Towards a global social contract
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.0-g (Published 01 April 2004) Cite this as: BMJ 2004;328:0-g
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
In your detailed panoramic view of health and ill health of the
inhabitants of our planet, I did not encounter even a morsel of reference
to mental health. If psychiatric morbidity and
mortality were factored in, not only the picture painted but also the
multi inferences drawn would be drastically different.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Global social contract, as a subject of your editorial was very well
chosen and pertinent to health and development issues for individual and
for partnerships in developing and developed countries. It contributes
to the ultimate and most ambitious health vision ever, Health For All,
(HFA).
The comparison in a related article of what made the Kalara state in
India and Syrilanka successful, clearly display a virtue of “political
commitment” to the “right mix of development and services” as the
cornerstone to sustainable development, of which health is integral as
defined in Primary Health Care, (PHC).
Between 1989 and 1999, I worked in Disaster programmes in Ethiopia,
Somalia, Sudan and Uganda. In Ethiopia, my office was within the building
of the UN Economic Commission for Africa; that gave me ready access to a
wide database of Africa’s woes in underdevelopment. Africa’s lost decades
was a familiar tune, within the conference rooms, coffee tables and
corridors and certainly, it still is. Being more of a public health
physician than a developmental specialist, the answers of colleagues whom
I interacted with increased my bewilderment and my silent quest for the
causes and remedies. For a non-economist, comparing countries that
achieved different indicators of development overtime but started off with
more or less similar baseline indicators looked the best option; similar
to a quasi-retrospective longitudinal study.
My stint in South East Asian economic tigers was perfect ground. The
silent question on the “virtue” was: not why but what did they do that
Africa did not? Though not all supported by hard data, these were
apparent: First, a commitment to meaningful rallying vision; secondly,
enforce accountability with meaningful wages against corruption; thirdly,
building an enabling environment for all spheres of development; fourthly,
heavy investment in human capital, and fifthly, systematic adaptation of
technology for local solutions and exports. The why became redundant, when
the above were in a cycle.
1. WHO Alma-Ata Declaration on PHC, 1978
2. OAU. Secretary-General's Report on Emergency Preparedness - The Action
Plan for Africa in Relation to Epidemics and Natural Disasters. Conference
of African Ministers of Health, Kampala. (1989)
3. UN-Economic Commission for Africa, African Alternative Framework to
Structural Adjustment Programmes for Socio-Economic Recovery and
Transformation (AAF-SAP); Document: E/ECA/CM.15/6 Rev.3, 1989
Competing interests:
None declared
Competing interests: No competing interests
While considering the health problems of South Asia, it is
astonishing that very little emphasis is given to the issues of financing
of health care in the special issue. South Asia is considered to be a sub
continent of problems and is second to Sub-Saharan Africa in terms of all
human development indicators. India is one among the very few health
systems having an unjustifiable degree of inefficiency and inequity in the
distribution of health status, due primarily to the type of financing,
organisation, management governs its health and medical care. With regard
to health outcomes, it is not only a question of how much a country spends
on medical care, the distribution of health care expenditure reflected
through who is bearing the burden of payments is also of paramount
prominence from an accessibility point of view. As the government spends
less than one fifth of the total health care expenditure in India, the
households are forced to spend huge amounts on health care, making each
small health care seeking event a financial catastrophe. Since private out
-of-pocket expenditure dominates [which is the most regressive and
inefficient form of financing care], the access to care for the lower
income groups is the first casualty. While WHO identified that reduction
of catastrophic health care expenditure is one of the most important
objectives of a health system, hospitalised Indians spent 58 per cent of
thier annual household expenditure on health care and one fouth of the
hospitalised population gets impoversihed due to medical expenses.1 Since
curative medical expenditure is one among the large number of inputs in
the household production of health, an abnormal increase in one input
called medical care leaves very little for other inputs like food,
education, spending on livelihood etc deteriorates not only the present
health status of an individual, but the long term economic security of the
individual due to the debt, or distress sales incurrred to finance medical
care. The population foregoing treatment attributable to the percieved
financial burden of treatment is increasing at a rapid rate as reflected
by National Sample Survey data. If the public health care services is
known for poor quality and inefficiency, the private medical care market
is infamous for its poor standards, over prescription etc.
