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Responsibility for Global Health Equity: the United Nations System and the World Bank

Emily Brock Global Institutions and International Development J.P. Singh 14 December 2011

Introduction Article 1 of the World Health Organizations Alma Ata Declaration states:
The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

This document, put forth at the International Conference on Primary Healthcare in 1978, was one of the first to promote health as a human rights issue rather than solely a medical issue. Especially with the increasing notoriety of pandemics like HIV/AIDS, tuberculosis and other tropical diseases, the need for responsibility from other sectors in preventing and containing these diseases has become apparent. While the Alma Ata Declaration calls for the claiming of responsibility for these harmful epidemics, it includes no specific guidelines or potential solutions for how to do so. The current landscape of global health in development involves two main camps, which often overlap: medical health and public health. The public health sector has largely taken up responsibility for promoting the human rights framework, even though public health had traditionally been focused on medical interventions. As the human rights-based approach to health development has evolved with the help of the public health sector, more recognition has been given to the social dimensions of illness and well-being. Studies documenting the infection of AIDS victims, as well as victims of other diseases, show that those most likely to be afflicted are often members of the community that are already stigmatized or marginalized (Davies 71; Mann 221). Stigmatized groups, varying across locations and cultures, can include physically and mentally disabled people, ethnic and religious minorities, gay people, women, and the very poor (which goes hand in hand with many of the other categories). A stigmatized

individual, as defined by sociologist Erving Goffman in his seminal work, Stigma, is someone possessing an attribute that makes him different from others in the category of persons available for him to be, and of a less desirable kind the extreme, a person who in is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person, to a tainted, discounted one (3). But stigma within itself does not represent the full extent of the suffering put on these groups that can contribute to health problems; there must be discrimination as well. Discrimination can be understood as the enaction of stigma within the community, and is viewed within the Declaration of Human Rights as a violation of the right to equal protection under the law, as well as a violation of the right to dignity. These violations, resulting in decreasing capabilities within the social infrastructure of the community, leave certain groups more susceptible to mental anguish, decreased standards of living, and often poor health outcomes as a result (especially for those whose stigma is health-related to begin with). From this perspective it becomes easier to see how closely health and human rights are intertwined. Many global institutions including the United Nations agencies (World Health Organization, United Nations Development Program, and UNAIDS) reflect a human rights paradigm in their development efforts. From this vantage point, many of the projects, legislation, and publications coming through these organizations focus on preventative public health initiatives, targeting not only the medical infrastructures of developing countries, but also social and educational infrastructures as a means of promoting and protecting human rights. Organizations like the World Bank, on the other hand, are driven by a more market-based approach that highlights the importance of stateled poverty reduction strategies that decrease the debt in developing countries, and

consequentially improve the healthcare systems of these countries. This strategy assumes that the head of state will have the best interests of their citizens in mind, as well as assuming that there will be an understanding of the social aspects of disease that is viewed as necessary for successful health outcomes. Since the human rights-based agencies understand the interconnectedness between social stigmatization and disease prevention, it seems that their actions would elicit better outcomes than market-driven strategies. Providing debt relief in a developing country does not necessarily mean that more funds will be given to good health initiatives. Therefore, I propose that the UN agencies (WHO, UNDP, and UNAIDS) will cater more to the needs of marginalized groups, therefore leading to more effective healthcare strategies than the World Bank, which focuses mainly on market-driven strategies.

Literature Review In his essay Why Health Equity?, Amartya Sen writes about not only the importance of providing health care, but of providing the capability to be healthy:
What is particularly serious as an injustice is the lack of opportunity that some may have to achieve good health because of inadequate social arrangements, as opposed to, say, a personal decision not to worry about health in particular. In this sense, an illness that is unprevented and untreated for social reasons (because of, say, poverty or the overwhelming force of a community-based epidemic), rather than out of personal choice (such as smoking or other risky behaviour by adults), has a particularly negative relevance to social justice. This calls for the further distinction between health achievement and the capability to achieve good health (which may or may not be exercised) (660).

