GlobalDisparities inHealth Rights: ACritical

Health Law and Ethics

Global Disparities in Health and HumanRights: A Critical Commentary

Solomon R. Benatar, MBChB, FRCP

Introduction

Global challenges at the millennium'sg1! end call for deep introspection by the peo-'m ple of the nations that have been most privi-

leged to benefit from scientific and eco-01ig nomic progress and for reevaluation of the

costs of such progress for those less fortu-nate. In this regard, we should consider howprogress is linked to exploitation of peopleand nature and how it contributes to thewidening national and global disparities (inhealth, wealth, and human rights) that nowjeopardize human health and survival. Suchthreats to billions of marginalized peoplecan be addressed only through a long-termperspective acknowledging that the self-interest of wealthy and powerful nationswill be optimized through the pursuit ofpolicies that foster all human well-being.Failure to respond to such global challengescan only lead to greater poverty and depri-vation, continuing conflict, escalatingmigration of "asylum seekers" from poor torich countries, and the spread of new andrecrudescing infectious diseases (for exam-ple, drug-resistant tuberculosis) and eco-logic damage that will harm all nationsindividually and the world collectively.

Consider, for example, that in the1960s the richest quintile of the world'spopulation was 30 times richer than thepoorest 20% and that this gap had increasedto over 60 times by the 1990s. An analogycan be drawn between this global scenarioand the problems faced in delivering healthcare, sustaining medical professionalism,and improving public health. Here the chal-lenge is to find ways of providing greaterequity in access to health care for individu-als within constrained budgets and themeans for improving population healthwithin nations and globally. If the annualper capita expenditure of $3500 on healthcare in the United States (10 times the totalannual per capita gross national product

[GNP] of half the world's population) is notenough to ensure access to a decent level ofhealth care for all US citizens, we must askwhat implications this has for US citizensand for the structure of health care systemsand health care delivery in poor countries.

I should like to offer here a synoptic(and therefore necessarily incomplete) per-spective on such complex global problems.My hope is that a perspective that acknowl-edges the complex roots of global dispari-ties while seeking resolutely to ensure morewidespread realization of human rights canrefocus attention on these issues and lead tomore open scholarly debate and new com-mitments to finding solutions that mayinfluence the future. Imaginative, globalthinking and visionary actions specific forparticular societies are the seeds for initiat-ing and propagating qualitative and quanti-tative changes that could have major long-term advantages for humankind.

Man 's Exploitation ofMan andthe Creation ofTwo Worlds

The Western world view has beenshaped over centuries through the power ofthe scientific method, analytical philosophy,industrialization, urbanization, democrati-zation, liberalism, and capitalism. The mod-em perspective emphasizes capitalism, thepursuit of rational economic self-interest,and the nation-state framework of interna-tional relations.12 These scientific, indus-trial, and economic developments, muchcherished in the Western world, have eman-

The author is with the Department of Medicine,University of Cape Town, and Groote Schuur Hos-pital, Cape Town, South Africa.

Requests for reprints should be sent toSolomon R. Benatar, MBChB, FRCP, Departmentof Medicine, University of Cape Town, Observatory7925, Cape Town, South Africa.

American Journal of Public Health 295


cipated human life and fostered unprece-dented human progress. However, theapplication of a somewhat libertarian ver-sion of liberal political philosophy,3 withoveremphasis on economic thinking (andunderemphasis on social and economicrights), has also been associated with ero-sion of spirituality, loss of a sense of com-munity, and division of the world (andmany countries) into a small, rich core anda large, poor periphery.4 Growing polariza-tion between these worlds as they drift apartthreatens the future of both wealthy andpoor countries. The failure of socialism, asimplemented under communist rule in theSoviet Union, has seemingly vindicated the"'capitalist" world view. However, celebra-tion is premature, because the crisis of lib-eral internationalism must now be faced,particularly in regard to the competing ele-ments of the liberal agenda-human rightsand the expansion of free trade.2 While theliberal vision has been effectively focusedon limiting excessive and arbitrary statepower, it has neglected the other greatenemy in today's world: violence amongthe poor and dispossessed and the disinte-gration of power leading to millions ofrefugees fleeing poverty and disaster.2'5

