 I'm Salvatore Bobonas and today's lecture is Inequality, Health, and World Society. Both infectious and lifestyle diseases closely follow socially determined patterns of incidents and prevalence. And of course, the ultimate health issue, the existence of human life itself, is closely tied to societal levels of development. World society theory implies a commitment to respecting human life everywhere, not just in the Eurocentric core of the world system, but unfortunately the global response to disease tends to focus on protecting individuals, more than on improving the robustness of society-wide responses to disease. Whether your income nor inequality causes good or bad health, both are indicators of the strength of society and the institutions that support good health. In the immediate sense, this means things like hospitals, medical facilities, and public health systems, but it also percolates through all of society to include less direct mechanisms like health insurance. It's great to have a fantastic hospital in your neighborhood, but if you can't afford to go there, it doesn't help you very much. Free vaccination, paid sick leave so you can afford to be sick and seek medical care. More broadly, there's health education. If you don't know about disease and the causes of disease and how to behave in healthy ways, you can't end up achieving good health. All the hospitals in the world are no good if you've ruined your own health, say, for example, through smoking two packs of cigarettes a day. Even more broadly is the availability of nutritious food in society, the avoidance of very dangerous work. In developed countries, we almost make fun of workplace health and safety. When the fire alarm goes off in our buildings, we often ignore it. Yet in poor countries, the lack of workplace health and safety and the lack of fire alarms in buildings causes hundreds of deaths. Even more broadly, countries that have supportive family policies and good employment opportunities create an environment in which people are able to seek and achieve good health. These good policies tend to be present in more democratic, more equal, less hierarchical societies. Thus, a holistic understanding of the determinants of health is necessary and leads to the suggestion that the spread of neoliberalism, the spread of the idea that policies should benefit individual talent and individual work, that kind of policy is probably harming health at all levels. In the most direct way, it's leading to the defunding of public hospitals and the reduction of health insurance, universal health insurance coverage, the elimination of sick leave. Even countries like the Netherlands and Denmark are having a reduction in the availability of paid sick leave because more and more people work for themselves in the gig economy instead of working in larger organizations where they have formal sick leave. It's leading to the defunding of public bodies that spread health information, the deregulation of food systems, neoliberalism and individualism are leading to policies that increase the stress on families and workers. People who have to find their own employment have a much higher level of stress than people who work for larger organizations where they simply show up to work every day and receive a salary. And finally, it's leading to less democratic, more hierarchical societies that may still have formal elections, but nonetheless have steeper hierarchies so only the rich can afford to run for office and large amounts of money are necessary to fund campaigns and ultimately this all leads to poor policies and poor health. Global health sector reforms are also threatening health in very direct ways and a good example of this is the hollowing out of the World Health Organization in the policy change in the year 2000. In the 1990s, the World Health Organization started as a laboratory based medical organization that provided direct health services, public health services to the poor countries of the world. Instead, the neoliberalization of health policy has led to the World Health Organization mainly being a bureaucratic organization that makes grants to NGOs and makes grants to government agencies that provide health services instead of providing them on a global basis for the whole world. So ironically, the rise of globalism in world society actually led to the defunding or the transformation of the main global health body. And as a result, most health funding now goes to special purpose vehicles that are perceived to be much more efficient and much less wasteful. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria which is funded by the Bill and Melinda Gates Foundation. This graphic below illustrates this shift in the way public health is managed instead of simply delivering public health services to the world. The World Health Organization encourages programs for good health, encourages the improvement of governance of health, promotes managerial excellence. And it's not actually delivering health services, it's focusing on management issues. Now, these new special purpose health organizations that are being funded by the rich world's foundations and the rich world's governments either through the World Health Organization or as a substitute for the World Health Organization are interested in particular diseases and particular problems, not in solving or providing the infrastructure for solving global challenges. And as a result, we've seen a series of international or global outbreaks for which the World Health Organization has been poorly prepared, secure acute respiratory syndrome or SARS, the H1N1 influenza outbreak in 2009, Middle East respiratory syndrome or MERS, and in 2014, 2015 the Ebola crisis in West Africa. As a result of the incapacity of the World Health Organization, the fact that the World Health Organization no longer has laboratories to identify new diseases like this, by default leadership has passed to those who have the resources. So the US Centers for Disease Control or the French Institute Pasteur have become the de facto global health monitors. Yet, these organizations have no responsibility for global health. Global