (28 January 2014) Bloomberg Business <> Accessed 14 June 2015
[16] van de Ven et al. Minimum Target Prices for Production of Direct-Acting Antivirals and Associated Diagnostics to Combat
Hepatitis C Virus (2014) Hepatology
[17] Marisol Cuellar Mejia and Hans Johnson, Immigrants in California (May 2013) Public Policy Institute of California <> Accessed 14 June 2015
[18] Enrico Marcelli, Manuel Pastor, and Steve Wallace. Ensuring California’s Future by Insuring California’s Undocumented: Why Excluding Undocumented Californians from the Affordable Care Act Hurts All of Us. (May 2014)
[19] Steven P. Wallace, Jacqueline M. Torres, Tabashir Z. Nobari, and Nadereh Pourat, Undocumented and Uninsured: Barriers to Affordable Care for Immigrant Populations (August 2013) UCLA Center for Health Policy Research <> Accessed 15 June 2015
[20] Ibid.
[21] Alexander EM Hess and Michael B Sauter, Countries spending most on healthcare (2 July 2013) 24/7 Wall St (Accessed 14 June 2015)
[22] Chuck Grassley, Senators Aim to End Patent Abuses that Cost U.S. Economy Billions of Dollars Every Year (29 April 2015) <> Accessed 15 June 2015
[23] National Institute for Health Care Management, Changing Patterns of Pharmaceutical Innovation (2002)
[24] Cynthia M Ho, Drugged Out: How Cognitive Bias Hurts Drug Innovation (2014) 51(2) San Diego Law Review 419-508
[25] Public Citizen, TPP: the ‘Trade’ Deal that Could Inflate Your Healthcare Bill <> Accessed 15 June 2015
[26] Ibid.
[27] Glenn Kessler, The Obama administration’s illusionary job gains from the Trans-Pacific Partnership (30 January 2015) <> Accessed 15 June 2015
[28] Donald W Light and Rebecca Warburton, Demythologizing the high costs of pharmaceutical research (2011)
The London School of Economics and Political Science 1745-8552 BioSocieties 1–17
[29] Gagnon M-A, Lexchin J (2008) The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 5(1): e1. doi:10.1371/journal.pmed.0050001
[30] Jake Sherman, John Bresnahan, and Lauren French, How Pelosi Broke with Obama (12 June 2015) Politico <> Accessed 15 June 2015
[31] Paul Lewis, Barack Obama given ‘fast-track’ authority over trade deal negotiations (24 June 2015) The Guardian <> Accessed 30 June 2015
[32] The Straits Times, US President Obama signs 'fast-track' trade bills into law, says tough battle still ahead (30 June 2015)