Respiratory Health in a Globalizing World

SOLOMON R. BENATAR

Bioethics Center, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital Observatory, Western Cape, South Africa

	CHALLENGES OF RESPIRATORY MEDICINE IN THE 1970s

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The early 1970s, when I embarked on my career in respiratory medicine, were times of great excitement and challenge in respiratory medicine. Advances on many fronts were providing a powerful new impetus to the field. Progress in physiology, exciting in its own right, was leading to improved life support in intensive care units (ICUs). Technical advances were encouraging transplant surgery. Large-scale, well-designed drug trials established short course chemotherapy for tuberculosis with hopes for eradicating this disease from the world. Inhaled corticosteroids were revolutionizing the treatment of asthma. Technological advances with new imaging and other diagnostic techniques such as fiberoptic bronchoscopy and a range of techniques for doing lung biopsies gave respiratory physicians a new interventionist role. These developments spawned a new generation of knowledgeable and competent respiratory physicians.

	THIRTY YEARS OF PROGRESS

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Much has been achieved during the past thirty years. Improved understanding of the pathophysiology of asthma, occupational lung diseases, chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung diseases, pulmonary hypertension, and other diseases has led to newer and more effective therapies. ICU care has been transformed by modern technology into a sophisticated and highly effective practice, resulting in the saving of many years of high-quality life. Noninvasive ventilation, domiciliary oxygen, continuous positive airway pressure (CPAP), and transplantation have radically transformed the lives of many patients with respiratory failure. New diagnostic techniques and increased rigor and standardization in the design of clinical studies have made major contributions to evidence-based practice.

	ON THE THRESHOLD OF A NEW ERA

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We are now on the threshold of a new era. Advances in genetics have the potential to transform medical practice, although many obstacles will need to be overcome to achieve desired goals. Some examples of what could be achieved include the ability to determine genetic susceptibility to disease and prevent disease by linking environmental control measures to those at particular risk; the use of gene therapy to correct genetic defects; and the use of new molecular biology techniques to design new, more specific therapeutic agents. New functional imaging diagnostic techniques, less invasive surgical methods, and specifically designed target drugs could contribute to more efficient treatment of many disorders. Advances in information technology could enable home monitoring of patients with asthma and chronic obstructive pulmonary disease (COPD) and further empower patients, especially those who can afford it, to care for themselves. Distance diagnosis and teaching (e.g., through Internet transmission of radiological and video images) and more widespread access to electronic literature sources could facilitate the spread of knowledge and expertise. While it is the hope of many that such advances will improve respiratory health globally, the risk that such advances will be available only to those with resources should not be underestimated (see below).

	RESPIRATORY HEALTH IN THE WORLD TODAY

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It is necessary to step back from these wonderful advances and the optimism of progress in treating individual patients and to reflect on the overall state of respiratory health in the world today as compared with 30 years ago. A few statistics reveal that improvements in respiratory health have not been shared by all. Lower respiratory tract infections account for 9.1% of disability-adjusted life years (DALYsyears of healthy life lost) from all diseases in the developing world and 1.5% in developed countries, while tuberculosis accounts for 3.1 and 0.3%, respectively. Lower respiratory tract infections cause 17.7% of deaths between the ages of 0 and 4 years in developing countries as compared with 6.1% in developed countries (1).

The problem of tuberculosis illustrates the paradox of how advances in scientific knowledge and the ability to cure individual patients have not been accompanied by public health gains. While in the 1970s there was hope of eradicating tuberculosis from the world at a price that was easily affordable, the threat now is that tuberculosis may become a multi-drug-resistant disease that is too expensive to treat except perhaps in the most affluent countries. This is not the result of lack of knowledge but rather an example of lack of wisdom in the application of knowledge and a failure to appreciate the complex social and economic aspects of health and disease (2, 3). There are other examples of the paradox between scientific advances and lack of improvement in public health. Many other organisms causing respiratory and other infections are becoming resistant to antimicrobial drugs (4). Lung cancer, one of the few malignancies for which the main cause is definitively known and that can be prevented, is on the increaseespecially in developing countries that have been targeted by tobacco companies (5). The incidence and prevalence of asthma are increasing. More than 25 new infectious diseases have emerged since the 1970s, with HIV/AIDS the most threatening (6).

These examples are disappointing to physicians. Understanding why we have failed to improve respiratory health at the world population level requires insight into the state of our world at the beginning of a new millennium, and appreciation that improving respiratory health globally will require new ways of thinking and innovative action. A brief review of the world at this time will illustrate these claims.