health is something they do out of a sense of responsibility and personal responsibility and institutional mission. But these are not global organizations. These are not organizations that have the broad spectrum of the countries or the people of the world as members. Ultimately, the US Centers for Disease Control is responsible to the US Congress. The French Institute Pasteur is responsible to its board of directors. These are not organizations that are responsible to the world as a whole. Yet, they're the only organizations with the capacity to spot global outbreaks like SARS, H1N1, MERS, and Ebola. When we look at this new approach to global health management, we realize we're not making much progress in establishing anything resembling a world society. The only collective global organizations we have have been defunded. Healthcare for the poor is primarily being directed to the charity sector. That is not being organized through state institutions, but through NGOs. Health education has become highly politicized, especially over the issues of abortion and homosexuality with the result that instead of having health education delivered by national education authorities in line with global advice, we have highly funded fights over exactly what will be taught in schools with the teaching being funded by or in some cases being lobbied against by developed country advocacy groups. We see dangerous working conditions spreading everywhere. The International Labor Organization has excellent sets of guidelines and standards on working conditions, but these are not enforced by anybody. Policies that are promoting family disintegration. And finally, again, less democratic, more hierarchical relationships, not just within countries, but globally. When the global peak health body is no longer the World Health Organization, but the U.S. Center for Disease Control, however undemocratic the United Nations is, nonetheless, certainly running global health from Atlanta by the U.S. government is much less democratic than running global health from Geneva by the World Health Organization, an official United Nations membership body. Nonetheless, the world's health is getting better, and not just in rich countries, but in poor countries as well. So this chart shows life expectancy in developed countries, rising, rising, rising since 1950, and in less developed countries, rising, rising, rising since 1950. Now, we are here, the rest of this graph is a projection, but as you can see, health in poor countries has grown much faster than health in rich countries. And this is a result of the fact that the natural human lifespan hasn't increased, but even though we have all of these problems of not providing a global health infrastructure, those targeted health interventions are preventing deaths in poor countries. And they're effective in doing that. There's no doubt about it. Nonetheless, as technology increases, health is improving everywhere just because technology is improving everywhere, whether that's the technology of immunization, improved vaccines, access to mobile phones, improving health information. The simple fact is that without any help from global civil society organizations, without any help from world society, health would still be improving in poor countries, simply because technology improves every year. We don't seem to be showing much actual commitment to world society principles when it comes to global health. In fact, we tend to focus on the prevention of the spread of infectious diseases from poor countries where they originate to rich countries who don't want them. And that's illustrated, for example, in the Ebola outbreak, where there were thousands of deaths in West Africa, yet much of the press attention focused on the one death in the United States, the one case in Brazil, the one case in France, the two cases in Spain. That got as much attention in the developed world as the large-scale suffering in poor countries in Africa. If we want to understand the world's response to infectious disease, perhaps we can look back at a disease that used to be prevalent everywhere, even in developed countries, tuberculosis. In the late 19th and early 20th centuries, tuberculosis was endemic in every country in the world. You see this kind of public health announcement, don't kiss the baby because an adult kissing a baby may be spreading tuberculosis to those young lungs. Tuberculosis is a bacterial lung infection that was the single largest cause of death in urban areas in Europe and America in the mid-1800s. But by the early 1900s, rates of infection had been brought down dramatically. They were brought down by society-wide group efforts, simple public health precautions. Advising people not to kiss, not to touch, to wash hands, to know no spitting laws. Many people think that Singapore's famous no spitting law is because they wanted to clean sidewalks. In fact, the real reason for no spitting was to prevent the spread of tuberculosis. Better ventilation, more spacious housing, all of these sorts of social policies dramatically brought down to tuberculosis rates even though there was still no cure for tuberculosis. Now, tuberculosis, it turned out, was easily cured with antibiotics and as a result, after World War II, tuberculosis was nearly eradicated from the developed world. When people got tuberculosis, they were simply cured one-on-one. That is, individual person got the antibiotic. As a result, there was no longer any need in the rich world for social cures for tuberculosis. We can go back to kissing babies because we know that there's herd immunity. The entire country is free of tuberculosis. But this shift in the 20th century, especially in the late 20th century, from social to individual approaches to disease has not worked effectively in poor countries. So in poor countries, tuberculosis is still endemic because many people can't afford the drugs because drugs are not fully administered. There are many counterfeit drugs. When we rely on individual responses to tuberculosis as an individual disease, we end up with a generation of superbugs, of multi-drug resistant tuberculosis, MDRTB. Multi-drug