63

GLOBAL PUBLIC
HEALTH
Alex Broom and John Germov

Overview
• What are the major health problems experienced by people in the poorest countries?
04
• Why do global health inequalities persist despite the availability of effective
interventions?
• What can be done to address global health inequality?

On 2 July 2005 a series of rock concerts were held across the world in the cities LIVE 8: THE
of London, Edinburgh, Philadelphia, Berlin, Paris, Rome, Moscow, Johannesburg,
and Barrie (near Toronto). During the concert, actor and singer Will Smith led
BEGINNING
the combined audiences of the concerts to click their fingers simultaneously OF AN END
to represent the death of a child occurring every three seconds due to poverty. TO WORLD
In Edinburgh, an estimated 225,000 people participated in a protest march HUNGER AND
and attended the concert. Approximately three billion people watched the POVERTY?
telecast. The concerts were organised by Bob Geldof and marked the twentieth
anniversary of the dual Live Aid concerts held in London and Philadelphia
that raised over US$200 million in 1985. While Live Aid helped to raise global
awareness of the African famine and provided short-term relief to millions, 20
years later the same problems continue to plague Africa—poverty, hunger, and
preventable disease.
The 2005 LIVE 8 concerts did not aim to raise money in the form of charitable
donations from the public; instead, they mobilised public pressure on the leaders
of the G8 nations, who were to meet at Gleneagles in Scotland on 6–9 July that
year. The G8 represents some of the world’s wealthiest and most powerful
countries: the US, Canada, the UK, France, Germany, Italy, Japan, and Russia.
The concerts were part of a week of social activism that culminated in the LIVE
8 organisers presenting the G8 leaders with a ‘LIVE 8 List’ of names of people
across the globe who signed their support (via the LIVE 8 website) for the ‘Make
Poverty History’ campaign. Names from the list were randomly displayed on
large screens during the concerts.
The LIVE 8 social protest held in 2005 was recognition that charity could only
be a Band-Aid to addressing global poverty and that permanent structural changes
in global affairs were required to solve the problem. The organisers called on the
G8 nations to cancel all ‘third world’ debt, to double aid, and to implement policies
to enable fair trade between developed and developing countries. On 7 July 2005,
the G8 leaders announced they would cancel the debt of 18 African nations
and increase African aid to US$25 billion by 2010. While this was a significant
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achievement, the deal affected only half of the countries afflicted by debt and international
trade rules were not greatly addressed. Actual debt relief and increased funding proved slower
to materialise than originally pledged, though debt relief for 35 of the 39 eligible countries
was achieved (totalling US$35.5 billion), and 60 per cent of aid funding was delivered by
2010 (ONE 2013).

Key terms
biomedicine/biomedical model gross domestic product (GDP)
colonisation/colonialism life chances
complementary and alternative medical pluralism
medicine (CAM) modernity/modernism
food security/insecurity social determinants of health
globalisation

Introduction
There are only two families in the world, as my grandmother used to say: the haves
and the have-nots.
SANCHO PANZA IN DON QUIXOTE DE L A MANCHA BY MIGUEL DE CERVANTES (1605)

This chapter explores the social patterning of health and illness at a global level. The most
severe health inequalities today exist between countries not within them—so much so, that
your chances of illness, disability, and premature death vary greatly depending upon your
country of residence.
Infectious diseases that are treatable and preventable plague the poorest nations, but not
LIFE CHANCES the wealthiest ones. Such different life chances are avoidable and inequitable. As the World
Derived from Max Health Organization’s (WHO) Commission on the Social Determinants of Health pointedly
Weber, the term refers
to people’s opportunity states, health inequalities between countries persist due to the:
to realise their lifestyle
choices, which are unequal distribution of power, income, goods, and services, globally and nationally,
often assumed to the consequent unfairness in the immediate, visible circumstances of people’s
differ according to their lives—their access to health care, schools, and education, their conditions of work
social class. and leisure, their homes, communities, towns, or cities … This unequal distribution
of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is
the result of a toxic combination of poor social policies and programmes, unfair
economic arrangements, and bad politics. (CSDH 2008, p. 1)
SOCIAL
DETERMINANTS OF
While the delivery of health care is important, solutions to global and national health
HEALTH
The economic, social, inequalities lie with interventions that address the social determinants of health.
and cultural factors that In this chapter we review the extent of global health inequality, examine the major
directly and indirectly
influence individual and reasons for the perpetuation of such inequality, and explore some concrete examples of health
population health. interventions that are making a difference. Furthermore, we examine grassroots experiences
 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 65

of health in poor countries and the interplay of modern forms of medicine with traditional,
indigenous health care practices.

