South Africa’s Duty to Support Health Research for the Global Poor
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This thesis provides the first account of the duties middle-income countries have to the global poor. More specifically, it argues for South Africa’s duty to support health research for the global poor. In 1999 the South African AIDS Vaccine Initiative (SAAVI) was given the task of developing and testing an affordable, effective and locally relevant HIV vaccine for southern Africa. This mandate appears to imply that South Africa has an obligation to support health research for the broader African region i.e. an obligation beyond its borders. South Africa has the means to fulfil, at least part of, this obligation, since it is a hub for both internally and externally sponsored health research. This prompts two questions. First, does South Africa really have an obligation to support health research whose intended beneficiaries lie beyond its borders? After all, South Africa is not a rich country but a middle-income country. Second, if there is an obligation, how far does it extend? Many theories of global justice accept that very rich countries have some obligation to those who are poor. The global justice literature has, however, been silent on the duties of middle-income countries. South Africa, and countries like it, occupies a unique position that has been neglected in the global justice literature. A middleincome country might have significantly more resources and research capacity than low-income countries, but still struggles to meet internal needs that high-income countries have largely addressed. It is therefore not immediately apparent what the global justice duties of middle-income countries should be. To address this question, I first defend the assumption that, in most cases, prioritising investment in the worstoff1 is the fairest way to allocate scarce health research resources, since, in most cases, adhering to this principle also serves to maximise total health benefits and increase global health equality. I then argue that when fulfilling duties to the worstoff, neither political boundaries nor national allegiances are morally important, and should not be used to prioritise the needs of some over those of others. This is because the duty to the worst-off is a specific duty of rescue. This rescue duty is so pressing that it trumps justice duties and special duties to co-nationals. Recognizing this rescue duty essentially moves the worst-off outside our political borders inside our scope of moral concern. As a result, South Africa has equal duties to the worstoff both within and beyond its borders. Given that a middle-income country, with limited resources, is not able to assist all the worst-off, I suggest a morally defensible way to prioritise within this set. Prioritising the worst-off in sub-Saharan Africa is morally permissible because it will, in most cases, produce a larger overall benefit. South Africa’s duties to the worst-off in the region are therefore equal to its duties to its own citizens who are among the worst-off, and can be prioritised over duties to the worst-off elsewhere. My account offers a morally sound way for South Africa to prioritise limited health research resources while fulfilling its duties to the global poor. Further, to inform how South Africa can begin to fulfil its duties, I identify gaps in global health spending, with a focus on the poor. I outline which populations are likely to be representative of the world’s worst-off. I identify what types of health research, in which disease categories, are priorities for these populations, and which of these are the most underfunded. This evidence base informs how South Africa can begin to focus its health research activities and resources. I recommend “next steps” for South Africa; offer suggestions for data collection, and insights on the duties of middleincome countries more generally. Finally, since most of the time the fairest way to allocate scarce health research resources, is to prioritise investment in the worst-off, I analyse a selection of the World Health Organisation’s global health research priority-setting exercises to establish whether they adhere to this prioritarian principle. I recommend that future global health research priority setting exercises narrow the scope of their recommended health research priorities.