The Indian health system needs to address two major issues with
regard to financing of care: 1)reduce the existing heavy bias which
favours tertiary care and urban centres (equity), but it is to be
remembered that the present level of health care expenditure on hospitals
by the government cannot be reduced because establishment costs are high
and abandoning results in heavy sunk costs; 2)expanding the resources by
the govenment in health sector to very high levels and one of the most
important reasons for Sri Lankan and Kerala success stories has been the
equitable and tolerably efficient spending by governments. However,
Kerala's health system is in a declining phase today due to the fast
decreasing public spending, increasing penetration of unregulated private
medical care market, skyrocketing mediflation etc. More often allocation
of funds for health care is a question of priorities as well. For the
Indian government, military is more important than health care of the
population because health care is never an eloctoral issue here, but war
is as shown by the government statistics. So it is not fully correct to
characterise resource shortage being the reason for less spending on
health care. The opinion that the increased funding through global "social
contract" may not work well, if history is any guide. The solutions are
not easy and it requires strong political will which cannot come on its
own and needs civil society's active pressure to push through the agenda
of people's health in public fora.
1.Peters et al. (2002), Better health systems for India's poor, The
World Bank.
Competing interests:
None declared
Competing interests: No competing interests
Dr. Smith has nicely outlined the major areas of concern for South
Asia, mainly India. Most of the facts tell their own story, but the
reality is more worrying. As pointed out, people are dying of easily
treatable conditions, which are not very expensive to treat. If a child
dies due to lack of BMT for leukemia/lack of IVIG for GBS, it may be
excusable to a certain extent on account of financial difficulties; but
how can we accept children dying of infectious diseases (diarrhoea, ARTI,
etc). Importantly, India cannot afford to ape the West nor can it afford
to conduct research in their fields of interests. Our needs are different,
we need more GPs, family physicians and simply more doctors, rather than
more superspecialists at this stage. We need to conduct research in areas
such as infections, malnutrition, etc, rather than newer therapies for
Alzheimer's disease at this stage!
Competing interests:
None declared
Competing interests: No competing interests
In India, two-third Infant Mortality is contributed by Neonatal
Mortality. The causes of deaths among the neonates are well documented
both in community as well as institutions. The required interventions have
also been identified. Still, every year 1.2 million neonates are dying
each year. Causes like birth asphyxia, hypothermia, and sepsis are
preventable and treatable with simple interventions. Till now, newborn
health has been attached to some other health program. This has not
resulted in a significant drop in the neonatal morbidity and mortality.
Also, the donor driven programs are terminated in the middle with the
change of agenda of these agencies. The need is to have a target oriented
specific program addressed to neonates. Local populace and local
governments at village level may be involved in the desgining and
implementation of such programs.
Competing interests:
None declared
Competing interests: No competing interests
Wat is the reference for author's statement in 2nd paragraph " a
third Pakistanis above 45 suffer from hypertension" ?? I really doubt this
high figure as I have been practicing medicine in Pakistan for alomost 15
yrs, till 2 yrs back.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR-A notable omission in your excellent Health in South Asia
theme issue is the absence of any reference to the public health problem
posed by accidental injuries, particularly the burgeoning road traffic
injuries and fatalities. The region is subject to an unprecedented
expansion of economic growth, urbanisation and motorisation occurring in
tandem. Data from Pakistan have demonstrated a disturbing parallelism
between the growth of vehicles on the road and the incidence of fatal
crashes.1 The Jinnah Postgraduate Medical Centre is the major trauma
receiving facility in Karachi and we had 3008 head injured patients
reporting to our Casualty Department in 2003. By comparison the same
Centre recorded 600 head injuries in 1970 and in both these periods, 32
years apart, the majority of serious injuries were sustained on the
roads.2
Our data also shows that most of the head injured in serious crashes were
pedestrians and riders of motorcycles unprotected by crash helmets.
Commercial vehicles were disproportionately involved in fatal crashes and
the victims were often young, economically active male bread-earners.
Health professionals involved with trauma care in all parts of the South
Asian region would immediately recognise this information as their own and
this commonality of increasing incidence, chaotic road usage with poor
adherence to traffic regulations and a preponderance of pedestrians and
public transport users amongst the injured and killed should be a strong
imperative for a co-operative approach to the solutions.
