Recall the 10–20 year within-country differences in life expectancy between high- and low-income neighbourhoods and the 30–40 year differences in life expectancy between HICs and LMICs. Do the differences among groups captured in the population health metrics matter normatively, and are they a concern of justice? What role did antimicrobials play in generating these differences and how might AMR
affect these differences?
Now, these formal measures might matter because those at the low end of the distribution are experiencing health deficits which we want to address as a matter of beneficence, or as a reciprocal obligation to supply a decent minimum arising from our economic
inter-dependence – or they might matter because the inequalities of which they form one extreme matter. It is easy to elicit some kind of normative concern about these inequalities but much more difficult to specify exactly what matters about them as inequalities. Two persons might have different life expectancies because of accident or genetic endowment; it’s not obvious why group differences matter. One possible starting place is the thought that if all else were equal the poor would be as healthy as the rich. That is, the poor do not constitute a separate natural kind with different potential to be healthy. If they are differentially unhealthy, it is because we fail to ensure that everyone has access to their potential to be healthy, because incomes are inadequate, housing poor, food of low quality, work hazardous, childbirth ill-supported, and access to care and social support for recovery from ill health limited. This line of thought is similar to the view of that health inequalities matter to justice when they are caused by or cause other injustices, but it maintains at its core the idea that health inequalities matter as such and can constitute injustice.
By analyzing the role of antimicrobials in broad trends for social inequality in health and global health inequality, I argue that understanding the causes and the narrative constitution of these trends renders sufficientism and prioritarianism less attractive as normative stands.
A common account of the broad trends in both global health and economic
development in recent decades is that within-country inequalities are widening, but between-country inequalities are narrowing – a narrowing that is particularly dramatic since the 1950s for health and 1980s for economic
status. The normative claim attached to this account (implicitly or explicitly) is a prioritarian or sufficientist claim that while things may look grim from the perspective of the middle classes of HICs, from the perspective of those who are truly the worst off, things have never looked better: more and more people in the world are relieved of the worst form of poverty (“absolute poverty”) and are achieving a sufficiency of health. In health, the worst off are doing even better: life expectancy is advancing faster than it did when the current HICs built their prosperous economies over the course of the nineteenth and twentieth centuries.
In the examples of the previous section (16.3), I outlined different ways that justice questions might reflect, be reflected by, or otherwise enter into health inequalities, by tying life course narratives to narratives that matter to justice – political and cultural economy, including gender relations. In the same manner, I will approach the significance of population health metrics in relation to justice by exploring the meaning of these metrics in terms of the typical and divergent life courses of the members of a population and in terms of the political and cultural economy of the communities in question (within-country communities and global communities).
The common narrative reflecting the sufficientist or prioritarian reading of narrowing health inequalities is the development narrative (political economy) linked to life course narratives via “transition” theory (demography and epidemiology).
Demographers long ago observed the tendency of populations to pass successively through certain stages, tied to their economic
development: populations move from having a high birth rate along with a high death rate (in foraging or pastoral economies), to a more stable and dropping death rate, while the birth rate remains high, resulting in a population explosion (from agricultural to early industrial economies), to a low birth rate-low death rate stage, which we see in the stable or shrinking populations of modern HICs (which depend at this stage on immigration for economic
growth). Epidemiologists in the mid-twentieth century linked these demographic changes to patterns of health and disease: the first stage of “pestilence and famine” with its characteristic population swings is followed by a second stage of greater stability but low life expectancy conditioned by infectious and hygienic diseases, initially from the close co-habitation of animals and humans and then the increasingly crowded, eventually urban, living conditions of humans with one another. With improvements in living standards and public health infrastructure, we enter a third stage where chronic (“man-made and degenerative”) diseases of later middle age emerge as common causes of death (Omran 1971). A combination of so-called lifestyle changes (e.g. smoking cessation, moderation of red meat consumption) and advanced medical technologies (e.g. cancer treatment) have pushed back these diseases of midlife and created the ongoing extension in lifespan that HICs are now experiencing, which some describe as a “fourth stage” of epidemiological transition (Olshansky and Ault 1986).
