The idea that there are drastic inequalities of medical resources between developed and undeveloped nations is not a new idea to emerge in global health. It is an issue that is not only almost universally agreed upon, but also documented and addressed in a variety of fashions. In the paper ‘Ethics and Governance of Global Health Inequalities’, author Ruger provides some bleak statistics: “Global health inequalities are wide and growing: a child born today in Afghanistan is 75 times as likely to die by age 5 years as a child born in Singapore. A girl born in Sierra Leone can expect to live 50 fewer years, on average, than her Japanese counterpart. The number of African children at risk of dying is 35% higher today than it was 10 years ago. Although the average global life expectancy has increased by 20 years over the past five decades, the poorest countries have been left behind.” In Improvising Medicine, author Julie Livingston documents these inequalities in stark clarity by telling the story of an oncology ward in Botswana. The doctors and nurses who work in the ward not only have very little medical equipment and treatment, they are also severely understaffed. Although these inequalities exist, the underlying causes of them are not so easily apparent. In addition, it is not certain how to change them in a favorable way.

How did these inequalities in medicine arise? Are they solely due to differences in socioeconomic status? Does the privatization of healthcare exacerbate these inequalities? Could be due to the fact that we as a global society place more value in some lives than others? As I attempt to explore each of these questions, keep in mind that the inequalities in medical resources are not only on a country to country basis. There are also inequalities between states, between towns, and between individuals.

In Improvising Medicine, the author uses case studies to explore the level of care provided in countries that have universal care compared to those where the medical industry is privatized. Although the level of care at the oncology clinic in Botswana (where they have universal healthcare) was significantly lower than in the US, the Batswana that arrived at ward fared better than their Zimbabwe counterparts, who at many times couldn’t afford the treatments.

Another way inequalities in medical resources can exist for so long is the differential values placed on human life. In the book ‘In the Company of the Poor’, Paul Farmer makes the encompassing statement, “The idea that some lives matter less is the root of all that’s wrong in the world”. This different valuing of human lives is apparent not only in the severe inequalities of medical resources but also when it comes to our response to large scale global health issues.

For example, during the Ebola outbreak last year, the WHO declared it a “public health emergency of international concern” on August 8th 2014, after there were already 1,779 infections, and 961 deaths. Had these deaths been majorly Americans rather than Africans, would we have spurred our reaction to the epidemic sooner? In fact, when only one or two Americans were infected with Ebola, the nation watched their cases very closely, and knew their individual stories, while the many deaths of Africans were little more than statistics and numbers in a chart.

So what can we do to alleviate these inequalities in medical resources? Should the whole global health system be completely changed to account for these inequalities? Or is humanitarian aid enough?

These questions are not easily answered. In the essay ‘Governance of Global Health Inequalities’, the author proposes a universal healthcare system that would not only encompass nations but the world as a whole. He called for a mass redistribution of medical resources. For this distribution to occur, he relied on people’s morals and good heartedness, rather than coercion.

Although his method sounds ideal, it’s hard to tell how realistic or feasible it actually is. Many people would most likely object to having any of their medical resources taken away from them after they are already used to having them, even if they are going to people who have virtually no medical resources. However, on the other hand I don’t think humanitarian aid is quite enough either. Humanitarian aid only goes so far as to help individuals who are in need of help in the present, but does not extend to drastically alter the health system in any way.

There are no simple answers to these questions. Although the path to take is not clear, there is no uncertainty that these inequalities must be abolished if there is going to be real, large scale improvement in global health.

Sources:

Griffin, Michael, and Jennie Weiss. Block. In the Company of the Poor: Conversations between Dr. Paul Farmer and Fr. Gustavo Gutierrez. N.p.: n.p., n.d. Print.

Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.

Ruger, J. P. “Ethics and Governance of Global Health Inequalities.” Journal of Epidemiology and Community Health. BMJ Group, n.d. Web. 01 Oct. 2015.

Schnirring, Lisa. “WHO Declares Ebola a Public Health Emergency.” CIDRAP Center for Infectious Disease Research and Policy CONNECT WITH US Newsletter Signup Facebook Linked In Twitter Email Alerts Contact Us MAIN MENU Main Menu. CIDRAP News, 8 Aug. 2014. Web. 1 Oct. 2015.

