New Health Systems
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New Health Systems

Integrated Care and Health Inequalities Reduction

Mohamed Lamine Bendaou, Stephane Callens

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eBook - ePub

New Health Systems

Integrated Care and Health Inequalities Reduction

Mohamed Lamine Bendaou, Stephane Callens

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About This Book

New health systems exist today thanks to the changing nature of diseases as a result of the integration of new technologies and new approaches in care giving and the management of healthcare systems. This book studies the health inequalities in these new health systems, structured according to the integrated health services approach. The authors investigate a wide range of debates and issues, including the consequences of a collaborative economy on healthcare and the possible "uberization" of a wide range of its services. The first part of the book offers an overview of the problem of inequalities in the field of health. The second part discusses the possibility of a sustainable and equitable architecture for health systems..

  • Explains the dynamics that animate Health Systems
  • Explores tracks to build sustainable and equal architectures of Health Systems
  • Presents the advantages and inconveniences of the different ways of care integration and the management of Health information systems

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Year
2017
ISBN
9780081017722
Part 1
Health Inequalities
1

The Origin of Inequality

Abstract

Between the years 2000 and 2015, the average gain in life expectancy around the world was 5 years. The gap between the countries with the shortest and longest life expectancy at birth is 36 years, but the city of London alone shows a gap of 17 years from the same indicator, despite guaranteed universal health coverage. If two such widely contrasting countries such as Sweden and Bangladesh are compared over the period between 1990 and 2010, only Sweden shows an increase in prosperity. However, the performance indicator for the health systems (measured as the survival rate for males to the age of 65 years) registered much higher growth for Bangladesh than for Sweden. Along the axis showing the variations on the health indicator, there are some strongly negative trends (countries with a high incidence of HIV/AIDS) and some strongly positive trends (countries emerging from a civil war) without any corresponding variations in prosperity. An offset axis for the average growth value of the health indicator also shows large amplitude variations in prosperity (for example, a negative variation for mining-dependent countries whose resources have run out) which does not alter the progress on the health indicator.

Keywords

Archaeological data; Force; Geographical redistribution; Global inequality; Inequality; Initial explosion; Medical ethics; Origin of Inequality
Between the years 2000 and 2015, the average gain in life expectancy around the world was 5 years. The gap between the countries with the shortest and longest life expectancy at birth is 36 years, but the city of London alone shows a gap of 17 years from the same indicator, despite guaranteed universal health coverage. If two such widely contrasting countries such as Sweden and Bangladesh are compared over the period between 1990 and 2010, only Sweden shows an increase in prosperity. However, the performance indicator for the health systems (measured as the survival rate for males to the age of 65 years) registered much higher growth for Bangladesh than for Sweden. Along the axis showing the variations on the health indicator, there are some strongly negative trends (countries with a high incidence of HIV/AIDS) and some strongly positive trends (countries emerging from a civil war) without any corresponding variations in prosperity. An offset axis for the average growth value of the health indicator also shows large amplitude variations in prosperity (for example, a negative variation for mining-dependent countries whose resources have run out) which does not alter the progress on the health indicator.
f01-01-9781785481659

