Transcript Adults and children estimated to be living with HIV/AIDS

The HIV/AIDS Pandemic:
a Human Rights and Health
Barometer of Our Times
Timothy H. Holtz, MD, MPH
MEDI 645: Human Rights, Social Medicine, and the Physician
Emory School of Medicine
March 14, 2005
We will cover…

HIV/AIDS pandemic

Human rights violations and HIV/AIDS

Human rights approaches to HIV/AIDS

Current global response

Community actions
“The full realization of human rights and fundamental
freedoms for all is an essential element in a global response
to the HIV/AIDS pandemic, including in the areas of
prevention, care, support and treatment, and that it reduces
vulnerability to HIV/AIDS and prevents stigma and related
discrimination against people living with or at risk of
HIV/AIDS."
00002-E-4 – 1 December 2002

The HIV epidemic has been accompanied by a parallel epidemic
of fear, stigma and discrimination.

Therefore…any modern dialogue about HIV prevention or care
requires also a discussion of human rights and how to protect
them.
00002-E-5 – 1 December 2002
AIDS pandemic
Adults and children estimated to be living
with HIV as of end 2003
Western Europe
North America
580 000
1.0 million
[520 000 – 1.6 million]
Caribbean
[460 000 – 730 000]
1.3 million
[860 000 –
1.9 million]
North Africa & Middle East
430 000
[270 000 – 760 000]
Latin America
1.6 million
Eastern Europe
& Central Asia
[1.2 – 2.1 million]
480 000
[200 000 – 1.4 million]
Sub-Saharan Africa
25.0 million
[23.1 – 27.9 million]
East Asia
900 000
[450 000 – 1.5 million]
South
& South-East Asia
6.5 million
[4.1 – 9.6 million]
Oceania
32 000
[21 000 – 46 000]
Total: 37.8 (34.6 – 42.3) million
4.8 million new infections annually
Estimated adult and child deaths
from AIDS during 2003
North America
16 000
[8 300 – 25 000]
Caribbean
35 000
[23 000 – 59 000]
Latin America
84 000
[65 000 – 110 000]
Eastern Europe
Western Europe & Central Asia
6 000
[<8 000]
49 000
[32 000 – 71 000]
North Africa & Middle East
24 000
[9 900 – 62 000]
Sub-Saharan Africa
2.2 million
[2.0 – 2.5 million]
East Asia
44 000
[22 000 – 75 000]
South
& South-East Asia
460 000
[290 000 – 700 000]
Oceania
700
[<1 300]
Total: 2.9 (2.6 – 3.3) million
About 14,000 new HIV infections per day in 2003

More than 95% are in low and middle income
countries

Almost 2,000 are in children under 15 years of age

About 6,000 are in persons aged 15 to 24 years

Almost 50% of all new infections are in women
Women are heavily impacted…
Percent of Pregnant Women 15-24 Years Old who are HIVInfected, 2000-3
Percent HIV-infected
35
30
25
20
15
10
5
0
AFRICA
Botswana
South Africa
Zambia
Namibia
Kenya
Mozambique
Ethiopia
Uganda
Nigeria
Tanzania
Cote d'Ivoire
Rwanda
CARIBBEAN
Haiti
Guyana
HIV prevalence among pregnant women in South
Africa, 1990 to 1999
HIV prevalence (%)
25
22.8
22.4
98
99
20
17
14.2
15
10.4
10
7.6
5
4
1.7
2.1
91
92
0.7
0
90
93
94
95
Source: Department of Health, South Africa
96
97
Changes in Life Expectancy in Selected
African Countries with High HIV Prevalence
1950 to 2000
65
Botswana
60
Uganda
South-Africa
55
Zambia
50
Zimbabwe
45
40
351950-55
55-60
60-65
65-70
70-75
75-80
80-85
Years
Source: United Nations Population Division, 1998
85-90
90-95
95-2000
United States: Invisible Epidemic?
90
80
70
1993 definition
implementation
Incidence
Deaths
Prevalence
400
350
300
60
250
50
200
40
150
30
100
20
50
10
0
81 82 83 84 15 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
Year
*Adjusted for reporting delays
0
Prevalence
(Thousands)
Number of Cases/Deaths
(Thousands)
Estimated Incidence of AIDS, Deaths, Prevalence
by Year of Diagnosis/Death
US, 1981 – 2002
Proportion of AIDS Cases, by Race/Ethnicity
and Year of Report, 1985 – 2002, US
70
Percent of Cases
60
White, not Hispanic
50
40
30
Black, not Hispanic
Hispanic
20
10
0
Asian/Pacific Islander
American Indian/
Alaska Native
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
Year of Report
HIV/AIDS in African Americans

