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International Obligation and Human Health: Evolving Policy Responses to HIV/AIDS

  • Paul G. Harris and Patricia Siplon


The world is in the early stages of what will be the greatest health crisis since the advent of modern medical technologies. Millions of people—particularly people in many of the world's poor countries—are infected with HIV. The vast majority of these people will go without modern medical intervention or substantial treatment, and will rapidly develop AIDS. The extent of this problem presents profound moral and ethical questions for the world's wealthy people and countries, for it is they who are most able to assist the poor in managing and reversing this human tragedy.



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1 UNAIDS, “Report on the Global HIV/AIDS Epidemic,” 2000; available at

2 Individual Members of the Faculty of Harvard University, “Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries,” April 4, 2001, p. 3.

3 UNAIDS, “Report on the Global HIV/AIDS Epidemic.”

4 Annan, Kofi, “Remarks to the United States Chamber of Commerce,” Washington, D.C., June 1, 2001.

5 Individual Members of the Faculty of Harvard University, “Consensus Statement,” p. 3.

6 Stine, Gerald, AIDS Update 2000 (Upper Saddle River, N.J.: Prentice Hall, 2000), p. 11.

7 These figures are taken from the Web page of USAID, “USAID CP FY2000: AFR Regional Report”; available at See Bates Gill and Sarah Palmer, “The Coming AIDS Crisis in China,”New York Times, July 16, 2001, p. A15.

8 An excellent and more extensive discussion of these interactions of poverty and HIV can be found in Brook K. Baker, “South African AIDS: Impacts of Globalization, Pharmaceutical Apartheid, and Legal Activism,” April 3, 2001, pp. 4–7; available at

9 An excellent snapshot of the tragic situations created by HIV in sub-Saharan Africa is provided in a Pulitzer prize-winning series by Mark Schoofs, “AIDS: The Agony of Africa,” Parts 1–8, Village Voice, November 9, 1999-January 4, 2000; available at

10 World Bank, “Difficult Health Policy Choices in a Severe AIDS Epidemic,” in Confronting AIDS: Public Priorities in a Global Epidemic (Washington, D.C.: World Bank, 1997); available at

11 Norimitsu Onishi, “AIDS Cuts Swath Through Africa's Teachers,”New York Times, August 14, 2000, p. A6

12 Peter Piot, UNAIDS Press Release, May 7, 2000.

13 See Donnelly, John, “Suddenly a Plan to Treat AIDS in Africa,” Boston Globe, February 13, 2001, p. A1.

14 Health, Reuters, “Civil War Looms unless Poor Countries Get Relief from AIDS,” May 8, 2001; available at

15 All of these figures are taken from Jubilee 2000 Coalition, “Eye of the Needle: African Debt Report,” November 2000; available at

16 For basic information on the development of the fund see United Nations, “Fact Sheet: A Global AIDS and Health Fund”; available at

17 DeYoung, Karen, “U.S. Gives AIDS Fund $200 Million Donation; Bush Vows More Money for Public-Private Project,” Washington Post, May 12, 2001, p. A19.

18 Vick, Karl, “Powell Talks of AIDS in Nairobi Slum,” Washington Post, May 28, 2001, p. A19.

19 See, for example, Rosenberg, Tina, “Look at Brazil,” New York Times Magazine, January 28, 2001.

20 See European Union Ambassador Erwon Fouere's letter to Dr. O. Shisana, November 24, 1997; available at

21 Health GAP Coalition, “US at WHA Colludes with Drug Industry” (Press Release, May 17, 2001).

22 Chris Tomlinson, “U.S. Speaker of the House Dennis Hastert Hears Appeal from Priest Treating Children with HIV,” Associated Press, April 12, 2001.

23 U.S. Secretary of State Colin Powell, Letter to European Union Health Commissioner Patten, April 25, 2001.

24 McNeil, Donald G. Jr., “U.S. at Odds with Europe over Rules on World Drug Pricing,” New York Times, July 19, 2001, p. A8.

