Equity in Global Health Security
By Margherita Cinà
Events such as the 2003 severe acute respiratory syndrome (SARS) epidemic, the 2014 West Africa Ebola outbreak, and the 2016 Zika pandemic not only stressed the interconnectedness of our world, but also highlighted the disproportionately distributed burden of disease that epidemics have around the world. Despite the increased visibility of global health security, there has been surprisingly little discussion on the equity dimensions of the global health security regime.
What does inequity in global health security look like? First, health equity is the absence of avoidable or remediable differences among groups of people. Thirteen years after the adoption of the International Health Regulations in 2005, there are still vast disparities both between developed and developing countries and within countries in terms of who experiences the highest burden of diseases and who has access to infrastructure for health security. Although more research should be conducted to illuminate the inequities that exist in global health security, initial evidence of the disproportionate burdens of mortality and morbidity on disadvantaged populations across and within countries highlights the existing in health inequities in global health security.
For example, diseases with potential to be considered “public health emergencies of international concern” are borne primarily on low- and middle-income countries. Since the coming into force of the International Health Regulations (IHR) in 2005, the world’s most visible outbreaks have originated in, and disproportionately affected, low- and middle-income regions: H5N1 originated in East Asia, Ebola in Guinea, and Zika in Brazil. There has also been a recent Ebola outbreak that originated in the Democratic Republic of Congo and has begun to spread to neighboring countries such as the Republic of Uganda.
A natural consequence of the location of these outbreak epicentres is that developing countries experience higher rates of mortalities and morbidities when the outbreaks occur. When the 2014 West Africa Ebola outbreak officially ended two and a half years after it began, there had been 26,600 reported cases of Ebola of which 11,325 resulted in death: 2,544 deaths in Guinea, 4,810 deaths in Liberia, 3,956 deaths in Sierra Leone, eight in Nigeria, six in Mali, and one in the United States. West African children were particularly impacted with almost 20 percent of cases occurring in children under the age of 15 and approximately 30,000 children losing their parents or caretakers to the virus.
There is also limited data on the unequal distribution of the burden of disease associated with epidemics within high-income countries such as the United States and Canada. The differences in disease burdens and in the existing capacities to respond to outbreaks, as well as the uneven burden within a country on vulnerable population, is a problem for global health security. The fair distribution of global health resources and infrastructure should be a key focus for all fields within global health, including global health security. While the aim to improve overall health is noble, health advances only for a select few should not be the overall aim of our collective global health efforts.
The need for equity in global health is also grounded in human rights law. The International Covenant on Economic, Social and Cultural Rights (ICESCR) prohibits discrimination of any kind in the realization of all the rights set out in this binding international instrument. Global health security is a component of the right to health under "Article 12" of the ICESCR, which states that the full realization of the right to health includes the need to prevent, treat, and control epidemic diseases. Steps taken to achieve the health security component of the right to health should, as a matter of international law, be pursued in a manner that addresses possible disparities between countries and between different populations.
Equity is also a vital component of global health security for a more pragmatic reason. It is necessary to consider equity within the global health security framework because, when faced with public health emergencies of international concern, the world is only as strong as its weakest link. With increased travel and mobility of individuals and goods, countries that have themselves built the capacities to detect and control the spread of disease, are also at risk. Despite having built core capacities, a country will still be vulnerable if its neighboring country, for example, does not have sufficient capacities to detect and contain a potential outbreak. Reducing disparities across and within countries will move the world closer to achieving its global health security goals.
As health becomes increasingly securitized, it is important not to lose sight of global health’s aim to improve health for all. Global health security should seek to improve health outcomes by simultaneously reducing health disparities between the rich and the poor. To move towards this goal, global health security should be driven by equity. Its goals should be to ensure that every country and all populations within a country have equal opportunities to benefit from the governance structures created to ensure that our world is safe from potential pandemics. As our world becomes more globalized and outbreaks remain an inevitable reality, global health security should help prevent, protect against, and control the spread of disease to all individuals no matter their nationality or socioeconomic status.
Margherita Cinà (L’19) is a Canadian lawyer pursuing an LL.M. in global health law and international institutions and a student fellow with the Global Health Initiative.