Global health inequality

In thinking about inequalities between countries it is useful, albeit sometimes problematic,
to group countries with similar living standards together. Traditionally, the world has been
divided into three distinct socio-economic groups: ‘first world’ (Australia, the US, the UK,
Germany, Japan, and others), ‘second world’ (the Russian Federation and former Eastern bloc
countries), and ‘third world’ countries (poor countries in Asia, Africa, the Middle East, and
South America). The United Nations (UN) prefers the terms ‘developed’ and ‘developing’
countries; the World Bank uses the terminology of high- and low-income countries; and the
WHO uses a range of regional categories. Each is politically loaded in one way or another and
as sociologists we need to be aware of the limitations of such categorical distinctions. For our
purposes we will use the terms (economically) richer and poorer countries, following Robert
Beaglehole and Ruth Bonita (2004), as this most clearly indicates the inequality (and often the
relationship) between countries of the world. In utilising these categories we are referring to
economics, not culture or history—indeed, some of the most ‘rich’ nations in these terms are
the poorest economically.
The extent of global health inequality, particularly between rich and poor nations, has long
been recognised. As Box 4.1 shows, declarations, goals, and plans of action have been produced
by the UN over many years. Despite these plans and some progress, the extent of global
health inequality remains unacceptably high. Most poor countries are yet to pass through the
‘epidemiological transition’ (Omran 1971), which refers to the changed pattern of disease in
a country away from infectious disease to chronic, non-communicable, and lifestyle-related
diseases (for example, stroke, heart disease, and cancer). Most infectious diseases are treatable
and preventable, particularly through immunisation and improved living conditions.

BOX 4.1
DOING HEALTH SOCIOLOGY: GLOBAL HEALTH STRATEGIES:
WE HAVE A PLAN …
The WHO was founded in 1948 following the endorsement of its constitution two years earlier, which included
the famous holistic definition of health as ‘a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity’ (WHO 1946). In 1978, the Alma-Ata Declaration called for an end to
health inequality in and between countries and posited the goal of ‘Health for All by the Year 2000’ (WHO 1978).
This was followed by the Ottawa Charter for Health Promotion (WHO 1986), which reaffirmed the goal of ‘Health
for All’ by outlining a range of key strategies. In 1996, world leaders agreed to the World Food Summit Plan of
Action, which outlined plans to meet a target of halving the number of undernourished people in the world by
2015 (FAO 1996). Further goals and targets to reduce poverty and inequality by 2015 were agreed upon in the
United Nations Millennium Declaration (2000), which established the Millennium Development Goals (MDGs).

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In 2008, the WHO’s Commission on the Social Determinants of Health (CSDH 2008, p. 2) reaffirmed the MDGs’
commitments through three overarching recommendations to:
1 improve daily living conditions;
2 tackle the inequitable distribution of power, money, and resources;
3 measure and understand the problem and assess the impact of action.
Such declarations, reports, goals, and strategies indicate a clear global awareness of the problem and
what needs to be done, with some progress made to date. The latest data on progress, or otherwise, can be
found on the UN MDG website.

LIFE EXPECTANCY
Since 1990, average global life expectancy has risen by four years to 68, but this general
improvement masks a significant gap between poorer and richer countries. In richer countries
the average life expectancy at birth is around 80 years, with the highest life expectancy in the
world found in Japan (83.6 years). In stark contrast, Sierra Leone records a low of 48.1 years
(UNDP 2013).
Much of the overall improvement in life expectancy across the globe is due to improved
infant and under-five child mortality rates, which decreased from 12 million to 7.6 million
between 1990 and 2010. That said, there were still 21,000 child deaths per day in 2010.
In addition to malnutrition, many child deaths are from preventable diseases, such as
measles, diphtheria, whooping cough, and tetanus—all of which can be addressed through
immunisation (UNICEF 2011).
Amid some progress, it is worth noting that average life expectancy during the 1990s and
early 2000s worsened in sub-Saharan Africa (mostly due to HIV/AIDS and conflict) and in
the former socialist states of Eastern Europe (mostly due to increased rates of poverty); and it
is only recently that these areas have shown improvement (UNAIDS 2012; UNDP 2005). In
the past two decades there have been many civil and between-country conflicts that have seen
horrifying numbers of people killed. Conflicts in Kosovo, Rwanda, Afghanistan, Iraq, the
Democratic Republic of the Congo, and the Darfur region of Sudan have resulted in genocide
and millions of deaths, which have decimated communities and are clearly reflected in average
life expectancy figures.
Life expectancy in the Russian Federation declined markedly from 70 years in the mid-
1980s to around 65 in the year 2000 (59 years for men); rising to 68 by 2009 (with men at
61.5 and women around 74 years). Much of this decline is explained by the social and
economic restructuring that occurred in the wake of the collapse of the Soviet Union. This
led to high rates of male unemployment and a reduction in expenditure on health and welfare
services. Sub-Saharan Africa remains the most troubling region in terms of mortality and
morbidity rates, with life expectancy approximating that of 1840 England. Since 1990, average
life expectancy has declined to around 46 years (UNDP 2013; 2005). In addition to deaths
from violent conflicts, the main cause of worsening life expectancy has been the spread of
HIV/AIDS. In 2011, it was estimated that around 34 million people were infected with HIV
globally, with sub-Saharan Africa accounting for 69 per cent of this figure (approximately 1 in
20 adults) (UNAIDS 2012, p. 8).
 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 67

