Millennium development Goal 6 and the trifecta of HIV/AIDS, malaria, and tuberculosis in Africa: a human rights analysis.

Author:Nnamuchi, Obiajulu

    At the Millennium Summit, convened as a key part of the Millennium Assembly of the United Nations, (1) in September 2000, participating world leaders unanimously ratified the Millennium Declaration--a set of objectives grounding the Millennium Development Goals ("MDGs" or "Goals"). (2) The MDGs consist of the commitment by the global community to pursue a number of objectively and quantitatively verifiable Targets, with the deadline for reaching most of these Targets set at 2015.' Strikingly, of the eight Goals to which each country aspires to attain within the specified time frame, one--MDG 6--is devoted to combating HIV/AIDS, malaria, and other diseases. (4) Considering the devastation these diseases have inflicted, and continue to inflict, upon the lives and wellbeing of Africans, it is clear that this Goal holds special significance for people in the region. But whether the benchmarks of MDG 6 would actually be attained, come 2015, is mired in controversy as pessimism remains rife about Africa's capability to achieve this or any of the other Goals.

    The African Union Conference of Health Ministers was quite categorical, "Africa is still not on track to meet the health Millennium Declaration Targets and the prevailing population trends could undermine progress made." (5) More recently, New York University professor of economics William Easterly documents other instances (6) including, inter alia, a statement by the U.N. Department of Public Information, "[a]t the midway point between their adoption in 2000 and the 2015 target date for achieving the [MDGs], sub-Saharan Africa is not on track to achieve any of the Goals." (7) But Professor Easterly vehemently disagrees with the conclusion, blaming the bleak picture on "poorly and arbitrarily" designed MDGs, the effect of which, in his view, has been widespread and misguided portrayal of Africa in a worse light than the true circumstances warrant. (8) Other scholars identify the "overly-ambitious" nature of the Goals themselves as the culprit. (9)

    But regardless of design flaws or the overly-ambitious nature of the MDGs, evidence is beginning to percolate indicating that whilst challenges abound, there are bright spots in several countries in the region. Even in nations seriously lagging behind, new initiatives continue to be rolled out, aimed at bridging the gap between current realities and the MDGs. The political leadership is adamant about its commitment to achieving the Goals. Speaking at the 2008 World Economic Forum in Davos, Switzerland, Umaru Yar'Adua, the late president of Nigeria, echoed the regional attitude, "[f]or us in Africa, the achievement of the MDGs is our sacred duty." (10) This is quite an encouraging proclamation; nonetheless, whether this rhetoric is being or will be acted upon by authorities in the region, and if the strategies would be sufficient to pull the region out of its present doldrums, will begin to unfold as the various benchmarks specified in Goal 6, the focus of this discourse, are examined and will become even clearer as the 2015 deadline draws nigh. A critical aspect of this paper is its identification of what it calls "special population groups" (the most vulnerable groups in relation to the diseases) as worthy of being put "in front of the line," so to speak, in terms of receiving necessary interventions. Prioritizing the interest of vulnerable groups in the overall scheme of attending to population-wide challenges is a key requirement of human rights. It is a catechism forcefully advanced in this discourse.

    This paper consists of six sections. Following the introduction, Part II examines global attempts to get a handle on the scourge of HIV/AIDS as well as factors standing in the path to success in Africa. It also identifies measures that hold prospect for reversing the status quo. Part III continues this theme, albeit with a different focus, by interrogating efforts to control malaria in the region. The section analyzes the wide disparities between countries in the region in terms of incidence and resulting mortalities and proffers suggestions on how to bridge the divide--a necessity for attaining Goal 6. In Part IV, the paper zeroes in on the prevalence of TB in Africa and the adoption of the World Health Organization's ("WHO") directly observed treatment short course ("DOTS") as part of the Stop TB Strategy, which was recommended by the WHO as the cornerstone of national anti-TB strategies. The section argues that although this approach has resulted in significant improvement in the control and management of TB, a lot more still needs to be done, including scaling up a range of critical interventions via increases in budgetary allocation to TB. Part V seeks a human rights solution to the tragedy resulting from the trifecta of HIV/AIDS, malaria, and TB. Its central argument is that while health care-based interventions are certainly critical to making inroads into the situation, it must be strengthened with deploying resources to the conditions that combined to subject people to these diseases and conditions in the first place. The section projects underlying or social determinants of health as holding the key to freedom from the stranglehold that these diseases hold on human lives and, borrowing from liberation theology, calls for prioritizing the needs of vulnerable groups. The conclusion--Part VI--is that operationalizing the human rights-based recommendation of the paper is fundamental not only to consigning HIV/AIDS, malaria, and TB in Africa to the abyss of history, but also to positioning the region on a sustainable path toward attaining Goal 6.


