dollars_hourglassEquity may be the single most important determinant of global health. The trickle down theory is not only inhumane, but it is ultimately unworkable. If we maintain the current level of inequity, a finite ecology will not sustain the kind of growth that would lift the poor out of poverty.
The Connection With Health

Even rather poor countries, as the example of Cuba makes clear, are able to sustain a level of health that is comparable to the wealthiest nations, if they make a commitment to primary health care and the equitable distribution of goods and services.

In 1971 Julian Hart formulated the “inverse care law” which stated that “the availability of good medical care tends to vary inversely with the need for it in the population served” In other words, those who need medical care the most are the least likely to get it. The dynamics that underlie this law have to do with the equitable distribution of food, clean water, and health care services. As Richard Smith, the editor of the British Medical Journal states in his article “Medicine and the Marginalised”, the inverse care law “is seen in its most extreme form on a global scale: the highest rates of sickness and premature death are in the developing world, whereas medical care is concentrated in the developed world.”

Key Issues

Can We Afford the Rich?


It is a well documented fact that the rich have fewer health problems than the poor. This is due in part because they get better nutrition, work in less dangerous jobs, and live in safer neighborhoods. They also have better access to more extensive and higher quality health services. No one seriously doubts these facts. With some notable exceptions such as Cuba, wealth by itself correlates strongly with health. If it were this simple, a general increase in the level of wealth across the board would improve everybody’s health. As the saying goes, “a rising tide lifts all boats.” This is essentially the position behind the the neo-liberal economic theory and practice that dominate the world today.

The concept of “equity” implies a comparison between one group and another – in this case between the rich and the poor. Advocates of the neo-liberal position would argue that health correlates to the absolute level of wealth – without regard to equity as such. If I have enough to eat it doesn’t really make any difference if someone else has ten times or a hundred times as much as I do. I can be healthy. This argument suggests that the issue of equity is simply a rather abstract question of “fairness.”

It is true that some absolute minimum of wealth is necessary for a healthy life. If a child simply does not have enough to eat, clean water to drink, a warm place to live, or access to primary health care, he or she will not be healthy. No one would deny the importance of this degree of wealth. But there are strong arguments that equity itself, far from being just a nice philosophical question, is a major determinant of health in the world today.

The under-five mortality rate for Cuba for example, is 9 per 1000 births which compares very well with the rate of 8 per 1000 in the United States. Yet the average per capita income in the U.S. is about 30 times that of Cuba. Cuba’s high performance is largely due to her commitment to equity. As this, and other indicators suggest, equity may be the most important single determinant of global health. The reasons why equity is a key factor in the struggle for a healthy world merit careful consideration.

The human economic system must be seen in the context of ecology. We live in a finite ecosystem. As many prophetic voices have made clear, infinite growth is not possible in a finite system. Many factors influence the carrying capacity of an ecosystem. Technology may increase the total size of the pie to be distributed. But at some point we reach a limit. If we have not already reached that limit, we are very close to it. Short of someone finding a cheap and infinite source of non-polluting energy, we can’t expect too many more technical bail-outs. At some point we have to come to terms with the finitude of our environment. The fact is that, under the current conditions of extreme inequity, we simply cannot produce enough economic growth to help the poor without precipitating an ecological disaster. This is not ideology but hard fact. If we remain hell-bent on maintaining the current levels of inequity in the world today, by the time the tide rises enough to lift the boats of the poor, it will have inundated the earth.

The carrying capacity of the earth is flexible to some degree. It is strongly influenced by the amount of resources that are consumed by various individuals and groups. According to the Ecological Footprint Campaign, if every one on the planet were to consume as many resources as the average citizen from the U.S., it would take 5 earths to sustain them. It would appear that we can no longer afford the very wealthy. They simply consume too much, and give too little in return.

Equity or Genocide?

