• Define the emerging discipline of global health ethics and its components
  
• Expand the dialogue on global health ethics and its relationship to human rights; culture, including race, gender, ethnicity, and religion; poverty; and ill health
  
• Discuss the concept of the “global being” or the “global person” in the milieu of equity, equality, justice, and benchmarks of fairness

The world is changing, and one product of this change is the rapid emergence of a new discipline: global health ethics, the theory and practice of ethics in a holistic manner informed by multiple disciplines. These disciplines include public and population health and health systems; biotechnology and other scientific research; philosophy, including ethics; and other fields, such as anthropology, psychology, sociology, economics, religion, and law. Practitioners of global ethics thus include not only health care workers and researchers but also practitioners of international biolaw, philosophers, bioethicists, moral and civic leaders, human rights advocates, environmentalists, experts in religion, social and biologic scientists, governmental officials, and nongovernmental organizations. Once considered independent of (and often competing with) one another, this diverse group has converged to achieve a common overarching goal: the well-being and thriving of the global being (person) within the worldwide community. This collective entity is embodied in each person and transcends differences between groups of people regardless of whether these differences are based on race, ethnicity, political affiliation, economics, culture, education, language, gender, age, or religion.

Whereas the traditional concept of international health focused on bilateral interactions between well-to-do and poor countries, the concept of global health reaches beyond the rich-poor dichotomy and geographic borders to the forces that separate the powerful, free, privileged population from the population that is powerless, unfree, and marginalized. In its acceptance of human diversity, global health is an expression of support for human rights. And with human rights as a key value, global health ethics thus provides moral guidance for world health systems and governance. It is critical that a very comprehensive World Health Organization (WHO) definition of health be used in our discussion, that is, health as a state of physical, social, mental, and spiritual well-being that extends beyond the absence of physical disease or infirmity.

For the purpose of our discussion, two definitions highlight different aspects of global health but to a certain extent are complementary: Velji and Bryant’s understanding and definition of global health “with a human face” emphasizes shared ideas, ideals, and values: global health is a new paradigmatic vision and action that rests on human ideas, ideals, and values of providing high quality of health for all globally. It has at its core equity, compassion, altruism, sharing, sensitivity, dignity, respect, philanthropy, and professionalism. It is bound by a global ethical code of conduct and governance that transcends borders, socioeconomic standing, ethnicity, caste, and religions. It enshrines the notion of the “global good.” Global health as a collective entity and enterprise is beyond the component disciplines, philosophies, and sciences but is informed by them. As a new mindset, global health is mindful of individual liberties and societal good. It enshrines the principles of equity, solidarity, beneficence, avoidance of malfeasance, promotion of fairness, and autonomy with responsibility. Global health is mindful of the privileged connections that exist between all human beings. It is science and evidence based and informed by the socially sensitive input of all parties involved.1

Koplan et al define global health in more practical terms with an emphasis on study, research, and practice: “Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.”2

In recent decades, the development of global health was greatly influenced by the 1978 International Conference on Primary Health Care, convened by the WHO and UNICEF in Alma-Ata (Kazakhstan, USSR).3 At that landmark conference, primary health care was established as a fundamental component of health care, with equity and the right to health care as core features. The conference responded to ongoing global changes, particularly with regard to their ethical dimensions.

Because it encompasses clinical/medical ethics, public health ethics, population health ethics, and bioethics, the study and practice of global health ethics are potent tools for alleviating human suffering, poverty, disease, and environmental degradation, both locally and globally. For instance, in the field of research, global health ethics challenges its practitioners not only to identify promising research subjects but also to assure respect for their equity, dignity, and human rights when interacting with them and their communities. Furthermore, global health researchers continue to be challenged by the extensive imbalance in research support available to well-to-do countries compared with resources available to poor countries: ninety percent of all medical research funds are expended by and for the wealthiest countries to address 10%—their share—of the worldwide disease burden.