	SOME CHARACTERISTICS OF OUR MODERN WORLD

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Population Growth

In 1999 there were nearly 6 billion people in the world. Another 80 million are added each year. World population doubled between the late 1950s and the late 1990s and is projected to reach 9.4 billion by 2050.

Economic Disparities

At the beginning of the 20th century the wealthiest 20% of the world's population were nine times richer than the poorest 20%. This ratio has grown progressivelyto 30 times by 1960, 60 times by 1990, and to over 70 times by 1997. The combined wealth of the world's 225 richest people is the same as the annual income of the poorer 50% of the world's population. The extent of absolute poverty has also increased. Today, almost half the world's population lives on less than U.S. $2 per person per day and more than 1 billion people live in absolute poverty on less than U.S. $1 per daynearly half of them suffering from chronic malnutrition (7). Even in the developed world one in six children lives below their country's poverty line. Indeed, many of the most serious social and health problems facing today's advanced industrialized nations have roots in the denial and deprivation faced by many in childhood (8). These economic disparities have adverse effects on health.

Relationship between Economics and Health

It is now well established that there is a definite relationship between wealth/poverty and health/disease, although this relationship is complex and not linear. Both absolute and relative wealth affect health. In developed countries health status is determined more by income differentials between rich and poor than by overall wealth (9). The United States spends a higher percentage of the gross domestic product (GDP) on health care than any other country (14%). Fifty percent of the U.S. $2 trillion spent on health care in the world each year is spent in the United States (5% of the world's population). Despite this, the United States is ranked 24th in overall population health as judged by disability-adjusted life expectancy, 37th in efficiency of its health care system, and 54th, alongside Fiji, in how fairly the financial burden of health care is distributed (10).

Poverty (defined as lack of economic resources, lack of education, lack of access to basic life resources such as food, water and sanitation, and lack of control over the reproductive process) directly accounts for almost one-third of the global burden of disease (11). Poverty leads to poor health, which in turn aggravates poverty. Despite the difficulty in making accurate intercountry comparisons it is clear that improvements in economic status are associated with better health statistics, and that economic growth is necessary to improve the living conditions conducive to good health, independent of benefits that may arise directly from health care. The falling death rate from tuberculosis in the prechemotherapy era illustrates the beneficial impact of improved socioeconomic conditions on this disease (12).

Disparities in Health and Disease

At the end of the 20th century patterns of diseases and of longevity differ markedly across the world. Life expectancy is increasing worldwide. However, in 16 of the world's poorest countries it has fallen in recent years. Life expectancy at birth ranges from well over 70 years in highly industrialized countries to below 50 years in many poor countries. In sub-Saharan Africa gains in longevity achieved during the first half of the 20th century are rapidly being reversed by the HIV/AIDS pandemic.

Of 52 million deaths in the world each year, 17.5 million (34%) are due to infectious and parasitic diseases (16 million of these in the developing world). Ten million (20%) result from diseases of the circulatory system (4.5 million of these in the developing world). Six million (11.5%) are from malignant diseases (3.5 million of these in the developing world), and 2.9 million deaths (5.6%) are due to respiratory diseases. Of all deaths, 6% are from acute lower respiratory infections, 5% from tuberculosis, and 4% from HIV/AIDS. Among the poorest quintile of people in the world, 55% die of communicable diseases, as compared with 5% of the richest. The World Health Organization (WHO) estimated that in 1998, 11 million children and adults of working age died of six infectious diseases that could have been prevented at the cost of U.S. $20 per life saved (13).

Poor countries bear over 80% of the global burden of disease expressed in DALYs. This burden is likely to increase as the epidemiological transition progresses, with added disability and suffering from noncommunicable causes of disability such as vascular disease, malignant neoplasms (especially of the lung associated with smoking), neuropsychiatric disease, accidents, and trauma. Tobacco is big businessan acre of tobacco sells for more than 20 times an acre of wheat. The main market opportunities now lie in less developed countries, not least of which is China, where tobacco consumption is higher than anywhere else and has increased by almost 50% in the past 20 years. Smoking-related deaths are projected to rise to 10 million a year by the 2020s, 70% of these in the poorer countries.