Wealth inequalities are typically the first types of inequalities that come to mind when thinking about disparities in the world. In that context, is the world as a whole growing more or less equal? Even though this is not a simple question to answer, based on extensive research by many economists data suggests that inequalities within nations are increasing, whereas inequalities globally are decreasing, as many underdeveloped nations are suddenly producing a very large middle class. Does this mean that at some point in time all the world economies will intersect and result in total wealth equality among all nations? The answer: not really, as there are many variables that contribute to this equation, including population growth, migration, underestimation of top incomes and tax, gender equality issues, war and violence, and cultural barriers.

How does this wealth inequality relate to health equality? It has been common practice to use a nation’s GDP as an indicator of the health of that nation’s population. Until recently, it was assumed that those countries with a lower GDP had poorer health outcomes as measured by infant and maternal mortality rates, and that more affluent countries had better outcomes. It is a fact that a nation’s GDP relates to its health, but not in a positive way always. On the contrary, the economic inequality within a sample population has a bearing on many health outcomes in that population, with bad outcomes at both ends of the spectrum, as exemplified by infant and maternal mortality at one end and obesity, cardiovascular disease, and diabetes at the other end. Social habits that breed with increasing affordability affect the rich and the poor equally in their own way, as evidenced by increased rates of cancer, violence, drugs, and trafficking and their impact on the society. Inequality also causes social isolation among all ages, especially in the elderly, which in turn leads to depression and other mental illness and more morbidity and mortality.

Additionally, it is ironic to see that the economic value of health care is an oxymoron in that if a nation faces a pandemic and a lot of money is spent on medical care, the nation’s GDP will artificially rise; however, it is not a desirable situation, and it does not relate to the nation’s health in a positive way. Because GDP takes into account all work regardless of its impact on the net financial change, it is misleading to rely on that metric to evaluate the status of a nation’s health. On the other hand, other measures like standard of living, discretionary income, human utility, mental status, and general happiness present in the population are a better indicator of a population’s state of wellbeing.

As depicted in Julie Livingston’s Improvising Medicine, there is a clear difference in the care given to cancer patients in Botswana when compared to similar patients in the U.S. This discrepancy not only stems from the socio-economic conditions in Botswana but also from lack of education, awareness, and cultural beliefs inherent in that area. The attitude of the caregivers towards their patients is also less than optimal, be it because of frustration or helplessness. This also ultimately affects the health outcomes of patients. I have had firsthand experience addressing malaria in Cambodia. The global statistic that 1 child dies every minute from malaria is astounding, especially because malaria is a preventable disease. Lack of awareness of the resources available to treat and prevent the disease, combined with gender discrimination, leads to further spread of the infection. Besides not being able to afford treatments, many in these endemic areas believe that some homemade concoctions can cure malaria, a cultural belief that leads to inequality of use of medical resources. If a family believes in the power of modern medicine but has limited financial resources, a sick male in the family receives treatment over a sick female. Gender-based discrimination results in inequality of medical resources, a practice that is not easy to uproot from societies.

In conclusion, it is important to recognize that there are many inequalities in medical resources, based on not only wealth, but on the type of insurance a patient carries, the society and cultural environment one lives in, and ultimately, one’s own willingness to either accept or reject the available resources. So one formula and rule does not fit everyone and the approach should be tailor-made based on each situation.

Discussion Questions:

1. In order to inculcate healthy habits and create wellness, it is oftentimes necessary to eliminate cultural bias. How important is it for the respective governments to get involved in the process? If there is resistance from the government, how should volunteers and health workers enter communities and impart education?

2. Gender bias has been a universal problem for centuries, and even in the United States, there remains some discrimination against women. Granted, the degree of discrimination is different, but the fact that it exists is true. That said, do we as a nation have a right to expect and enforce changes in other countries? Are we the gold standard that other nations need to follow against their will?

Works Cited:

Those concerned with health literacy hold the conviction that there is a standard of health-related knowledge that individuals must be familiar with in order to make lifestyle and medical decisions and govern their lives with intention. Inadequate health literacy has serious consequences in rates of individuals seeking care, ease of diagnosis, adherence to treatment, and health outcomes. In this way, health literacy itself functions as an unequally distributed medical resource. Yet most troubling is that poor health literacy can transform the healing processes that take place in hospitals into demeaning experiences in which desperate patients must surrender control over their bodies.

In Improvising Medicine, Julie Livingston writes that patients arriving at Botswana’s Princess Marina Hospital may not know the difference between diagnostic and therapeutic procedures, the purpose of the blood tests and biopsies being done to them, and even what exactly is the mass growing inside them that is threatening their lives. Despite the fact that a patient’s lack of understanding of his or her illness makes treating and helping the patient more difficult, doctors often do not answer patients’ questions. For instance, Dr. P., the sole oncologist at PHM who sees between 25 and 40 patients per day, usually does not have time to talk with patients much past laying out treatment plans and giving instructions (Livingston).