GLOBAL HUNGER AND THE MDGs

In 1996 at the World Food Summit (WFS), most governments agreed to the 2015 goal of
halving the number of people in hunger from the 1990 level. This goal was reaffirmed by the
UN MDGs agreed to in 2000 (see UN 2008), which aim to halve the proportion of
undernourished people in the world by 2015:

1 Eradicate extreme poverty and hunger: halve the proportion of people living on US$1
per day and halve malnutrition.
2 Achieve universal primary education: ensure all children can complete primary school.
3 Promote gender equality and empower women: achieve gender equity in primary and
secondary school completion.
4 Reduce child mortality: cut the under-five death rate by 75 per cent.
5 Improve maternal health: cut the maternal mortality by 75 per cent.
6 Combat HIV/AIDS, malaria, and other diseases: halt and reverse the proportion suffering
these diseases.
7 Ensure environmental sustainability: cut by 50 per cent the proportion of people without
access to safe drinking water and sanitation.
8 Develop a global partnership for development: reform aid and trade.

As shown in Figures 4.1 and 4.2, while the total number of undernourished people remains high,
it has declined over time, and more importantly the proportion of the undernourished population
has declined, making the MDG target of halving the proportion in hunger within reach (FAO 2012).

FIGURE 4.1 UNDERNOURISHED PEOPLE MILLIONS IN THE WORLD, 199092 AND 201012

1990–92 2010–12
H I
H I
G A
F
G A
F
E E
B
B

Total = 1000 million D Total = 868 million

D
C
C

NUMBER OF UNDERNOURISHED MILLIONS

199092 201012
A Developed regions 20 16
B Southern Asia 327 304
C Sub-Saharan Africa 170 234
D Eastern Asia 261 167
E South-Eastern Asia 134 65
F Latin America and the Caribbean 65 49
G Western Asia and Northern Africa 13 25
H Caucasus and Central Asia 9 6
I Oceania 1 1
Source: FAO 2012, p. 11

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FIGURE 4.2 CHANGES IN THE PROPORTION OF UNDERNOURISHED PEOPLE SINCE 199092

MILLIONS PERCENTAGE UNDERNOURISHED

1100 45
980 Number
1000 40
901 (left axis)
885
900 852 852 35
Prevalence
800 30 (right axis)