African Americans are only 13% of US population but are
half of the new AIDS cases and AIDS deaths in 2002

By the end of 2002, more than 185,000 African Americans
had died with AIDS

Poorest survival rates of all racial and ethnic groups
– late diagnosis
– poor access HIV therapy
Leading Causes of Death Among
Black Americans, 25- to 44-Years-Old,
United States, 2001*
1
2
3
4
5
6
7
8
9
10
HIV infection
Heart disease
Unintentional injury
Cancer
Homicide
Cerebrovascular disease
Suicide
Diabetes mellitus
Chronic liver disease
Nephritis, nephrosis & nephrotic syndrome
0
500 1000 1500 2000 2500 3000 3500 4000 4500
Deaths
* Preliminary death-certificate data for 2001
Majority of people with HIV/AIDS have no access to
treatment….
Yearly deaths as a proportion of 1995 values
The widening treatment gap
Source:
2.5
AIDS deaths in Africa
2.0
1.5
1.0
0.5
0.0
AIDS deaths in Western Europe
HAART
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Adapted from WHO/UNAIDS Statistics, & HIV/AIDS Surveillance in Europe, End- year report 2001, No. 66, CESES
Commonly heard arguments against using
ARVs in the resource poor settings…

Unsustainable

Inappropriate technology

Not cost effective

Not a priority in light of other demands

Too difficult to administer

Prevention is more important

Too expensive

Drug resistance

Corruption, thievery and sale

Stigma
00002-E-21 – 1 December 2002
What does human rights have to do with
HIV/AIDS?





Human rights are inextricably linked with the spread and impact of
HIV/AIDS on individuals and communities around the world.
A lack of respect for human rights fuels the spread and exacerbates
the impact of the disease.
This link is apparent in the disproportionate incidence and spread of
the disease among certain groups which include women and children,
and particularly those living in poverty.
It is also apparent in the fact that the overwhelming burden of the
epidemic today is borne by developing countries, where the disease
threatens to reverse vital achievements in human development.
AIDS and poverty are now mutually reinforcing negative forces in
many developing countries.
00002-E-22 – 1 December 2002
The major reasons why human rights
violations increase the risk of HIV/AIDS

Increased vulnerability: Certain groups are more vulnerable to
contracting the HIV virus because they are unable to achieve their
civil and political, and economic, social and cultural rights. Women,
and particularly young women, are more vulnerable to infection if
they lack of access to information, education and services
necessary to ensure sexual and reproductive health and
prevention of infection. People living in poverty often are unable to
access HIV care and treatment, including antiretrovirals and other
medications for opportunistic infections.
00002-E-23 – 1 December 2002
The major reasons why human rights
violations increase the risk of HIV/AIDS


Discrimination and stigma: The rights of people living with
HIV/AIDS often are violated because of their presumed or known
HIV status, causing them to suffer both the burden of the disease
and the consequential loss of other rights.
Stigmatization and discrimination may obstruct their access to
treatment and may affect their employment, housing and other
rights. The result is that those most needing information, education
and counselling will not benefit even where such services are
available.
Impedes an effective response: Effective HIV prevention,
treatment, support and care strategies are hampered in an
environment where human rights are not respected.
00002-E-24 – 1 December 2002
A human rights approach to HIV/AIDS I

There is clear evidence that where individuals and communities
are able to realize their rights – to education, free association,
information and, most importantly, non-discrimination - the
personal and societal impact of HIV and AIDS are reduced.

