Final Paper

In January 1976, the United Nations’ (UN) International Covenant on Economic, Social and Cultural Rights (ICESCR) officially recognized “…the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” ¹. Article 12 section 2 of ICESCR detailed the steps necessary to ensure these rights including, “The prevention, treatment, and control of epidemic, endemic, occupational and other diseases,” and “The creation of conditions which would assure to all medical services and medical attention in the event of sickness”¹. It has been thirty years and although there has been a lot of progress towards this goal, we have fallen far short of attaining the goals. This paper will discuss some plausible reasons we have been diverted from the noble and ethical path that was set out before us in Article 12 and offer suggestions about how we might resume progress toward the stated goals.

Examining the current status of public health thirty years after ICESCR illuminates some concerns and suggests that corrective actions are necessary. The triad of human immunodeficiency virus (HIV), tuberculosis (TB) and malaria are primary threats to global public health today even as new emerging infections, e.g. SARS and avian influenza join their ranks. The World Health Organization (WHO) has been collecting data on the prevalence of these diseases throughout the world and provides public access to the data on their website². We have chosen to illustrate disparities by geographical location by creating graphs representing WHO data.

HIV has become a global problem reaching into every country and every socio-economic stratum. As we discovered how the disease spreads and what can be done to treat and prevent infection, a dichotomy has evolved exposing a gap between countries with advanced technology from those without it. The prevalence of HIV/AIDS in selected countries for adults (per 100,000 population) is illustrated in Figure 1².

The overall distribution of HIV in Figure 2 was published by UNAIDS³. It is clear from these two figures that Sub-Saharan Africa and Southeast Asia have the largest number of HIV cases. Prevalence also varies by country, for example in Sub-Saharan Africa the prevalence is 5.9% whereas in North America it is 0.8% in 2006 ³. The data also shows that while the number of new infections per year in North America has remained the same from 2004 to 2006, the number has increased in Sub-Saharan Africa by 0.2 million people per year.

It is often argued that treating those infected is less cost effective than preventing infection, but it is clear that as the number and percentage of persons with the virus increase so too does the risk of the uninfected becoming infected. Missing from such perspectives is the cost to a community incurred when a significant portion of the population is unable to contribute to the economy due to illness or care giving. Treating HIV infection prior to the onset of immune compromise (CD4 < 200/ml blood) enables infected persons to return to work, raise their children, and contribute to community, and reduces the viral load thereby reducing risk of transmission.

The percentage of people with HIV that are receiving antiretroviral combination therapy is shown in Figure 3 (the standard of care in the U.S.)². While there is no current data on the WHO website for the number of people in the US and North America that are receiving antiretroviral therapy, it is clear that there is insufficient coverage in many regions of the world where the prevalence of HIV infection is greatest. Is it not an amazing fact that the number of persons being treated with proven effective therapy is so low in these countries. It the US, “Provision of antiretroviral therapy has resulted in a decline in AIDS death rates of 80% between 1990 and 2003”³. The major barrier to the universal availability of this treatment is the cost of the drugs. An argument can be made that HIV is a social disease in that infection can be prevented merely by the behavioral choices of the individual. This viewpoint leads people to claim that sharing effective treatment for HIV is not mandated by a concern for world health.

o state the obvious, tuberculosis is a treatable disease. In reality, treatment of TB is variable within the global community primarily due to cost and availability of appropriate antibiotics and the lack of testing for antibiotic resistance. Testing for resistance requires expensive technology, electricity, and skill, often in short supply in countries where TB is a serious and growing problem. Having first line antibiotics is less expensive and often is the only option available in areas where technology and money are scarce. Unfortunately, if first line antibiotics are used on resistant organisms it only feeds the resistance and does little to cure the infection. The second and third generation antibiotics are more expensive, due to patent protection, making them unavailable to many countries in need.

Figure 4 shows the global distribution of TB cases based on data from 2005⁴. The majority of the cases are in developing areas and regions where the economic and political support networks are unable to provide current effective intervention. Correspondingly, the lack of cases in the US and Europe reduces interest in treating a disease that is historically significant but no longer a major threat in these developed nations. Figure 5 shows the number of deaths due to TB in different regions of the world⁴. Do we need to repeat the fact that TB is a treatable disease? Brewer and Heymann note that the “TB mortality rates for patients have dropped from 50% at 5 years to <5% with the availability of effective treatment, even for those with multiple-drug-resistant disease”⁵.

The World Health Organization has a directly observed therapy (DOTS), short-course plan for tracking and treatment of TB, but it has not reached as far as it needs to. Sadly, TB is not the only treatable disease that has been neglected in the global community.

Why haven’t we reached the goal of providing basic healthcare to the global population as the UN tasked us with in 1976? One answer lies in the economic realm of free societies. In these societies, all persons are born free and entitled to human dignity and the pursuit of happiness, yet those who enjoy such freedom fail to use their power and economic resources to benefit other persons. “Out of sight, out of mind” is too simple an excuse. The root of the problem is more insidious than a denial of the need. The problem is privilege devoid of responsibility and compassion. Expecting a tax deduction for acts of charity does little to remove or correct injustice. Justice is more than charity, because justice removes the root cause of injustice. The majority of people in the US have become so locally focused that they can’t see past their half-cap-non-fat-double-mocha-chinos! In populist democracies, if the people do not insist their elected officials act on behalf of the poor, then government lacks the motivation to do so. Rhetorical suasion focused on a defense strategy against terrorism is used to justify aggressive acts of war in distant lands. There can be no peace without justice, but the foreign policies of nations with the needed resources for better intervention in global health have dedicated those resources to other ends.

