resources needed to ensure compliance with core obligations are available
even in resource-limited settings; meaning—and this is very striking—that
this is not one of those circumstances where defaulting countries could
unabashedly hide under the veneer of poverty. In essence, therefore, the most
appropriate way to explain the existence of large fistula cases in many third
world countries is to cast it as reflective of pursuit of measures that are
incompatible with core obligations, a violation of the right to health.177
This violation extends to underlying or social determinants of health—that
is, “socio-economic factors that promote conditions in which people can lead
a healthy life,”178 such as access to safe and potable water and adequate
sanitation, an adequate supply of safe food, nutrition and housing, healthy
occupational and environmental conditions, and access to health-related
education and information, including on sexual and reproductive health.179
The list is not exhaustive, and includes “adequate sanitation facilities,
hospitals, clinics and other health-related buildings, trained medical and
professional personnel receiving domestically competitive salaries, and
essential drugs, as defined by the WHO Action Programme on Essential
Drugs.”180 It is noteworthy that the items recognized as social health
determinants share striking similarity with those identified as core
obligations or of comparable priority181—meaning that the preceding
analysis regarding core obligations and their violation apply with equal force
to social health determinants.182 The key, therefore, is to think of the
pathology presenting as fistula as symptomatic of deficit of serious
commitment to human rights, persistent failure on the part of political
leadership in those countries to deploy resources that could have
reinvigorated and revamped ailing health systems.183
“To meet only one of these mothers is to be profoundly moved. Mourning
the stillbirth of their only baby, incontinent of urine, ashamed of their
177. General Comment No. 14, supra note 143, ¶ 48.
178. Id. ¶ 4.
179. Id. ¶¶ 4, 11.
180. Id. ¶ 12.
181. See id. ¶ 43-44.
182. See generally COMM’N ON SOC. DETERMINANTS OF HEALTH, WORLD HEALTH ORG.,
CLOSING THE GAP IN A GENERATION: HEALTH EQUITY THROUGH ACTION ON THE SOCIAL
DETERMINANTS OF HEALTH (2008), available at http://apps.who.int/iris/bitstream/
10665/43943/1/9789241563703_eng.pdf (providing an in-depth discussion of the concept of
underlying determinants of health).
183. See WORLD HEALTH ORG., THE WORLD HEALTH REPORT 2000: HEALTH SYSTEMS:
IMPROVING PERFORMANCE 152-55 (2000), available at http://www.who.int/whr/2000/en/
whr00_en.pdf (providing evidence in a finding which shows that in terms of health system
attainment and performance, these very health systems rank in the bottom vis-à-vis others).