Global Assembly on "Advancing the Human Right to Health"
Iowa City, Iowa, April 20-22, 2001
In the 1940s, the United Nations declared Health a Basic Human Right. The World Health Organization was created to help make that Right a reality. But during the next several decades, the Right to Health remained a distant dream for most of the world's people.
True, great advances were realized in medical science. The Western medical model, with its urban "Disease Palaces," costly doctors, and commercial pharmaceuticals, was extended into the Third World. But to a large extent, the benefits of Western medicine remained inaccessible to the poor majority living in rural areas and growing city slums.
During the same period (from the 1950s through the 70s), important public health measures to reduce infectious diseases were introduced through national and international campaigns. But, once again, these measures were unequally distributed. Millions of children continued to die from diseases that could have been prevented through clean water, immunization, and good nutrition.
It became clear that poverty and powerlessness were the underlying causes of poor health and early death.
In pursuit of Health for All
Hopes for a breakthrough emerged with the Alma Ata Declaration in 1978. The world's nations endorsed the goal of "Health for All by the Year 2000," to be approached through a comprehensive strategy called Primary Health Care. The Declaration not only advocated universal coverage of basic health services, but also called for a "new economic order" to assure that all people could have a standard of living conducive to health. To achieve greater equity in meeting health needs, it called for strong popular participation.
At that time there was lots of optimism. But the year 2000 has come and gone. And today the dream of Health for All seems more distant than ever. A reversal has occured of many advances made in earlier decades. The Third World has seen a resurgence of "diseases of squalor" such as cholera, malaria, tuberculosis, and even plague. New diseases such as AIDS are taking their highest toll in populations whose basic needs and rights remain grievously unmet.
Why is it that the Human Right to Health still remains so far from being realized? What are the necessary resources and prerequisites for this Right to be implemented? And what are the limiting factors?
The World Bank's "investment in health"
The World Bank -- the newest and strongest player in international health -- tells us that the key obstacles to approaching Health for All are economic. It points to the poor "cost-effectiveness" of Third World economies and specifically, of their health systems.
Figure 1. World Bank 1993 World Development Report
The World Bank has a very market-oriented concept of human health. It argues that good health is necessary for economic growth, and vice versa. The Bank's 1993 publication, "Investing in Health," advances a master plan for making health care cost-effective. (in terms of keeping a country's workforce free enough from illnesses to contribute maximally to economic growth). To figure out which health measures merit public support, the Bank invented DALYs, or "Disability Adjusted Life Years." It calculates how many DALYs can be saved by different interventions. In this scheme, the people of highest value are young adults, who are thought to work hardest. Infants, old people, and disabled persons have less value because they contribute little or nothing to the national economy; therefore they merit less public expenditure for their health (see Figure 1).
Dehumanizing? Absolutely! ... Yet the World Bank presents its regressive strategy with such beguiling doubletalk that it sounds deceptively progressive. So, watch out!
Since the mid-1980s, the World Bank has become the leading international agency for health policy planning in the South, relegating the World Health Organization to second-place. The Bank's health spending is now three times the entire WHO budget. It is an ominous sign when a giant financial institution (with strong ties to big business) bullies its way into health care. Yet with its enormous money-lending capacity, the Bank can force its health blueprint on poor countries.
In order to reduce government expenditure on health and make services "cost-effective," the Bank has pushed poor indebted countries to privatize public hospitals, and to introduce "cost recovery" schemes, including "user fees" for community clinics. Studies in several countries have shown that user fees have decreased utilization of medical services and increased child mortality, sexually transmitted diseases, and tuberculosis.
Figure 2. Outpatient attendance at Dwease Health Post, Ghana, before and after introduction of user charges in 1985.
In Ghana, Africa -- one of the Bank's high-profile success stories -- user fees in rural clinics were introduced in the mid-1980s, as part of Structural Adjustment. As a result, child mortality, which had dropped steadily for over a decade, almost doubled (see Figure 2).
The current trend of privatization and user fees burdens the poor with costs of basic services that used to be covered through progressive taxation. This is consistent with the conservative thrust of the globalized economy, which has consistently rolled back socially progressive policies of earlier decades. Put simply, health is no longer a human right. In the ethics of the global marketplace, you pay for what you get. If you can't pay, tough luck! Health -- and health care -- have become yet another profit-driven commodity. Its business as usual!
Inequity as a determinant of ill-health
The World Bank is correct when it says the major obstacles to Health for All are economic. However, the problem is not a total shortage of wealth. Rather it is the ruthlessly unequal distribution of wealth, and the misguided priorities of those who control most of the world's resources.