Today, global health practitioners and policymakers recognize that individual health security—an essential component of personal well-being—is a human right that every civil society is obliged (and therefore must be empowered) to protect. This obligation is emphasized in the United Nations (UN) Millennium Development Goals, which insist that major obstacles to human social, economic, and health development be addressed. In partnership with global health ethicists, these goals recognize that ethical reform in national and global governance is a necessity in the 21st century amid the threats and spread of global violence, erosion of health gains accumulated during the past two centuries, and emergence of novel health challenges.

Public health ethics focuses on the general public good of the population (instead of the individual). The “macro-ethics” of public health transcend both the “micro-ethics” of medicine (with its provider-patient relationship) and “meso-ethics,” which operate at institutional levels. Public health concerns envelop health and safety issues at the city, state, and country level. The principles and practice of public health may be at odds with the “micro-ethics” of individual rights and autonomy. A case in point is the classical ethical conundrum of mandating quarantine for a patient with a communicable disease such as tuberculosis or severe acute respiratory syndrome (SARS).

Clinical ethics (also called clinical medical ethics) is a burgeoning field that focuses on improving the quality of patient care by identifying, analyzing, and attempting to address the ethical problems that arise in clinical practice. Clinical ethics is acknowledged to be an inherently inseparable part of good clinical medicine and includes concerns of the patient’s family.4 Clinical ethics as a discipline consists of research, teaching, committee work, and consultation activities.4 The primary emphasis of clinical ethicists is the quality of end-of-life care and conflict resolution within the framework of clinical ethics committees. To date, clinical ethics as a distinct discipline has been primarily a phenomenon of developed countries and is based on secular premises: “Clinical ethics is not founded in philosophy, law or theology but instead on the subdiscipline of medicine, centering upon the doctor patient relationships.”4 In many institutions, committees that meet to discuss issues of clinical ethics are called “bioethics committees” or “biomedical ethics committees.” As an academic discipline, clinical ethics addresses questions at the clinical level, such as informed consent, autonomy, and death and dying.

Often called “bioethics,” biomedical ethics is an academic discipline limited to learned societies and academicians; it is the purview of departments of philosophy. At the national level, bioethical forums discuss institutional and national policies and issues such as health care rationing and access. Bioethics relates to the ethical questions and dilemmas that arise at the interfaces between medicine, biology, cybernetics, politics, law, theology, philosophy, technological research, and the ethics of morality, duty, and obligations. In the global context, newly emerging issues related to human genomic research and other major developments of biotechnology, such as cloning, xenotransplantation, and stem cell research, have become focuses of bioethics.

The post–World War II emergence of bioethics in the United States evolved around the Protestant values that predominated in US culture. This concept was elegantly encapsulated by Jonsen, who stated, “US medicine had in the immediate postwar years begun to build a wall around itself and within that wall a complex edifice. Three streams of bioethical concerns highlighted that reality. The therapeutic stream, which brought new treatments, found that it had to exclude persons from them, as the ‘God Committees’ chose some to live, others to die. The experimental stream, on the other hand, seemed to capture some, entrusting them into treatment they did not want or need, and repelling others from treatment they needed. The scientific stream was perhaps the most ominous, suggesting in the power the remaking of humans in an engineer’s image.”5 In the early 1960s, vigorous debate in the “God Committees” centered on the first genuinely life-supporting, lifesaving technology: chronic hemodialysis.5

The second bioethical model is that of “Euro-Ethics.” This model also has limited value because it lacks diversity and the notion of plurality. The focus of Euro-Ethics is the philosophy of medicine and epistemology; this focus contrasts with the American model of bioethics, which is more closely aligned with applied and practical ethics.5

