17. Partnerships for the Goals

Sustainable Development Goal 17: Partnerships for the Goals focuses on strengthening the means of implementation and revitalizing the global partnership for sustainable development.

Jillian Clare Kohler, PhD is a Professor at the Leslie Dan Faculty of Pharmacy, the Dalla Lana School of Public Health and the Munk School of Global Affairs and Public Policy. She is also the Founding Director of the WHO Collaborating Centre for Governance, Transparency and Accountability in the Pharmaceutical Sector. She is also a Connaught Scholar (2020). Prior to joining the University of Toronto, Dr. Kohler worked on pharmaceutical policy issues at UNICEF, the World Bank, and the Pan American Health Organization (PAHO) Headquarters. She continues to advise United Nations agencies, such as the UNDP, the UNODC and the WHO on issues related to pharmaceutical policy, particularly anti-corruption and related governance issues.

Andrea Bowra is a doctoral candidate in Public Health Sciences at the Dalla Lana School of Public Health, University of Toronto funded by a Canada Graduate Scholarship. She holds a Master of Public Health degree from the Dalla Lana School of Public Health, and a Bachelor of Health Science degree from Western University. Her doctoral research explores how accountability is taken up in global health systems in response to harms caused by the pharmaceutical industry. Andrea is the Managing Editor of the Turtle Island Journal of Indigenous Health and an organizing member of the Canadian Students for Sensible Drug Policy.

CREDITS: This podcast is co-hosted by Dr. Erica Di Ruggiero, Director of the Centre for Global Health, and Ophelia Michaelides, Manager of the Centre for Global Health, at the DLSPH, U of T, and produced by Elizabeth Loftus. Audio editing is by Sylvia Lorico. Music is produced by Julien Fortier and Patrick May. It is made with the support of the School of Cities at U of T. 

Transcript

Erica Di Ruggiero [00:00:06] I'm Erica Di Ruggiero And this is Healthy Cities in the Era, a podcast about the Sustainable Development Goals and how research conducted by faculty and students at the University of Toronto is helping to achieve them. We're recording for Toronto or Tkaronto, which for thousands of years has been the traditional land of the Huron-Wendat, the Seneca and the Mississaugas of the credit. Today, this meeting place is still home to many Indigenous people from across Turtle Island and we are grateful to have the opportunity to work on this land. In this episode, we'll look into SDG 17, which focuses on revitalizing the global partnerships for sustainable development and strengthening the means of implementation. SDG 17 entitled Partnerships for the Goals lists 19 targets and encompasses promoting the development and dissemination of environmentally sound technologies, promoting a universal rules based, open, nondiscriminatory and equitable multilateral trading system under the World Trade Organization and promoting effective public, public, private and civil society partnerships. As described by the United Nations, a successful sustainable development agenda requires partnerships between governments, the private sector and civil society. These inclusive partnerships built upon principles and values, a shared vision and shared goals that place people and the planet at the center. And these are needed at the global, regional, national and local level. This is especially pertinent to pandemic recovery as well as in our response to the climate and equity crises. In this episode, we will speak with Dr. Jillian Kohler about the complexities of public private partnerships with the pharmaceutical industry, the principles they should be built upon, and how corruption can undermine equitable action. She will also share her suggestions on what Canada can do better to support and achieve SDG 17. Then we will speak with Andrea Bowra about power imbalances, the exertion of influence to shape policy, and a lack of accountability within the pharmaceutical industry. She will discuss how partnerships can be utilized to mitigate harms caused by the industry and how we can challenge power structures that further marginalized members of our society. 

Erica Di Ruggiero [00:02:44] Jillian Clare Kohler is a professor at the Leslie Dean Faculty of Pharmacy, the two School of Public Health and the Munk School of Global Affairs and Public Policy. She is also the founding director of the World Health Organization Collaborating Center for Governance, Transparency and Accountability in the Pharmaceutical Sector. She's also a Connaught scholar, and prior to joining the University of Toronto, Dr. Koehler worked on pharmaceutical policy issues at UNICEF, the World Bank and the Pan American Health Organization headquarters. She continues to advise United Nations agencies such as the UNDP, the UNODC and the W.H.O. on issues related to pharmaceutical policy, particularly anti-corruption and related governance issues. So I'm really delighted to welcome Jillian Kohler, my colleague, to the program. Welcome, Jillian. 

