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How to Narrow the Health Gap
January/February 2007
by Jennifer Prah Ruger

Jennifer Prah Ruger is an assistant professor of public health in the department of epidemiology and public health at the Yale School of Medicine and an assistant adjunct professor at the Yale Law School.

A child born today in Afghanistan is 75 times more likely to die by age five than a child born in Singapore. A girl born in Sierra Leone can expect to die 50 years earlier, on average, than a girl born in Japan.

Now for the bad news.

The international development community has been spending billions of dollars to narrow the international health gap. Yet my South Korean colleague H-J Kim and I recently discovered that, in some parts of the globe, the gap is growing.

We found that in western, eastern, and central Africa (from Mauritania and Somalia to Angola and Mozambique) and in Afghanistan—places where babies and toddlers die at high rates—slower progress is being made to save young children’s lives than in North and South America, western Europe, and Asia—areas where the under-five death rate is low. In addition, countries in most of sub-Saharan Africa with the highest adult death rates are actually losing ground. More adults are dying of health problems in these nations now than in past decades.

Kim and I analyzed data collected by the World Bank over the past five decades. (The data are available in the World Development Indicators 2003 database.) Our study, published in the Journal of Epidemiology and Community Health in November, found many other indicators of serious trouble.

There are plenty of reasons for this disturbing increase. For instance, we found that countries with the worst health problems have four times the percentage of people living on less than $1 per day. They have one-fifth the outpatient visits, hospital beds, and physicians of their low-mortality counterparts.

If we value all humans' health equally, then threats to individuals' health, wherever they live, pose a moral or ethical challenge to our own sense of a just society. Being born into a country or society in which one has a good chance of being in the worse-off health group is morally arbitrary. It requires rectification. The determining factor in an individual’s health—or survival—should not be morally arbitrary. And the more deprived these individuals are, the more concerned we become as moral beings in a world of such unthinkable destitution.

We know from past research that health inequalities will not be reduced through market mechanisms alone. Government, policy, and individual and social commitments are required. And for regulation and redistribution to succeed, individuals must sacrifice some of their resources and autonomy.

I would argue that international and national responses to health disparities must be rooted in ethical values about health and its distribution. Ethical claims have the power to motivate; to delineate principles, duties, and responsibilities; and to hold global and national actors morally responsible for achieving common goals. Once individuals internalize these ethical commitments, they freely enter into them.

Unquestionably, individual nation-states have the primary obligations to address health inequalities. States are in the most direct position to reduce the shortfall between potential and actual health. In many countries, especially those in the developing world, the distribution of resources within society is inequitable. In Ghana, Indonesia, and Vietnam, for example, public spending on health significantly favors the wealthy.

But the international community must play a role. Global health institutions are important because they can help generate and disseminate knowledge and information. For example, they can help create new technologies—such as an HIV/AIDS vaccine. They can transfer, adapt, and apply existing knowledge for, say, preventing malaria. They can manage knowledge and information, such as statistics on inequality in infant and child mortality and on the best practices for reducing it. And they can help countries develop health surveillance and information systems.

Global health institutions can also empower individuals and groups in national and global forums. Indirectly, they can push for greater citizen participation in health-related decision-making in developing countries. Since greater empowerment in the health sector is built on more democratic governance overall, reform of state and social institutions may be needed to achieve these goals. And encouraging the political will for public action will be essential.

A moral framework should be applied to all global health policies. Reducing gaps in preventable mortality and morbidity should be the focus of the global health community in the twenty-first century.  

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