These are the economic
and epidemiological narratives behind how a non-transparent metric like life expectancy is read in health policy and understood to be a normative concern or a concern of justice. A life expectancy in the 40s reflects substantial maternal, infant, and child mortality caused by infectious and hygienic disease and the lack of empowerment of women to control their sexual and reproductive lives. A life expectancy in the 60s reflects a society in which heart disease and cancer are leading causes of death in later middle life, a phenomenon that emerged over the course of the twentieth century in HICs. A life expectancy in the 80s reflects improved prevention and treatment of these major killers and the emergence of new common forms of dying in advanced old age, e.g. frailty and dementia.
The dramatic narrowing of global health inequalities since the 1950s is called, within this narrative, the “accelerated transition,” reflecting the success of the international development agenda in achieving improvements in health status that outstrip the economic
and political development of the countries in question – that is, that outstrip both growth in GDP and changes in the franchise and effective political organization of workers to demand the health, education, and safety benefits of modern welfare states. By these means, industrialization and urbanization raised GDP while political change led to a larger proportion of the GDP being invested in the well-being of the population, in a process that involved the empowerment of workers and women, improving population health – although (given the dynamics of democratic pressure) achieving less success in addressing the needs of so-called minorities.Footnote 4
On this narrative, it seems natural to see the changes in global economic
and health equalities and inequalities in terms of the idea that some countries got a head start and some lag behind. A common economic
belief is that open markets and the transfer of skills and technology will ensure that LMICs continue to advance towards (eventually) “catching up.” The common narrative in health is that some (both low and high tech) public health technologies could be transferred in advance of economic
development, offering LMICs a leg up in the development process.
4.1 Is the Development Narrative True?
Is this development narrative true? Does it do the normative work it claims to do?
One important critique of formal measures of equality and inequality is that they are not transparently related to the underlying realities they measure (King et al. 2012; Harper et al. 2010; Mackenbach 2015, Mackenbach et al. 2016). King et al. point out that the same underlying reality can be represented as a narrowing of absolute inequalities or a widening of relative inequalities, for example. Similarly, the same numeric change may represent different causal pathways or encapsulate different social relations with different significance in terms of justice and injustice and different distributions of well being and suffering. This has implications for the normative concern that these measurements might inspire (which inequalities should we tackle?) and may even raise questions about the reality of abstract interpersonal measures (are inequalities simply imposed on the individual phenomena that, sufficientists and prioritarians argue, should be the object of our moral concern?).
4.2 Underlying Realities
The narrative that LMICs are “catching up” suggests that they are achieving what HICs have achieved, but doing so later. However, this suggestion is false. The accelerated narrowing of global health inequalities represents fundamentally different epidemiological patterns, causal pathways, and relations of concern to justice.
I described above how a population’s life expectancy in a given decade is “read” epidemiologically, and I noted that many different underlying patterns of health and disease can generate the same measure. Substantial infant and early childhood mortality in a subpopulation might depress life expectancy as much as widespread exposure of young adults to interpersonal violence, workplace hazards, tuberculosis, or HIV. Different narratives of political economy can in turn generate these patterns – the sub-population with elevated early childhood mortality may be indigenous or migrant; interpersonal violence may be a matter of warfare or the combination of lack of opportunity, crime, availability of guns, policing, and racialization.
The picture offered by transition theory is simplified (Frenk et al. 1991; Defo 2014). Researchers now emphasize that the same life expectancy in different populations may reflect different realities. They describe the transitions of LMICs as “incomplete” transitions, highlighting counter-transitions within LMICs and even within HICs. For example, LMICs did not leave infectious and hygienic disease behind. Rather, they are taking on the so-called diseases of affluence – diseases that arise from changes in work, nutrition, energy, and transportation – in addition to carrying an on-going burden of infectious and hygienic disease (Santosa et al. 2014; Defo 2014). Specific population groups within HICs experience the re-emergence of infectious and hygienic disease, while the emergence of so-called “diseases of despair” (suicide and substance abuse) may reverse health gains in HICs for some groups (Case and Deaton 2015) or for entire countries (some of the former eastern bloc). Global migration resulting from instability and lack of opportunity in LMICs and the need for low-wage workers particularly in the agricultural sector in HICs brings together the AMR
diseases of LMIC and the population health profile of HICs (Suk et al. 2009).