This lack of respect for patients’ understanding of their illnesses seems foreign to many Westerners who are accustomed to the privilege of doctor visits concluding with responses to laundry lists of questions and worries. But doctor-patient interactions in Botswana, which were born out of colonial and missionary medicine, are defined by a very different and stark power imbalance. Livingston writes,

The etiquette of the clinical encounter in Botswana…  has long been based on a top-down model. Patients do not expect to ask many questions…  while some patients were content to leave expert knowledge to the doctor, many others expressed a pent-up desire for biomedical knowledge, knowledge that might give more precise shape to their existential and phenomenological concerns. (76)

Further, the obvious gravity and urgency of cancer leads patients to feel understandable desperation, which strips them of even more of their authority over decisions regarding their body.

Another troubling consequence of poor health literacy and patients’ being forced to trust their doctors blindly is that doctors cannot be held accountable for their decisions. Because of strict TB treatment protocol in Carabayllo, Peru, Farmer recounts how poor individuals are frequently treated with drugs to which their strain of TB has already shown resistance (237). Of course, it is the health authorities and policies that are at fault for this ineffective and dangerous occurrence, but one must question whether an upper-class citizen of Carabayllo with a full understanding of drug resistance and treatment options could ever be manipulated and abused in this way. Health literacy gives individuals a voice and allows them to advocate for themselves.

Increased health literacy in impoverished communities could lead patients to develop heightened awareness of the substandard care they are receiving. The more that an individual understands about his or her condition and the treatment he or she should receive, the more aware an individual will be when treatment doesn’t proceed as it should (because of interrupted supply of medicine, lack of technologies, physician neglect, etc.). There is a moment in Monique and the Mango Rains when Kris Holloway notes, “I had noticed that the villagers loved shots. To many of them, shots represent the pinnacle of Western medicine, and Western medicine is good” (7). The ignorance behind the idea that shots are the pinnacle of Western medicine reveals how much medical technology the villagers don’t realize that they don’t have. While one could argue this ignorance is benign, our accepting this ignorance serves to validate the horribly damaging and dehumanizing conception that Africans are somehow ‘living in the past.’

Health literacy can be transformative when it empowers individuals to appreciate their rights regarding health and spread their knowledge. We see in Monique and the Mango Rains that Monique visits neighboring towns to teach women how to prevent diarrhea through basic sanitation and how to treat diarrhea with rehydration drinks (Holloway 56). In addition, a 15-year old named Emelin spoke to the U.N. earlier this year about the health issues that girls in her rural Guatemalan community face such as early pregnancy and gender-based violence. Emelin said, “We [adolescent girls] have a voice and we are going to use it” (Cole).

While putting the burden of reducing health inequalities on the shoulders of the oppressed is unjust and unproductive, it is important to acknowledge that improved health literacy does give oppressed individuals the ability to become catalysts for social change. Health literacy unites individuals over commitment to health and inspires communities to advocate collectively for their health needs.

Discussion Questions:

1. What responsibility, if any, do you think physicians have to ensure that their patients understand and are comfortable with courses of treatment? Is this responsibility greater in a place like Botswana where there exists a very tangible power imbalance between doctor and patient? Considering the dilemmas of language barriers and busy schedules, how much should we expect of doctors?
2. Outside of the doctor-patient interaction, how can health literacy promotion be incorporated into global health initiatives? What are the important aspects of effective health education programs (such as cultural sensitivity)?
3. Can health literacy empower patients to advocate for their health needs and even become catalysts for social change in their communities?

Course Readings:

Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: U of California, 1999. Print.

Holloway, Kris. Monique and the Mango Rains: Two Years With a Midwife in Mali. Ed. John Bidwell. Long Grove: Waveland, 2007. Print.

Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.

External Sources:

Cole, Diane. “Meet The 15-Year-Old From Rural Guatemala Who Addressed The U.N.” NPR, 12 Mar. 2015. Web. <http://www.npr.org/sections/goatsandsoda/2015/03/12/392174520/meet-the-15-year-old-from-rural-guatemala-who-addressed-the-u-n>.

Kanj, Mayagah, and Wayne Mitic. “Health Literacy.” Health Promotion Conferences. WHO, 26 Oct. 2009. Web. 2 Oct. 2015. <http://www.who.int/healthpromotion/conferences/7gchp/Track1_Inner.pdf>.

