1 See, e.g., Jan M. Agosti & Sue J. Goldie, Introducing HPV Vaccine in Developing Countries — Key Challenges and Issues, 356 New Eng. J. Med. 1908, 1908 (2007); Silvina Arrossi et al., Social Inequality in Pap Smear Coverage: Identifying Under-Users of Cervical Cancer Screening in Argentina, 16 Reproductive Health Matters 50, 50 (2008); Sue J. Goldie et al., Health and Economic Outcomes of HPV 16, 18 Vaccination in 72 GAVI-Eligible Countries, 26 Vaccine 4080, 4080 (2008); A.E. Pollack et al., Cervical Cancer: A Call for Political Will, 94 Int’l. J. Gynecology & Obstetrics 333, 333 (2006); Vivien Tsu & Carol Levin, Making the Case for Cervical Cancer Prevention: What About Equity?, 16 Reproductive Health Matters 104, 104 (2008); Scott Wittet & Vivien Tsu, Cervical Cancer Prevention and the Millennium Development Goals, 86 Bull. World Health Org. 488, 488 (2008).

2 World Health Org., Comprehensive Cervical Cancer Control: A Guide to Essential Practice 18 (2005).

3 Id.

4 J. Ferlay et al., Int’l Agency for Research on Cancer, GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide (2004), http://wwwdep.iarc.fr/; D. Max Parkinet al., Global Cancer Statistics, 2002, 55 CA Cancer J. Clinicians 74, 78 (2005).

5 See supra note 4.

6 D. Maxwell Parkin & Freddie Bray, Chapter 2: The Burden of HPV-Related Cancers, 21 Vaccine S3/11, S3/12 (2006).

7 Nancy Krieger, Defining and Investigating Social Disparities in Cancer: Critical Issues, 16 Cancer Causes & Controls 5, 5 (2005).

8 See supra note 1.

9 While human rights obligations attach to all members of society, including individuals, the private business sector, intergovernmental and non-governmental actors, this article limits its analysis to considerations of the human rights obligations attaching to government.

10 A.J. Culyer & Adam Wagstaff, Equity and Equality in Health and Health Care, 12 J. Health Econ. 431, 432 (1993); Anthony J. Culyer, Equity - Some Theory and its Policy Implications, 27 J. Med. Ethics 275, 275 (2001).

11 Margaret Whitehead, The Concepts and Principles of Equity in Health, 22 Int’l J. Health Services 429 (1992).

12 Id. at 431.

13 This concept tracks the general principle of horizontal equity insofar as avoidable and unnecessary differences suggest that the disparities in health status are capricious or related to irrelevant characteristics. Culyer, supra note 10, at 276.

14 Paula Braveman, Health Disparities and Health Equity: Concepts and Measurement, 27 Ann. Rev. Pub. Health 167, 167 (2006) [hereinafter Braveman, Health Disparities]; Paula A. Braveman, Monitoring Equity in Health and Healthcare: A Conceptual Framework, 21 J. Health, Population, & Nutrition 181, 181 (2003) [hereinafter Braveman, Monitoring Equity]; P. Braveman & S. Gruskin, Defining Equity in Health, 57 J. Epidemiology & Community Health 254, 254 (2003) [hereinafter Braveman & Gruskin, Defining Equity]; Paula Braveman & Sofia Gruskin, Poverty, Equity, Human Rights and Health, 81 Bull. World Health Org. 539, 539 (2003) [hereinafter Braveman & Gruskin, Poverty].

15 Braveman, Health Disparities, supra note 12, at 168.

16 Braveman, Monitoring Equity, supra note 12, at 181; Braveman & Gruskin, Defining Equity, supra note 12, at 254.

17 Braveman, Monitoring Equity, supra note 12, at 181.

18 Id. at 182.

19 See, sources cited supra note 4.

20 See, sources cited supra notes 4, 6.

21 Seema Parikh et al., Meta-Analysis of Social Inequality and the Risk of Cervical Cancer, 105 Int’l J. Cancer 687, 688 (2003).

