THE HUMAN RIGHT
TO HEALTH DILEMMA
Books on global health often start with a nasty shock: a disturbing detailed example, or bare statistics presented with a pretense of scientific objectivity. Take the following, unearthed by the Nobel Prize-winning development economist and political philosopher Amartya Sen, in a foreword to the wonderful book Pathologies of Power by medical doctor and anthropologist Paul Farmer, about whom we will be hearing more later. In 1990 the median age at death in sub-Saharan Africa was just five years, which is to say that the number of infants and young children who died before reaching the age of five was the same as the number of deaths of everyone who survived beyond five years.1 Looking at his source, the World Development Report for 1993, we see something even more troubling. In Mozambique, Sierra Leone, Guinea, and Afghanistan the median age of death was a mere two years. This compares to thirty-seven in India, sixty-four in China, and seventy-five in what the report calls “the Established Market Economies.”2
Very high levels of infant mortality were once a fact of life (if that is the way to put it) everywhere in the world, but they have not been seen for generations in those established market economies. Decent food and housing, as well as modern hygiene and sanitation remove many of the threats to infant health. The assistance of skilled midwives and doctors in birth shrink newborn mortality. And a range of medical techniques, from advanced surgery to simple powders to overcome diarrheal dehydration, can make a huge difference to survival in childhood. We do not need to make new medical discoveries or invent new vaccines or pharmaceuticals to prevent the great majority of the world’s infant deaths—or adult deaths, for that matter. So it may seem as obvious as anything that the world community has the moral duty to take action. But what sort of duty is this? And conversely, what sorts of moral claims does each individual have to a full life in good health?
Many theorists and activists now argue that there is a human right to health, and that the early death and recurrent illness of so many millions of people show that this right is being violated on a vast scale. But of course, the claim that there is a human right to health raises a whole host of further questions. Is there really a right to health? What does this actually mean? What does it call for in practice? Even those with good answers to the theoretical questions may feel daunted by the practical issues. Providing essential medical care and keeping people free from disease by providing nutrition, clean water, sanitation, and decent working and housing conditions may not seem much to ask, until we start to think about the cost and who should pay it. General programs to protect people from environmental threats to health and for universal advanced medical care are simply beyond the resources of many, perhaps most, of the countries of the world. Claiming that there is a universal human right to health can seem naive. It is, according to some commentators, utterly unrealistic, even close to dishonest. It has also been argued to be disastrous, diverting countries from systematic, cost-effective, investment in health systems, devoting funds to those who shout the loudest. But the main difficulty is this: how can there be a human right to health if the resources are just not there to satisfy it? 3
That dilemma is the subject of this book. On the one hand, the reasons for asserting a human right to health seem overwhelming. On the other, a universal human right to health seems impossible to satisfy in the current conditions of the world. Some theorists consequently reject the idea of a human right to health, arguing that we need to approach global health issues in a more pragmatic fashion. Others, more idealistic, have held fast to the idea of a human right to health, arguing that it is too important and basic to be surrendered. Their task is then to work out how to make the human right to health realistic. This book will be an exercise in cautious idealism.