 Ladies and gentlemen, welcome to the Disparities Workshop Seminar today as many of you know today is the last session of the year. Dr. Williver, who was scheduled for next week, had some child care issues and babysitting problems that she knew about well in advance and has begged out, leaving our distinguished guest today, Professor Dan Brock, to wrap up. He is the clean up hitter, okay? Dan is a dear friend, a colleague, we've known each other for many years. He is the Francis Glestner Lee Professor of Medical Ethics in the Department of Global Health and Social Medicine at Harvard, where he is also, I want you to hear all the different hats he wears, he's also the Director of the Division of Medical Ethics at the Harvard Medical School and the Director of the Harvard University Program in Ethics and Health. Professor Brock served on the, as the staff philosopher on the legendary President's Commission for the Study of Ethical Problems in Medicine in 1981-82, that was the commission appointed by Carter and ran through the early years of the Reagan administration. And Alex Capron was part of that group. They published six volumes with something like a dozen background volumes to the six reports that they issued all in about three years. I mean, it was an extraordinary output, dealing with questions like access to health care, end of life issues, doctor-patient relationship, and I don't know what else. It was really one of these memorable periods in American medical ethics. Dan has served on many other working groups, including the Clinton Task Force in 1993. He's been a consultant in biomedical ethics to the OTA, to the National Bioethics Advisory Commission, to the World Health Organization, to which he'll return next month in a trip back to Geneva. It's hard to say all the things that Dan has done, published widely in the field, serves on the editorial board of a dozen or so major medical journals in bioethics, health policy, and the like. Before I let you hear from Dan, I do just want to say a few words about his holding the Frances Glesner Lee Chair at Harvard University. Frances Glesner Lee was a Chicagoan, Dan tells me, born in 1878 and lived until 1962. During her years, she was one of these New England Dowager socialites dedicating her life to forensic medicine and scientific crime detection. In 1931, Mrs. Glesner Lee helped to establish the Department of Legal Medicine at Harvard, which then was the only such program in existence in North America. She loved dolls and doll houses and models, and she constructed, you have to hear me out on this one, 18 dioramas. These were called nutshell studies of unexplained death. These dioramas were used to teach detective methods to students, and they're still used today, somewhere at Harvard. The Frances Glesner Lee Chair was set up, Bill Curran, the great legal scholar at the Harvard Law School, who was one of the early pioneers in the field of medical ethics, was a holder of the Frances Glesner Lee Chair, and Dan succeeded Bill Curran in that chair. Something that Dan may not know, but I'm going to leave this with him, is that Mrs. Glesner Lee published an article called Legal Medicine at Harvard University, and this article was published in the Journal of Criminal Law, Criminology, and Police Science at through Northwestern University in January of 1952, and you are now the proud owner of Mrs. Glesner's Lee's paper. Without further ado, let me give you Dan Brock, who's going to speak on global health disparities. Why are they unjust? Dan, thanks so much. Thank you. You know more about Mrs. Lee than I do, or I now have learned some of that. When I was appointed to the chair, they told me it was a chair in medical ethics, and then I got the official document from the trustees and saying, you're Frances Glesner Lee, professor of legal medicine, and I called up and said there must be some mistake. I was told the chair would be medical ethics, I don't do legal medicine, I don't do illegal medicine, and they said, well, this had happened once before with Howard Hyatt, was dean of the School of Public Health for a while, and apparently it's very difficult to change the name of an endowed chair like that. You have to go to the state legislature. And so they said, what they did with Howard is they told him, just call it whatever you want, and so I have called it the chair of medical ethics ever since then. So I'm going to talk about global health disparities. I should tell you that this is not my computer. I'm appreciative of having it, but I don't know that I want to carry it around. So first I'm going to go very quickly over a little bit of data. So let me start out with a little bit of data on global health inequalities. This is probably familiar to most of you, and I'm going to go over this very quickly because I'm not an epidemiologist. I'm a philosopher by training, so I'm going to concentrate on the ethics here. This is just a map which very quickly tells you something about health disparities across the world. It's a map of healthy life expectancy. The dark blue is the best place to be, 71 to 75, roughly. The dark red is the worst place to be, 25 to 34. So there are enormous differences across the world, and you can see this map where they are. This is also a map of health inequalities, and I'm not going to go into the measure. But again, basically if you don't like inequalities, then you want to be in the blue parts. So even in the area where the health is worse, namely in Africa, the inequalities are also very seriously wrong, I would say. This is probably a chart that a graph that a lot of you have seen. This is a graph, it's a little outdated now, but it's life expectancy by health expenditure in different countries. And the take-home message here is that once you get to about $500 in per capita health expenditures, and that would be a little more now because that's old data, but once you get to about that, then you don't get much by way of improvement in life expectancy from