    1. Impact and Relevant Benchmarks

      There are two HIV/AIDS-related Targets: (i) to "[h]ave halted by 2015 and begun to reverse the spread of HIV/AIDS;" and (ii) "[a]chieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it." (11) Definitionally, at least, the first arm of the Target appears to have been met in most regions of the world, including Africa. (12) The most recent data shows a decline in the number of new infections globally. A total number of 2.5 million people (including adults and children) were infected in 2011, 20 percent less than 2001. (13) There have been dramatic changes in infection pattern and incidence in the last decade. The incidence of HIV infection declined amongst adults by more than 25 percent in

      thirty-nine countries, twenty-three of them in sub-Sahara Africa. (14) In fact, sub-Sahara Africa ranks second only to the Caribbean in reduction level, at 25 percent. (15) Despite these improvements, however, the region, comprising just 12 percent of the global population, bears the worst brunt of the pandemic, (16) accounting for nearly 70 percent of the global population of people living with HIV/AIDS ("PLWHA"), nearly one in every twenty adults (4.9 percent of people in the region). (17)

      In 2011, deaths resulting from AIDS-related causes totaled 1.7 million globally, representing a 24 percent decline in AIDS-related mortality in comparison to 2005 when the number was 2.3 million. (18) Although the number of people dying from AIDS-related causes in sub-Sahara Africa declined by 32 percent from 2005 to 2011, the region was still responsible for 70 percent of such deaths in 2011. (19) Of the 17.1 million children around the world who were estimated to have lost one or both parents to AIDS in 2009, 15 million of them lived in sub-Saharan Africa. (20) Although the number of PLWHA is growing, the growth represents an increase in longevity due to improved access to treatment and other support services. (21)

      The second arm of the Target, obligating countries to provide universal access to treatment for all those who need it by the year 2010, (22) appears to be more problematic as the deadline has passed and yet, except for Western countries, no other region met the Target. (23) Nevertheless, recent data indicate significant progress even in some of the worst affected countries. In fact, some dramatic result could have been recorded had it not been for the WHO's new recommendation on when antiretroviral therapy ("ART") should be initiated (CD4 count of or below 350 cells/[mm.sup.3] in contrast to the previous criterion of CD4 count of or below 200 cells/mm3). (24) This change and its result notwithstanding, 2011 represents huge advances in scaling up access to ART. For the first time ever, a majority (54 percent) of those in need of treatment in low and middle-income countries actually received it. (25) Even sub-Sahara Africa was not left behind. The region attained 56 percent coverage within the same period. (26) To grasp the real impact of this growth in the number of eligible people receiving ART, one has to see it in economic terms, in the sense of the effect on economic productivity (as mentioned in the abstract) in affected countries. At the end of 2011, 8 million people were receiving ART, representing "a 20-fold increase since 2003." (27) The availability of this life-saving intervention in low and middle-income countries has had dramatic impact, adding 14 million lived-years in these countries, including 9 million in sub-Sahara Africa. (28)

      The WHO defines "universal access" as the existence of "an environment in which HIV prevention, treatment, care and support interventions are available, accessible and affordable to all who need them." (29) A critical element of this definition is that achieving universal access does not necessarily mean that everyone in need receives ART, for even if treatment is available, accessible and affordable, there is no guarantee that some people would not, for whatever reason, decide against treatment. Given this consideration, one could surmise that the obligation incumbent on countries is to create conditions that are conducive for the "participation" of affected individuals in the "planning and implementation of their...

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