Abstract
The Global Burden of Disease Study (GBD), a landmark project undertaken in the field of global public health, has been able to generate health estimates and trends associated with a wide variety of public health issues across around 200 countries. While GBD has been useful in helping countries understand the gravity of public health issues they are facing, it also facilitates circumstances where lower- and middle-income countries (LMICs) have their input on public health issues stifled. Such situations are exacerbated by the complex relationships that exist within global public health, which oftentimes favor large organizations over individual LMICs in health discourse. As a way of introducing LMIC input back into conversations on public health and building a more comprehensive perspective on public health that extends beyond what GBD statistics can show, this paper finds utility in the examination of public health litigation as a source of qualitative information that can supplement GBD statistics.
Introduction
In global public health, there exist a variety of actors that all contribute to complicated, interrelated processes that are highly significant to the field. Unfortunately, the trend in global public health currently involves large, multinational actors dictating what sort of information should be collected, how it should be collected, and how it should be disseminated to inform health policy in lower- and middle-income countries (LMICs). Individual LMIC perspectives and priorities are subsequently sidelined in discussions about global public health. One global public health project, the Global Burden of Disease study (GBD), can be scrutinized to understand the complicated web of relationships that exist in the field and to more thoroughly understand how LMIC concerns are not given due consideration in efforts to promote the health of those regions.
GBD is an annually updated data repository sponsored by the Institute of Health Metrics and Evaluation (IHME) that contains information about disease burdens due to a variety of public health problems (i.e., tuberculosis or ischemic heart disease) in countries around the world. One of GBD’s main developers, Dr. Christopher Murray, has described it as “a systematic scientific effort to quantify the comparative magnitude of health loss from diseases, injuries, and risks by age, sex, and population over time” (Murray 2020, 1460). Essentially, GBD is a data tool that enables users to see the health burdens imposed by a variety of public health issues that exist in a given country. The GBD data that has been collected spans 195 countries and includes information about over 300 diseases and injuries, making it one of the most comprehensive public health data tools in the field of global public health. The study was initiated in 1990 and has been updated annually every year since 2015, with the most recent round of collection taking place in 2019 (Murray 2020, 1460). Over the course of this 30-year existence, the GBD study has gained prominence in the global health community because of its ability to facilitate the collection of data that is crucial to assessing the achievement of internationally sponsored objectives such as the Sustainable Development Goals (SDGs).
In 2015, the United Nations (UN) General Assembly set up the Sustainable Development Goals (SDGs), which were intended to establish a blueprint for internationally coordinated efforts toward global peace and prosperity. These goals were organized into 17 general categories that range from clean energy to health, with each category composed of multiple quantifiable targets. For instance, Goal 3 of the SDGs is to “ensure healthy lives and promote well-being for all at all ages” and includes the specific target of halving the number of global deaths and injuries attributable to road traffic accidents by 2030 (United Nations 2015). Since their creation, the SDGs have served as one of the standards for measuring progress in public health around the world for various health-related organizations. One such organization, the World Health Organization (WHO), has even developed an action plan in 2019 based on the guidance offered by Goal 3 and the SDGs in general.
Because the SDGs are so heavily rooted in quantifiable targets, they consequently rely on the collection of large amounts of quantitative information to determine the progress that is being made toward the achievement of their objectives. Because GBD can supply such information with its sophisticated modeling and data collection mechanisms, it quickly grew in popularity within the field of global public health to now become “arguably the de facto source in global health accounting” (Murray and Lopez 2017, 1460). The influence of GBD has also been extended by The Lancet, a global public health academic journal that routinely disseminates articles and studies that are informed by GBD-generated public health estimates.
While GBD data has undoubtedly been useful for informing health policy action, particularly for low- and middle-income countries (LMICs) around the world that may have undeveloped health data infrastructures, it is at the same time a key player in a process that shuts down input from LMICs and instead prioritizes the actions of large, powerful organizations when it comes to global public health matters. In essence, GBD’s usage of its extensive data collection and modeling mechanisms has produced multiple effects within the global public health community that have led to the devaluation of LMIC perspectives on the public health of their own countries.
The data and modeling efforts of the GBD study have been shown to insulate the study from criticism of its methods. A WHO official agreed that the GBD’s insistence on superior data collection and computing expertise “has an overwhelming effect” on public health discourse. The official goes on to say, “The IHME throws these big numbers and computing figures at you...the response to critical comments is that they have bigger and better data...that they have improved computing methods...it shuts down the conversation [about any criticism towards the GBD data] pretty quickly” (Mahajan 2019, 116). Organizations including WHO have described the difficulty of competing with the massive resources at IHME’s disposal. This development is significant because the WHO has cultivated close relationships with LMICs and makes use of these relationships to collaboratively produce health estimates that involve input from both WHO researchers and researchers from LMICs. GBD, while also collaborating with individuals in LMICs, does the vast majority of its health analysis within IHME without any external input (Mathers 2020, 10). As such, in the process of GBD’s encroaching influence on other health agencies like the WHO through its claim of sophisticated methodologies, the input of LMICs is lessened. There is more singularity in the way global health researchers/organizations think about public health when these other health agencies become sidelined in public health discourse.
In addition to the usage of its extensive data infrastructure as a defense against any potential criticisms from health agencies or LMICs, GBD’s data collection and analysis procedures have resulted in the underdevelopment of national health infrastructure within LMICs themselves. This is because its international reputation and claim of superior data collection mechanisms have hampered the national statistics offices (NSOs) of individual LMICs from being able to collect the data necessary to inform country estimates. Reports from officials in private hospitals and insurance companies in countries including Nepal and South Africa found that the tradition of sharing morbidity and mortality data with NSOs had been disrupted with the rise of GBD, with IHME at times getting priority for the data over the NSOs (Mahajan 2019, 116).