Furthermore, insofar as LMICs have substantially reduced childhood and young adult mortality from infectious and hygienic diseases, these reductions did not come from the developments in political economy that led to such improvements in HICs. In HICs, rising GDP went along with political changes (universal suffrage extending beyond male property owners to labourers and women, and various political movements organized around these identities) and these brought about improvements in determinants of infectious and hygienic disease. In HICs, antibiotics joined and accelerated an existing process of decline in infectious and hygienic disease after the Second World War (Mackenbach 1996). In LMICs, on the other hand, growth in GDP resulting from urbanization has not been distributed or re-distributed and invested to improve living standards and public health infrastructure to the same extent. Political empowerment is limited, in part by the actions of the very same global corporations that bring (some) growth in income to LMICs. In its place, a global network of health philanthropy has delivered effective prevention with vaccines and mosquito nets and treatment with antimicrobials for infectious and hygienic diseases that remain endemic. Antimicrobials played an important role in this so-called “accelerated” transition. The infectious and hygienic diseases that result from crowding and exposure to waste are managed medically e.g. by vaccination for prevention or by antimicrobials for treatment, and not by improved housing for primordial prevention. This is not a lag in economic
development or in the uptake of health-related technologies; it is a different path of economic
and social change. Even to describe it as “incomplete” is misleading, insofar as the term “incomplete” suggests that LMICs have reached a different point on the same pathway instead of achieving the partial benefits they have achieved from a different trajectory.
This is evident at the level of life course narratives. What a life expectancy of 60 looks like in a current MIC is not what a life expectancy of 60 looked like when HICs reached that stage. Parents in HICs may feel that childhood and adolescence are times of risk and danger, but very few children in HICs experience life-threatening diarrhea or pneumonia and virtually no adolescents and young adults experience TB. (The exceptions to this general picture are in communities within HICs that bear a heavy burden of colonialism such as indigenous communities (Orr 2013 and Møller 2010) and in the globally mobile working class (MacPherson et al. 2009), where migration is also conditioned by colonial histories in addition to current global supply chains.) Parents in LICs with superficially similar mortality figures continue to experience episodes in which their children’s lives threatened with diarrhea in infancy – but they now know how to treat it, as few people would have known in the HICs’ pre-transition period, and they have antibiotics available for managing severe cases where this is appropriate. Children in MICs do not enjoy a trouble-free childhood, but go through the distress of under-5 pneumonia or adolescent TB, while their parents experience the anxiety of trying to secure the antimicrobials needed to treat these conditions: for 5 million children with pneumonia in LMICs annually, their parents are unable to do this (Laxminarayan et al. 2016). The use of antimicrobials along with other readily transferable technologies sustain different underlying life course narratives in LMICs compared to those that typify HICs.
4.3 Underlying Causes
Without a basic understanding of the causal processes that characterize changes in population health and health inequalities, it is not possible to evaluate normative claims about the co-existence of narrowing global health inequalities and the within country widening health inequalities. Sampling changes in a given time period and presenting them as trends (or as trends that are causally linked – with the suggestion that health benefits are, as it were, transferred from the middle classes of HICs to the workers of LMICs) can misrepresent the broad causal picture as it unfolds.
The last 100 years, both globally and within country, constitute one period in a long-term process of widening social inequality in health. Broadly speaking, social inequality in health has risen ever since the Middle Ages (perhaps surprisingly), when nobles and peasants seem to have had similar life expectancies (Antonovsky 1967; Bengtsson and van Poppel 2011). The late 19th and early 20th century period – in which social inequalities in health narrowed within those countries that emerged as HICs – was an anomaly.
To relate the trends to transition theory, roughly speaking, we can say that pestilence and famine affect all social classes; as societies transition to agriculture, the wealthy still have surprisingly little protection from the infectious and hygienic diseases that characterize this stage of close co-habitation with animals and increased human crowding. This “agricultural transition” lowers life expectancy for individuals while increasing population size – a qualified form of “improvement” in population health. Urbanization and the initially slow but eventually rapid growth in economic
productivity associated with it, by contrast, both raise the life expectancy of the population and increase its size. However, this improvement both for individuals and for populations benefits those of higher SES more than those of lower SES, opening up differences in life expectancy that persist and for the most part continue to grow.
