Global Health and Global Health Ethics

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Global Health and Global
Health Ethics
Edited by
Solomon Benatar
Emeritus Professor of Medicine, University of Cape Town
Professor, Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Canada

Gillian Brock
Associate Professor of Philosophy, University of Auckland, New Zealand
c a m brid ge universit y press
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Cambridge University Press
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Global health and global health ethics / [edited by] Solomon Benatar, Gillian Brock.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-521-14677-7 (pbk.)
1. World health. 2. Public health–Moral and ethical aspects. I. Benatar, S. R. II. Brock, Gillian.
III. Title. [DNLM: 1. World Health. 2. Healthcare Disparities. 3. International Cooperation.
4. Public Health–ethics. WA 530.1]
RA441.G566 2011
362.1–dc22 2010042733

ISBN 978-0-521-14677-7 Paperback

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Contents

List of contributors page vii

Introduction 1 8 International health inequalities and global

justice: toward a middle ground 97
Norman Daniels
Section 1. Global health, definitions
9 The human right to health 108
and descriptions 11 Jonathan Wolff
1 What is global health? 13
10 Responsibility for global health 119
Solomon Benatar and Ross Upshur
Allen Buchanan and Matthew DeCamp
2 The state of global health in a radically
unequal world: patterns and prospects 24 11 Global health ethics: the rationale for mutual
caring 129
Ronald Labonté and Ted Schrecker
Solomon Benatar, Abdallah S. Daar and
3 Addressing the societal determinants of Peter A. Singer
health: the key global health ethics imperative
of our times 37
Anne-Emanuelle Birn
Section 3. Analyzing some reasons
for poor health 141
4 Gender and global health: inequality and
differences 53 12 Trade and health: the ethics of global rights,
Lesley Doyal and Sarah Payne regulation and redistribution 143
Meri Koivusalo
5 Health systems and health 63
Martin McKee 13 Debt, structural adjustment and health 155
Jeff Rudin and David Sanders

Section 2. Global health ethics, 14 The international arms trade and global
health 166
responsibilities and justice: some central Salahaddin Mahmudi-Azer
issues 75
15 Allocating resources in humanitarian
6 Is there a need for global health ethics? For medicine 173
and against 77 Samia A. Hurst, Nathalie Mezger and
David Hunter and Angus J. Dawson Alex Mauron

7 Justice, infectious diseases and 16 International aid and global health 184
globalization 89 Anthony B. Zwi
Michael J. Selgelid

v
 Contents

17 Climate change and health: risks and 24 Global health research: changing the
inequities 198 agenda 285
Sharon Friel, Colin Butler and Tikki Pang
Anthony McMichael
25 Justice and research in developing
18 Animals, the environment and global countries 293
health 210 Alex John London
David Benatar
26 Values in global health governance 304
19 The global crisis and global health 221 Kearsley A. Stewart, Gerald T. Keusch
Stephen Gill and Isabella Bakker and Arthur Kleinman

27 Poverty, distance and two dimensions of

Section 4. Shaping the future 239 ethics 311
Jonathan Glover
20 The Health Impact Fund: how to make new
medicines accessible to all 241 28 Teaching global health ethics 319
Thomas Pogge James Dwyer

21 Biotechnology and global health 251 29 Towards a new common sense: the need for
Hassan Masum, Justin Chakma and new paradigms of global health 329
Abdallah S. Daar Isabella Bakker and Stephen Gill

22 Food security and global health 261

Lynn McIntyre and Krista Rondeau
Index 333
23 International taxation 274
Gillian Brock

vi
Contributors

Isabella Bakker Angus J. Dawson

Department of Political Science, York University, Centre for Professional Ethics,
Toronto, Ontario, Canada. Keele University, Staffordshire, UK.
David Benatar Matthew DeCamp
Philosophy Department, University of Cape Town, Department of Internal Medicine, University
South Africa. of Michigan Ann Arbor, MI, USA.
Solomon Benatar Lesley Doyal
Bioethics Center, University of Cape Town, South School for Policy Studies, University of Bristol,
Africa and Joint Centre for Bioethics, University of Bristol, UK.
Toronto, Toronto, Ontario, Canada
James Dwyer
Anne-Emanuelle Birn Center for Bioethics and Humanities, SUNY Upstate
Dalla Lana School of Public Health, University of Medical University, Syracuse, NY, USA.
Toronto, Toronto, ON, Canada.
Sharon Friel
Gillian Brock National Center for Epidemiology and
Department of Philosophy, University of Auckland, Population Health, Australian National University,
Auckland, New Zealand. Canberra, ACT, Australia.
Allen Buchanan Stephen Gill
Institute for Genome Sciences and Policy, Department of Political Science, York University,
Duke University, Durham, NC, USA. Toronto, Ontario, Canada.
Colin Butler Jonathan Glover
National Centre for Epidemiology and Population Centre of Medical Law and Ethics,
Health, Australian National University, Kings College London, Strand, London,
Canberra, ACT, Australia. UK.
Justin Chakma David Hunter
McLaughlin-Rotman Centre for Global Health, Centre for Professional Ethics, Keele University,
Toronto, Ontario, Canada. Staffordshire, UK.
Abdallah S. Daar Samia A. Hurst
McLaughlin-Rotman Centre for Global Health, Institute for Biomedical Ethics, Geneva University
University Health Network and University of Toronto, Medical School, Switzerland.
Toronto, Ontario, Canada.
Gerald T. Keusch
Norman Daniels Department of International Health and Center for
Department of Global Health and Population, Global Health and Development, Boston University,
Harvard School of Public Health, Boston, MA, USA.
Boston, MA, USA.