700 25
23.2%
600 20
16.8%
15.5% 14.9% WFS target
18.3%
500 15

400 10
MDG target
300 5

0 0
1990–92 1999–2001 2004–06 2007–09 2010–12 2015
Source: FAO 2012, p. 9

The Food and Agriculture Organization of the UN (FAO 2012) estimates that during
2010–12, there were around 868 million people who were undernourished and faced life in a
FOOD SECURITY/ regular state of food insecurity (see Figure 4.1). Progress has been made since 1990–92, but not
INSECURITY in Africa, where the number of undernourished people has increased (though it is important
Food security refers
to the availability of to note that the population has also increased during this same period). As Figure 4.2 shows,
affordable, nutritious, trends in the proportion of people who are undernourished across the globe have declined
and culturally
since 1990–92, despite considerable population growth, though improvements have shown
acceptable food. Food
insecurity is a state of signs of slowing in recent years, reflecting the impact of the global financial crisis (GFC) that
regular hunger and fear occurred during 2007–08.
of starvation.
It is widely accepted that the world produces enough food to feed the total population
more than adequately (see Lappé et al. 1998; Lappé 2008). Despite this, hundreds of millions
of people lack sufficient access to nutritious food, leading to nutritional deficiencies that affect
physical and mental development, disease resistance, and life expectancy. Common examples
are iodine and iron deficiencies, beriberi (lack of B vitamins), scurvy (lack of vitamin C),
pellagra (lack of niacin), and rickets (lack of vitamin D), to name a few (Whit 2004). Amartya
Sen (1990) identifies two forms of hunger: famine (caused by war and natural disasters) and
the mostly hidden and less readily addressed ‘endemic deprivation’. Sen was one of the earliest
writers to argue that hunger persists due to insufficient wages or land to grow food, or lack
of access to public programs that subsidise the cost of food and guarantee access to food as a
basic human right. While there have been improvements in some regions of the world, food
insecurity persists to an unnecessary extent.
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Globalisation: progress or problem?

A key question in the context of global public health is the extent to which globalisation as GLOBALISATION
a social, cultural, and economic phenomenon has had positive or negative impacts (or none, Political, social,
as the case may be) in regard to quality of life and population health. Some stakeholders economic, and cultural
developments—
initially proposed that those nations that more effectively ‘globalise’ (mainly through trade such as the spread
liberalisation) grow faster and thus have a greater capacity to reduce poverty and improve the of multinational
companies, information
health of their populations (see Feachem 2001; Dollar & Kraay 2004). Such arguments tend to technology, and the
be economy-centric, in that faster growth (such as escalating gross domestic product (GDP) role of international
agencies—that result
per capita) is seen to equal better standards of living and thus produce better health outcomes.
in people’s lives being
Such arguments have been shown to be flawed, with scholars such as Leslie London and Helen increasingly influenced
Schneider arguing that: by global, rather than
national or local,
factors.
globalisation has opened dependent countries’ health systems directly to large
scale private investment, promoted deregulation of private health care, shrunken GROSS DOMESTIC
public expenditures on social services, facilitated health worker out-migration and PRODUCT (GDP)
reduced the policy room for states to articulate pro-poor policies inconsistent with The market value of
neoliberalism. (2012, p. 7) all goods and services
that have been sold in a
These and other scholars have argued that the situation is more complex than many country during a year.
economists would have us believe, in that globalisation has both positive and negative
implications. The positives potentially lie in the obligations of adopting global human rights
policies and models, with the ‘human rights-observing state’ likely to provide more effective
health services (London & Schneider 2012). This is the carrot-and-stick model, whereby
nation states are provided with better access to aid and credit through abiding by globalised
human rights conventions. Yet, as outlined by Schrecker and colleagues (2010) among
others, globalisation is creating new conditions of inequality, with problems that include
the emergence of a global labour market; binding trade agreements and processes to resolve
disputes; the increasing mobility of financial capital; and the persistence of debt.
Below, we outline some of the persisting inequalities across nations, despite the promise of
trade liberalisation and economic growth produced through globalisation.

POVERTY AND GLOBALISATION

It is estimated that approximately 40 per cent of the world’s population survives on US$2 or
less per day (CSDH 2008, p. 21). As Figure 4.3 indicates, there are major regional variations
in the number of people living on US$2/day, and there has been some improvement in the
percentage of people living on this amount in most regions. The benefits of globalisation have,
though, clearly not been evenly distributed. India is a case in point as it is often cited as a
globalisation success story in terms of its economic growth, primarily due to the development
of its information and communication technology industries. According to the World Bank,
India has the fourth largest economy in the world (World Bank 2012a). Yet, the benefits of
economic growth have not been widely distributed to its population; under-five child death
affects 61 per 1000 children in India, compared to 5 per 1000 in Australia (World Bank 2012b).
In 1980, the richest countries of the world, representing only 10 per cent of the global
population, had a combined national income that was 60 times greater than the poorest

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countries; by 2005 the income gap had increased so that it was 122 times greater (CDSH 2008,
p. 37). Figure 4.4 shows the extent of the unequal distribution of global income, depicted as
a champagne glass, in which the richest 20 per cent of the global population (the wide top of

FIGURE 4.3 REGIONAL VARIATION IN THE PERCENTAGE OF PEOPLE IN WORK LIVING ON US$2 PER
DAY OR LESS

%
100

90 World
Central & South East Europe
80 East Asia
South East Asia & Pacific
70
South Asia
60 Latin America & Caribbean
Middle East
50 North Africa
Sub-Saharan Africa
40

