BY ANNA BLAZEJOWSKYJ.
Photography by David Sachs and Anna Blazejowskyj.

** This essay by Anna Blazejowskyj won the second place prize in the Yale Global Health Review 2014 Class Essay Contest**

Affordable Care Act Rally at the SCOTUS

The idea of health as a human right presents a very complex, multi-dimensional dilemma. One of the greatest problems that arises in the health debate is that there is not a single, universal definition of health, nor a definite means by which to attain it. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” but does little to explain what complete well-being entails.[1] Taking this definition set forth by the leading international health authority, it becomes obvious that the right to health is about more than biomedical treatments of ailments; to fully examine health one must incorporate an understanding of the social determinants that impact one’s ability to attain the best possible care. In comparing the United States and South Africa in their approaches toward healthcare, the historical contrast in which these approaches are based, and the steps taken in response to the debate of health as a human right, it becomes apparent that although the United States is often considered to have a more advanced understanding of health than South Africa, South Africa is on the forefront of the movement toward the realization of healthcare as a human right.

When looking at a nation’s response to the debate of health as a human right, it is necessary to examine the history and culture in which present day perceptions and policies are based. In particular, it is important to focus on a nation’s practices towards marginalized populations. As Paul Farmer posits, “suffering is rarely separate from the actions of the politically powerful,” and thus it is necessary to frame the political context that contributes to the suffering that would naturally be associated with a violation of the right to health.[2] In the case of South Africa, an analysis of the current political climate in regards to health is not complete without examining the practices of the Apartheid regime. To begin, the Apartheid system was not merely for the segregation of the races. During Apartheid, whites were considered legally superior to Blacks, Coloreds, and Indians, and the government made sure that services that non-whites received, including medical care, were also inferior. For example, hospitals were assigned to particular racial groups and most were concentrated in white areas. With 14 different health departments, the system was characterized by fragmentation and duplication.[3] But more than the lack of access to care, the Apartheid system created many structural barriers that limited access to both “named” resources such as education as well as “unnamed” resources such as acceptance and power; these structural barriers ultimately constrained the agency of the non-white population, leading to ingrained feelings of inferiority.[4] However, on a more positive note, the inspiring, thoughtful leadership of Nelson Mandela and his counterparts also had a profound impact on the South African population. As William Gumede writes in his introduction to Mandela’s No Easy Walk to Freedom, the African National Congress’s success “turned the struggle against apartheid into a moral struggle”.[5] The fight for liberation brought to the forefront the ideals of equality and democracy, setting the stage for more recent battles for health rights and equalities.

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To compare, the United States was founded as a democratic nation, where equality and a democratic voice were intended to be inherent for every individual. However, history did not play out in such a manner, and within the context of the capitalist system, the economically powerful areoften the driving forces of legislation. The neoliberal model of governance and the mantra of success of the individual have created a system of gaping inequalities, where profits take precedent over the rights of the greater population. Corporations are an extremely powerful force, and one place where their influence can be clearly seen is in the implementation of healthcare, specifically in terms of the provision of pharmaceuticals.[6] As a legacy of the American dream, individuals demand access to the best care that money can buy. However, concurrently, those without money are left with little to no adequate care. Healthcare became viewed as a commodity, and the procurement of health required a necessary level of wealth. A minimal government system was designed to help the poorest of the poor, but healthcare for everyone was not considered in the context of a right until recent times.

