Global Trade and Its Global Trade and Its Impact on Public HealthImpact on Public Health

Lily Walkover, CPATH fellowLily Walkover, CPATH fellow

Center for Policy Analysis on Trade and Center for Policy Analysis on Trade and Health (CPATH)Health (CPATH)

Ellen R. Shaffer PhD MPH, Joe Brenner MAEllen R. Shaffer PhD MPH, Joe Brenner MAwww.cpath.orgwww.cpath.org

International People’s Health University June 28, 2007International People’s Health University June 28, 2007

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Introduction: Introduction: Public Health And Global TradePublic Health And Global Trade

Global trade agreements address Global trade agreements address public health concernspublic health concerns

Public Health not generally involvedPublic Health not generally involved Sustainable economic development Sustainable economic development

is a public health issueis a public health issue Trade negotiations are at a Trade negotiations are at a

crossroads: we can make a crossroads: we can make a differencedifference

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Outline: GLOBALIZATION & Outline: GLOBALIZATION & PUBLIC HEALTHPUBLIC HEALTH

1. Context: Economic Globalization1. Context: Economic Globalization

2. Trade Agreements and Public Health2. Trade Agreements and Public Health• Public Health’s Right to RegulatePublic Health’s Right to Regulate• Environment, Tobacco ControlEnvironment, Tobacco Control• ServicesServices• Affordable MedicinesAffordable Medicines

3. Public Health Representation in U.S. Trade 3. Public Health Representation in U.S. Trade NegotiationsNegotiations

4. Prospects for Progress: Bringing Public 4. Prospects for Progress: Bringing Public Health Voice to Sustainable DevelopmentHealth Voice to Sustainable Development

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1. Context: Economic Globalization1. Context: Economic Globalization

Threats to Global HealthThreats to Global Health Global Economic TrendsGlobal Economic Trends Barriers to DevelopmentBarriers to Development Sustainable Development: Prevailing Sustainable Development: Prevailing

Economic View Vs. Public Health Economic View Vs. Public Health ViewView

The Trade LandscapeThe Trade Landscape Trade Policy at a CrossroadsTrade Policy at a Crossroads

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Threats to Global HealthThreats to Global Health

Widespread threats to global health persistWidespread threats to global health persistAIDS, TB, MalariaAIDS, TB, MalariaInfectious diseasesInfectious diseasesChronic illnesses: Hypertension, diabetesChronic illnesses: Hypertension, diabetes

Environmental: Cancer, respiratoryEnvironmental: Cancer, respiratory

Coexisting with both unprecedented wealth Coexisting with both unprecedented wealth and economic inequalityand economic inequality • Americas have greatest income inequalitiesAmericas have greatest income inequalities

Inequalities: Health Care Inequalities: Health Care Expenditure GapExpenditure Gap

89% of all global expenditures on health care goes to 89% of all global expenditures on health care goes to 16% of the world’s population16% of the world’s population

Total world expenditure on Total world expenditure on healthcare healthcare $2.2 trillion$2.2 trillionExpenditure by the U.S. $1.1 trillionExpenditure by the U.S. $1.1 trillion

% GNP spent on health care% GNP spent on health care U.S. 14.1%U.S. 14.1%

SubSaharan Africa 1.6%SubSaharan Africa 1.6%

Benatar SR. Ethics and Tropical Diseases: Some global considerations. In: Cook Benatar SR. Ethics and Tropical Diseases: Some global considerations. In: Cook G, Zumla A, editors. Manson’s Tropical Diseases, 21G, Zumla A, editors. Manson’s Tropical Diseases, 21stst Edition. Edinburgh: Edition. Edinburgh: Elsevier Sciences. 2002:Pp 85-93; from Michele Barry, Yale Elsevier Sciences. 2002:Pp 85-93; from Michele Barry, Yale

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Global Economic TrendsGlobal Economic Trends Manufacturing, agriculture grow in Manufacturing, agriculture grow in

low/middle income countries low/middle income countries

Growth of services sector in Growth of services sector in wealthier nationswealthier nations

Greater quantity and accelerated Greater quantity and accelerated pace of cross-border financial pace of cross-border financial transactions and exchangestransactions and exchanges

The integration of economic and The integration of economic and political systems across the globepolitical systems across the globe• Who will control and benefit?Who will control and benefit?