The only period in which social inequalities in health narrowed for a time was the classic period of hygienic and sanitary reform at the end of the 19th and beginning of the 20th centuries – when initial steps to establish safety of the food supply, clean water, and sewage were taken in HICs (Soares 2007). At this point, the happy confluence of political change (increasingly wide suffrage), scientific development (the germ theory of disease), and growth in GDP contributed strongly to this narrowing.
The post-war growth of the welfare state, including systems of universal health coverage, by contrast, has at best slowed the growth of social inequality in health: it has not moved us in the direction of social equality in health (Sreenivasan 2007; Mackenbach 2012; Reid 2016). The better off get more out of the “fourth stage” of epidemiological transition by the differential benefit they derive from programs like universal health coverage. This is not to say that such programs do not promote social equality in health: it is plausible that the poor would have been left yet further behind without them (Reid 2016).
This sampling question is significant for the normative work that the development narrative is supposed to do. The narrative of local divergence (the almost-best-off falling a bit behind) and global convergence (the worst off catching up) relies on sampling HICs just after the one period in which inequalities narrowed (thereby excluding that narrowing) and sampling LMICs at a moment in history that includes the LMIC version of that era in which (in HICs) inequalities narrowed. The underlying dynamic is that as health improves, it improves more for the better off than the worse off, absent a period where we acted on the gains that could be made by providing the basic infrastructure of public health. The broad trend is the same globally and within country: it does not reflect a tradeoff in which we forgo goods for the already pretty-well-off and give them to the worse-off. On the contrary, as we saw in the previous section, we have taken a path to improving life expectancy in LMICs that seems likely not to lead to the same gains. The inference from a given period of narrowing to a broader pattern of a gap being closed is illicit.
4.4 Implications for Global AMR
The narrative of catching up ignores longer-term trends and obscures differences in typical and various life courses that cause the life expectancy gains in LMICs. Waning antimicrobial effectiveness will reveal the different underlying causes of these gains.
Current approaches to addressing the role of social determinants of health (SDOH) in the impact of AMR
, consistent with the model of global health that gave us the accelerated transition, is medicalized: medical technology transfer again takes the place of political development; inappropriate standards of evidence (the movement towards implementing evidence-based standards in development) direct efforts towards primary prevention and treatment and away from inter-sectoral cooperation on health-related primordial prevention. (See King, Chap. 19, this volume; Silva et al. 2020.) The WHO Global Action Plan
(2015a) speaks, for example, of “effective prevention of infections transmitted through sex or drug injection as well as better sanitation, hand washing, and food and water safety” as “core components of infectious disease prevention,” (§36) and “more widespread recognition of antimicrobial medicines as a public good … [being] needed in order to strengthen regulation
of their distribution, quality, and use” (§41) to address inappropriate antimicrobial use, and the development of awareness and improved veterinary education to address the overuse of antimicrobials in agriculture.
Awareness and education are inadequate to address the struggles of LMICs to promote appropriate antimicrobial use. These countries often make do with half the tax revenues proportionate to GDP or national income that HICs expect: enforcement to tame diversion and over-the-counter sales of antibiotics or the for-profit healthcare sector (a substantial source of poor prescribing – Kuo et al. 2017; Haire, Chap. 3, this volume; Liverani et al., Chap. 5, this volume; Ho and Lee, Chap. 25, this volume) are not free. Neither can LMICs confront the globalized agricultural sector that moves agricultural practices that involve the overuse of antibiotics from the increasingly intolerant regulatory environments of HICs to their permissive regulatory environments. To confront this would in turn require an end to pressure from global supply chains serving HIC-consumers against environmental and labour regulation
in LMICs (the justice dimensions of such dependencies are explored in the social connectionist model of Young 2006). Focusing innovation in anthelmintics, for example, on the needs of human beings vulnerable to parasites would change treatment possibilities (in accordance with the call of Shawa et al., Chap. 10, this volume), while reducing or eliminating agricultural use and improving health-related infrastructure – both of which involve political and economic
change – would change the distribution of health benefits.
In addition, there is another global structural relationship in inequalities related to antimicrobial use, insofar as antimicrobials are a common or public good, as discussed elsewhere in this volume (Smith and Coast, Chap. 17, this volume; Giubilini and Savulescu, Chap. 9, this volume). LMICs cannot “catch up” in antimicrobial use because HICs are on track to use them up, for their own needs or in service of HIC-led policies that encourage antimicrobial use in LMICs instead of balanced development, high taxation and regulation
, and democratic empowerment, the context in which conservative antimicrobial use can be implemented as policy.