30

20

10

0
1997 2002 2007
Source: CSDH 2008, p. 6

FIGURE 4.4 THE CHAMPAGNE GLASS EFFECT: THE UNEQUAL DISTRIBUTION OF WORLD INCOME

WORLD POPULATION
ARRANGED BY INCOME DISTRIBUTION OF INCOME
est
Rich

Each horizontal band

represents an equal fifth of
the world’s population
WORLD WORLD
POPULATION INCOME
Richest 20% 75%
Poorest 20% 1.5%
rest
Poo

Source: Adapted from UNDP 2005, p. 37

 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 71

the glass) own around 75 per cent of the world’s income, while the bottom 40 per cent have
around 5 per cent, and the poorest 20 per cent have only 1.5 per cent. The bottom 40 per
cent, approximately 2 billion people, represent those who are surviving on US$2 a day or less
(UNDP 2005).

The politics of ‘aid’

Let us remember that the main purpose of American aid is not to help other nations,
but to help ourselves.
US PRESIDENT RICHARD NIXON (1968, CITED IN HANCOCK 1989, p. 71)

Aid, or official development assistance (ODA), is a contentious issue, with many critics
highlighting that the amount of aid provided is inadequate, but more importantly, that it is
mostly ineffective and primarily used to benefit the national interest of the donor country.
In 2011, global aid was estimated at around US$125 billion. While this is a significant figure,
it should be treated with caution. Most countries are not meeting the preferred aid quantity
commitment of 0.7 of gross national income (GNI)—a target set in the 1990s and reaffirmed
by the MDGs for 2015. The current global average is 0.31 of GNI.
The US is the largest aid donor in monetary terms, but its contribution represents only
0.2 per cent of its GNI, while other countries are proportionally contributing more. For
example, Sweden and Norway have exceeded the 0.7 UN target for many years and currently
contribute 1.0 per cent of GNI (UNDP 2005; Development Initiatives 2012). Australia provided
AU$5.2 billion of aid in 2012–13, contributing around 0.35 per cent of its GNI to aid, below the
OECD average of 0.47 (Duxfield & Wheen 2007; AusAID 2013). The Australian Government
has set a modest ODA target of 0.5 of GNI by 2016–17 (AusAID 2013).
One of the reasons for the ineffectiveness of aid is that it is often conditional, meaning that
the donor country mandates how the aid is to be used. Such ‘tied’ aid usually takes the form of
requiring the funding to be spent on goods and services from the donor country. Others forms
of tied aid include funding a project determined by the donor country, or linking funding
to particular performance criteria (Duxfield & Wheen 2007). While placing conditions on
aid can limit the potential for fraud and mismanagement by the recipient country, it can
also limit its effectiveness if funds are thereby not addressing a priority area. Disaggregating
national and commercial interests from aid, and thus improving aid effectiveness, has long
been recognised as an important objective. This awareness has resulted in world governments
signing the Paris Declaration on Aid Effectiveness, which came into effect in March 2005 and
outlines a number of strategies and targets to improve the quality and amount of aid provided
(OECD 2008). The Paris Declaration was bolstered by the Accra Agenda for Action, at meeting
in the city of Accra in Ghana in September 2008, which detailed further commitments and an
accelerated timeline for implementation (OECD 2008). Partly due to the GFC, hardly any of
the commitments have been enacted.
Examining rates of mortality and morbidity, malnutrition, and poverty is clearly critical
for understanding and solving global health inequalities. Furthermore, access to biomedical
expertise, medical technologies, and ongoing health care funding is vital if we are to improve
the health and well-being of populations in poorer countries. Importantly, there are other

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factors that must be explored in order to shape our understanding of health and health care
in such countries. Health is not just a matter of providing the ‘best treatment’; it is also about
cultural beliefs and cultural heritage. As such, for the remainder of this chapter we will focus
on the roles of culture, identity, religion, and history in shaping support for, and use of,
different forms of medicine in poorer countries.

