American Journal of Law & Medicine

Human rights in health equity: cervical cancer and HPV vaccines.(Symposium)

ABSTRACT

This article seeks to demonstrate that health equity, as an empirical and normative concept, is reflected in the human rights to health and equality under international law. The obligations on government that flow from health equity as a human right are then examined. These include the obligation to act in pursuit of health equity as a policy objective, and the obligation to enact measures to ensure health equity as a policy outcome. These obligations are considered in relation to a promising remedial measure for social disparities in cervical cancer: HPV vaccines.

INTRODUCTION

Cervical cancer is widely referred to as a striking and tragic case of health inequity. (1) There is no shortage of scientific knowledge or technical intervention. Cervical cancer is preventable and treatable through existing measures. These measures have dramatically decreased cervical cancer incidence and mortality, but their benefits have been unequally distributed within and across countries.

While cervical cancer rates have drastically fallen in developed countries due to effective prevention and treatment, socially disadvantaged women within these countries remain disproportionately more likely to develop and die of cervical cancer. (2) In most developing countries, in contrast, cervical cancer rates have risen or remained unchanged. (3) More than eighty-three percent of the 493,000 incident cases of cervical cancer, and an even higher proportion of the 273,000 related annual deaths, occur in the developing countries of sub-Saharan Africa, Latin America and the Caribbean, South and South-East Asia, and Melanesia. (4) Cervical cancer is the primary cause of cancer-related deaths (5) and years of life lost (6) among women in developing countries. These women are more likely to be diagnosed with late-stage disease, receive either no treatment or treatment that does not meet currently accepted standards of care, and suffer without the benefit of pain control and other palliative care. (7) These social disparities in prevention, incidence, detection, treatment, and survival are avoidable, but are not avoided. For these reasons, cervical cancer is a health inequity.

The conceptualization of cervical cancer as a health inequity grounds ethical claims of injustice and political demands for action. (8) The health inequity of cervical cancer also suggests a legal claim. This article seeks to articulate this legal claim under international human rights law.

Part I examines the reflection of health equity as an empirical and normative concept in the human rights to health and equality. Given health equity as a human right, social disparities in cervical cancer are reconceived as a violation of international human rights law.

Part II focuses on the legal obligations of government that flow from health equity as a human right, and social health disparities as a human rights violation. (9) These obligations, broadly phrased, include the obligation to act in pursuit of health equity as a policy objective, and the obligation to enact measures to ensure health equity as a policy outcome. Part II considers these obligations in relation to a promising remedial measure for cervical cancer inequity: HPV vaccines.

While international law cannot itself remedy social disparities in cervical cancer, the framing of health equity as a human right may strengthen the normative commitment to ensure government action in pursuit of this goal.

I. HEALTH EQUITY AS A HUMAN RIGHT

A. THE EMPIRICAL AND NORMATIVE DIMENSIONS OF HEALTH EQUITY Health equity has a range of theoretical backgrounds and definitions. (10) Margaret Whitehead's 1992 formulation remains a standard working definition of the term. (11) Health inequity refers to "differences in health that are not only unnecessary and avoidable, but in addition unfair and unjust." (12) Subsequent iterations retain the empirical and normative dimensions of health equity, but modify their relationships. Health inequity refers to health disparities that are unjust because they are avoidable and thus unnecessary. (13) This definition raises questions of fact and value: whether differences in health are avoidable and thus unnecessary, and why are such differences unjust.

Paula Braveman and Sofia Gruskin answer these questions by focusing on social disadvantage as a key feature of health inequity. (14) While Whitehead does not explicitly use the term "disadvantaged" in her definition, Braveman explains that Whitehead intended to refer to differences that adversely affect "disadvantaged nations and groups" as implied by her examples. (15)

Health inequity, Braveman argues, is identified by the systematic tracking of health disparities with the social hierarchy, which consists of the different relative positions of social advantage and disadvantage as defined by, for example, gender, race, ethnicity, wealth, income, education, occupation, and geographic residence. (16) Social groups who have persistently experienced social disadvantage or discrimination in the past systematically experience greater health risk and worse health outcomes than the most advantaged social groups. (17) Health inequity thus refers to health disparities between social groups categorized by some important feature of their underlying social position, (18) social health disparities in short.