While the development of national statistics within LMICs becomes stunted because of GBD’s influence, the study also serves to highlight generalized public health trends within a nation rather than consider how a public health issue may be affecting members of a given populace on a case-by-case basis. When referring to the GBD study, epidemiologist Elizabeth Pisani succinctly argued, “standardized models that use estimated parameters to produce comparable data for close to 200 countries inevitably iron out precisely the differences and nuances that are most important for local decision-making” (Pisani and Kok 2017, 53). In other words, because GBD uses modeling capabilities that are meant to display health trends for many different countries, it is fundamentally unable to account for localistic circumstances within a particular LMIC that may be critical to public health. It instead uses a one-size-fits-all computation mechanism. Researchers from one African country explained the difficulty of trying to incorporate community opinion on public health and local knowledge of what is and is not captured by wide-ranging studies like the GBD. One researcher claimed, “…We hit the roadblock of one size fits all. We were told: ‘we can’t change things just for [your country], it has to fit into this big global model’” (Pisani and Kok 2017, 55). Thus, the generalized health estimates produced by GBD data analysis leave limited room for localistic perspectives to be effectively incorporated into the information produced by the study.
As such, the GBD study is innately associated with processes that all coalesce against the ability of LMICs to provide input on public health matters. GBD’s sophisticated data collection and analysis capabilities can shut down criticism, hamper the development of LMIC-affiliated NSOs, and contribute towards a generalized, one-size-fits-all standard for measuring public health that does not account for the nuance of LMIC localities. Critics of GBD advocate for the necessity of prioritizing LMIC perspectives to a greater extent, suggesting an increase in the number of resources devoted to analyzing the sociopolitical and cultural contexts surrounding health metrics as a way of lessening the monolithic influence of GBD data informed by IHME’s massive data collection infrastructure (Mahajan 2019, 118). This thesis is primarily concerned with addressing this solution, which aims to resolve GBD’s failure to consider national contexts in its presentation of worldwide public health trends and its tendency to limit the input that LMICs have on their country’s public health circumstances. In order to even the playing field in public health, it is necessary to expand resources devoted to exploring the sociopolitical and cultural contexts of LMICs in health metrics. Specifically, with such contexts in mind, conversations regarding global health would not be dominated by the GBD’s extensive data collection and analysis infrastructure and could instead involve accounts of how public health issues affect people in LMICs at a more micro-level (Shiffman and Shawar 2020, 1453).
Ultimately, however, global health researchers have not offered specific prescriptions for integrating sociopolitical and cultural contexts to global health metrics. Instead, researchers have addressed the topic normatively through a call for smaller-scaled qualitative information to supplement the GBD. Jeremy Shiffman, for example, is one outspoken researcher who insists that small-scale qualitative data should have more of a place in global health discourse to dampen the strong influence of generalized public health estimates produced by GBD. He broadly characterizes such qualitative information as “knowledge produced by studies employing ethnographic, comparative historical, and other qualitative methods that take time to absorb and that reveals the nuances and complexities of matters concerning human wellbeing” (Shiffman 2020, 1455). This type of data can be starkly contrasted with GBD data, which as aforementioned is meant to highlight generalized public health trends for a nation rather than consider how local circumstances may relate to a public health issue affecting members of an LMIC community. Like Shiffman, attorney and public health expert Alicia Yamin also advocated for contextually based qualitative information in public health, paying specific attention to sexual and reproductive health rights (SRHR). She suggests that “over-reliance on quantitative indicators obscures the structural challenges facing the advancement of SRHR, and therefore indicators should be coupled with qualitative information derived in context” (Yamin 2019, 52). While both researchers pointed toward specific qualitative information as a way to counterbalance the generalized data presented in GBD, neither goes into detail about where such information may be accessed or how it can be integrated with GBD data to inform more comprehensive outlooks on public health within LMICs.
The goal of this thesis is to highlight how public health litigation from a court case repository called the Global Health and Human Rights database is able to supplement GBD data and help provide a useful contextual understanding of the generalized trends that are displayed in GBD. Public health litigation also reveals insights on processes important to public health in various LMIC countries that are extraneous to what is actually shown in GBD data but are nonetheless important to consider when dealing with public health issues. Ultimately, litigation is an effective mechanism through which to understand public health issues because it is able to discuss large-scale societal issues and social phenomena through very specific case studies. By turning to case studies that discuss the intersection between public health and other aspects of society (such as class or social norms), the following research adds to the generalized way of communicating data as it presently exists in the GBD study. As will be highlighted later in the thesis, public health litigation is able to demonstrate the prevalence of factors that are important to members of LMIC populaces but ones that can easily fall outside of the scope of the generalized information presented in GBD data, such as specific human rights connected with a public health issue. The information contained within public health litigation can be coordinated with GBD data to build a more comprehensive understanding of public health that makes use of GBD’s data analysis capabilities but also incorporates LMIC perspectives. In order to display how public health litigation can exist in conversation with GBD data, this thesis will consider three country case studies and analyze both the litigation and GBD trends for the selected countries in tandem with one another.
General Background
Truly understanding the extent to which public health litigation can supplement GBD to build a more comprehensive picture of global public health in countries requires a deeper understanding of how the study operates, the types of data it presents, the relationships that exist between the study and other major players in the global health field, and the potential consequences of adhering to a system where the study is not taken in consideration with any supplementary information.
The GBD: A Closer Look
The stated purposes of GBD are numerous and include the following: to provide policymakers within countries worldwide with the most up-to-date information on disease trends and drivers of various health issues, to move towards the achievement of global health objectives like the SDGs, and to counter the politicization associated with advocacy groups through the provision of third-party health information (Shiffman and Shawar 2020, 1452). In order to work towards the achievement of these goals, the GBD has formed global partnerships that span 140 countries and 3,200 collaborators. Its public health estimates are generated using data from over 100,000 data sources including health surveys, country censuses, and vital registration data (GBD 2018). Because the GBD is a continuous study, there is also a mechanism in place to easily add in newly collected data sources and create updated iterations of GBD health estimates (GBD 2022). There is also an extensive and sophisticated infrastructure in place to generate GBD estimates. According to Dr. Murray, “GBD…tracks more than 1,000 health indicators…which are in turn double-checked against 20-40 statistical models…The computations are run on the IHME’s supercomputer, where 12,000 high-performance processing cores churn away at the maths…” (Murray 2016, 40).