The protection and promotion of human rights are therefore
essential to preventing the spread of HIV and to mitigating the
social and economic impact of the pandemic.
00002-E-25 – 1 December 2002
A human rights approach to HIV/AIDS II

The promotion and protection of human rights reduces
vulnerability to HIV infection by addressing its root causes; lessens
the adverse impact on those infected and affected by HIV ; and
empowers individuals and communities to respond to the
pandemic.

An effective international response to the pandemic therefore must
be grounded in respect for all civil, cultural, economic, political,
and social rights as well as the right to development, in
accordance with international human rights principles, norms and
standards.
00002-E-26 – 1 December 2002
A human rights approach to HIV/AIDS III

States’ obligations to promote and protect HIV/AIDS-related human
rights are defined in existing international treaties.

The United Nations human rights instruments and mechanisms
provide the normative legal framework as well as the necessary
tools for ensuring the implementation of HIV-related rights.
00002-E-27 – 1 December 2002
A human rights approach to HIV/AIDS IV

HIV/AIDS-related human rights include the right to life; the right to liberty and
security of the person; the right to the highest attainable standard of mental and
physical health; the right to non-discrimination, equal protection and equality
before the law; the right to freedom of movement; the right to seek and enjoy
asylum; the right to privacy; the right to freedom of expression and opinion and
the right to freely receive and impart information; the right to freedom of
association; the right to marry and found a family; the right to work; the right to
equal access to education; the right to an adequate standard of living; the right to
social security, assistance and welfare; the right to share in scientific
advancement and its benefits; the right to participate in public and cultural life;
the right to be free from torture and other cruel, inhuman or degrading treatment
or punishment.
00002-E-28 – 1 December 2002
“Most people who decide to become doctors
respond to a deep intuition about life and their
own lives. To become a doctor implicitly places
us on the side of those who believe that the
world can change--that the chains of pain and
suffering in the world can be broken....Thus, at a
profound, even instinctual level... people become
physicians to find a way to say “no” to disease
and pain, and to hopelessness and despair--in
short, to place themselves squarely on the side
of those who intervene in the present to change
the future.
The physician agrees to...stand by the patient
regardless of what happens--through their
suffering, and even to the edge of life itself. The
physician steadfastly remains with the patient
even when the only thing the physician can offer
is the fact of his or her presence. This is as
relevant to public health as for individual patient
care. Public health must engage in difficult
issues even when no cure or effective
instruments are yet available and public health
physicians also must remain with, and not
00002-E-29 – 1 December
2002
abandon, vulnerable
populations”.
July 1996
Jonathan M. Mann, MD, MPH
1947-1998
00002-E-30 – 1 December 2002
Global response has had devastating consequences:

Some advances but many
delays over last 20 years….
Insert favorite golfer here…
What have we been waiting for?
Why have we failed to stop the HIV/AIDS epidemic?
An outbreak of “-isms” and a lack of human rights…
Racism, prejudice and
discrimination

Complex biology

Individual vs. Community rights

Sexism--lack of womens rights

Religion

Beliefs regarding drug use

Pharmaceutical industry

World Poverty
– Debt
– Greed
– Corruption
– Economic colonialism
– Structural adjustment/health
sector reform
– Insufficient development aid

Ignorance--lack of education

Values regarding sex and
commercial sex work

Fear of Death

Public health obstacles

Tribalism
Military industrial complex/war

Nationalism


Lack of women’s rights

HIV/AIDS epidemic has highlighted the lack of basic
rights for women
discrimination
economic oppression
legal oppression
denial of equal opportunity to education
domestic violence
rape
Religion

Religious views have sometimes been an obstacle to
confronting the epidemic
Same sex relations
Sex before marriage
Condom use vs. abstinence
Sexism/gender oppression
Science vs. religious dogma
World poverty…
HIV/AIDS and Poverty