According to this definition, cervical cancer is a striking case of health inequity. Women belonging to disadvantaged social groups are disproportionately more likely to develop and die of cervical cancer across and within countries. The vast majority of the incident cases of cervical cancer and related deaths annually occur in developing countries. (19) Cervical cancer is the primary cause of cancer-related deaths and years of life lost among women in these countries. (20) Within all countries, cervical cancer disparities track indicators of underlying social position. A meta-analysis of fifty-seven studies revealed an increased risk of approximately 100 percent between high and low social class categories for the development of invasive cervical cancer. (21) This increased risk was apparent in all geographic regions, although it was stronger in Africa, Asia and Latin America and the Caribbean than in Europe. (22) These measures of cervical cancer disparities, moreover, may be underrepresented given misclassification and underreporting along indicators of social disadvantage in the data itself. (23) Cervical cancer inequity cannot be effectively decreased without improving the information systems necessary to measure disparities and monitor progress.

What renders social health disparities avoidable and thus unnecessary? The answer lies in their cause. Causes of social health disparities are complex and multifactorial, with epidemiology rarely able to establish relationships between cause and effect. The systematic association of greater health risk and worse health outcomes with social disadvantage--the association being significant, frequent or persistent rather than random or occasional (24)--nevertheless allows for a plausible general inference that social health disparities are informed by the social hierarchy and the social institutions that create, maintain and give it force. One such institution is the health system, which converts the social hierarchy into unequal health resources, access to services and health outcomes. Health inequity is a function of how governments distribute health resources and design health programs. (25)

The social hierarchy and the health distribution linked to this hierarchy are thus neither natural nor inevitable. Social health disparities result from an avoidable and unnecessary determinant: government action. Braveman explicitly defines health inequity as "a particular type of potentially avoidable difference in health or in important influences on health that can be shaped by policies." (26)

Preventable diseases warrant a comment in relation to the criteria of avoidable and unnecessary. It is suggested that health equity is of particular relevance to diseases, such as cervical cancer, where there is no shortage of scientific knowledge or technical intervention to prevent the disease. (27) Preventable diseases are analytically valuable insofar as they indicate what is theoretically attainable, and therefore set a minimum standard for what is potentially avoidable through government action. (28) Braveman is careful to note, however, that empiric evidence of avoidability in this sense should not be a prerequisite for a health disparity to qualify as a health inequity. (29) The unavailability of prevention measures may itself, for example, be a consequence of government action.

Cervical cancer is a preventable disease, a characteristic relevant to the characterization of social disparities in cervical cancer as avoidable and unnecessary. The prevention of cervical cancer is based on the discovery that infection with one or more high-risk types of the human papillomavirus ("HPV") is a necessary cause of cervical cancer. (30) HPV infection is a highly prevalent sexually transmitted infection. Most women will be infected with HPV during their lifetime, with high rates in young women following sexual debut. (31) While most infections are asymptomatic and transient, persistent or chronic infection over decades with a high-risk HPV type is associated with pre-cancerous lesions of the cervix that may progress to cervical cancer. (32)

Several factors are associated with increased risk of both initial infection with high-risk HPV types and developing cervical cancer once infected. Individual level factors include both biological factors (e.g. coinfection with other sexually transmitted agents and immunodeficieney) and behavioral factors (e.g. nonuse of condoms, multiple sexual partners, (33) young age at sexual debut). (34)

While differences in individual level factors may have some effect on social disparities in cervical cancer, (35) they are not considered the dominant cause of the social distribution. The most important determinant of social disparities in cervical cancer is a health systems factor shaped by government action: social disparities in access to prevention measures, namely cervical screening. (36)

Cervical screening allows for the early detection, follow-up and treatment of precancerous cervical abnormalities. (37) It is a viable and highly effective prevention strategy because of the prolonged progression from infection to disease. (38) In countries that have implemented high-quality screening programs using the Papanicolaou cytology method, societal average cervical cancer incidence and mortality rates have dramatically decreased. (39) These drastic reductions indicate the standard of health theoretically attainable among socially disadvantaged women, setting a minimum standard for what is possible through government action.

Central to health equity is thus not the association of health distribution with the social hierarchy, nor the fact of existing prevention measures, but the capacity of government to change the social hierarchy or to modify its effects on the distribution of health risks and outcomes. There are important reasons to empirically locate the cause of social health disparities in government action, among them, providing an explanation why social health disparities are unjust, the normative dimension of health equity.

Social health disparities are unjust, according to Braveman and Gruskin, because they result from government action that adversely affects the health risks and outcomes of groups already disadvantaged by virtue of their underlying social position. (40) Social health disparities result from government action that places already disadvantaged social groups at further disadvantage with respect to their health. …

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