HIV and Human rights 2010

HIV and Human rights 2010 - HIV and Human Rights HIV and...

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Unformatted text preview: HIV and Human Rights HIV and Human Rights April 2010 Frieda Behets Departments of Epidemiology, School of Public Health; Medicine, Division of Infectious Diseases University of North Carolina at Chapel Hill Outline Outline • • • • Should we care about HIV and human rights? The Universal Declaration of Human Rights The Millennium Development Goals The Global Human Right to Health – UN Institutions, Global Political Economy, Global Finance, Transnational Corporations, Aid, Governance The HIV/AIDS pandemic Framing determinants Global estimates for adults and children, 2008 • People living with HIV • New HIV infections in 2008 • Deaths due to AIDS in 2008 33.4 million [31.1 – 35.8 million] 2.7 million [ 2.4 – 3.0 million] 2.0 million [1.7 – 2.4 million] AIDS Epidemic Update 2009 http://www.unaids.org Adults and children estimated to be living with HIV, 2008 Western & Eastern Europe Central Europe & Central Asia North America [1.2 – 1.6 million] 1.4 million 240 000 Caribbean [710 000 – 970 [1.4 – 1.7 million] [710 East Asia 000] 000] 1.5 850 000 1.5 million [1.4 – 1.7 million] Middle East & North Africa [250 000 – 380 000] [700 000 – 1.0 million] 850 000 [220 000 – 260 000] 310 000 [1.8 – 2.2 million] 2.0 million Latin America Sub-Saharan Africa [20.8 – 24.1 million] South & South-East Asia [3.4 Oceania – 4.3 million] [51 000 – 68 000] 22.4 million 3.8 million 59 000 Total: 33.4 million (31.1 – 35.8 million) AIDS Epidemic Update 2009 http://www.unaids.org Determinants of the HIV/AIDS Epidemic Determinants (AIDS in the Twenty-First Century by Barnett and Whiteside, 2002) Determinants Distal determinants Macro environment Wealth Income Distribution Culture Religion Governance Interventions Social policy – Social redistribution redistribution Legal reform Human rights Taxation Debt relief Micro environment Mobility Urbanization Access to health care Levels of violence Women’s rights and status Social policy Economic policy Legal reform Employment legislation Behavior Rate of partner change Prevalence of concurrent Prevalence partners partners Sexual mixing patterns Sexual practices and Sexual condom use condom Breast feeding Behavior change Behavior communication communication Condom promotion and Condom marketing marketing Voluntary counseling and Voluntary testing testing IVDU harm reduction Proximal Proximal determinants determinants Biology Virus subtypes Stage of infection Presence of other Presence STDs STDs Gender Circumcision STD treatment Blood safety Anti-retroviral therapy Anti-retroviral during pregnancy during Vaccines/microbicides Vaccines/microbicides (when developed) (when Levels of inquiry Levels of inquiry • • • • • • Individual Partnership Social/sexual networks Community Societal/cultural Global The Driving Forces Affecting Human Health The Social-cultural capital Health Population Literacy Fertility Food and water availability Goods and services (health services, education) Ecological capital Food Water Biodiversity Climate change Indirect Effects Economic capital Income Infrastructure (Medical) Technology Transitions in a Globalising World, eds. Martens and Rotmans (2002); Figure 4.1 Total world population – 6,242 million in Total world population – 6,242 million in 2002 (Worldmapper.org) U.S. 309,150,396 World 6,817,421,367 14:00 UTC (EST+5) Apr 27, 2010 (http://www.census.gov) Life Expectancy at Birth, 2007 Life expectancy ­ an estimate of the average time that a Life expectancy ██ 77.5-80 ██ 77.5-80 75-77.5 newborn child is expected to live based on the current mortality ██ 75-77.5 ██ 72.5-75 72.5-75 rates and prevalence distribution of health states in the population. 70-72.5 ██ 70-72.5 Data Source: CIA World Factbook, 2007 ██ 67.5-70 67.5-70 ██ 65-67.5 65-67.5 ██ over 80 ██ 60-65 60-65 ██ 55-60 55-60 █ 50-55 50-55 ██ 45-50 45-50 ██ 40-45 40-45 ██ under 40 under ██ not available not Data Sources: World Resources Institute, 2006; United Nations World Population Prospects, 2004 Declining life expectancy Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950-2005 and UNAIDS, 2002. Report on the global HIV/AIDS epidemic The Top 10 Causes of Death Fact Sheet, WHO 2007 Healthy Life Expectancy by WHO Region, 2005 (Male and Female) Region, 80 70 60 50 40 30 20 10 0 Africa SE Asia E Med'n W Pacific Europe Americas USA 5455 40 42 66 63 53 54 68 62 67 63 67 71 World Health Statistics, 2007. http://www3.who.int/statistics/ HIV and Human Rights HIV and Human Rights Jonathan Mann, MD, MPH (1947­1998) “It was always safe for scientists and institutions to think of AIDS as a virus, a transmissible infection… but Dr. Mann structured it as a human rights issue, and a global rights issue.” James Curran 1. 