Despite the complicated mechanisms that are used to generate estimates, GBD data is delivered to health researchers and other stakeholders in easily digestible formats through data visualizations. The most relevant data visualization tool to this thesis is called “GBD Compare.” This tool allows users to explore the patterns and trends associated with a multitude of public health issues within a country by year, age, and gender. The tool can also be used to compare the impact of a particular health issue with another within a particular country or even to compare the impact of a single health issue between multiple countries. A series of visual displays for health information are provided in GBD Compare such as treemaps and line graphs, which display information regarding a health metric called a Disability-Adjust Life Year (DALY) (GBD 2022). In short, the functionalities that exist within GBD help stakeholders within the global public health field see broad country trends for a particular health issue, the extent to which that trend is occurring with other national health issues, and the progress (or lack thereof) that a country is making on a given health issue relative to other countries.
Organizational Relationships in Global Public Health
GBD exists in a very specific relationship with other major players in global public health which has strengthened the influence of its health estimates in the field. The relationship between GBD and the UN SDGs has already been explored. Namely, the extremely large amounts of data that go into producing GBD estimates make it a particularly attractive resource to the UN for the measurement of the targets within its global goals. GBD even has its own data visualization tool that is wholly purposed for displaying progress toward SDG targets through a clear, visual representation for different countries (GBD 2022). As aforementioned, GBD also exists in a close relationship with a journal called The Lancet, which has emerged as “one of the most powerful actors in global health” over the past two decades (Shiffman 2014, 298). The journal was able to rise in prominence in the global health field because it initiated a special series on global health in the late 1990s and has organized a series of commissions to motivate action on pressing global health issues (Shiffman 2014, 298). The Lancet has shown strong support for GBD. It has published a multitude of articles based on GBD data and even has a GBD Resource Center on its site that has collated all GBD-affiliated materials in the journal. Most recently, The Lancet has published a special issue on GBD that includes the study’s 2019 data (The Lancet 2020). The strong relationships that GBD has with both the UN and The Lancet are important to highlight not only because the combined influence of these organizations is affecting other major players in global health but also because they can work synergistically in a self-enclosed loop that is free from any major external interferences or challenges. Namely, GBD can produce the estimates necessary to evaluate UN SDGs, and the results can subsequently be reported in The Lancet.
The Implications of Adhering to the Status Quo in Global Public Health
The rise of GBD over the past 30 years has been associated with fundamental changes to the realm of global public health. Some of these developments were positive; for example, GBD is the first major public health study that provides all its information in easily accessible data visualizations that are made freely available online (Mahajan 2019, 113). This allows an increased number of people to access materials related to global public health rather than such materials only being made available to specific stakeholders making all the decisions on the public health front. Still, GBD is at the same time involved in many criticisms. In addition to how the study’s focus on complicated data collection and analysis methods reduces LMIC influence in public health, the GBD study is also criticized for a lack of transparency on how exactly its health estimates are generated (Shiffman and Shawar 2020, 1453).
In addition to the preceding criticisms, the GBD study also contributes to the persistence of an “audit culture” in the status quo. Namely, because of its close connections with the UN/the SDGs as well as its ability to display health trends in clear terms through data visualizations/DALYs, GBD has facilitated the integration of heavily financialized language in global public health discourse. “Return on investment” and “value for money” are examples of concepts that are much more readily used with the gaining popularity of GBD in the global public health space (Gimbel et al. 2018, 83). Because GBD is able to illustrate continuous health trends over specific time periods through its DALY measurements, donors look to it to assess the impacts of their funding within specific LMICs. As a result, the “audit culture” trend in global public health involves organizations “play[ing] the numbers game” by focusing on health issues that are readily quantifiable, setting benchmarks related to those issues, and collecting health information on those issues to clearly demonstrate the impact of funding to donors (Shiffman 2020, 2). In the process, individual issues that are important to LMICs but that cannot clearly be represented in GBD data visualizations may be ignored, leading to a singularized, economically oriented mindset for the allocation of public health resources. Of course, this singularized mindset is even further entrenched by GBD’s unbalanced power dynamic with LMICs, hampering the integration of their localistic perspectives in public health discourse.
The increased singularity in perspectives on global public health is also furthered through IHME’s training programs for researchers in LMICs. Specifically, IHME provides online courses, technical training workshops, and even a PhD program to train people from LMICs in the usage of the GBD interface and IHME modeling methods (Mahajan 2019, 114). In effect, IHME pushes forth its own economically oriented conception of how global health should be viewed in LMICs through such efforts. Adhering to the status quo as it exists in global public health could ultimately lead to a situation where an increasing number of health researchers endorse GBD metrics and any challenges to the study are stifled by pointing to those same metrics.
The Global Health and Human Rights (GHHR) Database
The “audit culture” trend taking place in global public health as a result of GBD can potentially be mitigated through the interjection of specific, qualitative sources of data that IHME does not specialize in collecting. By considering such sources in tandem with GBD estimates, there is not only the potential to move beyond a one-track conception of public health by incorporating LMIC perspectives but also to reveal insights about global health issues that go beyond the generalized trends that are shown in the GBD data. This thesis will use public health litigation found in The Global Health and Human Rights Database to supply such information.
