Table of Contents, Vol 12, No 2 (2010), Health and Human Rights (open access)

Table of Contents, Vol 12, No 2 (2010), Health and Human Rights

Social determinants of health: Convergences and dysjunctures

Table of Contents and Frontmatter HHR 12.2 Journal ABSTRACT PDF

Collaborative imperatives, elusive dialogues [Editorial] Alicia Ely Yamin, Alec Irwin ABSTRACT HTML PDF

Critical Concepts

The right to sutures: Social epidemiology, human rights, and social justice Sridhar Venkatapuram, Ruth Bell, Michael Marmot ABSTRACT HTML PDF

The social determinants of health, health equity, and human rights Audrey R. Chapman ABSTRACT HTML PDF

Social conditions, health equity, and human rights Paula Braveman ABSTRACT HTML PDF

Laurie Garrett, Council on Foreign Relations

December 1, 2010

Dear Friends and Colleagues;

The CFR Global Health Program devoted considerable time this year to the preparation of a Declaration and Statement for the UNAIDS High Level Commission on HIV Prevention. I chaired the Scientific Advisory Panel that painstakingly prepared the consensus documents. The Declaration was released today by the Commission, which is cochaired by Nobel laureates Desmond Tutu and Françoise Barré-Sinoussi.

· Declaration of the UNAIDS High Level Commission on HIV Prevention

· Press Release

· The Commissioners on World AIDS Day

Given recent successes in innovations for HIV prevention, there is hope that leaders worldwide can put attention and resources to pushing the pandemic backwards at a high pace.

Meanwhile, of course, there is great concern that the new Congress, taking their seats after the New Year in Washington, DC, will slash the budgets for foreign assistance, overall, and HIV treatment and prevention in particular. With this as background, former President George W. Bush penned an opinion piece in today's Washington Post, calling for continued support of HIV treatment and PEPFAR, the program he created during his first term.

As has been tradition in the United States since the presidency of George H. W. Bush, President Barack Obama issued a statement for World AIDS Day today.

Unfortunately, President Barak Obama did not mention prevention of the further spread of HIV. During his administration, Bush promoted the ABC's -- Abstinence, Be faithful, and as a last resort, use Condoms. This policy, which failed to stem the tide of spread of HIV, was not referred to in today's editorial. Former Bush speechwriter Michael Gerson and former PEPFAR Ambassador Mark Dybul co-authored another editorial of support for continued financing of HIV programs, appearing in Huffington Post.

Yesterday the Global Health Program convened an important meeting in New York regarding the impact of the world financial crisis on funding for global health, writ large, and HIV specifically. Dr. Christopher Murray presented the latest assessment of financing trends, from the Institute for Health Metrics (IHME). And Dr. Alexander Preker, Head Health Industry and Investment Policy Analysis for the Investment Climate Department at the World Bank, offered responding comments and analysis. Among the most important findings highlighted by Murray and Preker are:

- While support for global health in general, and HIV in particular, continued to grow in 2008 and 2009, despite the financial crisis, the rate of growth slowed. This trend overall is worrying.

- Globally, philanthropic and private giving dropped considerably, leaving a single player -- the Gates Foundation -- responsible for 57 percent of all nongovernmental support for global health. That is worrying because any policy changes executed by the Gates Foundation will have a disproportionate impact.

- Also globally, the United States was responsible for more than half of all government giving for global health, and a far more considerable percentage of HIV support. This renders the entire global health effort highly vulnerable to Congressional whims, budget cuts, or prioritizations.

IHME Report- Financing Global Health 2010: Development assistance and country spending in economic uncertainty

Sincerely,

Laurie Garrett

Senior Fellow for Global Health

College Campuses Are Producing a New Style of AIDS Activist

New York Times

November 30, 2010

College Campuses Are Producing a New Style of AIDS Activist

By SHERYL GAY STOLBERG
NEW HAVEN — David Carel was never a rabble-rouser. But amid the clutter of his dorm room at Yale University, Mr. Carel, baby-faced and slight-shouldered at 19, keeps evidence of his new life as an AIDS activist: posters, banners and the flier demanding “$50 bn for Global AIDS” that he concealed in his fleece jacket one Saturday in late October when, heart pounding, he sneaked past security into a Democratic campaign rally in Bridgeport.

There, Mr. Carel did something he “never would have imagined”: he heckled the president of the United States.