additional spending. You can see the curve sort of flattens out, I'm drawing the curve on it. And the United States is way out there, but it's not doing any better than Costa Rica is, for example, spending vastly less. So you don't get your money's worth if you spend a lot beyond that in terms of health outcomes. Now this is kind of hard to read, probably impossible actually. It's almost impossible for me to read, but the bottom line here is that again, if you just look at mortality, this actually has mortality data and then it has healthy life expectancy data, which includes both mortality and morbidity data. This is all WHO data, and in 2006 in mortality, this is the seven WHO world regions. If you were in the African region, healthy life expectancy was 51. If you were in the European or Americas, it was about 74, 75. Health expenditures, once again, huge inequalities. This is familiar to all of you, I think. And again, the expenditures are least, of course, where the burden of disease is greatest, namely in those countries that were in red on the map. And finally, just official development assistance. We have a lot of military, quote, development assistance these days, but this is non-military development assistance. And in the United States in 2007, it was 0.16% of gross national income. The, I think, Norway is the only country to have met the official goal that many countries have committed themselves to of 6 tenths of 1%. And we're at 0.16, so we're not doing all we might. So just put all this data together, and I whizzed over it. But very great differences in disease burdens across different regions of the world. Chris Murray's group out at the University of Washington, funded by Gates, is redoing the global burden of disease study that was done in 1993. And I've seen some of the results, things aren't getting a lot better in terms of inequalities. So very great differences in disease burdens across different regions of the world. Where the burdens are greatest, the least is being spent on health care, and often on other things which affect health like education and a lot of other things. And the additional spending in the wealthiest regions doesn't actually bring proportional health gains. So there's a big mismatch here. Some of you know about the so-called 1090 gap, which is that 10% of, 90% of the spending in health research is directed at what causes 10% of the global burden of disease. So there's a huge mismatch there too. To make it more concrete, each year millions of children die from easy-to-treat disease, malnutrition, unsafe water, about 3 million die of dehydrating diarrhea. I think that's still roughly the case. Each of them could be saved by a packet of rehydration salts costing about 15 cents. There's a fellow at Harvard who developed those and so he gets credit for having saved 40 million lives. And the estimated cost of, to illustrate something a little bit later, of getting a sick two-year-old to age six in Nigeria or Pakistan, where at that point he would have a 90% chance of surviving into adulthood. The cost of that was $128. So why are these disparities unjust? Well, first thing to say is I think that not all of them are. In particular, disparities for which the worst off are responsible in some reasonable moral sense of that are at least arguably not on just disparities. The difficulty is that not many disparities fit that category. So even if you adjust for health behaviors that people are responsible for, you still get most of these disparities looking unjust. Well, why unjust? The disparities in access to symphony orchestras, depending on where you live in this country. And the reason is, of course, obvious to all of you, health is a fundamental aspect of well-being. It's necessary for your opportunity to pursue a life plan, a life plan that you choose for yourself. Ill health can cause pain and suffering. Those are things we like to avoid. And ill health can, as these earlier slides showed, shorten life. So the claim is it's unjust for individuals to suffer these effects, pain and suffering, premature loss of life, and so forth, from a lack of basic health care. And one has to add or from correctable social determinants of health because it's important always to say in medical institutions that most of the action in terms of impact on health and health inequalities is from the social determinants of health and not from health care. And it's only libertarian theories that would reject that claim that it's unjust for individuals to suffer those harms from a lack of basic health care. So there's two fundamental issues here, only one of which I'm going to talk about. The first one is, is it the inequality that's unjust or is it how badly off the worst off are? And those are different views. The first is called the egalitarian position, obviously, because it claims the inequality itself is what's unjust. The other says it's the absolute condition of the worst off that is what is unjust. And even if the only way to make them better off would make the people above them still more well off, our focus should be on those for worse off. That's what's called a prioritarian view in this literature. That's a topic I'm not going to talk about. I think what I have to say mostly will reasonably fit your view if you're an egalitarian or if you're a prioritarian. Second fundamental issue is who's morally obligated to do something about this? To reduce disparities or to improve the condition of the worst off. And that's the question that I'm going to spend the rest of the time today talking about. So what I want to talk about is the obligation to respond. And of course, this is a way of filling in why are they unjust. It could be an obligation of various, located at various places. It could be an obligation for individuals like any of us. It could be an obligation of institutions, of nation-states, of international organizations. World Health Organization does a lot of things in the area of health, although it