Figure 3. Global distribution of income
Graphically, distribution of wealth in today's world has the shape of a wine glass: the richest 20 percent of people control over 80 percent of the wealth, while the poorest 20 percent control less than 1.5 percent of the wealth (see Figure 3). Spurred by the inequity of the free-market system, the gulf between rich and poor continues to widen, both within countries and between them. Of the world's 100 biggest economies today, 51 are transnational corporations, which are wealthier than most nations. The world's 350 richest men have a combined wealth equivalent to the poorer half of humanity. Similar inequity exists in the world's richest nation, the United States, where one of four children lives below the poverty line. Bill Gates, Head of Microsoft, has an annual income equal to that of the poorest 40 percent of Americans. No wonder the US has the worst health statistics of the wealthiest 24 nations!
This growing income gap is a major concern for health. Studies in different countries, analyzed by Richard Wilkinson in his recent book, Unhealthy Societies, shows the clear relationship between ill-health and inequity. Comparison of the different states of the USA, and likewise the different nations of Europe, show that the level of health of a population is determined less by its total wealth or GNP per capita than by the relative equality, or inequality, with which that wealth is distributed. These studies convey an ominous forecast for our globalized paradigm of development, which is relentlessly increasing the huge disparity in wealth and power, worldwide.
Good health at low-cost
Historically, alternative models of development exist which put the basic needs of all people before the economic growth of the ruling class. In 1985, the Rockefeller Foundation sponsored a study called "Good Health and Low Cost," to find out whether certain poor countries had achieved levels of health approaching those of rich countries. The study -- which included China, Sri Lanka, Kerala State of India, and Costa Rica -- found these countries had indeed achieved child-survival and life-expectancy rates similar to much richer countries. But how? It was found that although these countries covered a wide political spectrum, they had 4 things in common:
1. An overall political commitment to equity;
2. Universal education with emphasis on the primary level;
3. Free and equal health services for the entire population;
and perhaps most important of all:
4. Provision of an adequate calorie intake (enough to eat) for all citizens, in a way that does not disrupt traditional agriculture.
Sounds great! But it must be pointed out that each of these four countries that achieved "good health at low cost," has recently suffered setbacks. Each has found it hard to sustain its commitment to equity and "health for all," and at the same time survive the pressures (and threat of trade sanctions) from the globalized free-market power structure.
One country the Rockefeller study did not include, but which has made even greater achievements in health is, of course, Cuba. By requiring relatively equitable distribution of resources, and by giving top priority to people's basic needs -- including education, free comprehensive health services, and adequate nutrition for all -- Cuba has obtained a level of health equal to and in some ways better than the United States. It has done so with a GNP per capita of only 1/20 that of the United States! More remarkable still, Cuba has sustained its good health in spite of the devastating U.S. embargo. What the US fears most from Cuba is the example it gives the world that good health is possible when limited resources are equitably allocated.
Key resources: political will and "power of the people"
There is little question that the resources exist to make health a basic human right. What is missing is the political will of the world's ruling class: that relatively small, elite minority who control most of the resources and decision-making power.
There's a lot of euphemistic talk about "Democracy." Our newspapers, TVS, and schoolbooks tell us that most countries have at last become democratic. But too often what passes for "democracy" is a wolf in sheep's clothing. Although national leaders are elected by popular vote, too often the electoral process is corrupted by big money. Nowhere is this truer than here in the United States, where half the citizens feel so disempowered they no longer bother to vote. Huge campaign donations from corporations and other wealthy interest groups have so distorted the electoral process that what we call "democracy" is now an oligarchy of the ruling class. "One person one-vote" has been subverted to "one dollar one-vote." Even our revered "Free Press" is now anything but free. It has become another multi-billion dollar industry. The mass media are owned by the same giant corporations that own the oil industry, arms industry, tobacco industry, and transnational drug companies. The "news that is fit to print" is part of a giant machine of propaganda and social control that expedites the economic growth of the rich, regardless of human and environmental costs.
The result is the unhealthy stratification we see in the United States today: a class system with growing economic, racial, and health disparities, where poverty and luxury exist side-by-side and where 46 million citizens have little or no health insurance. Talk about sickening priorities! While the White House continues to increase its astronomical military budget, it refuses to approve a National Health Plan to cover basic services for all citizens. How can we speak of "democracy" in a nation where, last November, less than a quarter of the country's potential voters managed to elect a gang of self-serving politicians who cut rich people's taxes while slashing welfare for the poor.
Worse still, as the world's remaining Superpower, the United States is relentlessly globalizing its unjust, undemocratic, unhealthy, and unsustainable model of top-heavy economic development. Driven by greed, not need, this shortsighted paradigm not only jeopardizes the well-being of the world's poor, but is endangering our global environment and plundering the non-renewable resources on which the health and survival of all life on this planet depend.
