• I want my MDGs
• Whither the MDGs?
• Toilet trouble
• An island slakes its thirst
• Naga City’s class act
• A school board makeover
• Making sure Mama makes it
• No cure for costly medicines?
  Draft law affirms patient rights of drug firms
• Arroyo fails COA audit: Fairness of President’s books ‘doubtful’
• Gloria’s spending spree: Travel, ‘donations’ top Palace expenses
• First Person
  Still reeling from military junta, Burma a mess after cyclone
• Perspective
  An absolute privilege

VALLEHERMOSO, CARMEN, BOHOL — Had she been in the same situation eight years ago, Jesusa Panes would have probably just given birth at home, even without her husband in sight, and even if her neighbor the hilot (traditional birthing attendant) happened to be drunk. But things have not been the same for expectant mothers in this town since 2002, and so when the child in her belly starting demanding to be let out, Panes began trudging toward the birthing center that was several minutes away by foot from her home.

The drunken hilot did his duty by swaggering behind her, seeing to it that she got to the center safely. Carmen is in fact the only town in Bohol that has legislated that all mothers must give birth at designated birthing facilities in five barangays or at the town’s birthing center (rural health unit or RHU), a P2.5-million, sprawling facility that offers first-class service for very low fees. Carmen’s laws also say a hilot should bring laboring mothers to the nearest birthing clinic to ensure a comfortable and safe delivery. And even if a hilot is trained, he or she cannot aid in a delivery, unless a midwife sits nearby to oversee the process.

	THESE days, mothers like Lilia Angcog can give birth for only P500. [photo by Avie Olarte]

The result of such legislation has been practically no maternal death in Carmen’s 29 barangays in the last five years, save for one in 2006. According to Dr. Josephine Jabonillo, Carmen’s municipal health officer (MHO), that unfortunate mother-to-be tried to deliver at home, with her father-in-law as the hilot. The father-in-law turned out to be untrained; the woman hemorrhaged to death.

“Most maternal deaths can be prevented,” says Jabonillo, an obstetrician/gynecologist. “Mothers all over the world die due to the same major complications of pregnancy: hemorrhage, hypertension, sepsis, and unsafe abortion.”

Globally, women continue to die due to complications of pregnancy and childbirth at a rate of one per minute. The limited progress in making motherhood safer is more alarming in developing countries, where 99 percent of maternal deaths occur every year. Here in the Philippines, about 10 to 12 women die every day due to pregnancy-related causes. The government has even admitted that it may not meet its commitment to achieve Millennium Development Goal (MDG) Number 5 — to drastically reduce the number of maternal deaths — by 2015.

And yet here is this town of 41,519 people that has been demonstrating just how far better local governments can be at keeping mothers healthy. Aside from its innovative laws regarding maternal health, Carmen also has what it calls the Enhanced Safe Motherhood Program (E-SM), which not only pushes for a RHU-based delivery, but also includes a pre-natal assessment, monthly check-ups, access to medicines, and other maternal health services — all for a nominal fee.

Location map of Carmen, Bohol courtesy of Wikipedia

TO FULLY appreciate what Carmen has accomplished so far, consider this: as late as 2005, the proportion of births attended by skilled health workers nationwide stood at 63.7 percent. In 2006, meanwhile, the national maternal mortality rate — the number of deaths per 100,000 live births — was 162. To be considered as having met MDG No. 5, the Philippines has to have all births attended by skilled health workers by 2015, as well as have reduced the maternal mortality rate to 52.3.

This predominantly agricultural town with more than half of its people living under the poverty line has managed to best those numbers — and how.

Yet even up close, there seems to be nothing that can make Carmen stand out among other rural towns across the Philippines. There are the small town center that passes for its urban area and a collection of dusty barangays. There are some cars and jeepneys and a lot of motorcycles. And just like any other Philippine town, there are children — lots of them — scampering about in the streets.

Then again, there is that birthing center, a 10-bedroom facility that is complete with delivery tables and laboratory equipment and can top the services of any hospital in this province some 800 kms south of Manila. Completed in 2006, it won a Sentrong Sigla Award (Center for Vitality) the very next year. According to the Department of Health (DOH), it is one the best rural health units in the country.

Building a good facility was on top of Jabonillo’s list when she became the town’s health officer in 2002. But she says it was no easy task, recalling that she had to first lobby hard with the local government officials.

“Carmen at the time had a very high record of maternal death,” Jabonillo recounts, “So I told the mayor we had to address it.”

Although the E-SM was Jabonillo’s idea, the local health board (headed by the mayor, and with Jabonillo, a councilor, and a nongovernmental organization representative as members) helped craft the program.

For the past five years, Carmen has had no maternal deaths except for one in 2006. Credit that to its award-winning rural health unit, which is complete with bedrooms, delivery tables, and laboratory facilities. [photo by Avie Olarte]

Jabonillo says that the town records revealed that the maternal deaths in Carmen were often caused by unhygienic and improper birth delivery practices. She also noted that there were also few skilled birth attendants, while women barely had access to pre-assessed normal delivery from the provincial hospitals.

These days, aside from the main one in the town center, five of Carmen’s barangays have birthing facilities. There are no doctors in these centers, but a midwife is usually on call, along with an army of barangay health workers; should any complications arise, an ambulance (Carmen has six) can be dispatched to bring the pregnant woman to the RHU.

But convincing the women to try the services of these clinics proved difficult. For one, the women thought they would be charged high rates. For another, they were simply more used to the hilot, some of whom even discouraged the pregnant women from going to the RHU. (This is, after all, a country where half of births still occur at home, and a third assisted by hilots. In Bohol, 17 percent of all the births in 2006 were aided by trained and untrained hilots, most or 53 percent are assisted by midwives.)

On E-SM’s first year, the RHU had a total of only eight deliveries. But by 2006, which was also the year the council passed the ordinance banning trained hilot from delivering babies, about 400 women ended up giving birth in the town facility.

“Maternal and birth complications were reduced to 50 percent,” Jabonillo says, leading to Carmen’s near-zero maternal death record.

AT VALLEHERMOSO, one of the barangays with a birthing center, the barangay midwife keeps track of all the pregnancies in the area. The health unit has on its white wall a pregnancy watch board that lists the names of pregnant women, together with the estimated date of confinement, last menstrual period, place and (estimated) date of delivery. There are also free pre-natal check-ups and some medicines, like iron tablets (many of Carmen’s women are anemic), are free as well.

Lilia Ancog’s barangay has no birthing center yet, so when time came for her to deliver her third child, she went to the main birthing center in town. Even then, she says her total bill came to only P500, or about 25 percent of the cost of a hospital-based delivery. She says that with her two older children, she had paid double that amount, and those deliveries were even done at home through a midwife.

“(It’s) high quality obstetric services at very reasonable amount,” says Jabonillo, who does not charge a doctor’s fee for the deliveries she does.

The doctor says that all the birthing center’s proceeds go to buying medicine and supplies like gloves and cotton, on top of the P1-million worth of drugs that the local government allocates for the RHU every year.

A patient in Carmen can even end up not paying anything at all. Last September, Carmen came up with a program for indigents with the government-run Philippine Health Insurance Corp. Through the program, a patient can avail of the Maternity Care Package that covers the first three deliveries, newborn screening, laboratory works, accommodation, medicine, and the P500 user’s fee.

VALLEHERMOSO remains one of the most densely populated barangays in Carmen. More than half of its population live below the poverty line. [photo by Avie Olarte]

That’s not all: Carmen is also one of only three towns in Bohol that have adopted a Reproductive Health Care Code; Bohol province itself has yet to pass one.

Carmen’s code mandates, among others, that women must have access to safe and quality reproductive healthcare services and that there should be a continuous planning, implementation, and monitoring of effective reproductive-health programs.

The code also ensures a steady stream of funding for reproductive health services, on top of the P50,000 allocated for the reproductive health advocacy program. A look at the town’s spending pattern shows that it allots an average of nine percent every year for health services compared to an average of four percent for infrastructure. (In most towns in Bohol, as in many local governments, building roads and bridges is prioritized over health and social services.)

For sure, though, the code has its critics. Some church workers have called its proponents “devils” and even launched a radio program to discredit the local officials pushing for it. One official who suffered such a backlash is Nathaniel Binlod, a two-term town councilor and chairperson of the town’s health committee. He almost lost in the 2007 elections, he says, for openly advocating and raising awareness on reproductive health and population management.

“I’m not for abortion,” says Binlod, who was born and raised in Carmen. “What I’m campaigning for is responsible parenthood. Two to three children are enough.” (The average family size in Carmen at present is 5.3.)

ACCESS TO reproductive-health services in Carmen comes in the form of making contraceptives available to the public. Together with the United Nations Population Fund (UNFPA) — with which it has partnered for such things as the ambulances and setting up barangay birthing centers — the town has built a Pop Shop that sells condom and pills at lower prices than those at retail stores.

HEALTH workers keep track of the condition of pregnant women in Vallehermoso. [photo by Avie Olarte]

The RHU itself allots P50,000 to P75,000 a year for buying contraceptives alone. The award-winning facility even has a Family Planning Room where couples can consult with a doctor regarding which family planning method would be best for them.

More Pop Shops are already being put up in the barangays. But women like Beatriz Manda, a 44-year-old mother from Vallehermoso, are unlikely to step foot into one unless they visit a local health unit first.

Manda says the natural way doesn’t work for her and her husband, because she has irregular periods. They already have 11 children, with the youngest only five months old.