Nominally and conceptually, the modern discipline of bioethics is seen as an offspring of a Western, predominantly US, model characterized by scientific voluntarism or the technological imperative and libertarian or secular morals. This focus demonstrates radical change of the tradition of “bios (life) and ethike (ethos) through manipulation of life.”6 The discipline of bioethics as viewed by the developing world is “conceptually a synthesis of the advances of science and the mandates of conscience.”6 The Roman Catholic perspective, expressed predominantly in Latin America, is succinctly described as containing bioethical premises based on the principle of holiness of life and on the imperatives of natural law as supported by the moral theology of the Catholic church.6

Can the rules, laws, and principles of secularism be separated from religious rationales and the sanctions of God’s reward and punishment? Secularists and religious fundamentalists are at odds on several issues of current relevance in the new millennium. One danger of the Western (and particularly the American) form of biomedical ethics is the “unleashing of absolute individualism and moral atomism of a socially destructive kind.”7 This powerful, incessant drive operates in issues such as euthanasia, assisted suicide, abortion, purchase of organs for transplantation, all forms of reproductive technology and surrogate parenthood, preservation of confidentiality, and the use of public health funding for research.7

Traditionally, medical practitioners have focused on personal health from a limited perspective (prevention, diagnosis, and treatment) and were bound by ethics and covenants traceable to ancient civilizations (India, Persia, Egypt, China, Greece), whereas the new discipline of global health requires a vocabulary that defines health as a state of physical, social, mental, and spiritual well-being that extends beyond the absence of physical disease or infirmity. The new dialogue on global health has already outgrown the limitations of current terminology (e.g., “international health”), and no consistent vocabulary yet exists that adequately describes the conceptual framework and operationalization of global health ethics. Language is needed to fully convey the global cultural contexts for such terms as individual and public good, equity, inequality, rights, solidarity, beneficence, autonomy, justice, fairness, dignity, virtue, and responsibility. Indeed, with the onset of globalization—a set of new economic realities amid disappearing political boundaries—the world’s thinking must be reoriented to achieve health in this new millennium.

This reorientation is being guided by leaders in the emerging field of global health who contribute their experience and ideas regarding major health-related concerns of social science (e.g., societal discrimination and inequality, health care rights, population displacement, poverty, ethics of environmental practices and technology transfer, access to primary health care services, health care financing, education, global networking) and of natural science (e.g., diagnosis and treatment of diarrheal, respiratory, tropical, and infectious diseases; malnutrition; and global disease burden), summarized in two seminal volumes edited by Velji.8,9

Two volumes on global health, Global Health Education and Infectious Disease in the New Millennium, extended this dialogue further by engaging more global health thought leaders to focus on the 21st-century challenges and solutions.10,11

As an example of steps taken to address human rights and social determinants of health, both locally and globally, through education, service, and research, a consortium—originally named International Health Medical Education, subsequently renamed Global Health Education Consortium and now a merged entity, Consortium of Universities for Global Health,12 was founded in 1991, to address new challenges of global health, global health development, and education.13 The cofounders of this consortium stated their intent to impart a systemic networking approach to global health education by focusing on marginalized populations around the world. This intent was subsequently articulated also in the historic 1997 WHO policy statement, which stated that “Health for All in the 21st century … [must be] built on the genuine expressions of moral obligations to protect the vulnerable and to mitigate inequities … with … science-based and socially sensitive methods.”14

Accordingly, a director general of WHO articulated its changing role as the world’s health conscience: “The role of WHO … must include ethical standard setting to meet today’s and tomorrow’s needs in such areas as cloning, reproductive health, and access to triple-drug treatment for persons with HIV infection, or the use of interferon for hepatitis C carriers. Many issues relating to fair access to preventive, therapeutic and rehabilitative technologies should be considered, and ethical guidelines should be prepared.”15

From the perspective of the developing nations, globalization is manifested as an onslaught of ethico-religious, cultural, technological, economic, and informational changes that disrupt established societies. These globalization-related changes result in the marginalization of vulnerable populations, whose health is further affected negatively by additional phenomena present throughout the world: unethical organ donor policies, militarization, privatization, unfair trade practices, and economic sanctions.16–18 All these phenomena cause continuous and sporadic societal paradigm shifts that transcend national boundaries and affect the politics, ecology, economics, education, and health of entire societies. Without a commitment to ethical principles—human rights and freedom, justice, fairness, equity—the weak, disadvantaged global citizen is denied access to education, housing, jobs, and food and is placed in a lopsided struggle against the privileged citizen within a neoliberal, highly individualistic environment. Lack of ethical intervention will continue to erode health care not only in the developing countries but also in the developed nations.

