Justice: The Lost Value
It is a disgrace to find many millions worldwide dying from malnutrition, famines, diarrhea, malaria, and tuberculosis. Health services should be distributed in a fair way between rural areas and cities; and between tertiary hospitals and primary healthcare. Disease prevention, health education, and health promotion deserve their fair share. It is not only the number of physicians or nurses or beds that will improve the health standard of the nation. It needs equity in distribution of health resources and an efficient system of delivery. USA spends on health per capita double or triple of all the 28 industrialized countries; nevertheless, it is behind all these countries in certain health criteria put by WHO, such as infant mortality rate, and 5-year-old mortality rate. There are about 50 million citizens with no health insurance, or partial on and off insurance, in the USA until the beginning of the twenty-first century. The health system should move from only curative medicine to preventative medicine and health promotion.
KeywordsHealth Literacy Saudi Arabia Health Index Gross National Product Wealthy Country
All nations and cultures extolled justice, at least to a certain class of the community. The Indians had a strict caste system, which resulted in complete injustice to the lower castes. Similarly, the Greek and Romans had a strict system which excluded the slaves, and limited citizenship to a minority of the population. The old Egyptian Civilization had also a class system, which was not closed and persons with their ability and hard work could go up the ladder. Still in China, the class system was less obvious. Hamurabi of Babylon (1792-1750 BCE) was probably the first ruler who put a complete code (Hamurabi Code) which aimed at establishing peace, justice and prosperity to the people of Babylon. It succeeded to a great deal in fulfilling its aspirations, with the strong and just hand of Hamurabi who ruled for 42 years. However, the slaves were not included in the system, though they were treated relatively kindly. The Egyptian and Chinese systems allowed brilliant salves to be ministers and hold great responsibilities in these empires. Joseph was a slave but was raised to the highest post in Egypt under the King. Similarly many slaves in China were the generals of the army or admirals of the navy or ministers in the administration.
The Indians had a strict caste system and it was not allowed to move up the ladder. Similarly the Greco-Roman system was against slaves. Still worse was the European attitude in the sixteenth−eighteenth centuries. The slaves snatched from Africa and deported to the Americas, West Indies, and other colonies were brutally treated. More than 100 million Africans were taken from the black continent during two centuries. More than 70 million died in the hazardous journeys, the diseases that cropped, the stifling of mutinies, in the mines and fields of the white colonialists of both Americas (North, South, and Central America), and the many islands in the Caribbean (West Indies). They were maltreated all through those horrible times. Unfortunately, it is still there, though in a much smaller scale in USA, the world champion of democracy and human rights. There are about 50 million citizens with no health insurance, or partial on and off insurance, in the USA until the beginning of the twenty-first century (CE). Although the Afro-Americans constitute about 17 % of the population, they form more than 70 % of the prison crime population; and 90 % of those who received capital punishment in the twentieth century were blacks. Despite the tremendous improvements in the status of blacks since Martin Luther King cried, “I have a dream,” in the 1960s of the twentieth century, there are still many blacks suffering from degradation, crime, instability, and inequality, both in education and health services.
It is amazing to find USA spending the greatest amount of money ($7285 on each individual health in 2010)  while in Finland they only spent $2840 on each individual; but the infant mortality rate in USA was double that of Finland . In fact all the health indices put by WHO viz Infant Mortality Rate (the numbers of babies under 1 year that die in a certain year out of 1000, 1-year-old babies) or the 5-year mortality rate (the number of children under 5 who die in a certain year out of 1000 five-year olds) or longevity rate…or the number of women who die in parturition (delivery) or post partum in 100,000 deliveries in a certain year, or the number of persons who die in traffic accidents per 100,000 in a certain year in a certain country and so forth.