vii
 List of contributors

Arthur Kleinman Thomas Pogge

Department of Anthropology, Harvard University and Philosophy and International Affairs, Yale University,
Department of Global Health and Social Medicine, New Haven, CT, USA.
Harvard Medical School, Cambridge, MA, USA.
Krista Rondeau
Meri Koivusalo Department of Community Health Sciences, Faculty
National Institute for Health and Welfare, Helsinki, of Medicine, University of Calgary, Calgary, AB,
Finland. Canada.
Ronald Labonté Jeff Rudin
Department of Epidemiology and Community South African Municipal Workers’ Union, Cape
Medicine, Institute of Population Health, University Town, South Africa.
of Ottawa, Ottawa, Ontario, Canada.
David Sanders
Alex John London School of Public Health, University of the Western
Center for the Advancement of Applied Ethics and Cape, Bellville, South Africa.
Political Philosophy, Department of Philosophy,
Ted Schrecker
Carnegie Mellon University, Pittsburg, PA, USA.
Department of Epidemiology and Community
Salahaddin Mahmudi-Azer Medicine, Institute of Population Health, University
Department of Medicine, University of Calgary, of Ottawa, Ontario, Canada.
Calgary, Alberta, Canada.
Michael J. Selgelid
Hassan Masum Centre for Applied Philosophy and Public Ethics
McLaughlin-Rotman Centre for Global Health, (CAPPE), The Australian National University,
Toronto, Ontario, Canada. Canberra, Australia.
Alex Mauron Peter A. Singer
Institute for Biomedical Ethics, Geneva University McLaughlin-Rotman Centre for Global Health,
Medical School, Switzerland. University Health Network and University of Toronto,
Toronto, Ontario, Canada.
Lynn McIntyre
Department of Community Health Sciences, Faculty Kearsley A. Stewart
of Medicine, University of Calgary, Calgary, Alberta, Harvard Centre for Population and
Canada. Development Studies, Cambridge, MA, USA and
Department of Anthropology and Global Health
Martin McKee
Studies Program, Northwestern University,
London School of Hygiene and Tropical Medicine, Evanston, IL, USA.
London, UK.
Ross Upshur
Anthony McMichael
Joint Centre for Bioethics, University of Toronto,
National Centre for Epidemiology and Population Toronto, Ontario, Canada.
Health, Australian National University,
Canberra, ACT, Australia. Jonathan Wolff
Department of Philosophy, University College
Nathalie Mezger
London, London, UK.
MSF-CH Administrative Board, MSF-Switzerland.
Anthony B. Zwi
Tikki Pang
School of Public Health and Community Medicine,
Research Policy and Cooperation (RPC/IER), World The University of New South Wales, Lindfield, NSW,
Health Organization, Geneva, Switzerland. Australia.
Sarah Payne
School for Policy Studies, University of Bristol,
Bristol, UK.
viii
Introduction

The raison d’être for this book is to draw attention to emphasis on serving patients optimally and sustaining
what we consider to be one of the largest and most the professionalism required of health-care workers in
important challenges facing humanity in the twenty- the care of patients and the training of new generations
first century – to improve and promote global health. of professionals. Finally, marginal benefits for a few are
By global health we mean the health of all people glo- often prioritized while other cost-effective activities
bally within sustainable and healthy living (local and of potentially great benefit to many more people are
global) conditions. In order to achieve this ambitious ignored. Within limited resource environments, such
goal we need to understand, among other things, the strategies that contribute to costs of health care rising
value systems, modes of reasoning, and power struc- disproportionately are likely to prove unsustainable.
tures that have driven and shaped the world over the Disparities in health and in access to health care thus
past century. We also need to appreciate the unsustain- continue to widen globally. Such disparities, combined
ability of many of our current consumption patterns with population growth, unsustainable consumption
before we can address threats to the health and lives of patterns, the emergence of many new infectious dis-
current and future generations. eases (and multi-drug resistance), escalating ecologi-
The world and how we live in it have been changing cal degradation, numerous local and regional wars, a
dramatically over many centuries, but in the past fifty stockpile of nuclear weapons, massive dislocations of
years change has been more rapid and profound than people and new terrorist threats (to list just a few rel-
ever in the past. Many positive changes have been asso- evant factors) have severe implications for individu-
ciated with impressive economic growth, advances in als’ and populations’ health. Deeper understanding of
science and medicine and in social policies regarding the challenges we face and of the feasible changes that
access to health promotion. These include more equit- could be made to address these, are necessary first steps
able access to primary care, greater focus on a primary towards expressing better commitment to genuine
health-care approach, expansion of social programs to respect for the dignity of all people (and, indeed, show-
improve living conditions and a welcome increasing ing respect for everyone’s dignity is an ideal our inter-
emphasis on the rights of all individuals to be equally national agreements increasingly claim to embrace).
respected. Adequate understanding of ethical issues con-
Sadly, emphasis on the exaggerated expectations cerning health requires that we extend our focus from
of the most privileged people has resulted in neglect the micro-level of individual health and the ethics of
of a large proportion of the world’s population with interpersonal relationships to include ethical consid-
consequent widening disparities in wealth and health. erations regarding public and population health, and
In addition many of the world’s health-care “systems” justice concerns more generally. The domain of global
have become distorted, dysfunctional, and unsustain- health ethics provides a context within which the many
able. By distorted we mean that health-care services are relevant disciplines that have valuable insights to offer
not designed to meet the range of demands posed by can usefully engage, and through that engagement
local burdens of disease equitably. They are dysfunc- promote better understanding of the extensive changes
tional because they are driven more by adverse market that are needed. Furthermore, developing a global state
forces and the requirements of bureaucracy, than by of mind about the world, and our place in it, is arguably

Global Health and Global Health Ethics, ed. Soloman Benatar and Gillian Brock. Published by Cambridge University Press.
© Cambridge University Press 2011.
1
 Introduction

relevant to making many of the necessary, progressive about the adverse effects of focusing on short-term
changes. economic gains.
After noting the poor state of global health, there Probably the most striking feature about the state of
are three main issues covered by almost all contrib- global health is that it is characterized by such radical
uting authors. They direct our attention to ways inequalities. Here is just a sample of the more widely
in which we exacerbate poor global health, what noticed and documented kinds. Life expectancy at
we should do to remedy the factors identified, and birth varies enormously: from around 40 years in
offer reasons why we ought to do something about Sierra Leone or Afghanistan to twice that at more than
the highlighted problems, thereby connecting glo- 80 years for those lucky enough to be born in Japan or
bal health issues more strongly with the domain of Australia. Similarly, there is huge variation in maternal
justice. Many of the chapters in this volume provide mortality. A Canadian woman’s lifetime risk of dying
constructive suggestions about how national and from childbirth or pregnancy complications is 1 in
global policy and institutional changes could func- 11 000, whereas for a woman in the Niger it is 1 in 7.
tion differently to make significant improvements. Whereas malaria is almost entirely absent in high-
Together they contribute to a deeper understanding income countries, it kills around a million people each
of the challenges we face in trying to improve global year elsewhere.
health and provide much practical and theoretical As Ronald Labonté and Ted Schrecker observe,
guidance, which builds a case for our ability to make a largely accurate explanation for these types of dif-
a real difference if we so choose. ferences involves potentially avoidable poverty and
In what follows we give a brief synopsis of the material deprivation. However, these authors remind
chapters. A note about structure might be important us that we should resist the inference that policies that
here. Because almost all the authors cover the issue of promote economic growth are therefore the best way
responsibilities and global health, it has been difficult to achieve good population health. There is a thresh-
to impose a rigid structure on these chapters and the old level, at about $5000 (US), beyond which the rela-
subsections of the book. Like the subject matter under tionship between life expectancy at birth and per capita
investigation, several issues are intimately linked. incomes breaks down. In addition we see many coun-
tries with very good life expectancies at birth despite
Global health, definitions and quite low per capita incomes. For example in Costa
Rica, with per capita income of about $10 500 per year,
descriptions life expectancy is 79, notably more than the 78 years
Solomon Benatar and Ross Upshur pose many ques- those who reside in the USA can expect to live, where
tions about the term “global health” and what it means per capita income is greater than $45 000.1 Other social
to different people. They analyze various conceptions changes besides economic growth can have signifi-
of, and perspectives on, global health, and show how cant consequences for health. For example, improved
these can influence the focus of action for improve- female literacy and commitment to health as a social
ments. They also draw particular attention to two goal in Kerala (in India) have resulted in low infant
human-created problems (drug-resistant tuberculosis and maternal mortality despite very low income (per
and poor water management in the Aral Sea area) to capita income of about $3000). Another example is
show how the broad causal chain of health and dis- how increased urbanization and globalization have
ease goes beyond environmental and natural disasters allowed the consolidation of power over food systems,
to include avoidable problems directly attributable to which can lead to detrimental consumption patterns.
acts of human omission or commission. So, while in (Consider, for instance, how Mexicans now consume
the 1960s and 1970s we had the tools and resources 50% more Coca-Cola products per person than those
vastly to reduce the global burden of mortality and who reside in the USA.)
morbidity from tuberculosis, we failed to do so and
now face a future in which tuberculosis may become
an untreatable disease in poor countries where the 1
However, it should not be forgotten that economic
major burden of this disease is concentrated. The Aral
growth remains important in countries with very low per
Sea disaster provides an example at the micro-level capita incomes (for example, below $2000–3000), and
of the irrevocable damage we may do to our global that the extent of income disparities within countries is
water supplies if lessons are not learned in good time also important.
2
 Introduction

