Claudio Schuftan, Ho Chi Minh City
Inequality in health is a morally significant fact in itself. Yet the current status of health inequality trends among and within countries shows that health inequalities are increasing. The long-term solutions to this worrisome situation are not with political leaders and policy makers worldwide. Read here who must address these issues to demand actions from the latter.
From the human rights perspective, power imbalances underlie health inequalities. (1)
If you as a reader recognize and agree with a) the indivisibility of human rights, b) the equal importance of people’s socio-economic entitlements, and c) the principle of equity, you must accept that this runs counter to market-oriented development health policies still fostered by many a national and international development agency.
Therefore, what the adoption of the human rights framework brings to public health is that it ensures that social justice is made a constant counterbalance to the unchallenged utilitarianism at the root of obscene inequalities. Its adoption also ensures that checks on power relations are made routinely and that these checks are the main way to protect the vulnerable by opening avenues that confer communities the power to get actively and de-facto involved in setting and monitoring the policies and programmes that affect their health and wellbeing.
This basically makes human rights (HR) the centre piece of early twenty first century development struggles against inequalities in health. But mind you, the HR framework will only become a meaningful instrument to assure accountability in health if strong civil society pressures on government ultimately turn HR codes and standards into national laws and regulations.
Furthermore, HR are not just about empowering individual duty bearers, but are, by extension, a framework for the contestation of power, at local, national and international level. And where power is contested, we should expect that the products of this contestation will actually reflect the relative balance of forces (or power) of the different actors. Therefore, empowering claim holders in the health sector we must.
On the other hand, the current emphasis that has emerged as the dominant paradigm in the development discourses driven by most donor countries is a) on ‘good governance’ (no matter if participatory or not…), b) on ‘representative democracy’ (no matter if through rigged elections or not…), and c) on ‘civil liberties’ (no matter if fair to the marginalised or not…). This has ironically contributed to a de-politicisation of the inequality, of the HR and of the development discourse, because it strips the struggles for health of any content that challenges power imbalances –again at local, regional and international levels.
Because of the above underlying power issue, many have questioned “Why rights, why right to health now?” “Is human rights work the most effective way to tackle power imbalances?” And the response is: If and when the language of rights becomes denuded of a focus on power relations, it is turned into an ineffective, worthless technical exercise of compliance with existing norms; human rights then become palliative rather than the cornerstone to ease human suffering. In practice, in health, placing demands from a rights framework, among other, challenges ministries of health and service providers to see their role as fulfilling the state’s human rights obligation to assure comprehensive and universal health care rather than simply to deliver health services. [Think NHS in the UK].
There is no unambiguous answer to the question whether, in the reigning paradigm, public health still is a-bundle-of-services-shaped-by-ideologically-pro-status-quo-positions. But if you think it indeed is, the application of the HR framework is most probably the best currently available counterbalance to challenge a paradigm that desperately needs to be replaced.
The most common description of the current status of health inequality trends among and within countries is that health inequalities are increasing: a clear infringement of the human right to health. (2)
-A purely biomedical understanding of diminished health and of preventable mortality misses key dimensions of social and economic issues.
The differences in health statistics that impinge on HR, pertain to how health outcomes are distributed (the distributive pattern), to what is being distributed (the distributive currency), and to the area in which that assessment is made (the distributive locus). The non-disaggregation of health data by gender, ethnicity and socioeconomic status is what is fostering what we call prioritarianism. Prioritarianism puts greater weight on the health or wellbeing of those who are worse off rather than focusing specifically on the gap between them and those who are better off.
The emphasis must thus be on the equality of true access to services and the health outcomes the existing inequalities bring about. Emphasis must also be on equality in the resources being made available to all. Consequently, assessing equality has to focus on the inequality of social status/class, i.e., the equality in the relations among members of a population. This assessment is rarely done beyond reporting inequalities in money and, to a large extent, in health care and health outcomes.
Historically, the reduction in child mortality began to slow down in 1985 and reversed direction in 1994 before resuming its former downward trend beginning in 1997. How do we explain this interruption of more than a decade?: Structural Adjustment. This regime had dramatic negative effects on public health, leading to its visible deterioration. Add HIV/AIDS and the battle over patents of medicines (TRIPs) to these determinants and you get pretty much the full picture. (Child deaths from HIV/AIDS peaked in 2005 and have declined thereafter, no doubt as a consequence of people-demanded greater access to anti-retroviral treatments). (2) Furthermore, note that, in all countries of the world, child mortality is significantly lower for children of more educated women even after adjusting for the effect of income/wealth.
Only by the turn of the millennium did the devastating impact of the World Bank’s policies on children’s rights become impossible to ignore. Since then, the new global health actors (Gates, GAVI, Global Fund) work in close collaboration with Big Pharma and are in an important sense driven by the desire to generate a new regime for pharmaceutical innovation resulting in a new stream of revenue flows for the pharmaceutical industry. In this way, public (not really public?) health is being resurrected as a profitable area of investment in ways that shape the kinds of health care interventions that are prioritized and this forecloses the revival of a truly public health care infrastructure. This has resulted in overwhelmingly vertical funding schemes focused on single diseases. This vertical orientation has equally brought about a new dominance of public-private initiatives and other privately outsourced actors over national actors.