Figure 1.1 Country-wise variations in prosperity and health (World, 1990–2010)
Most countries fall into the upper right quadrant, with positive variations on both prosperity and health during the period from 1990 to 2010. The most intriguing explanations are also based on this conjoint rise in prosperity and health. Angus Deaton [DEA 13] highlights the novelty of having a greater number of people reach more advanced ages. At the same time, Richard Wilkinson [WIL 10] recognizes the smooth functioning of egalitarian societies (such as Sweden), which have combined improvements in prosperity and health. These interpretations are at quite a variance with the proposition made in Rousseau’s [ROU 55] classic text on the origins of inequality, where he associates improved health with a return to nature.
J. J. Rousseau [ROU 55], Discourse on the Origins and Fundamentals of Inequality among Men, 1755 (extract).
With respect to sickness, I shall not repeat the vain and false declamations which most healthy people pronounce against medicine; but I shall ask if any solid observations have been made from which it may be justly concluded that, in the countries where the art of medicine is most neglected, the mean duration of man’s life is less than in those where it is most cultivated. How indeed can this be the case, if we bring on ourselves more diseases than medicine can furnish remedies? The great inequality in manner of living, the extreme idleness of some, and the excessive labour of others, the easiness of exciting and gratifying our sensual appetites, the too exquisite foods of the wealthy which overheat and fill them with indigestion, and, on the other hand, the unwholesome food of the poor, often, bad as it is, insufficient for their needs, which induces them, when opportunity offers, to eat voraciously and overcharge their stomachs; all these, together with sitting up late, and excesses of every kind, immoderate transports of every passion, fatigue, mental exhaustion, the innumerable pains and anxieties inseparable from every condition of life, by which the mind of man is incessantly tormented; these are too fatal proofs that the greater part of our ills are of our own making, and that we might have avoided them nearly all by adhering to that simple, uniform and solitary manner of life which nature prescribed.
(p. 14, trans. by G.D.H. Cole, https://www.aub.edu.lb/fas/cvsp/Documents/DiscourseonInequality.pdf879500092.pdf)

1.1 A tale of two phases: an initial explosion followed by geographical redistribution

In Wilkinson’s [WIL 10] work, inequality arises from penury. Other authors such as Jared Diamond [DIA 97] also associate the origin of inequality with Force, simple brutal appropriation. The question of the origin of inequalities is debated today using archeological data. It is seen that the first agricultural societies remained egalitarian, while a short transition period (the Chalcolithic period) caused a shift from this state of equality to the most manifest proofs of social inequality, as with the pyramids of the first Pharaohs of Egypt, for example. Rousseau blamed the emergence of the Civil Law and yet, issues from the archeological period in question accompany the emergence of a Public Law. The specific conventions of this period are the conventions for the limitation of Force, as with the institution of the Flower War of the Aztecs, for instance. While agriculture arose without any real understanding of technical power [CAU 00], inequality emerged the moment knowledge was recognized as being powerful. This can be seen through the changes in pantheons, for example. The pantheons of the earliest agricultural societies were simple, organized around nature spirits, while the pantheons of the Metal Age were built of polymath divinities with many diverse technical powers.
We live today in “knowledge societies”, which are non-egalitarian. This has not come about through some historical accident, as the result of a particularly brutal conqueror or a particular episode of poverty.
Biologists make use of a “punctuated equilibrium model”: phases of explosion interrupt very long periods where few things change. The period between the start of the Metal Ages and the age of Rousseau and the EncyclopĂ©distes1 constitutes one such long period of stability. Most of the technologies described by the EncyclopĂ©distes of the 18th Century were introduced early in the Metal Ages: the wheel, writing systems, woven material, and animal traction. And so was inequality. There is evidence that allows us to conclusively date the emergence of inequality. The Varna civilization (in present-day Bulgaria) is the first known civilization in the European zone to have mastered the metalwork for gold and copper. Gold jewelry has been found in tombs, distributed in a very unequal fashion. Other Neolithic civilizations of the same period practiced funerary rites for their dead. While the fragmentary nature of archeological elements imposes great caution when interpreting the transition, when it comes to dating it, there is great certainty: inequality emerged during the transition from the Neolithic to the Metal Ages. One of the pieces of evidence of this transition period is a mummified body unearthed in the Alps, which dates to a period about 5,270 years ago. The corpse dates back to the Chalcolithic Age, the first Metal Age, and testifies to the man having died following a conflict that made use of copper weapons and sophisticated medical knowledge.
This constitutive and long-lasting regime of inequality belongs to traditional agricultural societies. These began to disappear very rapidly after the political and economic revolutions of the 18th Century. This new transition phase is undoubtedly still incomplete. The total inequality index, on a global scale, was rather low around the beginning of the 19th Century and is much higher today. This leads to a second debate concerning contemporary inequality and its origin in historical societies. Jared Diamond traces the origin of inequality to geographic factors, as present-day inequalities have a strongly geographical nature. Everyone knows about the satellite photographs that contrast the prosperity on one side of a border with the poverty on the other side, as with South and North Korea, for example. Given that there is a marked inequality from birth, arising from various social statuses, contemporary inequality is also based on place of birth.

