Facets of the global health divide

BMJ 2001; 322 doi: (Published 17 March 2001) Cite this as: BMJ 2001;322:a

Global inequities in health is the number one ethical issue of our age, argues Peter Singer, the Canadian bioethicist (p 673). Most of the sickness in the world is in the developing world, but most of the health care is in the developed world. This week's BMJ illustrates four facets of the divide.

Pharmaceutical companies are under increasing pressure to make their drugs affordable in the developing world and to produce drugs for the conditions that are unique to the developing world (p 629). Drugs for treating HIV infection are, for example, unaffordable to most of the world's poor, and yet they can stop the disease from killing. Countries like South Africa, Brazil, and India are responding by producing generic versions of patented drugs. Pharmaceutical companies take action against them, and the rich and poor worlds collide (p 635). David Taylor calls for “mutual respect and a pragmatic willingness to work together,” but argues that commercial companies can't solve the health divide alone (p 629).

Poor countries are deprived not only of drugs but also of scientific information (p 627). Research libraries in rich countries have had to pay more for less information as publishers have increased their prices, and libraries in the poor world have lost all access. The digital divide (measured by access to information on the internet) is more extreme than any financial or health divide. This is especially sad because increasing access to information increases its value for everybody (because people add new insights) and the marginal cost of electronic information is zero. Publishers, like pharmaceutical companies, need to find ways to provide their goods cheaply in the developing world, and an increasing number are doing so.

Even more fundamental than access to drugs or information is access to clean water, and it is only in the poor world that people do not have such access. Rhona MacDonald describes the terrible problem faced by Bangladesh, where people are being slowly poisoned by arsenic in their water (p 626). Wells were sunk to supply biologically clean water, but the geology of the rock means that the water contains arsenic. The problem is also seen in China, Mexico, Argentina, and Chile, and the solution is far from clear. Arsenic or dysentery is a poor choice.

About 98% of the 3.43 million adult deaths related to poor reproductive health occur in the developing world (p 636). Many international agencies have thus worked hard to try and reduce this dreadful toll, but their work has been severely disrupted by President Bush prohibiting the use of US funds by any agency offering abortion related services. The family planning organisations want the prohibition reversed.


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