25 These policies (and several more) are described in the context of the case of South Africa in Baker, “South African AIDS.”

26 For one account of the Abuja summit see John Donnelly, “Leaders Vow to Combat Africa AIDS Epidemic,”Boston Globe, April 29, 2001, p. A22.

27 For a description of Uganda's success, see Alex Duval Smith, “Faith, Hope and Charity,”The Independent (London), December 2, 2000, pp. 24, 25, 29, 30.

28 Barton Gellman, “Death Watch: The Global Response to AIDS in Africa: World Shunned Signs of the Coming Plague,”'Washington Post, July 5, 2000, p. Al.

29 One indicator of this lack of responsiveness is the absolute numbers in foreign aid devoted to this problem by developed countries. An excellent analysis is provided by Attaran, Amir and Sachs, Jeffrey, “Defining and Refining International Donor Support for Combating the AIDS Pandemic,” Lancet 357, No. 9249 (January 6, 2001), pp. 5761.

30 Barton Gellman, 'An Unequal Calculus of Life and Death,”Washington Post, December 27, 2000, p. Al.

31 Waldholdz, Michael, “Makers of AIDS Drugs Agree to Slash Prices in the Third World,” Wall Street Journal, May 11, 2000, p. Al.

32 The estimates provided later in this essay on the cost of financial assistance are predicated on these new developments in decreased drug pricing.

33 Theresa Agovino, “Delegate: AIDS Goal Too Ambitious,” Associated Press, June 25, 2001.

34 Arthur Kaplan, “Cheap Drugs Not Answer to African AIDS Crisis,” MSNBC, April 4, 2001; available at

35 Karen DeYoung, “UN to Commit to Plan of Action on AIDS; Diversity of Players, Urgency of Crisis May Complicate Focus of N.Y. Gathering,”Washington Post, June 24, 2001, p. A17.

36 Farmer, Paul et al. , “Community-Based Approaches to HIV Treatment in Resource-Poor Settings,” Lancet 358, No. 9279 (August 4, 2001), pp. 404409, and Harries, A. D. et al. , “Preventing Antiretroviral Anarchy in Sub-Saharan Africa,” Lancet 358, No. 9279 (August 4, 2001) pp. 410–14.

37 UNAIDS Press Release, “UNAIDS Calls on G8 for Massive Increase in Resources to Fight AIDS,” July 20, 2000; available at

38 For discussion of these estimates, see Eric Friedman and Paul Zeitz, “Estimating the Costs for an Expanded and Comprehensive HIV/AIDS Response in Sub-Saharan Africa” (Discussion Memorandum, March 28, 2001), and Individual Members of the Faculty of Harvard University, “Consensus Statement.”

39 Quoted in Joe Lauria, “AIDS Study Cites Dire African Need, $3 B Remedy,”Boston Globe, November 29, 2000.

40 Sachs, Jeffrey D., “A New Global Commitment to Disease Control in Africa,” Nature Medicine 7, No. 5 (May 2001), pp. 521–23.

41 See, for example, Lumsdaine, David H., Moral Vision in International Politics: The Foreign Aid Regime, 1949–1989 (Princeton: Princeton University Press, 1993); Noel, Alain and Therien, Jean-Philippe, “From Domestic to International Justice: The Welfare State and Foreign Aid,” International Organization 49, No. 3 (Summer 1995), pp. 523–53; and Imbeau, Louis-Marie, Donor Aid—The Determinants of Development Allocations to Third World Countries: A Comparative Analysis (New York: Peter Lang, 1989).

42 Singer, Peter, “Famine, Affluence, and Morality,” Philosophy and Public Affairs 1, No. 3 (Spring 1972), reprinted in William Aiken and Hugh LaFollette, eds., World Hunger and Morality, 2nd ed. (Upper Saddle River: Prentice Hall, 1996).