Low economic status is a predictor of increased mortality from HIV
disease even after controlling for confounders such as age, disease
stage, and access to care

Economics influence risk of infection and the spread of HIV
– Urban centers
– Trade routes
– Commercial sex workers
– Migrant workers
Low income is associated with greater risk of HIV
infection

A greater exposure to higher risk sexual experiences

Diminished access to health information

Higher frequency of sexually transmitted infections

Absent or delayed diagnosis

Less concern about one’s health and the future given harshness
of present
World Poverty/structural violence

6 billion people
– 2 billion have no power
– 2 billion live on less than 1$ a day
– 1.5 billion lack access to safe water
– 125 million children have no school
– 28 million disease-related deaths per year

Increasing inequality

Vast majority of people with HIV are living in
“resource-poor” countries
The share of the world’s wealth among the poor is
diminishing…
2.5
2
%
1.5
1
0.5
0
1960
1991
1997
Percentage of global income of world’s poorest 20%
Obscene economic disparity:
1990’s “Decade of Despair”

United Nations Development Programme’s 2003 Human
Development Report
– 54 countries becoming even poorer than before.
– Life expectancy has fallen in 34 nations

The income of the richest 10% of the US population is now equal to
that of the poorest 43% of the world

In Brazil less than 3% of the population own two-thirds of the
country’s arable land
Debt Servicing=AIDS Program Costs
Source: UNAIDS, 2001, World Bank "Financial Impact of the HIPC Initiative: first 22 country cases." 1st
March 2001. Figures do not include related costs of infrastructure, capacity building, and impact
mitigation.
Economic Solution?

New global economic system that is grounded in human
rights and environmental justice

Debt cancellation would be part of the new level playing
field
HIV/AIDS assistance: are we doing enough?
Very slow out of the blocks…

Fewer than one in five persons at risk for HIV
infection has access to even the most basic services;
standard services could prevent 29 million infections
by 2010

2001 established Global Fund

2002 1.2 billion dollars spent on HIV/AIDS

2003 WHO 3x5 initiative

2004 President’s AIDS Initiative
HIV/AIDS ODA in 1998:
Total amount obligated, in US$ million
and per US$ million of donor country’s GNP
1998 HIV/AIDS ODA in US$ million
147.3
26.3
HIV/AIDS ODA in US$ per US$ million 1998 GNP
USA
17
UK
19
7
2.1 Switzerland
15.2 Sweden
69
103
14.9 Norway
21.5 Netherlands
57
117
2.0 Luxembourg
14.0
Japan
4
15.0 Germany
1.5
Finland
7.8 Denmark
14.8 Canada
5.2 Belgium
12.2 Australia
150.0
100.0
50.0
0.0
7
12
46
26
21
35
50.0
100.0
150.0
President’s Emergency Plan for AIDS Relief
15 Focus Countries
Ethiopia
Haiti
Uganda
Guyana
Kenya
Rwanda
Côte d’Ivoire
Tanzania
Nigeria
Vietnam
Zambia
Namibia
Botswana
South Africa
Mozambique
FY 2004 Budget for Global AIDS: $2.2 Billion
“Sense of Congress” for Distribution of Funds
Orphans and
Vulnerable
Children 10%
Prevention*
20%
Treatment**
55%
Palliative Care
15%
*33% of prevention funds should be for abstinence-until-marriage programs
**75% of treatment funds should be for purchase and distribution of ARVs
Source: Public Law 108-25
Net Official Aid (Billion US$) by rich country donors to
poor countries
1.6
1.0
1.7
3.4
Goal is 0.7% of GNP
1.8
0.8
Billion US$
4.7 0.9
2.0
1.0 1.6 5.4
0.3
0.5
9.2
0.1
2.3 0.3
12.9
0.5 5.2
0.4 1.1
0.4
0.2
0.0
As % of GDP
0.6
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Po
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Ja
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Gr
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Military Industrial Complex
"Every gun that is made, every warship
launched, every rocket fired, signifies in
the final sense a theft from those who
hunger and are not fed, those who are
cold and are not clothed."
President Dwight D. Eisenhower
April 16, 1953
Military spending
Big Pharma and HIV/AIDS