But it may take some doing before she and her husband consider artificial family planning methods. “I’m afraid of the IUD (intrauterine device),” says Manda. “My husband meanwhile doesn’t like the condom, he says it might slip off.”

Someone also told her that once she has had a ligation, she wouldn’t be able to help her husband in the farm anymore.

Manda confesses that she has not paid a visit to the barangay’s midwife, who could help clarify common misconceptions on artificial family planning methods. But she says she is planning to go one of these days.

CONDOMS and birth-control pills can be bought for a cheaper price at Popshops. [photo by Avie Olarte]

If she opts to go to the RHU, she may just bump into Lilia Ancog, the mother who just gave birth there. Ancog is planning to visit the town doctor again as soon as she has had a few days of rest. She says she and her husband need a family-planning method aside from the natural way, which doesn’t seem to work for them. Her husband wants a fourth child, but Ancog says they can afford only three.

As for Jesusa Panes — the pregnant woman who with her drunken hilot walked all the way from her home to the barangay health center — she reached the place in one piece, the baby still safe in her tummy. And while she was sweating profusely when she arrived and was visibly worried that she would give birth any minute, she seemed to calm down somewhat after she downed a glass of spring water. As people fanned her, Panes politely declined offers to bring her to the nearest hospital, saying the midwife would take good care of her.

She later gave birth to a baby girl, her fourth child. Mother and newborn daughter are doing fine.

• I want my MDGs
• Whither the MDGs?
• Toilet trouble
• An island slakes its thirst
• Naga City’s class act
• A school board makeover
• Making sure Mama makes it
• No cure for costly medicines?
  Draft law affirms patient rights of drug firms
• Arroyo fails COA audit: Fairness of President’s books ‘doubtful’
• Gloria’s spending spree: Travel, ‘donations’ top Palace expenses
• First Person
  Still reeling from military junta, Burma a mess after cyclone
• Perspective
  An absolute privilege

IT WON’T be over even after the lady signs. And even after she signs it, the fight for popular access to affordable medicines won’t be over.

All that the cheaper medicines bill needs to be enacted into law is the signature of President Gloria Macapagal Arroyo. But some legal experts lament that as enrolled, the bill passed by Congress bears “imperfections” that effectively affirm the patent rights of big pharmaceutical companies over public health, a major hurdle to bringing down drug prices.

And while the bill introduced amendments to the Philippines’s intellectual property law, the weak and flabby wording of some provisions could challenge implementation, and keep the promise of cheaper drugs locked in litigation.

Lawyer Elpidio Peria, for one, says that as soon as Arroyo signs the bill into law, the battle shifts to the drafting of its specific implementing rules and regulations or IRR. And that, he says, should teach public-health advocates to study intellectual property issues in the pharmaceutical sector more judiciously.

Peria, an associate of the Third World Network (TWN), one of the nongovernmental organizations that had supported the Senate version of the bill, says that the drafting of the law offers one lesson: It is “dangerous” to leave the debate on intractable intellectual property issues to lawyers and policymakers alone.

“The (bicameral) debates only proved the esoteric nature of intellectual property, which makes it dangerous to be left to lawyers and policymakers,” says Peria. “The (Intellectual Property) Code amendments will now have to be scrutinized closely so that its imperfections might be augmented by the IRR.”

HAVE patent rights triumphed over public health?

Throughout the debate, public-health advocates and legal experts had welcomed the inclusion of amendments to the country’s intellectual property law in the final bicameral draft of the affordable medicines bill.

Undersecretary Alexander Padilla of the Department of Health (DoH) himself says that while the bill lost some of the provisions his department had championed, what is important now is that the law would contain “the more important patent flexibilities.”

The global nonprofit organization Oxfam International also says that, if applied by the government, the IP amendments “should help ensure that patent privileges of drug companies do not get in the way of promoting and protecting public health through affordable medicines.”

Yet the likes of Peria worry that the “simplistic debates” on price regulation and the Generics Act amendments had obscured the bill’s IP provisions. As a result, Peria notes, the IP amendments were not fine-tuned and rid of their inherent weaknesses.

Some legal experts now fear that despite its promise of affordable medicines, the law would face difficulties in its implementation, in large part because pharmaceutical companies could take advantage of the loopholes in the patent-related amendments.

Scuffles over ‘generics-only’

Up until the bill’s ratification by Congress in late April, the bicameral debates had focused mostly on the provision of House Bill 2844 that said only the generic names of medicines would appear on medical, dental, and veterinary prescriptions. This raised a howl among doctors who even threatened to declare a “hospital holiday” if the stipulation — which was among those being pushed by the health department — was not removed.

Later, the legislators wrestled over the House of Representatives’s proposal to create a drug price regulatory board. This further delayed the passage of the bill, which had been certified as urgent by the Arroyo administration way back in 2001.

In the end, the “generics-only” provision was dropped and the price-regulation board was replaced with a price monitoring and control mechanism that places the sole authority to impose price ceilings on the President, upon recommendation of the health secretary.

There were loud grumbles about a “watered-down” bill, but many also took comfort in the retention of several key provisions, including those on intellectual property.

“I would have been happier with the inclusion of the generics-only provision,” says Akbayan party-list Rep. Ana Theresia Hontiveros-Baraquel. But she is nonetheless pleased that the IP Code amendments, which were the intent of the original bill she filed in the House, were adopted.

Ireneo Galicia, former deputy director general of the Intellectual Property Office (IPO), also says he can live with the changes in the price control and generics provisions knowing how “politically” sensitive these issues are, as long as his main advocacy, the IP amendments on patent reforms, are intact.

“No doubt,” he says, “these will help immediately bring about the lowering of prices of patented medicines via the parallel importation provision, and in the long term via the early working and new use provisions.”

Drug patent provisions

For sure, the IP provisions included in the final draft of the bicameral bill are formidable. These include:

• adopting the principle of international exhaustion of intellectual property rights (IPR) for drugs and medicines to improve access to cheaply priced drugs anywhere in the world without risk of patent infringement;
• narrowing the definition of what medicines can be patented by disallowing the practice of evergreening — patent coverage for “new uses” of existing, already patented substances;
• providing for a broad parallel importation provision to allow the government to procure quality, affordable patented drugs and medicines from other countries;
• providing additional means to issue compulsory licenses so that the government can easily set aside patent restrictions in response to public health threats; and
• adopting an “early working” or Bolar provision, which ensures that affordable versions of patented medicines can be introduced into the Philippines market immediately upon patent expiration.

The bicameral version also adopted Section 93-A that was introduced in the House bill, which provides an alternative procedure for the issuance of a special compulsory license under the framework of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement.

The IPO itself has declared that these amendments are a legitimate exercise of the flexibilities accorded to developing countries like the Philippines in the Doha Declaration on the TRIPS and Public Health.

The World Trade Organization (WTO) had adopted the TRIPS Agreement in November 2001. More than six years later, however, such flexibilities have yet to be incorporated in Philippine intellectual property law that would have made it more responsive to the problem of inaccessible medicines and expensive drug prices.

Hole-ridden amendments?

Lawyer Peria says he is happy that the IP amendments made it to the final draft of the bill. But he echoes other experts in pointing out some of these are likely to face challenges from pharmaceutical companies in court. Congress should have strengthened these so they could withstand such challenges, he says.

In fact, from the outset, multinational drug companies, particularly those represented by the Pharmaceutical and Healthcare Association of the Philippines (PHAP), had opposed the proposed amendments to the intellectual property law. As the drug companies see it, these would weaken the country’s patent system.

In PHAP’s 27-page position paper submitted to Congress during deliberations on the bill, 17 pages were devoted to the changes in the IP Code, arguing that these are discriminatory and violative of the due process and equal protection clauses of the Constitution. It also said that these were inconsistent with the country’s international treaty obligations of the Philippines.

These days, Peria’s organization, TWN, has made known its concerns over the final draft’s Section 72, which is on the international exhaustion of patent rights. Peria says this provision was weakened when the bicameral panel opted to retain the national exhaustion principle by inserting the phrase “in the Philippines.” He says this provides patent owners with additional ammunition for litigation as they can argue that the national exhaustion rule still applies in specific circumstances when there is a patent existing in the Philippines for the drug in question.

Section 72.4 on the “early working” or Bolar provision adopted from the House bill, meanwhile, is also weak since it copied the data protection provisions of Article 39.3 of the TRIPS Agreement without its key provisos, says Peria.

These provisos, he explains, stipulate that data protection applies only to new chemical entities and that it should involve data generated through a considerable effort and investment. Without these, the section practically imposes higher levels of intellectual property protection — also known as TRIPS-plus rules — that tend to undermine or weaken the public-health safeguards allowed under TRIPS.

The same is true of Section 74 in regard to government’s use of an invention, says Peria, as it qualifies the public non-commercial use of the patent by the government with the phrase “without satisfactory reason.” This, the lawyer says, is an additional requirement that is not found in the TRIPS Agreement.

And while Peria says that a stipulation allowing government use in case demand for the patented medicines is not met is good, it could be subjected to litigation by the patent-holder because of the phrase “to an adequate extent and on reasonable terms.”

Tripping on TRIPS

Another problematic amendment is Section 93-A regarding the grant of a “special” compulsory license. The provision, he says, “operationalizes” Paragraph 6 of the Doha Declaration on TRIPS and Public Health that calls for making effective use of compulsory licensing by countries with insufficient or no drug manufacturing capacity.

Peria says that legislators may not have realized the international implication of their action when they “unwittingly” grafted to this section Article 31 bis. He says this is an amendment to the TRIPS Agreement that was meant as a “permanent solution” to the issues raised in relation to Paragraph 6 of the Doha Declaration.

