[This blog was co-authored by Eric A. Friedman and Lawrence O. Gostin, and was first posted with as a Health Affairs blog. It is connected to a related Health Affairs publication, Global Health: A Pivotal Moment Of Opportunity And Peril.]
In the current issue of Health Affairs, we explore a pivotal moment of opportunity and peril in global health, while identifying the leadership challenges of “the global health trio”—the World Health Organization, the United Nations, and the World Bank. Each of the challenges we pose share a common thread: poor and other marginalized populations are most vulnerable to current and emerging health risks. Maternal and child mortality, infectious diseases, non-communicable diseases, health harms from climate change and mass migration – all disproportionately affect those who are poor and less educated, indigenous people and immigrants, and others who experience social, economic, and political exclusion. Even antimicrobial resistance, in the United States and Europe primarily associated with hospital-acquired infections, mainly affects people in lower-income countries, and involve such diseases as AIDS, tuberculosis, and malaria, which are concentrated among poorer and otherwise marginalized populations.
These vulnerabilities cannot be resolved through technical solutions alone. Even if the UN Sustainable Development Goals are largely realized, poor indigenous women, sexual minorities, and persons with disabilities will not fully access health services if they face discrimination. Moreover, the types of solutions needed – good housing for all, health care that is as good for the poor as it is for the rich, effective enforcement of environmental regulations whether a poor black community or wealthy white suburban one is at risk – will not be forthcoming if political leaders do not look upon the homeless transgender woman of color as no less their constituent than the wealthy businessperson. Gaping health disparities exist not because the solutions are unknown, but because closing them is not a priority. Marginalized populations are vulnerable not only because the needed policies are not in place and being implemented, but also because the needed power dynamics are not in place.
The potential of international law
The scale of problem calls for using all available tools, including law. Public health law has contributed to immense health improvements, from mandatory vaccinations and road traffic safety to tobacco taxes and smoking bans. The global nature of the causes of health disparities, such as climate change and vast differences among countries in financial capacity, points to the importance of international law. The solutions are also international, applying to all countries, whether to eliminate discrimination, ensure financing, or develop mechanisms that allow people to meaningfully participate in developing the policies that affect their health.
As the Framework Convention on Tobacco Control demonstrates, the norms that a treaty establishes on health-promoting policies and globally shared expectations may be transformative. Further, treaties stand to increase accountability through courts and other mechanisms. As binding law, they can more effectively protect health from harm caused by other international legal regimes, such as trade and intellectual property.
The Framework Convention on Global Health
Accordingly, as the election for the next WHO Director-General got underway last year, we joined the Director-General of South Africa’s National Department of Health, a former Director of PAHO, civil society leaders such as the Vice Chairperson of BRAC International, and others in calling for the next WHO Director-General to make the right to health their foremost priority, with a Framework Convention on Global Health as the “centerpiece.” Read More
On December 3, 2016, I presented at the opening plenary session of the National HIV PrEP Summit in San Francisco. At the summit, NMAC released a State of the State report that Jeffrey S. Crowley and I prepared as the first part of a two-part Blueprint for HIV Biomedical Prevention. The State of the State report provides an overview of policies and programs that are critical to effective biomedical HIV prevention in communities of color. The report highlights current health department and community efforts to implement the new science in the United States. It also includes descriptions of the roles played by selected federal agencies in supporting biomedical HIV prevention and identifies some of their key recent initiatives.
Biomedical HIV prevention strategies offer a range of tools that can effectively prevent HIV infection. These tools include treatment as prevention (TasP), pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP). TasP involves providing early and sustained HIV treatment to HIV-infected people that first and foremost treats their HIV infection for their own health, but is also a very powerful tool for preventing HIV transmission to others. PrEP involves giving high-risk HIV negative individuals a reduced dosing of HIV medication (currently in a daily pill) and other services to prevent HIV infection. PEP involves providing persons who may have had a very recent exposure to HIV a short course of treatment (usually around a month) to prevent them from becoming infected.
