Ethical dilemmas and global health

Ever since a popular theory arose in the early-1970s (known as a theory of ‘epidemiologic transition’), we have become used to thinking that a country’s burden of disease shifts from acute infectious diseases to long-term chronic conditions as it develops.

Over the past few decades, however, this theory has been countered by the occurrence of emerging and re-emerging infectious diseases in developed countries and the growing burden of non-communicable diseases (NCDs, such as cardiovascular disease, cancer, chronic lung diseases and diabetes) in developing and developed countries alike, as well as by the rapid acceleration in the movement of diseases and their causes across borders. While much global attention has been given to the rapid spread of infectious diseases, less attention has been given to the rising burden of chronic non-communicable diseases around the world.

To address the oversight of chronic diseases in the world’s development programmes, in September 2011 the United Nations (UN) General Assembly held a rare, special session on the prevention and control of NCDs. Such a high-level session on a health issue was held only once before, on HIV/AIDS in 2001. Partly motivated by the arguments that HIV/AIDS was not just a health crisis but also a threat to national security, 189 countries signed up to the Declaration of Commitment on HIV and AIDS. That event proved a turning point in the global response to HIV/AIDS epidemic. The High-Level Meeting (HLM) on NCDs aimed to create a similar turning point by galvanising an increased and coordinated global response to NCDs.

There are wide-ranging arguments for why governments and their leaders should care about the prevention and control of NCDs both within and outside their borders. The main case for action includes the identification of the health burden of NCDs; NCDs as threats to economic and social development; the cost-effectiveness and -savings produced by NCD interventions; and the recognition that addressing NCDs requires leadership and coordinated, multi-sectoral policies domestically and across countries.

However, as anyone familiar with making health policy or with high-level UN conferences will tell you, there are politics involved. In the case of a UN conference, by signing up to a declaration, governments make a global public commitment to what is stated in the declaration. And so, understandably, months of preparatory work is done developing a final conference document which hopefully has a coherent vision, reasoning, and action plan. The few final months before the NCD conference involved difficult negotiations between various representatives of governments and some non-governmental organisations regarding what concrete commitments were being asked of different governments and non-state actors as well as what will be, and importantly, will not be included in the final conference document.

In an article published in the Bulletin of the World Health Organization, we reviewed the regional declarations leading up to the HLM in September to identify areas of intersection and divergence. Our analysis identifies four ‘ethical dilemmas’ facing Europe and the global community. We frame them as ethical dilemmas, in contrast to ‘concerns’ or ‘questions’, because underneath the politics and practical deliberations on what language to include and exclude in the final declaration and indeed, global response, lie different conflicting ethical principles. We are driven by the notion that politics, especially global health politics, can be richer than the pursuit of self-interest of different actors through greater reflection on the ethical issues at stake. These ethical dilemmas are not exhaustive or mutually exclusive. Without one general ethical theory that would organise and guide consistent reasoning through all of them, we identify them separately.

The four dilemmas we identified included:

Dilemma 1. Human rights approaches

Effective action on non-communicable diseases involves addressing multiple human rights, such as the right to information to make informed choices about diet and activity (e.g. food labels that people can understand), the right to bodily integrity (e.g. freedom from exposure to second-hand smoke), and the right to health (including access to essential medicines). These human rights may conflict with corporate rights such as the right of pharmaceutical companies to exploit patents or express freedom of speech (through marketing).

Dilemma 2. Social determinants or healthcare

The World Health Organization Commission on the Social Determinants of Health showed how an individual’s health is influenced by the circumstances in which they grow, live, work and age, and the systems put in place to deal with illness. The Commission also highlighted how health and longevity in both rich, middle-income and poor countries follow the socioeconomic gradient, and how inequalities in health within and across countries are increasing. Political leaders face difficult decisions about where to invest resources along the causal chain of disease. They must care for those already ill but also tackle the underlying causes of the diseases.

Dilemma 3. Resource allocation between domestic and global needs

Governments must balance the needs of their own citizens with their obligations to provide aid to other countries. There is a glaring global inequality in the burden of NCDs and in the domestic resources available to address them. This raises the basic question of the obligations of rich countries to help poor countries to deal with these diseases.

Dilemma 4. Setting priorities on NCDs

All governments must set priorities for action, such as whether to focus on interventions for those people in most need, those who would benefit most or on actions that would benefit the most people. The HLM initially prioritised four diseases (cardiovascular disease, cancer, chronic lung diseases and diabetes) with high mortality burdens and four risk factors (tobacco use, poor diet, harmful use of alcohol and physical inactivity). The case for focusing on these four NCDs is that they have common causes, and there are knock-on benefits of interventions into these specifics for the prevention of other NCDs. However, such a justification does not seem to be fully satisfactory in relation to individuals suffering from mental illnesses. The full extent of mental illnesses worldwide, and particularly in developing countries, is grossly under-recognised, requiring distinct interventions that do not completely come under the secondary benefits of addressing the four identified NCDs.

The final declaration signed at the HLM contains mixed messages regarding these four dilemmas. This is partly due to the need for achieving a consensus and pressure to achieve an outcome. However, the dilemmas still remain, and much greater deliberation, both at the national and global level is necessary in order for there to be an effective and enduring global response to the rising burden of NCDs within and across societies.

Dr Sridhar Venkatapuram is an affiliated lecturer at the University of Cambridge Department of Sociology and holds a Wellcome Trust fellowship at the London School of Hygiene and Tropical Medicine (LSHTM). Dr David Stuckler is a lecturer at the Department of Sociology and an honorary research fellow at LSHTM.

For further information, please refer to the authors’ article published in the Bulletin of the World Health Organization March 1 (2012); 90(3): 241–242.