resistant tuberculosis is spreading aggressively across South Asia and Latin America. And the reason is that people, well, if they're left to themselves to treat their tuberculosis, they get partial treatments. They buy drugs, but only when they can afford them. They buy the cheapest drugs, which may not be the most effective drugs. And as a result, as individuals, they partially treat their tuberculosis. And by partially treating it, they end up breeding the most resistant bacteria. That is, only those bacteria that are the hardiest and the most resistant drugs end up surviving and spreading to others. As a result, multi-drug resistant tuberculosis has become endemic, constantly present in much of Latin America and South Asia. And it's only a matter of time before it eventually spreads to the developed world as well. From a financial standpoint, it's simply impossible at this point to stop multi-drug resistant tuberculosis because costs rise exponentially with the prevalence of the disease. You know, the tuberculosis is everywhere. I mean, something like one third of the world's population carries the tuberculosis virus. The problem is that treating tuberculosis may be very cheap if treated properly within a national drug system. But the treatment of drug-resistant tuberculosis is incredibly expensive. And as people transition over from that cheap, easily treatable disease to having that expensive, not always treatable disease, costs rise at an enormous rate. So as multi-drug resistant tuberculosis spreads, we're seeing a health crisis in the making that we all know is there, and we can all see it happening. But because it hasn't yet reached the rich countries of the world that have robust public health systems, it is not yet, excuse me, not yet hit the headlines. But it's not just theoretical. This spread is happening, and it has yielded a fortress mentality. So far from having a world society approach to tuberculosis, the developed countries of the world have embraced a fortress approach to tuberculosis. If you enter Australia, you'll get an incoming passenger card. And one of the questions on the incoming passenger card is, if you are not an Australian citizen, do you have tuberculosis? It's right there on a par with do you have a criminal record? There's an implicit criminalization of those who have tuberculosis. And of course, the reason the question is there is that people with tuberculosis can simply be denied entry to the country to keep the disease out of the country. Tuberculosis is a disease of the poor people in poor countries, but it's percolating up to the rest of society. Now, tuberculosis is just a test case. Other disease challenges are sure to follow. We've only had antibiotics since 1928. In 2017, we've nearly exhausted the usefulness of common antibiotics. And in fact, we're always having a search for more and more expensive, more and more experimental, less widely effective antibiotics because the ones we've had for 50, 60 years no longer work. Now, if we're at the end of our tether, not really able to cure the worst forms of tuberculosis, no matter what we throw at them, after just 90 years of antibiotic resistance, where will we be in 500 years, in 1,000 years? I mean, if we expect humans to be on the planet in 500 years, admittedly a questionable expectation, but if we expect that, well, what will they fight disease with? We always imagine there'll be some magical future that will come to save us. But the fact is the individual treatment of disease with individual antibiotics simply has a limited shelf life. It's only lasted us 100 years out of the 10,000-year stretch of human history. Well, 100 years out of 10,000 isn't a very good record. We might even think of the 20 and 21st centuries as the antibiotics era when for a short time we were able to manage these diseases, but then they all came back. Global disease management is plagued by a silo approach that focuses on one person and one disease. But it doesn't have to be that way. We can much more effectively treat disease if we take a universal approach and we seek to establish robust systems that manage public health. Now, maybe the best example of that is smallpox. The world no longer has smallpox. It's been completely eradicated from the world because of a global institutional effort to destroy the disease everywhere, to inoculate everybody against the disease. We've almost got to the same place with Pakistan. Pakistan, I'm sorry, with polio. Polio now remains in just two countries, Pakistan and Nigeria. And if we had a real global institutional effort, we could perhaps eliminate polio as well as smallpox. It's noteworthy that the two places where polio remains are two places that are among the most socially excluded and marginalized in the world. The tribal areas of Afghanistan, which are home to the Taliban and other extremist anti-modern groups. And the north of Nigeria, which is home to Boko Haram. And again, extreme anti-western anti-modern groups. And these are groups that have feared the coming of world society, who explicitly fight against it. I mean, Boko Haram is explicitly founded on the principle that Western education must be destroyed. They don't want their countries being globalized. Now, we may not sympathize with their goals and with their means, but the fact remains that by taking a world society approach based on values that are embraced in the West and imposing these values, we've generated resistance that has led to resistance not just to democracy and resistance to women's rights and resistance to gay rights. It's also been resistance to public health workers. There have been murders of polio vaccinators in Pakistan. This is the backlash against the good that world society does. It may seem obvious that continuous management at an institutional level of infectious diseases through permanent global institutions is the obvious and necessary thing to do, but is it happening? It really isn't. Diseases get attention when they're new or epidemic. Global health institutions have been disintegrated into a silo approach where each disease gets its own organization, but no one is monitoring the