The Human Right to Health by Jonathan Wolff

The Human Right to Health, Jonathan Wolff (New York: W. W. Norton & Company, 2012), 208 pp., $23.95 cloth, $15.95 paper.

The modern day notion of human rights was shaped significantly by World War II and the subsequent Nuremberg Trials of 1948, which sparked a movement to codify a new standard of human dignity. The postwar campaign for a universal standard for all humans regardless of nationality, race, or religion produced the Universal Declaration of Human Rights (1948). And while the Declaration itself does not have the legal weight of a treaty or covenant, it nonetheless has served as a yardstick against which rights are measured.

Notably, the Declaration gives weight to two aspects of the rights paradigm of the twentieth century: the need for a government not to restrict the rights of or discriminate against its citizens, and the need for a government to deliver to its citizens a basic set of services, including education and health. These two pieces of the modernday human rights framework—sometimes referred to as “negative” and “positive” rights, respectively, and later codified in two covenants—the Covenant on Civil and Political Rights and Social Rights (ICCPR), and the Covenant on Social, Economic and Cultural Rights (ICESCR)—help frame the tension that Jonathan Wolff addresses in The Human Right to Health.

These elements of the Declaration were partitioned along the fault lines of the cold war, with Western states more supportive of the ICCPR, and the Soviet bloc more invested in the ICESCR. It is therefore unsurprising that, as Wolff describes the historical development of the idea of the right to health, his exposition becomes unavoidably political. In fact, for Wolff, governments, international financial institutions, flows of capital, and the donor-recipient relationship are all implicated in preventing the actualization of the human right to health today. The book also surveys public sector and civil society approaches to global health issues, donor and recipient relationships, and the political and moral complexities inherent in the notion of the progressive realization of the right to health.

Central to the book is the exceptional story of the global response to the HIV/AIDS pandemic, which serves as an important example in the development of the right to health. Wolff highlights the role civil society played in arguing for a broader framing of human rights—both in the anti-discrimination fight waged by and on behalf of those living with HIV/AIDS, and in the battle to force states and pharmaceutical companies to produce and disseminate on a large scale the drugs that have turned HIV/AIDS from a death sentence to a treatable chronic condition. On both the scholarly and grassroots level, the global response to HIV/AIDS, Wolff argues persuasively, “gave the human right to health movement an impetus and clear focus.”

Wolff’s thesis highlights the work of the late Dr. Jonathan Mann, who linked health and human rights, through the lens of the HIV/AIDS epidemic. Mann’s framework proposed three linkages between health and human rights: policies that lead to ill health; abuse, discrimination, or privation that leads to ill health; and lack of access to treatment. On the grassroots level, civil society—most notably, people living with HIV/AIDS—have had an enormous role in demanding a set of rights very much within Mann’s framework. Their fight was, clearly delineated through the Denver Principles in 1983. The principles have had a durable impact on discriminatory policies (and perhaps more importantly, on civil society participation) in every aspect of HIV/AIDS policy and planning throughout the world.

While the work of AIDS activist communities in the global North and South preceded the treatment of HIV by more than a decade, the human rights framing of the epidemic helped to assure that when treatment was available, the principles of human rights would be paramount in treatment access. Today, the success of this movement has provided more than eight million HIV-positive people throughout the world with free long-term treatment, monitoring, and care.

The story of the right to human health, however, is not a wholly victorious one. As Wolff points out, there are ongoing challenges in the interpretation and actualization of this right. Perhaps the biggest challenge is in its financing. The global burden of disease is disproportionately borne by the people who live in countries whose governments are the least able to finance an adequate health system. Wolff argues that some actions of international financial institutions such as the World Bank and the International Monetary Fund (IMF) have impeded the realization of the right to health. In the 1980s the World Bank and IMF adopted a strong neoliberal stance demanding constraints on the public sector by forcing the privatization of health, education, and other services in developing countries, with the belief that this would result in more rapid and sustained economic growth. These so-called “structural adjustment policies” were a precondition for the disbursement of loans that poor countries needed to function. As Wolff points out, it is generally held that these policies were a disaster for health in the world’s poorest countries, and that such policies explicitly inhibited the ability of governments to fulfill the right to health.

Wolff also scrutinizes the pharmaceutical industry and international intellectual property agreements, arguing that both have had a deleterious effect on achieving the right to health. Wolff shows the enormous influence of the pharmaceutical industry on global health matters, from its restricting of access to critically-needed drugs through exclusive patents and high prices (in the case of HIV/AIDS medicines), to its lack of interest in developing new drugs for the poor, even when the burden of disease is enormous (as in the case of tuberculosis). But he also highlights initiatives that have improved drug access, such as the utilization of the Agreement on Trade Related Aspects of Intellectual Property (TRIPS) and the creation of the Green Light Committee for drug resistant tuberculosis at the World Health Organization.

Further, Wolff is aware of another thorny challenge: that of the health-care workforce. The difficulty of keeping trained professionals in the countries with the greatest need has become an important aspect of the political economy for the right to health. The brain drain of health professionals continues at an alarming pace—from poor countries to richer ones, and from the public sector to the better paying private sector. The effect is that government programs—those charged with respecting, protecting, and fulfilling the right to health—have the least staff to provide services to those who are the most in need.

The Human Right to Health is meant to provoke the reader to think about how to bring all these pieces—the public sector, civil society, industry, patents, health financing, and human resources—together, in order to achieve the more rapid, progressive realization of the right to health in the decades to come. Readers will glean many insights from this fine book—insights in understanding the history of the human right to health, the progress that has been made in realizing this right, and the challenges that remain.

—JOIA S. MUKHERJEE

Dr. Joia S. Mukherjee is an associate professor in the Department of Medicine’s Division of Global Health Equity at the Brigham and Women’s Hospital and in the Department of Global Health and Social Medicine at Harvard Medical School. She has served as the Chief Medical Officer for the nonprofit Partners In Health since 2000.