Global Inequality & Access to Health Care

La Danse macabre. Paris, Guy Marchant, 1486 : Un moine, un usurier et un pauvre (monk, usurer and poor man)

La Danse macabre. Paris, Guy Marchant, 1486 : Un moine, un usurier et un pauvre (monk, usurer and poor man)

According to a recent study in The Lancet, “The world’s wealthiest two billion people get 75 percent of all the surgery done each year, while the poorest two billion get only 4 percent and often die or live in misery as a result.” It’s a striking fact; how are we to interpret it?

There are two metanarrative accounts of the relationship between inequality and health care. On a Whiggish, optimistic view, vast inequality can generate the capital necessary to fund investment in innovative health care technologies. Scholars like Richard Epstein have celebrated both general economic inequality and unequal access to health care particularly because, they claim, buying power at the top promotes investment in medical advances. On this view, innovations in the wealthy world can diffuse throughout lesser developed regions. Moreover, the rich can also subsidize the poor locally, paying for infrastructure that serves a broader community.

Interpreted less charitably, inequality enables the well-off to bid away resources and opportunities from the poor. Richer nations and persons may snap up limited resources; for instance, in 2009, Jeanne Whalen at the Wall Street Journal wrote an article entitled “Rich Nations Lock In Flu Vaccine as Poor Ones Fret:”

A scramble among wealthy nations to guard against a swine-flu pandemic is raising concerns that billions of people in poorer countries could be left without adequate supplies of vaccine. . . . The emerging battle between the haves and have-nots underscores a major weakness in the global health system: Pharmaceutical companies have severely limited capacity to produce flu vaccines in emergencies.

Inequalities can be even more stark at the R&D phase. If an anti-baldness cure can generate billions of dollars in revenue while a new therapy for tuberculosis only generates hundreds of millions, for-profit pharmaceutical companies may well have a fiduciary duty to invest scarce research dollars in the unhirsute rather than the truly unhealthy.

Lawrence Gostin’s recent article “Redressing the Unconscionable Global Health Gap” offers some practical ways of addressing these disparities:

The international community is deeply resistant to taking bold remedial action — more concerned with their geostrategic interests than the health of the poor. The scale of foreign aid is both insufficient and unsustainable and fails to address the key determinants of health. As a result, the world’s distribution of the “good” of human health remains fundamentally unfair, causing enormous physical and mental suffering by those who experience the compounding disadvantages of poverty and ill health.

Lest we dismiss such inequalities as “not our problem,” Thomas Pogge’s sobering new book elaborates on his earlier argument that wealthier nations are responsible for the plight of the poorest:

[P]olitical and economic inequalities are rising dramatically both intra-nationally and globally. The affluent states and the international organizations they control knowingly contribute greatly to these evils — selfishly promoting rules and policies harmful to the poor while hypocritically pretending to set and promote ambitious development goals.

Both Pogge and Gostin’s work should guide policy responses to the extraordinary disparities exemplified in the Lancet story. As I continue to study fractal inequality in access to medicine, I will be sure to consult their proposals for a more just world. I also hope to see proposals for taxation of “medical tourism” that would redirect at least some of the funds from overseas patients to infrastructure that would support underserved patients in the regions they visit.

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