Human domination and subordinationof others in the understandable (perhapsinevitable) pursuit of self-interest has longbeen clearly evident. However, morerecently the scientific credibility given to aform of rationality based on economics thathas fostered the growth of powerful andunaccountable multinational corporationshas led to the evolution of less obviousexploitative behavior. It is less widelyappreciated how these more sophisticatedand more covert means of achieving short-term economic self-interest cast a shadowover a broader moral conception of life.1-'3

Fortunately, our consciences can bereawakened through critical thinking andsocial activism. For example, a 50-year pro-gram against slavery ultimately led to itsdelegitimation; the implications of destruc-tive uses of nuclear power are increasinglybeing counteracted through endeavors todelegitimate nuclear testing and prevent thefurther development of weapons of massdestruction; the degradation of human dig-nity inflicted through colonial imperialismin Africa (and elsewhere) is being morewidely appreciated; there is a deeper under-standing that nazism in Germany reflectedsubmission to authority and that such sub-mission to authority also occurs with differ-ent implications in other countries; and theadverse effects of neocolonialism resultingfrom the collusion of superpowers withdespotic leaders in developing countries are

being exposed. Lessons learned from theseadverse experiences increase awareness ofthe need for attention to a conception ofhuman rights that goes beyond civil andpolitical rights.

The International Bill of HumanRights (which includes the United NationsCharter [1945], the Universal Declarationof Human Rights [1948], and the Interna-tional Covenant on Civil and PoliticalRights [1976], with its optional protocol)was a global expression of the rejection ofhuman domination and exploitation of fel-low humans, a dedication to the need forrespecting individual human dignity, and anattempt to foster this through developmentof international law. Nations that refused toidentify with the Universal Declaration ofHuman Rights (for example, the SovietUnion and South Africa) and placed whatthey perceived to be their own self-interestabove high aspirations delayed their ownprogress toward peaceful democracies. Thefailures of socialism under communist ruleand of apartheid provide powerful mes-sages in favor of valuing human dignity andhuman rights. But less obvious humanexploitation persisted and grew within andbetween even those nations that aspired tobe the international guardians of humanrights. Sophisticated forms of exploitation,propagated through cultural imperialism,militarism, and devastating wars intimatelylinked to economic power struggles thatshaped a globalized economy, inexorablywidened the gap between rich and poorpeoples and nations and prevented thewidespread access to education, employ-ment, and other opportunities required tofoster the realization ofhuman rights.

A brief overview of some demographicdata and of wasted resources on armed con-flict will vividly portray the consequentpredicament of the world's poor. In the1990s, 77% of the world's population livesin developing countries. The 85%:15% dis-tribution of global GNP between industrial-ized and developing nations reflects respec-tive average annual per capita GNPs of$12 510 and $71010 (Table 1). In 1986, 50%of the world's rapidly growing populationlived in countries where the annual percapita GNP was less than $270.10 Poverty isincreasing in most parts of the world, andthis is a major factor preventing sustainablecontrol of population growth, which in turnthreatens physical and mental health as theprerequisites for a decent human life andglobal survival.

In addition, modern international eco-nomic policies have resulted in the extrac-tion of vast quantities of material and humanresources from poor developing countries to

rich industrialized nations. 1,4,9-15 Total devel-oping country world debt in 1990 was $1.3trillion (double the level in 1980), and it hadgrown further to $1.9 trillion by 1995.1 Thenet transfer of resources from developing toindustrialized nations between 1983 and1989 was $241 billionl': "a kind of colonialtribute extracted by the rich nations from thepoorest people on earth"'" to service theindustrial world's deficits and growthrates.'0 Thus, "the debt burden is a scandalwhich in numerical terms makes the interna-tional slave trade of the nineteenth centurylook like a petty crime."'5 Trade protection-ism in industrialized countries costs devel-oping countries a further $150 billion annu-ally in lost export earnings.'0 Finally, thelosses incurred through the "brain drain" areincalculable.