The South Asian nations urgently need to collaborate to enhance road
safety research in their academic centres and in particular to study the
dynamics and behaviour of our vulnerable road users, with a view to
evolving programmes of traffic engineering germane to our conditions.
Industrial scientists of the region should be encouraged to work together
to design motorcycle crash helmets more likely to find favour with riders
in the prevalent hot and humid conditions. Most important, we need to be
able to learn from each other to bring more effective programmes to bear.
An example is the excellent pre-hospital care scheme developed in
Bangalore where a Comprehensive Trauma Consortium has established a
network of radio-controlled, position-sensed ambulances manned by
specifically trained paramedical personnel.3 They have for the first time
demonstrated in South Asia that the timely deployment of trained pre-
hospital care providers at the crash site improves the survival of
accident victims4 and their experience could well be replicated in other
urban centres of the region to save lives and maximise the potential of
recovery of those injured on the roads.
1. Hyder AA, Ghaffar A, Masood TI. Motor vehicle crashes in Pakistan:
the emerging epidemic. Injury Prevention 2000;6:199-202
2. Jooma R, Zarden AM. Comparison of two surveys 32 years apart of head
injured patients presenting to an urban medical centre during a calendar
year. J Pak Med Assoc. Submitted for publication.
3. Comprehensive Trauma Consortium.
www.roadaccidents.com/rd/ctc_detail.html (accessed 3 Apr 2004)
4. Venkataraman NK. Presented at 5th Asian Conference of Neurological
Surgeons. Djakarta. Feb 2004
Competing interests:
None declared
Competing interests: No competing interests
The BMJ is to be congratulated for a beautiful theme issue on 'Health
in South Asia'. International journals with such clout and wide readership
across the globe can only help to bring to light, to a larger world
audience, the poor health of fellow humans in the developing world. This,
I believe is one of the roles of a general medical journal.
(BMJ 2004;328:591)
As I read through this week's editors choice , BMJ 3 April 2004, I
stopped and reminded myself that I was actually reading about South Asia
not West Africa including Nigeria, Ghana and the rest, because it was like
de ja vu. It was really strange because I had a similar experience about
the vegetation, climate and people when we drove in a bus from the airport
to the private medical school in Manipal, Kartanaka, India in 1999 to
attend that year's BMJ's LEAP ( local editors and publishers )conference.
Be it communicable diseases, non communicable diseases, maternal and
infant mortality, the catastrophy of HIV / AIDS or the paltry allocation
to the health sector by governments,the picture is very similar ( probably
worse) as BMJ will expose when it visits Africa( see Richard Smith's
promise). Similarly the effects of rapid urbanisation to the detriment of
rural development, where most Africans live, can be seen in the rise of
fatal vehicular accidents, congestion and overcrowding, stress, depression
and anxiety states.
Factors such as prevailing illiteracy which feeds ignorance, poverty,
superstition, voodoo and black magic compound the awful statistics of
morbidity and mortality across all ages and both sexes in Africa. In most
of these countries hard data will be difficult to colect but the
lamentable state of health in the continent is there for all who live
there (or visit) to see.
One further similarity is that south Asia and Africa are emerging
from centuries of colonisation and plunder by their colonising masters.
Some will say it is harsh to judge their poor performance or make
comparisons with the colonising countries, only 50 years after
independence, whereas the colonisers have enjoyed centuries of
uninterrupted development and growth.
I don't know the answer, but whatever the case I can't wait for BMJ to
throw its search light on 'Health in Africa' to reveal all, warts and
all!.
Competing interests:
Joseph Ana is managing editor of BMJ West Africa edition and Trustee- Director of The NMF ( Nigerian Medical Forum,a UK registered charity)both of which have keen interest in seeing to improvements in health care planning and delivery in West Africa since 1991. Neither position attracts a salary but his travel expenses are often partially refunded.
Competing interests: No competing interests
May I submit that comparing the financial outlay in US $ terms in any
field of activity in various countries does not give the true picture. For
instance US$ 4 in India buy far more than an equivalent amount in the
United States. Therefore all figures should be corrected based on their
Purchasing Power Parity. As per my information US$ 1 in India equals US$
5.3 in the United States. Besides the cost of medicines in India is not
even one-tenth of US.