The problem of effective regulation
and orientation of the pharmaceutical industry towards population needs is not isolated to LMICs. Generic drug shortages in HICs contribute to AMR
by driving inappropriate prescribing (Shoham et al. 2016), and every action plan on AMR
highlights the failure of industry to invest in new antimicrobials, and not the problem that new antimicrobials, when found, continue to be marketed and deployed in ways that encourage non-beneficial and marginally beneficial use.
and Widening Within-Country Social Inequality in Health
Antimicrobials played a role in the so-called “fourth stage” of epidemiological transition, in which life expectancy has been extended by effective prevention and treatment for cancer and heart disease, among other medical conditions. Insofar as progress in addressing these large sources of disease burden for HICs involves advanced surgical and other tertiary care techniques (in addition to dietary change and tobacco control), this fourth transition relies on antibiotics that make surgical and immune-system suppressing chemotherapeutics possible. Even in countries with universal, comprehensive health care without financial barriers to access (like Canada), innovations in tertiary care provide more benefit to the better-off than the worse-off (Starfield 2011; Asada and Kephart 2007)Footnote 5 – contributing to the return to growing social inequality in health despite universal health coverage in contemporary medical care.
At a superficial level, we could speculate that the development of AMR
in HICs could undo a line of medical progress that has widened social inequalities in health. But there would be many opportunities for reassertion of the general pattern of the last several centuries, the pattern of the well-off capturing a greater share of benefits and experiencing a lower share of burdens. Moderating the use of antimicrobials to preserve their effectiveness calls on solidarity as a value (Holm and Ploug, Chap. 21, this volume); the implications of waning antimicrobial efficacy will put stress on this same value. For example, the tertiary care interventions of the fourth epidemiological stage are becoming increasingly expensive due to AMR
(Smith and Coast 2013; Cosgrove 2006; Teillant et al. 2015). This will continue for some time as those interventions gradually take on an unfavourable intrinsic harm-benefit tradeoff for the individual patient directly involved. It is only at this last stage (where the harm-benefit tradeoff shifts) that the loss of this technology would potentially narrow health inequalities by de-implementation of “fourth stage” interventions that have widened social inequalities in health. The effects of specialty and disease interest group advocacy in the intervening period may well result in even greater capture of the resources of the system for the better-off. The increasing cost of supportive care to maintain current surgical interventions while responding to AMR
may also feed a political discourse around system sustainability that contributes to eroding the comprehensiveness and depth of universal healthcare coverage. Social inequalities in health could continue to widen as services for those with less voice are eroded to enable the higher cost of coping with AMR
in the tertiary care sector that has served higher income persons well.
This is not just a HIC story. The Millennial Development Goals focused on child mortality and mortality of late adolescence/early adulthood (TB; the infectious and hygienic diseases), while the Sustainable Development Goals (SDG) on which the WHO embarked in 2015 focus on developing universal health coverage (UHC) and access to tertiary care – important for delivering the care necessary for chronic diseases and causes of midlife mortality that middle income countries are beginning to experience (WHO 2015b). The expected health transition from a higher burden of infectious and hygienic diseases to a higher burden of chronic, noncommunicable disease has informed this policy move. However, as we saw, MICs in particular are subject to the double burden of emerging chronic noncommunicable diseases alongside persistent infectious and hygienic diseases; they also experience a heavy burden from counter-transitions as new infectious and hygienic burdens arise (Cook and Dummer 2004; Santosa et al. 2014; Defo 2014). There is evidence that the prevalence of hospital-based resistant microbes is inversely associated with national income (Alvarez-Uria et al. 2016), suggesting that LMICs will also bear a heavier burden of hospital-based AMR
than HICs, at the same time that they face a heavier burden of community-based resistant diseases. These new health systems will face the same kinds of political struggles about universality, depth, and sustainability that are in play in HICs (Norheim et al. 2014). Given the extent of economic
inequalities within these countries, they will face these political struggles without the social solidarity that is somewhat protective of the breadth and depth of UHC in HICs. Indeed, some have speculated that AMR
could entirely derail the SDG
of UHC (Jasovský et al. 2016).