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Over the past 20 years, international development assistance for health has increased, albeit for some diseases more than others. However, the triple crises of food, fuel, and finance have raised questions regarding whether aid flows will continue to increase, or even be maintained in the coming future. Health and education are often the first victims of budget cuts in times of limited funding and competing priorities as they are viewed to be in the realm of “low politics” as opposed to security and military spending, which are seen as “high politics.” Cuts in overseas development aid will have a drastic impact on countries where external funding makes up a significant proportion of national health budgets. Although global health aid accounts for only 0.3% of total expenditures on health globally (6.5% in sub-Saharan Africa), in some countries like the Solomon Islands and Mozambique, for example, 82% and 66% of the national health budgets respectively come from external resources. WHO estimates that 23 countries have over 30% of their total health expenditures funded by donors.
On August 28, 2008, Michael Marmot, Chair of the Commission on Social Determinants of Health, formally handed over the Commission’s Final Report to Margaret Chan, the Director-General of the World Health Organization, at the Palais des Nations in Geneva. It was a significant moment. Dr. Chan addressed a hall packed with representatives of the world’s communications media in a speech that was remarkably direct. Dr. Chan reiterated the Commission’s position that to improve health and health equity action needs to be taken not just across the health sector but across all social and economic policy areas, and stated, “Social deprivation is not a matter of fate. It is a marker of policy failure.” This was a bold statement from one of the world’s leading diplomats. Policy failure! The phrase echoes the Commission’s assertion that “a toxic combination of poor social policies, unfair economic arrangements and bad politics is killing people on a grand scale.” The Commission’s messages are far reaching.
As a worldwide economic crisis emerged at the end of 2008, international health agencies were quick to highlight its predictable impact on health in the poorest of communities. The World Health Organization (WHO) underscored the need for a multisectoral approach to the crisis, “seeking health gains through demonstrating the importance of health in all policies” and whether current investments in health addressed the broader social determinants of health. However, despite good intentions and decades of discussion addressing the need for transformative changes globally to reduce poverty and improve health equity, little progress has been made.
A recent report on progress towards the Millennium Development Goals (MDGs) indicates that many targeted goals have not been met, with some goals lagging many years behind schedule (“Four years after the target date, gender parity in education has yet to be achieved”). Although progress towards achieving the MDGs has been made for some specific conditions (e.g., malaria), where targeted interventions have had an immediate impact, limited progress is reported in more complex areas such as maternal child health. Such complex health issues require structural changes, strong political will, long-term funding, and consideration of other health determinants, such as education and exposure to environmental hazards.
Judging by their contribution to the global burden of death and disability, chronic, non-communicable diseases (NCDs) are the most serious health challenge facing the world today. The statistics tell a frightening story. Over 35 million people died from chronic diseases in 2005 — principally cardiovascular disease, cancer, and chronic respiratory disease. Driven by population growth and population ageing, deaths from non-communicable diseases are expected to increase by 17% over the period 2005-2015, accounting for 69% of global deaths by 2030.
Cardiovascular disease (CVD), the leading cause of death in all regions except sub-Saharan Africa, is estimated to rise from 17.1 million deaths (2004) to 23.4 million deaths (2030). Cancer deaths will increase from 7.4 million to 11.8 million over the same period. Due to population growth, mergers and acquisitions, and the marketing of global cigarette brands in developing countries, deaths from tobacco will rise from 5.4 million per year (2005), through 6.4 million (2015), to 8.3 million by 2030. These figures include a doubling in tobacco deaths in low- and middle-income countries from 3.4 million to 6.8 million lives annually. By 2015, smoking will cause 50% more deaths than HIV/AIDS.
Public health agencies undertake a broad range of health promotion and injury and disease prevention activities in collaboration with an array of actors, such as the community, businesses, and non-profit organizations. These activities are “multisectoral” in nature and centered on public health agencies that oversee and engage with the other actors. Public health agencies can influence the hazardous activities in the private sector in a variety of ways, “ranging from prohibition and regulation to volunteerism, and from cooperation to cooption.” Hence, a public health agency that possesses the necessary administrative resources and authority is vital to the effective implementation of health policies and regulations.
In the developing world, however, many state health agencies lack these basic capacities in dealing with critical health threats, including their ability to avert epidemics of communicable diseases arising from poor sanitary conditions. A serious constraint is the shortage of public health funding for health agencies in the developing world for typical agency functions (e.g., surveillance, monitoring, assessment, and intervention). This is often aggravated by the transaction-intensive demands entailed in enforcing regulations among an array of private and public sector actors including individuals, businesses, and local bodies responsible for providing civic services.
When 47-year-old Simba Abalo, an unemployed retired soldier in Lomé, Togo, found out that he had AIDS in September 2007, he was unable to receive government-supplied antiretroviral drugs: “CAMEG [the state’s central medicines purchasing organization],” he said, “told me they were not taking any new cases for six months because they had run out of drugs.
