Poverty, Malaria and the Right to Health -- Exploring the Connections

Malaria is an extremely serious human rights issue. Six out of eight Millennium Development Goals (MDGs) cannot be achieved without tackling this disease. It is both a cause and a consequence of poverty. Its impact is especially ferocious on the poorest: those least able to afford preventive measures and medical treatment. Malaria kills well over 1 million people every year, claiming a child's life every 30 seconds. It impoverishes families, households and national economies, lowers worker productivity and discourages investment. It costs Africa $12 billion every year.


And yet, malaria is entirely preventable through an integrated package of interventions, such as properly maintained insecticide-treated nets, indoor residual spraying and information campaigns. If diagnosed and treated promptly and correctly, malaria is curable. New artemisinin-based combination therapies (ACTs), though effective, are expensive and beyond the reach of many in Africa, where the disease is most prevalent.
Recognizing malaria as a right-to-health issue does not provide a magic solution to an enormous complex problem1. But the right-to-health perspective -- the human rights analysis -- has a constructive contribution to make.
What is the right to health? The right to the highest attainable standard of health is codified in numerous legally binding international and regional human rights treaties. It is also enshrined in numerous national constitutions, over 100 of them comprising the right to health or health-related rights2. While the right to health includes the right to medical care, it also encompasses the underlying determinants of health, such as safe drinking water, adequate sanitation and access to health-related information.
The right to health also includes freedom, for example the right to be free from discrimination and involuntary medical treatment, as well as entitlements, such as the right to essential primary health care. The right has numerous elements, including child and maternal health and access to essential drugs. Like other human rights, it has a particular concern for the disadvantaged, the marginalized and those living in poverty. It requires an effective, inclusive health system of good quality.
International human rights law is realistic and recognizes that the right to the highest attainable standard of health for all cannot be realized overnight. Thus, the right is expressly subject to both progressive realization and resource availa-bility. Although qualified in this way, nonetheless, the right to health imposes some obligations of immediate effect, such as non-discrimination, and the requirement that a State at least prepare a national plan for health care and protection. The right demands indicators and benchmarks to monitor its progressive realization and encompasses the active and informed participation of individuals and communities in health decision-making that affects them. Under international human rights law, developed States have some responsibilities towards the realization of the right to health in poor countries.


At root, the right to the highest attainable standard of health consists of global standards; out of these standards derive legal obligations, and these obligations demand effective mechanisms of accountability. The combined effect of these three dimensions -- standards, obligations and accountability -- is the empowerment of disadvantaged individuals and communities.
The right to health poses awkward questions. As you devise this new health programme, how will you ensure that the voices of women and girls are heard and respected? How are you ensuring that the poor and marginalized have access to these health services? How are you measuring the impact of that new irrigation scheme on the health of neighbouring communities? How are you measuring whether or not access to health care is being progressively improved? If you are using indicators and benchmarks, are they disaggregated on the grounds of sex, ethnicity and other prohibited grounds of discrimination? Why are maternal and infant mortality rates static, or worsening, for some ethnic minorities? Are your health programmes respectful of minority cultures? Are they available in common minority languages?
Human rights not only lead to these awkward questions, they also require answers and accountability. For example, if health outcomes are not improving, or a new private-sector development is damaging people's health, or those living in poverty do not have access to essential medical care, we need to identify why, so that those responsible can take specific, targeted remedial action -- and if they fail to take all reasonable steps, the poor need to know why. In short, human rights accountability raises questions, with a view to finding out what works and what does not. Accountability is a powerful human rights tool for improving the health of all.
A joint endeavour. If we are to make progress, we have to get across the message much more clearly and widely, that human rights, including the right to health, are allies and assets for health professionals to use: to devise better policies and programmes; to raise more funds from the Treasury; to leverage more funds from developed countries to developing countries; in some States, to improve the terms and conditions of those working in the health sector; and so on. Together, the human rights movement and health workers can address the scourge of malaria and figure out how the right to health can reinforce existing anti-malaria initiatives and help to identify new effective anti-malaria policies, programmes and projects.
Under the right to health, individuals and communities are entitled to information and education on preventive and health-promoting behaviour, and how to access health services. In the context of malaria, this would include, among others, information and education on the proper use of anti-malaria drugs, insecticides and indoor residual spraying. The right also imposes responsibilities on Governments to adopt public information and education campaigns targeted at the most disadvantaged communities via the media, village health teams and health workers, schools and faith-based networks.
People are entitled to participate in health decision-making, including the identification of priorities and targets that guide the technical deliberations underlying policy formulation. They are also entitled to participate in the implementation of policies and programmes -- for example, community volunteers trained to identify symptoms and provide malaria treatments in remote rural areas, where there is no accessible system of health clinics and medical care.

