Eric A. Friedman
“No one will be left behind.”1 The bold promise at the heart of the Sustainable Development Goals (SDGs) must guide their implementation. This requires utterly transforming the lives and opportunities of those who are already furthest behind.
Such a transformation must occur through both national and global action, with a laser-like focus on equity. Inequities throughout the socioeconomic gradient must be addressed, with the greatest focus on those who are most disadvantaged and marginalized.2
I propose one overarching idea, that every country develops a national health equity strategy. Each strategy would:
- Identify all populations that are subject to health inequities
- Identify and analyze, for each population, the nature of these inequities, including their extent and their causes
- Based on this analysis, develop plans that are specific to each population to end these inequities, with actions harmonized across the diverse and overlapping populations to capture cross-cutting issues and synergies
- Translate these plans into specific and time-bound actions, with adequate budgetary and other resource requirements
- Develop time-bound targets on reducing and ultimately ending inequities, based on the maximum of available resources and capacity, and
- Ensure strong information systems to collect data to monitor progress.
Health equity strategies as part of the right to health
National health equity strategies should be understood as an element of the measures necessary to implement the right to health, under both State and international obligations. They must therefore be fully resourced, and regularly reviewed and updated. Municipalities, districts, and states (provinces) should translate the national strategies into the necessary actions within their jurisdictions.
The right to health’s commitment to equity and universality requires identifying and responding to all causes of inequity. While many barriers will be shared across populations, such as financial barriers, others will be specific to a smaller set of populations, such as linguistic barriers or physical access for people with disabilities.
Marginalized, disadvantaged, and vulnerable populations would need to be centrally engaged through the process of developing and implementing the strategies, from identifying populations suffering from health inequities to ensure that none is missed, to monitoring, reviewing progress, and revising strategies.
National health equity strategies will cut across a wide swath of the SDG agenda, providing direction for action not only on SDG 3 (Ensure healthy lives and promote well-being for all at all ages), but also on many of the other SDG goals and targets. The strategies will therefore need to engage all sectors that contribute to the underlying and social determinants of health, including the health system itself.
Accordingly, these strategies could provide a focal point for implementing the SDGs. Successful implementation, especially for the populations with the lowest health expectancies, would require far-reaching changes—from health systems to power dynamics—creating an impact beyond any particular population and beyond SDG 3.
Strategies needed in all countries
Every country needs such a strategy because people are left behind everywhere, as seen in the world’s richest country, the United States. A transgender woman of color in the United States has a life expectancy of 35 years.3 That is 44 years less than the average US life expectancy.4 Many factors contribute—discrimination by health workers and reduced access to health care, high rates of HIV (a 25% prevalence for black transgender individuals), drug and alcohol use, the vulnerability that comes from often being disowned by their families, living on the streets, violence, and suicide. Piling vulnerability upon vulnerability, many transgendered people lose their jobs because of their identity, and many turn to sex work to earn a living. Close to half of transgender people in the US attempt suicide.5
Native Americans living on South Dakota’s Pine Ridge Indian Reservation, like many American Indians, also endure many vulnerabilities—drug and alcohol abuse, poverty and unemployment, poor education, broken families, and violence. Collectively, these combine to sharply curtail lives, with the Sioux people who call Pine Ridge home having a life expectancy in the upper 40s.6 Homeless people, too, have multiple vulnerabilities and poor life chances, and according to one study, also a life expectancy in the upper 40s.7
Health disparities between black and white neighbors in the United States are also linked to a range of other inequities. In St. Louis, Missouri, residents of one mostly white suburb have a life expectancy greater than 91 years, while those who live in a mostly black suburb have a life expectancy of 56 years. As a report produced in the wake of the death of Michael Brown and subsequent riots in Ferguson, Missouri, explains, such disparities stem from “a complex, interconnected set of socioeconomic factors, including disparities in access to quality housing, healthcare, education and employment.”8
Whether the life expectancy between that of the lowest country, Sierra Leone (46 years), and the highest, Japan (84 years), narrows considerably over the next 15 years will reflect on the success of the SDGs.9 But so too will the success of the SDGs be judged by whether in the United States, transgender women of color, Native Americans, and blacks can live long and healthy lives. And as for the homeless—there will be no more homelessness, for all will be housed (SDG 11.1).
