BOOK REVIEW
Rebecca Riddell
When Misfortune Becomes Injustice: Evolving Human Rights Struggles for Health and Social Equality, by Alicia Ely Yamin (Stanford University Press, July 2023)
These are difficult days for hope in the struggle for health justice. A United Nations expert, condemning an “unrelenting war” on health systems in Gaza, declared this “the darkest time for the right to health in our lifetimes.”[1] Four years after the emergence of a devastating global pandemic, rich countries continue to champion pharmaceutical interests over access to care, and a much-needed pandemic treaty is off track, leading the World Health Organization’s Director General to warn that “future generations may not forgive us.”[2] Medical breakthroughs that should offer solace are out of reach for many. Consider the sticker price of two new cutting-edge treatments for sickle cell disease—reportedly US$3.1 and US$2.2 million each—unthinkable sums for most, but especially the estimated three-quarters of the world’s sickle cell patients who live in Sub-Saharan Africa.[3]
It’s quite a moment to pick up Alicia Ely Yamin’s excellent book When Misfortune Becomes Injustice: Evolving Human Rights Struggles for Health and Social Equality. The recently released second edition is an informed, engaging, and deeply insightful stocktaking of limited but real advancements in the right to health, understood in the context of skyrocketing inequality and a prevailing global economic order that has rendered the fulfillment of that right all but impossible.
Yamin starts with the genesis of multilateral rules and institutions following World War II, including the Universal Declaration of Human Rights, but also the Bretton Woods Institutions—designed to entrench US and Western European control over multilateral economic authority. From there, the book moves at a fast clip, canvassing the creation of human rights treaties and developments in the conceptualization and application of the right to health, as well as the simultaneous and relentless march of neoliberal policies and ideas that have undermined the realization of so many rights.
The reader is transported through time and through the world, from Argentina—where Yamin’s mother is from—to the United States, Tanzania, Costa Rica, and beyond, meeting the patients, health workers, and advocates whose struggles for care and for justice constitute the heart of the book. Yamin describes her work as a “historical account told through human stories,” observing that the stories we tell define the future we create. With her deep expertise in law and public health, and decades of experience as a leading scholar and practitioner, it’s hard to imagine a better storyteller.
When Misfortune Becomes Injustice is a damning critique of the political economy that got us here—the rounds of structural adjustment, austerity, privatization, and financialization that have weakened states’ capacity to provide public health care and embedded deeply unequal systems that segregate access to care.
Again and again, communities and researchers have shown how heavily privatized and commodified systems stratify, exclude, and impoverish. Globally, catastrophic spending on health care has been rising for two decades, and according to the latest data, health costs pushed 1.3 billion people into poverty in 2019.[4] This book is yet more evidence of the challenge of reconciling our status quo, where access to health care is often dependent on access to resources, with human rights guarantees of nondiscrimination and affordable care for all.[5]
Large companies also come in for rebuke, with good reason. For many of world’s biggest companies, health care is an asset, not a right.[6] These are major players in the global economy who charge massive markups, avoid taxes, exert undue influence over politics, and funnel extreme profits to those who own shares (shares that are, of course, highly concentrated among the very richest—consider that the world’s richest 1% owns 43% of global assets).[7] As I have written elsewhere, such companies have been aided and abetted by high-income countries shamelessly promoting their own private sector as a development solution, despite the poor and tragic outcomes associated with this approach.[8]
The book’s interdisciplinary lens speaks to the virtues of the human rights framework, with its demand to look beyond individual biology and behavior and toward the systems—health care but also economic, political, social, and legal—that shape our health. Yamin vividly captures the grave injustice of inequalities in health, including along lines of race, class, and gender. She compares, for example, the decades-wide gap between average life spans in Swaziland and those in Japan, but also between those in a predominantly white Boston neighborhood and those in a Black one less than a half mile away. The unacceptably high levels of maternal mortality, and its concentration in low- and lower-middle-income countries, provides another chilling example, especially given the preventability of most maternal deaths.
Yamin is also a critical thinker about human rights and their connection to law, which she describes as “at best” a conservative tool for social change. She notes that human rights are also “more than law” and can serve as valuable tools for mobilization. The book is in dialogue with other recent commentators about the role of rights standards and actors.
Yamin’s approach is neither to condemn nor to blindly extol. She criticizes how the political interests of the United States and Western Europe shaped the development of human rights, including the privileging of civil and political rights over economic, social, and cultural ones. But she also pushes back against the caricature of human rights as a mere foot servant to capital, insisting we pay attention to the “diverse set of practitioners, scholars and movements” who have used these rights to address social and economic injustice.
