The Twist of the Rope, pt 2

24 July 2013 by Tania Browne, posted in Global Health

The entwined knots of globalisation, and it's effects on the poorest of communities, are everywhere and getting worse. Even things we don't necessarily think of as having a link to the markets, such as natural disasters, leave their very worst effects on those in the shanty towns or scraping out an existence on marginal land that the rich have long since fled. Why is this our business, here in the wealthiest nations? We made it our business by building our businesses into global ventures.

In 2000 the United Nations created the Millenium Development Goals, in an effort to reduce the worst effects of poverty across the world by 2015. Three of the goals - reducing child mortality, improving maternal health and reversing the horrific sweep of AIDS and malaria - are directly health related, while four others address the social determinants of health - extreme poverty, undernourishment, environmental hazards and lack of access to education. The Millennium Development Goals inevitably require a revamp of the trade and foreign policies of the wealthiest nations to make sure that they're compatible with the goals, and also to help address the vast issue of asymmetry in the global marketplace. We need to acknowledge that low income and even middle income nations are at great disadvantage when it comes to trade - they cannot afford the expertise that would be needed to play a larger role in trade negotiations, or to pursue disputes when things have gone wrong. Also, their market size gives them only a very limited hand in negotiations - if Ecuador were to impose major tariffs on US goods - big deal. But if the US were to do the same to Ecuador for not "playing along" the implications could be huge on the national economy.

In the third of their papers on globalisation and the social determinants of health, Roland Labonté and Ted Schrecker come up with several areas of consideration that would lessen the huge gaps between the richest and poorest.

Equal access to Health Systems

In 2001 the Commission on Macro Economics and Health concluded that a package of basic, low-tech healthcare interventions costing around $34 per person would be enough to save 8 million lives per year by the end of that decade. But the average healthcare expenditure in low income nations, where 2.4bn of the world's population live, is $24. And that's just a mean average - in half of those countries it's $14 or less. Don't assume we're talking about state expenditure, either - the vast majority of that is through the private companies that provide most of the healthcare to the world's poorest people. For instance, in Vietnam in 2001 the total state healthcare expenditure was $4 per person. The economist Jeffrey Sachs estimates that in some sub-Saharan nations the total per capita revenue is $50 per person. Not for health, for everything.

Sadly, some major investments in global health are limited because they're not seen to be "for the public good". You may think this seems fair enough, until you realise that far from being a being a general phrase, in economics "public good" has a very specific meaning. A private good is a product for individual consumption that is both excludable and rivalrous, ie not something that anyone can have - it conveys privilege or, at least, money that not everyone has. A public good, in economic terms, is the opposite. Something that, through the fact it's available to everyone, does not devalue. The problem is, balance between private and pubic goods is ever changing and subject to the whims of politics and policy, and such changes in policy can be disastrous. The World Health Organisation concluded that research into malaria is seriously underfunded by the global community because it's seen as a local, not global issue - and therefore not a "public good".

In fact, many public goods for health such as vaccination and research into anti-biotic resistance are sorely undersupplied because they are seen by some as private goods. Scientific knowledge can be ring-fenced by the intellectual property rights of private companies, who while spending far more money on research than governments do, are far more likely to research drugs that will create future profit.

Expanding and Improving Development Assistance

Official development assistance from the wealthiest nations would need to double to allow the poorest countries to meet the Millennium Development Goals. And even that would be barely adequate. It doesn't help, according to Labonté and Schrecker, that a lot of the money goes to aid agencies for specific projects rather than as general budget assistance. If money is ring fenced it takes away the ability to use it elsewhere, however desperate a seperate situation may be.

Expanding Debt Relief

But development assistance hardly matters while, in every region if the developing world, it is completely engulfed by the outflow of debt service. In the mid 90s the Heavily Indebted Poor Countries Initiative was set up to identify those nations  most crippled by debt, and in 2005 the G8 summit committed to cancel all debts owed by the HIPCs to the World Bank, the International Monetary Fund and the concessional arm of the African Development Bank. However, the rigid conditions of the same old economic restructuring, assuming that rapid integration into the global economy was the best cure, still prevailed - we discussed in the last piece what further polarisation between rich and poor this precarious solution can lead to.

Health as a Human Right

Human Rights Law, starting with the 1948 Universal Declaration of Human Rights, includes various provisions relating to health and it's social determinants. In 2001 the Committee of Economic, Social and Cultural  Rights issued a further comment on Article 12, clarifying the right to health and the obligation of the state to provide for it to the best of their ability. As well as renewing previous commitments to maternal and child health, industrial hygiene and disease prevention, the comment  identified several "core obligations":

- access to health facilities, goods and services without discrimination

- access to minimum essential food and freedom from hunger

- access to basic shelter, housing, sanitation and clean water

- the provision of essential drugs (as defined by the World Health Organisation)

- to adopt and moment a national public health strategy

These obligations, depressingly and somewhat unsurprisingly, are overshadowed by the global marketplace. For instance the intellectual property rights of big pharma remain central to debates about access to medicines, despite the WHO's best efforts, and just as pressingly access to potable water for the very poorest is hampered by privatisation and commercialisation.

 

In the end, it's quite simple. The sacred tenets of globalisation would have us believe that the key to raising people out of poverty is economic growth. In reality, there is no evidence to show that even if economic growth happens and is sustainable, the wealth trickles down. The gap is widening, and it's high time to consider other ways to ensure a more equal distribution. Studies of Latin American nations have shown that progressive taxation would strike a bigger blow to inequality than further economic growth, yet governments are hampered by the threat that the wealthy will simply move their money across international borders to avoid taxation - or that such taxes will even push the foreign conglomerates who have invested  to move their operations elsewhere.

It's not a question of whether we have the funds to lessen health inequality and global poverty. We do. It's a question of whether we have the willpower to change it, a question of speed of implementation, and a question of targeting those with the most need first. And most of all, it's a question of taking one of our most fundamentally sacred beliefs - that The Market will lift people out of poverty - and admitting it's wrong.

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