So, when we talk about "Insuring the necessary resources for the human right to health" we must talk about distribution of those resources. Sufficient wealth and knowledge currently exist to meet the basic health-related needs of everyone. What we need is fairer, more equal sharing of resources. And for this, we need fairer distribution of decision-making power. We need a truly participatory democratic process, through which ordinary people can take greater control of decisions that affect their health and their lives. This, in turn, will require a more empowering approach to education. Which means that those of us concerned about the Right to Health must join progressive educators to build more honest and empowering approaches to information sharing.
The need for mass mobilization by well-informed people
I would propose that the most important resource for making health a human right is the so-called human factor: the people themselves. But "people potential" is still underdeveloped. For people to join in realistic, well-organized action for a healthier world, we need an "alternative information revolution." Progressive health workers, activists, and agents-of-change can help to develop bottom-up (and sometimes underground) pathways of communication which can gradually help to raise people's awareness about the root causes of their health-related problems and growing psychosocial distress.
In short, many more people -- especially the underprivileged -- need to become politically more astute. They need to learn why their governments spend so much on military hardware and so little on human needs. They need to know why the leaders they elect systematically roll back socially progressive policies, and why they deregulate the practices of giant corporations at the people's expense. They need to question why the newspapers proclaim economic prosperity, when daily wages buy less and less. They need to demand that our schools encourage cooperation rather than competition. Instead of instilling conformity and obedience, schools need to teach students to think and to question, empowering them to make their own observations, draw their own conclusions, and take united problem-solving action. Through such transformation of the educational process (whether in schools, in the workplace, or through the Internet), the seeds can be sown for building a healthier society based on democratic action of a well-informed public.
All this will take a long time and hard work. But ultimately "Poder Popular," the Power of the People, is the key resource for assuring all people's Right to Health.
Actions for assuring Health as a Human Right
Let us look at some choices for action which a well-informed public might take to help make Health a Human Right:
1. An important first choice in many countries, and desperately needed in the United States, would be to: Organize a strong popular lobby for election finance reform. Health rights can become a priority only when big corporations and wealthy interest groups have less control over politicians and public policies.
2. Another key action would be to: Demand more progressive taxation. Heavily taxing the very wealthy reduces inequity and can produce revenue to provide better public services.
3. Combat the current trend to privatize health services and to shift the burden of costs to those whose needs are greatest. In backward countries such as the United States, the public must insist on a universal comprehensive health plan, paid for through progressive taxation.
4. Demand radical cut-back of military expenditures, and lobby for laws to prohibit or severely restrict the sale of weapons of war, especially those that cause indiscriminate personal harm (such as landmines). Such laws would reduce health-destroying casualties and free-up money for the common good.
5. Advocate new methods to redistribute wealth for public benefit. One method with great potential is the so-called "Tobin Tax." Every day more than 1.5 trillion dollars changes hands through the so-called "Global Casino," as rich people endeavor to multiply their wealth through speculative international trade of currencies and venture capital. Worldwide, 300 times as much money is traded daily through such non-productive speculative transactions as changes hands for actual services and production. The proposed Tobin Tax -- which would levy a 0.1 percent tax on all international financial transactions -- could provide more than one billion dollars of revenue per day. If well directed, this huge revenue could pay for the basic health- and poverty related needs of everyone on earth whose needs remain un-met.
6. Interventions like the Tobin Tax, at best, are stopgap measures. Our long-term goal must be to: Transform our cruelly inequitable economic order into one which is fairer, more health-promoting, and more sustainable. To approach Health for All, basic health services must become available to everyone, regardless of their ability to pay. And equally important, society must embrace policies which assure that all people can have a decent quality of life.
The first requirement for health is sufficient food. Today the world has more hungry children than ever before. A family's ability to feed itself with dignity and self-determination depends on conditions such as fair distribution of land, opportunities for employment, and fair wages. In short, health rights depend upon a spectrum of other human rights.
Conclusion: Health is not for sale!
In closing, I would like to stress that if health is ever to be a human right, it must cease to be a commercial product, bought and sold in the marketplace. Medical research and development should be guided not by the profit motive, but by what ails or endangers the largest number of people. It is unethical for pharmaceutical companies to reap huge profits through legalized price-fixing of life-saving drugs. It is equally unconscionable for money-hungry politicians to threaten trade sanctions against poor countries that dare to produce and distribute such drugs at affordable costs.
In last analysis, to assure health as a human right, the whole globalized market system -- with its byproduct of increased poverty and ill-health -- needs to be reexamined, regulated, and eventually transformed, so that well-being of the people and the planet becomes a top priority. As individuals, communities, and nations, we need to evolve a sense of concern and compassion for one another. Those of us who happen to be more fortunate today must learn to collectively give a hand to those who happen to be less fortunate. In short, humanity must become one big extended family -- celebrating our marvelous diversity, yet making sure that each one of us has the freedom, equal rights, and a fair share of basic resources -- so that we can determine our destiny and sustain our health.