Global Development, Global Public Health, and Ethics
Abstract and Keywords
Rapid development has brought significant economic and health benefits, but it has also exposed populations to new health risks. Public health as a scientific discipline and major government responsibility developed during the nineteenth century to help mitigate these risks. Public health actions need to take into account large inequalities in the benefits and harms associated with development between countries, between social groups, and between generations. This is especially important in the present context of very rapid change. It is important to acknowledge the global nature of the challenges people face and the need to involve countries with different cultures and historical legacies in arriving at consensus on an ethical basis for global cooperation in addressing these challenges. This chapter provides an analysis of these issues, using examples on the management of health risks associated with global development and rapid urbanization and on the emergence of organisms that are resistant to antibiotics.
(p. 820) Introduction
“Development” is an often used yet contested concept, with differences in opinion as to how it should be understood and what its key dimensions are. At a basic level, the process of development involves multiple changes in the way people live and support themselves and their households. The relationship between development and health is complex and involves a web of direct and indirect connections. Changes in the way people live affect their health both positively and negatively. And, sickness and early death have a significant impact on well-being and development. For example, the transition from hunter-gatherer to agricultural production, thousands of years ago, led to increases in population and the development of towns and the benefits of more settled livelihoods, but it was also associated with much greater exposure to infectious disease (Cohen, 1991; McNeil, 1977). The same applies to the movement of people across long distances, which contributed not only to economic growth, but also to recurrent pandemics of plague in Asia and Europe and the enormous mortality from infectious disease in the Western Hemisphere after Europeans invaded it.
Until recently, the response to health challenges has been evolutionary: populations gradually attained immunity through natural selection, societies evolved cultural and religious practices to reduce the risk of transmission of diseases, and states played a role in protecting public health (Porter, 1999). Jared Diamond (2006) documents the devastating impact of a society’s failure to respond to health-related challenges and associated societal changes, with historical examples from Easter Island and Mayan Central America, for example, where population pressures and environmental degradation led to civil strife and violence, and eventually to a civilization’s collapse.
(p. 821) This chapter uses the term public health to refer to the science-based services that initially emerged during the nineteenth and early twentieth centuries in response to serious health problems in countries experiencing rapid development (Porter, 1997). Angus Deaton (2013) argues that the creation of scientific knowledge and the application of technological expertise to all aspects of economic and social organization were important drivers of this rapid development. Increases in productivity contributed to greater consumption, improved nutrition, and better health outcomes (McKeown, 1976). Government initiatives, based on public health science, also made important contributions to health improvement. Public health, as a field of research and social practice, provided a scientific and normative basis for changes in the role of the state. It developed in a context of political mobilization and struggle, which eventually led to an acceptance that governments have responsibilities for protecting populations against avoidable deaths and the high cost of ill health (Porter, 1999). The dominant understanding of the ethics of public health and the ways that ongoing debates about government’s role are framed reflect the social and political context of the nation-states where it developed.
Importantly, the distribution of the benefits and costs of development has been very unequal, and it continues to be so within societies and across the globe. Inequalities remain with respect to which “publics” of public health receive greater attention. This chapter’s analysis of public health and development emphasizes the impact of development and public health actions on the people who face lives of poverty and high levels of illness. For them, the complex relationship between health and development is less likely to come out on the positive side of the balance. This has implications for debates about the ethics of public health and development at national and global levels.
Overview of Ethics of Public Health and Development
A major characteristic of development since the Industrial Revolution has been the speed and interconnected nature of changes in technology, population size, urbanization, transportation, communications, and so forth. These changes have contributed to big rises in income and consumption in places where they occurred, although the distribution of benefits has been very unequal. These shifts also exposed populations to new health risks. Many people continued to live in poverty with deleterious health effects, and in some cases they experienced a worsening in well-being and health as inequalities widened. During the early phases of the Industrial Revolution, the intensified health risks were largely associated with infectious diseases (Szreter, 1997). For example, the concentration of large numbers of poor people in rapidly growing cities was associated with periodic outbreaks of cholera. This stimulated scientific discoveries that led to the germ theory of disease and eventually to public health actions that reduced the risk of cholera and increased the safety of cities (Evans, 1990). Public health responses were (p. 822) primarily confined to countries that benefitted from rapid development or to defined areas of colonies. This uneven distribution of benefits from advances in public health knowledge remains apparent, and outbreaks of cholera still occur where public health systems are weak.
