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INTERNATIONAL ENVIRONMENTAL LAW
The Protection of Public Health
Dr Elli Louka *
Table of Contents
1. Instruments of International Environmental Law
2. Facts, Figures and the First Malaria Eradication Program
3. The Stockholm Convention on Persistent Organic Pollutants and the Precautionary
Approach
4. The Roll Back Malaria Program and the Future of Malaria Prevention
5. The Role of a Global Health Organization.
1. Instruments of International Environmental Law
The protection of environment and the pursuit of public health seem like tautological
goals. The protection of environment from polluting discharges has as an inevitable
consequence the protection of public health. Many instruments of international
environmental law attend to the protection of public health by virtue of the pursuit of
environmental protection. Instruments of international environmental law geared to the
protection of public health focus, for instance, on the control of hazardous substances
ensuring that such substances do not affect drinking water supplies1 or on the phasing
out of chlorofluorocarbons (CFCs) that deplete the ozone layer causing eye cataracts
and skin cancer.2
Instruments of international environmental law establish standards so that industrial
discharges and sewage are not disposed of in the waters indiscriminately.3 Today the
air of many cities is cleaner because of standards that have been established to remove
pollutants from the air and, consequently, to reduce respiratory problems and other
ailments that could be caused by air pollution.4
From the Stockholm Declaration adopted in 19725 to the 1992 Rio Declaration6 to the
2002 Johannesburg Declaration7, that set the milestones for the development of
international environmental law, the primary focus of such law is the protection of
humans from the adverse effects of benefits brought by industrialization.
The Stockholm Declaration on the Human Environment is unequivocal about the
importance of the pursuit of environmental protection for the purposes of the protection
of human health. According to the Stockholm Declaration:
The protection and improvement of the human environment is a major
issue which affects the well-being of peoples and economic development
throughout the world.
The Rio Declaration buttresses the idea of the protection of public health. Principle 1 of
the Rio Declaration states that, "Human beings are at the centre of concerns for
sustainable development. They are entitled to a health and productive life in harmony
with nature." According to Principle 14 of the Rio Declaration:
“States should effectively cooperate to discourage or prevent the relocation and
transfer to other States of any activities and substances that cause severe
environmental degradation or are found to be harmful to human health.”
The issue of the protection of human health and the environment became most
prominent during the World Summit for Sustainable Development (WSSD) that took
place in 2002 in Johannesburg, South Africa. In fact, the emphasis on development
and the protection of human health from a variety of diseases that affect mostly
developing countries was so central during the conference that many view that the
WSSD was not really an environmental summit.
The WSSD, instead, has been characterized as a conference that ‘transgressed’
somewhat from the goal of the pursuit of environmental protection to the attainment of a
number of economic and other goals that affect mostly developing countries. According
to article 19 of the Johannesburg Declaration:
‘We reaffirm our pledge to place particular focus on, and give priority attention to,
the fight against the worldwide conditions that pose severe threats to the
sustainable development of our people, which include: chronic hunger;
malnutrition; foreign occupation; armed conflict; illicit drug problems; organized
crime; corruption; natural disasters; illicit arms trafficking; trafficking in persons;
terrorism; intolerance and incitement to racial, ethnic, religious and other hatreds;
xenophobia; and endemic, communicable and chronic diseases, in particular
HIV/AIDS, malaria and tuberculosis.” [emphasis added].
The issue of the importance of public health for the pursuit of sustainable development is
emphasized further in the Plan of Implementation adopted during the Johannesburg
summit. According to the Plan of Implementation:
“The Rio Declaration on Environment and Development states that human
beings are at the centre of concerns for sustainable development, and that
they are entitled to a healthy and productive life, in harmony with nature.
