The unconscionable health gap: a global plan for justice

[Guest guest]

The unconscionable health gap: a global plan for justice

Lawrence Gostin a

The Lancet, Volume 375, Issue 9725, Pages 1504 - 1505, 1 May 2010

Health has special meaning and importance to individuals and communities. WHO's

Constitution states that " the enjoyment of the highest attainable standard of

health " is a fundamental human right.

International law, moreover, requires states to guarantee the right to health.

The UN has specified the norms and obligations of the right to health, and

appointed a Special Rapporteur.1

Despite robust international norms, health disparities render a person's

likelihood of survival drastically different depending on where she or he is

born. WHO urges " closing the health gap in a generation " through action on the

social determinants of health.2

As the Marmot Commission observed: " the social conditions in which people are

born, live, and work are the single most important determinant of good or ill

health. " 3

International health assistance has quadrupled over two decades rising to

US$21•8 billion in 2007.4 This level of funding might seem impressive but sits

modestly beside the annual $1•5 trillion spent globally on military expenditures

(2•43% of global gross domestic product), and $300 billion in agricultural

subsidies.

Foreign aid simply is not predictable and scalable to needs and often reflects

donors' geostrategic interests rather than the key determinants of health.

Developed countries recognise the health gap, but are resistant to taking bold

remedial action.

If the health gap is unfair and unacceptable, how can the international

community be galvanised to make a genuine difference?

I propose an international call to action through a global plan for justice—a

voluntary compact between states and their partners.

Such a global plan for justice—a soft norm—could be achieved as easily as the

passage of a World Health Assembly resolution that authorised the

Director-General to negotiate funding, priorities, and implementation. It would

not require a treaty or new governance structure, but would encourage WHO to

exercise its constitutional powers and leadership.

A global plan for justice would set achievable funding targets for a global

health fund to be distributed according to need.5

Although WHO would negotiate the funding levels, developed countries could

donate, for example, 0•25% of gross national income (GNI) per annum, in addition

to current foreign assistance. The total amount countries should give, taking

into account both a global plan for justice and discretionary funds, would be

0•7% of GNI per annum.

Countries of the Organisation for Economic Co-operation and Development pledged

this level of funding for official development assistance in 1970, but most have

not come close to fulfilling their promise.6

A global plan for justice would guarantee a universal package of essential

services, comprising three core components: essential vaccines and medicines,

basic survival needs, and adaption to climate change.

Essential vaccines and medicines " satisfy the priority health care needs of the

population " .7 Yet, 2•5 million people die annually from vaccine-preventable

diseases. An additional US$1 billion would vaccinate more than 70 million

children in the 72 poorest countries.8

Many poor people also lack access to essential medicines, which is an

inexpensive way to treat common infections. For example, intestinal worm and

bacterial infections can be treated in a short time for a relatively low sum.

Public health emergencies, such as influenza A H1N1, underscore the crucial need

for fair allocation. Mass disasters almost inevitably lead to scarcity caused by

limited supply and a surge in demand.

Governments face intense pressure to protect their own citizens during mass

disasters, leaving the poor vulnerable as the rich stockpile life-saving

vaccines and medicines.

Biological interventions have limited effect because they treat only specific

diseases. What is truly needed, and which richer countries instinctively do for

their own citizens, is to meet basic survival needs—services essential to

restoring human capability and functioning. Basic needs include sanitation and

sewage, pest control, clean air, potable water, tobacco reduction, diet and

nutrition, health education, and well-functioning health systems.9

The Millennium Development Goals and the right to health both support the basic

needs approach.1

The scientific consensus is that climate change is anthropogenically forced and

affects ecological systems and public health. Climate change disproportionately

affects the most vulnerable. Yet, international negotiations still focus more on

environmental degradation and species reductions than on human health.

In the interests of global justice, the international community should not only

mitigate further climatic changes, but also implement adaption strategies that

enhance resilience.

Disadvantaged populations live on the edge and lack the capacity to ameliorate

the devastating effects. Rancorous disagreements marked the Copenhagen summit,

with protesters demanding " climate justice " .

The non-binding accord calls for $30 billion in aid allocated between mitigation

and adaption. The UN previously established adaption funds, but thus far

developed countries have pledged only $300 million, which is seriously

inadequate.

The international community must do more than lament ongoing, unconscionable

health inequalities. It must act boldly and with a shared voice, such as through

a global plan for justice. If the world does not act, the avoidable suffering

and early death among the world's least healthy people will continue unabated—a

breach of social justice that is no longer ethically acceptable.

I declare that I have no conflicts of interest.

References

1 Committee on Economic, Social and Cultural Rights. General comment 14: the

right to the highest attainable standard of health.

http://www.unhchr.ch/tbs/doc.nsf/(Symbol)/40d009901358b0e2c1256915005090be?Opend\

ocument. (accessed Jan 4, 2010).

2 World Health Assembly. Reducing health inequities through action on the social

determinants of health.

http://apps.who.int/gb/ebwha/pdf_files/EB124/B124_R6-en.pdf. (accessed Jan 4,

2010).

3 WHO. Final report of the Commission on Social Determinants of Health.

http://www.who.int/social_determinants/thecommission/finalreport/closethegap_how\

/en/index1.html. (accessed Jan 4, 2010).

4 Ravishankar N, Gubbins P, Cooley RJ, et al. Financing of global health:

tracking development assistance for health from 1990 to 2007. Lancet 2009; 373:

2113-2124. Summary | Full Text | PDF(870KB) | CrossRef | PubMed

5 Ooms G, Hammonds R. Correcting globalization in health: transnational

entitlements versus the ethical imperative of reducing aid-dependency. Public

Health Ethics 2008; 1: 154-170. PubMed

6 General Assembly of the United Nations. International development strategy for

the Second United Nations Development Decade—UN General Assembly Resolution 2626

(XXV).

http://daccess-dds-ny.un.org/doc/RESOLUTION/GEN/NR0/348/91/IMG/NR034891.pdf?Open\

Element. (accessed Jan 4, 2010).

7 WHO. Essential medicines.

http://www.who.int/medicines/services/essmedicines_def/en/index.html. (accessed

Jan 4, 2010).

8 Wolfson LJ, Gasse F, Lee- SP, et al. Estimating the costs of achieving

the WHO-UNICEF Global Immunization Vision and Strategy, 2005—2015. Bull World

Health Organ 2008; 86: 27-39. CrossRef | PubMed

9 Gostin LO. Meeting basic survival needs of the world's least healthy people:

toward a framework convention on global health. town Law J 2009; 96:

331-392. PubMed

a O'Neill Institute for National and Global Health Law, town University

Law Center, Washington, DC 20001, USA