La brecha

The Gap


During the second half of 2007, one out of every three households in Burkina Faso was unable to cover the daily cost of food because of an upswing in prices that doubled the cost of basic products such as fish. In the same year in the United States, 62% of personal bankruptcies were reported to be directly related to expenses incurred as a result of illness. Although Burkina Faso has a per capita income 85 times lower than America, both countries are affected by the same problem: the existence of extreme inequities. As a result, ever larger sectors of the world population find themselves in a vulnerable situation and are exposed to financial, climatic and health risks that grow more ominous with every passing day.

The arguments needed to address this issue have been accumulating in recent years as authors like Branko Milanovic and Thomas Piketty have, with their data, provided the impetus for a public debate that will shape the societies we will live in far beyond the present crisis and all over the world. This is a debate in which practical considerations are just as important as ethical principles. A system in which the richest 5% of the world’s population has captured 44% of the increase in global income since 1990 is not only morally repulsive, it is also a ticking time bomb that could destroy the political and economic stability of modern democracies: high levels of inequity fuel social instability, weaken the link between people and institutions, limit social mobility, and impede economic growth.

The problem is that ideological certainties are not always easy to translate into practical goals that can guide the actions of public and private actors. This stumbling block has been apparent during negotiations on the post-2015 development agenda that will replace the ageing Millennium Development Goals. While the report prepared by the UN Secretary General’s High Panel singled out the challenge posed by inequity as a top priority, ideas on how to address the problem are scarce. One of the most interesting suggestions has come from Kevin Watkins—director of the British think tank Overseas Development Institute—who recently proposed the creation of automatic mechanisms of intervention triggered when differences in basic indicators between the richest and poorest sectors of the population reach levels previously defined as unacceptable.

Watkins’ proposal would require data on income and social welfare that could only be provided by much more sophisticated information systems than those currently in place in many countries. This is not, however, a reason for inaction. We know, for example, that mortality among children aged under five years in Colombia is eleven times higher in the poorest quintile of the population than in the richest quintile. We also know that Colombia has national and international resources that could be used strategically to reduce this shameful equity gap. If we know all that, there are no reasons—beyond ideological ones—for leaving the criteria of equity out of future development goals in the case of an issue so central to the welfare of the Colombian people.

A new paper published by our Think Tank has highlighted the scale of this problem with respect to another issue of key importance for development—access to essential medicines. Thirteen years after the publication of the momentous MSF report Fatal Imbalance, which denounced the fact that 90% of the world’s biomedical research was focused on the interests of the richest 10% of the world’s patients, everything has changed but the result today is exactly the same. Although social activism, the commitment of private companies and the negotiating skills of large philanthropic institutions have made possible unprecedented advances in the field of tropical and infectious diseases—especially AIDs, malaria and tuberculosis—today the conflict between the pharmaceutical model and public interest has shifted to the arena of noncommunicable diseases: of the 14 million people diagnosed with cancer in 2012, 57% live in the developing world, where a diagnosis of breast cancer is tantamount to a death sentence. With rising mean income and life expectancy in developing countries, cancer, diabetes and hepatitis are becoming the AIDS of the twenty-first century, creating a situation that demands a response that is not forthcoming: effective prevention measures and access to quality treatment. Nothing very different from what you would expect from your own health care system.

Within the Global Health Inequities project, ISGlobal has commissioned a wide-ranging series of reports and papers on the subject. The conclusions of all of these papers transmit a central message: it will be impossible to guarantee the right to health in the twenty-first century if we do not succeed in limiting the high levels of inequity that are an obstacle to progress in too many poor countries, with implications that go far beyond the debate on pharmaceutical innovation. Investment in social protection systems, for example, is the only effective way to safeguard the population against catastrophic health expenditure (the possibility that a person will lose everything as the result of ill health). The good news is that the cost of the most basic level of protection is so low that affected governments and the international community will have to find very good excuses for not putting such networks in place: the investment required to ensure universal health coverage in low income countries would be 60 US dollars per person per year. While this amount is double what is currently being spent in these countries, it represents only 1 percent of the amount spent in North America.

Clearly, the old distinctions between the rich world and the developing world are rapidly becoming less and less useful in this debate. The devastating effects of the global financial crisis on the poorest sectors of the population in European countries and the USA have shown up the weaknesses of a system in which the possibility of a secure existence is becoming increasingly more uncertain. And as a result the lives of many people are growing dangerously similar to those of 3,500 million people living in poor countries. At the beginning of this new century, no battle for the fundamental rights of human beings can be limited to the borders of a single country because the social contract we have enjoyed until now will in the future have to be global or it will not survive.

Death from Noncommunicable Diseases

In developing countries, noncommunicable diseases—such as cancer, diabetes and hepatitis— have become the AIDS of the twenty-first century. In many countries, the death rate attributable to these diseases is rising steadily. The following are just a few examples of figures taken from the World Bank’s World Development Statistics.

  2000 2012
Afghanistan 26 37
Angola 17 24
Bangladesh 43 59
Benin 26 36
Botswana 15 37
Colombia 57 69
Ethiopia 19 31
India 48 60
Nicaragua 57 73
Peru 56 66
Rwanda 19 36
Vietnam 66 73

Differences in Health Expenditure

The following figures are examples of the amount spent on health care per capita in different countries according to data from 2010 published by the Pan American Health Organization (in US dollars).

  • Bolivia: $90
  • Bahamas: $2,711
  • Canada: $5,499
  • United States: $8,463

Inequity and Global Health: The Gap