Cameron Nutt, a medical anthropology student at Dartmouth, says he backs President Obama “100 percent.” But, incensed over the president’s “failure to remain true” to a campaign promise to spend $50 billion over five years fighting the AIDS epidemic overseas, Mr. Nutt disrupted Mr. Obama this fall at a Boston rally. His co-protesters included Luke Messac, a University of Pennsylvania medical student and a field organizer for Mr. Obama’s presidential campaign, and Krishna Prabhu, a Harvard University senior who caucused for Mr. Obama in Iowa in 2008 — and rescheduled his final exam in global health to attend the president’s inauguration.

“The promise has not been fulfilled,” Mr. Prabhu said, sounding more disappointed than angry.

Roughly a quarter-century after gay men rose up to demand better access to H.I.V. medicines, a new breed of AIDS advocate is growing up on college campuses. Unlike the first generation of patient-activists, this latest crop is composed of budding public health scholars. They are mostly heterosexual. Rare is the one who has lost friends or family members to the disease. Rather, studying under some of the world’s most prominent health intellectuals, they have witnessed the epidemic’s toll during summers or semesters abroad, in AIDS-ravaged nations like Rwanda, Tanzania and Uganda.

College activism, and AIDS activism in particular, is nothing new. On Wednesday, World AIDS Day, students across the nation will participate in speeches, fund-raisers and the like. But a loose-knit band of about two dozen Ivy Leaguers, mostly from Harvard and Yale, is using more confrontational tactics, as well as some high-powered connections, to wangle encounters with top White House officials in a determined, and seemingly successful, effort to get under Mr. Obama’s skin.

Their protests — which have drawn a sharp rebuke from the president (not to mention some disapproving parents) — come as many in the AIDS advocacy community are wondering aloud whether Mr. Obama is as devoted to their cause as his immediate predecessor, George W. Bush. In 2003, Mr. Bush began vastly increasing spending on lifesaving antiretroviral medicines for AIDS patients in impoverished nations; the number receiving the drugs has shot up from 50,000 to more than five million today. Yet the World Health Organization says as many as 10 million lack needed therapy.

While spending on global AIDS has gone up on Mr. Obama’s watch, and the United States remains the world’s largest contributor to such programs, independent analysts say that the rate of increase has slowed significantly and that it will be difficult for the president to keep his $50 billion pledge — or even meet a lesser goal, set in 2008 by Congress, of $48 billion for AIDS, tuberculosis and malaria by 2013. The task may grow even harder under a new Congress, with the incoming House Republican majority intent on cutting spending and Tea Party-backed Republicans in both chambers expressing skepticism about all types of foreign aid.

Still, armed with data from Health Gap, an AIDS advocacy group, the students are determined to hold Mr. Obama to his word. When Ezekiel Emanuel, a bioethicist and health adviser to the president (and brother of the former White House chief of staff, Rahm Emanuel) spoke at Yale two weeks ago, he wound up sparring with Mr. Carel at a fruit-and-cereal breakfast at the campus Hillel House, a meal arranged by a fellow Yale student, Dr. Emanuel’s daughter. Later that day, Mr. Carel led a demonstration outside Dr. Emanuel’s talk, which ended with students chanting at the adviser as they followed him down the street.

When Eric Goosby, Mr. Obama’s global AIDS coordinator, traveled to Boston in November for a panel discussion with Senator John Kerry, Democrat of Massachusetts, he was collared at a cocktail party by Mr. Prabhu, the Harvard senior. Also on the panel was Mr. Prabhu’s professor, Dr. Paul E. Farmer, founder of the global nonprofit Partners in Health.

“These students are my retirement plan,” Dr. Farmer said in a telephone interview from Haiti, where he is treating cholera patients. “A lot of them are doing much more than going to protests; they’re writing papers and articles, they’re doing graduate studies.”

Mr. Messac, the University of Pennsylvania medical student, explored the origins of Mr. Bush’s AIDS program in a 120-page paper, “Lazarus at America’s Doorstep,” for his Harvard undergraduate thesis. Mr. Carel, who spent last summer working at a hospital in the rural South African village of Tugela Ferry, now studies Zulu and persuaded a visiting professor from South Africa to let him take her upper-level course on “the political economy of AIDS.” (He had to skip Zulu class for the Emanuel protest; he said his professor understood.)

The students have also befriended a longtime veteran of the AIDS wars, Gregg Gonsalves, who at 47 is completing his undergraduate degree in evolutionary biology on a full scholarship at Yale. Mr. Gonsalves often lectures public-health classes on what he calls “ancient history” — the work of groups like Act Up in the 1990s.