The goals of sustainable development can only be achieved in the
absence of a high prevalence of debilitating diseases, while obtaining
health gains for the whole population requires poverty eradication. There is
an urgent need to address the causes of ill health, including environmental
causes, and their impact on development, with particular emphasis on
women and children, as well as vulnerable groups of society, such as
people with disabilities, elderly persons and indigenous people.”8
The Plan of Implementation further encourages the mobilization of adequate public and
private financial resources for research and development on diseases that affect mostly
the poor, such as HIV/AIDS, malaria, and tuberculosis, directed at biomedical and health
research, as well as new vaccine and drug development.9
The anthropocentric nature of international environmental law, while pervasive in
international instruments, is not always viewed favorably. The anthropocentric focus of
the Rio Declaration, and the balance in an uneasy text of environment and development
were not particularly welcomed by environmental groups.
Environmental groups viewed that 1992 was the year to adopt a declaration that would
unequivocally protect the ecosystems and the environment and it was time for
international law to withdraw from an anthropocentric orientation that has characterized
its evolution and adopt more of an ecosystems approach to environmental protection.
Therefore, while international environmental law and the protection of public health seem
like compatible goals and many environmental instruments could be seen as efforts to
protect public health from the adverse effects of polluting activities, at the heart of
international environmental law there is an embedded conflict about what to do with
when the goal of the protection of human health conflicts with that of environmental
protection.
The conflict between environmental protection and the protection of public health is
rarely stated as such conflict. Often it is presented as a conflict between the long-term
effects of a hazardous substance on environment and human health and the short-term
benefits from the use of a potentially dangerous substance. This is because it is
politically inconvenient to admit that a strict version of the protection of the environment
and the pursuit of public health could be antithetical goals. This is what they are,
however, when a strict focus on environmental protection has the effect of undermining
the goal of the protection of public health in the developing world.
This study focuses on one of the cases where the pursuit of stricto sensu environmental
protection has undermined the fight against infectious diseases in the developing world.
The case in point is malaria and the use of DDT, a potent hazardous substance, for the
fight against the disease.
2. Facts, Figures and the First Malaria Eradication Program
Between 350 and 500 million people in the world are infected with malaria in 107
countries and between 2 to 3 million deaths result from the infection each year.10
Malaria is an insidious disease. Those who do not die from malaria may end up to be
affected for life from the disease as malaria can be the cause of severe neurological
disorders, especially in children. In addition, malaria contributes to anaemia in children
and pregnant women, adverse birth outcomes such as spontaneous abortion, stillbirth,
premature delivery and low birth weight. Malaria causes damages to the economies of
developing nations estimated at half a billion dollars annually. In countries with the
highest burden of the disease it is estimated that there is an overall 1.3 percent
reduction in economic growth. This compounded over the years leads to significant
differences in GDP between countries with and without incidence of malaria and it is an
obstacle to the economic growth of an entire region.11
In some countries with heavy malaria burden, the disease may be responsible for 40
percent of public health expenditure, 30-50 percent of inpatient admissions and up to 50
percent of outpatient visits.12 Africa is mostly affected by malaria. One million Africans
die from malaria each year most of whom are children under the age of five. The
amount of resources needed to eradicate malaria in 82 countries that have the highest
burden of the disease is estimated to be USD $3.2 billion per year (USD $1.9 billion for
African countries and USD $1.2 billion for others).13 Presently it is estimated that only
200 million are devoted to the eradication of malaria.14
Malaria has been with humans since the beginning of history. Signs of malaria have
been discovered on Egyptian mummies and Hippocrates has documented the stages of
the disease. Alexander the Great is speculated to have died from malaria that led to the
termination of the Greek empire. The name of the disease comes from the Italian mal
aria meaning bad air.15
The malaria parasite is carried by mosquitoes that infect humans and transfer the
parasite to the blood stream attacking the immune system and vital organs. There are
four species of plasmodium that cause the disease: p. falciparum, p. vivax, p.malariae,
and p.ovale. The P. falciparum is the cause of most severe cases of malaria and it is
prevalent in Africa south of the Sahara and certain regions of South-East Asia and the
Western Pacific. The second most widespread plasmodium is the P. vivax and it is
predominant in Asia, various areas of the Americas, Europe and North Africa. Over 40
species of anopheline mosquitoes carry the parasite and transmit malaria. The most
efficient malaria vector is the anopheles gambiae. These mosquitoes occur only in
Africa and they are difficult to control. The occurrence of anopheles gambiae is
determined by climatic conditions and the tropical areas of the world, having the best
combination of rainfall, temperature and humidity, provide a good breeding ground for
the proliferation of anopheles.16
The first cure for malaria came from the cinchona tree found in South America. Quinine
was distributed worldwide in the fight against malaria. Quinine functions by blocking the
reproduction of parasites and was considered a miracle medication when it was
discovered as it saved many lives from the deadly disease. Malaria, though, is a
complex disease and the malaria parasite soon developed resistance to quinine.