Medical pluralism and traditional practices

BIOMEDICINE/ Unlike in the Australian context, in many poorer countries biomedicine is not the primary
BIOMEDICAL source of healthcare (WHO 2001). In fact, for many developing countries, traditional health
MODEL
The conventional practices are the status quo and biomedical treatments are new and even ‘foreign’ in cultural
approach to medicine terms (Tovey et al. 2007). This is particularly the case in rural and remote areas of Asia and
in Western societies, Africa where there may be no doctors or nurses within a few days’ walk. As such, billions of
based on the diagnosis
and explanation of people around the world rely, at least to some level, on traditional health practices, including
illness as a malfunction things such as traditional Chinese medicine (TCM) and ayurveda (an Indian traditional
of the body’s biological
mechanisms. This medicine) (WHO 2001; 2005a). In China and India, many people would view practitioners of
approach underpins TCM or ayurveda in the same way as we view our local GPs: as the providers of general health
most health
care to the masses.
professions and health
services, which focus A key question that always emerges for sociologists is what we actually mean when we
on treating individuals, use certain words. ‘Traditional’ is a particularly good example, as it is often used to describe
and generally ignores
the social origins biomedicine (that is, the ‘traditional’ versus ‘alternative’ medicine), but yet it is also used to
of illness and its describe practices like TCM or ayurveda. In this chapter when we use the term traditional
prevention.
medicine (TM), we are referring to local knowledge, belief systems, and therapeutic practices
COMPLEMENTARY that are generally used in poorer countries for health-related purposes (Tovey et al. 2007).
AND ALTERNATIVE Unlike, say, complementary and alternative medicine (CAM) in Western contexts, TMs have
MEDICINE (CAM)
A broad term to often been the dominant means of treatment for health problems for centuries (for example,
describe both TCM in Chinese society), and in some cases, they continue to dominate health care beliefs
alternative medical
and practices. TM is thus characterised more by longevity, cultural specificity, religiosity, and
practitioners and
practices that may often, but not always, by having indigenous roots (WHO 2001).
stand in opposition In recent times, the WHO has been promoting traditional health practices as one means of
to orthodox medicine
and also those who meeting the huge unmet health needs—as illustrated in the previous sections of this chapter—
may collaborate with, of the populations in developing countries (WHO 2001; 2005a). TMs are viewed by many
and thus complement,
orthodox practice
policy-makers as culturally appropriate, relatively cheap (as compared to many biomedical
(also referred to as treatments), and already available. As such, the WHO produced a Global Atlas of Traditional,
integrative medicine). Complementary and Alternative Medicine (WHO 2005a). This has in some ways set the agenda
in terms of health policy to support the development of indigenous practices and biomedical
THEORYLINK facilities concurrently; however, although promising in theory, the idea of promoting
See Chapter 22 for therapeutic pluralism and integrating the traditional with modern, biomedical treatments is
more about CAM.
not as simple at a grassroots level (Tovey et al. 2007). As illustrated in the following sections,
access to—and use of—health practices in pluralistic settings is often shaped by different forms
of structural inequalities, often reinforcing the divides (gender, caste, religion, etc.) already in
place (Pal & Mittal 2004). As such, medicine, in its many forms, has come to reflect wider
social forces and social problems that remain important for sociologists to study and critique.
 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 73