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Sustainable Economic Sustainable Economic DevelopmentDevelopment : : Competing ViewsCompeting Views

Prevailing Economic ViewPrevailing Economic View Facilitate tradeFacilitate trade to increase the wealth of to increase the wealth of

corporations and the poor.corporations and the poor. DeregulationDeregulation: Reduce laws and : Reduce laws and

regulations:regulations:• Facilitate faster flow of capital, Foreign Facilitate faster flow of capital, Foreign

Direct InvestmentDirect Investment PrivatizationPrivatization: :

• Turn public entities into private enterprisesTurn public entities into private enterprises• Save public funds, increase accessSave public funds, increase access

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Public Health Views:Public Health Views:Sustainable AlternativeSustainable Alternative

Countries determine mix of foreign Countries determine mix of foreign investment and local developmentinvestment and local development

Accountable, democratic governments Accountable, democratic governments Strong social institutions and infrastructureStrong social institutions and infrastructure

• Assure access to affordable vital servicesAssure access to affordable vital services Health care, education, water and sanitationHealth care, education, water and sanitation

• Promote equityPromote equity Reject trade policy that benefits few while Reject trade policy that benefits few while

inflicting economic harm on manyinflicting economic harm on many

Note CNote C

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What Do Trade Agreements Do?What Do Trade Agreements Do?

““Liberalize” trade:Liberalize” trade:

• Facilitate global corporate transactionsFacilitate global corporate transactions

Reduce barriers to trade – “protections” for Reduce barriers to trade – “protections” for locally made goods & services locally made goods & services • Tariffs (e.g. barriers to trade in steel)Tariffs (e.g. barriers to trade in steel)• Regulations (e.g. barriers to trade in services)Regulations (e.g. barriers to trade in services)

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StalemateStalemate

The major countries have sought The major countries have sought “liberalizing” measures for their “liberalizing” measures for their competitive sectors (services, goods) but competitive sectors (services, goods) but have been unwilling to make offsetting have been unwilling to make offsetting concessions in their noncompetitive concessions in their noncompetitive sectors (agriculture)sectors (agriculture)

Popular opposition: Seattle, Cancun, Hong Popular opposition: Seattle, Cancun, Hong Kong, Guatemala, ThailandKong, Guatemala, Thailand

Deadlock at WTO meetings: 1999, 2003, Deadlock at WTO meetings: 1999, 2003, 2005, 20062005, 2006

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Trade Policy at a CrossroadsTrade Policy at a CrossroadsTrade Gains ModestTrade Gains Modest

Recent studies by Carnegie and the World Recent studies by Carnegie and the World Bank show a one-time global income gain Bank show a one-time global income gain of less than $60 billion under any realistic of less than $60 billion under any realistic new WTO trade scenario.new WTO trade scenario.

That is 0.146 percent (about one-seventh of That is 0.146 percent (about one-seventh of one percent) of current global gross one percent) of current global gross domestic product (GDP).domestic product (GDP).

Kym Anderson, William J. Martin, and Dominique van der Mensbrugghe, Global Kym Anderson, William J. Martin, and Dominique van der Mensbrugghe, Global Impacts of the Doha Scenarios on Poverty, September 18, 2005.Impacts of the Doha Scenarios on Poverty, September 18, 2005. InIn Poverty and the Poverty and the WTO: Impacts of the Doha Development Agenda, WTO: Impacts of the Doha Development Agenda, ed. Thomas W. Hertel and L. Alan ed. Thomas W. Hertel and L. Alan Winters (Washington: World Bank, 2006), Winters (Washington: World Bank, 2006),

Sandra Polaski, Winners and Losers: Impact of the Doha Round on Developing Sandra Polaski, Winners and Losers: Impact of the Doha Round on Developing Countries. Carnegie Endowment for International Peace, 2006.Countries. Carnegie Endowment for International Peace, 2006.