43 Ibid., pp. 27, 31, 28.

44 Ibid., p. 28.

45 Ibid., p. 33.

46 Shue, Henry, “Equity in an International Agreement on Climate Change,” in Samson Odingo, Richard et al. , eds., Equity and Social Considerations Related to Climate Change (Nairobi: ICIPE Science Press, 1995), p. 386.

47 These are some of the major examples. Others can be found, such as the obligation to provide humanitarian relief—and at times to even intervene militarily—in times of civic, ethnic, and interstate conflict. See, for example, Weiss, Thomas G. and Collins, Cindy, Humanitarian Challenges and Intervention (Boulder: West view Press, 1996); and Smith, Michael J., “Humanitarian Intervention: An Overview of the Ethical Issues,” in Rosenthal, Joel H., ed., Ethics and International Affairs: A Reader, 2nd ed. (Washington, D.C.: Georgetown University Press, 1999).

48 See, for example, Patrnogic, Jovica, “Some Reflections on Humanitarian Principles Applicable in Relief Actions,” in Swinarski, Christopher, ed., Studies and Essays on International Humanitarian Law (Geneva: Martinus Nijhoff Publications, 1984).

49 McElroy, Robert W., Morality and American Foreign Policy (Princeton: Princeton University Press, 1992), pp. 5787. See also Weissman, Benjamin M., Herbert Hoover and Famine Relief to Soviet Russia: 1921–1923 (Stanford: Hoover Institution Press, 1974).

50 When asked why he thought the United States was providing food aid to North Korea, that country's consul-general to Hong Kong, Ri To Sop, told one of us on June 11, 2001, “It's humanitarian,” and “Because we are human beings.” This is a profound assessment, given his country's animosity toward the United States government.

51 See Harris, Paul G., International Equity and Global Environmental Politics (Aldershot, UK: Ashgate, 2001).

52 FCCC, Preamble, Articles 3 and 4. For a more detailed discussion of the common but differentiated responsibility principle, see Harris, Paul G., “Common but Differentiated Responsibility: The Kyoto Protocol and United States Policy,” Environmental Law Journal 7, No. 1 (1999), pp. 2748; and Harris, International Equity and Global Environmental Politics.

53 The principle of common but differentiated responsibility was acknowledged by, inter alia, the UN General Assembly (see GA Resolution 44/228 [1989]) and several climate-related meetings, including: the Second World Climate Conference, meetings of the Preparatory Committee of the United Nations Conference on Environment and Development, the Toronto Conference Statement, the Hague Declaration, and the Noordwijk Declaration. See Philippe Sands, “The ‘Greening’ of International Law: Emerging Principles and Rules,”Global Legal Studies Journal 1, No. 2 (Spring 1994).

54 Intergovernmental Panel on Climate Change, “The Regional Impacts of Climate Change: An Assessment of Vulnerability,” Summary for Policymaker(1997); available at

55 Ponting, Clive, A Green History of the World (New York: St. Martin's Press, 1991), especially pp. 387–92 and 405–406.

56 Borione, Delphine and Ripert, Jean, “Exercising Common but Differentiated Responsibility,” in Mintzer, Irving M. and Leonard, J.A., eds., Negotiating Climate Change (Cambridge: Cambridge University Press, 1994), pp. 8384.

57 Cf. Group of Seven Industrialized Countries (G-7) and Russia, “Final Communique of the Denver Summit of the Eight,” Denver, July 22, 1997, paras. 14–17. See Harris, “Common but Differentiated Responsibility.”

58 Kofi Annan, “Address to the African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases,”Abuja, April 26, 2001; available at

* The authors wish to thank the editors and anonymous readers for their very helpful comments, and the international joint research program of the Center for Public Policy, Lingnan University, for facilitating research for this essay.

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International Obligation and Human Health: Evolving Policy Responses to HIV/AIDS

  • Paul G. Harris and Patricia Siplon


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