NEWSBYMICHAEL KEIZER

(Photo credit: Group of windmills at Campo de Criptana in La Mancha, by Lourdes Cardenal.)

Last week, we saw why social and economic inequities are so important for global health and why global health professionals cannot afford to ignore them. I ended up with a difficult question: what can we do about them? Should we charge at full tilt at any inequity that seems to be related to adverse health results? Many of us being idealists, the temptation to do so is considerable. However, playing Don Quixote will probably not lead to appreciable progress, or at least not to the best results possible; to get results, we should ignore windmills and concentrate on targets that are more worthwhile.

As many social determinants of health lie firmly outside our fields of expertise, it will be necessary to forge links with other professions, many of which have come to similar conclusions. ‘Even' economists have concluded that inequities are as bad for a nation's wealth as they are for its health. Engaging in alliances will be necessary to arrive at any meaningful result, and (as a positive side effect) could lead to better inter-disciplinary cooperation on other subjects too.

Furthermore, an intensive information campaign will be necessary. Many non-health professionals are at best only vaguely aware of the impact of inequities on health: for many people, health is a highly technical subject, with hardly if any links to issues of social justice. We need to be relentless in informing (or indoctrinating) a wider audience about these links, and what they can do about it. In other words: this blog is in many ways a necessity.

This also means that we should be constantly on the lookout for non-health actions with important health consequences: not an easy task (how could public health professionals in the 1980s have known that the World Bank's new position papers would ultimately impact so much on public health?), but one that will be ultimately rewarding in its results.

Over the last couple of weeks, we have seen how not every inequality is an inequity: justice is what defines inequities, i.e. the fact that we can and should do something about them, but choose (for whatever reason) not to do so. We have also explored the relationship between (social) inequities and health, and found out that they are closely linked. Finally, we have had a look what health professionals can and should do about inequities; cooperation, alliances, partnerships, and information are keywords here.

Public health professionals can and should act meaningfully about social inequities; and in the process, we might actually learn something about what we in turn can do to help foster better economies, build better buildings, or grow better crops.

(Photo credit: Eva Ekeblad)

Back at the start of this series, I concluded that the best definition of equity we have implies that, by itself, the difference in life expectancy between Luxemburg and Burundi is not an inequity, as we have no realistic means to make Burundi as rich as Luxemburg. However, this breaks down on the level of income distribution: Burundi's 10 percent richest households have access to a third of the total income in the country, but its 10 percent poorest have only access to 1.8 percent. This inequality in income distribution is clearly avoidable, and that it is unnecessary and unfair is evident. However, does this have any implications for global health?

It turns out it does. Luxembourg, with its high life expectancy, also has a more egalitarian income distribution: 22 percent of income for the richest 10 percent, and four percent of income for the poorest 10 percent respectively. This is no accident: there is ample evidence that bigger income inequalities imply a worse health status - not only for the poor, but even when taken as an average. Let me repeat this: distribute your income more evenly over the population, and your average health status will increase as if by magic.

Hence, inequalities have relevance for global health, and inequities even more so as they depend on what we do and do not. WHO's Commission on Social Determinants of Health gathered convincing evidence that this holds true for many other inequities as well, e.g. those related to social exclusion; these are part of the whole complex of ‘social determinants of health'.

Does this hold true on an international level too? Would an elimination (or compression) of inequalities (economic and otherwise) between countries lead to a better health status of the world population? The disappointing answer here is: we just don't know. We cannot compare between worlds with more and less equitable distribution of resources over countries, and time series are only of very limited use in view of the many other factors that impact on health status. However, there is no real reason why a relationship that is so pervasive and clear on the level of national populations, should not hold true on the level of the world's population as a whole.

Clearly, this means that global health professionals should do something about social and economical inequities; but what? More on that in next week's article.

(Photo credit: Adam Gerard)

Commenter Catee Lalonde levels three fundamental critiques against Dahlgren and Whitehead's definition of inequity. The third one, about the meaning of ‘unfairness', is the topic of this posting.

Catee queries whether choices that we make as a society and that lead to serious inequalities (Catee cites the way the US has organised its health care system) mean that they are self-inflicted and consequently not unfair. The obvious answer here is: that depends. ‘Unfairness' should always be regarded in its context, and to understand that context we need to ask three basic questions about any disparity that could be unfair:

• Who is the disparity inflicted upon?
• Who profits from the disparity?
• Who inflicts the disparity?