The enormous size of these challenges calls for ethical policies that benefit the vulnerable and have equity at the core. This essential element was affirmed in the WHO Declaration of Alma Ata3 and was a centerpiece of renewing the WHO Health for All call.19 Health equity involves more than equality and is not a “vague but politically popular desire for social justice.”20 Instead, health equity is “a feasible and tangible process” in which health benefits are received according to measurable need, not on the basis of economic or political status.20

Surveillance of equity status is a practical management tool that makes the moral imperatives of social justice feasible.21 Inequities in health care—and especially in health outcomes—imply presence of a subset of measurable inequalities that are both unfair and avoidable. Equitable distribution of health care is not necessarily sufficient to overcome health inequities; health equity is measured also by the extent to which disadvantaged populations can exercise their human right to justice and fairness in the context of achieving well-being.

The 19th-century British epidemiologist William Farr is credited with having initiated the scientific study of health inequalities,22 a central feature of the European tradition, especially in the United Kingdom. Unlike the normative concept of health equity, health inequality is a primarily empirical concept that emphasizes the disparity between rich and poor populations and thereby avoids focusing on the health of the poor.23 The most daunting challenge of the third millennium is to understand the causes of health inequity and how health care is distributed within and between countries. Central to this concern is the need to create health systems on the basis of fairness, distributive justice, human rights, democracy, and peace-building—a suggestion echoed by a Rockefeller Foundation report,24 which presents diverse dimensions of health equity in 13 countries. The report explores fundamental issues, such as ethics and its measurement as well as causal analysis related to underlying social determinants (e.g., gender, globalization) and argues explicitly that specific fairness-related values are involved in distributing health care and facilitating positive health outcomes. The report discusses remediable health inequalities, including unequal access to resources—financial assistance, education, job security, clean air and water, sanitation, health care—and gender inequality. Within any society, health inequity is both a proxy and a barometer for marginalization, for deficiencies in social justice and human rights, and for lack of democracy.24

To be accurate, any ethics-based measurement of inequalities in health care requires a sophisticated technique. Ideally, this measurement technique would consider the distribution of ill health across the full socioeconomic gradient and not only within a selected segment of the population.

The classical health status indicators used for monitoring global health achievement includes rate of infant mortality, overall mortality and morbidity, and combined rates of mortality and morbidity (described by indicators such as quality-adjusted life years, disability-adjusted life years [DALYs], and health life years). (See Chapter 2 for more information on these measures.) However, these indicators fall short of monitoring equity in health care. The Council of International Organizations for Medical Sciences (CIOMS) working group suggested monitoring of other health services indicators, including accessibility, affordability, utilization, and coverage of health care along with its appropriateness and procedural fairness. Moreover, processes of decision making must be visible, and caregivers must be accountable.25

The sea-change in the ethical search for cost-effective and equitable care has focused on one vexing philosophical, theological question: How should life be valued? This question subsumes others: should life be valued in terms of economic and social productivity or in terms of a given duration of life, with its intrinsic value and variation by age, economic productivity, and social status? How do we measure the value of future life versus that of the present? As Morrow and Bryant state,26 measuring and valuing human life contribute importantly to understanding the disease burdens in populations and to guiding thinking about the most appropriate ways to address those burdens with health care intervention. Such interventions are mindful of ethical dimensions of health and human development.26 Are DALYs considered to be an ethical measure that is also sensitive—both quantitatively and qualitatively? How do these concepts fit into the ethics of public, global health decision making versus the traditional, doctor-patient–based ethics?26,27