2. 3. Health is a human rights issue Human rights are a health issue Linkages between health and human rights need to be measured HIV and Human Rights HIV and Human Rights Successful grass roots mobilization • The Treatment Action Campaign (TAC) in South Africa • “Since 1998, TAC has held government accountable for health care service delivery; campaigned against official AIDS denialism; challenged the world’s leading pharmaceutical companies to make treatment more affordable and cultivated community leadership on HIV and AIDS. Our efforts have resulted in many life­saving interventions, including the implementation of country­wide mother­ to­child transmission prevention and antiretroviral treatment programmes.” http://www.tac.org.za/community HIV and Human Rights HIV and Human Rights Examples of current issues • October 30, 2009: President Obama announces travel ban for HIV+ non­US citizens will end in January 2010 • “MSM are a high­risk group for HIV infection and human rights abuses in Malawi, Namibia and Botswana.” 34%­ 57% of MSM reported having been denied housing or health care, or afraid to seek health care or walk in community, or blackmailed. (Baral et al, PLoS one 2009) and convicted 9 MSM to 5 years in prison for being homosexual plus 3 years for “criminal association” (Moody, Bull World Health Organ, 2009) • In January 2009, the Senegalese government arrested HIV and Human Rights HIV and Human Rights Examples of current issues • AIDS stigma as an obstacle to uptake of HIV testing: evidence from a Zimbabwean national population­based survey (Sambisa et al, 2009 AIDS Care) AIDS day theme is "universal access and human rights," but in many parts of the world "legislation effectively criminalises populations living with HIV or vulnerable to HIV infection, such as sex workers, drug users, and men who have sex with men." (Moszynski, BMJ, 2009) • Human Rights Watch points out that this year’s world HIV and Human Rights HIV and Human Rights Examples of current issues • 2008 United Nations report: 94% of 133 nations report that their national HIV policies explicitly mention promotion and protection of human rights. • Only 22% of 133 nations report performance indicators • 71% of countries report protective laws or regulations for vulnerable subpopulations, yet 63% of those countries report existence of laws or policies that hinder access to HIV services for those populations. HIV and Human Rights HIV and Human Rights Examples of current issues • Exclusion of minorities, stigmatization and discrimination • • • • • • for sexual orientation, occupation, etc. Gender inequalities Neglect or abuse of children Poverty and inadequate access to primary health care Injustice in income and wealth distribution Impact of macroeconomics and the dominant economic model and increasing globalization ….. The Universal Declaration of The Universal Declaration of Human Rights (1945) • • Article 1. All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. Article 2. Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non­self­governing or under any other limitation of sovereignty. Article 3. Everyone has the right to life, liberty and security of person. • • • • Article 4. No one shall be held in slavery or servitude; slavery and the slave trade shall be prohibited in all their forms. Article 5. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. Article 6. law. Everyone has the right to recognition everywhere as a person before the The Universal Declaration of The Universal Declaration of Human Rights (1945) • • • • • Article 7. All are equal before the law and are entitled without any discrimination to equal protection of the law. All are entitled to equal protection against any discrimination in violation of this Declaration and against any incitement to such discrimination. Article 8. Everyone has the right to an effective remedy by the competent national tribunals for acts violating the fundamental rights granted him by the constitution or by law. Article 9. No one shall be subjected to arbitrary arrest, detention or exile. Article 10. Everyone is entitled in full equality to a fair and public hearing by an independent and impartial tribunal, in the determination of his rights and obligations and of any criminal charge against him. Article 11. (1) Everyone charged with a penal offence has the right to be presumed innocent until proved guilty according to law in a public trial at which he has had all the guarantees necessary for his defence. (2) No one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offence, under national or international law, at the time when it was committed. Nor