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2. Trade Rules vs. 2. Trade Rules vs. Public Health PrioritiesPublic Health Priorities

Right to RegulateRight to Regulate Trade Dispute ResolutionTrade Dispute Resolution Tobacco ControlTobacco Control ServicesServices Intellectual Property and Access to Intellectual Property and Access to

MedicinesMedicines AgricultureAgriculture

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““Liberalize” tradeLiberalize” trade Reduce barriers to tradeReduce barriers to trade

Threaten to pre-empt a wide range of Threaten to pre-empt a wide range of laws, regulations, policies, and laws, regulations, policies, and programs to prevent disease and programs to prevent disease and promote healthpromote health

Trade Rules Vs. Trade Rules Vs. Public Health PrioritiesPublic Health Priorities

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Laws and Regulations At RiskLaws and Regulations At Risk

Public subsidies for “safety net” health Public subsidies for “safety net” health servicesservices

Affordable medicationsAffordable medications Food safety/GMO foodsFood safety/GMO foods Quality standards for health care services and Quality standards for health care services and

products & allocation based on needproducts & allocation based on need Clinician licensingClinician licensing Health insurance & patient protectionHealth insurance & patient protection Distribution of alcohol, tobacco, firearmsDistribution of alcohol, tobacco, firearms Occupational safety & healthOccupational safety & health Public administration of water & sanitationPublic administration of water & sanitation

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Vectors of Pre-Emption: Vectors of Pre-Emption: Trade Agreement RulesTrade Agreement Rules

GATS (General Agreement on Trade in Services)GATS (General Agreement on Trade in Services)

Laws and regulations that are Laws and regulations that are “ “more burdensome more burdensome

than than necessarynecessary to ensure to ensure the quality of a service” the quality of a service”

can be challenged as barriers can be challenged as barriers to tradeto trade

Can bargain away health “protections” for services, Can bargain away health “protections” for services, affordable medicines vs. economic “protections” for affordable medicines vs. economic “protections” for goods, agriculturegoods, agriculture

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Enforcing Trade Rules:Enforcing Trade Rules:WTO Dispute ResolutionWTO Dispute Resolution

3 WTO-appointed trade 3 WTO-appointed trade

“experts” decide in closed “experts” decide in closed session if a WTO policy has session if a WTO policy has been violatedbeen violated

Can impose economic Can impose economic sanctions on losing country sanctions on losing country

Challenges domestic Challenges domestic sovereignty to regulate and sovereignty to regulate and protect health and access to protect health and access to vital human servicesvital human services

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Countries’ Right to Regulate Vs. Countries’ Right to Regulate Vs.

Corporations’ Right to SueCorporations’ Right to Sue Bilateral/regional agreements like Bilateral/regional agreements like

NAFTA provide a unique “investor’s NAFTA provide a unique “investor’s rights” mechanism rights” mechanism • Foreign corporations can directly Foreign corporations can directly

challenge national government actions. challenge national government actions. • Grounds: the loss of current or future Grounds: the loss of current or future

profits, even if is caused by a profits, even if is caused by a government agency prohibiting the use government agency prohibiting the use of a toxic substance.of a toxic substance.

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NAFTA Challenge to Health: MetalcadNAFTA Challenge to Health: Metalcad

State of San Luis Potosí - State of San Luis Potosí - permission to re-open waste permission to re-open waste disposal facility denied.disposal facility denied.

Geological audit - Geological audit - waste waste disposal site would disposal site would contaminate local water contaminate local water supply.supply. Community opposed Community opposed re-opening. re-opening.

Metalclad Company- local Metalclad Company- local decision was an decision was an expropriationexpropriation of its future potential of its future potential profits. profits.

Metalclad successfully sued Metalclad successfully sued Mexico. Mexico. Awarded Awarded $16.7 million$16.7 million..

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Does Public Health Ever Win?Does Public Health Ever Win?Rarely and BarelyRarely and Barely

2 cases in 10 years upheld public 2 cases in 10 years upheld public healthhealth

Global trade dispute panels: no Global trade dispute panels: no concept of public healthconcept of public health

Decisions set poor precedents, Decisions set poor precedents, delayed public health protectionsdelayed public health protections

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WHO/PAHO on WHO/PAHO on Tobacco and TradeTobacco and Trade

““Transnational tobacco Transnational tobacco companies…have been among companies…have been among the strongest proponents of tariff the strongest proponents of tariff reduction and open markets. reduction and open markets. Trade openness is linked to Trade openness is linked to tobacco consumption.”tobacco consumption.”

D. Woodward, N. Drager, R. Beaglehole, D. Lipson. Globalization, D. Woodward, N. Drager, R. Beaglehole, D. Lipson. Globalization, global public goods, and health. In: Trade in Health Services: global public goods, and health. In: Trade in Health Services: Global, Regional and Country Perspectives. N. Drager and C. Vieira, Global, Regional and Country Perspectives. N. Drager and C. Vieira, Eds. Washington, DC: PAHO, 2002. pp 6-7.Eds. Washington, DC: PAHO, 2002. pp 6-7.