doesn't deliver health care itself. Now states have the primary obligation in the world as it is now to protect the political liberties of their citizens and to protect the welfare of their citizens. That could only be because we don't have other alternative institutions that would do it more effectively. Or it could be that what we're really talking about in many cases is an obligation to relieve poverty, which is what leads to the kind of disparities that exist around the world. Now, so what kind of moral views could one appeal to in order to not just condemn these things, but have an argument that condemns these disparities? And most political philosophy, which is where one would find theories of justice, distributive justice, they focus on justice within nation-states. John Rawls, probably the most prominent political philosopher in the 20th century, he focused primarily on justice within nation-states. He then extended his view in a book called The Law of Nations, which I'll say something about, but most work examines or develops theories of justice that apply within a nation-state. And more recently, that's been less true. There's been extension to a global focus. It reflects the increased globalization of the world we live in, the various interactions that take place across borders, economic, social, cultural, and so forth. But the theorizing here, I guess the shame of my colleagues, is pretty incomplete and at an early stage. There are two polar paradigms, paradigm views here. One is usually called the cosmopolitan theory. Chuck Bites at Princeton is one of the principle examples of the cosmopolitan theorists. Basically, this view says the principles of justice within states that are appropriate within states also apply across borders. So you don't have different moral principles applying when you come to look at international or global issues. Now, that doesn't settle what the obligations are, because those within this cosmopolitan framework will disagree about what obligations you have within states, and so those disagreements just transfer out to the global context. And if you're a minimalist libertarian, you had Richard Epstein talking with you a while ago defending disparities. He's a minimalist libertarian. Then you'd defend those same inequalities at the global level as well, which I'm knowing Richard, I'm sure he did. But nevertheless, the cosmopolitan view is generally the most demanding because it says what the last bullet here says. There's no difference in the moral importance of a fellow citizen and his or her well-being and a foreigner's well-being. So the same principles and standards that apply domestically apply globally as well. That's the cosmopolitan view. In personal morality, however, it's common to believe in what are philosophers called agent-centered prerogatives. That is it's okay, anyone except utilitarian believes this, it's okay to give special importance to yourself, your own life plan, those who are especially close to you. And now, how much is a debated matter, but it's okay to give special importance to those to whom you're closely related. If you apply the same principles domestically and then internationally, you can see how agent-centered prerogatives might also justify giving special weight to your citizens, even in a cosmopolitan view. Now there's a conflicting paradigm at the other end of things. It gives special weight to nation-state relations. This is basically John Rawls's view, I think, but also Tom Nagel and Michael Blake are also in this camp. The general idea usually is that what's unique about nation-states is they coerce their citizens and they claim they're justified in doing so. And so there's a special justification then required to those over whom that coercion is being exercised with regard to how it's done. Now, one can immediately note that international organizations or treaties and so forth can be coercive as well, Trips is an example, but nevertheless, coercion is special in nation-states. Also, social cooperation is primarily, but less so all the time, with fellow citizens. And justice, as Rawls emphasized and others have since, justice concerns the terms of social cooperation. Now, economic, social, and political cooperation is increasingly across borders, so this becomes a less compelling reason for the nation-state view. And then there's some middle ground accounts of global justice. Josh Cohen and Charles Sable have one version of this. Norm Daniels has another. Basically what these accounts do is to use the facts of increased global interactions and institutions to ground significant global obligations. That is they sort of take the same intuition about justice that the nation-states view, namely justice is about the terms of social cooperation, but then we note that social cooperation is increasingly at the global level, not just at the nation-state level. But nevertheless, on this middle ground view, the obligations are less than they are to one's fellow citizens. And the problem here, in trying to use this work on justice to answer the question of who's obligated to do what in this context with regard to these disparities, is that these views are all pretty undeveloped at this point. At least that's how I would read them. There's broad disagreement across these three paradigms that I noted, and even within a particular paradigm, as I illustrated with the cosmopolitan view, there's disagreement as well. And we have disagreement every place in morality, so that's no big surprise, but the disagreement is less well-developed in this area because the theories are less well-developed. Work on justice traditionally has not had a global focus. So I'm gonna spend the rest of my time asking, are there other ethical sources for obligations to respond to global health and global health disparities? Besides these theories of justice, there may be some, what one can hope for here, and I think to some degree, the hope can be realized. What one can hope for is that there