shall a heavier penalty be imposed than the one that was applicable at the time the penal offence was committed. The Universal Declaration of The Universal Declaration of Human Rights (1945) • • • Article 12. No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence, nor to attacks upon his honour and reputation. Everyone has the right to the protection of the law against such interference or attacks. Article 13. (1) Everyone has the right to freedom of movement and residence within the borders of each state. (2) Everyone has the right to leave any country, including his own, and to return to his country. Article 14. (1) Everyone has the right to seek and to enjoy in other countries asylum from persecution. (2) This right may not be invoked in the case of prosecutions genuinely arising from non­political crimes or from acts contrary to the purposes and principles of the United Nations. Article 15. (1) Everyone has the right to a nationality. (2) No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality. Article 16. (1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution. (2) Marriage shall be entered into only with the free and full consent of the intending spouses. (3) The family is the natural and fundamental group unit of society and is entitled to protection by society and the State. • • The Universal Declaration of The Universal Declaration of Human Rights (1945) • • Article 17. (1) Everyone has the right to own property alone as well as in association with others. (2) No one shall be arbitrarily deprived of his property. Article 18. Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance. Article 19. Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers. Article 20. (1) Everyone has the right to freedom of peaceful assembly and association. (2) No one may be compelled to belong to an association. Article 21. (1) Everyone has the right to take part in the government of his country, directly or through freely chosen representatives. (2) Everyone has the right of equal access to public service in his country. (3) The will of the people shall be the basis of the authority of government; this will shall be expressed in periodic and genuine elections which shall be by universal and equal suffrage and shall be held by secret vote or by equivalent free voting procedures. • • • The Universal Declaration of The Universal Declaration of Human Rights (1945) • Article 22. Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co­operation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality. Article 23. (1) Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment. (2) Everyone, without any discrimination, has the right to equal pay for equal work. (3) Everyone who works has the right to just and favourable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection. (4) Everyone has the right to form and to join trade unions for the protection of his interests. Article 24. Everyone has the right to rest and leisure, including reasonable limitation of working hours and periodic holidays with pay. Article 25. (1) Everyone has the right to a standard of living adequate for the health and well­being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection. • • • The Universal Declaration of The Universal Declaration of Human Rights (1945) • Article 26. (1) Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit. (2) Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace. (3) Parents have a prior right to choose the kind of education that shall be given to their children. (1) Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits. (2) Everyone has the right to the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he is the author. Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized. • Article 27. • Article 28. The Universal Declaration of The Universal Declaration of Human Rights (1945) • Article 29. (1) Everyone has duties to the community in which alone the free and full development of his personality is possible. (2) In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society. (3) These rights and freedoms may in no case be exercised contrary to the purposes and principles of the United Nations. Nothing in this Declaration may be interpreted as implying for any State, group or person any right to engage in any activity or to perform any act aimed at the destruction of any of the rights and freedoms set forth herein. • Article 30. The Universal Declaration of Human The Universal Declaration of Human Rights – Not Universally Popular Women’s Rights Women’s Rights • 1980: United Nations General Assembly adopted the Convention on the Elimination of All Forms of Discrimination Against Women, or CEDAW. Seven countries have not ratified the international treaty: the