22 Id.

23 See id. at 687; see also Pollack et al., supra note 1, at 334 (noting that underreporting may result from an emphasis on maternal heath that prejudices older women); Rose Anorlu, Cervical Cancer: the sub-Saharan African Perspective, 16 Reproductive Health Matters 41, 42 (2008) (noting that underreporting is common in many areas of Africa); Emmanuela Gakidou et al., Coverage of Cervical Cancer Screening in 57 Countries: Low Average Levels and Large Inequalities, 5 Plos Med. 0864, 0867 (2008) (describing general problems with underreporting).

24 Barbara Starfield, Improving Equity in Health: A Research Agenda, Int’l J. Health Services 545, 547 (2001); Braveman, Health Disparities, supra note 14, at 171.

25 See Braveman, Monitoring Equity, supra note 12, at 188-90 (noting that equity is a matter of distributive justice); Braveman & Gruskin, Defining Equity, supra note 12, at 257 (noting that equity depends on the distribution and design of resources, policies, and programmes).

26 Braveman, Health Disparities, supra note 12, at 180. See also Braveman & Gruskin Poverty, supra note 12, at 540 (noting that government should seek to address health inequities not only through health policy, but through policy addressing the underlying conditions of social disadvantage, such as education, living standards and environment).

27 Pollack et al., supra note 1, at 337.

28 See generally Braveman & Gruskin, Defining Equity, supra note 12, at 255, for a discussion of avoidability in relation to health equity.

29 Braveman, Health Disparities, supra note 14, at 185.

30 J.M. Walboomers et al., Human Papillomavirus is a Necessary Cause of Invasive Cervical Cancer Worldwide, 189 J. Pathology 12, 18 (1999); Nubia Muñoz et al., Chapter 1:HPV in the Etiology of Human Cancer, 24S3 Vaccine S3/1, S3/1 (2006).

31 F. Xavier Bosch et al., Epidemiology and Natural History of Human Papillomavirus Infections and Type-Specific Implications in Cervical Neoplasia, 26S Vaccine K1, K2 (2008).

32 M. Stanley, Immune responses to human papillomavirus, 24S1 Vaccine 16 (2006).

33 This factor also includes the sexual behaviour of male partners. Women but not their male partners, for example, may be monogamous. Maribel Almonte, Risk factors for Human Papillomavirus Exposure and Co-Factors for Cervical Cancer in Latin America and the Caribbean, 26S Vaccine L16, L24 (2008).

34 World Health Org., supra note 2, at 35.

35 See, e.g., Parikh et al., supra note 19, at 689.

36 Id.; Lynette Denny, Prevention of Cervical Cancer, 16 Reproductive Health Matters 18, 19 (2008).

37 R. Sankaranarayanan et al., A Critical Assessment of Screening Methods for Cervical Neoplasia, 89 Int’l J. Gynecology & Obstetrics S4, S4-5 (2005).

38 Id. at S5; Lynette Denny, The Prevention of Cervical Cancer in Developing Countries, 112 BJOG: Int’l J. Obstetrics & Gynaecology 1204, 1204 (2005).

39 World Health Org., supra note 2, at 18; Gakidou, supra note 23, at 0863.

40 Braveman & Gruskin, Defining Equity, supra note 14, at 256; Braveman, Health Disparities, supra note 14, at 185.

41 Braveman & Gruskin, Defining Equity, supra note 14, at 254; Braveman, Health Disparities, supra note 14, at 182.

42 Braveman, Monitoring Equity, supra note 14, at 189.

43 In the literature, the principle of distributive justice that priority be given to the least advantaged in society is often referenced to the work of political philosopher John Rawls. See, e.g., Braveman, Health Disparities, supra note 14, at 183; W-C Chang, The Meaning and Goals of Equity in Health, 56 J. Epidemiology & Community Health 488, 489 (2002).

44 Rebecca J. Cook et al., Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law 151 (2003).

45 Braveman, Health Disparities, supra note 14, at 183; Braveman & Gruskin, Defining Equity, supra note 14, at 255; Braveman & Gruskin, Poverty, supra note 14, at 540.

46 International Covenant on Economic, Social and Cultural Rights, Dec. 16, 1966, 993 U.N.T.S. 3, (entered into force Jan. 3, 1976) [hereinafter CESCR].

47 Id. art. 12(1).

48 In this article, the term “right to equality” refers to both the right to equality and the right to non-discrimination.