are other, either better-developed or less controversial moral principles that we could appeal to instead of these theories of global justice, to ground obligations to respond to the global health disparities. So what are these other possible moral bases, and that's what I'm gonna talk about now. The first, what I'll call additional basis of an ethical obligation to respond to the disparities that I sketched at the outset, is that except for libertarians, oh well, then forget about the disclaimer if you don't like it. All moral, all plausible moral theories, how about that? I'm happy with that. All plausible moral theories, except at least a minimal obligation of what's called mutual aid, typically. I'll leave out the next point. Utilitarians, of course, would insist on a much stronger obligation of aid, but a principle of minimal mutual aid is common across otherwise widely different moral theories. The idea is that if you can prevent great harms, whether that be loss of life or other great harms to persons, at little sacrifice to yourself, at little sacrifice in terms of either cost or risk to yourself, then you're obligated to do so. So the standard kind of case is now you're walking along and there's a three-year-old child drowning in a pond, you've never seen this person before, but you could just go in and pull her out and if you don't do so because you don't wanna get your new shoes dirty, then you've violated a principle of mutual aid, even though you had no relationship to that child before. It was simply your ability and opportunity to do it that creates the obligation to do it. So one nice thing about this principle for the kind of case we're talking about is that it holds in the absence of any special relation between the person giving the aid and the person receiving it. And in many cases, people will argue, there is no special relation between me and someone in Tanzania who receives aid that I provide. It also, this obligation also is understood to hold in the absence of any right that the needy person has to have a particular person respond. My example of walking by the pond, it was only the guy who happened to be there at the time the child was drowning. So he had no other special relationship besides the ability and opportunity to provide the needed aid. And this principle is often thought to hold both for individuals but also for collectives because in many cases it's collectives that have the ability and opportunity to provide aid, in particular in the health domain. Now, the U.S. and many other governments do reject any legal obligation of this sort. Bless their hearts. There are a couple of objections to using this kind of, using this kind of argument. One is that one commonly hears. One is that for distant needy, those, for example, are principally in Africa, in the examples we're talking about. Ordinary human concerns and motivations simply can't be generated at a high enough level to lead to action for distant needy that I have no otherwise contact with. Now, actually I think this is a bad argument. It's a true fact for most people. But I would characterize it as a lack of vividness of the need of the distant needy. So it's a cognitive limitation of us but it's not a moral justification for not doing anything. Suppose that starving child from Tanzania happened to sit down next to you while you're having your lunch. Then would you be able to be motivated to share your sandwich with her? And I think then most of us could because the need would have become vivid. So it's an epistemological limitation when we don't have that child sitting next to us but halfway across the world. And of course modern communications make it a lot easier than it used to be to make the needs of those other parts of the world vivid to us in a way that wasn't possible before. So there's one other objection that one commonly hears here. That last objection is not a good one I think to the argument is that, and this one isn't either, it's that if most others won't in fact do their part in aiding, most of you probably don't, and you're an unusual population I think on this count I hope, most of you probably don't give significant sums to global health and to relieving global health disparities. So this objection says if most others wouldn't in fact do their part in aiding then what this will do is place an unfair burden, an excessive burden on those who do. Now what's confused about this objection is that the obligation is to aid when one can do, what makes it uncontroversial is the obligation is to provide the aid when you can do so at little cost or risk to yourself. That is with limited sacrifice. Now that I take it, then this objection gives us a reason to enforce that minimal obligation of aiding, but it doesn't give us reasons to say we're gonna take all your money because nobody else is giving. How much would this obligation require of people? Anybody gone to a movie lately? Well surely the answer is yes, or a bull's game or whatever. Just think about it with regard to individuals. When you go to a movie you nowadays pay about 10 bucks. It actually seems to have gone up in New York to 12 in many cases. That $10 could do much more good by being given to Oxfam for the work they do around the world. It's just, one can't make a plausible case that there's more good that comes when I go to that movie even if it turns out to be a really good movie, which may well not, then there's more good done in the world than would be done in the world if I gave that money to Oxfam instead. So $10 can pay for minimal essential medicines and other life-saving interventions. So now is it a big sacrifice if one doesn't go to the movie? Well it's a sacrifice, but it's not clear that it's a sacrifice that would justify your failing to provide that 10 bucks to Oxfam instead. So it certainly, this principle of mutual aid, minimal principle of mutual aid, certainly it can be applied to collectives as states as well as individuals. It certainly provides