United States of America, Iran, Sudan, Somalia, Nauru, Palau and Tonga. http://treaties.un.org/Pages/ViewDetails (accessed 4/14/10) Video Library Player: What Are You Carrying? http://video.nytimes.com/video/2010/03/08/opinion/1247467297119/what­are The Global Human Right to Health The Global Human Right to Health (TH MacDonald, 2007) • UN established in 1945 to promote international security, cooperation and peace • To make the Universal Declaration of Human Rights legally binding: The International Covenant on – 1) Civil and Political Rights – 2) Economics, Social and Cultural Rights • When a UN member ratifies a convention, it consents to alter its laws to conform to the convention, to report such changes, and to being monitored. The Global Human Right to Health The Global Human Right to Health (TH MacDonald, 2007) • WHO established in 1948 as UN’s agency for promotion of health – “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” • Primary health care as a “human right” and a comprehensive concept (to address social, economic and political causes and consequences of poor health)­ Alma Ata Declaration in 1978 The Global Human Right to Health The Global Human Right to Health (TH MacDonald, 2007) • Since 1988 WHO has increasingly seen PHC as desirable if it can be afforded and less as a human right because of financial globalization mechanisms and policies imposed by IMF, SAP and WTO • In 1944: Bretton Woods Conference (New Hampshire) to reorder the world’s finances and prevent international conflict ­ freedom of movement of goods between countries and US dollar as international currency regulation, private over public provision of services and goods, rejects redistributive policies (e.g. progressive taxation) and prioritizes low inflation rates. Low inflation benefits creditors, debtors lose. (Labonte et al, 2005) • Neoliberalism: ideology that emphasizes free markets over state Global Finance and Human Rights Global Finance and Human Rights (TH MacDonald, 2007) • World Bank and International Monetary Fund created to lend money to European countries destroyed by war less developed countries • After 1972­73 the WB and IMF loaned increasingly to • IMF loans are granted when the debtor nation agrees to structural adjustment policies ­ reducing expenditures for government services and privatizing health and education profitable for the banks in the developed world. • LDCs, especially those without domestic oil, were highly Global Finance and Human Rights Global Finance and Human Rights (TH MacDonald, 2007) • The IMF and WB work through commercial banks, mainly in US and UK. The repayment programs and SAPs generate great profits for the lending bank. Debtor nations often have to export goods to wealthy developed countries and privatize telephone and telecommunications, even water supply. • Peter Lee, March 11, 2010 Asia Times Online: “Somewhat absurdly, the DRC, even in the depths of the global recession in 2009, was making more than $170 million in interest payments to stay in the good graces of the IMF. This self­sacrifice is necessary so that the IMF will eventually certify to the Paris Club creditors that their $6 billion share of the DRC's $11 billion foreign debt is worthy of being written off.” DR Congo # 5 in 2009 (http://www.foreignpolicy) DR Congo # 5 in 2009 ( • The World Trade Organization established in 1995 to promote free trade. Global Finance and Human Rights Global Finance and Human Rights (TH MacDonald, 2007) detrimental effects on health and trade arising from WTO rulings, WTO policies undermine human rights. • Despite Doha Declaration in 2001 to protect LDCs from • Example – cotton: developed countries end export subsidies and reduce all tariffs more than those of LDCs. But domestic subsidies for cotton constitute about 85% of total US cotton support. under WTO rules deregulated developed world banks and transnational corporations can legally distort LDCs’ economies. • “The hidden face of developed world financial power” – 2007 World Development Indicators (World Bank) US Farm Subsidies: $177.6 billion US Farm Subsidies: $177.6 billion in 1995­2006 • 67% of all farmers/ranchers do not collect government subsidy payments in United States, according to USDA. subsidies or $130.6 billion over 12 years. • Among subsidy recipients, 10% collected 74% of all • Recipients in the top 10% averaged $36,290 in annual payments between 1995 and 2006. The bottom 80% of the recipients saw only $731 on average per year. http://farm.ewg.org/farm/region; accessed August 28, 2008 Globalization and its discontents Globalization and its discontents (J Stiglitz, 2002) • “Fiscal austerity, privatization, and market liberalization were the three pillars of Washington Consensus