Comparative Health-care Expenditure

Since the 1960s major advances in medicine and technology have been associated with escalating expenditure on health caremost of this in highly industrialized countries. Annual per capita expenditure on health care ranges from over U.S. $4,000 in the United States down to less than U.S. $5 in the poorest countries in Africa. Half the world's population lives in countries that cannot afford annual per capita health expenditures of more than U.S. $5-10, and many people do not have access even to basic drugs. The WHO has estimated that in 1990 the annual per capita cost of providing a basic package of public health and essential clinical services in a low-income country was U.S. $12. In most such countries health care expenditure is typically less than U.S. $6. Even though some parasitic diseases (e.g., onchocerciasis, schistosomiasis, and lymphatic filariasis) could be controlled by mass treatment campaigns using inexpensive drugs, the infrastructure required to provide such coverage is inadequate. Effective treatment of diseases such as tuberculosis and leprosy, and HIV/ AIDS, as well as prevention of HIV transmission, require more complex infrastructures than can be afforded on current health care budgets in poor countries (14).

In the 1990s, 89% of annual world expenditure on health care was spent on 16% of the world's population, who bear 7% of the global burden of disease (in DALYs) (15), and 90% of medical research expenditure was on health problems accounting for only 10% of the global burden of disease (16). These are examples of global injustice that should be intolerable if there were genuine commitment to universal human rights and human dignity, and to improving health at the level of whole populations. Vaccine development programs and drug donation programs for poor countries, admirably promoted and supported by some pharmaceutical companies and major foundations in the industrialized world, are necessary but insufficient responses to such injustices. Human progress and meaningful development in poor countries allowing modest increments in economic status, if combined with provision of a basic health care package, offers the potential for improving health significantly.

Military Expenditure and Foreign Aid

Industrialized countries spend on average 5.3% of the GNP on the military (global military expenditure in 1990 amounted to US $1 trillion) but less than 0.3% on economic aid to developing countries (17). The United Nations target is for rich countries to give 0.7-1% of their national income in foreign aid. Denmark, Norway, Sweden, and the Netherlands did well at 0.8% in 1997. However, on average, 21 Organization for Economic Cooperation and Development (OECD) countries donated only 0.22% of their GNP to development assistance in 1997, down from 0.25% in 1996. The United States donated less than 0.1% in 1997, down from about 0.2% in 1986 (18). This may surprise many Americans, as a poll conducted by the Program on International Policy Attitudes at the Maryland University showed that the median level of proposed foreign aid was 15 times greater than the amount actually spentrevealing the gap between concern expressed for the well-being of distant others and its translation into practice (19). The goodwill of many American citizens toward less fortunate people around the globe, for example, through volunteer programs and foundation support, must of course be gratefully acknowledgedbut this is independent of U.S. national policy that is resulting in progressive withdrawal of financial support to developing countries in recent decades. Many Americans may be unaware that the African continent as a whole does not feature on the U.S. foreign policy agenda (20).

There are close links between the arms trade and economic aid, with a considerable proportion of foreign aid repatriated to donor countries through arms sales. This link has contributed significantly to the escalating number of wars, conflict, and widespread torture since the Second World War. More than 110 million people have died in over 250 wars in the 20th centurythe bloodiest in human history. In 1980 there were about 22 million refugees worldwide. By the early 1990s this figure had almost doubled and by 1997 it had declined a little to just over 35 million. Such displacement of people and total disruption of social life has profound adverse effects on life and health, and refugee camps are often hot spots for epidemics.

Some Other Comparative Expenditures

The estimated annual cost of providing basic education for all in the world is U.S. $6 billion, and the cost of providing access to reproductive health services for all women in the developing countries is U.S. $12 billion. These costs are small in comparison with global military spending at U.S. $780 billion in the late 1990s (two thirds of its level in 1985 at the peak of the Cold War), U.S. $50 billion spent on cigarettes in Europe, U.S. $105 billion spent on alcoholic drinks in Europe, and U.S. $500 billion spent on narcotic drugs in the world (6). In the United States, more than U.S. $11 billion is spent each year by pharmaceutical companies in promoting and marketing drugs (21). The annual budget of the WHO in 1990 was equivalent to 2.5 hours of global military expenditure, and in 1997 the United States was $35 million in arrears of its contributions to the WHO (22).

Global Political Economy and Health

At the beginning of the 21st century, the world is thus characterized by widening disparities in economic and health status (between countries and even within wealthy countries where the size of the underclass is growing), and by suffering, conflict and alienation associated with pervasive social forces (9, 17, 23). Erosion of the economies of many poor countries, under the impact of the neoliberal economic policies driving globalization, has obstructed the introduction of effective forms of modern medicine into many poor countries and prevented achievement of widespread access to even basic health care for billions of people (23). Third world debt requires special mention. The ways in which such debts have been created, the fact that third world debt is a small component of total world debt and can never be repaid, and that in sub-Saharan Africa four times as much is spent on debt repayment each year than on health and education combined, make insistence on debt repayment the modern equivalent of slavery (25).

