Global Health Goals and Health Disparities
The UN and WHO don’t have formal power but have a history of facilitating unified responses to disasters and give the world a forum in which to attempt to work out differences address challenges. The WHO website reports that “We are now more than 7000 people from more than 150 countries working in 150 country offices, in 6 regional offices and at our headquarters in Geneva”. The WHO has been instrumental in dealing with health related issues after natural disasters, like the earthquakes and outbreaks of diseases all over the world. On a global level, we count on the WHO to keep the world safe and be the lead coordinator for the world’s health challenges. It’s tremendous responsibility.
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I have chosen Millennium Development Goal One: “eradicate extreme poverty and hunger” as my goal to explore. The UN’s website reports that “The United Nations Millennium Campaign, started in 2002, supports and inspires people from around the world to take action in support of the Millennium Development Goals”. In the United Nations report from 2015 on the effect of the Millennium Development Goals, Ban Ki-moon Secretary-General, United Nations, wrote in the forward:
The global mobilization behind the Millennium Development Goals has produced the most successful anti-poverty movement in history. The MDGs helped to lift more than one billion people out of extreme poverty, to make inroads against hunger, to enable more girls to attend school than ever before and to protect our planet. They generated new and innovative partnerships, galvanized public opinion and showed the immense value of setting ambitious goals. By putting people and their immediate needs at the forefront, the MDGs reshaped decision-making in developed and developing countries alike.
It makes sense that before we can move forward as a planet, we must have a cohesive vision of where we are trying to go. As it relates to MDG 1, the WHO reports that, “The target of reducing extreme poverty rates by half was met five years ahead of the 2015 deadline. In 1990, nearly half of the population in the developing regions lived on less than $1.25 a day. This rate dropped to 14 percent in 2015”. The official WHO report states that, “Globally, the number of people living in extreme poverty has declined by more than half, falling from 1.9 billion in 1990 to 836 million in 2015. Most progress has occurred since 2000. The proportion of undernourished people in the developing regions has fallen by almost half since 1990, from 23.3 per cent in 1990–1992 to 12.9 per cent in 2014–2016”. The UN’s Millennium Development Goals clearly show us that the world can work together and make positive impacts on the quality of life for over a billion people when we have clear inspiring goals set by an organization with the moral authority and global reach of the United Nations and the World Health Organization.
South Africa and Millennium Development Goal One
Progress towards Millennium Development Goal One for South Africa has been significant. The United Nations Development Programme report for South Africa reports that individuals living on less than $1 per day has fallen from 11.3% to 4%, less than $1.25 per day from 17% to 7.4%, between 2000 and 2013, achieving the goal of decreasing these indicators by half. The report concludes:
Several factors account for the observed decline in absolute poverty in South Africa. These include amongst others, overall economic growth for the period under consideration and re-allocation of government priorities through the introduction of an expansive social grants system. However, it must be further noted that these measures of poverty based on money measures do not take into consideration other forms of pro-poor government investments such as provisions in health care, water and sanitation, and electricity where targeted interventions are progressively directed towards the indigent. (UNDP 34)
In terms of statistics, the UN report shows that social grants increased from helping 2.6 million people in 2000 to helping 14.9 million people in 2011. Efforts have been made to provide free access for the “indigent” in South Africa to electricity, clean water and sewage and waste management. From 2004 to 2011 free access to sewage and waste management increased from 38.7% to 52.1%, free access to electricity increased from 29.3% to 50.4%, free access to clean water increased from 61.8% to 71.6%. (UNDP 26)
Millennium Development Goal one doesn’t seem specific to medicine and nursing. Judith A. Oulton, CEO of the International Council of Nurses gave a number of suggestions of how nurses can work to reduce poverty and it’s impact on health. Of her suggestions I will focus on two, first “lobby for anti-poverty policies and programs addressing job creation, education, access to health care, housing and other issues, and advocate for women and other vulnerable groups” and second, “work with the poor (whether, families or communities) in defining their problems and seeking solutions”. (314) Oulton asserts that “Nurses, more than any other health professional group, see the impacts of poverty on people’s health. It is incumbent upon all of us to help break the link between ill health and poverty”. (314) Our direct experience with individuals who suffer give us a uniquely intimate experience of the suffering of others and an authentic passion that has had tremendous impacts on people worldwide, particularly since Clara Barton and founding of the Red Cross in 1881. (redcross.org) An example of a group that lobbies in South Africa is South Africa’s Treatment Action Campaign. Their goal is to combine law and social mobilization to realize the right to health. “TAC was launched in South Africa on 10 December 1998, International Human Rights Day, by a small group of political activists. The rudimentary consensus within the group was that equitable access to health care, and in particular medicines for HIV, is a human right. In addition, the leaders of TAC appreciated that HIV, albeit a virus, is symptomatic of the deeper social and political crisis that faces poor people, and