Further demonstrating this ability to be nuanced but not neutral, she offers a clear-eyed qualification of every positive example. Even the boldest victories and greatest verdicts are only partial and take place within a long, iterative fight. Quoting Philip Alston on human rights, she reminds us that “dejection and despair are pointless and self-defeating. It’s assuredly not a lost cause, but we should not be fooled into thinking that it’s ever going to be a winning cause; it’s an ongoing struggle.” She captures an ambivalence toward human rights that I recognize in myself, and I enjoyed the discussion, but others may find that it too closely resembles an insider’s self-defense.
The book is a history and not a road map for the future, but Yamin offers guidance for the types of regulatory and legal changes needed at both the national and international level, and calls for addressing the “political determinants of health,” including by reigning in large corporations. She also shares her reflections on how to achieve a transformative human rights practice, including by tackling all forms of inequality, not just poverty, as well as democratizing knowledge and authority.
Four years ago, amid our heartache, many of us dared to hope that the pandemic might be a catalyst for positive change. But now we know, in so many ways, it was an accelerant for a world on fire. Amid hardship and loss, the richest countries largely looked after their own—providing financial support and snapping up access to medicines as only the highest-income countries could do—and the biggest firms reaped record profits that in turn turbocharged the portfolios of the super-rich. And now many countries face a debt crisis that further threatens their ability to invest in care and the social determinants of health.
It is easy to feel despair. But Yamin’s book, with its personal, thoughtful account of what has been achieved and what is left to do, gives me hope—which is, I believe, precisely what it is meant to do
Rebecca Riddell is the policy lead for economic and racial justice at Oxfam America and counsel to the Human Rights and Privatization Project at New York University School of Law’s Center for Human Rights and Global Justice, New York, United States.
References
[1] Office of the United Nations High Commissioner for Human Rights, “Gaza: UN Expert Condemns ‘Unrelenting War’ on Health System amid Airstrikes on Hospitals and Health Workers” (December 7, 2023), https://www.ohchr.org/en/press-releases/2023/12/gaza-un-expert-condemns-unrelenting-war-health-system-amid-airstrikes.
[2] C. Paun, “Biden’s Got Pharma’s Back in Global Pandemic Treaty Negotiations,” Politico (January 29, 2024), https://www.politico.com/news/2024/01/29/bidens-got-pharmas-back-in-global-pandemic-treaty-negotiations-00138133; Reuters, “World Risks Missing Deadline for Pandemic Accord, Says WHO Chief” (January 22, 2024), https://www.reuters.com/business/healthcare-pharmaceuticals/who-chief-worried-about-missing-deadline-pandemic-accord-2024-01-22/.
[3] R. Robbins and S. Nolen, “New Sickle Cell Therapies Will Be Out of Reach Where They Are Needed Most,” New York Times (December 8, 2023), https://www.nytimes.com/2023/12/08/health/casgevy-lyfgenia-sickle-cell-africa.html.
[4] World Health Organization and World Bank Group, Tracking Universal Health Coverage: 2023 Global Monitoring Report (Geneva: World Health Organization and World Bank, 2023).
[5] International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966); Committee on Economic, Social and Cultural Rights, General Comment No. 14, UN Doc. E/C.12/2000/4 (2000).
[6] N. Shaxson and C. Godfrey, Taken, Not Earned: How Monopolists Drive the World’s Power and Wealth Divide, (UK: Balanced Economy Project, 2024).
[7] N. Dearden, “Case Study: Big Pharma,” Global Justice Now (January 17, 2024), https://www.globaljustice.org.uk/wp-content/uploads/2024/01/Taken-Not-Earned-Big-Pharma-case-study.pdf; P. Krugman, “Wonking Out: Attack of the Pharma Phantoms,” New York Times (May 12, 2023); Oxfam International, Inequality Inc.: How Corporate Power Divides Our World and the Need for a New Era of Public Action (Oxford: Oxfam International, 2024).
[8] R. Riddell, “Why Is the U.S. Trying to Export Its Flawed Health-Care Policies around the World?,” Washington Post (January 10, 2022), https://www.washingtonpost.com/opinions/2022/01/10/usaid-private-health-systems-kenya/; Center for Human Rights and Global Justice and Economic and Social Rights Centre – Hakijamii, Wrong Prescription: The Impact of Privatizing Healthcare in Kenya (Nairobi: Economic and Social Rights Centre –Hakijamii, 2021); Oxfam International, First, Do No Harm: Examining the Impact of the IFC’s Support to Private Healthcare in India (Oxford: Oxfam International, 2023); A. Marriott, “Sick Development: How Rich-Country Government and World Bank Funding to For-Profit Private Hospitals Causes Harm and Should Be Stopped,” Oxfam Briefing Paper (June 2023), https://policy-practice.oxfam.org/resources/sick-development-how-rich-country-government-and-world-bank-funding-to-for-prof-621529/.