In the example of the US health system, there are two ways of answering these questions, depending on whether you look at it from an intra-societal point of view or from a global point of view.

To start with the latter: the way the US system is organised contributes to a lower health status of its population than of comparably wealthy countries. From this perspective, the disparity is inflicted upon the American people in general, nobody really profits from this disparity, and the disparity is a result of actions and choices made by American society itself. Consequently, the disparity can hardly be called unfair.

However, things suddenly look very different when we look at these same questions from a perspective that is placed within American society. It is clear that some groups, especially those who cannot afford private health insurance, are much more disadvantaged by the system than others. Higher income brackets (who can afford insurance or even can afford not to be insured and to pay costs out of pocket) are much less disadvantaged and could even profit from the system: in a system that ensures greater parity, their tax burden would probably be higher. The difficult question here is the last one: who inflicts this disparity? Different answers are possible, but one could argue that the American political system disenfranchises exactly the people who suffer from this disparity: the poor, and those who struggle just above the poverty line. (Note that I am don't know whether that this is really true, but it can be argued, and has been argued quite convincingly - see our sister blog on universal health care for the hows and whys.) If one accepts this, the conclusion that this disparity is unfair is inescapable.

Would this mean that it is also inequitable? Not immediately: remember that Dahlgren and Whitehead's three requirements are cumulative, i.e. a disparity needs to avoidable, and unnecessary, and unfair. It is clear that this disparity is avoidable: it might not be simple to change the health system, but it is not impossible. Whether it is also unnecessary can only be answered by the American people (of which I am not part): do you feel that these disparities are essential?

(Photo credit: John LeGear)

In last week's posting, I discussed commenter Catee Lalonde's first of three fundamental critiques of Dahlgren and Whitehead's definition of health inequities. You might want to look up the resulting further discussion in the comments: in the end, it comes down to another definition, viz. the definition of ‘global health'.

The second part of Catee's critique deals with what is called the political economy of health: how economic choices impact society's (and societies') health. In theory, Catee is obviously right: allocate sufficient resources, and all health inequalities could be resolved. However, reality is a bit different. There are three limits to resources for health:

1. The ‘hard' limit of what our ecology can bear. We already see the negative results of our over-exploitation around us, and there are hard limits to the resources available to humanity - including the resources for health. Within this limit, it is clear that we cannot improve health for all developing countries to the same level as developed countries (perhaps to its present level, but by the time we reach that level in the least-developed countries, health in developed countries will have progressed even further). Of course, it is possible to lower the level in developed countries to the same level as that of developing countries - but I don't think even the most diehard health equality advocate would propose that.
2. Within this limit, there is the realisation that allocating more resources to health can actually have negative results: in extremis, if we would allocate all resources to health we would have no resources left to generate new resources - in other words: health is dependent on its surroundings (e.g. the economy) and we cannot allocate every available dollar to current health efforts without seriously damaging our health in the long term.
3. A third limitation has to do with choices. Not all well-being arises from health, and as societies, we make certain choices concerning how we promote the well-being of the people. In this, societies are no different from people: you do not spend all your money on health, but buy the occasional book or DVD, drink a nice cappuccino instead of a glass of water, or (for those of us who are feel less secure at night) buy a can of mace. Similarly, societies spend resources on the arts, public security, and defence.  You might not agree with the exact allocation, but I don't think anybody would want to live in a world without e.g. any form of art. This puts a softer, but nevertheless very real limitation on what will be allocated to health.

These three limits mean that, both theoretically and practically, we will never be able to eliminate all health inequalities between societies. It all comes down to one of the basic axioms of economics: every possible direction of allocation competes for ‘scarce' resources (‘scarce' here has a rather technical meaning, but can be translated loosely as ‘limited'). Getting everybody everywhere to the highest imaginable health status is, sadly, no more than a pipe dream.