In all these indices, USA is the worst of all industrialized 28 nations. Beauchamp and Childress in “Principles of Biomedical Ethics”  say: “More than 40 million US citizens (approximately 18 % of the nonelderly population) lack health insurance of any kind. Inadequate insurance affects those who are uninsured, uninsurable, underinsured, or only occasionally insured. Although each year USA spends more resources on health care than any country in the world (double or almost triple any industrialized country, and 20 times what Cuba spends), it is the only industrialized nation with less than half of its population eligible for public health insurance” [2, 3].
“More than 50 million non elderly adults in the US—approximately 1/3 of that population—experience a gap in coverage within a 2-year period, approximately 2/3 of these have no insurance for at least one year .
“Many uninsured persons are employed, but by companies offering no health benefits. This situation is common with employees of small firms for whom the costs of maintaining insurance are much higher than for large employers. Many employee benefit packages also provide no coverage for dependents or part-time employees” [2, 4].
“Other US citizens are uninsurable, although many of them are employed by firms offering health coverage. The problem for them is that they are required to give full family and personal medical histories and to be examined fully prior to being eligible for insurance. Those with poor health or pre-existing conditions or family history of certain diseases are denied coverage or offered inferior and more expensive coverage. Many persons suffering from diseases that could need expensive medical management in the future are denied coverage. People who have HIV positive tests are also denied any coverage” .
It is strange to find some big firms in the USA denying their employees or some of them, any medical insurance. The law in the USA allows employers to offer or deny medical insurance coverage for their employees. The companies that offer medical insurance to its employees find it difficult to compete with the companies that offer no insurance benefit. This is partially redressed by reducing taxes of those offering insurance benefits. The system in the USA serves the wealthy, the big firms and companies. The taxes paid by the most wealthy constitute only a very small percentage of their income, while the less wealthy, the middle class, and even the poor bear the brunt of the taxes and pay a much higher percentage of their income as taxes (direct and indirect taxes). This is an unfair and unjust system. “The US pays 3.5 billion US dollars a day on health services; still the health of many Americans is in a sorry state. It is far from the top in life expectancy at birth. Infact mortality is 60 % greater than in Sweden. In 2000, about 14 % of the US population had no health insurance at all. Still others were covered only part of the year or were woefully under insured. There are dreadful differences in health based on income, education and race. Enormous International differences exist as well” [5, 6, 7].
50 million USA citizens are uninsured or only partially insured on and off. The majority of these are Afro Americans, or of Hispanic origin.
In USA, the companies are not forced by law to insure their employees or their dependents.
Most countries even in developing countries require from big companies health insurance or bear the responsibilities of providing health services to their employees and their dependents. In Saudi Arabia, all companies even very small businesses and shops have to provide some type of health services (sometimes the bare minimum).
The insurance companies can refuse any person or group of people to be insured, if they have the possibility of being affected by a chronic disease or liable to acquire a hereditary disease that may appear at the age of 40 or 50. All those suffering from congenital or hereditary diseases since childhood are not covered. Patients suffering from chronic diseases that may end, for example, in end organ failure (kidney, heart, liver, etc.) are denied health insurance. These companies are after easy profit and are similar to blood sucking vampires or blood sucking insects. They provide services only to gain more money. Otherwise, they may let you die or have long suffering before you die.
USA spends on health per capita double or triple all the 28 industrialized countries; nevertheless it is behind all these countries in the health criteria put by WHO viz: infant mortality rate, 5 year old mortality rate, longevity rate, mortality rate during parturition (delivery) and post partum (after delivery) for every 100,000 deliveries. It is amazing to find Cuba (and many third-world countries) having much better indices than the 50 million US citizens uninsured or partially insured. Cuba has better figures than the USA in term of longevity and infant mortality rates. Cuba is a poor developing country suffering from strict US blockade for many years (since the 1960s of the twentieth century) until now (2014).
There is a huge waste and inefficiency in the management of health services in USA evident by the huge difference between the expenditure of USA (on Health) and the other countries (developed and developing), and the end result is the worst in certain indices set by WHO among the industrialized (28) countries; and almost similar in some indices to Cuba, Malaysia, Thailand, etc.