Furthermore, quinine has considerable side effects.
In the 1940s, two significant developments contributed to the fight against the disease:
the development of a compound called chloroquine and DDT. Chloroquine was cheap,
safe and provided protection against malaria. DDT (dichloro-diphenyl-trichloroethane) is
a powerful pesticide. Small amounts of DTT can kill mosquitoes for months providing
sufficient time to disrupt the cycle of disease transmission. The good thing about DDT is
that it lasts twice as long as other pesticides and that it is more inexpensive than other
pesticides (usually one fourth of the price of other pesticides).17
The Global Malaria Eradication Program was launched in 1955 by the World Health
Organization (WHO) using DDT for the purposes of prevention and chloroquine for the
purposes of cure after infection. The objective of the program was to eradicate malaria
within ten years. DDT was sprayed in homes for the fight against the disease and the
chloroquine was widely distributed.
The effort was somewhat successful as malaria was wiped out from the Caribbean, the
South Pacific and the Balkans. In India and Sri Lanka malaria infections reached the
single digits. However, in much of the tropics malaria remained undefeated. The
malaria eradication program was abandoned in 1969. After termination of the malaria
program the disease reared its ugly face again in many places in which it was eradicated
before.
It was around that time that DDT started to develop a “bad name” as a persistent organic
pollutant whose adverse effects on humans and the environment -- while not firmly
established by scientific evidence – should be taken into account as a precautionary
matter. In a book published in the United States called ‘Silent Spring,’ Rachel Carson18
condemned the wide use of the pesticide and documented its pervasive presence in the
natural environment.
The book is believed to have launched the environmental movement in the United States
and led to the banning of DDT for agricultural use in that country in 1972. Soon, the rest
of the world followed and the use of DDT in agriculture was banned worldwide. While
the use of DDT was never banned for the fight against malaria, it became almost
impossible to fund a malaria eradication program that was based on the use of DDT.
According to some estimates, this effective ban on the use of DDT may have killed 20
million children.19 In addition to shelving DDT, an effective insecticide in the fight
against the disease, the malaria parasite developed resistance to chloroquine and the
drug lost its effectiveness.
3. The Stockholm Convention on Persistent Organic Pollutants and the
Precautionary Approach
Compared to the 1980s, the incidence of malaria increased in the 1990s in many areas
of the world in terms of the proportion of population affected by the disease, the gravity
of infections and the total number of deaths. Malaria increased in several countries in
Asia with an increased frequency of epidemics and stable patterns of endemic
transmission. In rural Africa, South of the Sahara, the child mortality rate is estimated to
have increased during the 1980s and the late 1990s.
Factors that have contributed to the increase of the epidemic include:
�� the resistance of parasites to anti-malaria drugs;
�� the breakdown of national control programs;
�� the collapse of local and primary health services;
�� the resistance of mosquitoes to insecticides; and
�� the effective phase-out of DDT, the most potent insecticide in the fight against
malaria.