As the report notes, to increase the effectiveness of HIV prevention tools in communities of color, it is important that community members know about these tools, find them acceptable, want to use them, and have access to them. It is also important to have medical providers who are knowledgeable and up-to-date about the latest research around all forms of biomedical prevention and who are willing and equipped to engage in honest conversations about sexual and other intimate behaviors, treat people with HIV, and prescribe both PEP and PrEP.
Building on our work on the report, we are focusing on critical policy issues that impact access to PrEP for young people. Ensuring that young people benefit from PrEP is critical to reducing disproportionately high rates of HIV in communities of color. Even as HIV infection rates declined nationally over the last decade, rates have increased among young gay and bisexual men of all races and ethnicities. HIV infection rates have increased most rapidly among young Black and Latino gay and bisexual men.
Young people face numerous barriers to accessing PrEP. Adults are able to consent to PrEP, but adolescents often cannot. In most states, PrEP is not available to adolescents without parental consent. Parental consent requirements can be a barrier because adolescents may not have disclosed their sexual behaviors to their parents or may fear the repercussions of disclosure.
Limited payment options are another barrier for both adolescents and young adults. Truvada, the only FDA-approved PrEP medication, is indicated for adult use only. This can make it more difficult for adolescents to access and use insurance or patient assistance programs to pay for Truvada as PrEP. Moreover, adolescents and young adults often access health care through their parent’s health insurance, which raises questions about confidentiality if insurance companies mail explanation of benefits forms or other documents to their parents.
The O’Neill Institute is committed to advancing the policy dialogue on PrEP. With support from amfAR, we have established a new project to explore how to support uptake of effective HIV prevention and treatment modalities for adolescents and young adults. For more information about HIV/AIDS initiatives at the O’Neill Institute, check out our webpage.
On December 13th, President Obama signed the 21st Century Cures Act into law. This law provides $6.3 billion for cancer cure research, and to address the growing opioid drug abuse epidemic. The Act also allows for a more streamlined approval process for the FDA to bring new drugs and medical devices to the market. While increased funding for health initiatives SHOULD have me dancing on my desk, I am underwhelmed by what this Act will do to improve public health. I am also concerned that the cuts made to existing initiatives to fund this Act do more to undermine the improvement of health in this country than to better it.
Funding cures by cutting disease prevention programs
As the name indicates, the focus of this Cures Act is to fund research and initiatives that promote the creation of cures for diseases such as cancer and Alzheimer’s. In order to fund this new initiative, Congress cut funding from several existing public health programs, most notably $3.5 billion from the Prevention and Public Health Fund, which was developed under the Affordable Care Act to prevent diseases like Alzheimer’s, chronic illnesses like heart disease and diabetes, and to promote increased vaccination. It seems counter-intuitive to gut a program that is trying to prevent illnesses from occurring in order to fund a program to find cures for the illnesses the former was trying to prevent altogether. I guess there is consolation in hoping the many people who will develop cancer and Alzheimer’s now due to the cuts in strategies that could prevent their illnesses will at least have a greater shot at being cured of their affliction… that is, if they live long enough to reap this “benefit.” To me, cutting prevention programs – which have proven records of efficacy and public health benefit, and that will likely tick up the prevalence of certain illness in the coming years – to fund the possibility of developing disease cures that could be 20 days or 20 years down the line, is just plain wrong.
Funding the POSSIBILITY of cures while Americans are still being denied cures that are already available: The ongoing Hepatitis C treatment access struggle
While Congress is throwing money at programs that might produce much-needed cures for illnesses at some point in the future, the legislative body continues to underfund and largely ignore supporting programs that will get already-existing cures into the hands of millions of sick Americans whose lives could be permanently improved by these therapies. Curative drugs for Hepatitis C – a disease that affects more that 4 million Americans – already exist. However, many still face numerous financial and procedural roadblocks to accessing these drugs. The poor, uninsured or underinsured are still being denied prescriptions for these drugs until their liver damage progresses to a more critical state. Medicaid programs continue to restrict access to Hepatitis C drugs to their recipients if they aren’t yet “sick enough” to warrant receiving treatment.