In an August 30, 2003 decision, the WTO General Council proposed a “temporary solution” by waiving the limitation that compulsory licenses should be predominantly for the supply of the domestic market. But patent experts and public-interest health groups criticized the decision, noting that it also imposed several conditions and procedures for generics exporters and importers that were largely seen as hindering access to medicines.

Essentially, what Article 31 bis does is to remove this limitation on the grant of compulsory licenses. But Peria says that by calling it “special,” Section 93-A is a “misapprehension” of Paragraph 6 of the Doha Declaration.

“(Paragraph 6) doesn’t refer to the license, but to the process that may be undergone by a country that accepts the Article 31 bis amendment to the TRIPS Agreement,” he explains. “What does that make of the other compulsory licenses in the other provisions of the IP Code? Is there basis for that distinction? Without any basis, the provision can be easily questioned in court.”

Besides, the amendment has yet to come into force, with less than two-thirds of WTO member-nations ratifying it.

Other potentially litigious amendments, says TWN, are the anti-evergreening provisions found in Sections 22 (on Non-Patentable Inventions from HB 2844) and 26 (on Inventive Step from SB 1658). Patterned after amendments in the India Patents Law, both sections exclude from patent protection “new uses” of a previously patented product or process. This addresses the phenomenon of “evergreening,” which consists of the patenting of minor changes to existing products (e.g., formulations, dosage forms, polymorphs, salts, etc.) thereby artificially extending the protection conferred by the original patent over a drug.

Peria says that what legislators might have thought of as double protection against the proliferation of frivolous patents on just about any demonstrable “new use” could be construed as a case of double standards. PHAP, which has insisted that the current IP Code has sufficient safeguards against double patenting and evergreening, may well question these provisions for making it doubly difficult for drug firms to comply, he says.

A veiled US warning?

Heightening worries of public-health advocates regarding the IP amendments is the release last month — just as the bicameral debates on the bill were winding up — of the annual IP report of the U.S. Trade Representative (USTR).

The report highlights, among others, the need for proper implementation of the TRIPS Agreement by developed and developing country-members of the WTO. According to the United States, it will consider all options, including (but not limited to) initiation of dispute settlement consultations in cases where countries do not appear to have implemented fully their obligations under the agreement.

Yet while the Philippines is on its Watch List, the USTR’s concern is more on the apparent increase in piracy cases, particularly concerning books, as well as illegal downloads using mobile devices and the Internet, and illegal camcording of films in cinemas.

Still, the report’s comments on Thailand, which remains on the USTR’s Priority Watch List, could be a veiled warning to the Philippines. After all, the report cites the “overall deterioration” in Thailand of IP rights protection, which includes the use of compulsory licenses to produce cheaper versions of patented medicines.

The USTR has urged Thailand to respect the viability of the existing patent system. It sides with the developed-nation pharmaceutical industry that has expressed concern that “the use of such licenses in mid-size economies such as Thailand could inflict economic harm on the industry and its ability to carry out research and development.”

The Office of the U.S. Trade Representative was suspected of attempting to modify some of the provisions in House Bill 2844 during the deliberations prior to its passage on third and final reading last year. An unsigned position paper circulated among members of the Lower House’s trade and industry committee was traced to the USTR based on references in the paper to U.S. “modern free trade agreements.”

The paper had called the legislators’ attention to the strict definition of patentability and the provision on the government’s use of compulsory licensing in the House bill.

Like many Filipinos, my family lacks a financial security net. We are not rich. We do not own our home. In the early 1990s, we had to sell our house in Laguna because Papa became jobless for a long time; the 1991 Gulf War forced him and other Filipino workers to leave their lucrative jobs there and head back to the Philippines. Yet while he was able to work abroad again, and my brother and I have held jobs for years, none of us has been able to afford to get sick.

That remains true to this day. Still, we have also found out that our family can survive serious health crises through a combination of sheer luck, audacity, an unwavering faith in both God and the innate goodness in other people — and perhaps the career path I chose.

I cite the last reason because honestly, it was through recommendations and tips from media colleagues that I was able to get help from the Philippine Charity Sweepstakes Office or PCSO and the Philippine Amusement and Gaming Corporation for one of our family’s latest medical emergencies. They turned out to be the main source of support for us. Of course, even if I weren’t a journalist, I would probably have approached these agencies anyway. But I would surely have had to go through the frustrating and painstaking process that most other Filipinos experience had I not known whom to seek there in the first place. I concede, the saying “it matters whom you know” applies here.

I also say luck because during my older brother’s hospital confinement last year, after he had a heart attack at the age of 37, I got to know several families, mostly poorer and lesser in opportunities than us, who really had no idea where they would be able to get the money to pay for their rising medical expenses.

Indeed, my greatest joy these days is that even as the medical bills (for drugs and check-ups) keep on coming, my family is still complete and with me as we await the coming of my child, a boy whom my partner and I plan to call Rafael — which means God has healed — when he is born in April.

A MOTHER and her new-born being treated at a government hospital. [PCIJ file photo]

TO THINK that just last February, my sister-in-law Kate and I were being told by doctors at the Philippine Heart Center in Quezon City to prepare at least P300,000 because my Kuya Ronnie’s heart problems may need major procedures to correct. They also said we could not afford to waste any time because a second heart attack could be fatal.

But where to get the money? Kuya was then a contractual call center agent while his wife worked as an engineer in a fabric company. While he was a member of the Social Security System (SSS) and the Philippine Health Insurance Corporation (PhilHealth), these were not enough to cover the looming expenses. Neither he nor his wife had any other insurance plan to rely on, and had counted only on their combined monthly salaries of P25,000 for their everyday needs, as well as any emergency that may arise. Whenever they could, they also put something away for their two-year-old daughter Jesi’s education.

Meanwhile, I was already helping take care of our parents. While Papa had a retirement pension from the SSS, this came to only P3,500 a month, and went mostly to buy groceries. Sometimes, Mama and Papa would treat themselves to a movie or two or eat in a fastfood chain. I had volunteered to pay for the rent of their apartment in Bulacan, as well as for Mama’s maintenance medicines for her heart and blood pressure problems (she had a heart bypass in 2000).

Papa’s stint overseas had not meant a bonanza for us. When the modest business he set up after he returned home for good failed in 2005 — after just several months of operation — he lost most of what he had earned all those years toiling in a foreign country.

It’s a good thing both my Kuya Ronnie and I already had jobs when that happened. Then again, we had been working long before that. My brother even had to forego college to help out, while I managed to stay in school and earn a degree even as I also did my bit to contribute to the family’s finances.

Kuya Ronnie eventually finished a two-year computer course. I took up journalism in the University in the Philippines. Papa is a mechanical engineer while Mama has a degree in architecture. But all those certificates and degrees have not necessarily translated into a financially secure future — or present, even.

In fact, before we transferred Kuya from our town hospital in Bulacan to the Heart Center, Mama and I had to pawn her pieces of jewelry, raising about P16,000. I thought that was a good enough buffer as we looked for other sources of money, but there were the doctors, talking about hundreds of thousands of pesos more. Money or no money, though, we were all determined that Kuya Ronnie would have whatever medicine, whatever treatment he needed and see his little girl grow up.

Two hours after he was admitted into the Heart Center, Kuya had angioplasty for two of his three blocked arteries. By day four of his confinement, our hospital bill was already running close to P400,000. All in all he was at the Heart Center for 23 days, and our bill reached nearly P1 million.

I KEEP saying our bill, because in this country, no one really gets sick alone. Not when you have your family. And your friends. I witnessed this during my family’s emergencies and in those of others. At the PCSO, which turned out to be our biggest savior, I met the wife of Kuya’s ICU “neighbor.” Already burning with fever due to fatigue and worry on how she was going to pay her husband’s hospital bills, she had been waiting for hours to have her name called so she could ask for help. Her husband’s bill by then had already reached P300,000. Her only prayer, she said, was that she would walk out of the PCSO building with a guarantee letter in hand that she could give to the Heart Center.

There was also this old woman I met in one of the hospital’s restrooms who told me, a complete stranger, that her granddaughter could not be discharged until they settled her account. Her apo was suffering from a congenital heart disease; the grandmother said their family, who hailed all the way from Negros Occidental, was counting on support from relatives abroad to see them through.

I have to admit that compared to them, we had it fairly easy. But then after he was discharged, Kuya still needed post-hospital care, which had its own set of price tags. There were the maintenance drugs that totaled some P5,000 a month, physical therapy sessions to regain his strength, and occupational and speech therapy sessions to address his expressive aphasia, a condition caused by stroke wherein the individual cannot express himself through speech or writing. My big brother had to study his alphabet and arithmetic all over again, as well as hone his reading and writing skills with the support of a professional occupational therapist.

My sorority sisters and members of our partner-fraternity provided contacts who could help my family pay for all these. Some of my former schoolmates who were working with politicians found ways to provide us with medical assistance through their bosses’ allocations. There were also financial contributions from other friends and relatives here and overseas.

By late August last year, Kuya was well on his way to recovery. And there was another great piece of news: I was going to have a baby! As soon as we learned about my pregnancy, my partner and I began setting aside an amount monthly, not only to prepare for Rafael’s coming, but also so we could move to a bigger place later. I began paying more attention to having up-to-date SSS and PhilHealth payments because claims from these would be helpful during childbirth.

At around this time, however, Papa’s stomachaches began becoming more frequent. A trip to the gastroenterologist resulted in an order for a battery of tests.

