Towards a global social contract

In South Asia, which contains a quarter of the world's population, half the population live below the poverty line. Some 34% of the world's child deaths occur in the region, which has almost two thirds of the global burden of malnutrition. Of the nearly 4 million child deaths a year over two thirds are attributable to infection. In addition, India has the second highest burden of HIV and AIDS in the world, with 4.58 million people infected with HIV.

Infection is rampant—but so are non-communicable diseases. India has more people with diabetes than any other country, and a third of Pakistanis over 45 have hypertension. In India about half of deaths from cardiovascular disease occur in people under 70—compared with a quarter in the developed world. The region also has increasing deaths from road crashes and violence.

In the United States health expenditure per person is around $4000. In Nepal the government spends $3 per person, while the Indian, Pakistani, and Afghani governments spend $4 per person. Less than half of children in Afghanistan are fully vaccinated against diphtheria, pertussis, tetanus, and measles, and only slightly more than half of children in India and Pakistan are vaccinated against measles. Yet in Sri Lanka 99% of children are vaccinated against all these infections.

We are publishing this theme issue on South Asia not only because the problems are formidable but also because there is such potential for improvement—and so many people with remarkable energy to make the improvements. Zulfiqar Bhutta, Samiran Nundy, and Kamran Abbasi, the three main drivers of the issue, point out how wise investment in Sri Lanka and Kerala—in primary care, vaccination, family planning, and education, particularly of girls—has reaped rich rewards (p 777). Other articles in this issue, which is written almost entirely by people from South Asia, show how health indicators have improved since South Asian governments stopped aping Western health services and placed greater emphasis on primary care.

But these are not simply problems for the entrepreneurial people of South Asia. The BMJ aspires to be global, and true globalisation would mean the rich accepting much more responsibility for the poor. Rich countries transfer a quarter of their gross national products within their borders in order to “fulfil the social contract”—providing education, health care, social services, income support, and the like. Yet the rich countries transfer only a fraction of 1% of their wealth to the poor world. There is no social contract between the rich and the poor world. The rich are willing to see those in the poor world starve, live on the streets, and die of treatable diseases in a way that is mostly unacceptable within the richer countries. A true global society would mean a global social contract between rich and poor.

This theme issue may be a small step towards such a society. Next, Africa.