The world spends almost $1 trillion ayear (according to 1990 figures) on militarygoods and services.'2"16 About 20% of theworld's 2.5 million research scientists andengineers (50% of physicists and engineer-ing scientists) work entirely on militaryresearch and development.'7 Approximately$340 billion worth of military arms weresold or given to developing countriesbetween 1981 and 1988, most of whichwere produced by the Soviet Union or theUnited States.'2 The value of arms pro-duced in developing countries (under theinfluence of superpowers' expansion oftheir military industrial complex) increased500-fold between 1950 and 1980 (from $2million to $1.1 billion).'2 Such militariza-tion and the associated militarism havecompromised the health of individuals andnations through many mechanisms: killing,maiming, torture, refugeeism, destruction oflivelihoods, diversion of resources, crime,terrorism, black markets, poverty, starva-tion, environmental damage, and destabi-lization within developing countries.

Industrialized countries spend an aver-age 5.4% of GNP on the military and only0.3% on aid to developing countries. TheNordic countries admirably contribute 0.9%of their GNP to developing countries, mostfor social development, whereas the UnitedStates focuses most of the 0.15% of itsGNP it donates on defense support forEgypt, Israel, Turkey, Pakistan, and thePhilippines.'0 In 1990, British aid fell bytwo thirds of its 1979 value to the lowestever, 0.27% of GNP.'5

Despite Henry Kissinger's statement atthe World Food Conference in 1974-"Theprofound comment of our era is that for thefirst time we may have the technical capac-ity to free mankind from the scourge ofhunger"-up to 1 million people died in theEthiopian famine,'8 the specter of Somalia

296 American Journal of Public Health February 1998, Vol. 88, No. 2


TABLE 1-Disparities between "Worlds Drifting Apart." (Data for 1988 from Human Development Report 199110)

Industrialized World

Population % totalGlobal GNP %GNP per capitaPopulation growth rate %Population poorMaternal mortality: 100 000Life expectancy yrUnder 5 mortality: 1000Annual urban population growth rate 1960-1990Population below poverty line %Share of world trade 1968Share of world trade 1988Annual per capita utilisation of energy (kilowatts per year)Losses from trade protectionism/yr

AgricultureTextiles

Developing World

2385$12 510 (USA $19 840)0.80.3 billion2474.5181.42%84.8%87.1%3.2 (USA 9)

and Rwanda haunts us today, and the indus-trialized world continues to impose austerestructural adjustment programs that divertresources away from food, education,health, and welfare in poor countries torepay debts that can in reality never berepaid.13"15

The wealthy, productive, and fortunatein the world cannot be burdened with all ofthe blame for the complex series of histori-cal developments that polarize the world.However, insight is required into the com-

plex adverse social forces initiated and sus-

tained over centuries,4,10,14,19,20 which, withdestabilizing effects of "independence"under adverse conditions,21'22 distanced andfurther separated many developing coun-

tries from the industrialized world.4 Regret-tably, disparities between rich and poorwithin industrialized nations have essen-

tially similar causes,4'9"14 highlighting thepervasiveness of adverse economic policiesand the need to ameliorate these policies toimprove social stability.23

Ecological Implications

Domination and subordination throughexploitation of people is not the whole story.For centuries, the goals of philosophy andscience had been the search for wisdom inunderstanding the natural order and endeav-oring to live in harmony with it. Since thescientific revolution, this integrativeapproach to nature has shifted toward an

aggressive quest to dominate nature in pur-suit of economic growth that has, untilrecently, included little concern for its pro-found ecological and, hence, evolutionaryconsequences. "We are destroying the lifesupport systems of this planet and threaten-

ing not only civilization as we know it, butalso the survival of our species.... Cumula-tive use of fossil fuels has doubled every

twenty years since 1890." 24 The world haslost 500 million acres of trees since 1972(roughly one third the area of the continentalUnited States). Lakes, rivers, even wholeseas have been turned into sewers andindustrial swamps.25 The 1 billion peopleresiding in industrialized countries use 10times the resources and produce 10 timesthe waste per capita of the 4 billion peopleresiding in developing countries.24 What isneeded now, as never before, is a major shiftin our way of thinking about the future.2F26