The Global Health and Human Rights Database is a database developed by the Lawyers Collective and the O’Neill Institute for National and Global Health Law in 2010 that organizes the health rights litigation produced by national courts around the world and is freely accessible to interested parties. Cases are archived into the database under three specific constraints: that they were adjudicated in an international regional, or domestic court or through a quasi-judicial body; that they involve the discussion of a particular health topic; and that they involve a reference to international or national health rights law (Global Health and Human Rights Database 2022). It should also be noted that the processes used by the Global Health and Human Rights Database to vet the cases that make it into its archives are informed by standard definitions and research practices. For instance, the definitions used to ascertain whether a particular case falls under the scope of a particular health topic are determined by definitions offered by the WHO (Global Health and Human Rights Database 2022). When placed next to GBD visualizations, the information contained with the litigation on this database can help contextualize the trends seen in GBD data and reveal insights into the sociopolitical and cultural concerns that pervade public health issues within particular nations.
Country Cases
The following section of the thesis will involve an in-depth examination of three public health issues in three LMICs using a two-step process: first, GBD data related to a particular health issue in an LMIC will be examined using the GBD data visualization tool available to researchers and its main points subsequently summarized. Then, a correlating piece of public health litigation conducted in the same LMIC and relating to the same public health issue will be examined to determine whether any qualitative information can be gleaned to supplement and contextualize the information found using the GBD tools.
The public health issues to consider for examination were determined based on the overlap of public health issues that were recorded in GBD statistics and those that were litigated in the Global Health and Human Rights Database. Nutritional deficiencies, violence, and HIV/AIDs were the public health issues that most clearly overlapped between the two data repositories. The countries were chosen for analysis through the filtering capabilities in the GHHR database itself. After the public health issues to be examined were chosen, only cases related to one issue were filtered out at a time. Then, the countries with the greatest number of cases litigated for a particular health issue were chosen to more closely examine in the analysis. Only cases litigated in low- and middle-income (LMIC) countries were considered in the analysis since these are the primary targets of public health interventions by global agencies. WHO’s identification system for country income level was used to filter out high-income countries from consideration. Thus, the series of cases that comprise the primary sources used in the analysis are the results that are provided in a filtered search of the database.
Once the public health issues, countries, and litigation for analysis were determined, the cases were surveyed in detail to ascertain any insights that could help explain the health trends shown in the corresponding GBD data visualizations. Furthermore, emergent themes in the cases were considered to speculate on factors that should be considered when designing future policies in the public health space for a particular LMIC.
An important limitation associated with the usage of the Global Health and Human Rights Database is that it is being continuously updated with new health rights litigation; as such, any analysis associated with it runs the risk of becoming outdated, though it is possible to both update findings as new cases are added or to purposefully constrain the period of case examination to a specific duration. On the topic of primary source reliability, the database links the official court documents associated with any case directly underneath short summaries of the cases themselves, which attest to their authenticity.
HIV/AIDs: Kenya
HIV/AIDs is a significant public health issue in Kenya. The first reported case of HIV/AIDs in Kenya was in 1984, but by the middle of the 1990s, it had evolved into an epidemic that was poised as one of Kenya’s biggest public health issues. The country is on the path towards recovering from its status as the site of the third-largest HIV epidemic in the world by making antiretroviral therapies (ART), among other health programs, more widely accessible (UNAIDs 2019). In addition to the increased availability of ART in Kenya, the national government mobilized resources to deal with the HIV/AIDs epidemic when it reached its peak impact in the 1990s. The reduction in health burden attributable to HIV/AIDS in Kenya at the turn of the century is likely due to the formation of the National AIDS Control Council (NACC) in 1999, a multisectoral agency committed to coordinating state-sanctioned policies to reduce the harmful effects of HIV/AIDS on the Kenyan populace. One step taken by NACC was to form a plan, called the Kenyan National HIV/AIDS Strategic Plan (KNASP), which involved the creation of a clear vision, benchmarks, and budgets for making progress toward reducing the burden of the public health issue over specific durations of time (International Labor Organization 2010, 1-2).
As a result of its impact on the nation of Kenya, HIV/AIDs is a public health issue that has gained significant attention both in GBD statistics. In addition, the issue has been litigated in cases across the country’s national court system. Ultimately, the insights revealed in Kenyan public health litigation concerning HIV/AIDs help to show that while the GBD data certainly makes the case for continued funding of policies that have reduced the health burden associated with the disease, future policy action should consider the protection of social rights such as privacy and protections for specific subgroups of the population in its design.
Figure 1: DALY Rates Associated with HIV/AIDS for the Kenyan Populace (1990-2019)
GBD data associated with HIV/AIDS within the Kenyan populace illustrates a bell-shaped type of curve for DALY rates across both sexes between 1990 and 2019. The data depicts a steadily increasing health burden associated with HIV/AIDS from 1990 to about 2000, at which point the health burden connected to this health issue decreases. Following 2000, there were steady decreases in DALYs associated with HIV/AIDS in the subsequent two years followed by very pronounced decreases (the most significant of which occurred between 2006 and 2007, when the DALY rate dropped from 17864 DALYs/100,000 population to about 15718 DALYs/100,000 population), before returning to steady decreases in the late 2010s. From a broad perspective, then, GBD data presents a narrative of a rising health burden due to HIV/AIDS in Kenya in the 1990s. This burden has been steadily controlled since the turn of the century by the Kenyan government and NACC, particularly in the mid-2000s, to come back towards pre-epidemic levels at present.