As a result of the historical and governmental context of these two nations, several challenges and inequities arise in both the United States and South Africa in the process of attaining health as a human right. To begin, the greatest challenge in the United States lies in the economic aspects of healthcare implementation. As a wealthy, developed nation, the United States has one of the least efficient healthcare systems; in 2010, the Commonwealth Fund ranked seven developed countries on their health care performance and the US came in last place.[7] Moreover, in rankings released by the WHO’s World Health Report that compared nations based on an index of five factors – health, health equality, responsiveness, responsiveness equality, and fair financial contribution – the United States was ranked 37th in the world. Although it came in 15th place in terms of performance, the US came in first place in terms of greatest overall expenditure per capita. To understand the vast amount of money spent on the health in the United States, it is necessary to note that in 2009, 17.6% of the GDP was spent on healthcare in the United States – approximately $8,086 per capita or a total health expenditure of $2.5 trillion.[8] Even with such expenditure, 22,000 people in the United States die every year because they lack health insurance and have dangerously limited access to care.[9] Insurance premiums reaching levels of about $13,375 per family per year demonstrate the extensive – bare minimum – costs for attaining care.[10]A focus on high-level tertiary care over primary prevention results in extremely high costs and unfavorable health outcomes, with a large portion of the population with little or no access to the most fundamental care. In terms of direct ideals about health as a human right, the National Economic and Social Rights Initiative summarizes the US approach quite clearly: “The United States does not recognize the right to health in its public policy, has nonational health care plans, and falls short of taking a comprehensive approach to health protection.”[11] Quite similarly, a key issue within the South African system healthcare implementation is efficient appropriation of funds. Within the context of the current system, inequities between the public and private sector result in poor outcomes in comparison to similar middle-income countries. According to the National Treasury’s Fiscal Review for 2011, 48.5% of governmental health expenditure was spent on the private system and 49.2% was spent in the public sector. Although these numbers do not seem worrisome at first glance, it is important to note that the private system covers only 16% of the population, a majority of whom have additional private insurance coverage. Thus, the 84% of the population that relies on public system must seek care in a system that lacks appropriate infrastructure and adequate personnel. Not only is a large portion of funds set aside for private system, but doctors are also concentrated there: 73% of general practitioners practice within the private sector.[12] Another fundamental challenge in South Africa is the AIDS epidemic. According to Brand South Africa, in 2011, the overall HIV prevalence rate in South Africa was 10.6%, and 16.6% of the adult population (aged 15–49) was HIV positive. Moreover, there are 5.38 million people living with HIV, up from 4.21 million only ten years earlier. What compounds the problems of HIV care is the incredibly high rates of TB co-morbidity. As stated in a national health profile, problems with TB are becoming more prevalent – “because of late detection and poor treatment management, drug-resistant forms of TB have increased significantly, with about 5,500 cases diagnosed during 2009”.[13] Overall, the high prevalence of these extremely transmissible infectious diseases among the poorest population leads to an incredibly high pressure on the public medical system, testing the boundaries of the nation’s limited resources and thereby increasing the burden to providing health for all.

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However, these difficulties should not overshadow the successes made in recent years to implement policies supporting the idea of health as a human right, particularly in South Africa. While the high prevalence of AIDS may be one of the most tragic problems for the South African population, it is also one of the leading motives for the promotion of health rights for all. One of South Africa’s greatest successes in the healthcare realm was the Treatment Action Campaign’s (TAC) successful legal challenge of excessive pricing of AIDS-related pharmaceuticals. In particular, the TAC argued that “profiteering by GlaxoSmithKline (GSK), the patent holder of AZT, from an essential medicine was a violation of the right to life – and demanded a price reduction.”[14] This became a legal battle – challenging the necessary action related to the constitutional promise of a “right to life” – as well as a moral dilemma. Attention to the issue of inadequate care and health as a human right was brought to the forefront; at its 2009 National Congress, the TAC made its vision clear: “In the context of the HIV/AIDS epidemic, the TAC aims to achieve universal access to prevention, treatment and care for all people living with HIV/AIDS and other illnesses.”[15] In its efforts, the TAC not only secured more affordable AIDS medications but also made a push for the introduction of additional resources into the heath system, particularly for the poor. Moreover, in addition to the access to affordable treatment enabled by the TAC campaign, the South African government has taken several steps to increasing the access to healthcare for all South Africans. National immunization programs have increased the rates of children receiving primary vaccines, and the national prevention of mother-to-child program (PMTCT) assures that all pregnant women are offered HIV testing and counseling. Also, the National Strategic Plan for HIV/AIDS and TB aims to address the socio-structural drivers of HIV/AIDS, maintain health and wellness, and protect human rights of sufferers. But most importantly, South Africa is in the process of implementing a National Health Insurance Scheme (NHI). Due to be phased in over the course of fourteen years starting in 2012, the aim of the NHI is to “promote equity and efficiency to ensure that all South Africans have access to affordable, quality health care services regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.”[16]

