How is it Determined?

In the opening of the 1998 movie A Civil Action, John Travolta plays theCivil_Action_poster protagonist, an aggressive Boston attorney. The film and a book of the same name are based on a true story of a court case about environmental pollution of water that took place in Woburn, Massachusetts, in the 1980s. In the film Travolta states:

“It’s like this……A dead plaintiff is rarely worth as much as a severely maimed living plaintiff. However, if it is a long agonizing death, as opposed to a quick drowning, or a car wreck, the value can rise considerably. A dead adult in his 20s is generally worth less than one who is middle aged. A dead woman is worth less than a dead man. A single adult less than one married. A black worth less than a white. Poor less than rich. The perfect victim is a white male professional, 40 years old in the prime of life and at the height of his career. And the least important? Well, in the calculus of personal injury law, a dead child is worth the least of all.”

These are stinging worlds that test the ethics of economics, law, and issues of justice. They are also an indictment on who gets the attention of those who are entrusted with the welfare of vulnerable populations. The words seem eerily applicable to the circumstances of the lead contamination of the water supply in Flint. Michigan in relation to how lives were valued.

When it comes to Public Health it is not necessary to dig too deeply to find examples of vulnerable populations that are pushed to the bottom of the list of healthcare priorities whether in Flint or in resource poor countries. HIV/AIDS is a case in point. Women and children in resource poor countries who were poor and lacked political, economic, and social power failed to get the attention of those determining their healthcare. As if it were not enough to have to contend with local government bureaucracies, even international organizations seemed to turn a blind eye to their needs. While wealthy countries were rapidly moving ahead with the 1996 recommendations of the world’s AIDS experts to treat all HIV individuals with highly active antiretroviral therapy (HAART), WHO recommended that in poor countries only the sickest be treated. It was a lethal decision that resulted in millions of women and children becoming infected or dying from HIV.  For 20 years WHO and even some NIH supported clinical researchers engage in a massive Orwellian experiment—for the first time in the history of medicine, known beneficial treatment for an infectious disease was withheld until women and children got critically ill and chances of recovery were diminished. None of this happened in the United States. Individual physicians caring for their HIV-infected patients provided them with potent new treatment even when government guidelines failed to recommend it. As a result, infections and death from HIV plummeted while the epidemic in poor countries expanded. In wealthy countries, with the use of HAART, the number of newly infected infants declined drastically, dropping from thousands in the US to fewer than one hundred by the year 2000. Soon, some medical centers no longer saw any HIV-infected infants. In 2015, along with a CDC report of a 20-percent decline in new HIV infections in adults in the United, the San Francisco Public Health Department reported that there were no new HIV-infected infants there in the previous two decades.

It is necessary to speculate on what could have happened had WHO recommended treating all HIV infected individuals with highly active antiretroviral therapy (HAART) beginning in 1996.  Conservative estimates of the number of deaths that could have been prevented can be calculated from the WHO estimates of the number of women and children that were HIV infected each year since 1996. Official WHO publications put that number at approximately 600,000/year. Had HAART been initiated, after factoring in a 2 year delay in  implementation and a conservative  estimate of a 20% decrease in HIV related deaths each year for 18 years, approximately 2.2 million lives of women and children could have been spared agonizing AIDS related deaths.

Public Servant vs Public Official

Although the countries involved in the lead poisoning and the withholding of life saving drugs differed markedly, there were many conditions in common. In spite of the severity of the health threats, they were ignored. The populations affected were poor and politically and socially disadvantaged.  In both circumstances, those responsible for protecting the health of individuals had lost the concept of “public servant” responsible to all the people in their purview – they had morphed into “public official” ignoring certain segments of society.

Travolta’s listing of value of human life seems to be invisibly in effect. The calculus and the ethics of the true value of human life is that it should not be determined by race, economics, politics, religion, gender or age.


Lead Contamination in Flint–An Abject Failure to Protect Public Health. Bellinger DC. N Engl J Med. 2016 Mar 24;374(12):1101-3. doi: 10.1056/NEJMp1601013. Epub 2016 Feb 10. No abstract available.

2006. “Achievements in public health. Reduction in perinatal transmission of HIV infection–United States, 1985-2005.” MMWR Morb Mortal Wkly Rep 55 (21):592-7.

CDC 2015. “HIV Transmission Risk.”, November 16. Accessed December 15, 2015.

Buchbinder, Susan. 2015. “Number of infants HIV infected in San Francisco.” October 21, 2015

See also “Treat All” in this blog.