Public health has played an essential role in enabling societies to benefit from rapid development by helping them avoid catastrophic health outcomes. For example, the social “decision” to create large cities entailed risk, but public health knowledge and practice made it possible to reap enormous benefits from the concentration of economic and social activity. Public health science has subsequently identified many more development-related health risks, and appropriate responses to these risks have enabled societies to benefit from new technologies, while limiting possible negative health outcomes.
Both the pace and geographical spread of change have substantially increased over recent years with rapid urbanization, the global spread of industrial production, major increases in intensive animal husbandry, and growing ecological stress and climate change (Bloom et al., 2007). Rapid economic growth has enabled many to escape poverty and reap health gains, especially in Asia. The pace of change is likely to persist for as long as people seek ways to ensure that they and their offspring have a better life. Very rapid development, however, exposes people to high levels of uncertainty and risks to their health. This is reflected in contemporary anxieties about emerging infectious diseases and the consequences of environmental pollution, and in growing concerns about increases in the proportion of deaths from noncommunicable diseases. Significantly, large numbers of people have been left behind and continue to experience poverty.
Public health services can contribute to a society’s management of rapid development by providing early warning of emerging problems and informing social responses to minimize health risks through preventative strategies, aimed, for example, at individual behavior or at amelioration of environmental conditions or structural inequalities (Bloom and Wolcott, 2013). In order to achieve these roles effectively, they need to be underpinned by agreed-upon social and ethical norms to guide the behavior of officials, public health practitioners, and citizens and to legitimate the use of state resources and power. In the present global context, there are large differences between countries in the formulation of ethical arguments for action on development and public health. Despite the differences, there is a need to reach agreement on a set of principles to provide a basis for global action (Pogge, 2008).
One approach for defining these principles is to agree on a core set of goods and services (including public health), access to which is recognized to be a “right” (Pogge, 2008). Deaton (2013) argues, for example, that efforts are needed to assist the many people left behind as others benefit from what he refers to as “The Great Escape.” Justin Yifu Lin (2012, 234) cites his education in the Confucian tradition as the basis for his desire to “find a way of contributing to the prosperity of my country [China] so that our people would be free from the fear of poverty and hunger.” Deaton and Lin emphasize the contribution of rapid economic and social development to well-being and health, but they also recognize that measures are needed to reduce the risk of deleterious health (p. 823) outcomes. Lin (2012) emphasizes the negative impact on large numbers of people trapped in poverty if their government fails to create the conditions for rapid development. He also refers to the sacrifices that a generation may make in investing in infrastructure, education, and research to improve the economic and health prospects of future generations. The mass movement of people to cities (in their own or another country) is another form of investment that migrants make in order to create opportunities for their descendants. It is also vital to assess likely harms to future generations from accruing debts to finance current consumption and from damage to important ecosystems (Sen, 2009).
Other analysts have focused on the complexity of social arrangements and the limited information available to planners and government decision-makers about the challenges individuals face, as well as their hopes and aspirations. This can result in serious policy mistakes (Ramalingam, 2013). Amartya Sen (2009) argues, for example, that many famines could have been avoided if policymakers had received early warning, and if they had been open to discussions on innovative strategies for addressing acute food shortages. He also argues that open and rational debates are an important mechanism for winning popular support for actions that are agreed to be in the public interest (of present and future generations). Others make a similar argument for participatory action research as a means of making known the understandings and points of view of social groups with relatively little voice in policy debates (Oswald, 2016). As the speed of change increases and the complexity of social organization grows, it is becoming increasingly important to ensure that all social groups have a voice in identifying new public health harms and in co-constructing the ethical norms that underpin public health action.