49 CESCR, supra note 46, arts. 2.2, 3.

50 Convention on the Elimination of All Forms of Discrimination against Women art. 12, Dec. 18, 1979, 1249 U.N.T.S. 13 (entered into force Sept. 3, 1981).

51 Id. art. 12(1).

52 U.N. bodies that monitor States parties’ compliance with international human rights conventions issue General Comments or General Recommendations, which are authoritative commentary on aspects related to specific articles in the conventions. This commentary is intended to assist States parties in complying with their obligations under the Conventions.

53 U.N. Comm. on Econ., Soc. and Cultural Rights, General Comment No. 14. The Right to the Highest Attainable Standard of Health, UN doc E/C.12/2000/4 (Aug. 11, 2000) [hereinafter General Comment No. 14].

54 U.N. Comm. on the Elimination of all Forms of Discrimination against Women, General Recommendation No. 24: Women and Health, UN Doc. A/54/38/Rev.1 (1999) [hereinafter General Recommendation No. 24].

55 Braveman, Health Disparities, supra note 14, at 184; see also Braveman & Gruskin Defining Equity, supra note 14, at 254.

56 General Comment No. 14, supra note 53, ¶ 7. “There are a number of aspects which cannot be addressed solely within the relationship between States and individuals; in particular, good health cannot be ensured by a State, nor can States provide protection against every possible cause of human ill health.” Id. ¶ 9.

57 Id. ¶ 8 (emphasis added).

58 General Recommendation No. 24, supra note 54, ¶ 17 (emphasis added).

59 General Comment No. 14, supra note 53, ¶ 9.

60 Id. ¶ 12.

61 Id. ¶ 12(a) and (d).

62 Id. ¶ 12(b).

63 Id.

64 Id.

65 Id. ¶ 12(c).

66 Id. ¶ 19.

67 Id. ¶ 18.

68 Id. ¶ 19; see also General Recommendation No. 24, supra note 54, ¶ 22.

69 General Recommendation No. 24, supra note 54, ¶¶ 6, 12(b).

70 Id. ¶ 22.

71 Gakidou et al., supra note 23, at 0864.

72 Id. at 0865.

73 The term “coverage” refers to “the proportion of women in the target age group who are screened at the recommended intervals during a given time period. The number of screening tests done is not coverage, since this number may include women outside the target age, and women screened more often than recommended.” World Health Org., supra note 2, at 83.

74 Id. at 18; Lynette Denny et al., Screening for Cervical Cancer in Developing Countries, 24S3 Vaccine S3/71, S3/71-72 (2006).

75 Gakidou et al., supra note 23, at 0863.

76 World Health Org., supra note 2, at 16.

77 See, e.g., Arrossi & Goldie, supra note 1, at 51; Denny, supra note 36, at 19.

78 See Silvana Luciani & Jon Kim Andrus, A Pan American Health Organization Strategy for Cervical Cancer Prevention and Control in Latin America and the Caribbean, 16 Reproductive Health Matters 59, 64 (2008) (Stating the utilization rates for indigenous women).

79 Mary Kawonga & Sharon Fonn, Achieving Effective Cervical Screening Coverage in South Africa through Human Resources and Health Systems Development, 16 Reproductive Health Matters 32, 32-33 (2008).

80 General Comment No. 14, supra note 53, ¶ 12(b); see also N. Wellensiek et al., Knowledge of Cervical Cancer Screening and Use of Cervical Screening Facilities among Women from Various Socioeconomic Backgrounds in Durban, Kwazulu Natal, South Africa, 12 Int’l J. Gynecological Cancer 376, 377 (2002).

81 World Health Org., supra note 2, at 20.

82 J. Bradley et al., Widening the Cervical Cancer Screening Net in a South African Township: Who are the Underserved?, 25 Health Care Women Int’l 227, 238 (2004).

83 V. Lorant et al., Equity in Prevention and Health Care, 56 J. Epidemiology & Community Health 510, 515 (2002).

84 Id.

85 Id. at 514-15.

86 Carlos A. Reyes-Ortiz et al., Health Insurance and Cervical Cancer Screening Among Older Women in Latin American and Caribbean Cities, 37 Int’l J. Epidemiology 870, 874-76 (2008).