In 1000 live births
The best figure
These figures improved remarkably by 2010, but still USA is at the bottom.
Inefficiency and waste emulating the US system in a worse way.
Much higher population than the others (28 million). By 2010, the infant mortality rate in Saudi Arabia came down to 12 per 1000 live births (was 27 in 2007 figures) but Malaysia infant mortality rate was only 3 per 1000 live births (better than USA figures and much better than Saudi Arabia figures) .
Malaysia spent US$ 604 in 2010 on health services. Saudi Arabia spent $768 while USA spent $7285 . Malaysia spent 1/12 what USA spent and nevertheless had better indices than USA. Similarly Singapore spent a small fraction of what USA did; nevertheless, the infant mortality rate was 2 since 2000 and a little above one in 2010. How amazing!!!
The health system should move from only curative medicine to preventative medicine and health promotion, as well. Most of the diseases nowadays are due to:
Junk Food—inducing obesity, which contains a lot of fat, many additives ,e.g., mono amino glutamate which gives good taste, increases insulin secretion, and ends in obesity and diabetes. Of course, there are other factors such as: more sedentary lifestyle, and in many third world countries including Saudi Arabia, opening more supermarkets, restaurants, and shops instead of playgrounds, walking stretches, and greenery.
Lack of Exercise
All types of Pollution
Sexually Transmitted Diseases, including HIV.
In developing countries, lack of clean water, sanitation, drainage system, malaria, tuberculosis, high infant mortality rate due to early stopping of breast feeding, malnutrition, and multiple childhood infections, all play havoc and cause shortened life span.
Unfortunately wars never ceased in Africa, Middle East, Iraq, Afghanistan, and so forth. Ethnic cleansing in Bosnia, Burma (Myanmar), and Fatani (Southern Thailand), sectarian violence in many other places, brought havoc to many countries. The worst sufferers were, as usual, children, women, and civilians.
Wars and Health
War and terrorism, which are inseparable, cause death and disability, profound psychological damage, environmental destruction, disruption of the health infrastructure, refugee crises, and increased interpersonal, self-directed and collective violence. Weapons systems such as weapons of mass destruction and landmines have their own specific devastating effects. Preparation for war and preparedness for terrorism bring constraints on civil liberties and human rights, increase militarism, and divert resources from health care and from other needed services. War and terrorism may be best prevented through addressing their causes, which include limited resources, injustice, poverty and ethnic and religious enmity, and through strengthening the United Nations and the treaties controlling specific weapons systems, particularly weapons of mass destruction. In particular, the United States should cease its interference in the internal affairs of other nations and its advocacy of unilateral pre-emptive war.
After starting with the horrors of World War II, he commented on war on terror that it elevated fear, engendered hate, and increased militarilism even among people far removed from the attacks…with loss of liberties, discrimination against groups and individuals who are not terrorists, and diversion of resources better used to deal with problems in health, education, and other social services.
Wars in the twentieth century killed 200 million people, more than half of them were civilians. During each year of the last decade of the twentieth century there had been 20 wars, mainly civil. Millions died, many millions were maimed, still more millions were refugees (Total refugees in the world are about 50 millions). The whole infrastructure of many countries was in shambles after these wars. Rape was rampant in all these wars. In Bosnia-Herzegovina (in former Yugoslavia) more than 10,000 Muslim women were raped by the Serbs militias and army. Children are particularly vulnerable during and after the wars both physically and psychologically.
Land mines killed and maimed many millions in the last three decades of the twentieth century and many millions were widowed and orphaned. With wars, millions are driven from their homes and become refugees. Many areas of Africa suffered also from drought; famine spread several times in Somalia, Ethiopia, and the Horn of Africa in the last three or four decades.