Africa

The African continent has been mostseverely affected by the temporal relation-ship of the powerful social forces describedearlier to its economic and political devel-opment.18'21'27-30 The desperate condition ofAfrica has recently been reviewed from dif-fering but complementary perspectives.31'32The withdrawal of industrialized nationsfrom even attempting to deal with the direcondition of the African continent isreflected in the writings of political scien-tists. "The crisis is so diffuse and of suchmagnitude that the United States and theworld at large shrink from engaging it.- 30"In fact, history mocks the very idea of an

international coalition to save Africa." 27

Economic analysts now suggest that "withthe end of the Cold War, Africa has lostwhatever political lustre it may once havehad." 27 Southern countries are weaker indi-vidually and collectively than 15 years ago,and the debt crises have reduced their con-

trol over their own economic destinies.33

International affairs in the 1990s are

increasingly dominated by economicaffairs. As the Cold War recedes, there isthe danger that it will be replaced by tradewars between the three major northern eco-

nomic blocks and that increased competi-tion between southern countries may extendto armed (even nuclear) conflict.33

Deeply troubling questions persist andcannot be ignored. As Gill has asked in hispowerful account of Africa: Whose indus-tries benefit from continuing underdevelop-ment in the Third World? Whose consumers

benefit from primary products that keepAfrican producers just above the bread line?Whose bankers benefit from Third Worldindebtedness? Whose arms manufacturersbenefit from African arms races? Whosedelicate consciences are soothed by the giv-ing of modest gifts?'8 Hancock has docu-mented these concerns in a devastating cri-tique of the inefficiency, inadequacies, andcorruption associated with many officialinternational development aid projects.'3

Human Rights and InternationalEthics

The Universal Declaration of HumanRights has no enforcement machinery, yetas a statement of aspirations it has served as

the basis for constitutions and bills of rightsin many countries. Regrettably, worldwidepaper support for such human rights is fre-quently not followed in practice.7'8 In a dis-cussion of such widespread violations ofthe declaration, a South African activist,34outspokenly critical of industrializednations' morality, has suggested that thestatement "All human beings are born freeand equal in dignity and rights" is not a

American Journal of Public Health 297

7715$7102.31.2 billion29062.81164.032%15.2%12.9%0.28

$100 billion$50 billion

February 1998, Vol. 88, No. 2


social fact either in any liberal democracyrooted in the laissez-faire principles of capi-talism or in socialist countries.

There is no equality between the peoples ofthe First and the Third Worlds and there isno equality between a child born in anAfrican township and one born in a whitesuburb. The child in the slum is bornneither within dignity nor in dignity and heor she is born with practically no rights.....Theologically, we are born free and equal,sociologically we are born into differentialsocio-economic-emotional situations; andin the world in which we live sociologydefines our reality.... On a global levelthe [Universal Declaration of HumanRights] fails because of the ethnocentricsatisfaction of developed countries withtheir own state of freedom and theirgeneral unconcern for the freedom ofothers.... Those under their jurisdiction,as colonized or, in the sense of capitalisticexploitation, continue to be treated aslesser people, deserving of lesser rightswhatever the noble articulations of the FirstWorld.... Self interest and expediency,and not mutual concerns for each other'sfreedom and dignity, govern internationalrelations.

The depressing reality of this view isintensified by the despicable attitude thattwo thirds of all of the people in the worldare "superfluous from the perspective of themarket. By and large we do not need whatthey have; they can't buy what we sell."35Inconsistencies in human rights standardsdemanded of other nations by powerfulnations, the lack of self-assessment regard-ing rights that a monitoring country itselfviolates, and the consequent influence onhuman rights elsewhere should also benoted.36'37 Human rights are most at riskwhen political, military, and economic con-siderations become the overwhelming pre-occupation of governments.8