DDT is part of a group of substances called persistent organic pollutants often referred
to also as the “dirty dozen”20 and its use is restricted by the Stockholm Convention on
Persistent Organic Pollutants.21 The goal of the convention is to protect the
environment and public health from persistent organic pollutants (POPs). POPs are
highly toxic substances that once released into the environment assume long lives,
usually accumulate in the fatty tissue of organisms and are believed to disrupt normal
biological functions. During the adoption of the convention environmental groups fought
to ensure the banning of DDT.22 Eventually DDT was banned except for its use in the
fight against malaria. According to the Stockholm Convention,
“Each Party that produces and/or uses DDT shall restrict such production and/or use for
disease vector control in accordance with the World Health Organization
recommendations and guidelines on the use of DDT and when locally safe, effective and
affordable alternatives are not available to the Party in question.”23
The Stockholm Convention has been hailed as the “global public health treaty” — a
treaty that could protect the world from both malaria and DDT.24 The Convention is
based on the precautionary approach as articulated in the Rio Declaration on
Environment and Development.25
According to the precautionary approach articulated in principle 15 of the Rio
Declaration:
“Where there are threats of serious or irreversible damage, lack of full
scientific certainty shall not be used as a reason for postponing costeffective
measures to prevent environmental degradation.”
Article 1 of the Stockholm Convention readily adopts the precautionary approach:
“Mindful of the precautionary approach as set forth in Principle 15 of the Rio Declaration
on Environment and Development, the objective of this Convention is to protect human
health and the environment from persistent organic pollutants.”26 Any state party to the
convention can submit to the secretariat a proposal for a listing of a substance as a
persistent organic pollutant. According to article 8 of the convention “the lack of full
scientific certainty shall not prevent the proposal from proceeding.”27
The precautionary approach adopted by the convention dictates that when a substance
raises potential threat of harm to humans and the environment, taking measures to
protect the environment should not be postponed even if the cause and effect
relationship between the use of the substance and the harm done is not fully established
scientifically. In other words, the precautionary approach requires that some
technological activities that could pose potential threats to our well being should not be
undertaken, even if there is no definite scientific evidence that the activity will cause
harm.
Based on this principle, one must assume that the potential risks of employing DDT are
so high that the use of substance is not justified. At this point the adverse effects of DDT
on health have yet to be proven. However, DDT has been found to have adverse
impacts on the immune and reproductive systems of animals and has adverse effects in
the embryonic, fetal and neonatal development of animals.28
DDT has been found also in human breast milk and amniotic fluid but “[t]here is no
evidence that exposure to DDT at levels found in the environment causes birth
defects."29
In the United States, the presence of DDT in the environment and in edible organisms
has been declining since 1972 when use of the chemical was banned in that country.30
At first blush the precautionary approach if followed consistently seems extreme. Many
technological activities that are prevalent today would have never happened if the
precautionary approach was literally taken into account in all circumstances. However,
according to environmental groups, the use of precautionary approach is justified
because of the so many unanticipated consequences of hazardous substances such as
PCBs (polychlorinated biphenyls) asbestos and CFCs. The precautionary approach is
an expression of the backlash against a tepid approach to environmental pollution that
that characterised international action. Many times states have failed to take decisive
action to deal with environmental problems, using as a justification the lack of scientific
certainty. This 'wait and see' attitude exacerbated many environmental problems that
could have been addressed more timely and effectively if lack of scientific consensus
was not used as an excurse for lack of action..31
The precautionary approach influenced the phasing out of DDT not only in agriculture
but also in the fight against malaria. As noted above, the Stockholm Convention did
outlaw the use of DDT. It allowed the use of DDT, though, in the fight against malaria in
the absence of effective and affordable alternatives. In the 1990s and early 2000s the
fight against malaria proceeded under the presumption that such effective and affordable
alternatives existed and that those alternatives were to be used instead of DDT. These
alternatives were endorsed despite concerns in medical circles that outlawing DDT could
only strengthen malaria in places of the world where indeed effective and affordable
alternatives to the use of DDT did not really exist.
For health professionals, the notion of precaution becomes problematic when too much
consideration regarding potential effects of substances on the environment result is
undermining the health of some of the poorest people in the world.
“[T]he very notion of “precaution” is churned to nonsense where potential risks to health,
known only through animal studies, supposedly justify banning a chemical with known
human health benefits in malaria control. Indeed, one could say that precaution takes
on a very different complexion in sub-Saharan Africa, where 1 in 20 children die of
malaria.”32
Much of the focus in the 1990s for the prevention of the spread of the disease was on
the provision of insecticide – treated nets (ITNs). It was widely promoted that the use of
nets could be as effective as spraying the walls of a house with DDT. This, of course,
sidelined the fact that in tropical and humid environments the use of nets may be
unworkable, as it is difficult to sleep, let alone sleep under an insecticide-treated net.