The 1993 World Bank Report Investing in Health28 focused on quantifying and comparing the disease burden borne by diverse populations. The metric created for this purpose was the DALY.29,30 Subsequently, the concept of the benchmarks of fairness, initially introduced by Daniels et al,31 queried various equity-related dimensions of health care reform, including provision of universal access to services, comprehensiveness of services, uniformity of benefits, equitable financing as determined by ability to pay value for money (clinical financial efficiency), public accountability, and degree of choice.32–34 Thailand, Pakistan, Mexico, and Colombia have modified and refined some of these matrices. In Pakistan, for instance, the following benchmarks were introduced: intersectoral public health; financial- and gender-related barriers to access; comprehensiveness and tiering of benefits; equitable financing; effectiveness, efficiency, and quality of health care; administrative efficiency; democratic accountability; and patient-provider autonomy.33

In the setting of low-income and insufficient data, unique thinking and creation of novel benchmarking tools are needed for building greater capacity to monitor and analyze policies from an equity-ethical perspective. In postapartheid South Africa, another tool—the equity gauge—was invented to enable legislators at both the national and subnational levels to monitor the impact of government policy on health systems.34

One cannot discuss global health ethics without addressing poverty, inequity, and injustice. This section examines some examples of these issues and how they affect the health of people around the world.

Orphans and Other Vulnerable Children of the Urban Slums of Africa

Of the 350 million children under 17 years of age who currently live in sub-Saharan Africa, 43 million (12.3%) are orphans.35 In addition to these children, however, a very large number of nonorphaned children in sub-Saharan Africa are nonetheless highly vulnerable for other reasons; therefore, focusing concern on orphans exclusively would be unfair and unjust. The orphans and other vulnerable children of Africa are the most disadvantaged of any in the world. The dimensions of such disadvantage reach far beyond what usually comes to mind in considering the lives of such children, whether these factors are physical, economic, social, cultural, educational, ethical, or rights based.

The practical realities of vulnerable children include a broad range of deeply troubling circumstances, including the circumstance of being orphaned, abandoned, or physically handicapped; forced to become a child soldier; being displaced by war or exposed to hazardous work; becoming a victim of human trafficking and other forms of abuse and neglect; living in extremely poor conditions; being homeless, living on the streets; or a combination of these circumstances. To these threats to health and well-being must be added the further burdens imposed by the HIV/AIDS pandemic: of the 43 million orphans living in sub-Saharan Africa, 28% were orphaned as a result of HIV/AIDS.35 (See Chapters 4 and 5 for more on this subject.)

These vulnerable children can thus be defined as those whose safety, well-being, and development are threatened. Of the many factors contributing to these children’s vulnerability, the most important are lack of care and affection, adequate shelter, education, nutrition, or psychological support, and, of course, frequent discrimination.

Recent research has identified two fundamental qualities that determine the caregiver’s ability to provide effective care: sensitivity and responsiveness to the child. These skills enable the caregiver to detect the child’s signals and to respond appropriately, in synchrony, to meet the child’s needs and promote the development of a child who is physically, intellectually, and socially healthy and more resilient to the damaging effects of poverty and violence.36 A useful approach might be to reach beyond the generalizations relating to these children to focus on the extremely vulnerable population of children living in Africa’s urban slums. Of people living in the large urban slums of Nairobi—70% of that city’s population—79% live in one-room homes without running water or sanitation and usually without electricity. One can only begin to imagine the extreme difficulties of families trying to build constructive lives under such circumstances; not surprising, therefore, is the exceedingly high mortality rate for children under 5 years of age. In some areas, this rate reaches 25% of children. More than half of these childhood deaths are associated with malnutrition.37