From August to December, Papa had to undergo ultrasound, enema, and blood tests, as well as urinalyses, and the more expensive CT scans and colonoscopy. That meant less money for my “baby kitty,” but the doctor had to be certain what was wrong with Papa. The tests cost thousands of pesos, and that was even though Papa availed of his senior citizen’s discount.

IF ONLY the tests showed that all he had was just indigestion. Unfortunately, the colonoscopy indicated colon cancer, and the doctors advised immediate surgery to prevent complications and to arrest the problem at its early stage. The amount needed within weeks: a minimum of P100,000 for the procedure only, excluding professional fees.

But just like in Kuya’s case, a combination of miracle, luck, knowing the right people, and having the right strategies helped us cope with the costs of Papa’s hospitalization and surgery. By then I could even joke that we seemed to be always “blessed” whenever one of us had to be hospitalized. There we were with neither insurance nor any real money, but each time, we received the best medical care that those coming from lower to middle-income families like ours could never imagine receiving.

Actually, seven years before, we had experienced a similar kind of blessing in what could have been one of our darkest hours. Mama had to undergo a triple heart bypass — and despite our lack of money, she was attended to by the same set of doctors who operate on showbiz celebrities, politicians, and business moguls. We later learned that the procedure alone would have cost something like P1.5 million. Yet Mama was asked to pay only P100,000 because a distant relative who happened to be sitting in the (private) hospital’s board intervened on our behalf.

That relative was no longer there when the time came for Papa to have his colon surgery at the same hospital. But we still knew enough people — one of whom was my eldest cousin — who could help Papa get into the hospital’s list of Health Service Program (HSP) beneficiaries. By being included in the list, one gets to avail of procedures that cost way, way below the original price, apart from discount privileges to as high as 30 percent and waived doctors’ fees. HSP also honors discounts for PhilHealth members.

So last December 28, while most people were busy preparing for the New Year, one of the best surgical teams in that private hospital worked on Papa to remove the tumor in his colon. The price: P87,000 for surgery that normally costs as much as P300,000. Aside from instant loans with interest from the respective offices of my sister-in-law and cousin, we paid the bill with part of my “baby kitty,” plus donations and small loans from relatives.

It was my family’s first time to celebrate New Year’s Eve in a hospital, and it was quite a unique experience. We had our Media Noche delivered courtesy of our relatives and enjoyed a safe and smoke-free celebration, which was good for my baby, too. But our best aguinaldo this New Year has been Papa’s quick recovery, as well as his latest biopsy results that indicate no more traces of cancer.

IT WILL take me maybe two more months before I can finish paying off the loans – just in time for Rafael’s arrival. As Papa and Kuya regain their strength, friends and relatives alike continue to marvel over how we were able to pull everything off, considering our situation. I can’t guarantee what worked for us will work for everyone else, but here are some of the ways my family and I used to help us get major medical treatment without much money:

First, we found dignity in asking help from people and groups whom we knew could be potential sources of support. When I prepared our solicitation letter, I wrote it as if I were writing to very close friends and kin. I never missed a detail and told the truth, especially about our financial situation. I myself was surprised with the overwhelming response; people who knew people who knew me — some even based abroad — called me up and gave significant financial help. Some even said that helping us was “cathartic” because they had undergone similar experiences.

Second, I did not hesitate to repeatedly ask for leads from colleagues. As I mentioned earlier, I was able to tap most of the major sources of support for Kuya’s hospitalization by way of tips or endorsements from media friends. This was also how I was also able to get support from political offices, government agencies, and private groups. I mapped every sector: church, media, government, business, foundations, nongovernment organizations, and individuals.

Third, I maintained an orderly case kit that I made available to anyone interested in helping us. In Mama and Kuya’s cases, I made a chronological brief and compiled all their medical records, receipts, endorsements from the barangay and local social welfare offices, and other pertinent data. I compiled these as if I were preparing media kits for a press conference or arranging my documents for a story. I also updated Papa’s records every night while we were at the hospital. Before he underwent surgery, his doctors received a clean and chronological compilation of all his diagnostic test results, including plates, frames, slides, and a videotape of his colonoscopy.

Fourth, we never stopped believing in the capacity of man to do good or to “pay it forward.” Until now, I am still amazed that I was able to raise around P150,000 from chip-ins alone from kin, friends, and even practical strangers for Kuya. And that’s apart from what my sister-in-law was able to raise from contributions of her relatives and friends.

Lastly, we never ran out of faith in the Power greater than us. It may be a cliché, but I know there was a reason why these trials were given to us, and that He would never abandon us.

I really hope other families who have to undergo such crises would be as fortunate as we have been. Money may be vital to get the best treatment in this country, but surely, we can also help make miracles – for ourselves and for others.

PCIJ series on cheaper medicine

• Price control board debate may delay cheap drugs law
• What price is right?
• Will public health trump patents in Congress?
• Tangling over TRIPS provisions

THE 2001 World Trade Organization (WTO) Ministerial Conference in Doha reaffirmed that the TRIPS Agreement “can and should be interpreted and implemented in a manner supportive of the WTO members’ right to protect public health and, in particular, to promote access to medicines for all.” The Declaration sustained the right of developing countries like the Philippines to enforce public health safeguards so as to enable price reductions via generic competition. “Paragraph 6 Public Health Solution” of the Declaration even directed WTO member countries to facilitate access to generic medicines by poor countries with insufficient or no pharmaceutical manufacturing capacities.

In a 2005 analysis, Carlos Correa, an international expert on intellectual property law and public health, said that the Philippines’ Intellectual Property Code had not contemplated several flexibilities in the TRIPS Agreement, particularly parallel importation and the “Bolar exception.” To develop a patent regime that provides for a comprehensive set of rules consistent with the Agreement and protects and promotes public health, Correa advised the country to look into other issues such as the extent of rights conferred by a patent application and grant.

But as the global nonprofit organization Oxfam International observes, the public health safeguards allowed under TRIPS have been constantly undermined, either weakened or eliminated by higher levels of intellectual property protection — called TRIPS-plus rules — that countries like the United States have vigorously pushed through bilateral and regional trade agreements, to the benefit of the pharmaceutical industry.

Some legislators even suspect the “unseen hand” of the United States in what they say was a recent attempt to modify some of the provisions in House Bill 2844. Apparently, an unsigned position paper was circulated among members of the House of Representatives’ trade and industry committee last month.

[PCIJ file photo]

“Predictably, the Office of the U.S. Trade Representative echoed the position of multinational pharmaceutical companies,” says Akbayan party-list Rep. Anna Theresia Hontiveros-Baraquel of the proposals in the paper. “They don’t want a stricter definition of patentability to protect the monopoly of big pharmaceutical companies. They also want to limit the government’s use of compulsory licensing.”

Though unsigned, what purportedly gave the U.S. link away was the reference in the paper to the “modern free trade agreements (FTAs) that the U.S. negotiated (with countries) such as Morocco, Oman, Korea, just to name a few, (that) specifically provide patent protection for new uses (of known substances).” This was punctuated by a question asking if the Philippines “really want(s) to go in the opposite direction,” which Baraquel considers as a veiled warning now that the U.S.-RP Bilateral Trade and Investment Framework Agreement (TIFA) is currently under negotiations.

According to Oxfam, expanding the scope of pharmaceutical patents to include new indications — or new therapeutic uses of existing medicines — and formulations, and limiting the grounds for issuing compulsory licenses to emergencies, government non-commercial use, and competition cases are actually among the common TRIPS-plus features in FTAs negotiated by the United States with other countries.

Oxfam says that the U.S. government has close ties with pharmaceutical companies, noting that there are 20 industry representatives who sit on the advisory committees of the Office of the U.S. Trade Representative.

Oxfam also considers it an attempt to enforce TRIPS-plus rules in the Philippines when Pfizer filed a patent infringement case in 2006 against the government for importing cheaper versions of its hypertension drug, Norvasc, whose patent was set to expire in mid-2007. The court has yet to issue a ruling on the case, which seeks to prohibit the government from doing parallel importation of a patented drug, even as an exercise of the “early working” doctrine that is allowed under TRIPS (and even by the country’s current IP Code, though not as an expressed provision).

WHO also recommends restrictions on advertising and promotion, enhancing generic competitiveness, and developing incentive systems to increase the use of generic medicines. Alone, price controls, the WHO says, run the risk of being ineffective and unsustainable.

The international health agency says that a price control mechanism is difficult to sustain and hard to implement because developing the system to establish “fair price” can be complicated. This in turn is attributed to the usually non-transparent pharmaceutical market, especially for medicines patented by multinational corporations.

“The determination of the ‘right’ or ‘fair’ or ‘proper’ price,” says WHO, “primarily relies on the transparent disclosure by the players in the pharmaceutical industry — the manufacturers, wholesalers and distributors — of the price components that they incur in the manufacture and distribution of their products.” Such a provision, it adds, is conspicuously lacking in the House bill.

[photo by Alecks Pabico]

According to Drugs and Money: Prices, Affordability and Cost Containment, a book commissioned by WHO’s Europe regional office, the “fair” price of an item is the result of a negotiating process between the supplier and the user. Compared to consumer markets that are usually transparent and where it is possible to obtain information on product characteristics and to compare prices, pharmaceutical markets are “often characterized by monopolies or oligopolies, while the user generally has insufficient insight into products and prices,” says the book. “If it is not possible to compare prices with those of other comparable products, it becomes very difficult indeed to know what a ‘fair’ price is.”