whole picture of global health. What the world really needs is an institutionalized commitment to a global public health infrastructure, but there's no movement in that direction. And this is really illustrated perhaps better than anywhere else by the 2013-2015 Ebola epidemic in West Africa. Ebola is a disease of failed states and failed public health infrastructure. Ebola is a terrible disease that is highly mortal. I mean, it causes death anywhere between 10 and 40 percent, 20 and 40 percent of the people who contract it. But you've probably noticed that most people in most functioning countries never hear about Ebola because Ebola is in fact very difficult to spread in conditions with basic sanitation and public health. Ebola is a disease that spreads in places where dead bodies lie on the street and children poke at the dead body in the street. That's not the sort of disease that occurs in developed or even in middle income countries that have functioning health infrastructures. It's noteworthy that the Ebola epidemic in 2013-2015 broke out in an area of the world that has had in the last 10 years or 20 years civil wars and civil conflicts that have destroyed the institutional infrastructure of the countries. Historically, Ebola was present in another set of countries that again have devastated infrastructure. The Democratic Republic of the Congo, which has been in disarray for the last 40 years, South Sudan, which was created in the middle of a civil war with Sudan and which now, immediately after winning a civil war with Sudan, now has its own South Sudan civil war that started at the moment of independence. These are places that have serious problems institutionally and they've led their places where there's been endemic Ebola, repeated Ebola outbreaks year in and year out over the last several decades. It's now spread to West Africa and one of the really vicious vicious things that reinforced that outbreak in West Africa was the fact that hospitals themselves became places of disease transmission. What few hospitals there are were so bad that people were simply catching the disease through being in the hospital or catching the disease by caring for people in the hospital. And to give you an example of what we mean by a hospital, here is an example of a hospital in West Africa. Very nice sign, Ministry of Health, World Health Organization. This is the door to the hospital. This is the drive leading up to the hospital. These are hospital workers carrying in an Ebola patient. This is hardly the environment in which disease can be contained and controlled and ultimately healed. The hospital conditions or clinic if you want to call them that were so bad in Liberia and Sierra Leone that hospital workers themselves went on strike in the middle of the Ebola epidemic. The reason was that they were dying. These were not heartless people trying to get more money out of their governments during a crisis. These were people who were being asked to die in service of their country not just without being paid in many cases, but without being provided with basic sanitary instruments like rubber gloves to protect themselves against disease transmission. No gloves, no masks, no soap, no running water to wash their hands. Hospital workers were not striking for better pay. They were striking for their own lives. And then of course in Guinea, hospital workers or healthcare workers were actually murdered by villagers because these people were coming into the village to try to ascertain the the incidents of Ebola in the village and villagers feared that these healthcare workers would themselves be bringing Ebola and so murdered them. And so this is not an environment in which disease can be managed. The problem here is just a complete lack of social institutions that can manage public health. Now there's a vaccine. I mean in 2015 field trials began for the Ebola vaccine. It seems to be effective and thus Ebola will be defeated the same way that tuberculosis has been defeated, meaning that people will be vaccinated if western aid workers will be vaccinated if they work in West Africa or Central Africa. If there is a person who contracts disease like Ebola in Africa who flies to the United States, well all of the people who come into contact with that person will be vaccinated against the disease. So Ebola like other infectious diseases is going to be defeated on an individual case-by-case basis. While leaving the roots of the public health epidemic in place, a lack of public health systems, lack of government capacity, no pay for healthcare workers, you know, alienated populations, all that remains we will solve in big quotation marks Ebola while leaving the way open for the next infectious disease to arise in its place. Look this is the National Bank of Liberia, the Central Bank of Liberia. Now think how this picture contrasts with the photo of the JFK hospital in Liberia. Maybe if this were the JFK hospital and the Central Bank looked like the clinic, maybe we would have more effective healthcare systems in developing countries. But unfortunately it's the bank that has the money and it's the bank that gets the infrastructure, not the healthcare clinic. NGOs like especially and I think heroically, medicine sans frontières, MSF are doing fantastic work but they're the first ones to say that what they really need is a functioning public health system in the country concerned, not just to cure people who get ill but to prevent people from getting ill, to prevent diseases from spreading in the first place. Key takeaways. First life expectancy is rising throughout the world but really this represents general technological progress more than any real achievement in public health. Second infectious disease epidemics grab the headlines but really they just illustrate long-standing structural inequalities in health systems. And finally silo approaches that attack one disease at a time are no substitute for well institutionalized public health infrastructures. Thank you for listening I'm Salvaturbo bonus you can find out more about me at salvaturbobonus.com where you can also sign up for my monthly global Asia newsletter.