In a recent opinion piece in the Financial Times, William Easterly argued that a rights-based approach to health care would favor the agendas of the rich and powerful, leaving the poor to die of neglected diseases. He then contends that holding ourselves to such unrealistically high standards would open the floodgates for unchecked spending, “since any of us could get healthier with more care.” Unfortunately, both of his slippery slope arguments are premised on inaccurate assumptions about the right to health, health spending dynamics in the US, and the history of global health assistance. The inequalities he describes are not the result of a push to promote health as a universal good. Instead, they are the flawed legacy of institutions and policies that persist in treating health as a commodity.

At a basic level, Easterly distorts the purpose and scope of a rights-based approach to health, specifically what is meant by “highest attainable standard of health.” He frames this as a personal right to absolute health, subject to immediate realization, when it is actually a collective right to equivalent health, subject to progressive realization (ICESCR, Art. 12). This mischaracterization underlies Easterly’s argument that human rights operate in a zero-sum environment. In reality, the right to health goes beyond mere delivery of goods and services; it is fundamentally concerned with promoting equitable outcomes and empowering people to achieve these ends. The problem is not one of scarcity: rich countries contribute less than 1% of their gross national income to support health care in poor countries. Rather, it is one of exclusion: the current balance of rights and duties fails to contemplate that everyone is entitled to a basic level of health. The Millennium Development Goals seem so ambitious because they seek to extend to all what those of us in the developed world take for granted — “minimum essential levels” of health and the preconditions for health, such as access to water, sanitation, and nutrition. While a certain amount of jockeying for priority is to be expected, it would take place within this basic inclusive framework. By resorting to economic scare tactics, Easterly displays fundamental misunderstanding of what is at stake in the human rights debate.

Additionally, Easterly fails to explain why global health assistance forms a rational basis for predicting how a rights-based approach would operate in the US context. First, domestic and foreign health allocations are driven by different political and public health considerations. Americans carry a larger chronic disease burden, while low-income countries, generally the target of global health funding, carry a larger infectious disease burden. For example, communicable diseases account for just 8% of years of life lost in the US but account for 68% of years of life lost in developing countries. By contrast, noncommunicable diseases account for 74% of years of life lost in the US but just 21% in developing countries (see the WHO 2009 World Health Statistics). Additionally, there are different delivery and funding mechanisms at work in each context. A recent survey of 12 African countries showed that there are 9 physicians per 100,000 people, whereas there are 270 physicians per 100,000 people in the US. Second, it is unclear how the right to health would result in both more spending and worse outcomes than the status quo. On the one hand, Easterly argues that it would lead to fierce competition for resources. On the other hand, he argues that it would result in reckless spending. The US health system is already characterized by overspending and overtreatment for tertiary levels of care (also see the Dartmouth Atlas Study), coupled with disparities in access and outcomes for the medically underserved. In fact, emphasizing universal access to primary care would result in saved costs and improved outcomes.

Finally, Easterly makes flawed assumptions about the historical drivers of global health assistance. First, his criticisms are misdirected, as the very policies and programs he decries were never based on the right to health. Instead, they reflect political decisions to fund targeted, vertical interventions over horizontal investment in the public sector. Second, his opposition to a rights-based framework is short-sighted since this siloed approach does not go far enough in promoting health. The WHO definition of health extends beyond mere absence of disease to “complete physical, mental and social well-being.” Yet the foreign aid “successes” Easterly cites, such as immunizations and antibiotics, were only aimed at preventing death. Because they do not address fundamental causes, they are incapable of preventing disease. It is ironic, then, that Easterly tries to support his complaints about global health funding by holding up the most vertical and least effective models of “global health care.” If good is measured by “obtaining the largest possible health benefits,” only a rights-based approach ensures these benefits go deep enough and broad enough to meet the needs of the poor.

At a recent conference, health delegates from 42 countries agreed to implement a new strategy that trains NPCs in emergency obstetric surgery to address the lack of health care workers. Along with other developing areas, most African countries are suffering from a significant lack of medical professionals. This shortage is particularly implicated in the high rates of maternal and infant deaths during childbirth. The WHO has estimated that in sub-Saharan Africa alone, there is a shortage of nearly 1.5 million health care workers; women there face a 1-in-13 risk of dying in childbirth. Most women are unable or unwilling to access medical facilities or workers, even during emergencies; for example, in Ethiopia, only 6% of all births occurred in a health facility.