Modernity, colonialism, and identity politics

The character of, and dynamics between, health practices in most developing contexts are
embedded in particular historical events and socio-political processes. Countries in Asia,
Africa, and South America, for example, were significantly influenced by colonial (and COLONISATION/
now post-colonial) rule (Arnold 2000), with health and illness closely linked to patterns of COLONIALISM
A process by which
political struggle and resistance (Ecks 2004; Khan 2006; Reddy 2006; Sujatha 2007). Many one nation imposes
forms of medicine (both biomedical and alternative, such as homeopathy) were introduced itself economically,
politically, and socially
by colonial rulers and fundamentally shaped landscapes of therapeutic practice in individual
upon another.
nations (Arnold 2000). The forces of ‘modernisation’, Westernisation, and globalisation have
each played important roles in shaping health and medicine in the developing world (Janes MODERNITY/
1999); however, post-colonial struggle, nationalism, and the reinvention (or rediscovery) of MODERNISM
tradition have played equally important roles (Ecks 2004). For example, for nations such as A view of social life
that is founded upon
India and China, traditional health care practices—including ayurveda and TCM—remain rational thought and
key to their national heritage and identity politics. Medicine, in its many forms, has become a belief that truth
and morality exist as
an important expression of political and cultural relations, both between economically
objective realities that
richer and poorer countries, and indeed between poorer countries (Khan 2006; Reddy can be discovered
2006; Tovey et al. 2007). The global environment is complex: this is not simply a matter of and understood
through scientific
‘Western’ biomedical dominance; it also involves the ‘rediscovery’ of traditional, indigenous means. See reflexive
medicine as an expression of post-colonial autonomy (Ecks 2004; Sujatha 2007). As such, modernity and
post-structuralism/
while the ‘project of modernity’ (as some may call it) continues to influence the trajectory of postmodernism.
health care in these countries (Janes 1999), so too do nostalgic and nationalistic notions of
medicine as part of cultural identity, and the rediscovery of the traditional as a key element
MEDICAL
of post-colonial identity. PLURALISM
For many nations medical pluralism is the norm, with a mix of potentially competing A general term that
refers to the vast array
and even conflicting ideologies and practices around health and illness (Haram 1991; Sujatha of healing modalities
2007). While nationalism and post-colonial identity work well in theory, in practice grassroots across the globe,
tensions often exist between practitioners of different forms of medicine and between ‘modern’ in particular to the
increasing popularity
and ‘traditional’ health organisations. For example, in their study examining the dynamics of alternative therapies
between traditional healers (called Hakeems and Pirs) and doctors in Pakistan in the context and their coexistence
with biomedicine
of treating cancer, Alex Broom and Philip Tovey (2007) found significant ideological conflict in Westernised
and often outright animosity between traditional practitioners and doctors. societies.
As shown in the excerpts presented in Box 4.2, there exists significant conflict between
healers and doctors in Pakistan, and similar dynamics can be found in other developing
countries as ‘modern’ forms of medicine become an increasingly important part of health
care delivery (Tovey et al. 2007). As such, while post-colonial autonomy and nationalistic
sentiment may be embodied in the promotion of traditional practices (Arnold 2000; Ecks
2004; Khan 2006), at a grassroots level, there may be significant struggle and ideological
conflict between traditional and biomedical practitioners. Furthermore, and as shown below,
access to traditional versus modern forms of therapeutic practice can be more about social
and economic status than actual preferences for particular therapeutic options.

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BOX 4.2
DOING HEALTH SOCIOLOGY: TRADITIONALISM VERSUS ‘WESTERNISATION’
Broom and Tovey’s (2007) study provides an illustration of the potential conflict and animosity between
traditional healers and doctors in Pakistan, as shown in the accounts of cancer patients seeking treatment:
Hakeems think that what they are doing is a justified and right treatment. Their method of treatment
is a lengthy one. They often don’t let patients visit doctors. (Female, 30 years, breast cancer) (p. 610)

Another respondent:
Traditional healers say that if you want to be cut into pieces then go to doctors … they say that doctors
will harm you and cut into you and that it is not natural. (Male, 55 years, bladder cancer) (p. 9)

Another respondent:
[Traditional healers] use very strong words for [doctors]; both traditional healers and doctors don’t
like each other. [Our healer] says in our community that both [hospital name] and [another hospital’s
name] kill people. (Female, 35 years, breast cancer) (p. 610)

Religion, caste, and gender: medical

pluralism in context
In Western contexts, health care delivery is dominated by biomedical approaches and thus
social inequality in relation to health is mostly considered to be about equity in access to GPs
and hospitals. Furthermore, access is largely mediated by socio-economic status and ethnicity
(the two are often intertwined). In the context of developing countries the situation is more
complex. While socio-economic status and ethnicity still play significant roles, geography
(rural and remote areas), gender, religion, and caste are also influential. Furthermore, there
is a distinction between what types of modalities different groups use. As such, health care
delivery is not only about limited health services, but also the divide between the types of
modalities available (that is, TMs versus biomedical treatments) to different parts of the
population. For example, in India, for most rural populations and the urban poor, traditional
practitioners of ayurveda and unani are the only source of health advice and treatment
(WHO 2005b). Use of a traditional practitioner may cost AU$1, whereas treatment at a public
or private hospital in India may cost AU$2000. In a context where a large proportion of the
population earn less than US$2 a day, there is no real choice. With serious illnesses such as
cancer, treatment in a hospital may cost several times the annual wage of a reasonably well-
off family. As such, families may have to consider whether paying for biomedical treatment is
‘worth it’ depending on the role or ‘value’ of the person who is ill (father, mother, or child). In
such contexts, and with the importance of the ‘breadwinner’, inequality for women in terms of
access to biomedical treatments for serious illnesses is a constant concern for policy-makers.
These kinds of concerns emerged in the study by Tovey and Broom (2007), as shown in Box 4.3.
 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 75