Sens description alerts us to the importance of providing the capabilities for social justice in advocating for health. Increasing the number of healthcare clinics in a given area is not a complete strategy for combating health inequality. There is a rich literature furthering the statement that the human rights paradigm, closely tied with issues of social justice, can provide more than the biomedical paradigm in finding solutions for modern

health challenges (Mann 924; Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 19; Braveman & Gruskin 533). Jonathan Mann, the late director of the UNs Global Programme on AIDS, supported this statement, writing, Despite the publics belief to the contrary, medical care is a relatively minor, albeit important, contributor to health, far outweighed by societal factors (Mann 924). The gross health-related violations of human rights are apparent; torture is widely understood to be both a threat to health and dignity, but the indirect effects of stigma and discrimination on health remained largely unacknowledged until recently. Until the 1970s, most public health projects were top-down in structure, focusing on increasing the number of health clinics and practitioners in poor areas in hopes of eliminating the most common tropical diseases (Braveman & Gruskin 541). Poverty reduction and human rights were not articulated as goals. The next twenty years saw an increase in the active implementation of human rights principles in health projects. Unfortunately, however, there has been a lag in the transition from optimistic rhetoric towards coordinated and active efforts aimed at promoting human rights. The true champions of this issue often find themselves lacking money and support from within the development community (Braveman and Gruskin 541). The discovery of HIV/AIDS as an incredibly threatening pandemic thrust the issue of human rights into the conversation on health. Due to the nature of the disease and the way it is spread, discrimination within society became inextricably linked with not only those who had the disease, but those who, by virtue of their characteristics or lifestyle, were vulnerable to contract it. It quickly became clear that traditional methods of preventing infectious diseases would not be sufficient. Researchers discovered that

married, monogamous women in East Africa, despite having wide access to condoms, were still contracting HIV at high rates. This pattern exhibits the inability of women to control who their husbands have sex with, and their inability to decline sex from their husbands. These characteristics, common in discrimination against women, nullify the usefulness of traditional preventative health measures (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 20). HIV changed the paradigm regarding disease from a health problem to a condition interlinked with social behaviors. Strategies that had previously dealt with diseases like smallpox necessitated containment and quarantine of the victims to prevent spreading, but these strategies also proved to be ineffective in reaching the root cause of HIV contraction (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 16). Many researchers posit that the linkage between HIV and social behavior is illustrative of a larger phenomenon in which susceptibility to disease and disability is linked with violations of human rights and dignity (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 21). Even as awareness has grown within the development field regarding the importance of alleviating stigma and discrimination in health work, in large part due to HIV/AIDS advocacy, there are many obstacles in the way towards the path to actually enacting these ideas in policy decisions. The main obstacle in many instances is the power of the state over development activities. While policies may be conceptualized by development scholars and public health experts, they are often implemented or supported by the state that they are targeting. This factor can lead to miscommunications and conflicted interests in the assessment of health problems, the implementation of the appropriate policies, and in the effective realization of these policies (Brennan, Fineberg,

Gostin, Gruskin, Lazzarini & Mann 13). The assessment process is often problematic because it is dependent on what the state deem to be serious and not serious health problems, as well as what the state sees as appropriate and safe measures for data collection. When asking citizens to disclose personal information, in writing or over the phone for instance, their responses might contribute to stigmatization if they were to be released publicly (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 14). Similarly, implementation and monitoring of health policies are dependent on the priorities of the government, which can result in discrimination of various groups and preference towards others. The government may not necessarily take socio-economic, financial, and logistical problems into account when creating public health services for citizens; for instance, health clinics must be reachable by public transport in order to reach poorer segments of the population (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 15). These are all potential barriers to the promotion of human rights within public health development when the state is directly involved in the development process. While this is not always the case, the hegemonic forces of many national governments represents a conflict of interests with the promotion of human rights in health development; this is a problem that needs to be addressed at the most fundamental level. In addition to grappling with the private interests of state actors, human rights-led health projects face another hurdle of the pharmaceutical companies that provide drugs and vaccines to developing countries. Even though access to pharmaceuticals is an essential aspect of healthcare, attention to the flaws in the system of drug regulation as a consequence of market-based incentives is crucial. It is generally acknowledged in the development community that drug research and development regarding health problems