In comparison, the United States has made few moves to try to implement national strategies for medical intervention. Although HIV rates in the nation are high – with 1,148,200 persons aged 13 years and older living with HIV infection in the United States according to the Centers for Disease Control and Prevention[17] – the illness does not have a profound effect on as large a portion of the American population as in South Africa. If following the South African model of an overwhelming health burden being the key catalyst for a movement towards health as a human right, it may be some time until one particular disease spurs the American people to action. First, although the burden of non-communicable diseases in the United States is high, there is not a single ailment that is profound enough to lead the American people to unite in protest. Moreover, a different political and economic legacy has left a nation apathetic towards the political scene –even when grand political action is mobilized, change is caught up in a long time struggle against profits and bureaucracy. However, successes too have been accomplished in the United States in regards to the promise of healthcare for all, especially in recent years. In particular, the Patient Protection and the Affordable Care Act signed into effect under President Obama has made an unprecedented step to increase efforts at universal healthcare provision. Among a few of its many changes, the act, known as Obama Care, prevents insurance companies from not providing coverage due to pre-existing conditions, increases the medical benefits of seniors –including lowering the cost of medicines and providing free preventative care, and expands Medicaid to an estimated 15 million of the US’s poorest citizens.[18] Although the legislation has been approved, it will be interesting to see how US ventures into the idea of health as a right for all people will play out over the next few years.

Health as a human right has not been at the top of the healthcare agenda. However, as vast changes are made to healthcare in the upcoming years, it is vitalthat the importance of health as a human rightis stressed in the process of policy implementation. To begin, healthcare should no longer be considered a commodity, its delivery swayed by profits, but rather a necessity that must be guaranteed to all. Change does not come easily, but as progress in South Africa has shown, it is at the hands of the people to fight with strengthand determination for the right to health, and thereby the right to life.

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[1]World Health Organization. PreambletotheConstitutionoftheWorldHealthOrganization.New York: Office Records of the World Health Organization, 1946.

[2]Paul Farmer,“OnSufferingandStructuralViolence:SocialandEconomicRightsintheGlobalEra” inPartnertothePoor:APaulFarmerReader,ed., HaunSaussy.(LosAngeles:UniversityofCaliforniaPress,2010),337.

[3] “Health care in South Africa,” last reviewed July 2, 2012, http://www.southafrica.info/about/health/health.htm.

[4]Pamela Braboy Jackson et al., “Race and Psychological Distress: The South African Stress and Health Study.” Journal of Health and Social Behavior 51 (2010): 471, doi: 10.1177/0022146510386795

[5] Nelson Mandela. No Easy Walk to Freedom, ed. William Gumede. (Cape Town: Kwela, 2013), Introduction.

[6]PLoS Medicine Editors, “Drug Companies Should be Held More Accountable for Their Human Rights Responsibilities,” PLoS Medicine 9 (2010): 1-2. doi: 10.1371/journal.pmed.1000344

[7] Adam Taylor and Samuel Blackstone, “These Are The 36 Countries That Have Better Healthcare Systems Than The US,” Business Insider, June 29 2012, http://www.businessinsider.com/best-healthcare-systems-in-the-world-2012-6.

[8] “Health Expenditures,” last updated February 13, 2014, http://www.cdc.gov/nchs/fastats/hexpense.htm

[9] “Human Right to Health,” last updated January 2008, http://www.nesri.org/sites/default/files/Right_to_Health.pdf

[10] “Employer Health Benefit Survey,” released August 20, 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-2013-chartpack.pdf

[11] “Human Right to Health.”

[12] “Health care in South Africa.”

[13] “Health care in South Africa.”

[14] Mark Heywood, “South Africa’s Treatment Action Campaign: Combining Law and Social Mobilization to Realize the Right to Health.” Journal of Human Rights Practice 4 (2009): 20, doi: 10.1093/jhuman/hun006

[15] Heywood, “South Africa’s Treatment Action Campaign,” 23.

[16] “Health care in South Africa.”

[17] “HIV in the United States: At a Glance,” last updated December 2, 2013, http://www.cdc.gov/hiv/statistics/basics/ataglance.html.

[18] “Obama Care Facts: Facts on the Affordable Care Act,” last updated December 20, 2013, http://obamacarefacts.com/obamacare-facts.php.

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