“Theirs is not a first-person commitment, in the sense that none of them is living with H.I.V.,” Mr. Gonsalves said of the new AIDS protesters. “It’s all based out of a sense of solidarity and social justice. I used to wonder where the next generation would come from. They’re here.”

Inside the White House, Dr. Emanuel, for one, is not impressed. He says the students are serving up tired arguments about dollar amounts that ignore the Obama administration’s emphasis on spending money more efficiently and offering services, like circumcision, that can reduce the spread of H.I.V. While Mr. Bush emphasized AIDS and malaria, Mr. Obama is promoting a six-year, $63 billion “global health initiative” that seeks to address a range of diseases, with emphasis on women and children.

“To be honest, and this is no put-down to the sincerity of the students, I didn’t hear a new argument that I haven’t heard for months,” Dr. Emanuel said in an interview after his breakfast with Mr. Carel. “I’ve not seen a blog post on the number of people we have circumcised, or the number of mothers we treat in maternal-child health. Those are real performance measures.”

Dr. Emanuel would not discuss any conversations with the president about the students, but Mr. Obama’s reaction when he was disrupted in October at the rally in Bridgeport made clear he was irked. “You’ve been appearing at every rally we’ve been doing,” the president complained, telling them it was not “a useful strategy.”

The students were pleased that he addressed them directly, but their heckling prompted even some fellow AIDS activists to take issue with their tactics. Regan Hofmann, editor in chief of Poz, a magazine for people living with or affected by H.I.V., questioned the wisdom of disrupting the president on the eve of a critical election for Democrats.

Mr. Carel says he and his fellow protesters thought long and hard about that. It was his first demonstration; his parents told him they wished he would be “more respectful.” His friends were shocked. Still, he says it was worth it.

“There are very few ways we could have any access to him,” he explained. “This was a way to get Obama’s ear.”

A New (more effective!) Way to Talk About the Social Determinants of Health

The Robert Wood Johnson Foundation has produced a very interesting document that reports on its effort to translate the science of "social determinants of health" into messages that resonate with all Americans, across the political spectrum. The full report is really worth looking at. (click on the title above to go to page and report)

Here is a small excerpt.

" Below you’ll find one long-form message that was developed, revised,
tested and revised again based on what the research showed us.
It was consistently the most persuasive message among all groups,
regardless of their political perspective. While we are not necessarily
recommending that you use this in its entirety, it is helpful to understand
why the phrase worked."

America leads the world in medical research and
medical care, and for all we spend on health
care, we should be the healthiest people on Earth.
Yet on some of the most important indicators,
like how long we live, we’re not even in the top 25,
behind countries like Bosnia and Jordan. It’s time
for America to lead again on health, and that
means taking three steps. The first is to ensure
that everyone can afford to see a doctor when
they’re sick. The second is to build preventive
care like screening for cancer and heart disease
into every health care plan and make it available
to people who otherwise won’t or can’t go in for
it, in malls and other public places, where it’s easy
to stop for a test. The third is to stop thinking
of health as something we get at the doctor’s
office but instead as something that starts in our
families, in our schools and workplaces, in our
playgrounds and parks, and in the air we breathe
and the water we drink. The more you see the
problem of health this way, the more opportunities
you have to improve it. Scientists have found that
the conditions in which we live and work have an
enormous impact on our health, long before we
ever see a doctor. It’s time we expand the way
we think about health to include how to keep it,
not just how to get it back.

WHY THIS WORKED:

• Audiences flat out didn’t believe the
statement, “America is not among the top
25 countries in life expectancy,” and they
responded negatively to any message
that led with that statement. However,
when we start off with something most
Americans already believe, “Americans
lead the world in medical research and
medical care,” they are more likely to
believe everything that follows.

• Words like “insured or “uninsured” are
politically loaded. But the phrase “ensure
everyone can afford to see a doctor when
they are sick” doesn’t touch existing
political hot buttons.

• Framing our message in the context of
accepted beliefs like the importance
of access to care or prevention helps our
message fit into the broader thinking of
what it takes to be healthy.

• The inclusion of specific solutions increased
acceptance of the core message.

• Illustrating with examples like “playgrounds
and parks” and “in the air we breathe and
water we drink,” makes the concept of
social factors more tangible.