that are endemic to poor countries is very inadequate (Kremer 67; Davies 157). The general reason for this occurrence is the fact that competitive markets do not reward research and development on these types of health problems; customers are often unable to pay and governments are able to force down drug prices, which decreases revenue, especially after expensive research and clinical trials (Kramer 67). Also, since pharmaceuticals are often purchased by national governments for their citizens, the interests of the state are again a risky factor in providing legitimate health care, especially to marginalized groups like the very poor. In the past, governments like South Africa have promoted domestically produced drugs that were supposedly effective in preventing mother-child transmission of AIDS, while the foreign-made drug Nevirapine, widely regarded as an effective drug in this respect, was called toxic (Kremer 73). According to researchers, it is imperative to start thinking about pharmaceutical regulations in terms of the global public good, which can be interpreted to mean the human rights of members of the global population: The international community could greatly increase [health improvements] by implementing systems to provide better access to existing pharmaceuticals and to manage their use, as well as by investing in the global public good of [research and development] on diseases that disproportionately affect the poor (Kremer 87). In an effort to remove responsibility from state and pharmaceutical companies, scholars have acknowledged the potential of global institutions to contribute to norms for the transfer of drugs from developed to developing countries, making decisions on the appropriateness of certain drugs for certain circumstances, which in turn the national government could then decide to follow through or not (Kremer 21). Another key task that has the potential to maximize effectiveness of human rights-

driven health practices is the task of creating clear measures for evaluating the severity of health-related human rights violations based on social stigma. Creating a system of measurement establishes accountability on the part of those governments or organizations who were previously able to avoid criticism due to a lack of understanding regarding the link between health and human rights. Most of the measures that currently exist to evaluate the relationship between discrimination and health problems are measures of socio-economic status across all levels of healthiness. Researchers point out that this system of measurement is too limited because it does not account for conflicting patterns in the relationship between socio-economic status and health (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 19). For instance, documented studies have shown that married Canadians experience longer life spans than their unmarried counterparts, and obese women, on the whole, experience lower levels of education and economic stability than their non-obese counterparts (Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 20). These inconsistencies cannot be explained through traditional socio-economic measures. Potential for a better system of measurement can be seen in one study, which revealed that even across highly varied cultural situations, stigma based on chronic health problems like HIV, tuberculosis, and physical disability resulted in similar characteristics of social marginalized and disqualification (Brackel 2). The areas in which decreased participation occur are marriage, friendship, employment, education, leisure activities, and general community participation (Brackel 2). The significance of these similarities across cultures is that it is possible for a universal measuring system to be used. One instrument, the stigma scale implemented in the Explanatory Model Interview

Catalogue (EMIC), is currently used to measure stigma as a result of negative community attitudes towards health problems (Brackel 5). The scale covers several emotional qualities associated with illnesses that results in stigmatization, like pity, shame, and concealment (of the health impairment), among others (Brackel 5). The strength of this measure, according to Brackel, is its usability across different illnesses and disabilities (5). Another general measure of stigma is called the Participation Scale. This scale measures the extent to which social participation is limited by an impairment-related stigma (Brackel 6). While it is often easy to recognize stigma within certain scenarios, it is imperative to have measures that can help us understand the magnitude and extent of these stigmas. While there are many impairment-specific measures of discrimination and stigma, it is necessary to have more general measures that can be used by public health officials and various health institutions in order to facilitate more effective decision-making regarding policy implementation. Other ways in which scholars attempt to improve the effectiveness of human rights-based health efforts are through developing dialogues on human rights with health professionals in attempts to institutionalize the application of the equity perspective in development efforts, as well as extending the functions of the public health sector to include influence over all conditions necessary for health (Braveman & Gruskin 539; Brennan, Fineberg, Gostin, Gruskin, Lazzarini & Mann 21). While finding a concrete measure to operationalize health-related stigma is valuable, many scholars focus their efforts on encouraging inclusion and collaboration as a means of promoting health equity. This includes promoting participation from civil society, NGOs, and groups representing the marginalized population itself, like womens

