An Introduction to Global Health Ethics

Andrew Pinto, Ross Upshur, Andrew D. Pinto, Ross E. G. Upshur

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136178016
• Edition: 1
• Topic: Médecine
• Subtopic: Épidémiologie

The field of global health is expanding rapidly. An increasing number of trainees are studying and working with marginalized populations, often within low and middle-income countries. Such endeavours are beset by ethical dilemmas: mitigating power differentials, addressing cultural differences in how health and illness are viewed, and obtaining individual and community consent in research. This introductory textbook supports students to understand and work through key areas of concern, assisting them in moving towards a more critical view of global health practise.

Divided into two sections covering the theory and practice of global health ethics, the text begins by looking at definitions of global health and the field's historical context. It draws on anti-colonial perspectives concepts, developing social justice and solidarity as key principles to guide students. The second part focuses on ethical challenges students may face in clinical experiences or research. Topics such as working with indigenous communities, the politics of global health governance, and the ethical challenges of advocacy are explored using a case study approach.

An Introduction to Global Health Ethics includes recommended resources and further readings, and is ideal for students from a range of disciplines – including public health, medicine, nursing, law and development studies – who are undertaking undergraduate and graduate courses in ethics or placements overseas.

PART I

Theory

1

The context of global health ethics

Andrew D. Pinto, Anne-Emanuelle Birn and Ross E.G. Upshur

Objectives

• To present a historical perspective on global health, using a political economy framework
• To discuss past and current definitions of global international health and relate this discussion to ethics
• To develop a rationale for global health ethics

A) Introduction

We live in a radically unequal world in terms of both health and its underlying determinants. Even the most cursory review of the available data makes this evident. On average, a person born in 2010 in Afghanistan, Chad or the Central African Republic can expect to live to approximately 48 years, whereas the average life expectancy is 80 years in the Republic of Korea, 82 in Iceland, and 83 in Japan (WHO 2011a). Globally, in 2009, approximately 8.1 million children died before their fifth birthday, deaths occurring almost exclusively in low- and middle-income countries (LMIC) (WHO 2011b). The vast majority of these are preventable deaths due to diarrhea, pneumonia and malaria (Jones et al. 2003). It is estimated that in 2008, 358,000 women died in childbirth, with 99 per cent occurring in LMIC. This has remained consistent ‘year after year’ and again, these deaths were/are almost entirely preventable through existing knowledge, health services and interventions to improve living conditions (Campbell et al. 2006).

Stark as these figures are, national averages hide within-country differences that are even more striking. Evidence cited in the Final Report of the Commission on the Social Determinants of Health (WHO 2008) demonstrates that the health of individuals and communities is intricately tied to social factors. These include income, class, education level, employment relations and race/ethnicity (Public Health Agency of Canada 2004).To take just one determinant, in every country, the poor fare worse than the wealthy. In Scotland, there is a gap of over ten years in healthy life expectancy – years spent in good health – between residents of the most deprived and least deprived neighbourhoods (Wood et al. 2006). Similarly, the maternal mortality rate is three to four times higher among the poor compared with the rich in Indonesia (Graham et al. 2004), and in Peru infant mortality is almost five times higher in the poorest quintile of the population compared with the wealthiest (Gwatkin et al. 2007). Across the world, certain racial and ethnic groups fare worse than others living in the same country. In an oft-cited example, African-American men in Harlem, New York were found to be less likely to reach the age of 65 than the average man in Bangladesh (McCord and Freeman 1990). Indigenous peoples, referring to communities that share a historic link with pre-colonial societies, have lower life expectancies than their non-indigenous counterparts in every country where this has been studied (see Chapter 6). For example, Indigenous Australian men have a life expectancy at birth of 59 years, compared with 77 years for all Australian men (Australian Government 2009). In Canada, Aboriginal men live on average eight years less than the male population as a whole (Anderson et al. 2006). Such disparities between rich and poor nations, and between privileged elites and marginalized populations within each country, are expected to worsen with the negative effects of climate change (Costello et al. 2009) – which is likely to affect LMIC disproportionately – and by the fallout of the 2008 global financial crisis (Catalano et al. 2011; Stuckler et al. 2011).

None of these realities is new or surprising to health professionals, academics and policy-makers who are interested in global health. As never before, we have available an abundance of knowledge about such deplorable health inequities, a term referring to the differences in levels of health between groups in a society that are unjust, unfair and avoidable (Whitehead 1992; Starfield 2006). Further, tackling such health inequities has risen on the political agenda. In October 2011, representatives from 125 governments met at the World Conference on Social Determinants of Health in Rio de Janeiro, Brazil. The text of the conference's Political Declaration contains statements such as ‘we need to do more to accelerate progress in addressing the unequal distribution of health resources as well as conditions damaging to health at all levels’ (WHO 2011c: 2). Addressing social inequity is even entering the conversation at the 2012 World Economic Forum, where typically the focus is on economic growth and competitiveness (WEF 2012).

Given the evidence that significant, remediable differences in health exist globally, and that there is a stated goal to address them, what is being done? Clearly not enough: inequities in health have persisted – and even increased – despite enormous resources being channelled into reducing them, despite a rich body of evidence on effective measures, and despite strongly worded statements by international bodies that these efforts should be a top priority (WHO 2008).

This book aims to help you explore why this is the case and what can and should be done. Changing the systems that result in unnecessary death and suffering is a key goal of global health practitioners. Here we hope to move the reader from an intuitive sense that something is wrong to a deeper understanding of how power, access to resources, justice and fairness apply to health – questions with which global health ethicists are wrestling in an ongoing manner. This chapter begins by reflecting on what is meant by global health and how the field and its precursors have evolved over time: before solutions can be proposed to address inequities, it is essential to understand in what context they have arisen. Recognizing that there is a multitude of ways to address a problem, we then argue that ethical perspectives can contribute towards formulating responses – in terms of both avoiding doing harm and actually improving global health inequities. Finally, we highlight what the remaining chapters will cover as an entrée to engaging in global health ethics.