87 Tsu & Levin, supra note 1, at 105, 107.

88 World Health Org., supra note 2, at 84.

89 Pollack, supra note 1, at 334.

90 Arrossi, supra note 1, at 54.

91 World Health Org., supra note 2, at 19; Arrossi et al., supra note 1, at 51; see also Pollack et al., supra note 1, at 334.

92 See C. Elias & J. Sherris, Reproductive and Sexual Health of Older Women in Developing Countries, 327 BMJ 64, 64-65 (2003).

93 Id. at 64.

94 World Health Org., supra note 2, at 88.

95 General Recommendation No. 24, supra note 54, ¶ 12(d).

96 World Health Org., supra note 2, at 48.

97 M.M. Watkins et al., Barriers to Cervical Cancer Screening in Rural Mexico, 12 Int’l J. Gynecological Cancer 475, 477 (2002).

98 World Health Org., supra note 2, at 91.

99 Braveman & Gruskin, Poverty, supra note 14, at 541. General Comment No. 14 further notes that the right to health includes certain components which are legally enforceable in national jurisdictions through domestic law including constitutional rights to equality and non-discrimination. General Comment No. 14, supra note 53, ¶ 1.

100 Denny et al., supra note 82, at S3/71-72.

101 See, e.g., Denny et al., supra note 36, at 18.

102 CESCR, supra note 4, art. 2.1; General Comment No. 14, supra note 53, ¶ 53.

103 General Comment No. 14, supra note 53, ¶ 53.

104 A.E. Pollack and V.D. Tsu, Preventing Cervical Cancer in Low-Resource Settings: Building a Case for the Possible, 89 Int’l J. Gynecology & Obstetrics S1, S1 (2005).

105 Denny, supra note 74, at S371; Sue J. Goldie et al., Cost-Effectiveness of Cervical- Cancer Screening in Five Developing Countries, 353 N. Eng. J. Med. 2158, 2158 (2005); Sankaranarayanan et al., supra note 42, at S8 (2005).

106 Denny, supra note 74, at S3/73-74.

107 Goldie et al., supra note 105, at 2167.

108 Luciani & Andrus, supra note 78, at 61-62; Tsu & Levin, supra note 1, at 108.

109 Gary Clifford et al., Chapter 3: HPV Type-Distribution in Women with and without Cervical Neoplastic Diseases, 24S Vaccine S26, S27 (2006).

110 Anna Koulova et al., Country Recommendations on the Inclusion of HPV Vaccines in National Immunization Programmes among High-Income Countries, June 2006–January 2008, 26 Vaccine 6529, 6534 (2008).

111 F.X. Bosch et al., HPV and Cervical Cancer: Screening or Vaccination?, 98 British J. Cancer 15, 16 (2008); Mark A. Kane et al., Chapter 15: HPV Vaccine Use in the Developing World, 24S Vaccine S132, S135 (2006).

112 Sue J. Goldie et al., Benefits, Cost Requirements and Cost-Effectiveness of the HPV 16, 18 Vaccine for Cervical Cancer Prevention in Developing Countries: Policy Implications, 16 Reproductive Health Matters 86, 93 (2008). The projection is based on making an HPV 16, 18 vaccine accessible to 70% of young adolescent girls in the 72 GAVI-eligible countries (countries with a Gross National Income (GNI) per capita below US $1,000 in 2003) and non- GAVI eligible countries in the Latin American and Caribbean region as well as China and Thailand. GAVI-eligibility refers to eligibility for technical assistance and financial support from the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization), a partnership of national governments, research and technical health institutes, the World Health Organization, the World Bank, UNICEF, the Bill & Melinda Gates Foundation, the vaccine industry, and civil society organizations. Id.

113 These obligations and much of the related analysis in Part II can be equally applied to low-technology non-cytologic screening methods.

114 See Davidson R. Gwatkin et al., Making Health Systems More Equitable, 364 Lancet 1273, 1277 (2004).

115 Fatima Alvarez-Castillo et al., Priority Setting, in The Right Reforms? Health Sector Reforms and Sexual and Reproductive Health 137, 139-140 (T.K. Sundri Ravindarn & Helen de Pinho eds., 2005).