To address the needs of those living in the slums, UN Habitat has committed its members to the Millennium Development Goal of improving the well-being of 100 million people dwelling in the urban slums of Africa, simultaneously expressing concern for the orphans and other vulnerable children in those slums.38

Given the immense burden on the health and well-being of those children, one can easily understand the existence of multiple approaches to alleviating these children’s problems. Indeed, no fixed set of answers exists, and accessible resources fall far short of need for them. Multiple approaches are thus needed and used, and a great challenge is to create coherent interaction among those responses.39

One distinct pattern of need is relatively new and underappreciated. There have been recent advances in the science of early childhood development that are exceedingly important. The National Academy of Science USA40 and the WHO41 report that early caregiver-child interactions, beginning in the early days of life, are strong foundational determinants of social, psychological, physical, emotional, and cognitive capacities of the young child; a strongly nurturing, loving, protective, stimulating caregiver-child interaction is essential for the child’s early development. In contrast, a negligent, unprotective, nonloving interaction can be disruptive, damaging, and produce lifelong negative effects. The nature of these caregiver-child interactions or attachments has been further defined as representing secure attachment (which is supportive, nurturing, and loving) or insecure attachment (which is negligent and disruptive). Considerable research has been focused on the nature of these attachments and their positive and negative consequences.

Applying these concepts to the circumstances of the lives of vulnerable children in slum settings adds insight not only into the risks to these children’s well-being but also into the nature of equity. Let us consider for a moment the place of equity in caring for these children. Equity in child care calls not for equal distribution of care but for delivery of care according to need. Health care programs for vulnerable children in the urban slums are challenged by the extreme scarcity of resources and active community participation. The aim of these programs is therefore to identify those children most in need and to respond accordingly.

A disturbing equity-related issue is the widespread underappreciation of the importance of early caregiver-child attachments for the foundational development of the child. For example, little local concern is expressed for orphans and other vulnerable children sitting in the trash and mud of an African slum community; the response to this situation is often, “They are poor to be sure, and perhaps hungry, but they are not being harmed.” In addition to the potential damage of malnutrition and exposure to infectious disease, the lack of sufficient, positive caregiver-child interactions early in these children’s lives does indeed cause them harm. The development of life skills—in particular, the ability to cope with the complex difficulties of their corner of the world—is seriously diminished in these children. Thus this emerging example illuminates the unseen inequities affecting a large number of children in Africa.

That these children lack opportunity to have a good life is a violation of their human rights, and this deprivation also must not be neglected. Working with UN Habitat in the slums of Nairobi, Bryant and colleagues have developed a project focused on the health care and social support of orphans and vulnerable children under 5 years of age in three slum communities of Nairobi, Kenya. One of the purposes is to develop a methodology that could be extended to other African communities. A prime focal point is to demonstrate the feasibility of achieving assessment of caregiver-child attachment by community health workers (CHWs) as a routine component of community-based primary health care (PHC). Given the effectiveness of such assessment, further community-based actions are to be taken, in support of secure attachment or corrective actions relating to insecure attachment.36

Thus an important component of the project is the selection and training of CHWs, eight in each of the three communities. There are now 2,400 community households in the three communities, each containing one or more children under 5, and the CHWs arrange to visit each of those households once every 1, 2, or 3 months, depending on the needs of the children. There are two major components of the work of the CHWs. One is to extend PHC to those children, including growth monitoring, immunizations, and use of insecticide-treated bed nets, handwashing with soap to prevent diarrhea, oral rehydration therapy, nutritional supplementation, and general child well-being. The second component includes assessment and monitoring of caregiver-child attachments. A methodology for assessing caregiver-child attachment was developed through an iterative process, building on other validated assessment tools.