Secondly, the article states that Indian Government spends US$ 4 per
year per person. The corresponding figure of the United States should be
the state's allocation, not overall expenditure. It is not clear as to who
spends US$ 4,000 per year per person? Is it the Government? If not the
comparison is not appropriate. In India 80 per cent of the health costs
are borne by individuals.
Competing interests:
None declared.
Competing interests: No competing interests
No Need for New Global social contract
We commend the ‘South Asia’ theme issue of the BMJ. The editor calls
for a new global social contract for the rich to help the poor.1 Please do
not weaken the poor by pretending to help. There are already social
contracts namely the agreements of the World Trade Organisation (WTO),
United Nations (UN), and World Bank etc. The social tenets of these
institutions are wantonly broken by the rich and powerful. ‘Iniquitous
decrees directed solely to private interest get passed under the name of
laws’.2 Rather than a new social contract, we need to renegotiate existing
international agreements to empower the third world. We list here a few
reasons why the rich need not donate and the poor should not beg.
Pakistan’s sick travel to India for life-saving surgery while both
countries are locked in a fifty-year old war. Despite the 1948 resolution
by the UN Security Council calling for a peaceful solution to the Kashmir
dispute, the five permanent members of this council fuel the war by
selling weapons to both sides. This global arms trade swallows up a
significant proportion of GDP of many poor nations at the expense of basic
needs of health, education and sanitation.
Ever heard of the poor subsidising the rich? The west poaches doctors and
nurses from developing countries to supply fodder for its health service.
A suggestion by the UN 3 that the rich countries could recompense by
repatriating a proportion of these migrants’ tax to their country of
origin has fallen on deaf ears. The apathy towards this brain drain is
even greater in the poor countries. The Indian government refuses to
recognise the overseas experience of the doctors wanting to return home.
Public health in the third world is under threat due to predatory patents.
The monopolistic nature of the pharmaceutical industry is unfavourable to
the poor and rich alike. Herbal extracts are being patented as new
discoveries in USA and Europe, when traditional knowledge of the medicinal
properties of these herbs existed in Asia over the millennia. As revenge,
Indian generic drug manufacturers like Ranbaxy play Robinhood to make
cheap drugs for which multinational pharmaceuticals own the patents. Come
2006, developing countries will have to abide by the WTO agreement on drug
patents.4 This will not be a bad thing after all, as it will force Indian
drug companies to invent their own drugs. Interestingly, the Bush
administration that blocks cheap HIV drugs to Africa, was willing to
bypass Bayer’s patent on Ciproflaxacin to import a cheaper version from
India during the anthrax attacks on America post-September 11.5 Justice
for all, eh?
Many Asian and African nations are so reliant on international aid that
they fail to make sufficient budgetary allocations for health spending
from their own GDP. India and China vie with each other to put their man
on the moon, while ignoring the HIV epidemic in their hinterlands. Neither
health nor education is an issue during elections, parliamentary debates
and budgets. Only a trickle of all international aid is used for the
intended purpose as politicians and bureaucrats swindle the rest.
International aid without good governance is counter-productive. It may
seem harsh to punish the poor for the fault of their rulers but these so-
called poor countries have abundant natural and human resources to lift
themselves out of Dickensian despair. No more aid please. Fair trade and
good governance are all we ask.
Dr. Vadivelu Saravanan, Newcastle and Dr. Rajeshkumar Balasubramaniam,
London
On behalf of Reach the Unreached, an Indian medical charity, Madras.
1 Smith R. Editor's choice. Towards a global social contract. BMJ
2004;328.
2 Jean-Jacques Rousseau. The Social Contract 1762;Book IV:Chapter 1.
3 United Nations Development Programme. Human Development Report 2001;Box
4.5, page 92. Oxford University Press.
4 World Trade Organisation. TRIPS and pharmaceutical patents - Fact sheet.
2003. http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm00_e.htm
accessed 2 May 2004
5 BBC News. America's anthrax patent dilemma. 2001.
http://news.bbc.co.uk/1/hi/business/1613410.stm accessed 2 May 2004.
Competing interests:
On behalf of The Reaching the Unreached Medical Charity, Madras, India
Competing interests: No competing interests