We have reached a point where we really only have two choices: equity or genocide. The logical choice is to implement economic policies that continue to reward effort in some reasonable way, but do not permit the current absurd and obscene accumulations of huge amounts wealth in the hands of a few. It makes little sense, for example that one family, like that of Bill Gates, should have a net worth of about 300 billion dollars. Also one has to wonder whether CEOs need an income that is over 400 times as large as that of the average workers in their companies. If we do not wish to take equity seriously, the other alternative is to kill off the excess population. In other words, some form of genocide.
Genocide has two forms: active and passive. When a country takes positive action that will predictably lead to the deaths of large numbers of people in any population, we would speak of active genocide. It could be argued that the deliberate destruction of the infrastructure in Iraq a decade ago during the Gulf war was a form of genocide. It is estimated that over a ten year period this resulted in about a half a million deaths. The use of depleted uranium in a war situation may also be considered a form of active genocide.

On the other hand, when the international community fails to take steps that are clearly required for the survival of millions of people, one would have to speak of passive genocide. It is difficult not to see examples of passive genocide in the failure of the international community to immediately make cheap AIDS drugs available to everyone needing them in the southern half of the African continent, or the refusal of the world bank to provide complete debt cancellation to poor countries that are unable to both service the loans and provide for even the most rudimentary needs of their people. It would appear that a choice has already been made. Those in power prefer genocide over equity as a solution to the strained carrying capacity of the earth.

An inequitable society is inherently an unhealthy society. In a society rift with huge discrepancies between the rich and the poor, the rich will wall themselves off from the poor, and in so doing make virtual prisons for themselves as well as ghettos for those they fear. The rich will also be forced to pursue repressive policies to keep the discontented in their place. One aspect of this will be the building of ever larger prisons. In an inequitable society only the very rich will have real access to the decision making processes. This produces a profound sense of alienation in those who have less. Such a society cannot help but create social, emotional and physical distress and disease.

Connections With Other Topics

Arms and the Military

Prince El Hassan bin Talal suggests that “The Third World War in Now.” Has it indeed already begun? If so, it is not essentially a war between nation states, nor between cultures nor between religions. While there may be secondary conflicts and intrigues based on such differences, the primary mainspring that is behind the escalating level of hostilities in the world today is the determination of the economically privileged to maintain their privilege at all costs. We are entering a war between the haves and the have nots. Inequity generates violence. As the degree of inequity increases so do the tensions leading to violence.

Corporate Ethics

Unregulated International corporations are creating an ever increasing and very dangerous gap between the rich and the poor. If the bottom line is always simply profit, then corporations cannot afford to be moral.


A finite ecological system will not sustain an infinite level of growth. For this reason we cannot sustain the life styles of the rich and at the same time lift the poor out of their poverty.


If we are to develop and sustainable level of growth, and at the same time address the needs of the poor, the issue of sharing the wealth – of equity – will have to be addressed.


As the wealthy seek to maintain their privilege in a world of increasing competition for limited supplies, the temptation to permit or even initiate genocidal processes will be great.

Humanizing Institutions

The defense of a highly inequitable system requires severe forms of repression, and this generates a growth in prisons and prison-like institutions. Indeed, in a situation of great inequity society itself takes on the aspect of a prison.

The United Nations

The United Nations probably represents the greatest hope for the survival of the world. Yet as it comes increasingly under the control of the wealthy, it becomes hobbled in its capacity to advocate for the sort of structural changes that are needed reduce war and to meet the health and welfare needs of people in the less developed countries.
What Can Be Done?

In the face of such a huge challenge, what can be done?

Perhaps the best starting point is to do whatever is possible to minimize our own footprints. In doing so we will be a witness to the fact that there is another way to live in the world. Measure your own ecological footprint at Redefining Progress, and pass this site on to others.

Then it is important to talk with others about the issue. Here is a good site that can be used to stimulate some discussion: Gritty.

In addition it is important to support with money, talk and work whatever political and social action organizations that seem most relevant to you. There are many organizations that are doing good work. It is impossible to say which one is the most important, but one that stands out in my mind is Jubilee Research which works on the issue of debt relief and the need for a more equitable treatment of the less developed nations.

David Werner sums it up nicely in his article The Need for a People’s Perspective.: “Perhaps most important of all, we need to become popular educators, helping ordinary people to see through the disinformation of the mass media, to analyze local and world events, to understand the roots of their hardships, and then to mobilize a massive demand for more responsible, democratic, and humane global leadership.”