an obligation to do more than most of us as individuals do because we go to movies, we don't just send to Oxfam. And it provides an obligation for more than states do as I mentioned before, it's 16, 100. So 1% of gross national income is what we provide. Gopal Srinivasan has a proposal for 1% of gross national income transfer from the seven richest countries which would quadruple the amount of this non-military aid. So and 1% is again, is it going to make our lives miserable? No, is it going to be a big sacrifice? No, would it be some sacrifice? Yes. So here's a second argument that one could appeal to try to ground our moral obligation to do something about these health disparities. The first arguments didn't rely on there being any special relationship between us and those who are suffering the disparities. It's just that we happen to have the ability and opportunity to do something about them and that's all it relied on. The second argument mostly comes from, excuse me, work of Tom Pogie. Pogie argues that it's not the case that we don't stand in any special relationship to those who are suffering the worst health disparities in the world, in particular, sub-Saharan Africa. Why is that the case? We're implicated causally in their lack of healthcare and lack of many other things. Why is that the case? Well, just to summarize this very quickly, our position in theirs emerged out of a long historical period, 19th century, 20th century, a process with massive injustices. And they ended up being the ones that suffered those injustices. We didn't, they included genocide, they included colonialism, they included slavery. So it was one process there that harmed them and benefited us even if we weren't always acting intentionally. The second is we all depend together on a single natural resource supply, a world or global natural resource supply. The Africans largely are excluded from the benefits of that, even though the continent is very resource rich. Why? Because the benefits go to either the developed world, which is getting the oil from Nigeria and so forth and so on, or to despotic rulers in the developing world countries. They don't go to the poor in those countries. And third, both these developing world countries, again using Sub-Saharan Africa as the example, they and we are part of a single global economic order that tends to perpetuate and aggravate extreme global economic inequality. And I'm just gonna give one example of that. Seizing political power by force in many of the African countries, which is how political power has been gained in a number of them, then entitles you in the economic order, maybe this will be changing, but not yet, entitles you to raise money in the capital market, international capital markets. It entitles you to sell off national resources for your benefit as opposed to, that is you the leader of the country who is seized power by force for your benefit, but not for the benefit of your citizens. And that with an economic order that allows that, that's a pretty big incentive for corrupt governments. It's a pretty big incentive for non-democratic and non-responsive regimes. What this appeals to is that the everyday moral belief that I think all of us have that if I cause somebody's harm or their great need, I have a responsibility to rectify it that you don't if you were an innocent bystander. Would this also be making an argument about what sort of need would be needed? Because if you're giving to doctors without borders and Oxfam like that, sure you'll be helping some people get food and doctors in crisis situations, but this speaks to more of a political inequality, I feel like, which still happens, which doesn't really get addressed by your typical $10 donation, right? Yeah, I'm trying to leave aside. I mean, that's a big piece of the work that needs to be done, because if one first says yes, there is, there are some plausible ethical arguments that we ought to be doing something to respond to these needs and disparities. Then the question is, because there are all kinds of needs and disparities, what is it that we should be doing and how do we organize it and so forth? And I'm just gonna leave that aside. A, I'm not at all an expert on it and B, I don't have enough time to do it. But it is the case that my former colleague, Jim Kim, who was head of global health at Harvard and then went to, he's now president of Dartmouth, and he believes the major thing that needs to be done in global health is to develop what he calls the science of implementation. How do we effectively do this? Now that assumes that we can have resources, we can call on to do it, and then we have to learn how to do it. And in the global health area, Jim Kim and Paul Farmers are partners in health, which some of you may know about and they have shown that it was possible to deliver aid in places like Haiti where people previously thought it wasn't possible to deliver medical care. So, but that implementation is simply a separate issue I'm not gonna take up. And I wouldn't have anything to say that would be worth your listening to. Couple of examples though, current examples. The brain drain in health personnel is a serious problem in a number of countries. Britain basically solicits nurses from a number of African countries and some East Asian countries. Philippines produces more nurses than they have need for because they know those nurses can get jobs elsewhere. So that's an area where the developing countries are specifically causing the health personnel shortage in other countries. Another example here just for, well, I won't explain this point, but I wanna make it. The IMFs, everyone knows about the IMF these days, right? They had another problem besides the one they just had. And actually the other problem was worse. Well, the imposition of what came to be called the Washington Consensus in the 80s and 90s. The imposition of that consensus which pushed privatization in poor countries in order to, as a condition for