Jillian Kohler [00:03:39] Thank you, Erica. So happy to be here. 

Erica Di Ruggiero [00:03:42] So I'd just like to start off with, you know, an overall question about your yourself and your research. So can you just tell us a little bit about yourself and your research? 

Jillian Kohler [00:03:53] Certainly in a nutshell, I started off my career working in the United Nations, doing policy on how to improve access to pharmaceuticals globally. And I am a professor at the Leslie Dan Faculty of Pharmacy with some cross appointments to the Dalla Lana School of Public Health and Munk School of Global Affairs and Public Policy. I'm a political scientist by training, and I've really focused my research in the past decade on issues related to access, including how corruption has an impact on access, as well as how issues such as patent protection for pharmaceuticals has an impact on access to medicines globally. 

Erica Di Ruggiero [00:04:34] Oh, that's great. So, you know, as you know, this podcast is about the SDGs and we're actually focusing on SDG 17, which is really about partnerships for the goals so that SDG highlights different partnership arrangements, including public private partnerships. So do you think global partnerships with the pharmaceutical industry should be encouraged? Bit of a provocative question. 

Jillian Kohler [00:04:57] It's a very provocative question. It's a great question. I mean, yes and no. I mean, I would say depends on how they're established. I'm fundamentally suspicious of partnerships with the industry because I would want to know what are the power relations within these partnerships? What does the industry stand to gain? Doesn't mean I'm against them. It just means I'm careful to consider what they actually mean in place. And that would really be different depending on the various models that are in place. And here, what I work on and what I didn't mention is I also lead a collaborating center, which you're part of on governance, accountability and transparency in the pharmaceutical sector. And I think those elements of transparency and accountability, if they're built in very, very strongly into a partnership with the industry, would be incredibly helpful. And then we could consider how beneficial a partnership actually is. 

Erica Di Ruggiero [00:05:58] No, I think that's a great point. And I really like the tie in with transparency and governance and accountability. All three of those things. We know the industry is transnational given its focus. And so sometimes and this is true about the SDGs, especially given that there are now focused on all countries, not just a subset, as their predecessors were. I'd love to hear your thoughts about how Canada can do better with respect to partnerships in this arena. 

Jillian Kohler [00:06:28] Again, it depends on whether we see value in doing partnerships. And what I would like to add is when we think about the pharmaceutical industry, it's a very complex industry. So there is the multinationals, which I'm assuming we're talking about here. There's also a lot of countries that have their own local industry. There's the generic industry, so there's a myriad of different types of industry. So in terms of what Canada can do better, I think we should be encouraging where we can for technology transfer for other countries to be able to know how they can do their own research and development so they can manufacture necessary produce as well as manufacture their own medicines. We saw during the COVID, even here in Canada, how reliant we were on external sources for our national well-being, our public health, for lives to be saved and lives to be lived well. And this is very, very problematic. So I think we should be advocating for self sufficiency not only here in Canada, but for low and middle income countries as well. I think that's critical and something that we have not done a good job doing so far. 

Erica Di Ruggiero [00:07:42] Well, it's a I think. Yeah, and it's a great example of a decision that was made, you know, several years ago, the kind of impact it's having now and hopefully a rethink as we start to build back better from COVID. I'm going to shift kind of the conversation a little bit to, you know, a word we sometimes hear when we think about certain industries. So how does corruption have an impact on desired health outcomes related to this SDG that's really focused on partnerships? 