• In the statement, “Scientists have found,”
other options were tested with more
specificity, such as “Scientists at the
Centers for Disease Control and at
universities around the country have
shown that the conditions in which
people live and work have more than
five times the effect on our health
than all the errors doctors and hospitals
make combined.” Presenting the fact
in a more colloquial, relatable way,
stripped of the academic support, is
more effective than a longer statement.

“Claptrap” from the UK's Department of Health

The Lancet, Volume 376, Issue 9753, Page 1617, 13 November 2010 Original Text

The Lancet


The Lancet remembers well the genuine excitement we felt at the commitment that the Labour government made in 1997 to attack health inequalities in Britain. The dismal record of the Conservatives before them—who hated the very idea of inequalities, preferring instead “variations” in health—left a deep scar on the National Health Service. The creation of Donald Acheson's Independent Inquiry into Inequalities in Health was a new opportunity to recalibrate the health service to meet the needs of the most deprived communities in the UK. Our sense of hope was, it turned out, misplaced. Labour presided over 13 years of failure. Inequalities in health widened despite huge investment in the NHS. The reasons for this failure have now been exposed in an astonishingly candid report, published last week by the House of Commons Public Accounts Committee. This committee examines how taxpayers' money is spent. It is chaired by a Labour Member of Parliament, Margaret Hodge. She has produced a tale of decrepitude at every level of the health system.

Labour was elected in 1997 with a promise and mandate to tackle inequalities in health. Yet it took 9 years (to 2006) before ministers and their civil servant officials made inequalities an NHS priority. “What on earth went wrong?”, asked Hodge. She was questioning the Department of Health's Permanent Secretary, Richard Douglas, together with Ruth Hussey (a regional director of public health) and Mark Davies (the Department's Director of Health Inequalities). Douglas was evasive. Hodge dismissed his “claptrap” as “despairing”. Eventually, he admitted that his Department's interpretation of ministers' election commitments was merely “aspirational” (ie, it did not have to be taken seriously).

The picture of government he painted was far from flattering. Figures showing the worsening situation for health equality would be sent to the Department and forwarded to ministers. But civil servants—including, it seems, the Chief Medical Officer—did little to address the growing problem. The best officials could do collectively was send out “toolkits” of guidance to primary care trusts and cross their fingers that they might trigger a response. But the Department had no mechanism to monitor or evaluate the implementation of what limited guidance it did provide. It was a “fair criticism” to say that “we were slow off the mark”, conceded Douglas. Members of the Public Accounts Committee were clearly shocked by this admission. As Hodge put it: “It takes us nine years—that is just gobsmacking.” Another said, “it's a mess, it's a tragedy really.”

The government and civil service were not wholly to blame. Where was the medical profession? Doctors are supposed to feel an acute responsibility to deliver the best health service to the whole population. It is on this basis that they ask the public and government to support generous pay increases and terms and conditions of service. These attitudes and behaviours are what we commonly mean by professionalism. It seems that doctors failed completely to live up to the rhetoric of their commitment to professional values. Members of Hodge's committee tried to find out why doctors had been so reluctant to address inequalities themselves. There are some simple and proven interventions that, if implemented evenly across the population, would go a long way to reduce inequalities in health—notably, smoking cessation and the treatment of high blood pressure and raised cholesterol. But doctors did not respond to the clear public and political call to take action on inequalities (and nor did the media). Instead, they sought to massively increase their salaries in a new general practitioner (GP) contract in 2005, one that itself was empty of commitment to reduce inequalities. People died because of this professional failure. The negotiators of that GP contract, together with the Department of Health, share a responsibility for those deaths.

During the course of this systemic failure, the Department of Health employed over 2300 people. Mr Douglas earns £170 000. Yet this great number of civil servants and their highly paid Permanent Secretary (including Mr Douglas's predecessors) failed to deliver on a public promise, democratically endorsed. A bureaucracy's first priority is usually to protect itself. Only secondarily will it try to deliver on the pledges of its political leaders. To call this period in the Department's history shameful does not even begin to do justice to the way it let down the millions of people to whom it owed a duty to serve. Despite the bland reassurances made to the Public Accounts Committee, there is not one shred of evidence that the Department has learned the lessons of this agonising debacle.

Cornel West keynote at American Public Health Association 2010 on Social Justice

Part 1. Click on title in video to go to youtube page for parts 2 and 3.

Making visible global injustice in health.

Making visible global injustice in health: mapping the causes of 57 million deaths

View more presentations from Sasi Research Group, Department of Geography, University of Sheffield.