By now we know
Social and environmental factors influence child development in a broad way and, through this process, also influence adult health. In a strong way, adult mortality is socially and economically differentiated in all countries. (Serious illness does not lead to bankruptcy where there is social insurance…). A lack of programmes targeting both children and overall economic wealth redistribution thus has long-term consequences for adult health and survival –their right to health included.
To date, global health inequalities in child health do remain highly pertinent. However, health inequalities within countries are widespread too. Economic disparities are not only persistent, but in some areas widening. The economic gap between urban and rural populations, and the formal and informal economic sector is starkly visible in health trends and outcomes. Large disparities in health services and outcomes are not confined to economically poor countries, but can be found in countries throughout the world, the UK no exception. In the United States, access to health services for children is highly unequal. Health prospects there intersect with race, gender and economic status.
We further note that, while some of the most celebrated global health interventions of the past few decades have targeted infants and in particular under-five year olds, the specific health risks of adolescents are still relatively neglected.
Why do social class differences in health reappear again and again in every new generation?
-Health in early life is heavily influenced by the social circumstances of the previous generation. Thereafter, life-long social circumstances have a dominant influence on people’s health and survival.
Child mortality in poor household is around double that of rich households in the same country. Study results show a gradient in infant mortality from income quintile 1 to income quintile 5. This is the typical pattern in any country. In the US, the mortality of white men and women with less than twelve years of schooling has been growing gradually worse over time. (2)
One can confidently ask: Is it more than likely that global market forces and corporate actors now exercise a growing influence over national income distributions, labour markets, consumption patterns, taxes and welfare/health policies in general that are too powerful for national governments to balance? There is nothing too powerful to be overcome …if there is the political determination prompted by the mass mobilisation of claim holders with clear demands. [Think NHS in the UK].
Bottom line here: According to the influential report of the WHO Commission on Social Determinants of Health (2008), health inequalities and the violation of the right to health are not consistent with a ‘business as usual’ approach to tackle them.
The long-term solutions are not with political leaders and policy makers worldwide. Who must address these issues to demand actions from the latter two?
Only the progressive engagement in HR and right to health work will lead to the needed activism in which profession, compassion and political solidarity become one and the same thing. Apathy turns our work into stagnation. We need to transform-apathy-into-activism; shift our attention from just reaching-the-poor-merely-as-an-extension-of-the-prevailing-paradigm to a-deeper-understanding-of-the-issues-of-poverty-and-inequality-and-their-underlying-reproduction-processes. What ultimately counts is our social and political accountability and our work in true partnership with those rendered poor.
As HR activists (and from within our respective professions), we cannot but become strong political players instead of implicitly protecting narrow group interests. This means helping generate new forms of HR-centred work leading to practices-of-direct-democracy in local government.
HR learning and new forms of progressive HR action are then needed in the health sector. We cannot merely denounce; we must also announce a new order –an order with more empowering-health-alternative-actions. We must thus strive to become proactive, not merely reactive.
The inescapable challenge before us is to redefine the strategies used in order to combat preventable ill-health, preventable malnutrition and preventable premature deaths. This invariably entails addressing and combating the social, economic and political determinants of health.
For this, we first need to help create a shared critical awareness of the immorality of the prevailing social, economic and political system responsible for the myriad violations of the right to health.
We further need to bring people both in the rich and the poor countries to a point where they become more vocal in their demands to change the mechanisms that lead to the conditions perpetuating ill-health, malnutrition, poverty, inequality and injustice. And this can only be achieved by creating a growing discontent that leads to a ‘constructive anger’ and to commensurate actions that address such injustice.
In short, starting with/from our work in health, we should all contribute, to the best of our abilities, to generate popular alternative development strategies with the corresponding set of tactics to implement them. But to make a difference, remember that standing alone changes little. So, network with other like-minded activists in the HR field!
(1) ‘Human rights and public health: More than just about civil liberties’, EQUINET AFRICA Newsletter Editorial, 2006. http://www.equinetafrica.org/
(2) Chapter 18 of the International Panel on Social Progress, 2016. https://www.ipsp.org/wp-content/uploads/2016/04/IPSP-Outline-April-2016.pdf
Claudio Schuftan, M.D., born in Chile and currently based in Ho Chi Minh City, is a freelance consultant in public health. He is the author of two books, several book chapters and over 85 scholarly papers plus over four hundred other assorted publications. He has carried out over 110 consulting assignments 50 countries in five continents. He has worked long term in the US, Cameroon, Kenya and Vietnam. He is currently an active member of he Steering Group of the People’s Health Movement He is the author of a long-running blog, the Human Rights Reader counting over 450 issues. www.claudioschuftan.com