that the growth of HIV to pandemic proportions is because HIV transmission is often via social fault lines created by poverty, inequality, and social injustice”. (Haywood) In the case of the TAC, one of their focus was using the law as a basis for their lobbying efforts, “TAC’s focus has been on the right to health. But the determinants of health are also in access to education, food, clean water, and housing. Fortunately, in its Bill of Rights, the South African Constitution recognizes these as rights that are measurable and justiciable. For example: TAC made a study of law and worked closely with progressive lawyers, many of whom developed their skills in using the law to undermine apartheid. TAC argued that the Constitution created a legal duty on the government to fulfil its human rights provisions. Therefore, with regards to the right of access to health care services, TAC argued that the government was obliged to take steps to overcome the unaffordability of medicines, especially when it has a legal means to do so”. (Heywood) Besides bring media attention to a problem based on moral arguments, I like the notion of pointing out the legal obligation of a nation, in this case South Africa, to take care of it’s poor. In regards to working directly with the poor, “in defining their problems and seeking solutions” TAC has a really inspiring example of how they have focused their advocacy. They have made one of their primary goal creating “treatment literacy” among the poor. HIV/AIDS has been a primary, but not exclusive focus. Haywood reports, “The model that was adopted came from the United States, where AIDS activists, led by people with HIV, had pioneered the idea of ‘treatment literacy’ among people with HIV. Treatment literacy recognizes that in order to fight for rights effectively, people also are required to understand the science of HIV, what it was doing to their body, the medicines that might work against it, the research that was needed etc. Emulating this model, TAC became the first AIDS activist organization to pioneer the concept and practice of HIV ‘treatment literacy’ in a developing country. Links were made with groups such as the Gay Men’s Health Crisis (GMHC) and ACT-UP, who in 1999 came to South Africa to provide training to the first cadre of TAC treatment literacy activists. Treatment literacy is the base for both self-help and social mobilization. Armed with proper knowledge about HIV, poor people can become their own advocates, personally and socially empowered. For example, in interviews conducted during an evaluation of TAC, its volunteers are quoted as saying ‘I am living because of TAC’, ‘TAC puts self-esteem back into people’, and ‘In TAC you are in a university. You learn and grow with knowledge’ (Boulle and Avafia, 2005)”. TAC is not a nurse driven advocacy group, but gives a fascinating example of how individuals, in our case, nurses, could drive at a macro level “advocating for action” the government of South Africa by partnering with lawyers and legal advocacy and also directly with the poor through education, empowering the poor to become their own advocates. If I were in South Africa, the first organization I would see if I could work with would be the Treatment Action Campaign. I am not sure if I would be more useful in working at lobbying governmental groups or in working directly with the poor. Haywood reports that “TAC volunteers who have been trained and have passed an examination are called ‘Treatment Literacy Practitioners’”. Becoming a treatment literacy practitioner would be a logical first step in being a nurse who could both lobby for change and work directly with the poor in South Africa. I am sure there are many other ways to do this, I am glad that found an example of an organization in South Africa that is already demonstrating how these roles can be approached. Besides HIV/AIDS, TAC also advocates things like access to clean water, food and waste management. Addressing HIV/AIDS, health education and advocating for basic needs can impact poverty and suffering for the whole population of South Africa.
In South Africa, the health disparities can be defined a number of ways, I am going to define health disparities in South Africa by which health system is used. South Africa has two health systems, a private and public one. Bogani and Benatar report that:
Annual per capita expenditure on health ranges from $1,400 in the private sector to approximately $140 in the public sector, and disparities in the provision of health care continue to widen.3 The national public health sector, staffed by some 30% of the doctors in the country, remains the sole provider of health care for more than 40 million people who are uninsured and who constitute approximately 84% of the national population.. Many of the state hospitals are in a state of crisis,26 with much of the public health care infrastructure run down and dysfunctional as a result of underfunding, mismanagement, and neglect.
Having a two tiered healthcare system has exacerbated the problems of access to good quality healthcare to the poor, and predominantly black population of South Africa. Basically, people dependent on the public hospitals get about one tenth the quality of care of the private hospitals.
Besides the entire poor population that is dependent on the understaffed and underfunded public health system, HIV/AIDS patients are a specific vulnerable group that is the population that constitutes to have the biggest health challenge in South Africa. Mark Cichocki reports that, “South Africa remains the country with the largest single population of HIV-infected people in the world. Studies suggest that 5.7 million South Africans are living with HIV, representing about 12% of the population (or nearly one in eight citizens). The HIV rate among adults is today over 18%. 45% of all deaths in the country can be attributed to HIV. 13% of South African blacks are infected with HIV versus 0.3% of South African whites”. The differences in black versus white rates of speak to the ethnic health disparity in South Africa. The percentage of blacks with HIV is 43 times greater than that of whites in South Africa.