advice throughout the 1980s and 1990s.” the WTO­and a few players­the finance, commerce, and trade ministries, closely linked to certain financial and commercial interests­ dominate the scene, but … many of those affected by their decisions are left almost voiceless.” • “… a few institutions­the World Bank, the IMF, Gross Domestic Product (GDP) Per Capita Gross GDP: total market value of all final goods and services produced within the country during a year period Data Source: 2008 CIA World Factbook GDP RIP GDP RIP E Zencey, NYT August 10, 2009 • Excludes valuable production, e.g. volunteer work, housework, child rearing, DIY home improvement. • Replacement of natural­capital service with built­capital service increases GDP ­ benefit from nature (e.g. sun drying of clothes) not appreciated and benefits (restoration or protection of quality of life) • GDP does not distinguish between costs/activity Human Development Index (HDI) Human • The HDI is a summary composite index that measures a The country’s average achievements in three basic aspects of human development: longevity, knowledge, and a decent standard of living decent GDP for measuring social well-being because: (1) perGDP capita GDP measures only income whereas the HDI is capita also weighted for longevity and education, and (2) HDI is influenced by the type of goods that constitute GDP is development and an HDI 0.8 or more is considered to represent high development • The UNDP claims that the HDI is superior to per-capita The • An HDI below 0.5 is considered to represent low An Human Development Index, 2007 ██ 0.950 and over ██ 0.900­0.949 ██ 0.850­0.899 ██ 0.800­0.849 ██ 0.750­0.799 ██ 0.700­0.749 ██ 0.650­0.699 ██ 0.600­0.649 ██ 0.550­0.599 ██ 0.500­0.549 ██ 0.450­0.499 ██ 0.400­0.449 ██ 0.350­0.399 ██ 0.300­0.349 ██ under 0.300 ██ n/a Data Source: United Nations Human Development Report, 2007-2008 Human Development Index Human Development Index 2002 (Worldmapper.org) In 2004, optimum score of 1000 if life expectancy ≥85, adult literacy and school enrolment 100% and GDP US$ ≥40 000. Norway: 956, highest score; Sierra Leone: 273, lowest score Percent of Global Income by Population Quintiles “Basic Dimensions of the Global Economy”, National University of Singapore http://courses.nus.edu.sg/course/socsja/SC2202/Forces/Global1a.html GINI Index GINI • A measure of income inequality within a measure • • society society A statistic that summarizes the dispersion of statistic the income shares across the whole income distribution distribution GINI Index will equal 0 when the distribution GINI is completely egalitarian; it will equal 1 or 100% if all of society’s income accrues to only one person/household unit, leaving the rest with no income at all. rest UNDP - World Income Inequalities Database, United Nations University, World Institute for Development Economics Research; http://www.undp.org/poverty/initiatives/wider/wiid_measure.htm Distribution of Income Equality (GINI Index) Note: A higher GINI coefficient indicates a higher level of income/wealth inequality Data Source: United Nations Human Development Report, 2007-2008 Global Inequity and Poverty Global • ~1.5 billion people survived on < 1 US 1.5 dollar/day in 2005 (MacDonald TH, 2007) dollar/day • One billion people live in slums (UNFPA.org) • 1.02 billion people do not have enough to eat ­ more than the populations of USA, Canada and the European Union; (Source: FAO news release, 19 June 2009) Annual per capita health expenditure by country type (2002) by $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 $29 Lower income $5,274 $3,039 $84 Lower medium income $310 Upper medium income High income USA World Development Indicators, 2005 Public health spending – 2228 billion PPP Public health spending – 2228 billion PPP (purchasing power parity) US$ total in 2001 (Worldmapper.org) Private health spending – 1847 Private health spending – 1847 billion PPP US$ in 2001 (Worldmapper.org) Physicians working – 9,569,128 in Physicians working – 9,569,128 in 2004 or recent (Worldmapper.org) Factors that impoverish LDCs Factors that impoverish LDCs (TH MacDonald, 2007) • Loss of agricultural income within LDCs due to cheap foreign agricultural products • Structural violence and injustice resulting from foreign multinational interests and corrupt leaders • Health aid flowing from LDCs to high income countries (23% of MDs in USA qualified in LDCs, 20% of MDs in UK from Asian origin – savings on training and pay) US$ 500 million/year subsidies to the developed world Africa since 1986 • Sen estimated that medical and paramedical training in LDCs amounts to • Trade liberalisation under WTO has exacted about US$ 272 billion from • Africa repaid US $ 255 billion >4 times