Already, a number of methodologies have been developed to calculate fair prices both at the level of manufacturers and exporters and at the level of the wholesaler and the pharmacy. But what all this entails is a whole gamut of considerations that goes into determining such a fair price, or the Maximum Retail Price (MRP) of certain drug formulations as House Bill 2844 intends to do. As WHO points out, the government must first be able to ascertain the price components of medicines as basis of the MRP.

Generally, these would include the Manufacturer’s Selling Price (MSP), freight costs, import tariffs, taxes, mark-ups, and distribution and dispensing fees. Data from the Pharmaceutical Research Manufacturers of America serve to illustrate the pricing structure of medicines that incorporates research and development expenses (15 percent), tariffs (23 percent for active ingredients and 12 percent for finished products), and add-ons (which can account for 50 to 80 percent of the price).

As a substantial component of the drug’s price, add-on costs can vary from country to country and from one product to another, with the largest slice going to wholesale and retail mark-ups, then to value-added tax (VAT) and other taxes.

Drug price components do need to be looked into, concedes WHO, but these should be based on valid, reliable, scientific data, as well as carefully thought-out, unbiased methodologies for data gathering, collecting, and analysis. Various aspects of prescribing, dispensing, consumption, and the ultimate consequences in terms of health and finance are also important variables that must be considered. The same is true for facts and figures on pharmaceutical expenditures, utilization, manufacturing costs, and health and economic outcomes.

Also for the government’s consideration are other parts of the drug components that will be subjected to control. “Of primordial significance,” says WHO, “is to decide whether the control must be placed at the level of the manufacturer or importer or at the level of the wholesaler.”

It appears though that the House bill wants the board to regulate all the sectors involved with drug trade — from manufacturers, importers, traders, distributors, down to wholesalers. This brings up the question, says a health economist, of whether it is practicable to do that or to just regulate the end-point of the industry, which are retail outlets, and the issue of pricing. “Furthermore,” he says, “monitoring all the other industry players is pointless because they are not legally allowed to sell to the public or consumers.”

BY THE time Hazel Divinagracia-Coton’s grandfather suffered his second heart attack last February, he was already on medication for diabetes. After the attack, 69-year-old Lolo Rodolfo was put on more medication, this time for his heart condition.

In total, his doctors prescribed 17 kinds of medicine for him to take each day, putting a strain on his family’s finances. Lolo Rodolfo and his wife relied on a P14,000 monthly pension, but with the promise of some monetary help from the rest of the family, they hatched a plan that had them buying only the “more important drugs” — worth a total of P600 a day — to see him through.

Lolo Rodolfo lasted six more months. He passed away last August, while members of the country’s Congress continued to bicker over two versions of a proposed cheap medicines law. Now, however, lawmakers themselves are saying that a bill ensuring access to affordable, quality medicines by majority of poor Filipinos is on the verge of finally being enacted into law.

Certified as an urgent piece of legislation by the Arroyo administration since 2001, the measure is set to be among Congress’s legislative priorities once sessions resume late this month. Late last year, both Houses passed two versions of the proposed law, and now a bicameral conference committee is supposed to reconcile these.

Both the bills’ principal authors, Senator Mar Roxas (Liberal Party) and Iloilo Representative Ferjenel Biron (Kampi), are optimistic that harmonizing the two drafts would be quick. Indeed, the two bills have a handful of similar provisions proposing to amend Republic Act 8293, or the Intellectual Property Code of the Philippines, aside from other reconcilable stipulations. Still, unless the matter devolves into one of political expediency, there may just be more Filipinos ending up like Divinagracia-Coton’s lolo as they wait for Congress to produce an affordable medicines law.

Just last week, doctors threatened to declare a “hospital holiday” should lawmakers refuse to take out a provision in House Bill 2844 that says only the generic names of medicines appear on medical, dental, and veterinary prescriptions. At the same time, legislators themselves are gearing up for debate over other “contentious” provisions in the bill, such as a non-discriminatory clause that makes it illegal for any retail drug outlet to refuse to sell medicines brought in via parallel importation by the government or any authorized third party. Yet what seems to upset economists and drug industry insiders and observers most is the House proposal to have a drug-price regulatory board.

“I see more risk than benefit in a mechanism that would ‘repeal’ the basic law of supply and demand, and put critical pricing decisions in the hand of a supposedly omnipotent body composed of a few individuals,” commented former Socioeconomic Planning Secretary Dr. Cielito Habito in a letter he sent to Roxas last December.

LATE this month, legislators will try to harmonize two versions of the bill that they say will help reduce the high cost of medicines in the country. [photo by Alecks P. Pabico]

Dr. Rene Azurin of the University of the Philippines Graduate School of Business, meanwhile, has called the proposal a “Trojan horse.” A price regulatory board would not only fail to bring down medicine prices, he says, it would “also create a convenient vehicle for entrenched interests to use in limiting competition and managing prices.”

Market distortions vs market monopoly

Azurin’s concerns echo those of the Philippine office of the World Health Organization (WHO), whose comparative studies of drug price regulations in several countries show that price controls don’t work. According to WHO researchers, these can even cause “market distortions,” giving rise to the “withdrawal of price-controlled medicines from the market and the introduction of new combinations to replace them at higher prices.”

Rep. Biron, though, argues that free-market competition cannot work in an imperfect world. He has also repeatedly said that prices of medicines can never be reduced for as long as the industry remains in the grips of a few giant players. “Legislative intervention,” says Biron, “is the only key to solving the rising cost of medicines.”

That there is a high degree of market concentration in the local drug industry is hardly debatable. By 2002, the total pharmaceutical market was already estimated at P65.7 billion, 72 percent of which is controlled by foreign companies, based on data by the Philippine Chamber of Pharmaceutical Industries (PCPI). The rest of the market is shared by top Filipino drug manufacturer United Laboratories (18.6 percent), and small Filipino-owned drug firms and other multinational firms owned jointly by Filipinos and foreigners. At present, the market is estimated to have grown between P85 to P100 billion, with the trend in revenue sharing remaining intact.

There is even greater concentration in the distribution sectors of the industry, with three firms effectively dominating the wholesale market while the Mercury Drug chain controls 40 to 50 percent of the retail market. Such a market structure, says Margaret Bengzon of the Ateneo School of Government, enables market leaders to exercise substantial control over price levels and set what is generally known in the business as “the highest price that the market will bear.”

Prices of pharmaceuticals in the Philippines are thus among the most expensive in the world — even higher compared to neighboring countries Thailand, Malaysia, and Indonesia, though drug companies have time and again attributed the price differences to cost and quality. The House bill goes also as far as rooting the problem to what Makati Rep. Teodoro Locsin Jr. (PDP-Laban) describes as the “inutility of government to use its power to restrain the unconscionable profits in drugs and medicines sucked in by multinationals here and nowhere else in the world.”

Improved, but still controversial

In truth, HB 2844 is an improved, more comprehensive draft of the same measure (HB 6035) that congressmen failed to pass on third and final reading before the 13th Congress adjourned in June 2007.

Aside from its own revisions to the IP Code and rectifying “infirmities” in the Generics Act of 1988 (RA 6675), HB 2844, among other things, also amends the Pharmacy Law (RA 5921) by allowing non-prescription or over-the-counter drugs to be repackaged in small quantities and sold in retail.

But industry players have balked over the bill’s “must carry” provision that will force even small drugstores with limited capitalization to stock drugs brought in through parallel importation. In the Senate, in fact, a similar stipulation was shelved after it was noted that medication needs vary across the country, and that requiring drugstores to have medicines their market does not need could jack up prices all the more.

Some industry insiders have also pointed out that Biron may have a conflict of interest in pushing the provision, since his family is into drug manufacturing, trading, and distribution with Pharmawealth Laboratories Inc. and Phil. Pharmawealth Inc. Biron, a doctor by profession, used to be treasurer of both corporations. Former Iloilo congressman and now Vice Governor Rolex Suplico, who was Biron’s co-author in a similar bill filed in the previous House, was once an incorporator and board director of Phil. Pharmawealth.

One health economist who declines to be identified says there is also no provision for conflict-of-interest declarations from the various members of the proposed regulatory board. “One assumes wrongly that the members have no conflicts or vested interests,” he comments.

As proposed, the board would have seven members, with the health secretary as chairperson and the trade and industry secretary as vice chairperson. The other members of the board are the Bureau of Food and Drug (BFAD) director, the Philippine Health Insurance Corporation (PhilHealth) president, and three presidential appointees: an academic from a health sciences school and two representatives from the consumers’ sector. The board will be assisted by a secretariat to be constituted from the organizational structure of the Department of Health (DOH).

This early, BFAD Deputy Director Joshua Ramos fears that it may just turn out to be “a paper price regulatory board and an administrative burden to the already overloaded government staff.” Though not completely against the board’s creation, Ramos says it would be better if it had its own budget and staff complement instead of being “an additional function of already existing government agencies using existing staff and within existing budget.”

The health economist, for his part, remarks that with the exception of the DTI secretary, none of the members of the board are presumed to have any business experience — despite the fact that they will be making regulatory and pricing decisions affecting free-market trade.

More than the board’s composition, though, Habito and other economists and business experts have counseled against price controls in medicines, particularly in the context of the current state of governance in the country, which they characterize as weak and prone to corruption. This, they argue, would only open up such a mechanism to the risk of “regulatory capture” — a situation wherein regulated entities take over the control exercised by their regulating body.

SPILLS from broken thermometers were stored in this bin prior to the Philippine Heart Center’s switch to non-mercury devices. [photo by Mira Mendoza]

The Philippine healthcare system has been slow to respond to the concerns raised over the continued use of mercury in medical equipment, including the lowly thermometer. Yet even foreign observers say the country has finally stirred into action regarding the use of the toxic substance in health devices.

