The Global Right to Health Health

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The Global Right to HealthHealth Wealth, Local
GlobalA Pessimistic Perspective

• Stan Houston
• Department of Medicine (Infectious Diseases
  General Internal Medicine) School of Public
  Health

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Health Disparity Between Rich Poor Countries

• Life expectancy at birth (both sexes)
• Botswana 35, Sierra Leone 41, Uganda 49
• Japan 82, Iceland Canada 80
• Under 5 mortality rate/1000
• Afghanistan 257, Niger 262
• Iceland and Singapore 3, Canada 6
• Maternal mortality rate/100,000
• Afghanistan 1900, Angola 1700
• Ireland 4

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Health Disparity Can Be Found Much Closer to
Home Effects of Relative, as Opposed to Absolute,
Poverty
Life Expectancy at Birth in the Eight Americas
PLoS Medicine Sept 06
In Canada, life expectancy at birth in 2000 for
First Nations men and women was 8.1 and 5.5
years less than for all Canadian men and women.
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Causes of the Health Disparity

• Determinants of Health
• Poverty, relative absolute
• Core direct and indirect determinant of health
• Water, sanitation
• ? Most effective technical intervention for
  health improvement
• ?Requires systemic political and economic
  solutionsjust trade arrangements, debt
  elimination and democracy and transparency in
  international financial institutions.

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Poverty In 2003, 1.2 billion lived on lt1/day,
a further 2.8 billion on lt 2
Gross National Income/capita (US) 2003 United
States 37,870 ____________________ 252
X Sierra Leone 150 How is this possible?
World distribution of income purchasing power
parity 1998 dollars Milanovic, B. Worlds Apart
2005 p. 129
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Some of the causes

• Historical disadvantage (see Guns, Germs Steel)
• All the rules are made by rich countries
• Massive debt (net cash flow is S?N)
• World Bank IMF requirements
• Contrary to historically successful policies
• Consistent track record of failure
• Massive ( profoundly hypocritical) subsidies by
  rich countries
• Brain drain
• Capital flight
• Armies, the arms trade war
• Corruption

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Interaction Between the Worlds Rich Half and
its Poor Half
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Water Sanitation
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Causes of the Health Care Disparity

• Lack of financial resources
• Drugs
• Vaccines
• Other diagnostic therapeutic technologies
• Other prevention activities
• Hospitals and other infrastructure
• Shortage of health care workers

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Doctors/100,000 Population
Lancet 053651893
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Migration Trends
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But Were Making Progress, Right?

• Which way are the trends headed?

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Summits, Declarations, Resolutions and now
Concerts and Wristbands

• 1948 Universal Declaration of Human Rights
  (including the right to medical care)
• 1978 Health for All by 2000
• The Global (ATM) Fund
• 3 by 5
• Stop TB
• Roll Back Malaria
• 2000 Millenium Development Goals (MDGs)
• 2001 Commission on Macroeconomics and Health

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IMF Results

• in recent decades, too many countries and nearly
  one-fifth of the world population, have
  regressedThis is arguably one of the greatest
  economic failures of the 20th century
• IMF statement accompanying the World Economic
  Outlook, April 2000
• 54 countries saw average income decline during
  the 1990s

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Progress?

• In 42 countries, life expectancy at birth was
  lower in 2001 than at a previous point, either
  1960, 1980 or 1990
• Lancet 20043631155-9

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Millenium Development Goal Education

• A girl born in southern Sudan has a better
  chance of dying in pregnancy or childbirth (1/9)
  than of completing primary school (1/100)
• Unicef in BMJ 20043281086

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N A T U R E 0 4 4 3 0 9 3 2
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Are all humans human, or are some more human than
others?

• Lt. General Romeo Dallaire

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Home on the Range in Alberta

• 4 brand new buildings on the hospital campus, but
  nobody can get a family doctor and an Emergency
  room wait can take your whole day

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The Elephants in the Emergency Room

• Training of Health Care Workers
• Numbers of health care workers trained
• Distribution of health care workers by specialty
  and geography
• Drug costs rising much more rapidly than any
  other costs
• How much do we really still believe in universal
  access to health care?
• Democratic priority setting in health

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Numbers

• There is a serious shortage of health care
  workers
• It is getting worse
• Distribution, by specialty and by geography,
  makes this shortage worse
• Our primary solution at present is to strip mine
  South Africas medical professionals
• Wonderfully qualified kids who want to be health
  professionals, cant get in

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Doctors/1000 population (OECD 2002)from Fraser
Forum Dec 2002
Since 1970 Canada has had the lowest rate of
increasing physician training among OECD
countries
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Stock of Foreign Trained Physicians as Total
Physicians
In 2004, 26 of Alberta Doctors were Foreign
Trained
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Prescription drug expenditures in the U.S,
l993-2000
154.5
2001
Source IMS Health
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While we abandon equity as a societal principle,
it gets tougher to maintain it as a principle of
health care

• Many patients costing 1500/day in our tertiary
  hospitals are there because of complications of
  lack of basic food and shelter

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Holding a Democratic Conversation on Health Care

• Medical costs can increase much faster than
  resources. We desperately need a process for
  making informed decisions about priorities, that
  reflect the public will
• Currently, priorities are set by true special
  interest groups e.g. politicians with
  ideological and economic interests and academic
  doctors with their own agendas

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Self Evident and Evidence-Based Principles in
Health Care Funding

• The laws of the marketplace dont work for health
  care
• You can only have one appendix removed
• Doctors, not patients, determine most health care
  costs
• User fees reduce access to care for those who
  need it most
• The costs of administration and profit taking
  (plus conflicts of interest) make private care
  more costly
• A private system will suck doctors out of the
  public system
• When people who make decisions about the public
  health care system have a vested interest in
  private care, that is a conflict of interest of
  the most egregious nature

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• If you keep doing what youve always done, youll
  keep getting what you always got.
• Dixie Snider, US TB doc