Furthermore, the nets provide protection for people who sleep under the net, while
spraying the walls of a house with DDT is like creating a net over the house. In addition
to the inconvenience of use, insecticide-treated nets are often quite expensive and
further burdened with taxes and tariffs that contribute significantly to their high cost.33
Indeed for insecticide-treated nets to be given a chance to work, they should be
distributed for free to the population.34
Other pesticides that were used in the place of DDT were not that effective and often
were much more expensive than DDT. South Africa phased out the use of DDT in 1996
and favored more expensive pyrethroid pesticides to its detriment: within three years
after the use of these alternative pesticides, mosquitoes developed resistance to them
and malaria cases rose from 4,117 in 1995 to 27,238 in 1999. South Africa was
compelled to return to DDT since “no other insecticide, at any price, was known to be
equally effective.”35
Integrated Vector Management has been proposed as a means to eradicate malaria in
some countries. This is an all encompassing term for a number of activities that could
be undertaken in the fight against malaria. For instance, in Mexico Integrated Vector
Management involved activities such as:
�� public education;
�� planting trees with mosquito repellant properties outside homes;
�� clearing of vegetation that facilitates the breeding of mosquitoes;
�� plastering homes with mosquito repellant calcium hydroxide (lime);
�� cleaning canals and removing algae; and
�� the use of larvicides.36
While these measures can work in some countries they have been proven ineffective in
Africa because of the particular patterns of spreading of malaria in Africa. Entomologists
believe that environmental control measures are ineffective in much of Africa (expect for
response to epidemics) due to the specific patterns of Anopheles gambiae, the mosquito
that is the carrier of the malaria parasite.37
The malaria parasite developed resistance against chloroquine that eventually became
ineffective in the fight against the disease. Experts now agree that a “cocktail” of drugs
rather than a single drug could be more effective in the fight against malaria. As it is the
case in the fight against the AIDS epidemic, a combination of drugs should reduce the
likelihood of a parasite developing resistance to a single drug. The artemisinin based
combination therapy (ACT), however, costs ten times more than conventional
medications used prevailingly in Africa that are now proven ineffective.38
According to the World Health Organization:
“The inappropriate use of antimalarial drugs during the past century has
contributed to the current situation: antimalarial drugs were deployed on a
large scale, always as monotherapies, introduced in sequence, and were
generally poorly managed in that their use was continued despite
unacceptably high levels of resistance.”39
4. The Roll Back Malaria Program and the Future of Malaria Prevention
In 1998, the Roll Back Malaria (RBM) campaign was launched as a combined effort to
fight malaria by the WHO, UNICEF, UNDP and the World Bank. The partnership among
the four organizations was loose and somewhat informal and this was initially viewed as
an advantage. Eventually, as a result of the informality, all responsibility for the
handling of the program was delegated to the WHO and, as consequence, the WHO
became the scapegoat for everything that was going wrong with the program.40
The Roll-Back-Malaria campaign became a WHO program with minimal contributions
from the other organizations rather than a true partnership of equals with specific
responsibilities in the fight against malaria.41 Another defect of the program was that it
did not have a clear governance structure, except for the periodic meetings of the
partners.42 The secretariat is located at the WHO headquarters strengthening
perceptions that the RBM was indeed a WHO program.43 The Secretariat reported to
the RBM program manager who, in turn, reported to the Executive Director of the
Communicable Diseases cluster of the WHO, not to the partnership. Overall the role of
the WHO in the program fell short of the technical leadership expected and required for
the fight against the disease.44 There was no database for monitoring the global trends
of malaria and no indicators were developed to assess the socio-economic impact of the
disease.45
The impact of the RBM program at the country level has been sub-optimal. In Africa
malaria is “still afforded a shockingly low priority within the national government and
health sector as a whole.”46 In most countries malaria programs have hardly any
resources and are located at the bottom of the organizational hierarchy of the ministry of
health.47 This is in contrast with the AIDs programs, which in most countries are
accorded high priority and in most cases report directly to the ministry of health.48
The truth of the matter is that governments can cope with a limited number of
‘emergency situations’ and the focus put on the fight against the AIDs epidemic has
reduced the attention span with regard to malaria. According to the team that evaluated
the RBM program, many government officials in Africa “share the fatalism towards
malaria that is commonplace in African villages.”49
“It was noticeable that when senior government officials talked about
malaria control, they talked mainly in terms of environmental measures.