The Sustainable Development Goals (SDGs) (UN General Assembly, 2015) can be viewed as a statement of global principles of ethics and development, which have secured support from the governments of all nations. Some commentators have referred to the lack of specificity of these goals. This reflects the rudimentary nature of agreements in a rapidly changing global context. A next step toward deepening these agreements is through dialogue aimed at building mutual understanding of values underpinning actions to tackle specific global public health problems. The next sections illustrate this argument with examples of the management of rapid development and urbanization and the growing concern with antimicrobial resistance.
Management of Rapid Development and Urbanization
The benefits and harms of development have been distributed unequally within and between countries. The early political mobilizations that led to the establishment of the normative values of public health were driven by the disproportionate burden of ill (p. 824) health borne by the poor combined with the realization that all population groups, rich and poor, were affected when an epidemic occurred (Szreter, 1997). During the nineteenth and twentieth centuries, there was a big divergence in development and public health between countries experiencing rapid industrialization and those left behind (Pomeranz, 2000). Large proportions of the population in the latter countries experienced severe and, in some cases, worsening poverty and exclusion from the benefits of the globalizing economy. Many countries became colonies, with governments that largely reflected the interest of the metropolis and the colonialists. Public health services in these countries reflected their highly unequal social structure and concerns directed at preventing epidemics that could endanger the dominant minorities, while the health needs of the majority were, and in some cases remain, neglected.
Large structural inequalities persist within and between countries in levels of income and wealth and in exposure to health risks. This raises ethical issues concerning the distribution of benefits and harms at local, national, and global levels, and between present and future generations. These considerations need to be taken into account in the formulation of strategies for enabling rapid development and mitigating the risks that emerge.
One important aspect of rapid global development has been the movement of very large numbers of people into urban areas. This has led to the rapid growth of densely populated cities. Those cities are often characterized by striking inequalities, which translate into health inequalities. A large proportion of their residents live in low-income settlements where the risk of transmission of infections is high. This is due, among other things, to contamination of water with human waste, low-quality housing, limited infrastructure for health provision, and compromised immunity due to malnutrition and chronic disease. Residents of such settlements depend primarily on informal markets to obtain health care, often at high cost. On the other hand, access to employment in cities might also mean that households have greater resources to address episodes of ill health and access to some form of health care than might otherwise be possible in rural areas. These urban communities are likely to be important channels for the transmission of new or re-emerging infectious diseases, such as the 2014–2016 Ebola outbreak in West Africa, and of infections resistant to antibiotics. They are also likely to suffer the most from such health risks. Expanding cities, in turn, have increasingly strong transportation links with other countries through which infectious diseases can spread. At the same time, the populations of these cities face risks of chronic, noncommunicable diseases associated with a number of aspects of urban lifestyles, limited access to recreational spaces, unhealthy food environments, and exposure to environmental pollutants.
Public health services and policies can play an important role in reducing the risk of deleterious health outcomes from rapid urbanization. However, they face ethical concerns. How much should societies invest in public health surveillance as a hedge against the possibility of the rapid emergence of unexpected problems? How should public health researchers and practitioners weigh the current and anticipated future benefits of particular forms of rapid urbanization against difficult-to-quantify risks of deleterious health outcomes? This is a particularly pertinent question in societies where many people are urgently seeking ways to escape poverty and improve their lives in accordance with (p. 825) their understanding of the available opportunities. Who should bear the cost of delays, because of potential health risks, in measures that could provide benefits to poor people? Whose point of view should count in making these decisions? Who is responsible for action to improve urban public health? What is the role of national and city governments? What are the responsibilities of stakeholders, such as urban-based companies and extractives, that benefit from improved urban infrastructure? Are there international responsibilities? The Chinese government’s Belt and Road Initiative, for example, is financing large investments in the infrastructure of several countries. They are likely to encourage urbanization and increased volumes of intercountry travel. What is China’s responsibility for potential public health consequences?