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Chilling Effect On Chilling Effect On Public Health RegulationsPublic Health Regulations

Canada proposes "plain" packaging for Canada proposes "plain" packaging for cigarettescigarettes

American tobacco companies threaten American tobacco companies threaten NAFTA suit for "expropriation" of their NAFTA suit for "expropriation" of their intellectual property – their trademarksintellectual property – their trademarks

Canada withdraws proposalCanada withdraws proposal

Will WHO framework convention for Will WHO framework convention for tobacco control violate WTO rules?tobacco control violate WTO rules?

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Intellectual Property Intellectual Property Rules and Rules and

Access to Affordable Access to Affordable MedicinesMedicines

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Global AIDS PandemicGlobal AIDS Pandemic

38 million people with HIV/AIDS38 million people with HIV/AIDS 5.8 million could benefit now from 5.8 million could benefit now from

effective drugs effective drugs Generic antiretrovirals inaccessible Generic antiretrovirals inaccessible

to millionsto millions 3x5 failed: ARVs increased 440,000 3x5 failed: ARVs increased 440,000

to 1M in the developing world to 1M in the developing world receiving treatment receiving treatment

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TRIPSTRIPS Trade-Related Aspects of Intellectual Trade-Related Aspects of Intellectual

Property RightsProperty Rights WTO AgreementWTO Agreement 20 year product and process patents20 year product and process patents

• can’t produce generics domestically while can’t produce generics domestically while patent in effectpatent in effect

Phased in: Phased in: • Covered all high income countries as of 1996Covered all high income countries as of 1996• Middle-income countries as of 2005Middle-income countries as of 2005• Least Developed Countries will be covered as Least Developed Countries will be covered as

of 2015of 2015

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What Do Patents Do?What Do Patents Do?

Monopoly rights to originator, can Monopoly rights to originator, can sell product without competitionsell product without competition

Protection for originator’s Protection for originator’s “intellectual property”“intellectual property”

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Role of Patent PolicyRole of Patent Policy Key incentive to innovationKey incentive to innovation Fairly compensates investments in R&DFairly compensates investments in R&D Assures timely access to new life-saving Assures timely access to new life-saving

drugsdrugs OROR Props up exorbitant pharma profits in Props up exorbitant pharma profits in

absence of actual innovationabsence of actual innovation Perpetuate monopoly as long as possible Perpetuate monopoly as long as possible

by extending patent terms, lengths.by extending patent terms, lengths. Discourage fair competition by genericsDiscourage fair competition by generics

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Political Crisis for PharmaPolitical Crisis for Pharma

Public outcry about high pricesPublic outcry about high prices• U.S. pays highest prices in the worldU.S. pays highest prices in the world• Reimportation proposals Reimportation proposals

Quality control: Quality control: • COX-2 inhibitors (painkillers)COX-2 inhibitors (painkillers)

Crisis in InnovationCrisis in Innovation• Fewer new drugs in research pipelineFewer new drugs in research pipeline• Business model stuck in vicious cycleBusiness model stuck in vicious cycle• Driven to seek blockbuster, copycat drugs Driven to seek blockbuster, copycat drugs

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Pharma Political Strategy:Pharma Political Strategy:Trade AgreementsTrade Agreements

A. Protect high prices in US marketA. Protect high prices in US market• Block reimportation (“parallel importation”)Block reimportation (“parallel importation”)

B. Seek higher prices in other developed countriesB. Seek higher prices in other developed countries• Pharma: price controls harm quality, access, Pharma: price controls harm quality, access,

innovationinnovation

C. Maintain IP structure in regional trade C. Maintain IP structure in regional trade agreements with low/middle-income countries agreements with low/middle-income countries • ““TRIPS-Plus” trade rules extend patentsTRIPS-Plus” trade rules extend patents• Restrict production and sale of generics Restrict production and sale of generics • Market to small number of wealthy individualsMarket to small number of wealthy individuals

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TRIPS Challenge to ARVs in TRIPS Challenge to ARVs in South AfricaSouth Africa

Pharma files TRIPS suitPharma files TRIPS suit Withdraws due to international Withdraws due to international

outcry, 2001outcry, 2001 Led to Doha Declaration, 2001Led to Doha Declaration, 2001

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Doha Declaration on the TRIPS Doha Declaration on the TRIPS Agreement and Public HealthAgreement and Public Health

Paragraph 4. “We agree that the TRIPS Paragraph 4. “We agree that the TRIPS Agreement does not and should not Agreement does not and should not prevent members from taking measures to prevent members from taking measures to protect public health.” protect public health.”

