In this essay I begin by asking what research on societal determinants of health suggests for the specific ideals we should aspire toward in addressing global health inequities. I consider a set of theories of justice that seems best-suited to attend to societal determinants of health and find them wanting given an impoverished conception of subjects. I suggest, first, a slight shift in focus away from individual selves and propose an ethic of ‘implacement’ or ‘place-making’ for persons (re) conceived as ecological subjects. In making this argument I draw on a not-so-novel epistemological framework, ecological thinking, and demonstrate its value for understanding and responding to global health inequities. Ecological thinking, indeed, suggests new ideas about the ethical norms that should guide work for global health equity. At the same time, it helps to shine light on the sources of responsibility. I will also argue that the grounding of responsibility for global health equity can be found not merely in shared humanity, compassion and participation in the processes that generate injustice, but also in our nature as ecological subjects, that is, interdependent beings who are in a profound sense constitutive of one another. The social connections between us – ‘across distance’ as they are often framed – are even tighter than most theorising about global justice acknowledges.

INTRODUCTION

Summary measures of population health combine information about morbidity and premature mortality within a single ‘metric’. Particularly prominent at the international level is the Global Burden of Disease (GBD) study, which uses disability-adjusted life-years (DALYs) to quantify the disease burden resulting from different health conditions across the world. The study aims to provide an objective assessment of the state of global health, capturing not only premature mortality but also the burden of non-fatal health conditions. Moreover, the measure can – and was explicitly designed to – inform policy decisions relating to global health, particularly about priority-setting and resource allocation. For example, the Disease Control Priorities Project uses GBD data to make health policy recommendations for developing countries.

From the beginning of the project, the salience of normative questions in designing an appropriate measure of global health was apparent. These questions were addressed explicitly in the development of the GBD approach and were the focus of much of the criticism voiced against the GBD and its methodology. This chapter focuses on the influence that concerns about the effects of global health measures on health policy have had on the development of the GBD methodology. The GBD researchers emphasise that when health indicators gain prominence, they inevitably have an influence on policy debates and decisions. It is incumbent on those developing such indicators to recognise this ‘normative shadow’ and to design health measures in such a way that their influence on policy is unproblematic.

INTRODUCTION

Health inequality or, more precisely, health inequity – morally problematic health inequality – has remained an important issue in many countries over the past few decades and recently became increasingly so in the global context (Segall 2009; Wikler and Brock 2007). Epidemiologists and public and population health researchers have documented numerous health inequalities and inequities within and across populations (Harper et al. 2007; James et al. 2007; Smits and Monden 2009; World Health Organization 2000). Over the years, many concerted efforts to reduce health inequities have emerged nationally and internationally, most notably the World Health Organization (WHO)'s Commission on Social Determinants of Health (2008). Among a profusion of academic and policy inquiries of health inequities, one of the most important recent developments is serious philosophical investigation into how to define health inequity. Informed by the literature suggesting the importance of social determinants of health, philosophers no longer consider illness as bad luck but regard the distribution of health as an issue of justice and fairness. Philosophically oriented scholars thus began to provide rich accounts of when health inequalities become of moral concern and why we should be morally concerned about some health inequalities (Daniels 2008; Hausman 2009; Marchand, Wikler and Landesman 1998; Segall 2009). These are important questions to be clear about. Without knowing what exactly we wish to reduce and articulating why we wish to do so, how can we begin the work and ask others to join the force?

Over the past century, there have been striking improvements in health across the earth, including among many of its poorest and initially least healthy people. In India and China, which together include more than one-third of the world's population, life expectancy has increased by more than twenty-five years since 1950. In China, life expectancy now stands at seventy-three years and trails that in Europe by only about three years. Those concerned about health have a great deal to celebrate.

The celebration is, however, spoiled by the glaring exceptions, which are clustered in sub-Saharan Africa, where life expectancies are typically in the forties and fifties. Hundreds of millions of individuals will have decades less of life than those who made better choices about where to be born, and their shorter lives will be burdened with more illnesses and disabilities. According to the World Health Report 2000, disability-adjusted life expectancy in Sierra Leone is under twenty-six!

Unlike the mass death and suffering caused by the 2010 earthquake in Haiti or the 2004 Indian Ocean tsunami, these global health inequalities seem to me, as to many others, not just a tragedy but also a moral outrage. What distinguishes the world's massive health inequalities from natural disasters is that the inequalities are up to us and consequently, unlike nature, subject to moral judgement. The forces of nature may do catastrophic harm, but they cannot do wrong. They are incapable of evil.

INTRODUCTION

In this paper I ask whether ‘illegal’ migrants have a right of access to the public health systems provided by nation-states as part of the welfare provision for their citizens. The answer will have something to do with whether we can establish that they have a right to health which states are obliged to meet. I will argue that they do have such a right, and that right must be met through access to public health systems regardless of ‘legal’ status. The argument has two parts: first, that the level of agency that should be enjoyed by all human beings, regardless of their ‘legal’ status, requires that they have access to a certain level of healthcare as of right, otherwise we deny them their full humanity – we cannot deny people full humanity simply because they do not enjoy full citizenship; second, that those states that have signed and ratified certain international instruments regarding the right to health are obliged, under those instruments, to provide public healthcare to all within their territory, regardless of status, and are in breach of their international obligations if they fail to do so. And so the argument has two aspects: the first ethical, the second legal.