The GBD has been an important source of information in influencing the direction of Kenyan health policy. The Kenya Vision 2030 plan, which aims to transform the country into a middle-income, industrialized nation by 2030, has in particular been directed by the statistics provided in GBD (Vision2030 2008). A policy report produced by The Kenya-based International Center for Humanitarian Affairs (ICHA) and the IHME in partnership with the Kenyan Ministry of Health found that the significant reversal in health burden attributable to HIV/AIDs at the turn of the century was likely set in motion by a “major expansion of priority health interventions such as antiretroviral treatment, insecticide-treated nets for malaria prevention, artemisinin combination therapy, and the rollout of anti-tuberculosis treatment during this period” (ICHA and IHME 2014, 22). These national-scale public health interventions were coordinated by NACC. The policy report explained that Kenya was moving in the right direction on the HIV/AIDs front, offering the implication that what was currently being done to mitigate the issue should be sustained and potentially expanded to see more reductions in health burdens (ICHA and IHME, 22). Accordingly, one policy goal that was developed as a part of Vision 2030 was “to enhance the capacity of NACC,” which is in line with the discussion in the policy report (Vision2030 2008).
Court cases surrounding HIV/AIDS in Kenya, while not directly contrasting with the information presented by GBD data (and indeed at times corroborating it), do reveal significant information about accessibility to medicine and privacy rights. This information is important to consider in policy-making around HIV/AIDs in tandem with the GBD visualization above. This is especially true with the HIV/AIDs provision of Kenya Vision 2030 in mind, as the NACC could be informed by public health litigation with its improved capacities for action within the country.
Ochieng v. Attorney General is a significant case listed in the Global Health and Human Rights database regarding the accessibility of medicine for the treatment of HIV/AIDS. In this case, petitioners living with HIV/AIDS argued against the constitutionality of Section 34 within the Anti-Counterfeit Act of 2008, suggesting that it curtailed their ability to secure affordable AIDS medication to treat their ailments. The Court ultimately sided with the petitioners, coming to the conclusion that Section 34 violated the constitutionally protected rights of life, dignity, and health for Kenyans (2). The Court framed its reasoning in a way that highlighted the particularized burden of HIV/AIDS for vulnerable groups. Specifically, the Court wrote, “There can be no dispute that HIV/AIDS constitutes a serious threat to the health and life of the petitioners in particular but to others within the general public who may be infected by the virus…particularly so with regard to children and women” (25). The parts of this statement concerning particularized impact of HIV/AIDS against children and women do indeed align with GBD, which allows for the stratification of DALYs by age and sex.
Importantly, however, GBD does not stratify health burdens based on income level, thereby not accounting for a critical determinant of a nation’s overall public health. The significance of income in public health, recognized by the Kenyan High Court in Ochieng, is perhaps best conveyed through its restatement of scientific evidence brought forward by the petitioners arguing that affordable treatment options, such as the generic drugs at risk of being detained under the Anti-Counterfeit Act of 2008, would reduce HIV transmission between mother and child by between 30 and 50% (25). As a consequence of not considering income levels in its data visualizations, GBD ultimately sits in a position that is removed from the impacts of HIV/AIDS on subsets of the Kenyan populace at the micro-level because it will resultingly be unable to offer any insights about the specific reasons for why income produces disparate health impacts that materially affect public health. In the case of Ochieng, the specific reason had to do with the accessibility of medication. This, taken together with the trends displayed in GBD, suggests the continued utility of much of the work spurred by NACC and the HIV and AIDS Prevention and Control Act of 2006 but also important omissions that need to be considered in any updated legislation, like medicine accessibility protections for low-income Kenyans.
On the relation of health burdens imposed by HIV/AIDS to privacy rights, the Global Health and Human Rights database offers three cases, all heard by the High Court of Kenya at Nairobi: Kenya Legal and Ethical Network on HIV and AIDS (KELIN) & Others v. Cabinet Secretary-Ministry of Health & Others (will be referred to as KELIN), AIDS Law Project v. Attorney General, et al. (will be referred to as AIDS Law), and J.A.O v. Homepart Caterers LTD, et al (will be referred to as J.A.O). While all three cases involve the right to privacy within the context of HIV/AIDS in Kenya, they all apply to particular subgroups of the population and suggest important implications for the Kenyan populace- with AIDS Law going so far as to present a direct challenge to the existing primary legislation governing HIV/AIDS practices in the state. The HIV and AIDS Prevention and Control Act of 2006. J.A.O, heard in 2004, involved an HIV-positive plaintiff who brought claims against her employer for subjecting her to an HIV test without consent and her doctor/hospital for disclosing her HIV status to her employer without her consent, subsequently causing the loss of her employment (3-4). The court eventually found that “the [plaintiff’s] dismissal from employment can be said to have been as a result of her being H.I.V positive” with such actions amounting to “inhuman treatment” (10). While not explicitly mentioning a right to privacy as a component of its reasoning, the Court nonetheless implicates it as a factor at play when dealing with HIV/AIDS in the workplace by simply relegating discrimination against those afflicted with HIV/AIDS as inhumane, thereby confirming the importance of confidentiality and discretion.
While J.A.O attempts to navigate HIV/AIDS within the context of the workplace, KELIN attempts to do so within the context of schools. The case, heard in 2016, involved a challenge to a directive issued by the Kenyan President Uhuru Kenyatta that mandated the state collection of information on schoolchildren living with HIV and AIDS as well as on the guardians of these children. The challenge was put forth by the main petitioner- The Kenya Legal and Ethical Issues Network on HIV/AIDS (KELIN), a nonprofit organization “working to protect and promote health-related human rights in Kenya.” The claim was made under the grounds that the directive violated Article 31 of the Kenyan Constitution, violates provisions of the HIV and AIDS Prevention and Control Act of 2006, and is ultimately against the best interests of children in Kenya (6). The Court agreed with KELIN, arguing that Article 31 was violated by the directive since it was to be implemented “without privacy guidelines to guide the collection of the data,” because “data would be collected without consent of the affected person,” and because “the collection of the data…would directly link the individual’s name with their HIV status” (29). The Court also found the directive to be in violation of Sections 21 and 22 of the 2006 Act, highlighting concerns about the lack of safeguards in order to protect the identity of children (29-30). KELIN is significant to consider in the public health landscape not only because it affirms the importance of privacy rights to Kenyans as J.A.O does (albeit in different societal contexts) but also because it suggests a social limit to data collection efforts that can take place in the state, even if those efforts are explicitly devoted to reducing public health burdens.