getting aid for loans and aid. In effect, dismantled healthcare systems and other social support systems in a number of poor countries. And that again is an example where we weren't just innocent bystanders, we were the people who created the problem. I've already said this. There are problems with this view as well. One has to try to figure out what's the baseline against which one would measure the harms that we've produced by this global economic order. And that's not a simple question. Because if you're gonna say you have special responsibility to do more because you made these people worse off, then the question is how much worse off did we make them? There are internal economic problems and political problems that may be not our fault. And if you look across the world, there are countries the same level of economic wealth that do vastly differently in their health systems and the health of their people. So there would be a problem applying this view if we had the political will to do so because then we would have to try to figure out how much of this is our fault and how much is not. Third additional basis for this obligation would be found in human rights. In bioethics, until recently, and I'm inclined to say still, appeals to human rights don't have much traction in this country in bioethics. In other parts of the world, they have vastly more traction. If you look at work done in bioethics on these kinds of issues in Europe, for example, appeals to human rights are very common. They are much less common here. Here are two articles from the Universal Declaration of Human Rights. Everyone has the right to a standard of living adequate for the health and wellbeing of himself and his family, including food, clothing, housing, and medical care. And the second relevant article is everyone's entitled to a social and international order in which the rights and freedoms set forth in the Declaration can be fully realized. Now, those are not things that have yet been achieved around the world, needless to say. But they were, they're obligations that most countries in the world have committed themselves to, as well as our country. And we have a lot of international institutions that try to move us in the direction of realizing these human rights. Human rights are a nice thing to be able to appeal to here for global health inequalities because we understand them to be the rights that people have just as persons. You don't get them by being a United States citizen as opposed to a Canadian system citizen or so forth. They are rights, they're human rights. That is they come to you as a member of the human species. Some of them are negative rights not to be interfered with. Many of the political liberties are of that sort. Though even those require positive action to protect them. But some are positive rights and health is one of the best examples of that. It's a positive right in the sense that a negative right, the idea is I respect your negative right not to be killed if I just don't kill you. If I simply forebear from doing that. A positive right requires me to do something. So if you have a positive right to health here, that's gonna be an obligation for somebody to do something to provide it. And positive rights, back when Mark was talking about when we were doing the work on access to health here, President's commission way back in about 1981, positive rights were assumed by policy makers, by most of them to be open ended. And so if you argued for right to health care, they assumed that meant everybody gets all the health care that they want. And so we made a decision, probably a mistake, but we made a decision to formulate the position in terms of a social obligation to provide it. So people wouldn't just automatically assume that if it's a right, it's an open ended right. Positive rights need not be open ended. They can be limited. You can see the important need for good drinking water. Now, where do human rights come from? Well, that's a problem. Here are just a number of possible ways one might defend them. One could understand them as necessary to satisfy universal basic human needs. That's true of many of them. There are a few things in the Universal Declaration of Human Rights that probably don't qualify as basic human needs, paid vacations, and other such things. They could be defended as necessary to protect the conditions for individuals of the autonomous, choosers, autonomous developers of their lives and with the ability to carry out the life plan they choose. They could, this is what is usually thought in Europe and in the UN organizations, they could define the proper recognition of the dignity of the individual. The Universal Declaration starts off with the dignity of the individual and these rights could be a way of giving more specific content to that notion. And if that notion is gonna be used in moral argument, somebody's gotta give it some specific content. They could be the institutional embodiment of a right to equal concern and respect that all people have, Ronnie Dworkin's kind of view. They could be institutional expressions of some kind of ideal contract theory. The point is there's a number of different ways you might defend them. They haven't been, none of these ways have been worked out to the extent that one would hope if one really wanted to think that you had a well-developed and articulated argument for the basis of human rights. And one could still, there's just no consensus on the proper basis of human rights either in general or their application to health. But it is the case that they have a certain legal basis in international law now and there are much more detailed covenants that countries have committed themselves to and there are some institutions that we can now use to try to get things done in order to respect human rights. There's been some talk of that in what we've been doing in Libya, for example. Just one point, if the right is to health as opposed to health care, and once again one