Of the 2,560 children assessed from July to December 2010, 2,391 (90.2%) were assessed as having a secure attachment with a parent or other caregiver; 259 (9.8%) were assessed as having an insecure attachment. Children with a secure attachment were more likely to have a normal weight-for-age compared with children assessed as insecure, and they were less likely to have diarrhea or malaria at the initial CHW visit. Following workshops focusing on methods to strengthen caregiving relationships, follow-up assessments showed that among the 259 children initially assessed as insecure, 215 (83%) were assessed as having a secure attachment.

Thus it is apparent that assessment of caregiver-child attachment in the setting of routine home visits by CHWs in a PHC context is feasible and may yield valuable insights into household-level risks and responsive actions. This reaches beyond a goal of child survival to important gains in early child development.

Further, we see here the affirmation of a methodology for encouraging and supporting secure caregiver-child attachments that can be community based and equitably distributed, accessible to all of sub-Saharan Africa. We do appreciate the complexities of building collaborative relationships supportive of such processes, but we see the potential benefits as exceedingly attractive to African communities.36 Special attention should be given to the five key strategies (see Table 21-1) discussed in “Framework for the Protection, Care, and Support of Orphans and Vulnerable Children living in a World with HIV and AIDS,” which appeared in Children on the Brink 2004.35

Inequity and Poverty in the Global Health Equation

Inequity is deeply rooted in the soil of poverty, and the oft-expressed question, “Am I poor because I am sick, or am I sick because I am poor?” points to the inter-penetrating relation between poverty and global health. Accordingly, global opinion is now focused on the health of the poor along with the ethical notion of inequality in health care. Poverty-oriented economics has thus gained recognition on the world stage.42 (See Chapter 19 for more information on this topic.) Nonetheless, societal discrimination at various levels and predatory unethical practices—prevalent globally, regionally, and locally—still prey on the vulnerable. After a long study of AIDS, Mann stated, “The central insight from a decade of hard work against AIDS is that societal discrimination is at the root of individual and community vulnerability to AIDS and other major health problems of the modern world.”43

Table 21-2 outlines a three-step process focused on ethics, which has been proposed for addressing the societal risk factors operating worldwide.43 Central to this three-step process is a concept applicable to a wide variety of global health problems, “A careful analysis of the major causes of preventable illness, disability, and premature death—including cancer, heart disease, injuries and violence and infectious disease—shows that they, like AIDS, are linked to societal discrimination and lack of respect for fundamental human rights and dignity.”43

In the 21st century, the primary cause of ill health is poverty. Recent climatologic and geologic catastrophes in the first few years of the present millennium—the Indian Ocean tsunami; Hurricane Katrina in the United States; and earthquakes in Turkey, Iran, Pakistan, and Haiti—garnered global attention to the susceptibility of vulnerable populations, especially the poor, to natural disasters, and massive amounts of aid were offered to help disaster victims. However mind-numbing “daily tsunamis” never register on the radar of the same donor communities in the same proportion. For instance, the HIV/AIDS pandemic costs the African subcontinent 1% of its gross domestic product each year. Malaria alone kills 2,800 Africans a day,44 and 314 million Africans—nearly twice as many as in 1981—live on less than $1 a day. Moreover, Africa is home to the world’s 48 poorest countries, including 24 of the 32 countries ranked lowest in human development.44 Every week, 10,000 women in the developing world die during childbirth and 200,000 children under the age of 5 years die from disease. Each day, more than 8,000 people die from AIDS-related conditions. In 2005 alone, 2 million people died from AIDS. Another hallmark of this impoverishment is the observation that an estimated 115 million children in developing countries have no schooling.44 And even Europe has not been spared: the Roma population for instance—a people once known as gypsies—is the largest, poorest, and fastest growing minority worldwide.44

In 2000, in response to the challenges of poverty and discrimination, 189 countries became signatories to the Millennium Development Goals (MDG) project, which clearly outlined targets for reducing poverty and other sources of human deprivation as well as promoting eight sustainable development goals (SDGs)44–46 (see Table 21-3).