Some gains in the state of world health have been effectively means that we cannot ignore these other
achieved through improved vaccination coverage more basic factors.
and access to affordable antiretroviral therapies, but Is all health inequality morally troublesome? We
much work remains to amplify these meager gains. might tend to think it must be, but on reflection we see
Providing extra resources for health care is at least that matters are not straightforward here. Lesley Doyal
part of what is needed. Jeffrey Sachs has calculated and Sarah Payne explore some inequality and differ-
that a tax of 1 cent in every $10 earned by the wealthi- ence related to social gender and biological sex. They
est 1 billion in the world could provide the $35 billion outline some important differences between male and
required per year to give the poorest 1 billion people female patterns of health and illness and offer various
a $50 annual per capita health-care package.2 Labonté conceptual tools we need to understand the implica-
and Shrecker conclude: “the fact that resource scarci- tions of these patterns, which patterns are objection-
ties condemn millions every year to premature and able, and what we should do about them.
avoidable deaths, and millions more to shorter and Martin McKee presents an account of how health,
less healthy lives than most readers of this volume take well structured and integrated health-care systems,
for granted, must be understood as policy-generated, and economic growth can all co-exist and be mutually
resulting from choices that could have been made dif- supporting. Health care, when appropriately deliv-
ferently and institutions that can function differently” ered, can yield substantial gains in population health,
(Chapter 2). which further reduces the demand for health care.
The distribution of power and of social, political, Better population health can result in faster economic
and economic resources is crucial in influencing and growth, through enhanced productivity. The add-
explaining population health. In her chapter, Anne- itional economic growth can increase resources avail-
Emanuelle Birn analyzes the societal determinants able for health care, and further investment in health
of health: factors that shape health at various levels care can also contribute to economic growth. None of
including household, community, national, and glo- this necessarily follows, however. Concerted action by
bal levels. Living conditions both at the household and governments is needed to ensure these relationships
community level can cause numerous ailments includ- are mutually supportive and beneficial.
ing respiratory, gastrointestinal, or metabolic diseases.
Availability of potable water and adequate sanitation Global health ethics, responsibilities,
are key factors. Though water is essential for life, more
than a billion people (one-sixth of the world’s popu- and justice: some central issues
lation) have an inadequate supply. The facts about Angus Dawson and David Hunter explore the question
access to adequate sanitation are even more striking – of whether there is a need for global health ethics. They
almost half the world’s population has inadequate begin by examining different ways of understanding
access to basic sanitation facilities, which can result the term “global health ethics,” and proceed to exam-
in soil contamination and increased rates of commu- ine arguments that could be used either to support or
nicable diseases. The impact of other factors analyzed rebut more substantive accounts of global health eth-
include: nutrition and food security (over 50% of child ics, including those based on beneficence, justice and
deaths are attributable to poor nutrition), housing harm, and more cosmopolitan accounts. Some of the
conditions, public health and health-care services, and arguments they explore, that are used to resist more
transportation. Social policies and government regula- substantive global health ethics, include ones concern-
tion (or lack thereof) can also affect health in dramatic ing the moral relevance of distance, property rights,
ways through, for example, the domains of educa- and duties to prioritize the interests of compatriots.
tion, taxation, labor, and environmental regulations. They argue that we need not take a stand on any of these
Patterns of unequal resource distribution and political arguments to make a convincing case for various global
power play a fundamental role in the societal determi- obligations we have with respect to health. Sometimes
nants of health. To address radical health inequalities a case for global responsibilities pertaining to health
can be marshalled via more self-interested concerns,
2
Jeffrey Sachs during a video conference presentation such as with infectious diseases, or with the public
at the Canadian Conference on International Health. goods nature of many global health issues (again, as is
Ottawa, October 2009. the case with infectious diseases).