The emergence of new diseases such as AIDS, that afflict predominantly those marginalized by poverty (80% of HIV- positive persons live in the poorest countries in the world), has been attributed to the social and environmental niches created by the nature of the global political economy and its ideology (26). Failure to appreciate such associations will result not only in inability to control such diseases as HIV/AIDS (as for tuberculosis in the past (2), but more importantly, will probably favor the emergence of new infectious diseases in the future. The changes in demography resulting from urbanization, migration, travel, multiple small-scale wars, ethnic conflict, and displacement of people and refugees facilitates the spread of such diseases from which no one should feel immune.

	WHO IS RESPONSIBLE?

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The facts and interpretations offered above are not intended to imply that the wealthy, productive, and fortunate in the world should bear the whole burden of the blame for the complex series of historical developments that polarize the world. Political realities within developing countries, including corruption, ruthless dictatorships, ostentatious expenditure by elites, and underinvestment in education and health, have contributed greatly to the suffering of billions. However, it is vital for privileged people to have insight into the extent to which these deficiencies in many developing countries have been facilitated by the policies of wealthy nations in pursuit of their own interests (24). Insight into how favored lives are sustained by overt and covert exploitation of unseen others could allow those of us who live comfortable lives anywhere in the world to appreciate that we do not have a monopoly of entitlement to the benefits of progress (30)

	A VISION FOR THE FUTURE IN A CHANGING WORLD

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All countries are facing fiscal constraints in health caresome because they are spending too much, often inefficiently, trying to apply all that is technically possible; others because their economies are eroding under powerful global forces. As the limits of medicine and how political and economic forces shape health care are increasingly recognized, it becomes necessary to question personal and social meanings of illness and what it means to seek help from our communities and those they empower to provide health care. Many countries consider access to basic health care as a basic human right that nation states should be committed to providing for their citizens. Some form of equitable health care is provided in all Western European nations and in Canada. Regrettably, the example of medical care as a marketable commodity (albeit with considerable state assistance for the poor and the aged) set by the United States is being widely mimicked. Such privatization of medical care, aided and abetted by structural adjustment programs promoted by the policies of the International Monetary Fund and the World Bank with American backing, is adversely affecting health in many poor countries (26). Acknowledging the need for universal access to a basic health care package could allow new relationships to be forged between physicians, patients, and society. The moral power and potential impact on global health of such action if exemplary leadership were to be provided by the United States should not be underestimated.

The conclusions flowing from the Copenhagen Seminars for Social Progress are that (1) economic globalization that propagates a model of development and progress based solely on freedom of the individual and acquisition and consumption of increased quantities of goods and services is not sufficient to create a harmonious world community; and (2) building a moral community focused on the common good will require a synthesis built around three substantive goals (democracy, a humanist political culture, and an economy oriented to meeting human needs in the widest sense), and two procedural goals (development of a coalition of social forces with a global agenda, and the building of a structure for multilateral governance) (35).

What can physicians do to improve the conditions described above? First, we have an obligation to know about and understand the impact of the global forces described on health. Second, we should become more introspective about our privileged lives. Third, we should appreciate that our personal skills, developed on the basis of labor and investment by previous generations, represent social capital and involve social obligations for us. Fourth, we should become a force in coupling excellent treatment of individual patients to national programs that improve public health within nations. Finally, we need to locate our activities within the global context described above and promote new ways of thinking about local and international activities that have the potential to improve well-being and health at the global level (36). Diagnosis is usually easier than effective treatment, but if physicians, scholars, and other influential persons (individually and collectively) were to accept these responsibilities there would at least be some hope of moving beyond the present impasse towards healthier and better lives for all.

	Footnotes

Correspondence and requests for reprints should be addressed to Solomon R. Benatar, Bioethics Centre, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital Observatory, 7925 Western Cape, South Africa, E-mail: sbenatar{at}uctgsh1.uct.ac.za

(Received in original form January 12, 2001 and in revised form February 21, 2001).

Acknowledgments: The author gratefully acknowledges the support of the University of Toronto through his appointment as a Visiting Professor in Public Heath Sciences and Medicine. The author thanks the many anonymous reviewers for their constructive and supportive comments.

	References

TOP CHALLENGES OF RESPIRATORY... THIRTY YEARS OF PROGRESS ON THE THRESHOLD OF... RESPIRATORY HEALTH IN THE... SOME CHARACTERISTICS OF OUR... WHO IS RESPONSIBLE? A VISION FOR THE... REFERENCES

1. The global burden of disease. Murray CJL, Lopez AD, editors. Geneva, Switzerland: World Health Organization; 1996.

2. Benatar SR. Prospects for global health: lessons from tuberculosis. Thorax 1995; 50: 489-491 .

3. Institute of Medicine. Ending the neglect: the elimination of tuberculosis in the United States. Washington DC: National Academy Press; 2000.