needs to just underline that the things that are the principal determinants of health in a country and the principal determinants of health inequalities in a country are not the access and inequalities in health care. They are what are commonly lumped under the social determinants of health, education, poverty, et cetera, et cetera. The Brits did a study called the Acheson Report about 10 years ago and focusing on causes of health inequalities. And they had 39 different areas of social policy that were contributing to health inequalities in Britain. None of these were health care. Well, there are problems for this few two and just to name two of them. Obligations for securing welfare rights are typically understood, as I've said before, to be the responsibility of nation states. But yet these are rights that one gets not by being a member of a nation state, one gets them by being a member of the human species. And that means that the obligations of others outside the state are still fairly indeterminate in this case. The other notion here is that defenders of human rights appeal to is the idea of progressive realization. That reflects that we don't have any way to produce all these rights for everybody right away. So we then commit ourselves to progressive realization of these rights. And that, of course, is indeterminate. So that doesn't give you much of a notion of what you have to do now and before the rights are fully realized. So conclusion, what I've tried to do is sketch for you some ways that ethicists would think about the global health disparities which are so glaring and would think about them from an ethical point of view, if you like. The most natural way to do that, of course, is through theories of distributive justice which I started with. The trouble there is that they, in the global context, are simply not very well worked out. And then what I've tried to do is to point to some other possible lines of moral argument which one could appeal to as a different kind of basis for an obligation to respond to these disparities. And then finally, what I haven't talked about at all is what someone asked, I think she's not there anymore, but what about the implementation issue? And clearly, if we take seriously that we really do have to do something, and in many respects, there are people doing a lot more about global health disparities than was the case 10 or 20 years ago. So if we take seriously the obligation to do something, then we have to determine how to implement actions that meet that obligation in a much better way than we now know. So thank you. Just remember that, pink is not mine. I will, I'll ask the first question. I think this is a fabulous review of why we have obligations to others. Beginning with distributive justice and then the three alternative lines helping with minimal risk to oneself, causing things that therefore owing reparations and finally the claim of human rights. As I said at the outset, your talk comes at the end of 26 or 27 other talks. I didn't know that when you asked me because there was somebody else who was supposed to come next week. But many of these talks dealt with our south side situation here. And any of those four theories could well be applied locally in Chicago or for that matter nationally to account for the terrible disparities in health. Maybe not quite as dramatic as the ones you showed on the maps at the beginning, but pretty terrible ones even in our own situation. And so my question is, I guess it's this cosmopolitanism versus the age and center thing. What are our obligations to the world when we've got these problems ourselves in our neighborhoods as well as in our own country? Well, I mentioned before Paul Farmer's group Partners in Health, they started outworking in South Roxbury in Boston before they went to Haiti and they still work in South Roxbury. Why did they go to Haiti and some of the other places that they work in Peru and Rwanda now? They've done work in the Russian prison system on tuberculosis and so forth. So why did they go to those other places when there was a lot of stuff to do at home? Well, because in many cases, the needs were greater and the resources to respond to them were not there. And there was a common belief when Paul and Jim Kim started Partners in Health that you couldn't effectively deliver medical care in very poor settings because you just didn't have the background infrastructure to do so. And basically I think they get more credit than anyone else for showing that was wrong. That's why they went into Haiti, poorest country in this hemisphere and they showed it was wrong there. And they brought treatment for AIDS, but also other forms of healthcare. Now, so then the question is, how do you divide up your attention in a way, right? And- Or your limited resources? Yeah, or your limited resources, which your attention is one of the limited resources. I don't have any neat, precise answer to that and I don't feel too bad about that because I don't think anyone else does either. But at least one of the things that one would look at is the degree of disparities and the seriousness of the needs and the resources that are already there to respond to them. I don't know a lot about the south side of Chicago, but I'll bet that with regard to access to healthcare, you're better off in the south side of Chicago than you are in Uganda or other sub-Saharan African countries. So that would say to me that if we think what we have to respond, what we have an ethical obligation to respond to are these very serious needs which are being unmet, then the obligation would seem to be stronger where the needs are greater. But it wouldn't, now, against that, the nation state folks would say, well, yes, the seriousness of the needs is morally relevant, but something else is morally relevant, namely the special relation we have to the south side of Chicago as opposed to the south side of Tanzania. Thank you. So towards the middle of the talk, you addressed the