original 1990 debt. The Sachs report: investing in health for economic The Sachs report: investing in health for economic development­­or increasing the size of the crumbs from the rich man's table? (A Katz, Int J Health Serv 2005) • The Commission on Macroeconomics and Health report (Sachs report of 2001) … encourages medico­technical solutions to public health problems; it ignores macroeconomic determinants and other root causes of both poor health and poverty; … it reflects one particular economic perspective to the exclusion of all others; and it recommends greater amounts of charity while preserving the status quo of a deeply unjust and irrational international economic order. Health is conceived primarily as an input to productivity rather than as a human right. The benefits that would result from simple, macroeconomic measures directed toward social justice and the meeting of basic needs are incomparably greater than those that would result from following CMH recommendations in terms of sustainable improvements in both health and economic well­being. The ultimate source of poor health status and miserable living conditions is the extreme concentration of power, nationally and internationally, in the hands of the few. • • • Undernourishment in 2002 Undernourishment in 2002 (Worldmapper.org) The Millennium Development Goals The Millennium Development Goals (Geneva, 2000) The Millennium Development Goals The Millennium Development Goals (Geneva, 2000) • A pact between the world’s major economic players and those in less developed nations • Rooted in Human Rights Framework • Freedom, equality, solidarity, tolerance, respect for nature and shared responsibility • Eight goals are inter­linked and minimum development goals • The World Bank, IMF, regional development banks and WTO have agreed to be accountable for these goals • Cost: about US$ 50 billion per year (government expenditures in (TH MacDonald, 2007) 2003 globally for arms: 900 billion; agricultural subsidies in wealthy nations about US$ 300 billion/year) The Millennium Development Goals The Millennium Development Goals (Geneva, 2000) 1. 2. 3. 4. 5. 6. 7. 8. Globally, achieve by 2015: Eradication of extreme poverty Universal primary education Promotion of gender equality and empowerment of women Reduction of child mortality Improvement of maternal health Combating HIV/AIDS, malaria, TB and other diseases Environmental sustainability Global partnership for development The Millennium Development Goals The Millennium Development Goals • Threats to achieving the goals: – Delays in implementation – Resistance to MDGs in the high income world • National and corporate interests vs. global welfare • US government: in 2005 John Bolten (acting US Ambassador to the UN) wanted 750 changes to the 39 pages long UN Report including removal of all 14 references to the MDGs that included <reducing by half the number of people living on less than US$ 1 per day by 2015> (1.3 billion people in 2005). (TH MacDonald, 2007) Foreign Aid and Health Foreign Aid and Health Newsweek, July 21, 2003 Newsweek, July 21, 2003 Newsweek, July 21, 2003 Poverty reduction needs both aid and trade (Lancet, 2006; 368: 706) (Lancet, • Commitment to Development Index (CDI): a composite Commitment score for rich countries to track their commitment to poverty reduction ( http://www.cgdev.org/section/initiatives/_active/cdi) • • • • Development aid in 2005: 106.5 billion $ Includes aid to Iraq and debt relief “… quality and type of aid matters just as much as “… quantity.” Aid is less important than “pro-poor economic growth”; Aid trade, migration, security matter more. trade, Trade and social determinants of health Trade and social determinants of health (Blouin et al, Lancet 2009) Financing of global health: tracking development Financing of global health: tracking development assistance for health from 1990 to 2007 (Ravishankar et al, Lancet 2009) • Development assistance for health from $5.6 billion in 1990 to $21.8 billion in 2007 • Proportion of DAH channeled via UN agencies and development banks decreased • GFATM, GAVI, and NGOs increased • Increased funding since 2002: public funding, philanthropic, in­kind corporate donations • Total DAH received positively associated with disease burden and negatively with per capita GDP Good governance Good Globally, in low, middle and high income Globally, countries countries Politics and health outcomes (Navarro et al, Lancet 2006) (Navarro • Do political ideologies of governing parties affect Do indicators of population health? indicators • Policies aimed at reducing social inequalities have a Policies salutary effect on infant mortality and life expectancy at birth. at Millennium Development Goals Millennium