We live in a world of extraordinary inequities. Poverty and inequity are the world’s greatest killers. In the 20 years after the Cold War, 360 million people have died from hunger and treatable diseases – much more than from all 20th-century conflicts.
Inequities in health are among the most visible of all in a world in which the gap between the mean GDP of rich and poor countries more than doubled in the 25 years to 2005. The developing world bears an extraordinarily inequitable burden of infectious disease, 90 per cent of it, and yet these countries represent just 12 per cent of all health spending.
AIDS is a classic example. Of the 30 million AIDS deaths since the virus that causes the disease was identified 30 years ago this week, 90 per cent have occurred in Africa.
Yet, against such odds, the face of AIDS has changed from one of desolation to one of hope.
When AIDS was first identified in fewer than 20 patients in the US who presented with unusual symptoms in the early 1980s, millions of Africans were already infected, but there was no system in place to detect this. The sub-Saharan epidemic spread unchecked for another 20 years: while science rapidly responded in the global north, barely a single patient in the developing world had access to treatment from an international program until 2001.
What AIDS has since shown us is what can be achieved when the world resolves to fight a pandemic, when the right to health is aggressively asserted, when we see and act on medicine and health care as a ”global public good”.
The global effort to defeat AIDS over the past three decades has demonstrated a long-suspected truth: health should no more be seen as a consequence of economic growth.
In 2000, the world set itself the ambitious Millennium Development Goals, endorsing that change in paradigm about how health relates to development. Experience has validated the concept. In its last report, the United Nations Development Program showed that the countries that invested the most in health and education in 2000 are also those in which the Human Development Index has progressed the most in the past 10 years.
AIDS is perhaps the pre-eminent example of successful investment in health. Eight million people have gained access to antiretroviral treatment, compared to just a few tens of thousands 10 years ago. As a result of investments in HIV prevention and treatment, mortality from AIDS and the number of new infections have decreased worldwide by 25 per cent in just the past five years.
Several factors have been key to this remarkable progress.
First, one cannot underestimate the impact of activism and social mobilisation against the inequity of access to care, as exemplified by Justice Edwin Cameron of South Africa, himself living with HIV, in his call to action at the International AIDS Conference in 2000. ”I exist as a living embodiment of the inequity of drug availability in Africa,” he said. ”I stand before you because I am able to purchase health and vigour. I am here because I can pay for life itself.”
This is an activism that began in the global north and has spread to nearly every country in the world. It is a movement that has grown beyond AIDS to a global movement of citizens who have brought new life to the idea of health as a human right and new pressure on governments to fulfil their responsibilities.
Another key factor has been the global political commitment to funding health, beginning with the G8 meeting in Okinawa in 2000 and continuing through key instruments such as the Abuja declaration in 2001 committing African heads of state to dedicate 15 per cent of their national budgets to health by 2010, the UN General Assembly special session on AIDS 2001 and the Gleneagles G8 commitment to providing universal access to HIV treatment.
A third factor is what I would call ”innovation” in the way in which aid is provided through new global mechanisms and partnerships, and in the way it is accounted for – increasingly, based on performance of programs.
In the case of AIDS treatment, delivery of what was once seen as a very complex intervention is now largely governed by simplified algorithms for health workers and nurses. Many patients receive routine care and adherence support, and have their prescriptions refilled, without ever seeing a doctor.
What the World Health Organisation calls ”task-shifting” and a ”public health approach” to treatment and care was seen as revolutionary only a decade ago and has forever changed our thinking about what can be achieved in chronic care in resource-limited settings.
The question today is whether this remarkable progress can be sustained and amplified as 8 million people are still in urgent need of treatment – in a global context that has changed significantly from what it was 10 years ago.
The world is no longer a relatively simple configuration of the G8 powers and the rest, or a global north and global south. Rather, we live in a multipolar world in which Brazil and Latin America, China, Australia and Indonesia, India, Russia, Africa, Western Europe and the US interact in complex ways, so the concept of global solidarity becomes increasingly subordinate to national and regional agendas, especially since the global financial crisis.
And while inequities between countries have decreased, and the overall proportion of people in extreme poverty has decreased, the inequities within countries are now increasing everywhere, particularly in middle-income countries and emerging economies.
There are now nearly twice as many people living below the threshold of poverty in middle-income countries as in low-income countries. Emerging economies will have to redistribute large amounts of funds to the social sector and prioritise social investments. It will make some governments feel very uncomfortable.
But there is a way forward as AIDS has shown – take the rollout of antiretroviral drugs over the past decade as a piece of inspiration. What many of us working in the field considered to be utopia not so long ago has become an achievable global target.
Finally, let’s not forget the end game: inequities in health also systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised group) at further disadvantage. Health is essential to overcome the other effects of social disadvantage. AIDS has shown us there are no excuses not to do so.