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and disabled persons groups. Instead of putting knowledge solely in the hands of health experts and large development organizations, the view is that the real repositories of local knowledge on disability in particular countries are the disabled people that live there, and the most efficient way to tap into their local knowledge is to provide them with mechanisms for making their needs known (Metts xv). Providing these opportunities promotes inclusion, which is the basis of work on eliminating discrimination and social injustice. Many organizations, including many within the UN system, have actively taken up the aim of inclusion and collaboration in disability policy as well as other types of policies. Overwhelmingly, the span of literature involving health and the promotion and protection of human rights gives strong arguments for the existence of a link between them. While we know that all humans have the right to be healthy under the definition offered in the Alma Ata Declaration, encompassing physical, mental, and social well being, we now have to ask whose responsibility it is to provide these rights. The health initiatives led by national governments and pharmaceutical companies have certainly caused a great deal of harm to citizens in developing countries, though not in all cases. Many people in the development community believe the task of promoting human rights in health is best suited for global development institutions to take up, and at this point in time most agencies (including the WHO, UNDP, UNAIDS, and the World Bank) have done so to some extent. An evaluation of the work of these organizations is useful in examining the degree to which health policies cater to marginalized and stigmatized groups, therefore implying more successful development efforts than those organizations that largely ignore human rights. Changing the development paradigm to favor the

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promotion of human rights in health policy and practice can hopefully lessen the prevalence of stigma and discrimination within society, thereby improving health conditions for millions of citizens in developing as well as developed nations.

Case Studies The most highly publicized health concern that has serious implications for human rights violations is the HIV/AIDS virus. While the WHO, as the worlds leading health agency, initially took up the cause of AIDS eradication with its Global Programme on AIDS (GPA) in the late 1980s, other UN organizations like UNAIDS (GPAs replacement), UNDP, and lending organizations like the World Bank have also taken up the initiative of combating AIDS. While each organization recognizes the responsibility to contribute to the eradication of AIDS, the extent to which they implement a human rights paradigm will show the extent to which they understand the social complexity surrounding the virus. The Global Programme on AIDS was established as a branch of the WHO in 1987, after recognition of the gravity and scope of the AIDS epidemic. Jonathan Mann, hired as the head of the GPA, was highly successful in framing AIDS as a multisectoral issue (Lisk 16). He believed that the social impact of AIDS, and its contribution to stigma and discrimination, was one of the most damaging aspects of the disease. Discrimination, Mann believed, would lead AIDS victims to remove themselves from society and operate underground, therefore making themselves inaccessible to health interventions (Lisk 17). To enact a multisectoral approach, Mann promoted collaboration with other UN agencies, and in turn helped the GPA to become the coordinator for a

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unified, global response to AIDS. Some of the GPAs main focus areas during Manns tenure included public education to raise prevention awareness, exchange of information, coordination of research, and other efforts that increased knowledge as a means of promoting understanding of the full, multisectoral scope of AIDS (Lisk 16). In 1988 Hiroshi Nakajima was hired to replace Halfan Mahler as director-general of the WHO. Nakajima proved to have a different conceptualization of AIDS than both Mahler and Mann, preferring a solely biomedical model over a multisectoral model (Lisk 20). As a result, Mann soon stepped down from his position within the GPA. The capacity of GPAs role as a coordinator of the global response to AIDS was significantly diminished with the arrival of Nakajima; the organization was no longer focused on the whole issue, only the biomedical side. The GPA lost support as a result, and it was eventually decided that the UN system needed a new alternative, which they found in the joint, co-sponsored, UNAIDS organization (Lisk 25). UNAIDS has been successful, like the GPA was initially, in combating stigma towards AIDS victims. The program emphasizes structuring country-specific development programs, taking into account the social, economic, political, and cultural factors at play involving AIDS that can exist in specific locations. In this way, UNAIDS has extended the legacy of Mann, who strived to counter the human injustices associated with the spreading of AIDS, rather than focusing on drugs and other medical interventions. Franklyn Lisk acknowledges that AIDS is a long wave epidemic that would require more than a quick medical fix to eliminate completely (23). The forces at combating AIDS must come from the fundamental sectors in which it originates, which are inherently social. The UNDP and the WHO, while perhaps not as influential as UNAIDS whose