1.2 An initial explosion: was Rousseau right?

There are several answers to the question on the origin of inequality. The oldest answer is the one proposed by Rousseau. According to Rousseau, “iron” preceded “wheat” and the inequality between men, farmers, may be traced back to the institution of property. Modern archeology, however, disproves these points, showing that the invention of agriculture was not accompanied by a recognition of the transformative power of technical developments. While Neolithic societies – the first agricultural societies – were organized by large collective rites, there was no real social hierarchy. The grand rituals allowed people to enter into the rhythm of all living things – men, plants and animals, all of which live and die. Private law did exist, and these primarily agrarian societies could, sometimes, survive for several millennia.
Inequality is one of the markers of the end of the Neolithic period. The first Metallurgic Age, made up of the Copper and Iron Ages, was a transition between the Neolithic period and the highly hierarchized societies of the later Bronze Age. Thus, the question of the origin of inequality has been precisely dated by archeology, with an egalitarian “wheat” age preceding a non-egalitarian “iron” age.

1.2.1 Archaeological data

The first human groups of the modern biological species were hunter-gatherers. They spread out over the globe, diversifying culturally. This diversification may have led to about 15,000 spoken languages, each with a very small group of speakers. The languages of the hunter-gatherers made it possible to adapt well to a given environment. The vocabulary to specify a common component from the environment would have been extraordinarily precise, with different terms designating animals that were not of the same age, a snowy coat covering the environment or a nutritive plant. Under conditions that remain mysterious, there was an episode of wide linguistic unification to introduce more conceptual communication devices: a single term for snow, understood by a large number of speakers. These linguistic tools established the principle of a socially stratified society.
Renfrew [REN 94] proposed a schema (oversimplified, no doubt) of linguistic unification by diffusion of Indo-European language in the European context. Archeological sites in present-day Belgium allow us to imagine the situation around 5000 BC. This was a “pioneer” context: pioneer farmers settled along large waterways and progressively cleared land, which was essentially forest land. Archeological sites provide evidence of armed conflicts with the occupants of this forest. The farmers succeeded in settling here and organizing resources such that the number of speakers of their language increased. Although this explanation is over-simplified, it allows us to introduce the two aspects of societies that are related to the emergence of inequality: on the one hand, we have the diversity of small groups of humans whose resources are primarily acquired through hunting and gathering; on the other hand, there are societies that resemble the village in the world of Asterix: some specialization, clearly defined professions such as the blacksmith, and social stratification, with the Druid being the repository of power in the village. Magical power resides in one social stratum, that of the Druids, such that, according to Caesar, they could order warriors to end combat.
The recognition of the power of knowledge came about in the first Metallurgic period, as can be seen through the representation of the gods: the first agrarian societies worshipped deities linked to natural cycles, while the first metallurgic societies have complex pantheons, where deities are associated with technical attributes. Archeologists state that “wheat” preceded “iron” and private law preceded the recognition of technical power, contrary to the “iron, wheat” sequence postulated by Rousseau.
Pre-Columbian societies testify to the conditions in which inequality emerged. An initial metallurgy was limited to goldsmithery: with neither tools nor arms being made. The economy remained barter-system driven. Peddlers would demonstrate their high social status by organizing potlatches, ostentatious consumption of their surplus goods. Economic actors in the Copper Age societies played no role in affirming social inequality.
The Flower War Agreements, which limited warrior operations, were the driving forces behind the emergence of private law and social stratification. Aztec society had a school, the Calmecac, reserved for the elite. Pierre Clastres concluded that there was no possibility of organized powers emerging from primitive warrior societies. An economy driven by the predation of small bands may endure, but without leading to complex social structures. An understanding between priests and warriors formed the foundation of Aztec society. One official historiography recalls the past of the Aztec warrior bands and thus justifies the existence of an aristocracy. Inequality was born of hierarchy, of the regulation of sacrificial power. It was institutionali...

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