Development Goals Millennium Development Goals Millennium Development Goals 2008 Report – the good news • The overarching goal of reducing absolute poverty by half is within reach for the world as a whole; • In all but two regions, primary school enrolment is at least 90%; • The gender parity index in primary education is ≥95% in six of the 10 regions, including the most populous ones; • Deaths from measles fell from over 750,000 in 2000 to <250,000 in 2006, and about 80% of children in developing countries now receive a measles vaccine; in 2007, and the number of people newly infected declined from 3.0 million in 2001 to 2.7 million in 2007; before the target date of 2015; • The number of deaths from AIDS fell from 2.2 million in 2005 to 2.0 million • The incidence of tuberculosis is expected to be halted and begin to decline Millennium Development Goals Millennium Development Goals 2008 Report – the good news • Malaria prevention is expanding, with widespread increases in insecticide­ • Some 1.6 billion people have gained access to safe drinking water since 1990; treated net use among children under five in sub­Saharan Africa: in 16 out of 20 countries, use has at least tripled since around 2000. • The use of ozone­depleting substances has been almost eliminated and this has contributed to the effort to reduce global warming; • The share of developing countries’ export earnings devoted to servicing external debt fell from 12.5 per cent in 2000 to 6.6 per cent in 2006, allowing them to allocate more resources to reducing poverty; drugs and rapidly spread mobile phone technology throughout the developing world. • The private sector has increased the availability of some critical essential Millennium Development Goals Millennium Development Goals 2008 Report – the bad news • The proportion of people in sub­Saharan Africa living on <$1 per day is unlikely to be reduced by the target of one­half; • About one quarter of all children in developing countries are considered to be underweight and are at risk of having a future blighted by the long term effects of undernourishment; secondary school enrolment by the target date of 2005, only 18 are likely to achieve the goal by 2015; vulnerable jobs as own­account or unpaid family workers; cent of parliamentarians; • Of the 113 countries that failed to achieve gender parity in both primary and • Almost two thirds of employed women in the developing world are in • In one third of developing countries, women account for less than 10 per • More than 500,000 prospective mothers in developing countries die annually in childbirth or of complications from pregnancy; Maternal mortality for 181 countries, 1980–2008: a Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5 (Hogan et al, 2010 Lancet) • MDG 5 target is 75% reduction in maternal mortality ratio (MMR) from 1990 to 2015. • Maternal mortality evaluated in 181 countries for 1980–2008, from vital registration data, censuses, surveys, and verbal autopsy studies. • Estimated 342 900 (uncertainty interval 302 100–394 300) maternal deaths worldwide in 2008, down from 526 300 (446 400–629 600) in 1980. • >50% of all maternal deaths in six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). maternal deaths worldwide in 2008. • In the absence of HIV, there would have been 281 500 (243 900–327 900) • Substantial progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving Millennium Development Goals Millennium Development Goals 2008 Report – the bad news • Some 2.5 billion people, almost half the developing world’s population, live without improved sanitation; live in slum conditions; • More than one third of the growing urban population in developing countries • Carbon dioxide emissions have continued to increase, despite the international timetable for addressing the problem; • Developed countries’ foreign aid expenditures declined for the second consecutive year in 2007 and risk falling short of the commitments made in 2005; • International trade negotiations are years behind schedule and any outcome seems likely to fall far short of the initial high hopes for a development­oriented outcome. Bibliography Bibliography • The Global Human Right to Health. 2007 Theodore H MacDonald, Radcliffe Pub Ltd. Oxon, UK • International Guidelines on HIV/AIDS and Human Rights. 2006 Consolidated version, UNAIDS • Health for Some: Death, Disease and Disparity in a Globalizing Era. Labonte R, Schrecker T, Gupta AS, 2005 CSJ Research and Education Books Ltd. London, UK. • Globalization and its discontents. 