3
 Introduction

Indeed, infectious diseases are one of the most factors are socially controllable, it is in our power to
important areas for global concern. Historically, these remedy these.
have caused more morbidity and mortality than any Jonathan Wolff makes a case for the strategic value
other cause, including wars. Tuberculosis alone has of a human rights approach in contributing to positive
killed a billion people during the last two centuries. But, global health outcomes. Whatever concerns one might
as Michael Selgelid argues, infectious diseases do not have about the philosophical or theoretical grounds
affect us all equally. These primarily affect the poor and for the approach, it does have an important advantage,
marginalized who are more likely to live in the kinds of namely that in many cases because human rights are
crowded and poor conditions conducive to spreading objects of actual international agreements, there are
infectious diseases, lack adequate hygiene provisions some powerful mechanisms of enforcement available
necessary to prevent or treat diseases, or lack access for protecting health in certain cases. Illustrating the
to adequate health care should they become infected, approach with reference to case law, he shows how and
and are malnourished which also weakens immune when the approach might prove especially effective.
systems. Infectious diseases therefore cause more mor- Several other authors discuss the issue of human rights
bidity and mortality in developing countries. However, and health – its pitfalls and possibilities. Some are more
since epidemics in one country can easily spread to skeptical about its current usefulness and draw atten-
others (and become more virulent and harder to treat tion to the fact that failure to meet human rights on
in the process), rich countries have good self-interested a grand scale is predominantly the outcome of defects
reasons to be concerned about health-care improve- in global legal and economic structural arrangements
ment and poverty reduction in developing countries, (see Chapter 19 by Stephen Gill and Isabella Bakker).
in order to protect their own populations adequately. The idea of who is responsible for doing what with
Michael Selgelid argues that wealthy developed coun- respect to global health is a key issue and one touched
tries also have ethical reasons to fund poverty and dis- upon by most of the contributors to this volume. Allen
ease reduction in poor developing countries in virtue Buchanan and Matthew DeCamp offer some use-
of other normative commitments, such as to equality, ful guidelines in translating our shared obligation to
equality of opportunity, reducing injustices, or to pro- “do something” to improve global health into a more
moting well-being. determinate set of obligations. They argue that states
International health inequalities are very often in particular have more extensive and specific respon-
rightly disturbing, such as those concerning the dif- sibilities than is typically assumed to be the case, as
ferences in child mortality before age five or mothers’ they are the current primary agents of distributive
death rates during labor. Is it fair that there should be justice, influential actors in the burden of disease,
such clear losers in the “natural lottery,” constituted and indeed have the greatest impact on the health of
by where one happens to have been born? Should individuals in our world. But non-state actors (such
such an arbitrary fact about one get to determine one’s as the World Trade Organization and global corpora-
life prospects in such radical ways? Norman Daniels tions) have important responsibilities as well, which
argues that “health inequalities between social groups are discussed. Furthermore, institutional innovation
are unjust or unfair when they result from an unjust dis- is needed to distribute responsibilities more fairly and
tribution of the socially controllable factors that affect comprehensively, and to ensure accountability. Some
population health and its distribution” (Chapter 8). of the determinate obligations they identify for states
The sources of international health inequalities are include avoidance of committing injustice that has
explored more systematically and divided into three health-harming effects, for example not fighting unjust
categories: some result from domestic injustice in wars abroad or assisting in training military person-
the distribution of socially controllable factors (such nel of states likely to use force unjustly. In supporting
as inequities experienced by different races); some unjust governments and upholding the state system,
result from international inequalities in factors not we contribute to upholding unjust regimes that have
directly concerned with health such as natural condi- health-harming effects. Simply refraining from such
tions; while others result from international practices activities could do much to improve global health. As
that harm health more directly, such as through our one example they point out that between 2000 and 2006
failure to build worker health and safety protections 3.9 million people died in the Congo from war and that
into our trade agreements. Since many of the causal every violent death in that war zone was accompanied

4
 Introduction

by no fewer than 62 “non-violent” deaths in the region, countries owe to the wealthy, focusing especially on
from starvation, disease, and associated events. structural adjustment programs. They also explore
Solomon Benatar, Abdallah Daar and Peter the connection between debt and health and note that
Singer argue that improving health globally requires the magnitude of the debt owed by poor countries is
an expanded ethical mindset which appreciates that frequently unpayable, especially in the case of Africa
health, economic opportunities, development, peace, (the poorest continent) and not least because of the
and good governance are all linked in our interdepend- ongoing extraction of resources from such countries
ent world. They suggest that such understanding, com- that intensifies their poverty and reduces their ability
bined with a set of values that meaningfully respects to repay debt.
the dignity of all people, could promote their flourish- The link between international arms trading and
ing more broadly construed than merely in economic global health is easy to appreciate. In his contribution
terms. Five transformative approaches are outlined: (1) to this volume, Salahaddin Mahmudi-Azer outlines the
developing a global state of mind about the world and socio-economic impact of the global arms trade, with
our place in it; (2) promoting long-term (rather than special attention to its undesirable effects on human
short-term) self-interest; (3) striking a balance between health and the environment. These adverse impacts
optimism and pessimism about globalization and soli- include death, injury, and maiming from weapons-
darity; (4) strengthening capacity and commitment to use in conflict. There are massive opportunity costs to
broadening the discourse on ethics through global alli- health, economic development, and human well-being
ances; and (5) enhancing production and widespread when there is large-scale diversion of resources from
access to public goods for global health. They argue health and human services into weapons expenditure.
that an expanded moral discourse that goes beyond the The impact of conflict can be far-reaching and includes
notions of individual freedoms and rights to include important effects on children, such as psychological
discourses that promote the idea of economic growth damage, loss of educational opportunities, destruction
associated with fairer distribution, should comprise of families and nurturing environments, abuse, and the
the agenda for ambitious multidisciplinary research conscription of child soldiers. With trade in weapons
and action. growing fast and currently constituting “the largest
economy in the world” the effects on human health
Analyzing some reasons for poor and well-being are worrisome. He outlines some of the
health measures currently underway to limit the global arms
In Chapter 12 Meri Koivusalo traces the many ways trade and further measures that could be undertaken,
in which trade can and does affect health and vice including the role governments and bioethicists might
versa. It is clear that robust interests in trade can usefully play.
undermine health-related priorities and practice. The indirect effects of war on health are often
For instance, trade liberalization policies in agricul- unappreciated, and protracted health crises are often
tural products can affect price, availability, and access a festering feature of war-torn countries. Samia Hurst,
to basic food commodities that result in less healthy Nathalie Mezger, and Alex Mauron describe the ethical
diets for local populations, and related issues of food challenges that face such organizations as Médecins Sans
security. Furthermore, trade liberalization has made Frontières with humanitarian agendas that are driven by
available more hazardous substances such as tobacco a rights-based view of international health. They illus-
and alcohol, leading to unhealthy consumption pat- trate how the challenges extend beyond meeting emer-
terns. Poor, developing countries may be more vul- gency needs to dealing with more protracted crises, and
nerable to adverse effects of trade liberalization than the implications these have for “propping up repressive
wealthier ones. We need improved global governance and irresponsible governments” (Chapter 15). They
concerning health and trade, which better acknowl- focus on how resources could be fairly allocated when it
edges and tackles the wide-ranging effects of trade is not possible to meet all needs, and they offer a variant
on health. The call for better global governance in a of the Daniels and Sabin account of procedural fairness
variety of domains is one that is made by many other as a plausible option.
authors. The high media profile of humanitarian crises
Jeff Rudin and David Sanders explore the ori- in recent years has attracted resources from wealthy
gins and factors that perpetuate crippling debt poor countries. While some of these resources are new,
5
 Introduction