In the private sector such as with large international drug companies, profit reigns supreme. There are no limits on profit. There may be statistics related to poverty but no caps on wealth. How often are we challenged to defend a free society that praises wealth without concomitant expectation of generosity? Profits promote progress in science and technology to greater heights while simultaneously putting essential, life saving curative drugs beyond the reach of the populations that need them most. A paper published in the May 2007 edition of Globalization and Health states: “…about one-third of the world’s population does not have access to essential medicines. Currently, 80 percent of the world’s population lives in developing countries, but consumes less than 20 percent of all pharmaceuticals.⁸”

The World Trade Organization’s Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement was designed to protect the patent rights of industrialized nations on the international stage. Ethical justification for intellectual property rights not withstanding, the TRIPS agreement limits the ability of poor countries to purchase drugs to treat persons infected by HIV, TB, and malaria. Although meant to insure recovery of cost of development for the pharma-industry, the agreement actually imposes drug prices beyond the access of the very people in need.

An alternative is to evoke the compulsory licensing provisions in the agreement meant to address the issue of access to essential medicines in developing countries. Unfortunately, the requirements of these provisions were designed in an impractical way that requires the country in need of the compulsory license to manufacture the drug themselves for use within their own borders. It seems fair on the surface, but the problem arises when the countries that need the license don’t have the facilities to manufacture the drugs and are unable to utilize the license! In August of 2003 this situation was “rectified” via a waiver that allows countries with manufacturing capabilities to obtain a compulsory license to manufacture essential medicines under patent protection for export to countries that meet the “need” category⁸. While this was an attempt to increase accessibility to essential medicines, there is still a gap in application along with conflicts and constraints that have been imposed as TRIPS-plus legislation⁹. These gaps and constraints leave the global health situation no better off than it was before the 2003 waiver.

Another solution to the severe discrepancies in global health was posited by ICESCR¹ and is more clearly and strongly laid out in the language of the follow-up document “The right to the highest attainable standard of health”¹⁰. ICESCR defines what each country must do within their own borders to protect each person’s right to health, but did not clearly define the responsibility to the global community. In light of this and other issues, the UN Committee on Economic, Social and Cultural Rights drafted “The right to the highest attainable standard of health: 11/08/2000” (General Comment No 14)¹⁰. General Comment 14 (GC14) discusses “Substantive issues arising in the implementation of the International Covenant on Economic, Social and Cultural Rights”. The document offers more detail as to what the “highest attainable standard of health” means and specifically addresses the issues of availability, accessibility, acceptability, and quality of healthcare. Included in the availability description is a direct reference to “essential drugs” as defined by the WHO Action Programme on Essential Drugs. In addition, the document makes frequent mention of the need for individual and joint efforts to accomplish these goals and calls on all state parties to “…prevent third parties from violating the right in other countries…” if they have legal power to do so.

The opening line in GC14 is the key to outlining the necessary shift in global priorities: “Health is a fundamental human right indispensable for the exercise of other human rights”¹⁰. Knowing what is right and doing it is an ancient philosophical paradox. Sadly, patent law has trumped the recognition that a right to health is a humanitarian fundamental norm. Simple greed and the freedom to exercise business on a for-profit basis are far removed from the principle of recovery of investment costs. It is rhetorically easy to assert a right to health within one’s own democracy but to grant inclusion of all persons equally requires a more generous nature; one that seems to be missing in the most developed nations.

A Potential improvement may be to equate the imperatives and enforcement of ICESCR on parity with TRIPS. Herein lies the test case: will the international agreement inherent in the human rights of all persons articulated in ICESCR be recognized as morally compelling in equity with a national plan, e.g. TRIPS that requires all countries to abide by the standards including developing countries (by 2006) and least-developed countries (by 2016)⁸. There is language in the GC14 that implies that the task is too great and leniency must be inherent in the enforcement because governments may not have the funds to comply. They may not have the funds or desire to comply with TRIPS yet they are still expected to do so by 2016! Somehow it is easier to hold other countries accountable when there is an income interest for the developed nations involved instead of expenditure.

It may seem intuitively obvious that persons regardless of location, culture, and economic status share identity as one species. The mentality with which we treat disease – preventable and treatable illnesses – around the globe reveals how far we are from recognizing our common humanity. What can we do to stimulate greater healthcare for the common good? One avenue is through education and media awareness. So-called western music and dress make it into the recesses of the global family – so why not medicine? Public media can be instrumental in making us all more aware of the need, the common humanity we share, and the challenge we face in global health. Populations with wealth, freedom to share, and lack of awareness can be inspired to give generously as happens in response to natural disasters: tsunami, hurricanes, earthquakes, floods, etc. In privileged populations, more education is needed about infectious disease and how isolated pockets of drug-resistant TB have a way of traveling in a mobile society, putting less differentiation between “us” and “them.” People must be convinced that what happens elsewhere in the world affects them and their children. The challenge is large and individuals may feel unable to meet the demand, so education about ways to make a difference is imperative. We know how to treat HIV, TB, and malaria – the challenge is finding the will to do what we know we can do.

*Response for this article should be addressed to Dr. Ann Boyd

Professor of Biology, Hood College

401 Rosemont Ave

Frederick, MD 21701, USA

Email: boyd@hood.edu