Global Health Unequal Distribution: The Need For Active Moral Imagination (Part 1)

Key Facts

The discovery of the structure of the DNA, in 1953, was the landmark of a new era that about fifty years later, Francis Collins, the director of the Human Genome Project, called the “genomic era” that has been affecting almost every aspect of human life. One of the most striking features of this new era has been an increasing awareness of the unequal distribution of wealth and health around the globe. In effect, during the last century, despite the tremendous explosion of knowledge and investment in science and technology, disparities in wealth and health within and between nations have been progressively widening.

Although the global economy has increased 7-fold since 1950, the disparity per capita gross domestic product (GPD) between the 20 richest and the 20 poorest nations has more than doubled. The global pyramid of wealth from 1997 to 2007 has showed that the inflation-adjusted incomes of the top 0.1% of the wage earners increased 390% in comparison with an increase of just 5% of the incomes of the bottom 99% of the earners.

In spite of unprecedented advances in science, technology and medicine, marked disparities in the distribution of global health are currently very apparent as some global health parameters eloquently indicate. Although worldwide life-expectancy has improved dramatically during the 20th century, recently this trend has been reversed in the poorest countries. In 2011 life expectancy was 80 years in Canada and in high-income countries, whereas in some sub-Saharan countries it was only 40 years. In addition, in 2004 South-East Asia and Africa together bore 54% of the total global burden of disease as measured by the disability-adjusted life year (DALYs) rate. In particular, premature mortality rates and years lost due to disability rates were respectively seven and eighty times higher in Africa than in high-income countries. Global infant mortality rate has decreased from 61 deaths per 1000 live births in 1990 to 37 in 2011. However, the risk of a child dying before completing the first year of age was about 6 times higher in the World Health Organization (WHO) African region than in the correspondent European one. In 2012 the maternal mortality ratio in developing countries is 240 per 100 000 births versus 16 per 100 000 births in developed countries. Ninety-nine percent of all maternal deaths occur in developing countries, in low-resource settings due to medical problems that could be easily prevented by providing access to antenatal and perinatal care and skilled care during childbirth. Within countries maternal mortality presents large variation between women with high and low income and between women living in rural and urban areas.

Due to modern advances in medical technology, in many industrialized countries the total expenditure in health as percentage of the GDP has been escalating rapidly. The United States alone spends more than 50% of the global health care expenditure for a population that accounts only for 5% of the world population. However, in some developing countries, especially in Sub-Saharan Africa, the proportion of GDP spent on health care has significantly decreased over the past 20 years.

Global Health

Due to the great variability of health distribution across and between countries global health has recently emerged as an important area of study, research and practice that addresses transnational health issues by identifying their determinants and suggesting workable solutions. In reality the notion of health across countries emerged in the 16th century in Europe when nation-states began to cooperate to control the spreading of epidemics, especially of plague. In the 19th century, during the European colonization period, the term “international health” was coined to indicate the ill conditions of the people living in the developing countries that could pose a serious medical threat to the European colonizers.

Then, in the 20th century the foundation of the major international institutions of health, the discovery of the impact of the social factors on individual and public health contributed to the broadening of the global health topics that have become increasingly interdisciplinary. In this respect, it is still under debate whether global health is to be equated to public health or whether it constitutes an autonomous entity. Some researchers argue that global health corresponds to the notion of public health since its main purpose consists of reducing the global burden of disease through the combination of population prevention policies and individual clinical care with a particular attention to the improvement of the health population in the developing countries. Harvey Fineberg and David Hunter in their recent editorial on the January issue of the New England Journal of Medicine have defined global health as “the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities and deaths”. This goal can be achieved by the combination of clinical care at the level of the individual person with health promoting and preventive population-based programs. On the other hand, an increasing consensus has gathered around the idea that global health aims not simply to reduce the worldwide disease burden, but also to improve the social, political and economic dimensions of human life. Therefore, global health has been progressively relying on the contribution of various disciplines outside biomedicine and public health that identify the causes of the current global economic, political, social and ecological instabilities. Increasing evidence has confirmed that one of the main factors implicated in the current world economic instability is the disjunction between a massive economic growth and a just distribution of economic and social benefits. This disjunction has been associated with the fact that the developed countries have valued global economic growth as an end in itself. In addition, wealthy nations have been continuously extracted financial, human and material resources from developing countries and have contributed to maintain the debt of poor countries at unbearable levels through trade protectionism and farming subsidies. Global political and social instabilities have been associated with wars, ethnic conflicts, genocides, large scale disruption of communities and people displacements, international terrorism, fragmentation of social services. From the human rights standpoint, both global political authorities and single nation-states have failed to guarantee the respect of political and civil rights along with the promotion of economic and social rights.

Finally, global ecological instability and unsustainability have been directly associated with environmental degradation, global warming, and loss of biodiversity that have contributed to the development of new infections and of a growing burden of chronic diseases in numerous countries. In short, the current dominant understanding of global health acknowledges that the global economic, political, social and environmental processes unequivocally impact health and healthcare and that various disciplines are to cooperate in the identification of workable solutions across the world.

Despite the lack of an unanimous definition of global health, many strategies have been designed for improving the health of all. They have been classified into

four main categories: 1. philanthropy from individuals, foundations and organizations; 2. long-term aid from affluent countries; 3. emergency humanitarian interventions and 4. expansion of the ethical discourse on global health.

The last category mainly appeals to moral imagination based on the assumptions that health inequalities pose ethical challenges to the global community and national and international responses should stem from the appreciation of the ethical aspects of human health. Ethical values, then, can assist to delineate principles, duties and responsibilities and to hold international and national institutions morally accountable for promoting the global common good. Though the reduction of global health inequalities has been directly associated with the promotion of global justice, the more fundamental challenge currently facing the national and international political and economic authorities is the configuration of a moral and anthropological framework compelling a more equitable distribution of health and health services between and within countries.

 

Recommended articles

 

  1. Fineberg HV, Hunter DJ.  A global view of health – An unfolding series. N Eng J Med 2013; 368: 78-79    

2.   World Health Organization. Data and statistics    http://www.who.int/research/en/  (accessed on 3-24-2013)

3.   Muray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013; 369: 448-457

4.   Benatar S, Upshur R. What is global health?  Pages 13-23 in Global Health and Global Health Ethics. Edited by Benatar S. and Brock G. Cambridge University Press: Cambridge, UK, 2011   

5.    Benatar SR, Gill S, Bakker I. Global health and the global economic crisis. Am J Public Health 2011;101:646-653

6.     Daniels N. International health inequalities and global justice: toward a middle ground. Pages 97-107 in Global Health and Global Health Ethics. Edited by Benatar S. and Brock G. Cambridge University Press: Cambridge, UK, 2011