INSURING THE NECESSARY RESOURCES FOR THE
HUMAN RIGHT TO HEALTH: NATIONAL AND INTERNATIONAL MEASURES
Address by David Werner
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.
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