World Trade Organization Ministerial World Trade Organization Ministerial Meeting, 2001Meeting, 2001

Compulsory licensing allowed Compulsory licensing allowed • Can authorize generic production of Can authorize generic production of

patented drugs patented drugs

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TRIPS-PlusTRIPS-Plus

Debate: Maximum or Minimum?Debate: Maximum or Minimum? Can bilateral and regional Can bilateral and regional

agreements give patent holders agreements give patent holders greatergreater monopoly rights than they monopoly rights than they enjoy under TRIPS?enjoy under TRIPS?• US: Yes, through bilateral/regional FTAsUS: Yes, through bilateral/regional FTAs• India, China, Brazil, South Africa: No, use India, China, Brazil, South Africa: No, use

the WTOthe WTO

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U.S. Imposes TRIPS-Plus RulesU.S. Imposes TRIPS-Plus Rules

CAFTA – enactedCAFTA – enacted Proposed:Proposed:

• Andean FTA: Peru, Panama, ColombiaAndean FTA: Peru, Panama, Colombia• South KoreaSouth Korea• Thailand: withdrew from negotiations Thailand: withdrew from negotiations

after coup, issued Compulsory Licensesafter coup, issued Compulsory Licenses• Southern African Customs Union: Southern African Customs Union:

withdrew from negotiations withdrew from negotiations

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Agriculture, Trade and ObesityAgriculture, Trade and Obesity

1.1. Global agribusiness and transnational shifting of Global agribusiness and transnational shifting of raw materials to processed foods, high calorie raw materials to processed foods, high calorie soft drinks and snackssoft drinks and snacks

2.2. Nutrition transition during globalization – dietary Nutrition transition during globalization – dietary convergence and consumption of foods high in convergence and consumption of foods high in fats and sweetenersfats and sweeteners

3.3. Cultural change: urbanization, eating outside Cultural change: urbanization, eating outside house, global supermarkets house, global supermarkets

Michele Barry, MD, YaleMichele Barry, MD, Yale

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3.3. Democracy in Trade Policy: Who Democracy in Trade Policy: Who Decides?Decides?

Who decides for the US?Who decides for the US? Campaign for Public Health Campaign for Public Health

RepresentationRepresentation Trade Advisory CommitteesTrade Advisory Committees 2007: New Views in Congress2007: New Views in Congress Public Health GoalsPublic Health Goals

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Democracy in Trade Policy Democracy in Trade Policy Who Decides for U.S.?Who Decides for U.S.?

US Trade Representative (USTR) Susan US Trade Representative (USTR) Susan Schwab, appointed by the PresidentSchwab, appointed by the President

““Fast Track” Rules: Congress has limited Fast Track” Rules: Congress has limited authority to amend trade agreementsauthority to amend trade agreements

Expires June 30, 2007Expires June 30, 2007

The public can speak upThe public can speak up

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Campaign forCampaign forPublic Health RepresentationPublic Health Representation

US Trade Representative Advisory US Trade Representative Advisory CommitteesCommittees

Mechanism for domestic input into Mechanism for domestic input into trade negotiationstrade negotiations

Provide formal, informal advice to Provide formal, informal advice to executive branchexecutive branch

110 meetings in 2001110 meetings in 2001

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Trade Advisory Committees:Trade Advisory Committees: Big Business: 42Big Business: 42 Public Health: 0 Public Health: 0

Pharma 20 Public Health 0

Tobacco 7 Public Health 0

Alcohol 6 Public Health 0

Food 5 Public Health 0

Health Insurance 4 Public Health 0

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Public Health Takes ActionPublic Health Takes Action

Public health and medical groups file Public health and medical groups file federal lawsuit for representation: 2005federal lawsuit for representation: 2005

One tobacco control rep appointedOne tobacco control rep appointed USTR reports appointing 2 public health USTR reports appointing 2 public health

reps to Committees on Pharmaceuticals and reps to Committees on Pharmaceuticals and Intellectual PropertyIntellectual Property• Now 42 to 2-3Now 42 to 2-3

2007: Congress demands greater 2007: Congress demands greater transparency, accountabilitytransparency, accountability