The looming shortages of food crops are causing an increase of food prices, which many poor countries cannot afford. Hundreds of thousands of children were recruited in these wars (from age 7 to 17). In South Sudan, there were more than 300,000 children under arms from age seven to seventeen. Similar figures were found in Angola, Zaire, Congo, etc. From 1986 to 1996 united Nations organization reported that killing of two million children, six millions were maimed and twelve millions were without homes. There are more than 100 million land mines over the globe. There are ten million in Afghanistan, another ten million in Angola, seven million each in Cambodia and Iraq, and so forth. Thousands are killed or maimed each year, mainly children. The United Nations called for moratorium in production of these land mines, but the largest producer USA objected, followed by Israel, Hungary and Romania. The manufacturing of a landmine costs $3 but to dismantle it costs up to $1000!!
Iraqi children suffered greatly since 1991 (2nd Gulf War) until 2003 (invasion of Iraq) when the suffering became worse. Millions died in these wars and its sequelae (being maimed, orphaned, malnourished, spread of malignancy due to the depleted uranium used in missiles during attacks in the war on Iraq, and to squash the mutiny and revolts in Ba’qooba. The war on Iraq was costing $4 billion a month (2003–2011).
Children in Labor
United Nations agencies report that 800 million children under 15 years of age are working daily to get sustenance allowance, losing their right to education and play. Many are involved in very serious hard jobs which expose them to physical and mental ailments. Between 50 and 60 million children aged 5–11 are exposed to such horrendous situations.
Street Children: United Nations agencies report 100 million children without homes living in the streets, and are used by gangs to distribute drugs, stealing (pick pocketing), begging and prostitution. About a million children are working in prostitution in Asia (Thailand, India, Cambodia, Philippines, etc.) and are used to attract tourist from Europe, Australia and USA. There are also another million in Latin America working in prostitution.
A BBC documentary film was broadcasted in June 2001, which exposed the horrifying situations in these countries. Millions of children suffer annually from sexually transmitted disease. Two million children between 10 and 14 get infected with HIV annually. About half a million are born with HIV from mothers already suffering from HIV. The brunt of the attack is in Subsaharan Africa. The total number of children suffering from HIV infection globally has reached ten million. The majority are in Subsaharan Africa, and are denied the new retrovirus drugs as they are very expensive. India and Brazil manufactured the generic drugs, but the big Pharma are fighting back and refusing to allow the distribution of these cheaper drugs.
Maldistribution of Wealth
The three top wealthiest persons in the world possess the equivalent of Gross National Product (GNP) of 35 developing nations put together, whose population exceeds 600 million.
The wealth of the richest 200 persons exceeds the income of 2400 million persons of world population.
The developed nations constitute 15 % of the world population, but have 85 % of the world wealth.
Even in these wealthy countries there is a huge difference between the elite oligarchy controlling the wealth, and the masses; especially in USA, but not limited to it.
More recently, the Oxfam report to the last World Economic Forum held at Davos between 23 and 27 January 2013, declared that the wealthiest 85 persons in the world own half the wealth of the whole world, and their income exceeds the income of 3500 million of the world population.
Similarly in the developing or poor countries, there are few who are very rich while the rest of the populations are destitute.
Health services, when available in these countries, are located in the cities and mainly serve the rulers, the military, or their cronies. The rural areas are left with very little health services if any.
The Health Human Resources (health work force) is the number of people engaged in actions whose primary intent is to enhance health, according to WHO “World Health Report 2006” . They include physicians, nurses, midwives, dentists, allied health professionals, community health workers, social health workers as well as health management and support personnel. Human resources for health are identified as one of the core building blocks of a health system .
The World Health Organization (WHO) estimates a shortage of 4.3 million personnel (physicians, nurses, midwives, and support workers) worldwide. The shortage is most severe in 57 of the poorest countries, especially in sub-Saharan Africa, reaching crises level as declared on World Health Day 2006 .