4. Garrett L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000.

5. Parkin DM, Pisani P, Lopez AD, Masuyer E. At least one in seven cases of cancer is caused by smoking. Global estimates for 1985.  Int J Cancer 1994; 59: 494-504 [Medline].

6. World Health Organization. World Health Report 1996: Fighting diseases, fostering development. Geneva, Switzerland: World Health Organization; 1996.

7. United Nations Development Program. Human development report. New York: Oxford University Press; 1998.

8. UNICEF. UNICEF annual report. New York: United Nations; 2000.

9. Wilkinson RG. Unhealthy societies: the afflictions of inequality. London: Routledge; 1996. 

10. World Health Organization. World Health Report 2000: Health systems, improving performance. Geneva, Switzerland: World Health Organization; 2000.

11. World Health Organization. World Health Report 1995: Bridging the gaps. Geneva, Switzerland: World Health Organization; 1995.

12. Porter JDH, McAdam KPWJ, editors. Tuberculosis: back to the future. London: John Wiley & Sons; 1996.

13. World Health Organization. WHO Annual Report 1999: Making a difference. Geneva, Switzerland: World Health Organization; 1999.

14. Benatar SR. Prevention of vertical HIV transmission: the controversy in South Africa. J Women's Health Law. 2000; 1: 313-318 .

15. Iglehart J. American health services: expenditures. N Engl J Med 1999; 340: 70-76 [Free Full Text].

16. World Health Organization. Investing in health research and development. Report of the ad hoc committee on health research relating to future intervention options. Geneva, Switzerland: World Health Organization; 1996.

17. Sivard RL. World social and military expenditure. 16th edition. Washington DC: World Priorities Press; 1996.

18. Anonymous. Foreign aid. Economist 1999, February 13, p. 115.

19. Institute of Medicine. America's vital interest in global health. Washington DC: National Academy Press; 1997.

20. Association of Concerned Africa Scholars. Special issue: progressive Africa action for a new century. ACAS Bulletin 2000;57/58.

21. Wazana A. Physicians and the pharmaceutical industry. JAMA 2000; 283: 373-380 [Abstract/Free Full Text].

22. Bloom B. The future of public health. Nature 1999;402(Suppl):C63-C64.

23. Benatar SR. Global disparities in health and human rights: a critical commentary. Am J Public Health 1998; 88: 295-300 [Abstract/Free Full Text].

24. Falk R. 1999. Predatory globalization: a critique. Cambridge: Polity Press; 1999.

25. Pettifor A. Debt: the most potent form of slavery. London: Christian Aid Society; 1996.

26. Lee K, Zwi AB. A global political economy approach to AIDS: ideology, interests and implications. New Political Econ 1996; 1: 355-373 .

27. George S, Sabelli F. Faith and credit: The Wold Bank's secular empire. London: Penguin Books; 1994.

28. Abbasi K. The World Bank and World Health. Br Med J 1999; 318: 1132-1135 [Free Full Text].

29. Alexander T. Unravelling global apartheid: an overview of world politics. Cambridge: Polity Press; 1996.

30. Benatar SR. Africa and the world. S Afr Med J 1994; 84: 723-726 [Medline].

31. Rist G. The history of development: from Western origins to global faith. London: Zed Books; 1997.

32. Lancaster C. Aid to Africa: so much to do, so little done. Chicago: University of Chicago Press; 1999.

33. Sandbrook R. Closing the circle: democratization and development in Africa. London: Zed Books; 2000.

34. Hochschild A. King Leopold's ghost. New York: Houghton Mifflin; 1998.

35. Anonymous. Building a world community: globalization and the common good. Copenhagen, Denmark: Danish Foreign Ministry; 2000.

36. Benatar SR. Streams of global change. In: Bankowski Z, Bryant J, Gallagher J, editors. Ethics, equity and health for all. Geneva, Switzerland: Council for the International Organization of Medical Sciences; 1997. P. 75-85.

37. Benatar SR. Millennial challenges for medicine and modernity. J R Coll Physicians 1998; 32: 160-165 .

38. Benatar SR, Singer PA. A new look at international research ethics. Br Med J 2000; 321: 824-826 [Free Full Text].

39. Benatar SR. Global issues in HIV research. J HIV Ther. 2000; 5: 85-92 .

40. Benatar SR, Daar A, Singer PA. Global health ethics. In preparation (2001).