Stocks of antiretrovirals had become depleted after the Global Fund to Fight AIDS, Tuberculosis and Malaria suspended part of its grant to Togo in 2006 and failed to approve a new grant request in 2007, reportedly because of oversight irregularities. “Even if they had the drugs,” said Abalo, “I could not have paid more than US$4 a month since I had just lost my job as a security guard earning US$70 a month.”
In January 2010 the Director General of the World Health Organization (WHO) called for an “informal consultation on the future of financing for WHO” and in her opening remarks expressed the need to make the WHO fit for purpose given the unique health challenges of the 21st century.
Margaret Chan referred to the constitutional role that WHO has to “act as the directing and co-ordinating authority on international health work” and stated clearly that global health leadership today and for the future must be earned through strategic and selective engagement. She said, “WHO can no longer aim to direct and coordinate all of the activities and policies in multiple sectors that influence public health today.” This is a clear challenge that she has put to the global health community in recognition that WHO’s role must be clarified in the face of major change.
The United Nations Convention on the Rights of Persons with Disabilities (the CRPD or the Convention), adopted on December 13, 2006, and entered into force on May 3, 2008, constitutes a key landmark in the emerging field of global health law and a critical milestone in the development of international law on the rights of persons with disabilities. At the time of its adoption, the U.N. High Commissioner for Human Rights heralded the CRPD as a rejection of the understanding of persons with disabilities “as objects of charity, medical treatment and social protection” and an embrace of disabled people as “subjects of rights.”
The text of the Convention itself, and the highly participatory process by which it was negotiated, signal a definitive break from previous international approaches that focused on disability within a medical model framework. In contrast to traditional approaches, the CRPD embraces a social model of disability, concentrating the disability experience not in individual deficiency, but in the socially constructed environment and the barriers that impede the participation of persons with disabilities in society.
A decade ago, Jonathan Mann made a powerful case that human rights could provide a vocabulary and mode of analysis for understanding and advancing health. He made the case well, and put the idea into inspired practice, but the idea was neither new nor his alone. The idea that social justice — and henceforth in this article we will use that term loosely (and with obvious imprecision) to embrace goods like human rights, social equality, and distributive justice — was intrinsically important to health resonated with the social epidemiology already gathering force (not to mention an enduring theme running through the history of public health work). That social structure and relations of power explain a great deal about the level and distribution of population health was implicit in the work of pioneers like Geoffrey Rose, evident in Marmot’s seminal Whitehall studies, explicit in the writings of Mervyn Susser, and the main thrust of scholars like Nancy Krieger and Meredeth Turshen. Although researchers tend to avoid using a term with such normative weight, it is safe to say that Mann — and Susser, and Marmot and Krieger among others — were right: social justice is central to the proper understanding of health.
Natural selection generated a natural sense of justice. This natural sense of justice created a set of natural rights; rights humans accorded to each other in virtue of being members of the same tribe. Sharing the responsibility for natural rights between all members of the same tribe allowed humans to take advantage of all opportunities for cooperation. Human rights are the present day political emanation of natural rights. Theoretically, human rights are accorded by all humans to all humans in virtue of being humans; however, the idea that the corresponding responsibility is now shared among all humans is not broadly accepted. The natural sense of justice creates an ambiguity: on the one hand humans consider the nation they belong to as the social system that should guarantee their human rights (and likewise they do not consider themselves as having responsibility for the human rights of inhabitants of other nations); on the other hand, as cooperation between nations intensifies, expectations of global mutual responsibility increase as well.
Global health is a concept which in recent years has evoked a lot of interest from both academics, politicians, celebrities, and the media. The term “global health” implies a globally shared responsibility to provide health as a public good through an expansive number of initiatives. This emerging era of consciousness about our international interdependence, regardless of a problem’s geographic location or type of disease, may be a good moment for exploring the strengths and weaknesses of an international law approach to global health challenges: a global health convention.
The most prominent global health initiatives are the Millennium Development Goals (MDGs), the 2005 Paris Declaration Process on Aid Effectiveness on the need for alignment and coordination (PDP), and the 2008 Accra High Level Forum on Aid Effectiveness (AHLF). These instruments have yet to prove their value, and the funds annually disbursed, approximately $25 billion in 2009, could have better effect if the negotiated principles from the PDP and the AHLF were followed.
In coming decades, enhanced global health governance will be crucial to achieving international health and development objectives in the face of a number of challenges; this article focuses on one of them. Climate change, which is now widely recognized as the defining challenge of the 21st century, will make the work of ensuring the conditions in which people can be healthy more difficult in a myriad of ways. Scientists from both the health and climate communities have been highlighting the significant interaction between climate and health for decades and have made significant strides in integrating health and environmental research. Those of us in the law and policy community have been a bit slow to catch up, and have only just begun to call for better integration of our responses to health and environmental concerns. Environmental health specialists at the World Health Organization have recently pointed to a mandate for better integration of health and environmental concerns within the United Nations system. The Millennium Development Goals interweave health, environmental, and development concerns.