AIDS Law, a case heard in 2015, rather than applying privacy rights perspectives to HIV/AIDS in different societal contexts, instead applies such perspectives to critique the HIV and AIDS Prevention and Control Act itself. The AIDS Law Project, an NGO operating within Kenya focusing on legal issues associated with HIV/AIDS, claimed that Section 24 of the Act, which details ways in which transmission can be mitigated, contains overly broad, unconstitutional language (2). More specifically, the primary claim of the AIDS Law Project was that a failure of the act to define terms such as “contact” could lead to situations where Kenyans could face criminal sanction under the legislation without even having complete knowledge of what behavior is subject to prosecution, a violation of Article 50 of the Kenyan Constitution (2). The other pertinent claim made by the AIDS Law organization was that Section 24 of the 2006 Act violated Article 31 of the Constitution, the same Article considered by other cases existing at the intersection of privacy and HIV/AIDS, on the grounds that there was no stipulation in the legislation requiring any “contacts” of those infected with HIV/AIDS to themselves commit to confidentiality after being told of any diagnoses (5). The Court ruled in favor of the AIDS Law Project regarding these constitutional challenges, which further solidifies how the social factor of privacy can reign in public health interventions surrounding HIV/AIDS. In addition, the Court’s decision interestingly illustrates somewhat of an internal tension within the 2006 Act, as one part of it (Section 24) was struck down in part because it violated privacy rights while other parts of it (Sections 21 and 22) were used in KELIN as a way of advancing privacy rights.
The tension that exists between AIDS Law and KELIN highlights the need for updated legislation related to HIV/AIDS in Kenya, one that removes any ambiguity associated with privacy rights (something important enough to the Kenyan populace within the context of HIV/AIDS to have been brought to the state’s highest Court three times in the span of about a decade) and codifies important protections for lower-income groups (such as an assurance of accessibility to generic drugs for HIV/AIDS treatment) as a way of continuing the downward health trend displayed by GBD data. The litigation also presents some specific guidance to NACC as it experiences expanded capacities under Kenya Vision 2030. Namely, because the public health litigation makes abundantly clear how important the right to privacy is for the Kenyan populace, it is important for NACC to include this factor in its design of public health interventions rather than simply sidelining such considerations in an effort to further reduce the HIV/AIDs health burden in the country.
Nutritional Deficiencies: India
Malnourishment, from a purely numerical perspective, is a persistent public health issue in India despite the launch of several government-sponsored programs to abate the problem. A Food and Agriculture Organization report on the topic of food security estimated that 190.7 million Indians (over 10 percent of the total population) were undernourished between 2014 and 2016 (Gonmei and Toteja 2018, 511). Micronutrient deficiency is a specific example of one component of malnourishment in India, which can lead to a difficult cycle of malnourishment, lowered productivity, impaired learning ability, underdevelopment, and poverty (Gonmei and Toteja 2018, 511). Furthermore, in addition to having one of the highest national health burdens due to underweightedness in the populace, India also is seeing an increasing number of overweight persons in the country. The coexistence of both a large contingent of underweight individuals and a growing contingent of overweight individuals in India due to nutritional deficiency has resulted in what researchers call the “double burden of malnutrition” (Kulkarni and Gaiha 2017, 108).
Figure 2: DALY Rates Associated with Nutritional Deficiencies for the Indian Populace (1990-2019)
From a broad perspective, the GBD data displays an overall reduction in DALYs attributable to nutritional deficiencies over time in India. Still, despite the gradually descending dots in the plot, the reduction in DALYs between individual years is more pronounced in the 1990s and 2000s than they are in the 2010s. This indicates that while there has been continuous progress in reducing the health burden attributable to nutritional deficiencies in India, any interventions taken to reduce this burden had larger impacts when the DALYs associated with the health issue were higher.
GBD data on nutritional deficiencies in India has been useful in justifying public health interventions that have shown to be effective during previous implementations. In response to micronutrient deficiencies, for example, the Indian national government engaged in the fortification of high-consumption commodities such as rice (Bhatnagar and Kanoria 2020). With the GBD estimates continuing to trend downward, policies such as fortification continue to be endorsed as proven, cost-effective, and easily scalable public health interventions to address nutritional deficiencies (Venkatesh et. al 2021, 10). While such an intervention certainly may present an effective way to reduce nutritional deficiency DALYs in India, it is too broad to consider the specific contingencies that can exist in the realm of public health for the extremely diverse groups that populate the nation, and such programs should be more specifically tailored to individual subgroups and specific geographic areas that exist within the nation.
Consider, for example, how low-income groups in India may fall under the radar of national public health interventions. The GBD data plot displays a reduction between the years 2010 and 2012 from about 1507 DALYs/100,000 population to 1429 DALYs/100,000 population, signifying, from a purely numerical standpoint, a reduction in the health burden imposed by nutritional deficiencies for the Indian populace. As a supplement to this information, however, it is important to also consider the contextual information found in Premlata v. Government of NCT Delhi. In this case, which was decided in 2011, the High Court of Delhi relayed two significant pieces of information about nutrition-related public health issues that add layers of nuance to the generalized story depicted by GBD statistics on the problem. First, the court discovered that Delhi had placed a cap on the number of Below Poverty Line (BPL) ration cards it issued, which would enable cardholders to obtain food assistance from the government. The Court subsequently claimed that “Denial of a ration card to a BPL person is virtually a denial of his or her right to food.” Second, the Court heard concerns from a Petitioner in the case regarding the quality of foods grains that were being offered for sale at a Fair Price Shop. Following the raising of this issue, the Court emphasized the importance of “having in place an appropriate grievance mechanism that can address all issues connected with the distribution of rations through the public distribution system.” Through just the two examples raised in this piece of litigation, a theme of structural shortcomings when it comes to satisfying the nutritional needs of a low-income subgroup in the Delhi region of India emerges. Namely, specific mechanisms of access (the BPL cards) and redress (the ability to voice grievances with poor quality food items) when it came to the health issue of nutritional deficiency are demonstrated to be important in interventions that target the problem.