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4. Prospects for Progress: Public Health 4. Prospects for Progress: Public Health Voice for Sustainable DevelopmentVoice for Sustainable Development

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Public Health CampaignsPublic Health Campaigns

Help reframe the debate on global trade Help reframe the debate on global trade and economic developmentand economic development

Declare health care & water vital human Declare health care & water vital human rightsrights

Engage in dialogue and decision-making Engage in dialogue and decision-making process to protect health care services process to protect health care services and promote public healthand promote public health

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Call for Accountability:Call for Accountability:Health Must Take Priority Over Health Must Take Priority Over

Commercial InterestsCommercial Interests Assure that health care and public health takes Assure that health care and public health takes

prioritypriority Assess impact of trade agreements on healthAssess impact of trade agreements on health Include public health community in negotiationsInclude public health community in negotiations Exclude provisions that could harm health, access Exclude provisions that could harm health, access

to medications, health care, and other vital to medications, health care, and other vital human serviceshuman services

Assure universal access to health care, water and Assure universal access to health care, water and sanitation, affordable meds, education, and sanitation, affordable meds, education, and environmental safetyenvironmental safety• American Public Health Association, Medical Students American Public Health Association, Medical Students

Assn, Nurses Assn, Public Health Officers, World Assn, Nurses Assn, Public Health Officers, World Federation of Public Health AssociationsFederation of Public Health Associations

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States, Cities, TownsStates, Cities, TownsConcernedConcerned

““State and local officials are gravely State and local officials are gravely concerned about the prospect of the concerned about the prospect of the Singapore FTA dispute resolution Singapore FTA dispute resolution mechanism… no provision remotely mechanism… no provision remotely similar to NAFTA’s should be included in similar to NAFTA’s should be included in future agreements…”future agreements…”

• Executive Directors of National Conference of State Executive Directors of National Conference of State Legislators, National League of Cities, National Legislators, National League of Cities, National Association of Towns& TownshipsAssociation of Towns& Townships

- Comments to USTR, Fed. Register, August, 2002- Comments to USTR, Fed. Register, August, 2002

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2007: New Views in Congress 2007: New Views in Congress

Freshmen members dubious on tradeFreshmen members dubious on trade Re-negotiating Andean agreementsRe-negotiating Andean agreements Resistance on KoreaResistance on Korea Democrats’ Statement of principlesDemocrats’ Statement of principles Opposition to renewing Fast TrackOpposition to renewing Fast Track

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Getting Specific: Getting Specific: Public Health Objectives for 2007Public Health Objectives for 2007

CPATH and Major Public Health GroupsCPATH and Major Public Health Groups

1.1. To assure democratic participation by To assure democratic participation by public health and transparency in trade public health and transparency in trade policy policy

2.2. To develop mutually beneficial trade To develop mutually beneficial trade relationships that create sustainable relationships that create sustainable economic developmenteconomic development

3.3. To recognize the legitimate exercise of To recognize the legitimate exercise of national, regional and local government national, regional and local government sovereignty to protect population health sovereignty to protect population health

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Getting Specific: Getting Specific: Public Health Objectives for 2007Public Health Objectives for 2007

4.4. To exclude tariff and nontariff provisions in To exclude tariff and nontariff provisions in trade agreements that address vital human trade agreements that address vital human services services

5.5. To exclude tobacco and tobacco productsTo exclude tobacco and tobacco products

6.6. To exclude alcohol products To exclude alcohol products

7.7. To eliminate intellectual property provisions To eliminate intellectual property provisions related to pharmaceuticals from bilateral and related to pharmaceuticals from bilateral and regional negotiations… and promote trade regional negotiations… and promote trade provisions which enable countries to exercise provisions which enable countries to exercise all flexibilities provided by the Doha Declarationall flexibilities provided by the Doha Declaration

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Protect Global HealthProtect Global Health

Center for Policy Analysis on Trade and Center for Policy Analysis on Trade and Health (Health (CPATHCPATH))

Joseph Brenner MAJoseph Brenner MAEllen R. Shaffer PhD MPHEllen R. Shaffer PhD MPH

www.cpath.orgwww.cpath.orgcpath@cpath.orgcpath@cpath.org

Join the Listserv – send blank message to:Join the Listserv – send blank message to:join-G-H@list.cpath.orgjoin-G-H@list.cpath.org

Phone: 415-933-6204Phone: 415-933-6204 Fax: 415-831-4091Fax: 415-831-4091