Private philanthropic foundations have also had a major ethical and practical role in addressing the problems of global health. The long-standing philanthropic efforts of the Rockefeller Foundation, the Aga Khan Foundation, the Aga Khan Health Services, and other key players47–49 have now been boosted by more recent contributors, such as Ted Turner, the Bill and Melinda Gates Foundation, and Warren Buffett.

In 1999, the Bill and Melinda Gates Foundation assumed a major leadership role in the global fight against HIV/AIDS, malaria, tuberculosis, and other underfunded diseases endemic in the developing world. A total of US$6 billion had been pledged by the foundation until June 2006, when Warren Buffett announced his contribution of some US$38 billion to the foundation for its global efforts. The Global Fund to Fight AIDS, Tuberculosis, and Malaria promised $4.8 billion to 128 countries, and the [US] President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) pledged US$15 billion to help “selected countries.” The Global Alliance for Vaccines and Immunization (GAVI) has been involved in 72 countries, using a budget half of which was contributed by the Bill and Melinda Gates Foundation.50

In 2009, President Obama’s complex Global Health Initiative proposed a 6-year $63 billion effort to develop a comprehensive US response to global health challenges,51 but it is currently facing opposition due to US policymakers’ efforts to rein in runaway budget deficits. In addition to the budget impasse, the global financial crisis, and the economic stagnation in donor countries, the annualized rate of growth in development assistance for health has slowed from prior years, which will result in the inability to meet the goals of the MDGs by 2015.52 However, a bigger challenge will be in selecting, launching, and funding the post-2015 SDGs.

Aside from these financial challenges, ethical questions abound as to appropriate priorities in distributing health services and funds for these and related services and measuring their impact. A recent focus on global health is the complicated, confusing interrelationships between 30 stakeholders—Tanzania, for example, where the HIV/AIDS epidemic highlights ethical dilemmas.50,53 Aid to intended recipients is often blocked by the “architectural indigestion” that can result from the differing political agendas of multiple donors combined with their often inadequate attention to health ethics.

In response to the mounting evidence and research on social determinants of health inequalities, the WHO Commission on Social Determinants of Health was launched to focus on the world’s most vulnerable populations.54 The commission seeks to ensure that public policy is based on a vision of the world where people matter most and where social justice is therefore paramount.

The G8 countries—the United States, Canada, Great Britain, France, Germany, Japan, Italy, and (nominally) Russia—account for roughly halve the world’s economic activity and dominate the decision-making processes of both the World Bank and the International Monetary Fund (IMF).55 Support from the G8 is therefore critical for improving the key social determinants of health, which include education, housing, sanitation, nutrition, and safe, clean food and water. Intervention by the G8 is pivotal also for reversing the severe debt crises of developing nations (especially those in sub-Saharan Africa), where fragile, destabilized economies are susceptible to internal strife and further crises, health crises foremost among them. The roots of these debt crises are sociopolitical, historical, and economic; for example, postcolonial African nations experimented with Marxism and socialism, which furthered both the extension of debt and loss of infrastructure. Famine, drought, and wars added more burdens. A recognized effect of deep national debt in the developing countries is the debt-death link: The higher the interest payment owing on a nation’s debt, the lower the mean life expectancy of that nation’s citizens. This link is now well accepted internationally as a necessary focus of debt relief,56 especially given that the heavily indebted developing countries spend far more money for arms than for reducing debt. By 1990, for example, sub-Saharan Africa was receiving US$11 billion annually for military weaponry; and developing countries, including those south of the Sahara, sent to the developed countries a staggering US$220 billion more than these developing countries received in aid.56 Under this scenario, the 1994 World Bank report predicted that the sub-Saharan black states will require 40 years to reach the level of wealth that existed there 20 years previously.57 For the world’s poorest countries, debt burden is thus the “new slavery.”58 Jubilee 2000, a coalition of more than 90 organizations, including Oxfam, Christian Aid, and the British Medical Association, have spotlighted this relation between the creditor nations, the IMF and World Bank.58