The right to health, not equity, challenges intersectional disadvantage in global health

 

Assuring healthy lives and encouraging wellbeing for all people at all ages is the bold sustainable development goal for global health. But to accomplish this, we must first understand who is being left behind and why.

It is generally acknowledged that intersectionality is a particularly effective analytical tool for understanding individual and population-level disadvantage. Investigating intersectionality involves examining relationships between multiple facets of society (such as family, government, heteronormativity, neoliberal globalism) and determinants of health (such as sex, socioeconomic or Indigenous status). Overlapping levels of exclusion from power lead to disadvantage.

Two major answers are usually recommended: the first is an equity-based framework, and the second is rights-based. This blog makes the case that a right-based framework is more effective. Equity-led frameworks are atheoretical. They don’t challenge or illuminate underlying assumptions and country-specific norms that policy-makers and researchers themselves adhere to. Rights-based health is intertwined with cultural, economic and political rights, and institutional accountability. It actively seeks justice from treaty-based international normative standards and thus is more likely to disrupt disadvantage between and within nations. Both acknowledge intersectionality, but only the latter frames the individual as inherently dignified rather than problematic.

To illustrate my case, I invite readers to consider two examples: Closing The Gap (CTG) aimed at Indigenous Australians, and the global distribution of Covid-19 vaccines in the current pandemic.

The widening health and socio-economic gaps between First Nations and other groups in Australia are well documented. CTG, the Australian government policy response, began as a dashboard of classical health equity indicators such as childhood mortality, life expectancy, literacy and numeracy. Epidemiological factors were assessed, gaps identified, and targets for deafness, blindness, rheumatic heart disease, diabetes and other diseases were established. Despite over a decade of significant financial expenditure, annual parliamentary reports acknowledged policy failure. This had occurred in three ways. First, the policy did not consult with those who would be most affected; instead, many ‘body-part’ targets were set by ministerial direction. Second, it concentrated on health organisations and sidelined other sectors such as housing and the legal system. Finally, the source of the gap – race and racism, not resourcing –  was neither acknowledged nor addressed. At times, failure of the strategy itself was used to justify ongoing paternalism.

Following extensive advocacy by Indigenous groups, CTG at last pivoted toward prioritising Indigenous cultures, full participation, and government accountability for systemic racism. Initiatives such Birthing on Country interlink health and cultural rights. A referendum on constitutional recognition for First Nations will be held in late 2023. That is to say, genuine human rights goals are key to reconfiguring power disparities between Indigenous peoples and their governments, and between Indigenous and non-Indigenous Australians.

The second example typifies power disparities between nations. The dominant discourse in high-income countries is of ‘generous aid’ offered to the global south and low-income countries who are homogeneously ‘diseased’ and ‘problematic’. This discourse overlooks structural causes  for inequity from neo-colonialism, government-aided capitalism, trade protectionism by multinational industries and opaque financial flows.

Maldistribution between high and low income nations (80% vs 0.3%) was clearly a problem following the development of the first Covid-19 vaccines. COVAX – framed as aid – was created by Gavi, WHO and several other partners in response. First, this was inadequate. Second, recipient countries waited for ‘leftover’ vaccines – while young, healthy people in high income nations received boosters. South Africa and India campaigned for TRIPS waiver for Covid-19 vaccines, therapeutics and diagnostics at the WTO. The strength of the underlying ideological commitment by high income countries and pharma-companies to the current hegemony was exposed by their withdrawal. Although a compromise was brokered in mid-2022,  only around 26% of people in low-income countries are vaccinated. This may result in problems that are difficult to track, such as increased human trafficking and missed schooling for girls. The lack of a unified attack against a common threat has led to worsening health parity between nations. Several factors inhibit the implementation of the right to health between nations. The connections between economic and health rights need to be considered in ongoing advocacy, policy and evaluation. Countries cannot make use of even limited IP waivers for medical products without local manufacturing capacity. Treaty bodies need to be empowered to adjudicate between nations. The obligations of transnational health actors like private philanthropists, NGOs and companies under human rights law can also be strengthened.

Intersectionality recognises the temporality of advantage and disadvantage. Comparing health outcomes to the most privileged is not a safeguard when even they lose health due to global climate change. A rights-based perspective invites more sectors including political, media, legal and civic organisations to participate in health. The objectives of global health depend on the discipline’s capacity to create more space for those we exclude as they lean into existing strengths, hold social institutions accountable and effectively mobilise to advocate for their preferred solutions.

 

About the author: Dr Sophia Samuel is a medical editor at the Australian Journal of General Practice and a general practitioner currently working at North East Public Health Unit in Melbourne, Australia.

Competing interests: None

Handling Editor: Neha Faruqui

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