The history of medicine is fraught with unnecessary racialization. In “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body,” Comaroff writes about how the black body became “associated with degradation, disease, and contagion” and how colonial medicine “link[ed] racial intercourse with the origin of sickness.” These overtly racist ideas have decreased in influence over time. However, even today, the remainders of these ideas still manifest themselves in racial inequalities in treatment and access to medical resources, and in the general racialization of medicine, both in the U.S. and around the world.

Smedley and Smedley write about the consistent racial and ethnic disparities in health care in their paper, “Race as Biology is Fiction, Racism as a Social Problem is Real.” They report a series of shocking statistics, which include that Africans Americans and Hispanics in the U.S. tend to receive lower quality health care across many different disease areas, African Americans are more likely than whites to “receive less desirable services, such as amputation,” and that these disparities are “found across a wide range of clinical settings including public and private hospitals, teaching and nonteaching hospitals.…” Similarly, Livingston details a scenario where a patient O (a black man) is expected to endure an incredible amount of pain during a bone-marrow biopsy without making any sounds of pain. When Mr. J (a white man) undergoes a similar bone marrow aspiration, Dr. A holds his hand and the Motswana nurse comforts him. Livingston writes that “his whiteness apparently creates different expectations around his stoicism.” Smedley and Smedley write that racialized science (and any science that looks for differences between racial groups) can only maintain and reinforce existing inequalities. Although many racial disparities in health are also the product of socioeconomic differences, Smedley and Smedley argue that when we accept this concept, there is the implicit idea that these socioeconomic differences are acceptable.

In her recent book, Breathing Race into the Machine, Lundy Braun writes about racial comparisons in lung capacity and about the race correction of spirometers. Since the 19^th century, it has been a well-established concept in scientific literature and in the medical community that African Americans (and most other racial groups other than people classified as whites) have a lower lung capacity than whites. Therefore, when doctors measure patients’ lung capacity even today, their spirometer values are “race corrected.” This means that the spirometer values considered “normal” for black patients are reduced, and black patients are not offered treatment or any sort of medical interventions for lower lung capacities than white patients with the same numbers. There are a few issues with this practice.

First, using race to correct for lower lung capacity ignores socioeconomic or environmental reasons for this decreased lung capacity. Often race issues are tied to socioeconomic differences and socioeconomic factors in lung capacity can also be connected to environmental explanations. Neighborhoods with lower socioeconomic status and high rates of minorities have also been shown to have higher rates of environmental pollution. Secondly, there is the issue of whether race should even be considered when taking this kind of medical measurement. When Braun interviewed physicians, they did not have a standardized way of determining race. Some physicians determined their patients’ race by looking at them and others asked patients to self-identify. Modern genomics show that there is more genetic variation within a race than there is between races, so using race as a biological concept seems even more flawed.

In the scene from Improvising Medicine, the doctors expect different things from the black man than from the white man and accordingly treat the two patients in different manners. However, juxtaposing Braun’s work on spirometers and race correction with Smedley and Smedley’s statistics on racial inequalities seems to create a sort of tension. Medical professionals are acknowledging how a certain minority group has worse health than others, but at the same time, they continue to be given worse care in the hospital. Race is one of the major factors in health care inequalities, and it would seem like acknowledging it would help fix this problem. Often, the first step to resolving an issue is addressing the issue and determining the roots of the problem. Nonetheless, the race correction of spirometers seems racist and unproductive in its current use.

It would be incredibly problematic if this type of race correction occurred globally and included other measures of health. Race correction could become a way of explaining structural violence and inequality produced by racial and socioeconomic factors, as well as becoming a method through which further inequalities were perpetuated through the decreased distribution of therapy or other medical interventions to these groups.

Discussion Questions:

1. How do we move forward from simply acknowledging and naming racial inequalities in health to working to eliminate these inequalities (especially if simply making physicians aware of these inequalities doesn’t change anything)?
2. If race is more of a social concept than a biological one, how productive is it to acknowledge race in terms of medical inequalities?
3. How can race correction (and other similar viewpoints in the general public or in the medical community) be eliminated?
4. Thinking about how “normal” is thought of differently (in relation to PTSD symptoms in Liberia, or classifying “normal” around the world), can race correction be justified if it shifts measurements towards the average value of the under-privileged community?

Sources:

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

J. Livingston. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham, N.C.: Duke University Press.

Shaban, H. 2014. “How Racism Creeps Into Medicine.” The Atlantic. [http://www.theatlantic.com/health/archive/2014/08/how-racism-creeps-into-medicine/378618/, accessed Sept 29, 2015].

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.