others represent shifts in allocations within only min- caused the problem, they will have to take a lead role in
imally increased Official Development Aid (ODA) solving it. Their inability (and perhaps unwillingness)
budgets. Indeed there have been significant shifts away to forge an agreement to reduce emissions fairly consti-
from projects that may contribute to structural devel- tutes a major inequity. There is much developed coun-
opments with the potential to advance the economies tries can and should be doing here, such as assisting in
of poor countries, towards humanitarian emergencies the provision of affordable, clean household energy in
and specific health problems – for example HIV/AIDS. developing countries.
Whether or not such aid is effective has been a topic of David Benatar observes that concern with global
great controversy in recent years. Overlapping and con- health ethics is invariably limited to ethical issues that
testing views have been offered.3 While it is clear that pertain to global human health, rather than a more
some impressive short-term gains have been achieved expansive notion of global health that includes other
in focused areas (such as HIV/AIDS) it is generally species. He argues that this focus is unfortunate, and
agreed that for a variety of reasons little real develop- that we do have duties (whether direct or indirect) con-
ment of infrastructure or of economies has resulted cerning non-human animals and the environment. He
from ODA. Anthony Zwi reviews some controversial draws attention to the ways in which human and animal
aspects of ODA, such as trends in the magnitude of such interests coincide and also the ways in which environ-
aid, the intentions that lie behind it, possible shortcom- mental degradation from our mass breeding and con-
ings (in particular as ODA relates to global health) and sumption of animal products threatens human health.
some emerging issues that require attention. He does While there is widespread awareness of how destruc-
so by considering the “seven deadly sins” associated tion of the environment can affect human well-being
with ODA described by Nancy Birdsall. These consti- and health (through processes such as global warming,
tute impatience with institution building, envy among ozone depletion, and desertification), there is much
competing donors, ignorance as evidenced by failure less awareness of how connected animal and human
to evaluate impact, pride (failure to exit), sloth (using interests are. Many infectious viral diseases have ani-
participation to justify ownership), greed (stingy trans- mal origins, including some of the most recent high-
fers), and foolishness (under-funding of public goods). profile ones, such as SARS, HIV, and “swine influenza.”
He focuses his discussion on how these sins impact on Although some animal to human transmission of dis-
health, and concludes with some recommendations for eases is probably inevitable, much could be avoided
new approaches. through better treatment of animals, especially keep-
Moving towards macro scale considerations, Sharon ing them in less crowded, more sanitary conditions. Of
Friel, Colin Butler and Anthony McMichael argue that course, if humans did not eat them in the first place,
although anthropogenic climate change will affect all fewer animals would be bred for human consumption,
human beings, it will affect the poorest and most disad- and the risks would reduce.
vantaged much more intensely. Their chapter outlines Lying at the heart of many of these upstream causes
the various ways in which this is likely to come about, of poor health is the way in which the global economy
and the implications for policy. Some of the pathways operates. Stephen Gill and Isabella Bakker describe
that will lead to health inequities include the fact that three foundational political economy concepts (new
extreme weather events are likely to increase, resulting constitutionalism, disciplinary neo-liberalism, and
in more general destruction, flooding, infectious dis- exploitative social reproduction) that correspond
ease, or food shortages, all of which affect those with to some of the dominant historical structures of glo-
fewer resources much more than the better-resourced. balized capitalism. They also discuss three perspec-
Rising sea levels, drought, water insecurity, and human tives on capitalism and the current global economic
relocation are other mechanisms through which it crisis: pure neo-liberalism, compensatory neo-liberal-
can be predicted that the more vulnerable will suffer ism, and heterodox economics. They then argue that
disproportionate effects. Considering that developed we currently face not only an economic or financial
countries emitted much of the greenhouse gas that crisis but a more profound organic crisis which reflects
the contradictions inherent in “market civilization”
3 characterized as it is by individualistic, consumerist,
See, for instance, William Easterly (The White Man’s
Burden 2006), Paul Collier (The Bottom Billion 2007), privatized, and energy-intensive myopic lifestyles.
Jeffrey Sachs (The End of Poverty 2005), and Dambisa Solving global health challenges will involve, in their
Moyo (Dead Aid 2009) for some of this debate. view, addressing this more organic crisis. For instance,
6
 Introduction

analyzing the global food crisis and resultant increased of resources helpful in maintaining corrupt and
global malnutrition, we see multiple factors playing a repressive regimes.
part, including trends towards greater centralization But these are by no means the only institutional
of ownership and control in the agribusiness industry, arrangements that perpetuate poverty. The list would
and greater enclosure by corporations of food sources also include upholding grossly unjust intellectual prop-
once held in common. Diversion of food resources, erty regimes that require all members of the World
particularly grain, into biofuel production is of further Trade Organization to grant 20-year product patents
significance. As with food markets, there is a similar which effectively make new medicines unaffordable
shift to more market-based models in the provision of for most of the world’s population. Reforming these
health care, where health becomes another commodity unjust “TRIPS” arrangements are the focus of Pogge’s
and there is continuing pressure to devolve the costs chapter.
(and risks) of health financing, to individuals. They Advocates of these arrangements often argue that
conclude with suggestions for reversing these trends such patents are necessary to compensate innova-
and with the need to identify obstacles to realizing tors for the large investments necessary to develop
change – for example the tax system. new drugs. While Pogge is well aware of the need for
incentives and rewards to compensate for research and
Shaping the future development investment into new drugs, he presents
As Thomas Pogge notes, about one-third of annual an alternative proposal which can overcome at least
human deaths are traceable to poverty and these are seven failings of the present pharmaceutical regime.
easily preventable through such measures as safe These include: high prices, neglect of diseases concen-
drinking water, vaccines, antibiotics, better nutrition, trated among the poor unable to afford the high prices
or cheap rehydration packs. Is there an obligation to for drugs (such as malaria or tuberculosis), a bias
alleviate world poverty, and to prevent such deaths? towards developing maintenance rather than curative
Pogge argues that whatever the merits of the case that or preventative drugs, massive wastefulness in policing
we should help more, there is much more clearly an patent law, the illegal manufacture of counterfeit and
obligation to harm less. How do we currently harm the often ineffectual drugs, excessive marketing, and
poor? In multiple ways, he argues. One can challenge inattention to ensuring patients are using the drugs in
the legitimacy of our currently highly uneven global beneficial ways.
distributive patterns concerning income and wealth, The structural reform idea that Pogge offers is for
which have emerged from a single historical process a “Health Impact Fund” (HIF). Financed mainly by
pervaded by injustices (such as slavery and colonial- governments, this proposed global agency would pre-
ism). One might also criticize the dense web of institu- sent pharmaceutical innovators with an alternative
tional arrangements that we have created, and now fail option to participate during its first 10 years in the
to reform, which “foreseeably and avoidably” perpetu- HIF’s “reward pool,” thereby being entitled to a share of
ate poverty. Pogge has argued that the way in which we rewards equal to “its share of the assessed global health
fail to reform these various institutional arrangements, impact of all HIF-registered products” (Chapter 20).
which foreseeably and avoidably perpetuate massive The innovators would have to make the drug widely
global poverty, is morally culpable. and cheaply available wherever it was needed, indeed,
Notable among these arrangements are the inter- would be incentivized to do so. Pogge, and an interdis-
national resource and borrowing privileges, referred ciplinary team, develop the details of the fund, so that
to in several chapters in this volume, which allow it presents a clear alternative to the current regime and
whoever holds power to sell the country’s resources one that is not guilty of the seven main failings identi-
legitimately (the international resource privilege) and fied above. Importantly, it provides significant rewards
borrow in the country’s name (the international bor- for the development of drugs that would address some
rowing privilege), no matter how power was obtained. of the most widespread global diseases concentrated
These privileges have disastrous effects for developing among the poor, who currently do not have the pur-
countries, especially in fostering corrupt and oppres- chasing power to command the attention of drug devel-
sive governments, as they incentivize the seizing of opers. Since Pogge has presented a feasible alternative
power through illegitimate means and enable the con- to TRIPs agreements for rewarding drug innovators,
solidation of that power by providing a steady stream our imposition of these regimes on the world’s poor is

