Benedetto Saraceno
A new measure has been proposed capable of intercepting socioeconomic deprivation, educational levels and material living standards at the same time. The measurement of socioeconomic status through this composite index would be the most suitable tool for monitoring health inequalities.
Health inequalities are all those unfair, avoidable and remediable differences in achieving optimal health for all. However, the state of the planet is dramatically ill due to climate change, irresponsible and rapacious exploitation of resources, growing geopolitical tensions, mediatized and ignored carnage and the increase in the number of human beings forced to flee and migrate. And all these factors of physical, psychological and social suffering are increasing and now more than potential risk factors should be considered as risks powerful and certain. In this context, a question that has always been at the center of the debate on Global Health is obviously the measurement of inequalities: that is, how such heterogeneous differences can be measured, whose operational definition and therefore quantitative measurement is often difficult.
National statistics have proven inadequate to measure health inequalities both due to the generic nature of the indices used and because they are often unable (and sometimes unwilling) to intercept inequalities in the most marginalized and vulnerable groups such as, for example, populations living in remote rural areas, indigenous minorities and immigrants. It is also interesting to note that some authors include among the inequalities in global health also the systematic recruitment of health personnel from low- and middle-income countries to high-income countries (1). From Multidimensional Poverty Index proposed by the United Nations (2) a new measure has been proposed capable of intercepting socioeconomic deprivation, educational levels and material living standards at the same time (3). The measurement of socioeconomic status through this composite index would be the most suitable tool for monitoring health inequalities.
The proposed Index (Socioeconomic deprivation Index) uses eight indicators relating to two dimensions, Education and Living Standards.
DIMENSION 1DIMENSION 2EDUCATIONLIFE STANDARDSINDICATORSINDICATORSYears of schoolingAvailability of fuel for cookingActual attendance at schoolAvailability of toiletsAvailability of drinking waterAvailability of electricityAdequacy of housing (floor, roof, walls)Resources (refrigerator, radio, TV, computer, bicycle, motorbike, cart pulled by animals)
The authors used this overall index of social and economic deprivation correlating it to the levels of coverage and accessibility of interventions for maternal and reproductive health and have been able to demonstrate excellent levels of consistency between the state of socioeconomic deprivation and health. The first issue of 2024 of Bullettin of the World Health Organization (4) is entirely dedicated to inequalities in global health, the possibility of measuring their impact and the urgency of developing an agenda aimed at decolonizing global health.
Even though decolonization dates back several decades, a new type of colonialism has developed, fundamentally based on heavy political and economic interference and influences that manage to extract material and human resources from low-income countries. Starting from Michael Marmot’s classic and fundamental analyzes on the determinants of health (5), it has been widely demonstrated how financial deregulation policies, the tightening of the defense of intellectual property rights (drugs and vaccines) and interventions in poor countries of international finance agencies (International Monetary Fund and World Bank) aimed at the privatization of health systems replaced by rapacious insurance systems, have progressively created an impressive gap in health indicators: those of rich countries are improving and those of poor countries are worsening. Furthermore, since each North has its own “internal” South, even the most deprived and vulnerable population groups in rich countries are exposed to similar phenomena of internal neocolonialism.
The dramatic asymmetries in global health are reflected at three levels:
inequalities in the training of healthcare personnel they ensure that universities in rich countries dominate in the formulation of the global research agenda, use poor countries as research grounds and often finance themselves with contributions from students who come from poor countries and attend academies in rich countries.the dominance of global health and trade policies which penalize poor countries. Just think of the promotion of artificial breastfeeding as an alternative to natural breastfeeding, the systematic sabotage of the policies of essential drugs and generic drugs in favor of drugs still subject to patent and, last but not least, to the ambiguous intervention in poor countries by powerful private charitable organizations that are often driven by the interest in protecting rich countries from infections coming from poor countries rather than by structural interventions that change the conditions of absolute poverty.the policies of “extraction” of the wealth of poor countries which often consist both in the abuse of the defense of intellectual property rights and in the promotion of health systems heavily dependent on the financial and technical intervention of private multinationals in the health sector.
It is not easy to indicate solutions in the face of this set of factors that converge to increase health inequalities. Only the strengthening of the multilateral bodies of the United Nations system, both in the sense of an increase in its spending capacity (increasingly eroded by bilateral investments by states and private foundations) and in the sense of greater political, economic and technical independence from the sector private (there is no doubt that the influence on the specialized agencies of the United Nations of BigPharma, of Philanthropic Foundations, of the Food and Agricultural Sector Industry has increased). Therefore, the alarm raised by the WHO is above all aimed at combating the phenomenon of the so-called “Forum Shifting” that is, that set of strategies that tend to influence and manipulate international negotiations in the field of health. Major negotiations are currently underway to update the International Health Regulations and create a Pandemic Agreement. It involves improving instruments of international law that bind states to regulate rights and obligations in the field of health (for example, in health emergencies, pandemics, natural or man-made disasters, in the regulation of health products, patents and of the suspension clauses thereof).
The “invincible armada” of multinational healthcare companies is now ready to launch a deadly attack on the universal right to health and universal and free access to the healthcare system. Defending yourself is an ethical, political and technical obligation that concerns all ministries of health in the world but also all healthcare professionals.
Benedetto Saraceno, Lisbon Institute of Global Mental Health
References
Walton-Roberts M, Bourgeault I. (2024). Health workforce data needed to minimize inequities associated with health-worker migration. World Health Organ. 2024 Feb 1; 102(2): 117–122. Published online 2023 Nov 21. doi: 10.2471/BLT.23.290028.Global multidimensional poverty Index 2023. Unstacking global poverty: data for high impact action. . . . New York, Oxford: United Nations Development Program & Oxford Poverty and Human Development Initiative; 2023.Ferreira LZ, Wehrmeister FC, Dirksen J, Vidaletti LP, Pinilla -Roncancio M, Kirkby K, Ricardo L, Barros A, Hosseinpoor AR (2024). A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions. Bull World Health Organ. . . . 2024 Feb 1; 102(2): 105–116. Published online 2023 Dec 8. doi: 10.2471/BLT.23.290866.Tangcharoensathien V, Lekagul A, Teo YY. (2024). Global health inequities: more challenges, some solutions. Bull World Health Organ. 2024 Feb 1; 102(2): 86–86A. Published online 2024 Feb 1. doi: 10.2471/BLT.24.291326.Wilkinson R & Marmot M. (edts). Social determinants of health: the solid facts. 2nd edition. World Health Organization, Copenhagen, 2023.
asymmetries in global health, socioeconomic deprivation, health inequalities, Forum Shifting, International Health Regulations, educational levels, Multidimensional Poverty Index, United Nations, WHO, Pandemic Agreement, Socioeconomic deprivation Index, material living standards