These concerns should not be misinter-preted as a "collectivist" critique of Westernliberal values; rather, they underscore theclash between competing elements of theliberal agenda: human rights and the expan-sion of free trade.2 The financial revolutionthat has been associated with massiveexpansion of the world economy since theSecond World War, together with the revo-lution in communications that encouragesinternational speculation and instantaneoustransfers of vast sums of money, has fos-tered the growth of an integrated globaleconomy. This has allowed multinationalcorporations, unfettered by the democraticrequirement of accountability, to wieldgreat economic and political power.Through such processes, the combinedassets of the top 300 firms in the world nowconstitute roughly 25% of the world's pro-ductive assets. Their formidable economicpower and transnational mobility increas-

ingly undermine the ability of nationalgovernments to provide the legal, monetary,or protective functions necessary for a well-working national economy. The trillion-dollar-a-day market for foreign exchangeeffectively places the valuation of anynation's currency at the pleasure of the"market" rather than at the discretion of itsmonetary authorities, thus disrupting therelationship between the economy and thestate. Less than 10% of the trillions of dol-lars transacted across financial networks arefor trade in goods and services. Of the 5.6billion people in the world, about 3.6 billionhave no cash or credit with which to makepurchases, and more and more people areclamoring to get into the global labor pool.The naive view that these trends can onlybe beneficial has been contested, and someof the adverse implications of such "irre-sponsible forces" (both for industrializeddemocracies and for developing countries)have been described.38'

Overemphasis on market forces and oncivil and political rights has eclipsed theneed to affirm the associated social and eco-nomic rights that foster essential commu-nity values.39'4' A broader formulation ofhuman rights must include state and corpo-rate duties to avoid depriving, duties to pro-tect from deprivation, and duties to aid thedeprived.42 Articulating the problems of liv-ing in the modern world and vigorouslyproposing possible solutions to theappalling conditions confronting humanitytoday must become intellectual and politicalpriorities if human rights are to be morewidely achieved.39'41'43 The challengesinvolved in redistribution of wealth, propa-gation of the education and skills requiredto sustain development, and reparations forcenturies of human and environmentalexploitation are fraught with diffi-culty.40'44'45 They are, however, surelyessential both within nations (as in the newSouth Africa) and at the global level toensure that progress since the scientific rev-olution is not limited to the rich at theincreasing expense of the poor.4"14'38'4044 4

Medical Practice and Healthfor All

The foregoing suggests an analogybetween global trends and Western medicalpractice. Advances in medicine and tech-nology have provided many with much cel-ebrated relief from suffering, hope for cure,and additional years of productive and sat-isfying lives but, through overaggressiveapproaches to transplantation and use oftechnology, have also inflicted intense suf-

fering on others in the quest for newknowledge.47'48

The progressively dominating influ-ence of "economic rationality" (with moneyas the bottom line) in medical care and itsbureaucratic implementation by powerfulmultinational drug companies, insurancecompanies, and managers are also impover-ishing the concept of medicine as a caringprofession. "Increasingly, physicians findthemselves engaged in bureaucratic andpolitical struggles that sap their time andenergy, exhaust their patience for treatinguninsured people, and erode their dig-nity."49 Impressive scientific and medicaladvances with profound impacts on humanwell-being have, regrettably, become asso-ciated with an inequitable, costly "medicalindustrial complex" within the most power-ful nation on earth.50

Market-driven health care in a power-ful nation has profound symbolic and mater-ial effects on health services worldwide.Health care delivery is being transformedfrom a professional service delivered withdedication, concern, and compassion withinmutually rewarding and trusting healingrelationships4951 toward the sale of a com-modity in an adversarial marketplace inwhich professional satisfaction from patientcare is being eroded and increasinglyreplaced by rewards external to the profes-sional service: satisfying health servicebureaucrats and acquiring wealth, scientificfame, and prestige among peers. Legitima-tion of this transition transmits a powerfulmessage that gravely undermines the willand ability of other nations to develop andsustain equitable access to affordable healthcare. Established national health systems(for example, those in Canada and theUnited Kingdom) are fracturing under theinfluence of the market model, and healthcare refonn in the new South Africa is beinglargely confined within a shrinking andweakened public sector while a bloated pri-vate sector continues largely unaffected.52

Efforts to reverse these trends by dedi-cated and enlightened physicians5051'53-55are supported by professional organizationsin the United States56'57 and throughchanges in medical education that incorpo-rate education in the humanities into themedical curriculum.58 59 However, healthcare reform in the United States, and else-where, remains an elusive goal. Debatemust go beyond medical education and thephysician/patient relationship to includeconsideration of macro-allocation ofresources, the structure of health care sys-tems, and ways to deliver health care thatwill enhance the dignity and lives of indi-vidual patients and advance population


health. Recognizing international disparitiesin health and health care provision as thesingle gravest problem of medical ethicschallenges physicians, lawyers, and ethi-cists to become involved in global aspectsof justice, human rights, and healthcare.6067