Issues surrounding access to treatment have called into question
profit motive and corporate responsibility
– Used enormous resources and clout to fight access to
treatment/use of generics
– Profit motive vs. humanitarian or human rights concerns
– 500 million drug development costs
• What about Government contribution to ARV development
costs?

NGO/activists and developing country producers have won the first
round
– WTO/TRIPS?
Competition is good for prices…
During the last 60 minutes…
571 people infected with HIV
342 deaths from AIDS
HIV/AIDS web counter/clock
Since the beginning of the epidemic….
25,000,000+ AIDS deaths
Not all bad news…
HIV prevalence rate among
13 to 19-year-olds, Masaka, Uganda, 1989 to 1997
5
girls
HIV prevalence (%)
4
boys
3
2
1
0
1989/90
1990/91
1991/92
1992/93
1993/94
Source: Kamali et al. AIDS 2000, 14: 427-434
1994/95
1995/96
1996/97
Côte d'Ivoire Minister of Health Gets Tested for
HIV
00002-E-57 – 1 December 2002
Couple Counseling at Uganda Antenatal Clinic
00002-E-58 – 1 December 2002
HIV Testing Outreach, Botswana
00002-E-59 – 1 December 2002
Youth Center, Kenya
00002-E-60 – 1 December 2002
Radio Serial Drama for Behavior Change,
Botswana
00002-E-61 – 1 December 2002
Thai AIDS Clinic
Trend in HIV prevalence in 21 year old military
conscripts in Thailand
HIV prevalence (%)
5
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
Source: Armed Forces Research Institute of Medical Sciences, Thailand
1999
Activists and generic drugs force lower
prices for treatment…
Annual cost per person for triple therapy in Africa
(US$)
$12,000
$10,000
Drug Access Initiative
$8,000
$6,000
Domestic production
$4,000
Accelerated access initiative
$2,000
February-April 2001 offers
$0
1991
1993
1995
1997
1999
2001
2003
Positive lessons from AIDS Epidemic






People are heroic and often exhibit unimaginable
dignity
Epidemic is not inexorable
– Prevention works
• Uganda, Senegal, Thailand
Effective prevention and care efforts involve
– Governments, communities, individuals
Prevention and care efforts must involve and reach
out to the marginalized
Prevention and care work together
Top down and bottom up are both needed
Top down

Global commitment to confront the epidemic

Government commitment—ensure prevention and care services

Establish basic treatment approach for everyone

Guarantee regular supply of medicines for everyone

Involve stakeholders in key decisions
Baby getting nevirapine to prevent mother-child HIV
transmission, Uganda
Drug Distribution Network and Field-Based
Monitoring, Uganda
Field officers, who carry drugs, forms, and
supplies for specimen collection, visit each
patient weekly and can visit up to 10 patients
per day.
Antiretroviral Treatment Program, Kibera Slums,
Kenya
Clinical Training, Ethiopia
Bottom-up

Community must organize to demand rights from their
governments

Meaningfully involve people with HIV/AIDS

Broad coalitions/common grounds

Enlist allies in dominant countries

Work to re-define the paradigm so that it is people-centered and
has a focus on achieving equity as soon as possible
HIV, Health and Your Community:
A Guide for Action
Community mobilization is essential….
Extra Slides
Information Gap

Rwanda 1992—no materials

Fewer than five percent of people infected with HIV live in
industrialized countries
– Most information regarding HIV/AIDS is written for people in
these countries
– More than 100,000 scientific articles on HIV and AIDS
• Most have little relevance for most people living with HIV
• Little usefulness for most health care providers

Comprehensive guide to prevention is needed
Commercial sex work

Economic exchange of sex
interdiction approach
moral judgement
denial
hypocrisy (e.g., international sex tourism)
HIV/AIDS forces us to confront death

Tough death
Denial—HIV/AIDS is uniformly fatal
Irrational fear of contagion
Prolonged suffering without the basic medical care
Human rights vs. Public Health

Does human rights emphasis hamper public health efforts?