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goals are directly related to diseases like AIDS, still use a human rights paradigm to frame the social dimensions of the AIDS epidemic within the international development community. Combating HIV/AIDS, malaria, and other diseases is one of the eight Millennium Development Goals set forth in 2000. Among the targets for this development goal are halting the spread of AIDS by working towards equal education for all children, providing accurate information for young adults, as well as medical indicators including equal access to antiviral drugs (UNDP.org). The human right to education and information access, regardless of social and economic status, is embodied in these targets. They seem to encompass a full range of explanations concerning the inaccessibility of certain groups to medical care and education. There are no targets directly involving discrimination and stigma towards AIDS victims, however. It is possible that the target for education includes promoting inclusion and equality within society, but it is worth mentioning explicitly as a key facet of AIDS policy work. The main work done by UNDP to promote health equity lies in its promotion of the general human rights paradigm and their focus on AIDS education and information within the Millennium Development Goals. The World Banks main AIDS projects occur within their Multi-Country AIDS Programs (MAPS), focusing on AIDS relief in sub-Saharan Africa. The MAP approach, as described by the World Bank website, highlights the importance of assistance that is comprehensive, flexible, and adaptive (Worldbank.org). The specific projects implemented by MAPS include efforts to empower communities and civil society, build government capacity, and collaborate with UNAIDS to build support on AIDS prevention, care, and treatment (Worldbank.org). The Bank seems to embody exactly the

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kind of collaboration and multisectoral strategies that Mann praised during his time at GPA. However, the Bank also faces criticism because of the failures of the MAPS program. According to Catherine Weaver and Susan Park, the World Bank was unsuccessful in facilitating local initiatives and establishing government capacity (466). Weaver and Park quote the authors of Reinventing the World Bank, Johnathan Pincus and Jeffrey Winters, who describe the MAP approach to AIDS work as the taxi-cab approachin which the country is in the drivers seat, but no one is going anywhere until the Bank climbs in back, gives the destination, and pays the fare (Weaver and Park 467). The attention that the World Bank claims to pay to the specialized needs of community members appears to be mostly rhetorical. This has a lot to do with the Banks focus and attention to providing good research, which led to neglect of the actual project implementations. While the Bank has always fostered its legitimacy through its reputation as a knowledge broker, there was simply too much focus on that aspect of the MAP development initiatives. While several in-depth research reports were done for the MAPS program in Africa, there was little consequential communication between NGOs, CSOs, and the Bank (Harman 488). This weakened engagement within the organizations involved. This factor, combined with inadequate funding given to the local organizations, resulted in the failure of MAPS (Harman 488). So it was not the fault of market-driven strategies that contributed to the ineffectiveness of the World Banks AIDS program in assisting local stakeholders, but the internal preferences given to research and knowledge production that led to the suffering of the actual implementation of the program in Africa. Gender equality and reproductive rights are another area where institutional

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policies have the power to affect health outcomes. Womens reproductive health is an important human rights issue because in many areas of the world women have little agency over choosing sexual partners, when to have children, and which reproductive health care options to seek (Davies 77). The lack of autonomy in these cases, especially when it collides with other health concerns like HIV, implicates womens rights as a crucial element of health equity reform. While UN organizations like WHO and UNDP focus on gender in research and development policies, there is a lack of commitment to handling reproductive health from a sexual standpoint. Many programs have focused on maternal and prenatal care, without emphasizing the importance of family planning, birth control, and sexual rights of women. The UNDP was criticized strongly when it neglected to include sexual rights within the Millennium Development Goals. The goal to promote gender equality and empower women includes the targets of increasing the education levels and employment opportunities for women (undp.org). The goal to improve maternal health is almost exclusively targeting the care of women who are already pregnant, although there is one target that promotes contraceptive use among women (undp.org). The need to promote sexual agency among women is not mentioned. While the WHO and UNDP clearly promote gender equality from a human rights standpoint, there scope of those rights is not exhaustive. It seems that this may come down to cultural or religious issues associated with sexual rights of women that could contribute to decreased legitimacy or funding from member states as well as private donors. The misgivings of the UN organizations on behalf of health equity for women seem small in comparison to the work of the World Bank on the issue. While the Bank

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has acknowledged the importance of targeting women as a means of poverty reduction, they do so not from a human rights standpoint, but from a market-driven standpoint. The World Bank has taken up the initiative of increasing primary education for girls not because it increases agency and knowledge, but because 'primary education is the largest single contributor to the predicted economic growth rates of high-performing Asian countries (Hales 151), as articulated by World Bank staffer George Psacharopoulos. Critics of the World Bank posit that these gender policies not only dont apply to the human rights of women, but they function because the oppression of women is reinforced (Hales 150). While the World Bank, like the UNDP and WHO, claims to work towards womens empowerment, their definition of empowerment is based upon the actions that promote the most economic growth. While economic growth certainly has the potential to contribute to womens autonomy, the most important aspects of inequity like discrimination and abuse are never explicitly dealt with. In this way, women remain a tool for market growth within the World Bank paradigm, and their actual level of empowerment remains secondary. Physically and mentally disabled people represent another group that often falls victim to social marginalization, and consequentially experiences health inequity. Like infectious diseases and other conditions that cause impairments, disability was mainly addressed from a medical standpoint until the late 1970s. While a physical or mental impairment itself leads to limited capabilities, the social context in which many disabled people find themselves limits their capabilities even further. Disabled people often experience diminished opportunities for education, healthcare, social inclusion, and workplace options. These exclusions often contribute to poverty, which contributes to