2002 Joseph E Stiglitz, Penguin • Human Rights in the Global response to HIV: Findings from the 2008 United Nations General Assembly Special Session Reports. Gruskin et al. JAIDS, 2009 Resources Resources • Making sense of the global economy: 10 resources for health promoters. Mohindra KS, Labonte R. 2010, Health Promotion Int • Life and Debt – a documentary on the impact of the International Monetary Fund, the World Bank, the Inter­ American Development Bank and current globalization policies on a developing country such as Jamaica. http://www.lifeanddebt.org/ • Nef, the new economics foundation – “economics as if people and the planet mattered” http://www.neweconomics.org/ HIV/AIDS prevention, care HIV/AIDS prevention, care and treatment Global support WHO’s 3 by 5 Strategy WHO’s Treating 3 million people by the end of 2005 Emergency scaling up of antiretroviral therapy The Five Pillars of the Strategy Global leadership, strong partnership and advocacy Urgent, sustained country support Simplified, standardized tools for delivering antiretroviral therapy Effective, reliable supply of medicines and diagnostics Rapidly identifying and reapplying new knowledge and successes http://www.who.int/3by5/publications/documents/en/3by5StrategyMakingItHappen.pdf ART Coverage of Adults as of June 2005 “Since its creation in 2002, the Global Fund has become the main source of finance for programs to fight AIDS, tuberculosis and malaria, with approved funding of US$ 19.3 billion for more than 572 programs in 144 countries. It provides a quarter of all international financing for AIDS globally, two­thirds for tuberculosis and three quarters for malaria.” • At the end of December 2009, programs financed by the Global Fund • • • were providing ART to 2.5 million people, provided treatment to 6 million people who had active TB, distributed 104 million insecticide­treated nets (ITNs) to prevent malaria, combined efforts saved an estimated 4.9 million lives http://www.theglobalfund.org accessed 4/24/2010 The Global Fund: Resource Mobilization The http://www.theglobalfund.org/en/files/publications/basics/progress_update/progressupdate.pdf • Passed by Congress in May 2003, approved expenditure of $15B Passed $15B over 5 years over Domestic $17.5B – Domestic HIV expenditure was $17.5B in FY2005 Botswana, – Africa: Botswana, Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia Namibia, – Caribbean: Guyana, Haiti – Asia: Vietnam • Focus on 15 ‘target countries’: • “During its first phase, PEPFAR supported the provision of treatment to more than 2 million people, care to more than 10 million people, including more than 4 million orphans and vulnerable children, and prevention of mother­to­child treatment services during nearly 16 million pregnancies.” PEPFAR Allocation of resources Laid out in the bill passed by Congress: Laid 55% for HIV treatment (75% of this to be spent on purchase (75% and distribution of ARVs) and 15% for palliative care 20% for HIV/AIDS prevention (1/3 of this to be spent on abstinenceuntil-marriage programs) 10% for orphans and vulnerable children PEPFAR: Reauthorization in July 2008: $48B over 5 years 2008: • • • • • • • $39 billion for: PEPFAR bilateral HIV/AIDS programs PEPFAR U.S. contributions to the Global Fund to Fight HIV/AIDS, U.S. Tuberculosis and Malaria $5 billion to: The President’s Malaria Initiative to fight malaria through The bilateral programs around the world $4 billion for: Bilateral programs to fight tuberculosis, the leading killer Bilateral of Africans living with HIV http://www.pepfar.gov/press/107735.htm; accessed August 28, 2008 http://www.pepfar.gov/press/107735.htm Program Targets 2010­2014 : Program Targets 2010­2014 : • Working in partnership with host nations, PEPFAR will support: • Treatment for >4 million people • Prevention of >12 million new infections • Care for >12 million people, including 5 million orphans and vulnerable children http://www.pepfar.gov/press/107735.htm; accessed 4/24/2010 PEPFAR Achievements PEPFAR Achievements • Through its partnerships with more than 30 countries, as of September 30, 2009, PEPFAR directly supported life­saving antiretroviral treatment for over 2.4 million men, women and children. nearly 11 million people affected by HIV/AIDS, including 3.6 million orphans and vulnerable children. In FY 2009, PEPFAR directly supported prevention of mother­to­child transmission programs that allowed nearly 100,000 babies of HIV­positive mothers to be born HIV­free, adding to the nearly 240,000 babies born without HIV due to PEPFAR support during FYs 2004­2008. In FY 2009, PEPFAR also directly supported HIV counseling and testing for nearly 29 million people, providing a critical entry point to prevention, treatment, and care. http://www.pepfar.gov/press/137673.htm accessed 4/24/2010 • Through September 30, 2009, PEPFAR partnerships directly supported care for • • • ...
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