Indeed, in its latest report on global mercury reduction, the international organization Health Care Without Harm (HCWH) cites the Philippine experience as a model in switching to alternatives and creating policy solutions. This is even though the Department of Health (DOH) has yet to release a much awaited administrative order (AO) that outlines what needs to be done to reduce the presence — and use — of mercury in the healthcare system.

The United Nations Environment Programme (UNEP) has already identified mercury pollution as a major environmental and human health problem. In a 2002 report, it also tagged the healthcare sector as a significant source of mercury releases. It added that Asia accounted for over half the global emission of 5,000 metric tons a year.

The Philippines has no available statistics on the country’s own mercury releases. Nevertheless, the health department’s draft AO, which was crafted earlier this year and cited by the HCWH as a major plus in the country’s mercury-reduction efforts, mandates the phaseout of mercury-containing thermometers and blood pressure devices along with other products that make use of mercury (dental amalgam and some laboratory chemicals). The AO also orders the substitution, where possible, of safer alternatives for batteries and certain vaccines that use mercury. Emphasis on mercury-waste management, fluorescent lamp recycling, and safe disposal are among the other high points in the proposed AO.

But if DOH seems to be taking its time releasing the AO, at least it’s not because it suddenly lost its political will, as is often the case with many government agencies on the verge of a big switch. It’s because, explains Ana Rivera, supervising health program officer of the DOH-Environmental and Occupational Health Office, the health department belatedly realized that it cannot implement the change by itself.

“After our initial meeting on the proposed AO,” says Rivera, “we realized that we had to coordinate with partner agencies. Given the scope of the proposed AO, the health department will need the assistance of the Department of Trade and Industry (DTI) in giving accreditation for alternative products based on the criteria that the Bureau of Health Facilities Development will provide.”

Meanwhile, last February, the DOH issued a memorandum containing guidelines for handling accidents involving mercury at home, school, and medical facilities. The memo, which is similar to a previous HCWH fact sheet released four months earlier, includes first-aid/pre-hospital treatment for mercury victims. But Faye Ferrer, HCWH Southeast Asia’s program coordinator for mercury says the memo’s real highlight is when it says that “the best way to prevent mercury spills is to not store mercury at home, in schools, and in the workplace.”

IN ITS 2002 report, UNEP said that 10 percent of the mercury releases generated by the healthcare sector came primarily from the incineration of medical waste that contains significant concentrations of the substance. Fortunately, the Philippines has banned the incineration of hospital waste, with the law on this taking full effect in 2003. But hospital facilities have since been left wondering how best to dispose of the various products and devices that use mercury.

In truth, this is among the problem points in the draft AO. Rivera says that issues regarding a centralized storage facility for the phased-out products would first have to be discussed with the Department of Environment and Natural Resources (DENR). An engineer, she mulls aloud, “Do we store the mercury-containing products in the hospital, or in the DOH? Where will the temporary storage be set up until a final disposal area is established?”

Aside from the ubiquitous thermometer, medical devices containing mercury include blood-pressure monitors, gastrointestinal tubes, and dental amalgam and other laboratory chemicals. Mercury is present as well in some pharmaceutical supplies like vaccines, nasal sprays, and diuretics. Fluorescent lamps, batteries, switches, thermostats also use mercury.

Dumping waste with mercury in landfills enables the toxic substance to enter and accumulate in bodies of water where it can transform into the more dangerous methylmercury. This inorganic form of mercury is absorbed by fish tissue and increases in predator fish that are on top of the aquatic food chain. In recent years, several warnings have been issued by both international and local environment agencies to avoid eating mercury-contaminated fish.

Methyl mercury affects a person’s neurological functions. Even low doses can have dire consequences on children, who can have their cognitive thinking, memory, and language and motor skills seriously affected. Even a developing fetus is not spared as methylmercury can pass through the placenta, targeting the unborn child’s brain where it causes permanent harm.

FOR SURE local healthcare professionals have long been aware — however vaguely — of the risks posed by materials and products that use mercury. But concerns about these dangers were apparently put in the backburner by most; it took a groundbreaking conference on mercury last year and a particularly nasty incident involving the substance at a Parañaque school for members of the healthcare community to finally take a more careful look at the dangers in their midst.

Ironically, officials at the Philippine Heart Center — where the mercury conference was held in January 2006 — took even longer than that. Four months after the conference (organized by HCWH in association with UNEP, and with the support of DOH, DENR, and the Heart Center itself), the hospital’s Waste Management Committee invited Rivera as a resource person for one of its regular meetings. Admits Ester Borja, head of the committee and chief of the Heart Center’s Auxiliary Services Department: “It was through Engineer Rivera’s account of her personal experience that we learned about the gravity of the St. Andrew’s School mercury spill. This made me and the rest of the committee to seriously consider a phaseout of all mercury devices.”

A PHC staff shows beads of mercury from broken thermometers collected using a tongue depressor. [photo by Mira Mendoza]

St. Andrew’s was the Parañaque school where early last year at least 24 students, mostly aged 13, wound up in the hospital as confirmed cases of mercury poisoning. Investigation showed that the students were poisoned after they were allowed to play with 50 grams of mercury intended for a science experiment. The school had to remain closed for months while local and international experts cleaned up and decontaminated it.

Rivera herself notes an increase in reports of mercury spills in healthcare facilities following the release of the DOH memorandum on how to clean up after mercury accidents, indicating a rise in awareness and concern about the substance’s possible effects. On average, the health department receives at least two calls per month requesting for assistance on handling mercury spills. But Rivera says that in a monitoring exercise conducted by the DOH last May on four government hospitals, the results were ominously “significant.”

She explains that this can only mean a history of spills that have not been cleaned up properly in these facilities (which she declines to name). Rivera points out that mercury is a persistent element — and becomes even more so in an airconditioned enclosure. She says that simple cleaning using a broom or worse, a vacuum cleaner, could only aid in spreading the contamination.

Absorbed by carpet, or trapped in floor cracks and crevices, elemental mercury can easily volatilize into mercury vapor, contaminating indoor air. Inhalation of mercury vapor in the short term will not readily manifest symptoms. Generally, a month or more is needed to produce symptoms.

The hospitals that were monitored have since been advised on how to reduce their indoor mercury levels to safe standards (0.2 micrograms per cubic meter). Rivera also reports that the raised awareness regarding mercury’s dangers has led to hospital workers themselves clamoring for the release of the health department’s AO on mercury.

PRESSED TO issue a memo banning the purchase of mercury thermometers by all hospitals by 2008 while the AO remains in limbo, the DOH has instead offered to have all government-regulated hospitals in Metro Manila put any mercury thermometer bought for 2008 on hold while those that have yet to place an order for such would be told not to proceed.

Many hospitals, however, are already taking it upon themselves to move toward mercury-free healthcare — with or without an AO, memo or no memo. HCWH even says there are more than 50 such hospitals. Ferrer also says these are currently developing policies or guidelines on evaluating safe alternatives to devices containing mercury and even testing some of options to the mercury thermometer and sphygmomanometer (the more formal name for the blood-pressure monitoring contraption). Some have also gone on to purchasing digital thermometers, albeit only for select wards.

Although HCWH has yet to name the hospitals that it says are bent on becoming mercury-free, two facilities are already recognized as pioneers in effectively accomplishing a complete phaseout of mercury thermometers and blood-pressure monitors. Both hospitals have removed these devices even in their respective purchasing policies.

The Manila Adventist Medical Center, a 150-bed private hospital, decided to switch to mercury-free alternatives after the January 2006 mercury conference. By mid-2006, it had successfully replaced all its mercury thermometers and sphygmomanometers.

The other hospital is actually the Heart Center, where the board approved Borja’s recommendation for a phaseout of mercury devices soon after Rivera’s talk. The Center’s Products Standards Committee was then assigned to evaluate and present criteria for non-mercury alternatives.

Meanwhile, the hospital’s Waste Management Committee started its mercury spill management training for its staff. Mercury spill kits were distributed to each nursing unit. Spills were no longer ignored, but were reported. According to Borja, this was how they found out that between February to June 2007, there were 32 thermometer breakages in the hospital.

A thermometer contains about a gram of mercury. The HCWH says, “Thermometer breakages on a case-to-case basis pose some harm to patients, nurses, and other healthcare providers when mercury is absorbed through the skin or mercury vapor is inhaled.”

Borja relates how the Waste Management Committee’s insistence for the nurses to personally do the cleanup (within a five-minute deadline) eliminated any resistance to the use of digital alternatives. By last July, the Heart Center had purchased its first batch of digital thermometers — partially financing the transition by passing on the cost to patients. This has led to some resentment from patients who rue the huge leap in price (almost P200). But Borja says the nurses have been very successful in convincing patients that the added cost would go a long way in ensuring a healthier environment for all.

Similar efforts are being undertaken in other DOH-retained hospitals, such as the National Kidney and Transplant Institute and the Philippine Children’s Medical Center, both in Quezon City. Rivera is also proud to say that although the San Lazaro Hospital in the DOH compound in Manila has not completely gone mercury-free yet, its staff have “a strong awareness and knowledge of healthcare waste management.” One proof of this, she says, is its own initiative to phase out dental amalgam.

THE HCWH identifies three fundamental challenges that implementing a transition to mercury-free healthcare faces: accuracy, affordability, and disposal.