Jillian Kohler [00:08:13] Well, great question. And obviously something that I'm working on now with and thought about for a long time. I think the short answer is in every way possible, it has an impact because no matter how good the intentions, even if we have the best partnerships in place with the smartest people that are in it for the right reasons and doing the right things at the end of the day, if they're I mean, let me just stop for a moment and go back. There's always, always corruption risks within the health system, within the pharmaceutical system in particular are highly vulnerable to corruption. So whatever we want to achieve will potentially be undermined if there is corruption in place. And what do we mean by corruption? It could mean that products aren't delivered to the public health care systems, but are siphoned off and sold in the private sector by some government officials. It could mean that there's collusion between certain medical suppliers or distributors so that prices aren't what they should be. If there are supposed to be free, they're actually being charged. It can mean kind of a payoff for poor regulation so that products that shouldn't be on the market are actually there. So there's many different ways that corruption can unfortunately manifest itself. So unless we consider how to embed within any public health initiative, any global health initiative, anti-corruption mechanisms, we're always at risk of, quite frankly, failing. 

Erica Di Ruggiero [00:09:45] Mm hmm. Yeah. And I think that links back to your earlier point around governance and the strength of governance, but also transparency and accountability mechanisms. And and I know your your research has been really contributing also to the monitoring aspect of, you know, what's actually happening and thinking about corruption in a nuanced way, as you've nicely described. So I know you mentioned COVID earlier, and of course, an ongoing discussion in that realm is about trips. And so what does the TRIPS initiative mean for global partnerships with the pharmaceutical industry? Can you unpack that for us. 

Jillian Kohler [00:10:24] Sure. Let me just start off just in case there's some listeners who don't know what TRIPS means, because it's it's a term that some people don't know. So it means trade-related aspects of intellectual property rights, which is a mouthful. But essentially in simple terminology, what it is, is it's an a global standard for patents, which essentially means that countries that are part of the World Trade Organization have to enforce certain types of controls in their market to make sure that pharmaceutical patents are respected. They vary depending on whether they're low income, middle income and high income. So I'm not going to go into all of that. But essentially what it is, is it allows companies that produce products to have patents, which in turn can have an impact on access. Obviously it has an impact on pricing. What we've seen within COVID is, to be quite blunt, again, is disheartening because a lot of the same arguments that we heard during the nineties when HIV AIDS crisis was erupting globally and how industry was pushing. For patents when people were dying are we're hearing again when it comes to COVID vaccines and the importance of protecting industries, profits so that they can do research and development. While I say that we need to think about a completely different model because when we have products that can save lives, we should not even be considering protecting industry profits. And this goes back to kind of the thornier question at the beginning, where we are beholden, quite frankly, for a lot of our public health essentials to the private sector. And we don't really have the recourse that we need when crises like the COVID 19 pandemic arise, and we've been living through it. So the waiver was put forward by countries like India and I believe Brazil and others have been on board. Interestingly enough, even the US actually did support it under Biden, which was quite interesting. We were, as Canadians, kind of quiet, kind of mealy mouthed on it. And the European Union has been not supportive at all and it's it hasn't gained traction. And to me that's very, very problematic because again, I'll just say it. We should not be thinking about profits when we have public health crises. And during those times, patents should actually just, quite frankly, go out the window. I mean, when we need to save lives, products should be manufactured and provided to those in need. 

Erica Di Ruggiero [00:13:03] Mm hmm. Yeah. No, I think you're this example is one of many where I'm not a lawyer. But when you think about how pharmaceutical companies can be personified as having rights to, you know, in this case to prevent access to lifesaving medicines or vaccines is is on you know, it needs to be stopped. But very troubling. 

Jillian Kohler [00:13:27] And we can yeah, we need to I mean, listen we need to benefit from industry's know how and they can do a lot of good but we shouldn't be beholden to their preferences. So this is when we talk about partnerships. Going back to my initial point, we really have to look at power relations and how they play out and what do they really mean because the word partnerships to me can conceal a lot of different things and it sounds really good. It's like the nice buzz word, but at the end of the day, what does it really mean and who really benefits? 

Erica Di Ruggiero [00:13:58] Yeah, now, well said. They're not neutral, that's for sure. And there are lots of power asymmetries, so thanks so much, Jillian. Really appreciate the opportunity to chat with you and thanks for making the time. 

Jillian Kohler [00:14:09] My pleasure and great to speak with you, Erica. Thank you so much. 