7
 Introduction

not only harmful but morally culpable, and our failure of aid that goes to assist a developing country, approxi-
to reform current regimes is unjust. mately $6–7 (US) of corporate tax evasion flows out.
Another high profile approach to improving global She reviews some current widespread practices that
health is through the Grand Challenges supported by facilitate massive tax escape, such as the use of tax
the Bill and Melinda Gates Foundation. These have a havens, transfer pricing schemes (that allow goods to
specific focus on technological solutions – for example be traded at arbitrary prices in efforts to suggest large,
vaccines for HIV and malaria, and new diagnostic untaxable losses are being incurred), or practices of
technologies. While acknowledging that the role of non-disclosure of sales prices for resources (that greatly
advances in biotechnology may have been overplayed assist corrupt leaders in diverting revenue from devel-
recently, to the neglect of other powerful determinants oping countries for their own private use). Ensuring
of health, Hassan Masum, Justin Chakma and Abdallah adequate revenue collection and tax compliance is
Daar credibly explore where and how advances in bio- important for development and democracy, in addition
technology might usefully assist in improving global to ensuring developing countries can adequately fund
health. They remind us that while many such advances essential goods such as health care. She also considers
take a very long time to improve the health of whole some proposals concerning global taxes that have a
populations, the long-term potential of biotechnology reasonable chance of success and, in some cases, have
should not be underestimated. already been implemented. The “air-ticket tax,” oper-
It is interesting to note that while massive attention ated by the WHO, which collects revenue to address
has been directed to providing life-extending treat- global health problems such as malaria, tuberculosis
ments to all with HIV/AIDS who need this, much less and AIDs, is one example.
attention has been directed to the need to provide life- Tikki Pang draws attention to multiple problems
saving food for the millions of people who die from that pervade health research, such as the fact that
malnutrition. And indeed antiretroviral treatment agendas for health research are largely uncoordinated,
works best in those who are well nourished. fragmented, and heavily influenced by donor agen-
Lynn McIntyre and Krista Rondeau address the cies. He argues for the need to change the global health
issue of food security and argue for the important research agenda. Properly coordinated and harmo-
connection between food security and global health. nized health research could play an essential role in
They explore five challenges to food security, namely alleviating the massive problems currently facing the
those presented by climate change, pockets of famine, developing world. We need new strategic thinking and
population growth, agricultural production and sus- he argues that key elements to a new health research
tainability, and dietary transition, especially as popula- agenda would involve inclusiveness in defining pri-
tions become more urbanized. They also discuss which orities, ensuring more equitable access to the benefits
interventions to address these challenges are likely to be of research, and ensuring better accountability in
most promising. Prominent among these strategies is research activities.
the need for investment in agriculture, back to the lev- An issue that troubles many in developed coun-
els previously common in the 1970s. Agricultural pol- tries concerned with global health ethics is the way
icies, research, and technology should aim to address in which clinical research is being increasingly “out-
productivity and poverty alleviation, to enhance cap- sourced” to poor countries with vulnerable popula-
acity for food production. This broad strategy will tions. Does the severe deprivation in these countries
have different implications for different economies. In render such activities exploitative? Or, alternatively,
middle-income countries this might translate into bet- by providing some benefits (albeit sometimes small
ter integration into market chains while in low-income ones) to these people, are we assisting them? Under
countries where more staple crops should be produced, what conditions is research in developing coun-
the focus might be on more affordable inputs (such tries morally defensible? Alex London investigates
as seeds, fertilizer or credit) and improved access to this issue in his chapter. By outlining his Human
technology. Development Approach to international research he
In her chapter, Gillian Brock examines how reform- argues for a position in which basic social institu-
ing our international tax arrangements could be espe- tions can be expected to advance the interests of all
cially important in ensuring that everyone has the community members. Moreover on this approach,
prospects for a decent life, which importantly includes there are obligations to ensure that the results of the
enjoying access to decent health care. For every dollar research are translatable into sustainable benefits for
8
 Introduction

its population. This entails obligations either to build closest to us and excessive focus on unachievable
alliances with those able to translate the research into moral maximums.
sustainable benefits or to “locate the research within Jim Dwyer engagingly reflects on his experiences
a community with similar health priorities and more of teaching global health ethics. He reviews some of
appropriate health infrastructure” (Chapter 25) the content of his syllabus, the students’ reactions to
Instructive examples of research that pass and fail the it, and his own reflections on these experiences. In
test are discussed. a particularly useful section he explores a notion of
Kearsley Stewart, Gerald Keusch and Arthur responsiveness to global health injustices and offers
Kleinman note that debates shaping global health guidelines for assisting students in thinking about
research, ethics and policy have developed along morally appropriate responses to problems of global
two tracks – one characterized by a neo-liberal health.
approach and another that focuses on human rights, In their second chapter, the final chapter in this
social justice and a broader, more inclusive model of volume, Bakker and Gill pose the challenge that new
the determinants of health. They argue that these paradigms are needed to make the changes required
two approaches are now converging around a focus for meaningful improvements in global health. They
on values. In their chapter they provide a synopsis recommend at least three broad areas that need
of papers that emerged from a conference in which more attention. First, we should attend better to our
participants addressed such questions as: “What interdependencies with each other and with nature.
values are deeply embedded in the most important Second, we need to improve socialization of the risks
global health policies? How do we combine moral experienced by the global majority. Indeed the pub-
philosophy, applied (empirical) bioethics, econom- lic sector needs to be made more accountable to the
ics and public health, and engage people in high needs of the public as a whole, and this should be
income countries in work to improve the health connected to policies that also make private corpo-
of people in resource poor settings?” (Chapter 26) rations more socially accountable and expects more
They argue that “an empirically based ethnographic of them in sharing the costs of the social goods and
approach may be the best way to effectively bridge infrastructure from which many of their activities
local narratives of health with cosmopolitan glo- benefit. Third, we need to develop a new idea of “com-
bal health values that shape macro-level policies.” mon sense” by nurturing progressive values. Some of
(Chapter 26) In support of this proposal they dis- the more particular ideas they consider include a call
cuss the value of such an approach to resolving the for new measures “to provide adequate financing to
problems that arose between local communities rebuild and extend the social commons with these
and global interventions in the WHO Global Polio resting upon a more equitable and broad-based tax
Eradication Initiative in Nigeria. system where capital and ecologically unsustainable
Jonathan Glover examines the psychology of our resource consumption are taxed more than labor”
attitudes to poverty and he explores some of the moral (Chapter 29). The need for new media, more respon-
claims for why we should, but do not, more vigorously sive to the diversity of public opinions, is also high-
assist those in desperate need. In his examination of lighted as is the need for more critical reflection on
our tendency towards paralysis he examines the ideas orthodox economic thinking.
of both physical and moral distance, and beliefs that To improve people’s health globally and pursue
the problem is insoluble or cannot be addressed by the goals described in this book will require a con-
individuals. He rejects many common arguments siderable amount of collaborative multidisciplinary
used to rationalize not assisting, and reminds us of research and pervasive community engagement at
the power of collective action, for example the cam- many levels. It is arguable that this challenge is as
paign for debt relief. In examining the moral claims great as, if not greater than developing an HIV vac-
of the poor on the rich he discusses humanitarian- cine. If equivalent research resources and intellectual
ism, compensatory justice, and the moral scandal attention were to be allocated to such research, sig-
of extreme poverty. He concludes with an examin- nificant progress is entirely possible. While we have
ation of how much is required of us and with a rec- considerable intellectual and material resources to
ommendation for a sustainable balance between the improve global health, there is little reason to expect
extremes of limiting our moral obligations to those that major new initiatives, such as those envisaged