While not dealing with a particular class of society, Kranti v. Union of India & Ors addresses a subgroup of the Indian populace that inhabits a particular geographic area of the nation with respect to nutritional deficiencies. It deals with the public health issue within the context of a natural disaster. Specifically, the plaintiffs in the case, which was overseen by the Supreme Court of India in 2007, were heavily affected by the 2004 tsunami and argued that their local administration was ineffective in providing them with relief in the subsequent multi-year recovery process. The plaintiffs were inhabitants of the Andaman and Nicobar Islands, which are a group of islands that are situated southeast of the Indian subcontinent but are part of the nation (1). The plaintiffs insisted that to disburse necessary provisions more efficiently, there should be multiple Lok Adalats (which refer to the local courts to which the applications for relief are submitted) in the affected islands rather than in one specific location. Having multiple locations would have facilitated the application for and eventual provision of food aid, among other resources (2). The Court, while not mandating the local administration to implement more local courts, did encourage the possibility (6). Such an implementation would have reduced the health burden associated with nutritional deficiencies for those on the islands affected by the tsunami.
These two cases illustrate that addressing the problem of nutritional deficiencies in India goes beyond broad-stroke public health intervention recommendations like the continuation of improved fortification. While such measures are certainly significant, the public health litigation demonstrates that it is also important to consider factors such as barriers to nutritional resource access for certain cohorts of society and how those barriers can be removed at both the national and local levels within the country.
It should be noted that GBD statistics have been used to inform multiple studies that have guided Indian health policy, including the India State-Level Disease Burden Initiative of 2015. The initiative highlighted the inequalities in DALY reduction for non-communicable diseases (including malnutrition) among the various states in India, demonstrating that many poorer northern states did not experience as much of a health burden reduction as states elsewhere in the country and advocating for increased allocation of resources to those states that seemed to be lagging according to the numbers (“The India State-Level Disease Burden Initiative” 2018). In addition to helping with resource allocation, this broad analysis is also useful in allowing states to compare progress with one another and coordinate strategies. Still, the state analysis informed by GBD statistics for India does not reach the level of specificity that an examination of public health litigation can achieve in terms of an ability to highlight the highly specific situations of communities within states, including those mentioned in the two cases, and subsequently inform policy action.
Violence: Colombia
Violence is a public health issue that, in the case of Colombia, can be further separated into distinct categories: interpersonal violence, conflict/terrorism, and police violence/executions. Interpersonal violence, as defined by GBD, involves “death or disability from intentional use of physical force or power, threatened or actual, from another person or group not including military or police forces.” Interpersonal violence by and large usually deals with intimate partner violence, physical, sexual, or psychological harm inflicted by partners or spouses, within the context of public health (GBD 2022). GBD defines conflict and terrorism with the following: “Conflict is armed violence between states, governments, and societies with destruction, mortality, and use of military forces. Terrorism is the unlawful or threatened use of force or violence against individuals to achieve political, religious, or ideological objectives” (GBD 2022). Police conflict and executions include “the lawful or threatened use of force or violence against individuals or groups of people or property in an attempt to achieve political or socioeconomic objectives for a state” (GBD 2022). Both GBD and the Global Health and Human Rights database contain information that spans across all these categories.
Interpersonal Violence
Interpersonal violence remains a pressing issue in Colombia, despite the series of laws that have condemned and criminalized it. Interpersonal violence against women, in particular, remains a significant public health problem in the country. In fact, of all the violence cases that were recorded through Colombian medical and legal services in 2016, 72% of instances were against women and girls (“Colombia Changes Laws on Domestic Violence Due to Push from Humphrey School Researchers” 2021).
While interpersonal violence is considered in both the GBD and public health litigation, the litigation effectively adds to the generalized trends displayed in the GBD statistics by illustrating the extent to which the issue intersects with health rights. Gaining a larger purview for understanding interpersonal violence thereby enables policymakers to adopt more comprehensive action toward the mitigation of the public health issue in Colombia.
Figure 3: DALY Rates Associated with Interpersonal Violence for the Colombian Populace (1990-2019)
Overall, the DALY rates depicted in the GBD data for interpersonal violence in Colombia show a general decline between 1990 and 2019, with a considerable upward trend that occurred between 1997 and 2002, when the DALY rate increased from about 4468 DALYs/100,000 population to 5649 DALYs/100,000 after a period of sustained decline in the early 1990s. This was followed by a drastic drop in the DALY rate between 2002 and 2003 from about 5649 DALYs/100,000 population to 3841 DALYs/100,000 population and a subsequent continued general decline.
One case contained within the Global Health and Human Rights database helps to develop a broader narrative surrounding violence as a public health issue by exploring its intersection with other human rights, including the right to dignity and access to care. This piece of litigation, entitled Case T-209/08, was heard before the Colombian Constitutional Court in 2008. The petitioner was the mother of a victim of rape who became pregnant but was denied a legal abortion by two hospitals because the hospital staff collectively claiming conscientious objection to the procedure. The complaint was made against the hospitals involved (5). The Constitutional Court found that “clinics, hospitals, healthcare centers or any institution with such a name, cannot claim a conscientious objection against performing an abortion” because “conscientious objection” has been previously construed to only reference “a duly supported religious conviction” of an individual (17-18). Moreover, the Court recognized a need to qualify an individual’s right to conscientious objection so as not to make it absolute, claiming, “the exercise of the right of conscientious objection is subject to the legal framework and…cannot become a mechanism for discrimination against women or violation of their rights” (19). Such a statement is noteworthy because it explicitly prioritizes certain rights over others when they come into conflict with one another. The case itself is significant within the context of violence as a public health issue for two reasons. First, it helps to demonstrate that violence, and specific public health issues in general, cannot be examined in a vacuum because they are innately connected with other rights and health determinants, all of which need to be considered in totality in order to design the most effective public health intervention and resultingly create the most meaningful public health improvements for a particular society. Case T-209/08, through its consideration of how the DALY burden associated with an unwanted pregnancy resulting from an instance of interpersonal violence could be reduced with the reigning in of an individual’s social liberties (i.e., the right to conscientious objection), shows how any individual public health issue can exist as part of a larger sociocultural matrix.