Antimicrobial Resistance, Development, and Global Consensus
This section illustrates the challenge of constructing an ethics of global public health, using the example of the global response to antimicrobial resistance (AMR). AMR is a global public health crisis, said to have the potential to kill more people than climate change (Davies, 2017). The development, production, and distribution of antibiotics was a significant achievement of the second half of the twentieth century (Laxminarayan et al., 2015). It involved a combination of basic science, the organization of mass production and distribution, and the creation of institutional arrangements to enable people to use these products safely and effectively. The countries at the forefront of development integrated the arrangements for antibiotic production and use into their existing health systems. The widespread use of antibiotics is widely acknowledged to have made a large contribution to health improvements in these countries. However, it has also been associated with the emergence and spread of drug-resistant organisms.
During the last quarter of the twentieth century, access to antibiotics spread to areas where these institutional arrangements are absent or nascent. This access was stimulated by well-publicized efforts to provide access to effective treatment of common infections, often based on syndromic diagnosis and sometimes as a means of providing prophylaxis for groups of people, such as sex workers, who are at high risk of infection. It was also a result of the rapid spread of markets for drugs and medical care associated with rises in income and increases in the availability of information, including through advertising in the mass media. These developments have contributed to reductions in maternal and child mortality, for example, in Bangladesh (NIPORT, 2012). They were also associated with the further emergence of organisms resistant to antibiotics. In high-income settings, the inappropriate use of antibiotics in health care and in commercialized agriculture has continued to lead to problems of resistance.
In 2015 the WHO launched a Global Action Plan on AMR (WHO, 2015). The immediate source of pressure for action was the growing problem of antibiotic-resistant infections (p. 826) in hospitals and community settings in high-income countries. This is a particularly severe problem for people with immune systems that are compromised from a congenital abnormality, HIV infection, immunosuppressive treatment, or the effects of aging. In countries where entitlement to medical care is part of the social contract, the treatment of these people has become a growing problem. Despite the local nature of this manifestation of the problem, there is a growing realization that an effective response must include action in other countries and coordination at a global level.
One strategy for addressing the challenge of antibiotic resistance is to substantially increase investment in research and development of new antibiotics and other forms of antimicrobial therapy (O’Neill, 2016). In order to maximize the future benefits of investment in new antibiotics, governments and pharmaceutical companies will need to agree to limit their use to cases where existing treatments fail. This means that companies will not earn revenue from these drugs for a long time, and governments will need to finance the investment. Clear rules will be needed concerning the use of these products. But who should produce the rules—governments who are financing the investment, the governments of other countries with the capacity to produce pharmaceuticals, or all governments? The answer is important, because companies in a number of countries have the capacity to reverse-engineer new compounds and sell them at a high price. Their governments will need to prevent this. They are unlikely to do so, however, unless they have played a role in formulating the rules, and unless their health facilities have access to the new drugs. To be just, the rules will have to be understood by all. Among other things, this commitment to justice would mean making the “right” of access to antibiotic treatment of common infections a global reality in order to address the continuing excess mortality from treatable infections. Laxminarayan et al. (2016) point out that the lack of access to timely treatment of infections presently kills more people than AMR.
The existence of antibiotics is known almost universally around the world. Many populations believe that access to antibiotic treatment of common infections is an entitlement, even if they must still pay out of pocket. Indeed, there are very few places where people cannot obtain these drugs if they can afford to pay. In countries without a well-organized health sector, antibiotics are sold in unregulated markets, and studies have found high levels of antibiotic use by people using these markets (Peters and Bloom, 2012; Laxminarayan et al., 2016). Treatment efficacy, however, is frequently compromised by substandard products and the use of partial courses of treatment, affecting the quality of care and increasing the risk of antibiotic resistance. One approach to this problem would be for governments to close these markets if they had the capacity to do so. Although this may be an appropriate long-term goal, in the short run it could deny access to life-saving drugs to many people. Measures to address this problem could include investment in the development of vaccines, new combinations of existing drugs, and inexpensive diagnostic technologies. A global strategy for addressing AMR will need to balance the needs of large numbers of poor people, who rely on informal markets for antibiotics, against the needs of a subgroup of very sick people, based mostly in more affluent countries, with the aim of increasing the capacity for just and sustainable management of antibiotic use (Buckland-Merrett et al., 2016).