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declining health. This pattern reveals the fact that poverty, health, and disability exist in a vicious cycle that still remains unaddressed in many international agencies. This is the case for UNDP in their Millennium Development Goals, of which the first goal is to eradicate poverty, yet there is no mention of disability as a key contributor to continued poverty. While the UN was active in promoting inclusive policies in earlier years with the establishment of the International Decade of Disabled People in the 1980s, the UNDP has not reached its potential in addressing the gravity of disability issues. The WHO has done a great deal to champion the Community Based Rehabilitation (CBR) strategy for combating disability discrimination and promoting human rights. The WHO, along with other UN organizations like the ILO and UNESCO have produced several strategy papers outlining the importance of community leadership and participation of disabled-persons groups and civil society. The implementation of CBR initiatives has seen mixed results, but the focus on inclusive practices brings WHO closely in line with issues regarding marginalization and stigma towards disabled people (WHO, ILO, UNESCO 2). These organizations have continued to develop CBR goals over the years. In 2004 they released a revised strategy paper emphasizing the importance of [activating] communities to promote and protect the human rights of people with disabilities through changes within the community, for example, by removing barriers to participation (WHO, ILO, UNESCO 3). By removing barriers and improving capabilities, CBR has the potential to remove many of the social barriers that contribute to poor health outcomes for disabled people, and as a result, help to eliminate poverty. Not surprisingly, the World Banks evaluations of its own performance on

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disability-related development work cite an impression of deep and nuanced understanding of the issue. They refer to the creation of a Disability and Development team as a step towards progress, and add that the Bank has primarily helped to advocate for disability as an issue, which raised awareness internally and also among other development agencies (World Bank 206). While the World Bank may view itself as a legitimating force in the area of disability policy, their track record for successful outcomes is not as stellar. One of the main contributions of the Bank to the area of disability and illness is the DALY measurement system, or Disability Adjusted Life Years. This system, which has increasingly been used as a tool to measure the impact of health problems on developing countries, measures the burden of disease on society. This measure also determines how many resources should be allocated to various areas based on the level of burden. Critics of the DALY measuring system claim that it is an inadequate and inequitable measure of the impact of disease and disability on society. Through various methods of weighting and discounting certain factors, essentially these measures place a different value on years lived at different ages and at different points in time. They value a year saved from illness more for the able-bodied than the disabled, more for those in middle age groups than the young or the elderly, and more for individuals who are ill today compared with those who will be ill in the future (Anand and Hanson 310). Judging from these factors, DALY seems to be an inappropriate measure for determining resource allocation since it favors certain lives and physical capabilities as more valuable and less burdensome than others. This measure not only fails to uphold standards of human rights, but it works to foster the cycle of inequality and limited capabilities that characterize the disabled experience.

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Moving away from solely disability related policies, the World Banks more general strategy of using Poverty Reduction Strategy Papers (PRSPs) in development efforts is problematic and needs to be addressed. The guidelines within PRSPs apply to all areas of poverty reduction and development, but they are particularly salient in examining their contribution to health equity. PRSPs were developed as a replacement

for an older method of designating development efforts, the Structural Adjustment Program (SAP). SAPs were programs put into place by the World Bank for countries who required loans. Critics cited that these programs seemed to voice the concerns of Washington rather than the needs of the local environment (Davies 43). The SAPs involved a set of economic reforms that were designed to reduce government spending, increase the influence of the private sector, and thereby open up markets to competition. This often resulted in the cutting of food subsidies and rising in food prices (Davies 43). In response to criticisms, the World Bank replaced the SAP with the PRSP. This method was supposed to be more participatory because it involved collaborating with the local government and civil society to form poverty reduction strategies. Instead this forum for collaboration was revealed to be non-transparent, and did not offer any kind of voice for civil society to implement change (Davies 47). A leader in the protest of the PRSP method, Gloria DeSilva, said I cant accept this as being conducive to the reduction of poverty. This is about opportunities and privileges being offered to multinational organizations and big business ventures to invest in the country, while the people are burdened with an increasing national debt (Yeo 14). The World Banks PRSP method of designing development projects is a good example of the inability of market driven plans to cater to the rights of marginalized groups. These people remain voiceless