B) Historical roots of global health

‘Global health’ has entered into widespread use relatively recently and has been rapidly adopted, particularly in North America, as a field of study and practice. Yet whether it is even a new or separate field remains controversial (Farmer et al. 2009; Fried et al. 2010). Using the term ‘global health’ became common in the early 1990s, when the end of the Cold War appeared to open up new possibilities for health cooperation across countries to address problems of shared concern (Kickbusch 2002; Birn 2011; Bozorgmehr 2010). Among powerful players it has largely replaced ‘international health’, which in turn displaced ‘tropical medicine’ or ‘colonial medicine’ as the dominant term to capture the activities characterizing this field. Tracing the links between these conceptualizations is important to understanding the values and theories that underpin the field today.

Going back more than a millennium, outbreaks of plague periodically turned health into a regional or even a global problem, but until the rise of the modern state and a system of inter-state relationships, there was no organized mechanism to focus worldwide attention on health. By the nineteenth century, a confluence of developments – the most intense period of (European) conquest and imperialism, the industrial revolution, the concomitant revolutions in transport and global commerce, and the rise of modern medicine – forced sustained attention to health as more than a local matter.

Starting with Spain and Portugal's first invasions of Africa, South Asia and the Americas in the fifteenth century, the nations that established colonies in the so-called tropics were concerned with protecting soldiers, settlers and merchants from novel diseases that they were exposed to, both to secure their investments and to maintain their hold on power (Berlinguer 1992). As imperial enterprises became more permanent, colonial authorities also became concerned with maintaining the productivity of, for example, miners and plantation workers. Colonial powers set up medical offices and systems of regulation and intervention across their possessions to control epidemics, stave off uprisings, protect settler populations, and apply the disease-control tools of the day to ‘civilise’ subject populations (Birn et al. 2009).

Tropical medicine emerged in the nineteenth century, together with the new fields of bacteriology, parasitology and helminthology, closely related to the needs of colonialism (Arnold 1997). The development of this field was underpinned by the formulation in the colonial imagination of the ‘tropics’ as an exotic other (Said 1979) with purportedly distinct ecological characteristics. European and colonial tropical medicine institutes mounted field trials and measures focusing on epidemics and other health problems that threatened trade, productivity and the viability of colonies (De Cock et al. 1995). Religious missionary work and proselytizing was also closely related to the expansion of colonies and provided moral justification, especially through the building of hospitals and clinics and the provision of health services to indigenous communities as a key part of winning over the local population. For example, the Belgian regime in the Congo was extremely brutal, even as missionaries from a variety of countries helped it establish one of the most extensive networks of health clinics in any colonial territory. These efforts drew on European conceptualizations of indigenous peoples as weak, of different races being more or less suited for labor in the tropics, and of the racial superiority of people of European stock (MacLeod and Lewis 1998).

During the second half of the nineteenth century – at the height of the industrial revolution – the modern international health system was conceived, motivated by a growing (if divisive) belief that disease could spread rapidly through trade (e.g. the nineteenth century's repeated cholera pandemics) and the movement of people (in terms of large-scale immigration and the annual Hajj). Facilitated by a diplomatic context favouring state-state cooperation in the wake of the 1815 Congress of Vienna, most European countries recognized that the ongoing threat posed by epidemics to commerce and to their populations demanded some form of international agreement to reform quarantine measures (Harrison 2006). The first International Sanitary Conference was held in Paris in 1851, but inter-imperial rivalries resulted in little concrete action for several decades, even as the opening of the Suez Canal in 1869 shortened trade routes between Europe and East and South Asia (Bynum 1993). Finally, in 1907, the Paris-based Office International d'Hygiène Publique, mandated with the interchange of health information and the development and oversight of sanitary treaties, was founded. A fully fledged international health organization was founded after World War I – the League of Nations Health Organization (LNHO), based in Geneva. Drawing on social medicine approaches, the LNHO's ambitious agenda included not only infectious disease control, but also: vital and health statistics standardization and dissemination; running expert commissions charged with standardizing medications and vaccines; and studies of broad public health issues such as housing, medical education, health systems and services, economic depression, nutrition, human trafficking, rural hygiene, chronic disease, and the social causes of infant mortality (Borowy 2009).

By this time, an International Sanitary Bureau for the Americas had already been established in Washington, DC (in 1902, eventually becoming the Pan-American Health Organization in 1958), technically the world's first multilateral health organization. With the United States as the hemisphere's dominant power, and bolstered by its invasion and occupation of Cuba (justified largely as a means of controlling yellow fever), international sanitary agreement was easier to reach, especially given yellow fever's ongoing threat to commerce throughout the region. The renewal of the construction of the Panama Canal in 1904, key to the USA's global trade aspirations, further stimulated intra-continental disease-control efforts. Under French control since the 1880s, the project had stalled for decades after some 20,000 French and Jamaican workers died from yellow fever and malaria. A massive US military-led effort was marshalled to eliminate the breeding grounds of insect vectors, but it ignored the endemic problems of local populations such as tuberculosis and infant diarrhea. Once the Canal opened in 1914, there were renewed fears about – and redoubled efforts to control – the spread of communicable diseases through international trade.

A key player in this period was the Rockefeller Foundation, which helped popularize the term ‘international health’ through its influential International Health Board and Division (Cueto 1994). Launched in 1913, the Foundation pioneered cooperative public health efforts in almost 100 countries and colonies across the world through disease campaigns, support for public health institutionalization training, the establishment of schools of public health, and...