9
 Introduction

in this text will be implemented without a great deal References

of effort in mobilizing the political will to do so.4
Collier, P. (2007). The Bottom Billion: Why the Poorest
However, like Jonathan Glover and others, we retain
Countries are Failing and What Can Be Done About It.
an element of hope that well-constructed arguments
Oxford: Oxford University Press.
can, on occasion and in the right circumstances, play
Easterly, W. (2006). The White Man’s Burden. Why the West’s
a significant role in influencing the future. To end
Efforts to Aid the Rest Have Done So Much Ill and So Little
on a more optimistic and inspiring note, as Nelson Good. Oxford: Oxford University Press.
Mandela famously said: “It always seems impossible
Moyo, D. (2009). Dead Aid: Why Aid is not Working and How
until it’s done.”5 There is Another Way for Africa. London: Allen Lane.
Sachs, J. (2005). The End of Poverty: Economic Possibilities
4
for Our Time. New York: Penguin Press.
We note here that the topics covered in this volume are
by no means fully inclusive of the numerous problems
that undermine and aggravate conditions for overcom-
ing global health challenges. For example we have not
included chapters on such issues as child labor, use of
children as soldiers, trade in sex and drugs, those cul-
tural practices that have serious adverse health effects,
pervasive corruption in business and in health care, and
widespread Mafia-like organizations that increasingly
influence (even control) the lives of many. All of these
contribute to global injustices as well.
5
Inaugural address, 1994.

10
Section Global health, definitions and

1 descriptions
 Section 1 Global health, definitions and descriptions
Chapter
What is global health?

1 Solomon Benatar and Ross Upshur

Introduction and others in wealthy countries, or also those whose

lives and health are adversely affected by unspeakable
To profess interest in global health is one of the latest
injustices driven by now recognized seriously flawed
trends in medicine, and many universities, especially
economic policies that have sustained and intensified
in North America, are developing Departments or
poverty and miserable living conditions for so many?
Centers of Global Health (McFarlane et al., 2008; Drain
In this chapter we highlight some of the key con-
et al., 2009). The rapidly proliferating spectrum of new
ceptual issues involved in situating our contemporary
organizations, alliances and funds to address global
understanding of global health.
health issues has generated a challenging new “global
health landscape”(Global Health Watch 2 – People’s
Health Movement, Medact and the Global Equity Some definitions of health
Gauge Alliance, 2008). But it is neither entirely clear All definitions of health are potentially contentious.
what is meant by “global health,” nor how this term is On the one hand such definitions may be too narrow,
being used by a range of actors. while on the other they may be too broad. However,
On the one hand we need to ask if it is: (a) a descrip- some form of definition is required to frame clearly the
tion of the medically measurable health status of object of inquiry. Although most definitions of health
all individuals globally (a medically defined state of are contentious, inquiry in the absence of some defin-
affairs); (b) an assertion about (or aspiration to) the ition leads to non-transparent reasoning and often fos-
state of health of all throughout the world (an activ- ters argument at cross-purposes. In order to mitigate
ist agenda); (c) about providing medical treatment to this possibility, we explicitly provide selected defini-
all globally who are suffering from medically defined tions of health before proposing our candidate inter-
diseases (an extended biomedical approach to health); pretations of global health.
(d) a description of how health services are, or should Individual health. While many refer to individual
be, structured and governed worldwide (a governance health narrowly as the absence of disease (usually phys-
of health issue); (e) about measures to improve health ical, but also mental), the Alma Ata definition of individ-
governance and reduce disparities in health and health ual health is much broader (a state of complete physical,
care across the globe (a global social justice issue); or mental and social well-being, and not merely the absence
(f) reference to the quest to sustain a healthy planet (an of disease or infirmity) (Tejada de Rivero, 2003).
environmental health concern). Public health. The definition of public health is
On the other hand we could ask if it is merely a new also contentious, with some favoring a narrow per-
“in vogue” term for what was previously called inter- spective that “uncouples the etiology of disease from
national health or whether it is truly a recognition of its social roots” Fee & Brown, 2000) and focuses on
what global health means in a post-Westphalian world statistics, epidemiology and measurable proximal
in which diseases know no boundaries and the lives of risk factors, while others prefer a broader view that
all people are of equal moral worth. does not separate public health from its broad socio-
And then of course we need to ask who are the major economic context. This broader view is considered
players setting the agenda in the field – only academics to have “intellectual merit” because it identifies the

Global Health and Global Health Ethics, ed. Solomon Benatar and Gillian Brock. Published by Cambridge University Press.
© Cambridge University Press 2011.
13
 Section 1. Global health, definitions and descriptions