116 Id. 168.

117 CESCR, supra note 46, art. 12.2.

118 CESCR, supra note 41, art. 12.2(c).

119 CESCR, supra note 41, art. 12.2(d).

120 General Comment No. 14, supra note 53, ¶ 43(a),(e).

121 See FE Andre et al., Vaccination Greatly Reduces Disease, Disability, Death and Inequity Worldwide, 86 Bull. World Health Org. 140, 143 (2008).

122 General Comment No. 14, supra note 53, ¶ 16.

123 Id. ¶ 17.

124 Id. ¶ 16.

125 Id. ¶ 43(f).

126 Id. ¶ 20; General Recommendation No. 24, supra note 54, ¶¶ 24, 31.

127 General Comment No. 14, supra note 53, ¶ 34.

128 General Recommendation No. 24, supra note 54, ¶ 30.

129 Id. ¶ 29.

130 Braveman, Monitoring Equity, supra note 14, at 185.

131 Fatima Alvarez-Castillo et al., supra note 130 at 138.

132 Richard T. Mahoney & James E. Maynard, The Introduction of New Vaccines into Developing Countries, 17 Vaccine 646, 648 (1999).

133 See, e.g., Sue J. Goldie et al., Health and Economic Outcomes of HPV 16, 18 Vaccination in 72 GAVI-Eligible Countries, 26 Vaccine 4080, 4080 (2008).

134 Gauri, Varun & Khaleghian, Peyvand, Immunization in Developing Countries: Its Political and Organizational Determinants, 30 World Dev. 2109, 2110 (2002);CrossRefGoogle Scholar Hausdorff, W.P., Prospects for the Use of New Vaccines in Developing Countries: Cost is Not the Only Impediment, 14 Vaccine 1179, 1182 (1996).CrossRefGoogle Scholar

135 Mahoney & Maynard, supra note 132, at 648.

136 World Health Org., supra note 2, at 20; Jennifer L. Winkler et al., Determinants of Human Papillomavirus Vaccine Acceptability in Latin America and the Caribbean, 26S Vaccine L73, L73 (2008).

137 Walraven, Gijs et al., The Silent Burden of Gynecological Disease in Low Income Countries, 112 BJOG: Int’l J. Obstetrics & Gynecology 1177, 1177 (2005).CrossRefGoogle ScholarPubMed

138 World Health Org., supra note 2, at 19.

139 Alvarez-Castillo et al., supra note 131, at 138-39.

140 Braveman, Monitoring Equity, supra note 12, at 184.

141 Elias & Sherris, supra note 88, at 64.

142 Reichenbach, Laura, The Politics of Priority Setting for Reproductive Health: Breast and Cervical Cancer in Ghana, 10 Reproductive Health Matters 47, 55-56 (2002)CrossRefGoogle ScholarPubMed; Winkler et al., supra note 125, at L76, L77.

143 George, Asha, Using Accountability to Improve Reproductive Health Care, 11 Reproductive Health Matters 161, 165 (2003).CrossRefGoogle ScholarPubMed

144 See Alvarez-Castillo et al., supra note 131, at 138.

145 See id. at 155-56.

146 See id. The term benefit does not refer to the therapeutic value of the intervention, its effect on the health status of social groups, but service utilization or the monetary value of the intervention. Benefit-incidence analysis, which combines measures of the cost of health services with information on utilization distribution, is the equity analogue of cost-effective analysis for efficiency. Gwatkin, Davidson R., 10 Best Resources on … Health Equity, 22 Health Pol’y & Plan 348, 349 (2007)CrossRefGoogle Scholar.

147 Cesar G. Victora et al., Explaining Trends in Inequities: Evidence from Brazilian Child Health Studies, 356 Lancet 1093, 1098 (2000); Gwatkin, supra note 112, at 1276 (2004).

148 J. Tudor Hart, The Inverse Care Law, 297 Lancet 405, 405-12 (1971); Victoria et al., supra note 147, at 1093.

149 Victora et al., supra note 147, at 1093.

150 Id.

151 Id.; Gwatkin et al., supra note 114, at 1276.

152 See Bosch et al., supra note 126 at 17; E.L. Franco, Health Inequity Could Increase in Poor Countries if Universal HPV Vaccination is Not Adopted, 335 BMJ 378, 378 (2007); Kane et al., supra note 126 at S132.

