Inequality means that we are not so healthy, and that we don’t get good healthcare. We need to change this, says Dinyar Godrej.
Leela is in her sixties and works seven nights a week.
Her job is to look after Preeti, a woman in her eighties who has dementia. Leela keeps her safe through the night. She helps her get to bed, then she sleeps on a mattress on the floor. She gets up every time Preeti wakes up (often), takes her to the toilet, washes the sheets and clothes by hand, and gives her a bath. Her work ends at nine in the morning. Sometimes Preeti takes Leela’s hand to thank her, but this breaks the social barriers of class in India. Leela is very devoted, but she would love a regular day off work.
If Leela feels ill, she asks one of Preeti’s children for a paracetamol. If she is too tired or ill to work, her son takes her to a doctor for the poor, who gives her an expensive injection.
Resting after treatment by doctors at the Daawad hospital in Eyl, Somalia, before beginning the journey home. Frederic Courbet/Panos Pictures
The injection is probably only vitamins or salt solution, but, for Leela, it shows she is taken seriously. The doctor cannot tell her to rest, as he knows she can’t. He cannot suggest anything that will need treatment, as he knows she doesn’t have the money for this.
However, Preeti’s family can pay for specialist doctors to visit their mother’s home. Or they could send her to the expensive, new hospital, built on free land with subsidies from the government if they promise to keep a few beds for the poor. Even Western foreigners come to this hospital, people who have been waiting too long, or who want cheaper treatment.
But Leela is still in a better position than some of the poor in the countryside in this huge and very unequal country. In many villages, people die because they feel they have no money for an X-ray to diagnose TB. TB treatment can cost only $20.
The public health system in India has far too little money: the Indian government spends around one per cent of GDP on health (but it is the ninth largest buyer of arms in the world). Gita Sen (policy analyst) said: “Poor people are going less to health centres they went to before, because they almost never have the free drugs now. This is ironic as India is now respected in Africa for cutting the cost of drugs by exporting generic drugs to them.”
So the new healthcare system in India, and most of the world, is capitalist. There are small areas of technical excellence for the rich, and much less help for the poor. Many people have noticed recently that the Indian government is making a commitment to health care for all; but Indians will only believe this if it starts to happen.
Almost everyone agrees with the idea of a right to life. But some people don’t agree with the right to health, as it costs money. The negative result of both of these rights can be the same – no life, or even murder.
In the West, where there is more money, there is less money available for general healthcare because money needs to be spent on advanced, complicated treatments (instead of prevention of disease or promotion of good health). Also, fraud committed by the big pharmaceutical companies doesn’t help. In September, the New England Journal of Medicine said that 26 companies were fined over $11 billion in the past three years for crimes such as not giving safety information and promoting drugs for wrong uses. This is just part of what is happening. This industry needs to make money, so they produce expensive copies of drugs which are worth little, instead of real innovation.
In most of the world, preventing and promoting health is just as important and cost-effective. This includes very basic things like enough food, clean drinking water, sanitation, education to improve job opportunities and health decisions. Treatment needs to be safe, suitable, effective and public. Medical costs mean that poor people have impossible “choices” to make: having no money or food, buying some medicine and hoping it will work, or no treatment at all.
In 1978 there was an important conference in the former Soviet Union. Medical policy-makers and world government representatives agreed on health for all by 2000. They said that healthcare would be practical, scientific and socially acceptable; that technology would be available to all; and that it would cost what each country can afford.
This wonderful vision was lost in the 1980s when the World Bank and the International Monetary Fund (IMF) made countries cut public spending to pay their debts. They introduced “structural adjustment programmes” (SAPs), which made poorer countries charge for healthcare, and called this “community financing” or “cost sharing”.
Volunteer dentists and assistants treat 30 patients at a time at Soft Shell, Kentucky, at a weekend of free treatment –lucky patients among the millions of US citizens with no health insurance. Dermot Tatlow/Panos Pictures
In a lot of Africa, they destroyed the public health system, made the poorest people suffer and let diseases spread that could have been stopped. Patients waited much too long before they asked for help. When they started charging only 33 cents at health centres in Kenya, half the people stopped going. Also many skilled healthcare workers left the continent.