They referred to clearing undergrowth around villages and improving
drainage as the key interventions. Entomologists believe that these
measures are ineffective in much of Africa (except in response to
epidemics) due to the specific breeding patterns of Anopheles gambiae.
This scientific information apparently has not yet been widely accepted in
some government circles.” 50
Furthermore, National Malaria Control Programs (NMCPs) have been undermined due
to the ill-advised effects of decentralization that has jeopardized health service
delivery.51
Overall the RBM program has concentrated on producing paperwork rather than
achieving results on the ground. While the program produced Country Strategic Plans
for the fight against malaria, these strategic plans rarely provided information on how
these strategies were to become operational in terms of use of subsidies, distribution
channels and communication approaches such as social marketing on how to get
access to vital drugs.52 The program has been overwhelmed by the sheer number of
countries that need help in the fight against malaria. In Africa 50 countries are affected
by malaria and more than 100 countries are affected by malaria worldwide. The high
number of countries affected by malaria makes it impossible for a single program, such
as the RBM, to assist them all.53 Furthermore, some of these countries may not be able
to address malaria not because of the paucity of resources directed at them; but
because, no matter the amount of resources, countries marred by government failure,
civil wars and economic crisis have to deal with too many systemic governance issues to
seriously do something for diseases that afflict their population.
Today efforts have been undertaken to revamp the RBM program in terms of its
governance structure so that it can play a role in the fight against the disease. In
addition to the RBM program, the Global Fund to Fight AIDs, Tuberculosis and Malaria
has been developed. The fund devotes 24 percent of its resources to the fight against
malaria, while the majority of resources are expended on the fight against HIV/AIDs (58
percent) and 17 percent of the resources are devoted to the fight against tuberculosis.54
In mid-2000s there has been an increasing level of attention to the fight against the
disease and, about 30 years after its effective ban, DDT has acquired renewed
‘respectability’ in the fight against malaria. Based on a news release of the WHO,
according to Dr. Anarfi Asamoa-Baah, WHO Assistant Director-General for HIV/AIDs, TB
and malaria:
“Indoor residual spraying [IRS] is useful to quickly reduce the number of infections
caused by malaria-carrying mosquitoes. IRS has proven to be just as cost effective as
other malaria prevention measures, and DDT presents no health risk when used
properly.”55
And according to Dr. Arata Kochi, Director of WHO’s Global Malaria Programme, “One
of the best tools we have against malaria is indoor residual house spraying. Of the
dozen insecticides WHO has approved as safe for house spraying, the most effective is
DDT.”56
It seems further that the Sierra Club and the Endangered Wildlife Trust, environmental
nongovernmental organizations that had opposed the use of DDT in the past, now
approve such use for the purposes of indoor residual spraying for the control of malaria.