153 Mahoney & Maynard, supra note 132, at 646.

154 See, e.g., Efren J. Domingo et al., Epidemiology and Prevention of Cervical Cancer in Indonesia, Malaysia, the Philippines, Thailand and Vietnam, 26S Vaccine M71, M77-78 (2008).

155 Koulova et al., supra note 125 at 6530.

156 Kane et al., supra note 152, at S135; Mahoney & Maynard, supra note 132, at 646.

157 Mahoney & Maynard, supra note 132, at 646.

158 Gwatkin et al., supra note 114, at 1276.

159 Koulova et al., supra note 155, at 6534.

160 Gwatkin et al., supra note 114, at 1276.

161 General Comment No. 14, supra note 53, ¶ 33; see also id. ¶ 53 (noting that individualized national strategies will have to be developed).

162 General Recommendation No. 24, supra note 54, at ¶ 17.

163 U.N. Comm. on Econ., Soc. & Cultural Rights, General Comment No. 3. The Nature of States Parties’ Obligations, ¶ 4 UN Doc. E/1991/23 (1990), [hereinafter General Comment No. 3]; see General Comment No. 14, supra note 53, ¶ 53.

164 General Comment No. 3, supra note 163, ¶ 4.

165 General Recommendation No. 24, supra note 54, at ¶ 9.

166 Id. at ¶ 12.

167 Agosti & Goldie, supra note 1, at 1909.

168 See Franco, supra note 152, at 379; Rengaswamy Sankaranarayanan et al., Human Papillomavirus Infection and Cervical Cancer Prevention in India, Bangladesh, Sri Lanka and Nepal, 26S Vaccine M43, M48 (2008).

169 General Comment No. 14, supra note 53, ¶ 47.

170 General Comment No. 3, supra note 163, ¶ 13.

171 See Jon Kim Andrus et al., Introduction of Human Papillomavirus Vaccines into Developing Countries - International Strategies for Funding and Procurement, 26S Vaccine K87, K92 (2008).

172 CESCR, supra note 46, art. 2.1; General Comment No. 14, supra note 53, ¶ 38.

173 General Comment No. 14, supra note 53, ¶ 33.

174 General Recommendation No. 24, supra note 49, ¶ 22.

175 See Winkler et al., supra note 125, at L76-77.

176 Richard K. Zimmerman, Ethical Analysis of HPV Vaccine Policy Options, 24 Vaccine 4812, 4814 (2006).

177 Agosti & Goldie, supra note 1, at 1908; Gauri & Khaleghian, supra note 134, at 2113; Kane et al., supra note 152, at 138; Mark Nichter, Vaccinations in the Third World: A Consideration of Community Demand, 41 Soc. Sci. & Med. 617, 618 (1995).

178 General Recommendation No. 24, supra note 54, ¶ 18.

179 Domingo et al., supra note 140, at M77-78; Sankaranarayanan et al., supra note 153, at M48; Winkler et al., supra note 125, at L77.

180 General Comment No. 14, supra note 53, ¶ 36; General Recommendation No. 24, supra note 54, ¶ 18.

181 General Comment No. 14, supra note 53, 44(d).

182 See Domingo et al., supra note 154, at M77.

183 Agosti et al., supra note 1, at 1908-09; Domingo et al., supra note 154, at M78; Jane Harries et al., Preparing for HPV Vaccination in South Africa: Key Challenges and Opinions, 27 Vaccine 38, 41 (2009); Kane et al., supra note 152, at 135; Amy E. Pollack et al., Ensuring Access to HPV Vaccines through Integrated Services: A Reproductive Health Perspective, 85 Bull. World Health Org. 57, 60 (2007).

184 Agosti & Goldie, supra note 1, at 1908-09; Pollack et al., supra note 168, at 60; Winkler et al., supra note 125, at L75.

185 General Recommendation No. 24, supra note 54, ¶ 31(b).

186 Denny, supra note 43 at 1210.

187 Anne-Emanuelle Birn, Gates's Grandest Challenge: Transcending Technology as Public Health Ideology, 266 Lancet 514, 515 (2005).

188 See Nancy Krieger, Proximal, Distal, and the Politics of Causation: What's Level Got to Do with It?, 98 Am. J. Pub. Health 221, 227 (2008).

189 Mahoney & Maynard, supra note 132, at 651.

190 Gwatkin et al., supra note 114, at 1279-80.