During the 2006 mercury conference, Dr. Esperanza Icasas-Cabral, now the social welfare and development secretary and former president of the Philippine Hypertension Society, added another hindrance: sheer habit. She pointed out that doctors who were trained in mercury-containing devices showed resistance to switching to alternatives. The mercury manometer, for instance, has occupied an eminent position in blood pressure measurement since 1926. “It’s a long tradition that is not easily forsaken,” Cabral said.

But Cabral added that mercury-free sphygmomanometers like the aneroid type are more economical in the long run as they eliminate the risk of spills and associated training costs. In addition, non-mercury blood-pressure monitoring devices have passed various studies in the United States and the United Kingdom that were conducted to test their accuracy. It has been established as well that as with any blood pressure monitoring device (mercury, aneroid, or digital), calibration is essential in ensuring accurate readings.

On the issue of affordability, the HCWH recognizes that replacing mercury-based medical devices is seen as an expensive proposition for cash-strapped healthcare sectors in the developing world. Rivera cannot help but agree, saying, “There really is a resistance with the initial capital outlay.”

“But,” she says, “we explain that in the long term, training healthcare workers on how to handle mercury spills and the cost of cleanup and decontamination do balance out.”

As for disposal issues, the problem lies with what will be done with the retired mercury-containing devices once healthcare facilities make the switch. There is still no single solution to the long-term retirement of mercury wastes, although there are short-term options being done in North America and many European countries like storing mercury waste on-site, extended product responsibility, national regulations, and collection programs.

Last July, DOH formed a technical working group (TWG) to address the local healthcare system’s problem with mercury, including disposal. The TWG is composed of representatives from its concerned bureaus, the DTI, DENR, hospital administrators, health sector representatives, technical experts, and environment groups such as HCWH and the Basel Action Network.

HCWH knows there are many obstacles in the path toward a mercury-free healthcare system. But it would rather emphasize the positive, citing the initiatives — however simple and slow-moving — from both government and private facilities as evidence that this is not impossible to achieve.

Mira S. Mendoza is a freelance writer-researcher and graphics artist.

FUEL storage tank of the dismantled Hoval medical waste incinerator at the Davao regional Hospital in Tagum, Davao del Norte. [photo courtesy of EcoWaste Coalition]

Thermal processes rely on heat to destroy pathogens (disease-causing microorganisms) and are further classified into low-heat (operating below 177°C), which uses moist heat (usually steam) or dry heat (hot air); medium-heat (between 177°C and 370°C), and high-heat (operating from around 540°C to 8,300°C).

Chemical processes employ disinfectants to destroy pathogens or chemicals to react with the waste. Irradiation involves ionizing radiation to destroy microorganisms while biological processes use enzymes to decompose organic matter. Mechanical processes, such as shredders, mixing arms, or compactors, are added as supplementary processes to render the waste unrecognizable, improve heat or mass transfer, or reduce the volume of treated waste.

Local waste treaters like Chevalier commonly employ autoclave technology, a wet-heat treatment using steam to disinfect waste. Others, including private hospitals, use microwave technology, a steam-based, low-heat thermal process with disinfection occurring through the action of moist heat and steam.

Thermal treatment technologies using high-heat processes like pyrolysis and gasification systems have also been promoted as clean non-incineration alternatives, but tests have shown them to be capable of generating dioxins, furans, and other pollutants.

Local healthcare industry insiders say that everything that goes into yellow trash bags (infectious, pathological, pharmaceutical) goes to the waste treater. Sharps can be classified under infectious waste — especially if the hospitals do not have the sharps handlers, needle destroyers, and such — which means they also go to companies like Chevalier for proper disposal. Genotoxic, chemical, and other wastes go to particular TSD (transport, storage, and disposal) facilities capable of handling such waste types.

So far, Chevalier has passed all the inspections done by the various Waste Management Committees of its clients. But it seems it has been having problems with the final disposal of the treated waste. The Department of Environment and Natural Resource Region IV office has been insisting that Chevalier’s dumpsite in San Pedro, Laguna be registered as a TSD facility. But Chevalier says the site’s operator is balking because it fears that the land would have little value left if it is converted into a controlled landfill. The operator has thus barred Chevalier from dumping treated waste there until the matter is settled. Chevalier has been storing the treated waste in its premises in the meantime.

Chevalier pollution control officer Victoriano Andutan Jr. explains that the DENR still categorizes treated waste as hazardous waste. But Andutan argues that this should not be so since the trash has already undergone autoclave/microwave disinfection, rendering it free from bacteria.

Recently, though, his company managed to secure an extension to dump its treated waste at the San Pedro dumpsite until April 2008. Its contract with government hospitals expires at the end of 2007.

MEDICAL waste used to be dumped and burned along with ordinary domestic waste. [photo courtesy of HCWH]

But these days, Ester Borja, chairperson of the Waste Management Committee (WMC) of the Philippine Heart Center (PHC), is grinning from ear to ear — and it’s not because of the news of the P10,000 bonus to government employees. It’s because for almost two years now, the Heart Center has not only reduced the amount of waste it generates significantly, it has managed to earn six-figure amounts from waste trading.

This is on top of the fact that it — along with other hospitals across the country — has done away with incinerating infectious waste since 2003. Earlier this year, too, the Heart Center began phasing out gadgets (like thermometers) and equipment that use mercury, a potent neurotoxin that can cause developmental defects and can harm the brain, kidneys, and lungs.

Borja is likewise pleased to announce that the PHC’s Nutrition and Dietetics Division has agreed to replace styrofoam packs with biodegradable boxes as food containers, especially for take-home meals. And for several years now, the Pharmacy Division has been using paper bags when dispensing medicines to patients. In addition, the talks have started for the hospital’s Purchasing Division and the Bids and Awards Committee to adopt green purchasing policies for medical supplies during the next bidding schedule.

The Heart Center is actually among the four Metro Manila tertiary government hospitals chosen by Health Care Without Harm (HCWH) to include in its documentation of local best practices in hospital waste management. The resulting report, which was released earlier this year, debunks an enduring perception that government-run hospitals are less capable of properly handling waste. The experiences of the Heart Center, San Lazaro Hospital, Philippine Children’s Medical Center (PCMC), and Ospital ng Muntinlupa, show as well that healthcare-waste management can be effectively implemented in developing countries like the Philippines, where incineration is even banned.

“Their practices show what is doable,” says Merci Ferrer, Asia coordinator of HCWH, a global coalition of environmental health advocates working to reduce pollution in the healthcare industry. Yet even these exemplary hospitals may still be stuck in their old, wasteful — and quite harmful — ways had it not been for the growing green awareness in the last decade or so, and the eventual (if belated) moves of the government to make healthcare facilities clean up properly.

MOST HEALTHCARE waste are considered to be no more dangerous than any ordinary household trash. But there are types that do expose humans — healthcare workers and the public alike — to graver health risks. These include infectious materials that, according to an assessment done by the World Health Organization (WHO) in 2002, make up 15 to 25 percent of total healthcare waste. These could be in the form of sharps like needles, scalpels, or broken glass (one percent), body parts waste (one percent), chemical or pharmaceutical waste (three percent), and radioactive and genotoxic waste, or broken thermometers (less than one percent). (see Table)

In the same study, the WHO also cited estimates of infections worldwide caused by injections using contaminated syringes ? 21 million cases of hepatitis B virus (which was 32 percent of all new infections in 2002), two million hepatitis C virus cases (40 percent), and 260,000 HIV cases (five percent).

Yet from only nine tons of infectious waste per day based on a 2000 study done by the Metropolitan Manila Development Authority (MMDA), the figure almost doubled to 17 tons per day in a 2001 study commissioned by the Japan International Cooperation Agency (JICA), and to 27 tons a day in 2003, according to an Asian Development Bank (ADB) report. WHO has estimated that, based on population projections, local healthcare waste could reach as much as 69.5 tons per day by 2050.

In the past, many healthcare facilities relied on incinerators as a waste-disposal option. The JICA study revealed, for instance, that almost half of the 158 facilities surveyed disposed their infectious wastes through incineration. The ADB study, meanwhile, found that only about five tons of infectious wastes generated daily were disposed of either through incineration or non-burn technologies (autoclave, microwave), while 22 tons were either buried on site or irresponsibly thrown along with the rest of the municipal waste for dumping in open dumpsites or landfills.

Then in June 1999, Republic Act 8749, also known as the Clean Air Act, was signed into law, thereby signaling the end of the use of incinerators for waste disposal. Two years later, the Department of Health (DOH) began revising the existing healthcare-waste management manual developed a decade before by the agency’s Environmental Health Service and the Metro Manila Authority (now the MMDA).

The changes dealt mainly with ensuring that the manual was attuned to the provisions of the Clean Air Act and another new law that was also instrumental in pushing for reforms in the management of healthcare waste: RA 9003, or the Ecological Solid Waste Management Act of 2000. Among others, this law requires the promotion of recycling and composting in dealing with solid waste. (Previously, the disposal of hospital wastes was governed primarily by RA 6969, or the Toxic Substances, Hazardous Waste, and Nuclear Waste Control Act of 1990, which covers only infectious and pathological wastes, and expired pharmaceutical products.)

The manual’s revision, as then health secretary Manuel Dayrit explained, was meant to widely disseminate the proper use of existing technology and knowledge on healthcare-waste management. With its practical information on alternative yet safe, efficient, and environment-friendly technologies, the manual has to this day been serving as a useful guide in the planning, implementation, monitoring, and evaluation of the healthcare-waste management programs (HCWMPs) of hospitals, health centers, laboratories, pharmaceutical firms, blood banks, and other health-related establishments.