The United States President’s Malaria Initiative (PMI) has endorsed the use of DDT for
indoor-spraying for the protection against the spread of the disease. According to the
coordinator of the PMI, it is anticipated that fifteen of the country programs of President
Bush’s $1.2 billion initiative to reduce the incidence of malaria includes substantial
indoor residual spraying that includes the use of DDT.57
While this looks like an open endorsement of the DDT for the purposes of malaria
control several misgivings remain. Interestingly, while the Director of the Global Malaria
Program of the WHO has endorsed the use of DDT, as the most effective pesticide in
the fight against malaria, the Director of the WHO Office on Public Health and the
Environment during the Third Conference of the Parties to the Stockholm Convention
“stated categorically that the WHO strongly supports the Stockholm Convention, and it is
committed to reducing reliance on DDT in malaria control.”58 Overall the use of DDT for
the fight against malaria generates fears that the chemical will be overused and will be
applied to outdoor areas rather than used selectively according to the WHO guidelines.59
In this context, the European Union has recently warned Uganda that it would ban any
agricultural imports of that country if the use of the DDT were resumed for malaria
control. This has produced headlines in Africa of the kind “Europe Hinders War on
Malaria.”60
At the same time, there are reports that malaria may spread even further.
Increasing number of settlements in forest fringe areas increases the number of people
exposed to malaria. In civil strife and natural disaster situations, malaria grows rapidly.
Given changing settlement patterns and the absence of effective control programs,
malaria has been pushing outwards in terms of latitude and altitude. With regard to
latitude malaria is moving northwards in the Sahel and southwards in South Africa.
Malaria transmission is found also in higher altitudes than before in East Africa that may
have to do with population pressure or the adaptation of mosquitoes to higher altitudes.
Climate change is expected to worsen the number and intensity of malaria outbreaks.61
Simultaneously, there is a concern about decreased sensitivity of the parasite to the
ACT combination therapy in South East Asia. The WHO is urging pharmaceutical
companies to invest in the next generation of anti-malarial drugs but there is no much
incentive to do so for the cure of a disease that affects the most disadvantaged of the
world’s population.
5. The Role of a Global Health Organization
The issue of malaria brings to the fore the fundamental question of what the role of a
World Health Organization is today. Today the WHO is dedicating a large amount of its
resources to the fight against what are called life-style diseases, which affect the more
affluent strata of our societies, such as diseases that develop due to tobacco use or the
diseases that are the result of obesity.
According to WHO’s agenda, health is “a complete state of physical, mental and social
well-being, and not merely the absence of disease or infirmity.” 62 While the WHO has
concentrated its efforts on cutting down its expenses and there has been a refocus on
infectious diseases, there is still a lot of emphasis on matters that have nothing to do
with the traditional definition of disease. Certainly resources dedicated to the fight of
lifestyle diseases (such as tobacco use, obesity) have the possibility of galvanizing
public attention and may influence the policies of some countries which, in turn, may
influence the choices of people in favor of healthier lifestyles. But in a world where
resources are scarce, a global health organization has to make choices and establish
priorities.
The WHO is already losing what could have been a leading role in the fight against
infectious diseases. For instance, with regard to the fight against AIDs, the WHO is just
a partner along with the World Bank, the UNICEF and others under an umbrella program
called UNAIDs.
According to a World Bank publication,63 1.3 billion or around 24 percent of the world’s
population is classified as poor. Accepting this definition would mean that the remaining
76 percent of the world’s population lie outside the poverty group as defined by the
World Bank.64 The World Bank has found that communicable diseases matter more
than non-communicable diseases to the poor. The groups for which non-communicable
diseases are important tend to be rich. To the extent that this is the case, any shift of
emphasis in the global health agenda from communicable diseases to noncommunicable
diseases will have important distributional implications. Although such
shift may be justifiable on the basis of trends in the society as a whole, it would work to
the detriment of the poor. According to the World Bank, the shift from communicable to
non-communicable diseases will benefit the rich “who would therefore gain at the
expense of the poor. This is obviously a disconcerting possibility.” 65 It is more than
disconcerting possibility. It provides additional evidence that the concerns of the most
poor of the world rarely reach global agendas. About 500 million people suffer from
acute malaria per year that leads to more than 1 million deaths. Eighty-six percent of
these deaths occur in Sub-Sahara Africa. Globally 3 000 children die from malaria
everyday and 10 000 pregnant women die from malaria in Africa every year. Malaria
disproportionately affects the poor with almost 60 percent of malaria cases occurring
among the poorest 20 percent of the world’s population.66
* Dr Elli Louka, Marie Curie Fellow to the European Commission, Princeton University.
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