The Cures Act allocates $1 billion over the next 2 years for the treatment of those with opioid addiction. Injection opioid abuse is strongly correlated with increased risk and higher rates of Hepatitis C infections. It is not enough to just treat the addiction: there must also be services available to meet all of the health care needs of those in addiction recovery, including their Hepatitis C infection. The lack of discrete references to any plans to increase support for Hepatitis C initiatives as part of these new public health programs, despite the direct relationship between injection opioid abuse and high rates on HCV transmission, gives me little reason to feel encouraged that resources allocated for Hepatitis C services will improve.
This is NOT THE WAY to secure the nation’s health
The government MUST stop the piecemeal funding of public health programs, and invest in comprehensive strategies that provide long-term solutions and make the most efficient use of limited resources to maximize the reach and impact of the initiatives. It also cannot continue to throw money behind the latest politically popular issue before effectively resolving existing public health needs. The support of public health programs cannot ebb and flow with political transitions. It must remain consistent, especially when initiatives show proven efficacy and benefit. It is the moral and legal responsibility of the government to protect the health of the people, and our leaders need to let this obligation, rather than political influence, rule their decision-making at it relates to funding and other allocations for public health initiatives.
This week marks the 10th anniversary of the adoption of the Convention on the Rights of Persons with Disabilities (the Convention) by the United Nations General Assembly. The Convention has been ratified by 170 countries and established frameworks and reporting requirements to ensure the inclusion of all individuals with disabilities in social, political and economic life. The World Bank estimates that one billion people, or 15% of the world’s population lives with some form of disability making the Convention a critical accountability tool to ensuring the rights of a huge number of individuals worldwide.
Since the adoption of the Convention and due to the commitment of a huge number of disability advocates around the globe, there have been enormous strides in the advancement of disability rights and inclusion including having disability rights included in the Sustainable Development Goals, movements away from the institutionalisation of those with disabilities and the generation of action plans at the national level in several countries to create concrete strategies for disability inclusion. However, despite these advances, there is much work still to be done.
There are very real battles being fought to ensure adequate access and inclusion across all social situations, particularly legal interventions, health care, education, public transportation and employment and those with disabilities are still extremely vulnerable to poverty, exploitation and marginalisation. Particularly vulnerable are those with disabilities who are caught in the global forced migration crisis, facing the vulnerabilities associated with their migration status compounded with the vulnerabilities of their disability. The UN notes that forced migrants with disabilities are more likely to be ‘sidelined n every aspect of humanitarian assistance due to physical, environmental and societal barriers against accessing information, health and rehabilitation service and human rights protection’.
The anniversary of this groundbreaking tool is an opportunity to evaluate where the global community has succeeded and to celebrate those successes, but it is also an opportunity to review where we have fallen short and to double down on our commitment to ensuring inclusion and equity for those living with disabilities and to seeing those priorities work through national and international policies across the board.
A few weeks ago I wrote a blog post about what the results of the cannabis ballot initiatives could mean for legalization in the U.S.. I mentioned that although four new states legalized cannabis for personal use, it will be a couple of years until we see these fully implementing their regulated markets. However, while we wait for those state’s to join California, Washington, Oregon, Alaska and DC, we have a lot of information to analyze how legalization is looking so far. All these numbers will also help shape any new state’s model to come, trying to fill gaps or improve problems that may arise.
In October, the Drug Policy Alliance released a report detailing what we know so far about cannabis legalization in the states that are already up and running. While it is still too early to make any definite conclusions, preliminary reports suggest that the effects of legalization have been either positive or negligible. The report focuses on four main areas: youth use, arrests, road safety and tax revenues. Here are some of the biggest findings. Read More
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.