(Photo credit: Ian Burt)

In last week's article on equity, justice and global health, I took as a starting point Dahlgren and Whitehead's definition of inequity: an inequality is inequitable if it is avoidable, unnecessary, and unfair. Commenter Catee Lalonde critiques this view on three fundamental issues:

1. All (or almost all) inequalities are due to specific actions or inactions, and this by itself makes them unfair. Consequently, the definition is internally redundant.
2. Hardly any health inequality would be necessary if sufficient resources would be allocated to alleviate it. Consequently, the ‘necessary' part of the definition is externally irrelevant.
3. One could query the intrinsic meaning of ‘unfairness': Do choices that we make as a society and that lead to serious inequalities (Catee cites the way the US has organised its health care system) mean that they are self-inflicted and consequently not unfair?

These are hard questions, and very cogent ones. They are important, not only for the results they have on inequities and how we deal with them, but also because of the implicit questions they ask about global health in general: Is there a limit to health? Where does personal responsibility take over from society's? Could present-day health efforts impact negatively on tomorrow's health status? Can there be health inequities between societies, or only between individuals? And many others. I will go into Catee's first critique this week, and will write more about the other two next week.

However, I would first like to make a point about definitions in general and about this definition in particular. Definitions are not goals by themselves: we define things to help us in our discussions. They serve as shorthand, so that when we talk about ‘lions' we do not have to refer to ‘tawny coloured, social African and Asian predators, second-biggest in the genus Panthera, the male of which is easily recognised by its mane'; our meetings are long enough as it is. A definition's value is determined by how well it fits with our mental image of the concept it describes. Dahlgren and Whitehead's definition is definitely not perfect, but it is the best I have been able to find - others are just even further off. So if somebody here would come up with a better definition, either from literature or original, I would be more than happy to adopt it and use that in further discussions.

So let's start with Catee's first point. Personally, I do not see why any inequality due to specific action or inaction would by itself be unfair. We all make choices and need to live with the consequences, and that we make different choices with different consequences does not automatically make the results unfair. The stunt man, the hoon driver, the couch potato: they all make choices and the results, a drastically lower life expectancy for all three of them, are not automatically unfair. Of course, I purposefully muddied the water here by including that last example: society and how it is organised can have a big influence on e.g. physical activity, and hence couch-potatoness and its results can be unfair - but not automatically. I have friends who are well-educated, well to do, live in places that are just made for walking and bicycling - and still are couch potatoes, because they choose to be so. Unfair that they will live shorter lives? Hardly.

(Image credit: The Edinburgh Blog www.theedinburghblog.co.uk)

Inequities: they are everywhere, aren't they?

The world is not a fair place. Anybody harbouring any illusions on that account should have a quick look at sites like Gapminder, which aims at showcasing the world's inequalities, or online database NationMaster, which consolidates and presents numerous (inter)national statistics. An insightful example is NationMaster's ranking of life expectancy at birth, which goes from 84 years for Macau, to 32 years for Swaziland. However, are these inequalities also inequities, and if so, what are the global health dimensions of these inequities? This article is the first in a short series that explores these two questions, as well as the question of what global health professionals can and should do about inequities.

What is an inequity?

From a global health perspective, the very least one can say is that there seems to be a clear link between a country's poverty and its health; e.g. Luxembourg, with the highest GDP per capita in the world, has a life expectancy at birth of 79, whereas the average Burundian, living in the country with the lowest GDP per capita, can expect to live 52 years when born. However, is this inequity, or ‘just' inequality? To answer this, we would first need a definition of inequity.

There are many different definitions of inequity. For example, Braveman and Gruskin see inequities as inequalities that are systematic between groups. A big problem with this definition is that it would lead to an endless stream of perceived inequities, as almost any inequality has some systematic element in it. A much better definition, hailing back to a 1990s paper by Whitehead and Dahlgren, suggests that inequalities are inequitable when they are avoidable, unnecessary, and unfair. This states much more clearly what exactly the injustice inherent in inequities is: they are not just unpleasant facts, but the result of our actions (or lack thereof). It relates much more closely to our instinctive understanding of inequities: an inequality is only an inequity if somebody, somewhere could have prevented or remedied it, the inequality is not a necessary by-product of a policy that aims to achieve a higher goal, and if we feel that the inequality is unfair to its victims.

This would imply that, by itself, the difference in life expectancy between Luxemburg and Burundi is not an inequity, as we have no realistic means to make Burundi as rich as Luxemburg (but it will not come as a surprise that I will qualify this considerably in the next article in the series). Neither is the difference in life expectancy between a person with a normal, active lifestyle and a professional daredevil an inequity, as it would not satisfy the fairness test: most of us would feel that the daredevil takes those risks purposefully and well-aware, and that he should reap the drawbacks as well as the benefits.