Do we have ethical obligations to promote global health equity? If so, what prioritised values should represent the satisfaction of those moral duties? These are not easy questions to answer and despite a general agreement that current inequalities in global health provision exist, as well as some agreement that a response is required, there is little consensus about what ethical foundations apply when responding to these inequalities. In an effort to provide some response to this lacuna, the purpose of this chapter is to explore three diverse normative arguments about why we might have global health responsibilities and to examine their relationship with distributive principles for the alleviation of global health inequalities. Through this examination it will be argued that current theorising about global health rests on opposing ontological worldviews about what global health should prioritise and that these pre-suppositions result in distinctively antagonistic normative demands about how we should calculate the distribution of global health. Moreover, by examining these ethical positions together (assuming that some movement toward the elevation of global health inequality is important) the philosophical attractiveness of a cosmopolitan approach to global health will be stressed.

INTRODUCTION

Medical migration – the mass movement of medical professionals from the developing to the developed world – is widely seen as one of the most profound problems facing health systems in the poorest countries of the world. Skilled health-workers leave high disease burden areas with acute staff shortages in order to serve patients in low disease burden regions, which are already well equipped. The result of medical migration is deepening global inequality in health.

Sub-Saharan Africa is widely regarded to be suffering the greatest crisis in human resources for health, and data suggests that the problem is likely to grow (Dovlo 2007: 42). The brain drain of health-workers escalates the severe health crises in high disease burden regions that already face a critical shortage of health personnel. World Health Organization (WHO) data show that thirty-six countries in Africa do not meet the ‘Health for All’ target of one doctor per 5,000 people. On average, there are 1.4 skilled health personnel for every 1,000 people, compared to ten in Europe and in North America (World Health Organization 2006: 98). The WHO has estimated that in order to meet the health-related Millennium Development Goals (MDGs) the number of health-workers in Africa would need to triple. Actual trends, however, run contrary to the global policy target. On the one hand, data from OECD countries show that, in particular in the English-speaking high-income countries, 20–35 per cent of the practising doctors are foreign-trained (OECD 2010).

INTRODUCTION

A striking feature concerning the state of global health is that it is characterised by some radical disparities, including those in life expectancy, maternal mortality and malaria-related deaths. Do we have any responsibilities with respect to improving global health? I begin my answer to this question by surveying a number of international practices that contribute to poor global health. We can then appreciate the wide range of different kinds of international practices and policies that facilitate poor global health. Which, if any, are we obligated to reform in our decidedly non-ideal world? How should we allocate responsibilities fairly in bringing about some necessary reforms? I argue that there is an important class of remedial responsibilities that falls on many citizens of affluent, developed states, and their primary agents of change, governments. In order to appreciate why this conclusion follows, I analyse the notion of remedial responsibilities and the grounds on which it may fairly be allocated.

GLOBAL HEALTH: SOME PROBLEMS AND PATTERNS

One of the most striking features about the state of global health is that it is characterised by radical inequalities. Here is just a sample of the more widely noticed kinds. Life expectancy at birth varies enormously: life expectancy in Sierra Leone or Afghanistan is about forty years, whereas those lucky enough to be born in Japan or Australia enjoy a life expectancy of twice that at approximately eighty (Benatar and Upshur 2011: 14–15).

The International Covenant on Economic, Social and Cultural Rights (ICESCR) proclaims a universal human right to health, in Article 12, which reads:

Let us briefly note some features of this right. First, this is a positive right that requires positive action on the part of corresponding duty bearers; the legal duties to fulfil this right fall primarily on one's state. Second, this is a right to the enjoyment of health, rather than a right to goods or services (such as healthcare) that would enable one to have a healthy life. In other words, it is a right to a certain outcome in terms of health and not merely to the opportunity for health. Third, it is a right to the highest attainable standard rather than an adequate or sufficient level of health. However, the highest attainable standard is normally interpreted in a rather conservative fashion, in the sense that it refers to the highest standard achievable in a specific country, given its resource limitations. This means that not all right-holders everywhere are entitled to the same level of health.

The interest in the ethics of health inequalities rather than just health or healthcare is becoming more widespread and gaining momentum. In particular, health researchers and others concerned about the social determinants and social gradients (that is, inequalities) of preventable ill-health and premature mortality are increasingly drawing on the normative domain of social ethics and justice. At the same time, political philosophers are extending their traditional scope of concern about social justice and inequality into the domain of health. Ethical evaluation of global health inequalities, then, requires integrating reasoning across empirical health sciences and normative ethics and extending the scope to include all societies and the entire human species. While this description may initially suggest a two-step – first domestic, then global – reasoning process, it is not only plausible but perhaps logically and ethically necessary that both empirical and normative analyses of health and health inequalities require starting with a global perspective.

The flip side of the ethics of (global) health inequalities being of interest to diverse actors and encompassing diverse concerns is that discussions can cut across each other, misunderstandings across disciplines or the research versus policy divide can give rise to antipathies, not to mention that a wide range of philosophical and ethical issues as well as related ambiguities become enmeshed. The joining up of health, inequality and ethics increases complexity multiplicatively rather than additively. For example, while stark numerical inequalities in health outcomes may initially provoke moral indignation, why exactly are health inequalities a moral worry?