It is arguable that the delivery of global health has reached an impasse. This is evident not only in unresolved debates that are raging about where to allocate health aid or how to sustain and expand funding for AIDS treatment, but also in challenges facing national health systems that are incapable of purely domestic resolution. But there is some irony and much opportunity in this situation. Not only have the last 20 years seen an unprecedented growth in funding for health, mainly through funding for AIDS, but there has also been a range of initiatives and ideas that have generated better knowledge not only of the determinants of health, but also of how to attain it. Scientists, public health experts, and activists have created a store of intellectual knowledge, technology, and ideas, which, if properly and fairly deployed, might provide the opportunity to re-launch tangible progress towards the progressive realization of the right to health on a global scale.
Sexual assault cases are challenging for both the patient and provider, particularly given the emotional and logistic overlays in the majority of these cases. In this article we offer sexual assault programs information and areas for consideration when developing a policy addressing sexual assault examinations on patients who are either incapacitated or otherwise unable to consent to examination. This information is based on our experience in creating and implementing such a policy for our program. We also offer the written policy and associated consent form that we designed (see Figures 1 and 2).
The protocol manual for sexual assault medical forensic examinations authored by the Department of Justice actually recommends that each and every sexual assault nurse examiner (SANE) program have “internal policies based on applicable jurisdictional statutes governing consent for treatment of vulnerable adult patients. In cases of adolescents, the jurisdictional statutes governing consent and access to the exam should be followed.“
Washington, D.C.’s City Council has recently taken the first step towards legalizing the use of “medical marijuana” in accordance with the provisions of the Legalization of Marijuana for Medical Treatment Initiative of 1998 (Initiative 59). This action was not overruled by the United States Congress within the 30-day deadline imposed by the District of Columbia’s Home Rule Statute. The Council is now crafting regulations that will govern the therapeutic and palliative use of this drug with the goal of avoiding some of the problems faced by the other states that have legalized medical marijuana; however, the proposed rules do not establish criteria for legitimate medical practice when medical marijuana is recommended (discussed infra). If the enabling regulations are passed by the D.C. Council and not rejected by the Congress, the District of Columbia will join over onequarter of the states in legalizing medical marijuana (Table I). On the other hand, if the D.C. Council fails to act favorably on the final regulations (or if Congress nullifies the Council’s approval), then the effective legalization of medical marijuana will die and not be reconsidered until next year.
The 1981 Uniform Determination of Death Act (UDDA) states:
An individual that has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.
The “whole-brain concept of death,” appealed to in the UDDA, has been roundly criticized for many years. However, despite a great deal of legitimate criticism in academic circles no real clinical or legislative changes have come about. At least one reason for this inertia is aptly stated by James Bernat, one of the principal and founding proponents of the brain death doctrine: “In the real world of public policy on biological issues, we must frequently make compromises or approximations to achieve acceptable practices and laws.” While acknowledging that the brain death doctrine is not flawless and that he and other proponents have been unable to address all valid criticisms, Bernat nonetheless maintains that the brain death doctrine is optimal public policy.
The new science of genomics endeavors to chart the genomes of individuals around the world, with the dual goals of understanding the role genetic factors play in human health and solving problems of disease and disability. From the perspective of indigenous peoples and developing countries, the promises and perils of genomic science appear against a backdrop of global health disparity and political vulnerability. These conditions pose a dilemma for many communities when attempting to decide about participating in genomic research or any other biomedical research. Genomic research offers the possibility of improved technologies for managing the acute and chronic diseases that plague their members. Yet, the history of biomedical research among people in indigenous and developing nations offers salient examples of unethical practice, misuse of data and failed promises. This dilemma creates risks for communities who decide either to participate or not to participate in genomic science research.
Parents, providers, policy makers, and the public need to talk about the implications of advances in genomic technologies for state run newborn metabolic screening programs. Technologies, such as highly multiplex testing and whole genome sequencing, are raising old issues with new urgency and are posing new challenges that threaten to overwhelm newborn screening programs.
Newborn screening programs in their current form were born in the late 1960s. Robert Guthrie developed a screening test for phenylketonuria (PKU) that could be performed on blood spots collected on filter cards that Guthrie also developed. States rapidly established newborn screening programs, which were almost always mandatory, in response to advocacy by geneticists and parents. Although the programs initially varied in form and experienced significant pushback from the medical community, by the early 1970s, all states had established programs with centralized laboratories, and the medical community had come on board.
Our course on social justice and health began as an experiment between Roger Williams University School of Law and the Warren Alpert Medical School of Brown University. As a course for both law and medical students, it broke relatively new ground by focusing on the intersection between law and the social determinants of health and the ways in which lawyers and doctors might partner to address social and health disparities. The course blends professionalism, ethics, and problem-solving by using case studies that raise practical challenges at the intersection of poverty, law, and health. This kind of collaborative, interdisciplinary teaching presents many challenges and rewards, which I discuss in this essay.