The research and development community also has an obligation under the right to health to address the health needs of the entire population, including disadvantaged groups. There is a large number of compelling and competing research and development health needs in all countries. Given the burden of malaria, clearly it is a disease that should be prioritized. There is a need not only to encompass classic medical research, including the development of drugs and vaccines and the improvement of diagnostics, but also in operational or implementation research on the social, economic, cultural, political and policy issues that determine access to health care and protection. On malaria, applied social science for public health is therefore crucial, with a view to dismantling societal obstacles to health interventions and technologies.
And, of course, States have an obligation to take steps individually and through international assistance and cooperation towards the full realization of various rights, including the right to health. Thus, developed countries have a human rights responsibility to help the developing world deliver the right to health. These transboundary human rights obligations reinforce MDG 8 -- a global partnership for development. However, the human rights responsibility for international assistance and cooperation is not confined to financial support; it also requires donors and others, including pharmaceutical companies, to coordinate effectively and align their initiatives with a country-owned national plan for malaria.
From the human rights perspective, all malaria initiatives must be subject to effective, accessible and transparent monitoring and accountability, to ensure not just financial propriety but also that the initiatives are conforming to human rights standards and delivering to all without discrimination. I do not know of any effective, transparent, accessible and independent accountability mechanism that is reviewing malaria initiatives in relation to human rights requirements. Crucially, this human rights requirement of effective accountability extends to donors and the international community, and applies to public and private actors, including pharmaceutical companies. Governments have signalled their determination to achieve MDG 6 -- combat HIV/AIDS, malaria and other diseases. More funds are being committed; some progress is being made; some lives are being saved. Yet, malaria is still not seen as a human rights issue, even though the scale of preventable malarial mortality and morbidity is catastrophic.
Among the reasons for this myopia is the reluctance of the classic human rights movement to go beyond civil and political rights, and to embrace economic, social and cultural rights, such as the right to the highest attainable standard of health. Another reason is that most health workers have yet to grasp that human rights can help them fulfil their professional objectives. Most health workers have not yet understood that human rights are a useful advocacy and campaigning tool, a device for sharpening malarial policies, a way of underpinning policies with a legal obligation, and a method of ensuring effective, independent accountability of all parties, including donors and pharmaceutical companies.
A call to action. It is time for a "Human Rights and Malaria Call to Action" to make plain that malaria is a very grave human rights issue. Every day, thousands suffering from malaria are denied their fundamental human rights. The traditional human rights movement must take malarial mortality and morbidity as seriously as they take death penalty cases and "disappearances".
Health workers and human rights workers must work together for a common cause. They must identify a sensible, practical human rights-based approach to malaria that strengthens prevention and treatment, including for infants, pregnant women and those living in poverty. All parties working on combating the disease, encompassing pharmaceutical companies and public-private partnerships, have human rights duties. Key objectives must be the strengthening of health systems and the introduction of effective, independent accountability mechanisms for all those working on malaria.
Human rights do not provide magic solutions because there are no magic solutions. But human rights have a distinctive, constructive contribution to make. In the struggle against malaria, it is time for the human rights contribution to be made -- without exaggeration, but with clarity and conviction.
This article is based on Paul Hunt's talk given at the first annual Human Rights and Malaria Lecture, organized by the Malaria Consortium, on 10 December 2007. For more information, please visit www.malariaconsortium.org.

Notes 1. The full title of the right is the "right of everyone to the enjoyment of the highest attainable standard of physical and mental health". For convenience, this is often shortened to the "right to the highest attainable standard of health" or the "right to health". For a fuller introduction to the right to health, see E/CN.4/2003/58, paras. 10-36. This and other UN reports are available online www2.essex.ac.uk/human_ rights_centre/rth/rapporteur.shtm).
2. Eleanor Kinney and Brian Clark, "Provisions for Health and Health Care in the Constitutions of the Countries of the World", Cornell International Law Journal, 37 (2004): 285-355.