By expanding the number of NPCs and training them in surgical childbirth procedures, it is hoped that more births will be attended by trained health care workers who can assist women during emergencies. A program in Mozambique that trains midwives in surgical techniques has already achieved significant results. The country is on the way toward meeting several of the UN’s Millennium Development Goals, particularly those surrounding maternal and newborn health.

In a similar low-tech program, USAID’s maternal health group ACCESS (Access to Clinical and Community Maternal, Neonatal, and Women’s Health Services) focuses on developing and extending home and community based interventions. A new report from ACCESS is a guide for carrying out “community mobilizations” to improve maternal and newborn health. The program focuses on identifying the specific obstacles of the community, and working with the population to implement realistic changes. For example, essential interventions like the use of misoprostol (which induces labor) can generally be provided safely by trained health care workers at the household and community level, and prevent almost 70% of infant deaths. Additionally, simple preparations, such as providing folic acid to the mother during pregnancy and preparing a clean space for the birth, can be done by community health workers trained in pregnancy and childbirth.

More information:

Video: Birth of a Surgeon (documentary of Mozambique’s midwife training program)

In War and Isolation, a Fighter for Afghan Women

Bold Solutions to Africa’s Health Worker Shortage

Malawi: Role of traditional birth attendants to change

Global Low-cost Health Initiatives

This report, which compiled past scientific work on the effects of climate change, also warned that severe weather events, along with the physical and mental health problems associated with them, are likely to increase, especially in countries with less developed public health systems. In general, vulnerable groups such as the elderly, children, and people living in poverty experience more severe health effects from climate change. The report states that “[t]he greatest health burdens related to climate change are likely to fall on the poor…” because they often lack resources and choices in their ability to avoid harm. In particular, the report noted that the poor and elderly faced the most severe circumstances during Hurricane Katrina, and that Native Americans are uniquely vulnerable to global warming because they often rely on reservation land for their livelihood and cannot easily relocate.

A second report, from the Global Humanitarian Forum, calls climate change a “silent crisis” that kills 300,000 people each year and displaces 26 million more. The vast majority of these deaths occur in developing nations, although the world’s 50 Least Developed Countries contribute to less than one percent of global emissions. Women and children are hit particularly hard by displacement caused by climate change. Further, the report suggests, climate change threatens to undermine each of the eight global Millennium Development Goals. More than one third of the population is currently vulnerable to climate change, most of these people living in “the semi-arid dry land belt [of sub-Saharan Africa], easily flooded regions on the Equator, and glacier regions.” People in these areas are especially vulnerable to drought, melting ice sheets, floods, storms and sea level rise.

Climate change is also increasing the spread of diseases globally. For example, Lyme disease, once believed to be eradicated in the US and Europe, has now reappeared with warmer temperatures. Similarly, mosquitoes carrying malaria are now able to thrive in previously colder climates, where populations have little natural resistance.

The report also discusses how climate change is likely to increase and intensify poverty globally, as the poor have little access to safety nets such as insurance against damage or disaster. Changes that negatively affect agriculture, fishing or tourism can lead to significant loss of income, and it is estimated that over ten million have already sunk into poverty due to climate change.

The release of these reports coincided with the start of discussion in the US House of Representatives on the new climate and energy bill, the American Clean Energy and Security Act (see full act here).The House passed the bill on June 26 by a narrow margin, and it is now in discussion in the Senate. However, many environmental groups warn that, if passed as currently written, the bill will not go far enough in preventing catastrophic events.

See more:

Climate Change and Global Health: Quantifying a Growing Ethical Crisis

Suffering the Science: Climate change, people, and poverty

Climate-Change Report: From Bad to Worse

Study: A Fairer Way to Cut Global CO2 Emissions

CBO: Climate bill costs to be modest

The Human Cost of Climate Change

The Carbon Counter