(Photo credit: Louis (CR Artist) @ flickr)

Victoria, the Australian state in which I live, has a women's health policy. Great... until the moment you realise that, on average, the state's women's health status is much better than those of its men: women live five to six years longer, and are 60% less likely to die from cancer or ischemic heart disease; men are two to three times as likely to die from accidents, and a staggering four times as likely to die from suicide.

Victoria does not have a men's health policy.

In many developing countries, the average woman dies much younger than the average man. Maternal mortality, unfair living conditions, and higher impacts of major diseases demand an unacceptable toll on women - much more than on men. Yet very few of these countries have developed (let alone put into practice) targeted measures to improve women's health.

Yet in Australia, women are obviously much more likely to suffer from maternal health issues than men; and in many developing countries, men are more likely to die from violence than women. And again: in Victoria, Koorie/aboriginal women have a shorter life expectancy than men, even non-Koorie men - and in many developing countries, rural men are likely to have a worse health status than urban women.

Silly debates on whether we should concentrate on men's or women's health are less than helpful. It is time for gendered health: a thoughtful recognition of differences in gender whenever we consider a (global) health issue, without resorting to knee-jerk references to either women's or men's health. And when I write ‘thoughtful recognition', I particularly think of knock-on effects, like the effect of early mortality of sole providers on the health of their families, or of early mortality of mothers on the health of their children (to name just two, rather role-confirming but real-life issues).

It is time to no longer use women's (or men's) health as lazily applied, blanket concepts or political correctness. If we are serious about the health of men and women, we should be serious about gendered health.

(photo credit: gullevek)

Discussions about health and human rights since the 1980s, even within the limitation of the lack of a truly integrated approach, have led to real progress: the rights-based approaches to health and development have made human rights integral to many discussions of global health work.

There is no single, canonical rights-based approach: rights-based approaches are many and diverse. However, while keeping this in mind, some common elements can be identified.

As the name implies, the rights-based approach uses human rights as its starting point for discussions about health: it looks at health through a ‘human rights lens'. As a result, it demands attention for many societal root causes for health issues. However, it does not address explicitly the impact of health on human rights conditions, nor does it readily recognise the interdependent relationship of the two. It puts a strong emphasis on process, making it as important as the health outcomes per se.

Its success has also been its failure. It has been immensely successful in putting human rights in the limelight as a determining factor for health and as a valuable tool for discussions about health and health policies. However, in doing so, it has neglected the intricate links between the two, to the point where it is sometimes accused of doing away with the classical public health approach, or even with ‘social justice', even when those approaches are more productive. Although advocates of the approach contend that the rights-based approach never meant to protect individual rights at all costs, they do not address the fact that this is how it works out in many practical cases - nor that even when it doesn't work out like that, its practitioners still tend to put more weight on individual human rights than on collective rights.

A last word

This was the last posting in the series on health and human rights. The series is the condensation of a personal search for the interface between two of my most abiding interests. This search, although satisfying by itself, has left me less satisfied with where we are today. Although the intricate and interdependent nature of health and human rights is recognised, the most important exponent of the movement, the rights-based approach, is highly rights-focussed; in practice, its entails primacy of (individual) human rights over (global) public health.

In my view, a new, practical synthesis of health and human rights needs to be found. My vision of an integrated field of health with human rights is output-oriented, but not solely output in the health sense: human rights and health outputs are treated as equal and (more importantly) mutually reinforcing. It integrates the fields in any health or human rights program from start to finish:

• When selecting a possible issue for intervention, by querying implications for health and human rights.
• When first designing the program, by continuously querying the intended and likely results for both health and human rights.
• When implementing the program, by linking back to public health and human rights theory and practice.
• When monitoring and evaluating the program, by incorporating both health and human rights indicators.

This is an ambitious (perhaps over-ambitious) program. However, it will deliver a new challenge to practitioners of both (global) health and human rights; hopefully making us practitioners of health-with-human-rights.

(photo credit: takomabibelot)

(Rudolf Virchow, the 18th-century advocate of health as a social rights issue.)

In my previous posting, I wrote about the negative impact health interventions can have on human rights. This time, I would like you to consider how the global health effort and other human rights can benefit from each other.

