DOUBLE STANDARDS IN GLOBAL HEALTH

TB POLICY AND HUMAN RIGHTS

SALMAAN KESHAVJEE, MD, PHD, SCM

HARVARD MEDICAL SCHOOL BRIGHAM AND WOMEN’S HOSPITAL PARTNERS IN HEALTH

THE UNION – NORTH AMERICA REGION ANNUAL MEETING CHICAGO, ILLINOIS FEBRUARY 29, 2020 Picture source: https://www.pinterest.com/pin/395050198535540893 Photo: Harvard Medical School

TUBERCULOSIS 10 million people sick each year

4,000 people die every day Rich Poor countries countries

• Passive case detection • Low sensitivity test • Treatment only for sensitive strains • No preventive therapy • No infection control PART 1 “Otherness” as a product of our colonial past Chained Congolese slaves on a Belgian Rubber Plantation (circa 1900s)

Source: https://www.laprogressive.com/wp-content/uploads/2012/03/drc-slaves.gif African girl in a exhibit, Brussels, Belgium, 1958

Source: http://www.popularresistance.org/deep-racism-the-forgotten-history-of-human-/ Source: Library of Congress; Congolese Ota Benga on display in the , New York City, 1906 American Invasion of the Philippines (1899-1914)

Source: http://silentcrownews.com/wordpress/wp-content/uploads/2017/03/US-soldiers-and-Moros-killed-Philippine-American-War-19062.jpg Source: http://www.welcometomy brain.net/2011_08_01_arc hive.html

Photograph taken by an American photographer during the American invasion and occupation of the Philippines (ca.1899-1900) Winston Churchill and Jan Smuts Source: http://www.flickr.com/photos/hilton-t/4616092624/ Franklin Roosevelt and Winston Churchill aboard the USS Augusta off the coast of Newfoundland, 1941

Source: https://www.smithsonianmag.com/smart-news/months-pearl-harbor-churchill-and-roosevelt-secret-meeting-180964435// Brazil signs the U.N. Charter at a ceremony held at the Veterans' War Memorial Building on 26 June 1945.

Source: http://www.unmultimedia.org/photo/detail.jsp?id=235/235833&key=5&query=subject:%22Founding%20of%20the%20UN%22&sf= Source: http://www.who.int/archiv es/fonds_collections/bytit le/fonds_3/en/

League of Nations Hygiene Section, Geneva, Switzerland, 1925 The Chicago Freedom Movement (Chicago Open Housing Movement) Summer 1966

Sources: 1. King in the , HBO, 2018 2..King in the Wilderness, HBO, 2018 3. http://www.peoplesworld.org/article/the-chicago-freedom-movement-summer-1966/ 4. https://www.chicagoreporter.com/the-roots-of-the-chicago-freedom-movement/ 5. https://learninglab.si.edu/resources/view/59703 PART 2 Neoliberalism and the reinforcement of difference NEOLIBERALISM

• An unfettered market will lead to general equilibrium • state regulation – “interference – distorts the market • believe in laissez faire economics, free trade

Mises Hayek Friedman Rational Choice/ Homo economicus • rationally calculating individual • maximizing individual welfare • living in a world of perfect certainty • fully grasping consequences

Human capital

• support to citizens (health, education, and other public goods) is an investment into instruments of capitalist production • Rights distributed because of potential contribution to the economy rather than because somebody is a citizen or is human

Source: http://wytwornia.blox.pl/resource/Los_Angeles.jpg The Bureaucractization of Neoliberalism PART 3 TB policy: naturalizing the double standard SECRET SAUCE

COMPREHENSIVE

SIMULTANEOUS Divergence of policies for rich and poor: Ignoring the evidence

• 1950s: recommendation to use INH monotherapy in poor countries because of concerns over cost

• As early as 1964, the WHO’s Expert Committee on Tuberculosis discouraged the use of IPT outside of rich countries, “arguing that cost, logistical difficulties, the likelihood of defaulting, and other concerns all made it 2015 unfeasible.” • This decision was reaffirmed in 1974 and 1982 Source: PAHO Focus on cost STRUCTURAL ADJUSTMENT

IMF conditionality for loans to countries • Stabilization: cutting government spending • Liberalization: reversing “price distortions”; charging user fees • Privatization: selling state assets

Source: http://paper-bird.net/tag/neoliberalism/

1993 – World Health Organization declares TB a global emergency • 8 to 9 million cases of active TB each year • 1/3 of world’s population (2 billion people) infected with “latent” TB Concern over cost led to an unscientific approach to TB

1. Political commitment 2. Diagnosis with sputum-smear microscopy 3. Standardized short-course chemotherapy 4. Regular supply of high-quality drugs 5. Standardized recording and reporting Basic principles of epidemic control for TB MISSING KEY COMPONENTS • Search actively for newly infected people among the contacts of current patients using FOR CONTROL a sensitive test (x-ray) AND ELIMINATION • Start therapy quickly for people with disease; give the safest, most effective multi-drug therapy in the shortest time

ill-suited for children • Ensure adherence to therapy with supports ill-suited for people with HIV • Treat all contacts that do not yet have ill-suited for drug-resistance disease with post-exposure prophylaxis Does not address poverty • Ensure proper infection control MDR-TB is too expensive to “ treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.” - World Health Organization Groups At Risk, 1996

Photo: Open Society Institute/Pep Bonet TUBERCULOSIS (TB) • 4,000 people die every day from TB • 1,000,000 children get TB • Millions of preventable deaths • Growth of DR TB

Date Sources: Raviglione et al., The Lancet, 2012; WHO Global Tuberculosis Report 2017, WHO. PART 4 What would a human rights perspective look like? Source: timeschangin.blogspot.com Comprehensive epidemic-control strategy

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Community- Community- based care based care delivery delivery for for TB chronic diseases

HIV Hepatitis C Diabetes Heart Disease Mental illness Дякую நன்잿 شكراً جدا ً धन्यवाद Gracias 谢谢 @s_keshavjee Thank you Kahm uhn Siyabonga شكريه Спасибо Asante Cảm ơn bạn Ngiyabonga Merci ขอบคุณ Terima kasih გმადლობთ Photo: Pep Bonet/Open Society Institute