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actors in a system dominated by a neoliberal paradigm, rather than a human rights paradigm. As Anita Ghai has emphasized in her publications on human rights, privileging the paradigm of profit over humanity needs to be interrogated so that a humane society can be sustained Ghai 292). If we view inclusion of socially marginalized groups as a facet of a humane society, then it is crucial to identify the development strategies that detract from this goal. Market driven development strategies, while not always negative in outcome, still represent a significant barrier to the promotion of human rights, and consequentially health equity.

Discussion and Conclusion The purpose of this analysis is not to find blame within institutions, but to ask the question of whose responsibility it is to take up the cause of health equity, and which agencies might be best equipped to do so. We have seen from influential human rights actors like Amartya Sen and Jonathan Mann that all humans deserve the right to live healthy lives, in all senses of the word. While the World Bank, UNDP, WHO, UNAIDS, and countless other institutions have acknowledged this right in various forums, there is clearly a disconnect between recognizing the right to be healthy versus actually providing the capability to do so. While this is an instance of seeking the protection of human rights, at a deeper level it is an instance of seeking accountability and responsibility for an issue that is important, but not necessarily at the top of the roster at many organizations. Is it the responsibility of the World Bank, as primarily a lending institution, to solve the intricate problems that associate stigma with poor health? Or is it the responsibility of the WHO and UNDP who, under the UN system, seek to uphold

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human rights in the greatest capacity? This analysis, while far from exhaustive, is meant to be a means of evaluating what these three agencies, in addition to a few others, have contributed to health equity. Looking at their practices and policies regarding HIV/AIDS victims, women, and disabled people, can be an illuminating exercise not to see how institutions respond to these individual issues, but to see how they advocate for the rights of marginalized groups as a whole. In reality these stigmatized conditions cannot be separated; HIV victims are predominantly women, women may become disabled through prenatal healthcare neglect, and disabled people may have become impaired because of HIV symptoms. All of these outcomes are based on the persistence of the same attitude; that some people, by virtue of a physically or socially undesirable trait, do not deserve the full extent of human rights, including the capability to be healthy. Based on this analysis, an obvious barrier to achieving equality for marginalized groups is the preference for economic growth over human rights that pervades the international development landscape. Anita Ghai supports this claim, saying, The responsibility, I believe, for turning impairment into disability, lies within the economic system (291). In todays economic climate, it is a persons ability to function in the contemporary workforce that determines his status and quality as a human being. So what is to be done? Undoubtedly the answer involves deliberation between wide varieties of actors, especially those that arent often granted a powerful voice. The UN Secretary General, Kofi Annan, has contributed to this process by creating the Global Compact, a program that deals directly with businesses and corporations, provoking these actors to set new norms for human rights, labor, and the environment (Murphy 177). Just

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as promoting human rights in general involves a multisectoral approach, the promotion of health equity, as Jonathan Mann maintained, also need to be viewed from many angles. Involving the voices of the marginalized themselves, along with NGOs and other local actors could provide a richer and more dynamic research culture in which to address the issues surrounding stigma and health. As articulated by Fiona Kumari Campbell, we need a vibrant research culture that should not just be housed in medicine but also in departments of [religious] studies, psychology, literature, architecture, law, sociology, cultural and theatre studies (Campbell 1471). When Craig Murphy was a nineteen-year-old undergraduate, just becoming interested in issues of social justice, he was able to study the cocoa trade in Ghana, which he discovered was an arrangement rife with imperialism and injustice. Since the time of his experience in Ghana, Murphy writes, I have wanted to amplify the voices of the politically marginalized and to imagine what the world would be like if their views really counted (Murphy 6). Perhaps steps towards empowering these voices can lead to the types of dignity and self-actualization that are closely connected with overall health, happiness, and well being, to which every human is entitled.

Works Cited

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