Erica Di Ruggiero [00:14:20] Andrea Bowra is a doctoral candidate in public health sciences at the Dalla Lana Public Health, University of Toronto, who is funded by a Canada graduate scholarship. She holds a master's of public health degree, also from the Dalla Lana School of Public Health and a Bachelor of Health Science degree from Western University. Her doctoral research explores how accountability is taken up in global health systems in response to harms caused by the pharmaceutical industry. Andrea is the managing editor of the Turtle Island Journal of Indigenous Health and an organizing member of the Canadian Students for Sensible Drug Policy. Welcome to the program. I'm delighted to welcome Andrea Bowra to our program. Andrea, can you tell us a little bit about yourself and your research on exploring accountability in global health systems and related partnerships? 

Andrea Bowra [00:15:11] Thank you, Eric. I'm excited to be here. So I'm currently finishing up my second year of my Ph.D. in Social and Behavioral Health Sciences at the University of Toronto. My doctoral research looks at how our global health systems hold or really fail to hold transnational pharmaceutical companies accountable for the harms they cause to individuals and groups. So specifically as a case study, I look at how global health systems responded to Purdue Pharmaceuticals, which is a transnational pharmaceutical company, and how they mislabeled and mass marketed OxyContin an opioid painkiller and in doing so catalyzed the opioid overdose crisis that Canada and the US are currently facing in relation to partnerships and taking an actor network approach to my research, which means that I'm interested in the relationships between actors and global health networks and how power and accountability flow and are exerted within these networks. 

Erica Di Ruggiero [00:16:05] Well, delighted to hear you're taking that action network approach, because the global health system, of course, is a complex arena that's shaped by interactions between a constellation of very complex actors, so very pertinent and a very topical issue that you're addressing. On that note, while drug use and misuse is actually often viewed as a local or national issue, how can global partnerships work towards reducing harms from drug use, be it illicit or pharmaceutical? 

Andrea Bowra [00:16:37] Yeah. And that is a huge question, but super important. And I think there are different facets of substance use that call for very different approaches and partnerships as well. And so there's kind of two sides that I can speak to that question on the side of illicit drug use, and I can use opioids as an example. The overdose crisis is highly concentrated in Canada and the US because of our unique combination of social and structural issues, including the weak regulation of the pharmaceutical industry, like, for example, when OxyContin and other prescription opioids flooded the market, but also our lack of affordable and accessible housing, racism, ongoing colonial processes and all of these have compounded to create the enormous opioid crisis that we're facing today. But getting back to the role of global partnerships and what role they can play at baseline, we need to learn from what other countries have done to, first of all, avoid this type of crisis in the first place, but then also how others have addressed and continue to address illicit drug related issues. And this would include learning from countries such as Portugal, Netherlands, Argentina and quite a few more actually, who have decriminalized drug use to some degree and invested instead in harm reduction and public health services. 

Erica Di Ruggiero [00:18:00] So I think, you know, I'm glad you brought up the question about Portugal. Just really briefly, why do you think they were successful in decriminalizing drug use and what are the specific lessons we can learn? 

Andrea Bowra [00:18:16] On the one hand, it's quite a smaller country than, say, the U.S. or Canada to begin with. So they were able to move that legislation forward to actually take the steps to decriminalize drug use, which there's been a lot of barriers to here in North America. But they have seen kind of really amazing results in doing so and investing, shifting funds away from policing and surveillance and punishment of people who use drugs towards the essential health and social services, including even basic structures such as housing. Affordable housing. Yeah. 

Erica Di Ruggiero [00:18:51] Yeah. Which links back to some of the, you know, other issues that you raised, I think, which are really important in terms of what determines some of these issues. Was there anything else you wanted to add? 

Andrea Bowra [00:19:04] Sure. I mean, on the pharmaceutical side of things, because that's more on the illicit drug side of things, even though they're definitely over overlapping. But the pharmaceutical, pharmaceutical companies and the broader industry continue to continue to perpetuate harm in many ways to people through misrepresentation of products and like in the case of OxyContin, but then also through inaccessible pricing. And so for global partnerships, it's more important than ever because of the increasing number of pharmaceutical companies that are working across borders. And we currently don't have the means to regulate the transnational activities of pharmaceutical companies, which can be such a big issue. 

