In a recent opinion piece in the Financial Times, William Easterly argued that a rights-based approach to health care would favor the agendas of the rich and powerful, leaving the poor to die of neglected diseases. He then contends that holding ourselves to such unrealistically high standards would open the floodgates for unchecked spending, “since any of us could get healthier with more care.” Unfortunately, both of his slippery slope arguments are premised on inaccurate assumptions about the right to health, health spending dynamics in the US, and the history of global health assistance. The inequalities he describes are not the result of a push to promote health as a universal good. Instead, they are the flawed legacy of institutions and policies that persist in treating health as a commodity.
At a basic level, Easterly distorts the purpose and scope of a rights-based approach to health, specifically what is meant by “highest attainable standard of health.” He frames this as a personal right to absolute health, subject to immediate realization, when it is actually a collective right to equivalent health, subject to progressive realization (ICESCR, Art. 12). This mischaracterization underlies Easterly’s argument that human rights operate in a zero-sum environment. In reality, the right to health goes beyond mere delivery of goods and services; it is fundamentally concerned with promoting equitable outcomes and empowering people to achieve these.... The problem is not one of scarcity: rich countries contribute less than 1% of their gross national income to support health care in poor countries. Rather, it is one of exclusion: the current balance of rights and duties fails to contemplate that everyone is entitled to a basic level of health. The Millennium Development Goals seem so ambitious because they seek to extend to all what those of us in the developed world take for granted — “minimum essential levels” of health and the preconditions for health, such as access to water, sanitation, and nutrition. While a certain amount of jockeying for priority is to be expected, it would take place within this basic inclusive framework. By resorting to economic scare tactics, Easterly displays fundamental misunderstanding of what is at stake in the human rights debate.
Additionally, Easterly fails to explain why global health assistance forms a rational basis for predicting how a rights-based approach would operate in the US context. First, domestic and foreign health allocations are driven by different political and public health considerations. Americans carry a larger chronic disease burden, while low-income countries, generally the target of global health funding, carry a larger infectious disease burden. For example, communicable diseases account for just 8% of years of life lost in the US but account for 68% of years of life lost in developing countries. By contrast, noncommunicable diseases account for 74% of years of life lost in the US but just 21% in developing countries (see the WHO 2009 World Health Statistics). Additionally, there are different delivery and funding mechanisms at work in each context. A recent survey of 12 African countries showed that there are 9 physicians per 100,000 people, whereas there are 270 physicians per 100,000 people in the US. Second, it is unclear how the right to health would result in both more spending and worse outcomes than the status quo. On the one hand, Easterly argues that it would lead to fierce competition for resources. On the other hand, he argues that it would result in reckless spending. The US health system is already characterized by overspending and overtreatment for tertiary levels of care (also see the Dartmouth Atlas Study), coupled with disparities in access and outcomes for the medically underserved. In fact, emphasizing universal access to primary care would result in saved costs and improved outcomes.
Finally, Easterly makes flawed assumptions about the historical drivers of global health assistance. First, his criticisms are misdirected, as the very policies and programs he decries were never based on the right to health. Instead, they reflect political decisions to fund targeted, vertical interventions over horizontal investment in the public sector. Second, his opposition to a rights-based framework is short-sighted since this siloed approach does not go far enough in promoting health. The WHO definition of health extends beyond mere absence of disease to “complete physical, mental and social well-being.” Yet the foreign aid “successes” Easterly cites, such as immunizations and antibiotics, were only aimed at preventing death. Because they do not address fundamental causes, they are incapable of preventing disease. It is ironic, then, that Easterly tries to support his complaints about global health funding by holding up the most vertical and least effective models of “global health care.” If good is measured by “obtaining the largest possible health benefits,” only a rights-based approach ensures these benefits go deep enough and broad enough to meet the needs of the poor.
[Editor's note: This is a guest post written by Sarah Mi Ra Dougherty.]