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The first strategy I would highlight for addressing the disparities in South Africa would be health education, with a dominant focus on prevention of HIV/AIDS through safe sex practices and access to and compliance with antiretroviral therapy. One challenge with health education for the poor is that there is a tremendous shortage of nurses and doctors in South Africa. Bongani and Benatar report that, “South Africa requires at least three times its current health workforce to provide adequate care for patients with HIV/AIDS.54 The recent thrust toward training more community health workers and the successful development of front-line worker–based programs to control tuberculosis and HIV infection offers considerable promise”. (1348) Community health workers are going to be a critical component in addressing South Africa’s health disparities. In addition to community health workers, I would look to the Cuban model of healthcare to address the disparities in South Africa. Sam Lowenberg reports:
This hands-on, low-tech approach to medicine is fundamental to Cuba’s unique approach to health care, which makes up for low resources by emphasizing prevention and primary care. The country has the world’s highest doctor-to-patient ratio, about 67 physicians per 10 000 people (in the UK it is about 36·5 per 10 000 people). A family doctor and a nurse are assigned to care for 150-200 families. These doctors live in the same communities with their patients, usually know them by name, and get to know many of the personal issues, social pressures, and environmental factors that could be affecting their health. Community doctors divide up their population by risk factors, such as smoking, drinking, or hypertension, and give those patients special attention and assistance. (327)
A long term, well designed investment in health education for decades could have a tremendous impact. I think that the Cuban approach should be adapted to every underserved economically challenged group possible, and would an ideal way to recreate the South African public health system.
My second focus would be getting resources to combat HIV/AIDS to the poor. This means access to HIV testing and increasing access to antiretroviral therapy (ART). Fortunately, Bogani and Benatar report that “Spending on HIV increased at an average annual rate of 48.2% between 1999 and 2005. The level of growth was consistently higher than that in other areas of national health expenditure and has continued at an annual rate of approximately 25%, with dedicated HIV funding estimated at $400 million (in U.S. dollars) per annum, of which approximately 40% comes from international donors. Of 6 million HIV-positive South Africans, more than 2 million receive ART”. (1345) At least the effort is underway, obvious about two thirds of the HIV infected population still required treatment in 2005. In addition to treatment, resources to prevent HIV transmission are necessary, particularly the distribution of condoms and safe sex education.
With the Millennium Development Goals, the UN and WHO provided a challenge, and the world did a remarkable job of acting on the challenge. Millennium Development Goal One, to “reduce severe poverty by one half was met five years early” worldwide according to the WHO final report. I focused on South Africa, which has met the goal, but as my research demonstrates, still faces tremendous poverty and has a two tiered healthcare system leaving 84% of their population with substandard care. The biggest health challenge in South Africa is HIV/AIDS, and blacks are the primary victims of it. The primary short term goal needs to be making access to antiretroviral therapy for all individuals with HIV/AIDS happen immediately, as well and universal access to condoms and safe sex education and promotion. In addition to working to increase resources dedicated to caring for the poor, replacing the current public health system with a preventative community based system like Cuba’s would allow for maximum impact from the limited resources dedicated to healthcare for the poor and mostly black population of South Africa. This would require the creation of many doctors, nurses and community health workers, ideally with educational funding tied to the graduates being required to work in the public health system and work to solve the problems created by the health disparities created by poverty and the two tiered health system that currently exists.
- Bongani, M., & Benatar, S. R. (2014). Health and health care in south africa — 20 years after mandela. The New England Journal of Medicine, 371(14), 1344-1353. doi:http://dx.doi.org.americansentinel.idm.oclc.org/10.1056/NEJMsr1405012
- Cichocki, M. History of the HIV in South Africa, https://www.verywellhealth.com/hiv-around-the-world-south-africa-48673
- Heywood, M. Journal of Human Rights Practice, Volume 1, Issue 1, 1 March 2009, Pages 14–36, https://doi.org/10.1093/jhuman/hun006
- Oulton, J. Breaking the health and poverty link, https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1466-7657.2007.00615.x
- American Red Cross, https://www.redcross.org/about-us/who-we-are/history/clara-barton.html
- Central Intelligence Agency, https://www.cia.gov/library/publications/the-world-factbook/geos/sf.html
- South Africa MDG Report 2013, http://www.undp.org/content/dam/south_africa/docs/ Reports/The_Report/MDG_October-2013.pdfp://www.ke.undp.org/content/kenya/en/home/post-2015/mdgoverview/overview/mdg1/
- United Nation Millennium Development Goals, http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf
- World Health Organization, https://www.who.int/about/who-we-are/en/
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