(p. 827) These arguments demonstrate the need to build a global consensus on an action plan to address AMR that should be underpinned by dialogue and agreements on what constitutes a just approach. Rules regarding, for example, the production, distribution, and use of new antibiotics will need to be widely agreed upon if they are to be enforced. Otherwise, the announcement of the development of a new product could simply create incentives to manufacture and sell it at a premium. Similarly, the understandings of the public and how the rationale for regulations is conveyed to them will strongly influence the degree to which a population accepts measures that limit access to certain antibiotics.
A global action plan will inevitably involve trade-offs between measures that benefit different population groups in each country and between countries considered to be at different levels of development. It will also involve appreciating differing understandings and perceptions by different population groups. In order to secure active consent, it will be important that the justification for the allocation of resources and for actions that limit access to antibiotics are understood to be just by all concerned parties. Actions that mostly benefit severely ill patients in better-off countries are unlikely to gain global support. A just action plan will also need to address the challenge of infectious diseases in all population groups.
The challenge of AMR also raises questions about the distribution of benefits and costs of development between generations. The residents of high-income countries have secured health benefits from antibiotics for many years, while resistance has been rare. More recently, access to antibiotics in countries with poorly organized health systems has contributed to a decrease in childhood mortality among population groups that are struggling to acquire benefits from development. However, this use of antibiotics will have a negative impact on future generations. How much risk of avoidable deaths should the present generation bear to preserve the efficacy of antibiotics? Should antibiotics be withheld from people in resource-poor countries with weak regulatory systems? Or, should the residents of rich countries, who have many opportunities to preserve their health, be asked to forgo the use of these products? Should they be withheld from residents of rich countries with severely compromised immunity?
Conclusion: Ethics of Public Health and Development for the Twenty-First Century
The examples above illustrate the kinds of challenges that public health practitioners and policymakers face in the context of rapid development and increasing globalization, where the benefits of these processes are unevenly distributed. These conditions reveal the complexity of the interaction between development and health. As the twenty-first century moves on, we can anticipate major health challenges associated with the (p. 828) accelerating growth of cities, the spread of industrial processes, and increasing ecological stressors. This will require large, public health responses at local, national, and global levels. However, the persistence of deep structural inequalities means that the distribution of risks and potential benefits of an intervention will have to be taken into account. As in the earlier phases of development, public health can play an important role in identifying potential health challenges, in addition to making contributions toward the design of interventions by governments and other stakeholders at local, national, and global levels to mitigate potential negative impacts. Such efforts at mitigation need to be inclusive so that those most at risk of negative health effects receive attention. This requires a public health system that is attuned to the issue of justice.
The construction of an ethics of public health that is appropriate for this era and that takes account of divergent perspectives and positions is an important task. It will take place in the context of major changes to the arrangements for global governance. The governments and private companies of large countries, such as India and China, have an increasing impact around the world. These countries are experiencing rapid development, and their governments are under pressure to create increasingly sophisticated institutions. Debates within these countries about public health and the responsibilities of national and local governments will have increasing influence on global political and ethical discourse. Global rules will also need agreement from low-income countries, since the failure and/or inability of their governments to implement basic public health measures can have a large impact on global health and on problems like AMR. This illustrates the need for an inclusive dialogue on what constitutes a just approach toward public health at a global level.
During the nineteenth and twentieth centuries, the establishment of effective national public health systems made important contributions to development. Furthermore, the construction of an ethical case for government interventions to protect public health influenced understandings of the role of the state. In the present period of rapid and globalizing change, it is important to strengthen global public health arrangements to protect against possible risks to health. One element of this endeavor will be the establishment of a normative basis for public health action that is acceptable to all actors. We do not yet have global agreement on ethical principles for complex global challenges. These principles will need to be clarified as countries build mutual agreements to address specific issues, such as AMR. We cannot assume that the perspectives developed by the economically dominant countries of the last century are “universal” in this regard. An ethics of public health and development for the twenty-first century will need to emerge from broad dialogue and the process of consensus building.
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