fundamental causes of many public health problems, year and most seriously by environmental degradation
and provides more complete and concise explanatory and climate change that have profound implications
models (Fee & Brown, 2000). for health (Garrett, 1994; Benatar, 2001, 2009; see Friel
While Verweij & Dawson (2007) have been criti- et al., Chapter 17, this volume). Seeing global health as
cal of making definitions of public health so broad that intimately connected to adverse social and economic
they are impossible to address, Powers and Faden, in forces requires a mind-set shift that seems to have
their book on the foundations of public health and eluded some (Koplan et al., 2009).
health policy (Powers & Faden, 2006), have offered an Using Richard Lewontin’s idea of “biology as ideol-
even broader perspective in arguing that: ogy” (Lewontin, 1991) we can restate what he has said
the foundational moral justification for the social institution of about science as follows in relation to “global health as
public health is social justice … Our account rejects the separate ideology”:
spheres view of justice in which it is possible to speak about justice Global health is a social concept about which there is a great deal
in public health and health policy without reference either to how of misunderstanding, even among those who are part of it. Global
other public policies and social environments are structured or to health work, like other productive activities (for example the state,
how people are faring with regard to the rest of their lives. the family, sport) is a social institution completely integrated into
and influenced by the structure of all our other social institutions.
International health has its focus on health across
Those who work on global health view the topic through a lens
regional or national boundaries and on the provision of
that has been moulded by their social experience. Global health
health-care assistance in one form or another by health
work is a human productive activity that takes time and money,
personnel or organizations from one area or nation to
and so is guided by and directed by those forces that have control
another, usually poorer nations (Birn, 2009a). Many
over money and time. People earn their living by “doing global
of the new Departments and Centers of Global Health
health” and as a consequence the dominant social and economic
in North American universities are focused on such
forces in society determine to a large extent what global health is
endeavors (Drain et al., 2009).
about and how it is pursued.
Global health goes beyond international health to
include acknowledgment of the lack of geographic or Stuckler & McKee (2008) have suggested that there are at
social barriers to the spread of infectious diseases, and least five metaphors that can be applied to global health.
indeed the interconnectedness of all people and all life Global health as foreign policy is driven by political
on a threatened planet. A broad definition of global motives with a view to pursuing strategic interests and
health could be offered by re-phrasing Winslow’s 1920 economic growth. Global health as security seeks to pro-
definition of public health (the notion of which has tect local populations against infectious diseases and bio-
been discussed in detail by Verweij & Dawson, 2007) terrorism. Global health as charity focuses on “victims”
and further expanding this. and addresses issues of poverty and disempowerment.
Global health is the science and art of preventing disease, prolong- Global health as investment is focused on those whose
ing life and promoting physical and mental health through organ- improved health could maximize economic growth.
ized global efforts for the maintenance of a safe environment, Global health as public health is aimed at decreasing the
the control of communicable disease, the education of individ- global burden of disease and focuses on those diseases
uals and whole populations in principles of personal hygiene and that constitute the largest proportion of this burden. The
safe living habits, the organization of health care services for the authors acknowledge that while there is much overlap
early diagnosis, prevention and treatment of disease, and atten- in how these are applied, the policies that will be pur-
tion to the societal, cultural and economic determinants of health sued (by the USA and other powerful groups) crucially
that could ensure a standard of living and education for all that is depend on which metaphor is dominant.
adequate for the achievement and maintenance of good health.

Global health is thus about health in a world char- State of health globally
acterized by spectacular medical advances and amaz- What is generally clear is that despite major progress
ing economic growth but also by aggravation of wide in medicine and massive growth of the global econ-
disparities in health and well-being by powerful social omy there are wide and widening disparities in health
forces. Such a world is now under severe threat as evi- as conventionally measured, with almost 50% of all
denced by re-emergence of infectious diseases, resist- people in the world lacking access to even the most
ance to drugs to treat infections that kill millions each basic health care, and living greatly deprived lives

14
 1. What is global health?

under conditions of severe poverty and environmental impacts worsened by systematic, often remediable,
degradation in both rural and urban contexts (Global disadvantage of whole populations. Climate change
Health Watch, 2005–2006, People’s Health Movement, together with competition for resources, marginaliza-
Medact and the Global Equity Gauge Alliance, 2005). tion of the majority of people in the world and global
Roughly one-third of all human deaths (18 million militarization have been described as the major threats
annually), are due to poverty-related causes (and 50% of to world peace (Abbott et al., 2007).
these are children under 5 years of age). People of color,
females and the very young are heavily over-represented Measuring health
among the global poor (Pogge, 2009). Life expectancy How can we measure or quantify good or poor health?
ranges from about 40 years in such countries as Sierra Can poor health be measured entirely through such
Leone, Angola and Afghanistan to over 80 years in quantitative metrics as life expectancy, or morbidity
others such as Japan, Switzerland and Australia. and mortality from various diseases, as so popularly
Africa is the most severely afflicted region. Of over portrayed in a succession of World Health Organization
800 000 deaths globally from malaria each year 91% (WHO) Annual Reports? Alternatively, should the
are in Africa and 85% of such African deaths are in concept of health and disease also embrace qualita-
children under 5 years of age. Of 33 million people liv- tive assessments of the social suffering, for example of
ing with HIV in the world in 2007, 22 million were in raped women, children who are orphaned or abused,
Africa. Five million African children under the age of 5 those who are displaced refugees or homeless and
die each year of preventable diseases. Of the estimated those who suffer slow painful deaths without palliative
536 000 annual maternal deaths globally, 99% occur in care (Benatar, 1997)? How could such suffering best be
developing countries, including Africa. Globally, there documented?
are 963 million who are undernourished; 884 million Considerable resources have been devoted to the
who lack access to safe water; 2500 million who lack improvement of population-based metrics. The Bill
access to basic sanitation; 2000 million who lack access and Melinda Gates Foundation has funded the Institute
to essential medicines; 924 million who lack adequate for Health Metrics and Evaluation at the University
shelter; 1600 million who lack electricity; 774 million of Washington. The mission of this organization is to
adults are illiterate and 218 million children are child improve the health of populations by providing the
laborers – all of which are both indicators of poverty best information. This is a key task. Important ques-
and directly or indirectly aggravate poor health. There tions remain about what the most important health-
are data showing that chronic diseases are also increas- related information is, who collects it, for what (or
ing globally bringing new challenges to health systems whose) purposes and to what ends.
in both rich and poor countries, and there has been The recently published WHO report on social deter-
a call for a set of grand challenges in global chronic minants of health, Closing the Gap in a Generation, has
disease management (Daar et al., 2007). many shortcomings (Birn, 2009b) but it does point the
Concerns for the health impact of global warm- way to including several new measures such as access
ing and other associated dimensions of environmen- to land rights, social empowerment and gender equity
tal degradation are increasing. The health of billions that promise to move measurement beyond the con-
of people will be affected by climate change – through fines of simple epidemiological indicators of morbidity
direct long-term effects on water security and food and mortality (Commission on Social Determinants of
chain integrity, population migration and displace- Health, 2008).
ment, redistribution of vector-borne diseases, and sig- It is essential, moving forward in global health,
nificant short-term health impacts from catastrophic to engage a wide range of communities to determine
extreme climatic events (Costello et al., 2009; see Friel what kinds of information they need to improve their
et al., Chapter 17, this volume). There are also signifi- health and well-being. The era of “data raiders,” where
cant environmental health concerns globally that are researchers extract data, human tissue and other forms
not directly associated with climate change such as of information from communities for research pur-
chemical contamination of food and water supplies poses with no prenegotiated agreement on the owner-
and the health effects of persistently accumulating ship of the data, the purposes of its use and any benefits
toxic agents and deteriorating air quality. These are that may or may not accrue to the community should
all global in nature, but may have differential health come to an end.

15