implications for the individual, I think as it stemmed from the minimal aid philosophy. Could you revisit where we left that because it seems like it was left in somewhat of a problematic state insofar as there's the $10 for going to the movies versus Oxfam, and so that $10 clearly falls into this minimal burden to you, but aid to the other. But if we go by that marginal benefit for who criteria, then it seems impractical for most anybody, even the people in here who do heroic global health work to live at sort of a sustained level of fulfillment of your sort of international obligations. I mean, there's not lots of nice suits in the room, there's lots of nice watches. What's the practical means of sort of reconciling that marginal, that minimal marginal expenditure? Well, I think I can't certainly give you a precise amount that each of us should be giving our resources. Peter Singer gives 25% of his income to mostly global charities. He's written a lot about this and so people know what he's done. He thinks he doesn't do enough. He thinks he does less than he should. On the other hand, just imagine if a lot of us gave 25%. There's an organization that was started at Oxford that is spreading to this country, apparently. People who are committing to provide, to give a certain amount of their income, I think it's somewhere like 15% to global poverty and global health. Now, the thing I'm confident about is that almost all of us do much less than we should and I certainly include myself in that. So that when you think about it in terms of this, the first thing you should do is feel guilty. Now, does that mean we can never buy a book again? Even if we use an e-reader, which is cheaper sometimes, does that mean we can never have a bottle of wine? Does that mean that we have to give up all the things which are a piece of our lives? No, because I said, in order to make the obligation plausible across many different views, it's an obligation of minimal mutual aid. That is, aid you can give that will prevent great harms at little cost or risk to yourself. That is, at minimal sacrifice to yourself. Now, going to one less movie and sending that 10 bucks to Oxfam instead, I take it would, for most of us, get covered under that. On the other hand, does it mean, as I say, that you can never buy another CD, you can never, and so forth and so on? No, because then one's talking about a much greater sacrifice in the life that you have chosen for yourself. Where that line gets drawn, I'm not so concerned about where that line gets drawn, partially, because I have no plausible answer to where it draw it, but also because I think, for most of us, when we think about it in these terms, we think, well, we're clearly below the line, and to get closer to it, we would have to do more than we do. I'm kinda concerned about, at least my issue, I think encapsulates to what many people have been saying, which is that, yes, we can have a minimal obligation to give, and we probably know that, I mean, politicians probably know that, well, debatable, but it seems like there's a problem getting that information to, you know, the average day person, if we all have some kind of obligation to give, I mean, the foreign aid issue, where most people think we spend too much foreign aid, et cetera, and I'm curious why there hasn't been more effort in that area through social media, video, besides, I don't know, the 12 a.m. feed the children commercial you see every now and then. So basically, I think, I'm asking, what role does the Garf Mint multinational organizations have in that facet? Well, if you go back 20 or 30 years, it's hard for you with personal, by personal experience, but increasingly easy for me, if you go back 20 or 30 years, then the recognition of these problems and the attention to them in the media is vastly greater than it was 20 or 30 years ago. When we, Mark mentioned that the President's Commission that I worked on back in 1981 did a report called Securing Access to Healthcare, and one of the things we did in that report was to try to estimate the number of people that didn't have health insurance in this country. That was not an available figure. And the estimate that we came up with that at that time, since 1981, was 22 million Americans. Now, of course, everybody knows it's now closer to 50 million. Nobody believed it. They said, oh, you must have forgotten to count Medicare or you must have forgotten to count Medicaid because it simply wasn't a piece of public consciousness and the data was very hard to come by. Nowadays, everybody knows it. Now, have we done all that we should to respond to that? No, obviously, but if Obama's plan does move forward, it will not eliminate those 50 million uninsured from being uninsured, but it will reduce it by a substantial amount. Congressional Budget Office estimates 16 to 18 million will remain uninsured, but that's a big step in the right direction. So, I think it's everybody's responsibility, frankly, and some of us can do some things and others of us can do other things. You guys are probably most of you in the healthcare profession or in one way or another, and that means that you have abilities to do things. Notice that one mutual aid argument was relied on the ability and opportunity for you to provide the necessary aid. Well, you guys are developing the ability and we'll have the opportunity to do it that nobody wants to have a philosopher providing healthcare, so I don't have the ability and opportunity to do it directly. So, I think, you know, different ways in which we can do this. I happen to think that the work Chris Murray's group out at Washington, which is funded by Gates, is doing to update the data is also extremely important because it moves a lot of people when they can, people who are funders, when they can measure the outcome. That's what moved Gates. So, there's just a lot of different roles and plenty of room for everybody, I think. Please join me in thanking Professor Gates. Very good.