The World Bank has denied this. They say their plan was for the poorest people not to pay anything, and that others should pay according to ability. They said that small fees would make people value the health services more and not waste them. But these people are so poor, they have nothing to waste. They have only ever seen rich people waste money. The Bank’s policymakers did not understand the reality. Their suggestions had no chance of success as there was little administrative support, corruption and no communication with the poorest people.
Still today in countries like Tanzania, 73 per cent of women having a baby in government hospitals still pay, even though this should be free. Tanzania tried to introduce health insurance, but only 15 per cent of people have this. Most Tanzanians will continue to not want medical care because it costs too much.
We have lost three decades now, and the World Bank, the IMF and the rich nations must now cancel the poor countries’ debt. After years of campaigning, this is beginning to happen, but there is still a huge amount of debt.
Now people are talking again about healthcare for all – as if it were a new idea. In September this year, the medical journal The Lancet published several articles about this at the UN general assembly. The world wants healthcare to be public; it takes some time for world institutions to do what they want. Ironically, one of the writers for The Lancet, who is now fighting for “healthcare for all”, David de Ferranti, used to be with the World Bank supporting paid healthcare.
Another writer is Jeffrey Sachs, an economist, who says: “Poor health has bad effects, from individuals to the community, and from poor countries to rich countries. So everyone has an interest in making sure that the poor have health care.” Sachs says that a minimal healthcare package would cost around $50 – 60 for each person for a year. This cost is too much for the poorest countries where only around $9 is possible. International help is needed. But this needs to be more than vaccination programmes and individual help. It is a healthcare crime that nearly a billion people often have no food. The vision for healthcare for the world must be a vision for more equality.
This vision must be more than minimum healthcare. It must be enough. It must be more than simply preventing or curing diseases, to building health. This is not very possible with a free market in medicine and people paying for healthcare. But it would be more possible if earnings were higher and more equal. The vision must be public and political.
It must also fight against social inequality, not support this as most healthcare systems do. It is very clear that social inequality is a very important cause of bad health in countries with great poverty: here, only the rich can have the good standards of health that many people have in richer countries. But in the last twenty years, many studies have shown that social inequality is also a very important cause of bad health in rich countries.
Michael Marmot’s book The Status Syndrome (2005) says that poverty is more than just how much money we have; it affects how much we can be part of society and how much control we have on our life. Societies that are not equal do not have strong social groups, which could help with these negative effects. The stress of feeling unimportant and having no control starts many health problems eg. immune deficiencies, blood sugar and blood pressure problems. This is closely related to the Western world’s illnesses: obesity and depression.
A change to health inequality does not mean everyone would be very rich; it means everyone would be more equal. Unequal countries like Britain and the US have worse health than countries that are more equal, like Japan and Sweden. High-tech medicine is used less here. Amartya Sen, the Indian economist, says that life expectancy in Britain improved fastest during the world wars, when societies helped each other more. (The opposite is true in Russia: male life expectancy fell greatly after the Soviet Union broke up. Life in the Soviet Union was not perfect, but breaking up society affected health.)
Social inequality is now getting worse with the financial crisis, and so will health and healthcare inequality. The British NHS (National Health Service) was created after World War II, when social groupings were very strong. It was shown at the London Olympics as a social treasure, but it is now being cut and privatized. Greece and Portugal are now raising health fees and the diseases of poverty are returning.
But other countries with middle incomes eg. Thailand, Mexico and Brazil, are improving healthcare. This shows that healthcare is a political challenge. Cuba is committed to social equality and has an amazing healthcare system even though it has so many problems.
In Australia, there is the “Close the gap” movement to improve the health of indigenous people. The government has said that the health of aborigines can only be improved by many different things which will make them more equal. Money has been set up for this. In Britain in 1997, the Acheson Inquiry investigated inequalities in health, but this has had very little effect. Why? Because the inquiry said there was no easy solution: we should protect the poor in an unequal society by, for example, creating jobs and providing secure social housing.
Medical science has developed greatly in the last century. The Majority World can take small actions to make big differences in people’s lives. But this is not all. The inequalities in health and healthcare will only end when we see them as part of the systems in the inequality in the world. We need a lot of political vision and will to change that. This is the challenge.
As this article has been simplified, the words, text structure and quotes may have been changed. For the original, please see: http://www.newint.org/features/2012/11/01/healthcare-keynote/