Global health solidarity needed
Should it choose to deploy them, the United States has the resources to implement a national health equity strategy. Other countries, even with an earnest commitment to do so, simply will not have the resources to thoroughly address health inequities. Lower-income countries will often require external resources to fully implement national health equity strategies. Reducing global health inequities requires funding, and other global actions, such as ensuring that trade agreements do not limit access to affordable medicines.
The SDGs lack any real strategy for the solidarity in global health that is needed to “leave no one behind.” A full commitment to heath equity, domestically as well as globally—to implement national health equity strategies and to forge and carry out a global health equity strategy—will require more than the SDGs. One approach offers great potential: a Framework Convention on Global Health (FCGH), the proposed right to health treaty aimed at national and global health equity. Along with national and global health financing strategies to promote the conditions required for good health, the FCGH promises to elevate health across all sectors, catalyze progress on national health equity, and crucially, increase accountability, thereby responding to another SDG shortcoming.10
The SDGs are agreed and adopted. It is now time to identify the approaches to implement them nationally so the promise of leaving no one behind becomes a reality. National health equity strategies, supported by the FCGH, is such an approach. For those discriminated against, the excluded, the disparaged, the marginalized, the vulnerable, there is no time to lose.
Eric A. Friedman is Project Leader for the Platform for a Framework Convention on Global Health at the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center in Washington, DC
1 United Nations General Assembly. Transforming Our World: The 2030 Agenda for Sustainable Development. UN Doc. A/RES/70/1, September 25, 2015. http://www.un.org/ga/search/view_doc.asp?symbol=A/69/L.85&Lang=E. (soon to be available at: http://www.un.org/en/ga/70/resolutions.shtml)
2 Marmot Review, Fair Society, Health Lives: Strategic Review of Health Inequalities in England Post-2010 (2010), p. 15. Available at http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review.
3 K. Holloway, “Five transgender women of color have been murdered in the past five weeks,” AlertNet, February 12, 2015. Available at http://www.alternet.org/news-amp-politics/five-transgender-women-color-have-been-murdered-past-five-weeks.
4 World Health Organization, World Health Statistics 2015 (2015), pp. 46, 50. Available at http://www.who.int/gho/publications/world_health_statistics/EN_WHS2015_Part2.pdf.
5 J.M. Grant et al., Injustice at Every Turn: Report of the National Transgender Discrimination Survey (2011), pp. 72-83. Available at http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf.
6 N.D. Kristof, “Poverty’s Poster Child,” New York Times, May 10, 2012. Available at http://www.nytimes.com/2012/05/10/opinion/kristof-povertys-poster-child.html.
7 W. Hawke, M. Davis and B. Erlenbusch, Dying Without Dignity: Homeless Deaths in Los Angeles County: 2000-2007 (Los Angeles and Washington, DC: Los Angeles Coalition to End Hunger & Homelessness, National Coalition for the Homeless, 2007), pp. 4-5. Available at http://www.nationalhomeless.org/publications/dyingwithoutdignity/dyingwithoutdignity.pdf.
8 Ferguson Commission, Forward Through Ferguson: A Path Toward Racial Equity (2015), p. 152. Available at http://forwardthroughferguson.org/wp-content/uploads/2015/09/092115_FergusonCommissionReport.pdf.
9 World Health Organization, World Health Statistics 2015 (2015), pp. 46, 50. Available at http://www.who.int/gho/publications/world_health_statistics/EN_WHS2015_Part2.pdf.
10 Platform for a Framework Convention on Global Health: Realizing the Universal Right to Health, May 14, 2015. Available at http://www.globalhealthtreaty.org/docs/platform-for-an-fcgh-full.pdf.
Other papers by the author published in the Health and Human Rights Journal