Sunday, August 8, 2010

Charity or social justice? Financing global health

by Andrew Bresnahan

In August 2010, Bill Gates and Warren Buffet, two of the richest people in the world, revealed they had persuaded 40 US billionaires to sign the "
Giving Pledge", an agreement to use a majority of their wealth for philanthropy. So is there anything wrong with such an extraordinary act of charity?

Perhaps quite a lot. As Reinhold Niebuhr pointed out in the 1930's, "philanthropy combines genuine pity with the display of power, which explains why the powerful are more inclined to be generous than to grant social justice." Healthy systems of social welfare depend on equitable financing and coherent investment - and there are convincing arguments that charity tends to deliver neither. Many of these arguments are explored in a brilliant piece on the BBC's website reviewing ethical arguments against charity.

As response to the January 12th earthquake in Haiti demonstrated, questions of financing and accountability are of urgent importance for global health delivery, especially when acute disasters are layered on top of "the chronic but devastating disasters that stifle the lives and hopes of millions of people - lack of access to medical care, food, clean water, decent housing, schools, and jobs". In the face of these real needs, Partners in Health (PIH) has established a 20-years tradition of working alongside local Ministry's of Health. While so much of their work is made possible through private fundraising, PIH frame their practices not as charity but as "'pragmatic solidarity - a commitment to struggle alongside the destitute sick and against the economic and political structures that cause and perpetuate poverty and ill health."

Another example of global health solidarity in action is the March 2010 agreement between Cuba, Brazil, and Haiti to build a public health care system in Haiti. The agreement builds on Cuba's long-term commitment to medical internationalism in Haiti which predates the January 12th earthquake, and is based on an $80 million funding commitment from Brazil to set up a network of primary care and epidemiological surveillance facilities staffed by Haitian, Cuban, and Latin American personnel trained at the Latin American School of Medicine in Cuba.

In the context of the global financial crisis and fiscal austerity in Europe and North America, questions of financing primary health care are all the more important. Proposals for a "windfall tax" for environmental and social justice, a global "Robin Hood tax" on international financial transactions, and better progressive taxation are suggestive of the innovative alternatives to a dependence on charity for financing health and human development.

We shouldn't shy away from questions of financing global health. Indeed, they are essential not only for ensuring access to essential medical services, but also to broader systems of social welfare capable of addressing the social determinants of health. Every disease has a biological story and a social story, and our solutions to disease need to be both medical and social. As British epidemiologist Geoffrey Rose writes in the closing words of his Strategy for Preventative Medicine: "the primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart." The challenge of global health financing is to discover how best they can be brought together.