A terminal cancer patient cannot easily exercise their right to work (UDHR art. 23.1), nor can a comatose mother easily choose the kind of education for her child (UDHR art. 26.3). This is perhaps even clearer on the population level: e.g., a population ravaged by disease will not find it easy to take part in (or even have a) cultural life (ICESCR art. 15.1 sub a). Hence improving the health status of an individual or population will have positive effects on their ability to exercise other human rights as well.

It might even be clearer that human rights impact on health than the reverse - think of violations like torture or arbitrary detainment. However, the influence of human rights on health is much more pervasive: e.g., on first sight, the right to association might seem irrelevant to health, until one realizes the importance of NGOs for the global health effort. Perhaps a more obvious (but still often overlooked) example is the impact of discrimination of e.g. disabled persons on their health status.

In this context, it might be good to recall what I wrote earlier about Paul Farmer's ‘structural violence': social and economic inequities directly or indirectly determine who will benefit fully from human rights like health - and who doesn't. A good example from my adopted home country, Australia, is how earlier human-rights infractions have caused a significant lower health status for the aboriginal population.

The rise of this realization is often (and a bit lazily) placed with the first HIV/AIDS crisis of the 1980s. However, one can make a convincing argument that this approach is in fact much older, and that parts of it were already present in the writing of 19^th-century health advocates like Virchow, Leubuscher, and Villermé - and even as early as the 18^th-century work of Neumann. In this view, the human-rights approach to health is nothing more than an attractive "repackaging" of older ideas about social determinants of health.

Be that as it may, it is clear that this approach has been very successful - more so than Villermé or Virchow ever were. Health work has benefited from the development of human rights in many ways: by their explicit recognition of health as a right; by empowering the most vulnerable and marginalized; as a conceptual framework for analysis and response; as a standard to which governments can be held accountable, and consequently as a powerful tool for advocacy; and by using the existing human rights monitoring mechanisms for the health effort.

(Actors playing lepers. The treatment of lepers as late as 1996 in some developed countries would not be acceptable under current understanding of their human rights. Photo credit: SantiMB @ flickr).

"It is my aspiration that health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." - Kofi Annan

Global health efforts can have a powerful impact on human rights, even separate from their impact on health-as-a-human-right. They can promote other human rights in various ways; on the other hand however, limitations on e.g. the right to freedom have sometimes been justified with public or global health considerations.

Like I have said before: human rights rarely (if ever) deal with absolutes. Here, too: in most (going out on a limb, I would say: probably all) human rights instruments, rights limitations are possible, e.g. "...for the purpose of promoting the general welfare in a democratic society" (ICESCR art. 4). Global health considerations could be seen as "promoting the general welfare". This has been frequently invoked in the context of infectious diseases, e.g. HIV/AIDS, SARS, XDR-TB, and most recently swine flu.

This was recognised at an early stage, and in 1984 the Commission on Human Rights of the UN Economic and Social Council formulated the so-called 'Siracusa Principles', which give guidance when limitations of human rights are necessary. These Principles, although not part of any international treaty, are seen as highly authoritative interpretations of (amongst others) the ICESCR. The main Principles are:

• lawfulness: the restriction must be enshrined in law;
• necessity: the restriction must be "necessary", i.e. must respond to a pressing general need, pursue a legitimate goal, and be proportionate to that goal;
• subsidiarity: from all possible option, the least intrusive and restrictive must be chosen;
• non-arbitrariness: the restriction is not unreasonable or discriminatory.

The Siracusa Principles are highly restrictive in that they put a very high threshold before they justify limitations as acceptable. This is not always well understood, and sometimes limitations on human rights are argued based on selective reading from the Principles.

Based on the dictum that "[h]ealth policies and programs should be considered discriminatory and burdensome on human rights until proven otherwise", Gostin and Mann developed a more comprehensive approach to limitations on human rights and their impact. In their ‘human rights impact assessment', six steps lead to an assessment of the acceptability of a health intervention. The analysis encompasses trade-offs between rights encroachment and health improvement, and includes an assessment whether liberty-limiting interventions target only significant risk and are the least intrusive alternatives.

In a nutshell: global and public health considerations can be used to justify putting limitations on human rights - but only in rare circumstances and under strict conditions. Anything new here? Only for those who still cherish the idea of human rights as absolutes.