There is an estimated shortage of 1.18 million mental health professionals, including 55,000 Psychiatrists, 628,000 nurses in mental health and 493,000 Psychosocial Care providers . There is also a severe shortage of Midwives and Obstetricians in many developing countries, which ends in higher maternal death and ailments, higher stillbirths and infant mortality rates.
The differences are staggering between developed and developing countries, and worse in rural and underserved areas. Unfortunately, when poor countries spend a large sum of money to bring forth physicians, nurses, and midwives, a substantial number of them migrate to wealthy countries to get better jobs and training. The brain drain is from the poor to the wealthy countries (from underdeveloped to developed countries of the West especially USA). The best of these physicians, nurses, and health professionals find lucrative jobs in these wealthy countries, including Arabian Gulf countries. The world map of health resources shows the worst shortages in Africa, India, and some parts of Latin America.
However, the availability of a sufficient number of health providers does not guarantee a high standard of health, as shown by the figures from Saudi Arabia. According to the report of Ministry of Health, Saudi Arabia published in 2008, there were 53,000 physicians and dentists (11,000 were Saudi) . The population was reported at 25 millions which means one physician for 500 people; the number of hospital beds was also one for each 500 of the population. Saudi Arabia was spending 768 US dollars per capita. The number of health technicians including nurses was about 153,000, i.e., 2.9 health technicians and nurses for each Physicia .
These figures are fairly satisfactory (though there is a definite shortage of health technicians, including nurses) but the end result of infant mortality rate, 5-year-olds mortality rate, longevity, maternal death during delivery, and postpartum are not satisfactory. Malaysia, who spend less than Saudi Arabia has better health indices, viz, infant mortality rate, 5-years-old mortality rate, and so forth. Similarly, Cuba and Sri Lanka have performed well.
It is not only the money spent, the number of human power working in health services, or the number of beds available that determine the health and well being of a certain community or country. It is how the resources are spent and where they are spent. Inefficiency, waste, and spending more than 90 % of the resources on large fantastic hospitals, will not provide better health indices. The health services should be distributed in a fair way between rural areas and cities; and between tertiary hospitals and primary health care. Disease prevention, health education, and health promotion deserve its fair share; otherwise discrepancies will continue between the rich and the poor, the town and city dwellers and the rural, desert area and shanty town dwellers. The end result will be poor health indices.
There is no doubt that USA is the number one country in terms of spending on health, research and medical advancement, availability of hospitals, great physicians, surgeons, and health providers; nevertheless, it is no better than Malaysia in certain indices mentioned above set by the WHO. It is definitely far from the high standard of Singapore, Japan, Nordic countries, or Western Europe in these health indices.
Certainly, it is not only the number of physicians or nurses or beds that will improve the health standard of the nation. It needs equity in distribution of health resources and an efficient system of delivery.
Similarly on a global level, a better use of resources, equity in distribution, concentration on primary healthcare, provision of clean potable water, healthy food, healthy environment, good drainage system, changing lifestyle, no smoking, no prostitution or sodomy (sexually transmitted diseases and HIV), no famines, fair distribution of wealth and justice in all walks of life, will definitely improve the health of the world population. But nothing could be achieved if there is no world peace, if the machine of war goes on bringing havoc and misery to all except those who manufacture these wars and all types of weapons.
The world has to change to be more peaceful, more equitable, and more just, otherwise we will all suffer for many generations to come.
Although justice is a core value of USA, the actual facts of life show intolerance, injustice in different racial and ethnic groups of USA. The health disparities between the white Americans, especially the WASP (White Anglo Saxon Protestant) Americans and the Afro Americans and Latinos, are staggering.
In all diseases, e.g., diabetes, hypertension, malignancy, infant mortality, 5-year mortality, motality, and complication of parturition (delivery) and postpartum, sexually transmitted diseases including HIV, the Blacks and Latinos suffer to a much higher degree than the whites [13, 14, 15, 16].
