Double Standards in Global Health: Medicine, Human Rights Law and Multidrug-Resistant TB Treatment Policy

Abstract The human rights arguments that underpinned the fight against HIV over the last three decades were poised, but ultimately failed, to provide a similar foundation for success against multidrug-resistant TB (MDR-TB) and other diseases of the poor. With more than 1.5 million deaths since 2000 attributed to strains of MDR-TB, and with half a million new, and mostly untreated, MDR-TB cases in the world each year, the stakes could not be higher. The World Health Organization (WHO), whose mandate is to champion the attainment by all peoples of the highest possible level of health, recommended unsound medical treatment for MDR-TB patients in resource-poor settings from 1993-2002. Citing cost considerations, WHO did not recommend the available standard of care that had been successfully used to contain and defeat MDR-TB in rich countries. By acting as a strategic gatekeeper in its technical advisory role to donor agencies and countries, it also facilitated the global implementation of a double standard for TB care in low- and middle-income countries (LMICs), upending important legal and scientific priorities. This raises serious questions about whether the organization violated international human rights standards and those established in its own constitution. While calling for additional analysis and discussion on this topic, the authors propose that policymakers should reject double standards of this kind and instead embrace the challenge of implementing the highest standard of care on a global level

Limited good and limited vision: multidrug-resistant tuberculosis and global health policy

Almost a third of the world's population is infected with Mycobacterium tuberculosis, the organism that causes tuberculosis disease. Most of those infected never fall ill, but individuals who do can recover if they have access to effective therapies. This paper discusses certain ethical and ethnographic issues raised by cases in which patients are infected with M. tuberculosis strains resistant to at least the two most powerful drugs on which therapy is usually based. In most poor countries, people with such multidrug-resistant tuberculosis (MDR-TB) were, until very recently, considered "untreatable." In addition to being consigned to a permanent state of ill health, they were also at risk of transmitting their resistant strain to others. In this paper we discuss the logic of "cost-effectiveness," which international health policy-makers utilized to make the case that treatment of MDR-TB is not feasible in resource poor settings. These analyses, which have held sway in public health policy for many years, are flawed, we argue, because they ignore and conceal the social determinants of access to health services and often rely on assumptions rather than evidence. We propose that policies based solely on analyses of cost-effectiveness of specific interventions for individual settings can be short-sighted and, because they do not pay sufficient attention to the social, political, economic, epidemiological and pathophysiological factors influencing the production of health, will ultimately hinder progress toward effective global TB control.Tuberculosis Health policy Cost-effectiveness Poverty

Transforming South–South Technical Support to Fight Noncommunicable Diseases

At the UN High-Level Meeting on non-communicable diseases (NCD) in September 2011, each member state was challenged to create a multisectoral national policy and plan for the prevention and control of non-communicable disease by 2013. Few low-income countries, however, currently have such plans. Their governments are likely to turn for assistance in drafting and implementation to multilateral agencies and Contract Technical Support Organizations recommended by development partners. Yet because many NCD seen in the lowest-income countries differ significantly from those prevalent elsewhere, existing providers of external technical support may lack the necessary experience to support strategic planning for NCD interventions in these settings. This article reviews currently available mechanisms of technical support for health sector planning. It places them in the broader historical context of post- World War II international development assistance and the more recent campaigns for horizontal “South-South” cooperation and aid effectiveness. It proposes bilateral technical assistance by low income-countries themselves as the natural evolution of development assistance in health. Such programs, it argues, may be able to improve the quality of technical support to low-income countries for strategic planning in the NCD area while directing resources to the regions where they are most needed

Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations

The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked “brain drain” from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems

An assessment of interactions between global health initiatives and country health systems

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity value for money, and outcomes in global public health, then these opportunities should not be missed