Erica Di Ruggiero [00:19:45] Mm hmm. Yeah. So it really presents, I think, some really complex challenges which the SDGs, like SDG 17 point us to that partnerships do matter in global public health. So you know what, as a student and you mentioned that, you know, you're just finishing up your second year at the School of Public Health here at the University of Toronto. What advice do you have to students who may want to pursue a career in global health or other fields that aim to pursue equity? And really, I think think about those power imbalances and how to correct them and how these power imbalances result from influential industries such as the pharmaceutical sector. 

Andrea Bowra [00:20:30] It's a good question. And I mean, the state of inequity and power imbalances within health systems can be super disheartening at times because of all of the power and financial resources that industry has and how they exert these resources to shape policy and influence government. And we've seen that even exacerbated over the past year during COVID 19 pandemic, with the further rise of pharmaceutical companies and even companies like Amazon and other corporations. Yeah. So my advice would be not super specific to the pharmaceutical sector per say, but I would recommend getting involved in grassroots level organizing within but also outside of the academic setting and that can be related to whatever issue the students are passionate about. And that's because change that actually benefits those who are typically more marginalized is made from the ground up because the people who hold and exert the power are currently benefiting from the structures in place and benefiting from the marginalization of others. 

Erica Di Ruggiero [00:21:31] Yeah, and I think it's an important reminder of the role of civil society. Arguably in academia. We are interested in generating knowledge, but also working hand in hand with civil society to mobilize that knowledge for systemic social change. And policy change, I think is really the goal. Great advice, Andrea. Thanks so much for joining us today and for sharing your perspectives on your research. 

Andrea Bowra [00:21:55] Thank you so much for having me. 

Erica Di Ruggiero [00:21:58] Thank you. The conversations with our speakers today have shed light on the importance of transparency and accountability and partnerships within and beyond the pharmaceutical industry. Both speakers highlighted the need to critically examine power relationships in partnerships and shared cautionary tales of how corruption resulting from the role of transnational corporations can manifest in poor health outcomes globally. The need for anti-corruption governance mechanisms in all public health and global health initiatives is urgent. Dr. Jillian Kohler highlighted the complexities in seeking partnerships with the pharmaceutical industry and the importance of scrutinizing what the industry stands to gain from the proposed partnership. Dr. Kohler acknowledged that Canada should be encouraging the transfer of technology to other countries to better support the research, development and manufacturing of their own medicines, and also advocate for self-sufficiency both in Canada and in low and middle income countries to avoid undue reliance on external sources for lifesaving medicines and vaccines. As was witnessed during the pandemic, we are left with a poignant image of the power held by an industry that has been criticized as putting profit over lies during the pandemic. Andrew Bowra commented on the weak regulation of the transnational pharmaceutical industry and how actions by this industry can concentrate poor health outcomes in societies that are already made unstable by preexisting social and structural issues, such as lack of affordable and accessible housing, systemic racism and ongoing colonial processes. She proposed that global partnerships with countries that have addressed or avoided crises such as the opioid epidemic can provide valuable lessons that Canada can learn from. Our guests this week called for more work to be done to promote equitable access to pharmaceuticals globally, reduce corruption and reduce potential harms that are caused by some actors in the pharmaceutical industry. Both guests acknowledged that there can be benefit in partnerships if done in an equitable and transparent manner, but cautioned that if attention is not paid to power relations and power asymmetries, partnerships can exacerbate existing inequalities. Healthy cities in the city era is made with the support of the School of Cities at the University of Toronto, whose mission is to bring urban focused researchers, educators, students, practitioners and the public together to explore and address complex urban challenges. We'd love to hear your thoughts on healthy cities in the SDG era. If you enjoyed this episode, please rate, subscribe and share to help others find the series. You can find healthy cities in the SDG era on Spotify, Apple Podcasts and the Dalla Lana School of Public Health YouTube page, as well as our Center for Global Health website. Join us for our next episode when we'll look at SDG 14 Life Below Water. Thank you for tuning in and we look forward to speaking soon. Take care.