BY 2003, in anticipation of the challenge they faced with the growing volume of hospital wastes, the DOH and the Department of Environment and Natural Resources (DENR) began working together on a framework that outlined the safe disposal of wastes by healthcare facilities. (By then, too, the MMDA had begged off from its task of regulating hospital waste in Metro Manila, and had asked the DOH to assume responsibility for the oversight of the waste management process in the metropolis.)

It took almost two years for the DOH and DENR to finally issue the guidelines, which was contained in a joint administrative order dated August 24, 2005. Nonetheless, the order was able to clarify the jurisdiction, authority, and responsibilities of both agencies in dealing with healthcare-waste management, thereby harmonizing their respective efforts.

The DENR, through the Environmental Management Bureau (EMB), was made responsible for issuing the required permits for firms engaging in the business of handling, storage, treatment, and disposal of healthcare wastes. EMB has also been tasked to take the lead in monitoring compliance with environmental standards of hospital waste generators, transporters, treatment, storage and disposal facilities, and final disposal facility operators.

The DOH, for its part, was put on top of the development of HCWMP training programs, assisting all health facilities in preparing their plans for the effective implementation of their waste management programs. Toward this end, the health department has constituted a technical working team (TWT) on healthcare waste management, in which 17 government hospitals, among them the Heart Center, sit as members.

The Heart Center’s Borja says the team conducts monthly meetings wherein an assigned member hospital presents its best practices in waste for benchmarking purposes. She also says, “The hospitals in the TWT are tasked to monitor and assist other hospitals which have deficiencies or difficulties in their waste management plans and programs. The team is also currently updating and standardizing the DOH Waste Management Manual.”

THE Philippine Heart Center’s infectious waste storage area located at the back of the hospital. [photo by Mira Mendoza]

There are viable alternatives to incineration that are safer, cleaner, do not produce dioxin, and are just as effective at disinfecting medical waste. In its 2001 report on non-incineration medical waste treatment technologies, Health Care Without Harm explored four basic processes used in medical waste treatment: thermal, chemical, irradiative, and biological.

HCWH’s FERRER praises the four government hospitals her group included in its documentation project for being able to employ alternative systems to minimize, manage, and dispose of their waste, while remaining faithful to DOH requirements. But she is particularly delighted at the various ways these hospitals are making the most out of their recyclable and reusable wastes that have in turn become effective income-generating activities.

At the 301-bed Heart Center in Quezon City, for example, Borja reports that last year, they were able to earn P642,000 from the sale of scrap paper, plastics, wood, and metals (including old elevator parts), up from just P156,000 the previous year. And in the first five months of 2007 alone, she says they had already earned P377,000 from selling recyclable trash.

The waste trade is part of the “Trash to Treasure” program of the WMC, which was set up in 2001 to monitor and implement proper waste segregation and disposal practices through approved hospital and government guidelines. The income generated from the trash sales are then used to fund additional operating expenses of the hospital, which treats an average of 10,000 in-patients and 73,000 out-patients every year.

That’s not all. Out of the discarded empty cans of soda, milk, and nutritional supplements that Borja’s committee is able to collect, the hospital gets to have wheelchairs for physically handicapped patients. This is made possible by an arrangement between the PHC and the Tahanang Walang Hagdanan Foundation, which fabricates wheelchairs out of recycled tin scraps. According to Borja (who is actually the head of the Heart Center’s Auxiliary Services Department), 220 kilograms of tin scraps can produce one wheelchair.

Even the hospital’s Christmas decorations have been made in the green spirit by the hospital’s very own nurses, who used recycled materials.

Over at the PCMC, a 200-bed government hospital in Quezon City that specializes in pediatric care, waste segregation has not only allowed the hospital to earn from recyclable non-biodegradable wastes, but also from food discards that are sold to piggery owners. (The discards do not include those from the communicable unit that goes to the infectious waste bin.)

SPACIOUS storage facility for recyclables at the San Lazaro Hospital. [photo courtesy of HCWH]

In 2004, it reported earnings of about P12,000 from the sale of dietary slops alone. For the staff’s waste segregation efforts, a profit-sharing scheme has been put in place so those directly involved could receive incentives, particularly for the sale of food wastes.

“Recycling and reuse have physically reduced our waste by 30 percent,” says Jara Corazon Ejera, deputy director of the hospital’s support services who worked in tandem with Dr. Corazon Rivera, who was the Waste Management Committee head until she retired last April.

Even with Rivera’s departure, Ejera says they have not made any deviations from their usual practices, except in the case of the disposal of disposable diapers, which they used to regularly compost. They had to abandon that practice, however, after erroneous media reports accused them of burying infectious waste within the hospital compound. Remarks Ejera: “What people don’t know is that 60 percent of what makes up disposable diapers is compostable. The plastic portion is the only thing disposed.”

For a smaller hospital like Ospital ng Muntinlupa, which has limited financial resources, the sale of recyclable materials like newspapers, ink cartridges, aluminum cans, and plastic bottles has helped augment its waste management budget. The revenue is in fact covering the expenses of the housekeeping department, primarily for emergency purchases of supplies such as cleaning agents, additional trash bins, and doormats.

Built in 2001 and originally managed by a foundation, the 149-bed capacity hospital was turned over to the city government in April 2006. The transition from private to public operation, including abiding by the government procurement process, has proved challenging to the hospital administration and staff. But this has not deterred them from instituting a cost-efficient and resourceful waste management system that has even produced role models like Landré Jebone, housekeeping officer-in-charge who was recently awarded as “Huwarang Lider ng Muntinlupa” for waste management.

The 900-bed capacity San Lazaro Hospital, meanwhile, is demonstrating how waste management is possible on a large scale. The hospital, the DOH-designated referral center for infectious diseases, even has its own healthcare-waste management manual, based on the standards set by the health department, crafted by its Waste Management Committee.

THE STRENGTH of San Lazaro’s waste-management system lies in part in its training program. Hospital staff get regular waste management training for five days every quarter, during which they not only listen to lectures on proper waste handling, but are taken to ecological tours of landfills and waste treatment facilities. After completing the training course, selected participants are trained further as future trainers or facilitators.

As for the Heart Center, the HCWH says in its report that the key to its success is the “strong leadership of a very visible waste management committee” which has gained the active support of the hospital administration and most, if not all, of its 1,800 staff in implementing its waste management programs. This in turn has helped the hospital’s dedicated WMC to minimize waste to the lowest level possible. But one of its notable practices is the way it monitors infectious waste generated by each nursing unit, from both the staff and patients. A monthly bar chart is drawn to observe the trend in the volume of infectious waste produced. The unit that has the highest volume of wastes is then invited to attend the WMC’s meeting for clarification and recommendations on how to reduce waste.

“Similarly, the unit and the staff (that) have shown efforts to reduce their wastes through proper segregation are given a letter of appreciation in recognition of their support,” says Borja, happy to announce that last year’s recipients of the special citation were the Operating Room and Renal Division.

Aside from the bar graph, compliance is also monitored through surprise waste bin inspections by WMC members. “If necessary, pictures will be taken and these will be shown as video materials during employee/patient orientation programs,” says Borja. Should admitted patients miss any session on the standard operating procedures arranged by the nursing staff, they are given on-the-spot instructions during inspection by the committee.

Some healthcare industry insiders estimate that of the total waste generated by local hospitals, only 10 percent is infectious waste. But aside from the fact that such waste can pose serious health and environmental risks, the special attention given to it by the Heart Center’s WMC is also because the hospital has to pay a service waste treatment provider, Chevalier Enviro Services Inc., between P20 to P25 per kilogram of pathogenic or infectious wastes. Big hospitals like the Heart Center generate some 200 kg to 400 kg of these kinds of waste per day, which means the PHC could be paying Chevalier a low of P1.4 million per year to a high of P3.65 million.

Yet precisely because of the potential hazards posed by infectious wastes, Borja says the WMC’s work does not end after the hospital has turned over its infectious wastes to Chevalier, as it continues to monitor their transport and off-site treatment by the private service contractor.

“The ‘cradle-to-grave’ responsibility of the hospital is assumed from the time the infectious wastes are generated, collected from the hospital, treated at the plant, and disposed to its landfill,” insists Borja.

As such, the committee requires Chevalier to submit permits, clearances, certificates of compliance, technology performance/efficiency tests, and other pollution-control requirements for inspection and validation. The waste treater is also required to attend monthly WMC meetings whenever there is a report of non-compliance from both parties.

For sure, there are still some lapses in waste management, due mainly to budgetary constraints, even among the PHC and the three hospitals that agreed to be part of HCWH’s documentation project. But Ferrer says of the four exemplary hospitals, “By taking part in the study, they did not only take steps to better their own facilities and share what they knew, they also showed how hospitals should be at the forefront of promoting proper waste management. We hope other hospitals would take the first step.”

WHETHER it’s beer, stress, or too much sleep, there is a form of poison present in the lives of many of us.

We asked people to name their poisons, be it stress, negativity, or a set of squabbling parents. You’d be surprised at what they had to say.

In this issue

• Power and poisons
• In search of green alternatives
• Cleaning up the ‘King’
• Harnessing the wind
• Photo gallery: The windmills of Ilocos Norte
• Building the breathing spaces
• Photo gallery: The house on M. Viola Street
• First person: Starting a ‘clean’ revolution
• Short-circuited reforms in the power sector
• A commission of power
• Toxins ‘R’ Us
• Podcast: Name that toxin
• A puff of a test
• Video: Toxic city
• What’s swimming in your soup?
• Waste not, want not
• Hazards of healthcare waste
• There’s something about mercury

Public Eye

• No coming-out party for PLLO
• Has NEDA gone nada?
• From newshound to news target