The Future

Complex interlocking contributions tothe emergence of an unequal world need tobe openly acknowledged and addressed ifprogress is to be made toward widespreadachievement of human rights and improvedpopulation health.3'4 10,42-44,63-71 Sustaininghuman development requires a much moresophisticated approach than can beachieved through patemalistic dispensationby well-intentioned but largely unaccount-able aid agencies13"18 or through WorldBank loans.71 The 1991 Human Develop-ment Report describes a human develop-ment index (calculated on the basis of liter-acy and life expectancy, as well as percapita GNP) that goes beyond economicconsiderations alone and suggests linkingfinancial aid to human development ratherthan merely to consumption, as a strategy toaccelerate human development as a unify-ing concern for both industrialized anddeveloping countries.'0

There is now also growing acknowl-edgment of the enormous disparity betweenexpenditure on military endeavors and onsustainable development and of the poten-tial for the diversion of resources to the lat-ter in order to foster self-actualization andself-sufficiency, which could help spreadrespect for and achievement of humanrights.72'73 Linkage of economic growthwith human rights through human well-being is the key to progress and is a unify-ing concern for developing and industrial-ized countries.'0'44

The operationalization of suchprocesses through (1) cancellation of someof the unpayable debt accumulated by someof the poorest countries in the world,'5'32 (2)continuing attempts to redirect militaryexpenditures toward social development,72(3) taxation on electronic financial transac-tions, and (4) suggestions such as those bySusser65 and others66'67 to advance theachievement of global health and humanrights are the challenges of the future.These challenges, it is hoped, will beadvanced through linkage with the plannedWorld Health Organization proposal for aglobal health charter.74

There is also a need for us to begin tounderstand diverse world views and value

systems.75 Progress lies not in propagatingfalse dichotomies but, rather, in working toacquire deeper understandings of differ-ences and the willingness to create solidar-ity through greater identification with com-mon human attributes and aspirations.68'69Wealthy nations that show concem largelyfor their own short-term economic self-interest could consider whether they areunintentionally behaving like countries thatfailed to identify with the Universal Decla-ration of Human Rights in 1948. The credi-bility of their commitment to contributingto achieving a broad range of human rightsfor all is now in the world's spotlight. Theirability to acknowledge and act on theirawesome responsibility to humanity willshape the world's future.

The universal humanistic ideals forwhich medicine strives are, like humanrights for all, unattainable without seriousattention to the concept of internationalinterdependence and the consequent restruc-turing of health care systems, especiallythose in powerful and wealthy nations thatserve as role models for the world.57'76'77 TheAmerican Association for the Advancementof Science has demonstrated vision andadmirable moral responsibility in its call fora human rights approach to health carereform.57 Further support could be providedthrough forging closer links between thebioethics movement and the promotion ofhuman rights.65-7'78-80 These ideas, like thecall for transnational actions by physiciansand lawyers,66'67 are embryonic but areincreasingly widely shared73'74 and in needof much hard work to be developed intoaction plans.

The complexity of these tasks shouldnot be a deterrent. As the celebrated Niger-ian author Chinua Achebe has stated,despair should not eclipse hope: "neitherhistory nor legend encourages us to believethat a man who sits on his fellow will someday climb down on the basis of soundsreaching him from below. And yet we mustconsider how so much more dangerous ouralready very perilous world would becomeif the oppressed everywhere should despairaltogether of invoking reason and humanityto arbitrate their cause." 81 D

AcknowledgmentsI am grateful to Professors Heribert Adam, KogilaMoodley, H.C.J. van Rensburg, Peter Folb, andFredrik Barth; Dr Elena Nightingale; and theanonymous reviewers for their constructive assis-tance and encouragement and to HarvardUniversity for a Fellowship in the Program inEthics and the Professions in 1994/95, duringwhich this project was further developed.


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GlobalDisparities inHealth Rights: ACritical