Human rights minimally conflict with public health restrictions as long as the
objectives and processes used to make the decision to restrict the rights are clear

SIRACUSA (1985)
– Proposed restriction has to provided for and in accordance with the law
– Restriction must be directed toward a legitimate objective of general interest
(e.g., prevention of HIV transmission)
– Restriction must be strictly necessary to achieve objective
– No less intrusive means should be available to reach objective
– Cannot be unreasonable or discriminatory—burden of proof falls on those who
want to restrict the rights and concrete public health evidence is needed to
respond to questions regarding the last three criteria

Human rights should be used a criteria for public health success
Human rights and health issues

Article 25 of the Universal Declaration of Human Rights (1949):
“everyone has the right to a standard of living adequate for
the health of himself and his family including food, clothing,
housing, and medical care and necessary social services”

Article 12 of the International Covenant on Economic, Social and
Cultural Rights (US has not ratified)
“Right of everyone to the enjoyment of the highest attainable
standard of physical and mental health”

Equity is a major issue
Liberation Theology and Health

Observe
– Analysis

Judge
– Structural violence

Act
– Not just report one’s findings but struggle for the less
fortunate’s liberation (read survival)
Evolution of an epidemic
1986
1991
2001
Americans’ Perceptions of
Urgent Health Problems of the World
100%
90%
80%
Based on interviews with 800 adults ≥18
years old done in October and November
2002
70%
60%
50%
49%
40%
25%
30%
24%
20%
11%
10%
9%
4%
3%
2%
1%
Violence/
War
Biological
Terrorism/
Smallpox
West Nile
Virus
Malaria
0%
HIV/AIDS
Cancer
Hunger
Health Care
Costs/
Insurance
Infectious
Diseases/
Disease in
General
Q2. What would you say is the most urgent health problem facing the world at the present time?
THE GALLUP ORGANIZATION
Copyright © 2002 The Gallup Organization, Princeton, NJ. All rights reserved.
AIDS is caused by HIV

Sexual transmission

Blood borne—transfusion, injection drug use

Perinatal--during and after birth
Massive HIV/AIDS case load
Impact on health care workers:






Increasing demand for care and support in
health facilities and communities
Overburdened in-patient and out-patient
services
Increased need for knowledge and skills
on HIV/AIDS
Increased need for voluntary confidential
counselling and HIV testing
Fear and discrimination
Burn out
TB: Global Public Health Importance
Tuberculosis is a major global killer….

16–20 million people with active TB globally

11 million people are currently infected with TB and HIV

8 million new TB cases annually

2 million TB deaths annually (including TB-HIV)

TB is the biggest killer of people with HIV/AIDS

TB is the largest cause of death among women
of reproductive age
Estimated HIV-MTB co-infection prevalence, 2000
Rate per 100 000
<5
5 - 9.9
10 - 99
100 - 999
1000 - 4999
5000 or more
No estimate
Source: Corbett EL, Watt CJ, Walker N, Maher D, Raviglione MC, Williams B, Dye C. (submitted for publication).
Africa: HIV is driving the TB Epidemic
TB Notification Rates, 1980-1999
500
450
Zimbabwe
400
350
300
250
Malawi
200
Kenya
150
Tanzania
100
Côte d'Ivoire
50
0
1980
1985
1990
1995
2000
Years
World Health Organization
Percent of Cases
Estimated Adult/Adolescent AIDS Cases by
Exposure Category and Year of Diagnosis,
1985 – 2002
70
60
Men who have sex with men (MSM)
50
40
30
20
Injection drug use (IDU)
Heterosexual contact
MSM & IDU
10
0
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
Year of Diagnosis
Racism, prejudice and discrimination