There is another factor discerned recently and dubbed Health Literacy. It is claimed that 90 million American adults lack the literacy skills needed to use the healthcare system [17, 18, 19]. The prevalence of limited literacy is high among those with lower levels of education, the elderly, the minorities, and those with chronic disease. An emerging literature has begun to describe the myriad of health consequences of limited literacy. Indeed, limited literacy has been shown to be an independent risk factor for worse health status, hospitalization, and mortality [18, 19, 20]. “Despite the clear injustice of health care system that is organized for the most literate and powerful members of our society, the medical ethics literature has neglected some of our most vulnerable patients by remaining largely quiet about the ethical implications of health literacy” .
Limited health literacy has been shown to be an independent risk factor of worse outcomes and health disparities independent of race and education . There is no real autonomy if there is no health literacy, and there is no real justice for those who lack health literacy” .
Conclusion: What Should We Aim For?
The World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease.” It decided in Alma Ata (1978) that the world should reach this Utopian level by the year of 2000.
By 2000, things got far worse than what they were in the 1970s of the twentieth century.
Equity in distribution of wealth: It is shameful to find the wealthiest three have more than Gross National Product (GNP) of 35 developing nations whose populations exceed 600 million; and the 85 wealthiest persons own half the wealth of the whole world, and their income exceeds the income of 3500 millions of the world population.
It is a disgrace to find many millions dying from malnutrition, famines, diarrhea (6 million children die of diarrhea annually because of lack of clean potable water), malaria (more than 2 million die of malaria, mostly children in Africa), 2 million die of tuberculosis (mostly in Africa and many of them due to HIV).
These inequalities could be corrected if the wealthy people and wealthy countries donate 2.5 % of their wealth to the poor and needy both in their countries and outside their countries. The 2.5 % is the obligatory Zakat (alms-giving) in Islam required from all those who have more than their basic requirements for a decent life. If this corner of Islam is fulfilled, the problem of poverty, inequality, huge problems in health, and education will gradually be overcome.
Let us hope that at least the world population will get clean potable water, at least two nourishing healthy meals per day, good drainage system, child and maternal care which would reduce the infant mortality rate, the 5 years mortality, the stillbirths, the deaths and diseases occurring due to parturition and postpartum, and so forth. Health education for everybody, banning smoking all over the world, curbing diseases of obesity, diabetes, hypertension, and reducing the incidence of cancers by removing mutagens in food, water, air pollution, irradiation, and so forth.
The Utopian goal of WHO defining health as “a state of complete, physical, mental and social well-being and not merely the absence of disease and infirmity” will never be reached in this world. We must aim at preventing wars, preaching peace, and implementing the bare minimum of justice and equality. We cannot allow three persons to have more income than 600 million of the world population, and it is hazardous to world peace if the wealthiest 85 persons amass more income than 3500 million of the world population put together. Spending trillions on the war industry is not going to leave the world in peace; it has to make wars to continue usurping the wealth of the world.
Financial gimmicks and derivatives owned and played by a few experts in the financial field brought havoc to the world, the worst was the debacle of 2008, where trillions of dollars were lost, and the ordinary taxpayers were forced to pay the wealthy banks, otherwise the whole system would melt down. These inequalities and the abhorrent system behind them should be corrected; otherwise the whole world including the wealthy industrialized nations will suffer. There is a real need for a new world order, unlike that preached by President George W. Bush and his staff and advisers who waged wars and brought misery and havoc to different parts of the world.
The time for world peace and equity in distribution of wealth, education, and health has come. There is no other alternative. The people of the world should come together to fulfill these rightful ambitions for the future for the coming generations.
Notes and References
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- 9.World Health Organization (2006) The world health report 2006: working together for health, Geneva http://www.who.int/whr/2006
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- 12.Scheffler RM et al (2011) Human resources for mental health-workforce shortage in low and middle income countries, Geneva–WHO 2011 http://whqlibdoc.who.int/publication2011eng.pdf/9789241501019
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