Imagine a scenario in which, at birth, we knew nothing about ourselves or our conditions: whether we were born female or male, whether or not we were white, whether we suffered from some kind of disability, whether we had come into the world in a rural area in Africa or in a hospital in Barcelona. Imagine that you have absolutely no information about what fate has in store for you, and then answer the following question: What do you consider to be fair or unfair? If there is a possibility that you have been born female, would you accept as inevitable that you would earn 30% less than a man for doing the same work? Would your views on the need for extreme migration controls be different if it was possible that you had been born on the wrong side of the border?
Would your views on the need for extreme migration controls be different if it was possible that you had been born on the wrong side of the border?
This thought experiment—called the “veil of ignorance”—inspired the work on social justice of the US philosopher John Rawls. The possibility that we might belong to the losing side helps us to understand the need for corrective mechanisms and the importance of having a redistributive system that ensures that everyone will enjoy the same rights and opportunities. No one can change the baseline conditions allotted to each person by nature or chance, but we can certainly make sure that those conditions do not come to represent a life-long handicap. Equity can rectify inequality.
There are few examples that illustrate this argument as well as health inequities. At this time, medical advances that are the stuff of science fiction exist alongside the medieval living conditions of half of the world’s population. The 34-year difference in life expectancy between Japan and Sierra Leone reflects parallel universes in which health care, nutrition and access to vaccines and medicines can determine a person’s lifespan even before they are born. There are also inequities within countries, even in the most developed economies; just ask the almost 30 million citizens living without any kind of health or medical insurance in the United States today.
The 34-year difference in life expectancy between Japan and Sierra Leone reflects parallel universes in which health care, nutrition and access to vaccines and medicines can determine a person’s lifespan even before they are born
And the struggle to eliminate avoidable inequalities goes way beyond ethical considerations. Today we know that, as well as being unjust to the disadvantaged, inequity is also prejudicial to the common interest. One study estimated the cost of health inequity in the European Union at around 980,000 million dollars a year. This figure is based on the amount that the system would save if populations with less education and lower incomes achieved the health levels enjoyed by populations with second- or third-level education. Many other studies, carried out in very diverse contexts, have reported analogous findings, underscoring the importance of social inequity with respect to economic productivity, tax income, and health care costs.
For all of these reasons, the international community has made the extension of Universal Health Care (UHC) one of its top priorities. While different versions of UHC have already been implemented in developed countries and many emerging economies, a large part of the world population still lacks a basic health care safety net. The Sustainable Development Goals have endorsed the extension of UHC as an antidote to the catastrophic health expenditure incurred by patients with certain diseases, which condemns millions of families to a downward spiral of debt and poverty. UHC is also seen as a mechanism for achieving the final victories in the epic battles of global health, such as the war on malaria, infant mortality and HIV/AIDS. In regions such as sub-Saharan Africa, the goal is to build and consolidate effective primary and secondary health care networks. In other regions, for example the European Union, the challenge is to overcome the exclusion from the system of vulnerable groups, such as undocumented migrants.
Today we know that, as well as being unjust to the disadvantaged, inequity is also prejudicial to the common interest
In the 21st century, fundamental rights, such as health, must not be determined by a post code. The tools we need to correct these inequities already exist. We just have to use them.
In ISGlobal, we have chosen a new format to illustrate health inequities—a comic strip, which you can read here.
Comic: Inequality in Health