There continues to be an outbreak of prejudice and discrimination…

In the United States….
“Haitian disease”
“GRID”
Rock Hudson was a major breakthrough in US
“Self-inflicted disease”
“God’s wrath”
Health care workers refused to work with people with HIV or who
they thought had HIV
Kids not allowed to attend school—Ryan White
Current HIV epidemic among minorities
Disease and poverty:
GNP per capita and TB incidence
. Indonesia
300
250
200
. Bangladesh
. India
TB
150
Incidence
. China
100
50
. Canada
0
0
5
10
15
20
GNP per capita in thousands of US Dollars
. US
25
30
Current WB/IMF debt relief programs are inadequate

In 2002 Malawi received initial debt service cut of $28 million, or
30% per cent.

Money used for a 45% rise in total 2001 social expenditure

The breakdown of the $28 million for spending in the 2001 budget
is:
– $7.3 million more on critical drugs for hospitals and health
centers
– $2.7 million for extra staff and support in primary health centers
– $1.1 million for training more nurses
– $3.8 million for training new teachers
– $6.1 million for repairs to schools and new teaching materials
– $4.2 million for borehole construction and maintenance
– $2.7 million for agriculture expansion
Debt

In Zambia, where primary school rates are
falling and one in five adults is HIV positive, has
to find $176 million a year for debt repayments,
compared to the $76 million currently spent on
health and $70 million on education…….
Net official aid (billion US$) by rich country donors to poor
countries
12.9
13
12
11
Aid in terms of billion US$
10
9.2
9
8
7
6
5.2
4.7
5
4
3.4
3
2
1
5.4
1.6
0.9
0.1
0.3
0.3
0.4
0.5
1
1.7
1.6
1.8
2.3
2
1.1
0.5
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0
Comparison of Apparel Manufacturing Wages
in 1998
$Hourly wage US
8
7
6
5
4
3
2
1
0
U.S.
Jamaica
Haiti
China
By Kurt Salmon Associates

“Race to the Bottom” supported by World Bank / IMF
policies
World Bank plans to loan $23 million for a new free trade zone
in Haiti
– The zone will build clothes factories for Tommy Hilfiger and
Levis
– Haitian workers make 30 cents / hour
– Mexican and Jamaican workers make 75-85 cents / hour
– In July 2003, the management in Mexican factories that
produce Tommy Hilfiger and Levis products fired and
assaulted union workers
Need for Holistic Public Health Perspective

Current focus on behavioral theory/interventions and biomedical
model
– Improve individual “self-efficacy”
– Provide treatment for individuals

Too little emphasis on changing global and societal structural
violence
–
–
–
–
Customs
Laws
Policies
Unfair economic system
World Economic System:

World Trade Organization
– GATT, GATTS, TRIPS…etc.

Multi-lateral trade agreements
– NAFTA, CAFTA, FTAA…..etc.

World Bank and IMF
– US has veto power over WB and IMF
– Structural adjustment programs control developing
country economies
Structural Adjustment Programs
Conditions for Structural Adjustment Loans
– Reduce govt. spending (cut health/education programs)
– Devalue local currency (make exports cheaper for North)
– Cut wages (become more “competitive”)
– Change to export economy (e.g. grow coffee not corn)
– Remove restrictions on foreign corps. (allow multinationals
to operate freely)
– Privatize state companies (sell state resources to private
corps. - assisted thru devalued currency)
Bello
International Forum on Globalization
Effects of Structural Adjustment Programs


Diminished economic growth
– Latin America GNP:
• Increased 73% 1960-80
• Increased only 7% 1980-02
Accruing interest has led to a cycle of dependency
– Tremendous rising debt in the Global South
• 1980 was $609 billion / 2001 was $2.4 trillion
– For example:
• Nigeria took $5B loan, has paid $16B, and owes $32B
International Forum on Globalization
Center for Economic Justice