Conflict/Terrorism and Police Violence/Executions
Conflict, terrorism, police violence, and executions are part of a subset of violence that has ravaged Colombia for decades as a result of civil war. Specifically, an intrastate conflict between an insurgent group called the Revolutionary Armed Forces of Colombia (FARC) and Colombian national authorities has existed since the 1960s and only recently resulted in a ceasefire in 2016. The conflict left 220,000 dead and millions displaced from their homes (Felter and Renwick 2017). Despite a temporary cease in hostilities, the after-effects of the conflict persist in the nation to sustain violence as a relevant public health issue, such as a decentralized police force that lacks authoritative accountability (Matanock 2021).
Figure 4.1: DALY Rates Associated with Conflict and Terrorism
Figure 4.2: Executions and Police Conflict for the Colombian Populace (1990-2019)
The DALY rates depicted in the GBD data for conflict and terrorism and executions and police conflict (above) interestingly mirror each other in terms of trends, with the data for the former displaying a general decline and the data for the latter displaying a general increase between 1990 and 2019. The DALY rate for conflict and terrorism was highest in the 1990s and in the very early years of the 21st century, achieving its overall peak in 2002 with a DALY rate of about 539 DALYs/100,000 population before reaching an overall sustained decline throughout the course of the rest of the GBD collection years. The increasing trend displayed in the executions and police conflict DALY rate data rose steadily between 1990 and 2009, beginning at about 2 DALYs/100,000 population and increasing to about 38 DALYs/100,000 population before then proceeding into somewhat of a decline until 2015 (at which point the DALY rate had receded to about 25 DALYs/100,000 population) and again resurging in more recent years. Thus, contrary to the DALY rates associated with interpersonal violence, conflict, and terrorism, the DALYs attributed to executions and police conflict are moving in an upward trend, suggesting a high priority to formulate public health interventions to mitigate the health burden in this subsection of societal violence.
The public health litigation related conflict/terrorism and violence by state actors from the Global Health and Human Rights database not only gives context to the trends displayed in the GBD visualizations through its exploration of societal phenomena such as displacement, but it also suggests practical ways to move towards progress on reducing violence.
One significant case from the database focuses on the importance of displacement as a component of violence, bringing forth a unique argument that explains how a specific subset of the population within Colombia is made to grapple with the occurrence. Ituango Massacres v. Colombia heard in front of the Inter-American Court of Human Rights in 2006, dealt with displacement as a result of paramilitary conflict that was generated within the state, highlighting the particularly potent effects that such a process can have on children. The Court found that the state of Colombia violated Article 19 of the American Convention, which protects the rights of children by allowing paramilitary conflicts to occur. In narrowing its focus on children, the Court argued that children who were displaced as a result of violence have a “special vulnerability…because children are less prepared to adapt or respond to this type of situation and suffer its excesses disproportionately” (100). In other words, the health burden imposed by displacement on children is disproportionately higher than in older age groups because children have less capacity to deal with such challenging circumstances. More than simply pointing out where the nation committed violations of international convention, the Court ordered damages to be paid to those who were affected by the conflict. It also ordered Colombia to take steps toward preventing future calamities of the same nature, such as through implementing a state-sponsored training program “on human rights and international humanitarian law for the Colombia Armed Forces” or publishing the Court’s ruling in an official national newspaper, likely in order to increase public awareness about the issue and promote state accountability (151). The case thus demonstrates its significance when considering violence as a public health issue because it highlights particular subsets of the population like children, that need to be given particular consideration in the design of public health interventions and illustrates examples of how such interventions can be implemented and maintained in the nation. Papers associated with Colombia and the GBD published in The Lancet, which have likely been used by the Colombian government to inform health policy action on violence in the nation, do not reach the level of granular detail that public health litigation on the issue is able to reach. Ultimately, such qualitative information would enable the administration to inform more intricate health policy that is informed not only by statistical modeling but also by the circumstances of members of the Colombian populace itself.
Conclusion
Viewing the public health litigation from the Global Health and Human Rights database in tandem with the GBD health estimates for the three countries shows that the litigation can be useful for offering context to the trends that are displayed in GBD data visualizations and creating a more comprehensive understanding of how public health issues persist in specific communities. Still, other avenues can and should be used for gaining contextual understandings of quantified health estimates such as ethnographic interviewing. The country case studies in the previous section demonstrate, however, that public health litigation can be used to understand how national legislation and action can impact individual subgroups within a society. They very apparently point out the shortcomings of existing laws as they apply to specific cohorts of a populace in the context of particular health issues, thereby highlighting the ways in which such laws can be improved for the future. These insights, in combination with those gained from GBD trends, provide effective blueprints for countries to make progress on public health issues with both the human rights and public health of their populaces in mind.
Future research on public health litigation in the field of global health can potentially survey the determinants of health that the GBD does not collect information on but that the Global Health and Human Rights database does, such as access to education. Such a survey could have the potential to not only produce a more comprehensive understanding of how various social factors impact global health but could also illustrate the utility of considering health factors that fall outside of the purview of GBD.