BOX 4.3
DOING HEALTH SOCIOLOGY: POVERTY AND RELIGIOSITY
In Tovey and Broom’s (2007) research, cancer patients talked about who accesses which treatments in their
community and why:
Most of the people go to doctors; basically it is the matter of money. The wealthy people go to doctors
and poor people go to Hakeems. (Male, 12 years, diagnosis unclear) (p. 657)

Another respondent:
Poverty takes [people] to traditional healers. They … know well that there are specialist doctors for
the particular disease, but they are bound to go for traditional healing. People seek the treatments like
Dam Darood, spiritual healing, as people are poor. They prefer self-medication and traditional healing
because they don’t have access to modern treatment … If they seek the help of doctors [and the
hospital] they have problems with accommodation, food etc. (Male, 37 years, fibrosarcoma) (p. 657)

Another respondent:
[We] have firm belief in Dam Darood [spiritual healing]. Islam gives you a complete code of life. So
being an honest Muslim like others, I have a blind faith in Dam Darood. All diseases are caused by God’s
will, and I think prayer and Dam Darood do matter a lot for healing and [we use them for] any particular
disease. (Husband of female, 47 years, breast cancer) (p. 659)

A key theme that emerged from this work was medicine as a form of distinction (Bourdieu
1979/1984); that health practices have become embedded in class and caste dynamics and
therapeutic modalities (that is, traditional versus biomedical) intertwined in key structures of
social inequality in Pakistan (Tovey & Broom 2007). Poor people within these communities
are opting for traditional practices due to the costs of biomedical treatment; a medico-
cultural divide exists whereby consumption of certain practices is tied to social status. This
is complicated further in contexts in which practices are intertwined with religious/spiritual
beliefs, and this is the case for many traditional medicines. For example, in India and
Pakistan, Hindus and Muslims use different forms of traditional medicine (ayurveda and
unani, respectively). Furthermore, healers may concurrently be religious mentors, and thus
the rejection of a treatment they may offer can result in community disapproval and even
explicit anger from community healers (see Tovey et al. 2007). Using a particular practice
can therefore be just as much about faith and illustrating your commitment to Islam as, for
example, purely selecting the most ‘effective’ (in biomedical terms) treatment. As such, in
many poorer countries there remains a certain acceptability of certain traditional practices
as religiously based, rather than socio-economically driven. It is increasingly the case that
the wealthier cohorts in developing countries use biomedicine and the poorer use TMs. This
suggests that WHO’s policy of promoting TM may in fact be exacerbating a therapeutic
divide between the rich and the poor.

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Conclusion
In this chapter we have explored a range of issues facing poorer countries in terms of health
and well-being. The most severe inequalities currently facing the world are for most of us ‘out
of sight and out of mind’. So, too, are major killers in the developing world such as malaria,
dengue fever, typhoid, and polio, as they have been eradicated in wealthier nations.
The statistics, such as those presented in this chapter, make the health problems impacting
on poorer countries seem huge, perhaps even insurmountable, but solutions are available for a
relatively small cost. We already have the treatments for many common conditions that cause
premature death and thus what is needed is economic support and determination from richer
nations. As we have emphasised, it is vital also to remember that addressing global health
inequality is much more complex than merely facilitating a biomedical, Western intervention.
Such colonialist thinking results in fractures between implementing biomedical solutions and
implementing localised values and belief systems. While money and biomedical technologies/
treatments are urgently needed, there is also a real need for a comprehensive understanding
of the interplay of culture, identity, belief, and health. In the face of globalisation, local belief
systems and cultural values remain strong and are vital to understanding experiences of
disease and treatment choices. Without an understanding of cultural and social processes,
we will never be able to support the amelioration of health problems in poorer countries
successfully.

SUMMARY OF MAIN POINTS

• The social determinants of health are most significantly evidenced through the inequalities between richer
and poorer nations.
• Despite the fact we have the ability to produce enough food to feed everyone on the planet, global hunger
continues to plague millions each year due to poverty and a lack of global effort directed at redistributing
sufficient resources.
• While aid can make a difference to poorer countries, much of it has limited effectiveness because it is used
to serve the national interests of donor countries.
• Medical pluralism, particularly the use of CAM therapies in poorer countries, shows the importance of
considering the role of culture, identity, religion, and history in effective and culturally appropriate health
interventions.

SOCIOLOGICAL REFLECTION
DOES SOCIAL PROTEST MAKE A DIFFERENCE?
What is your reaction to the LIVE 8 campaign? Do such social protests really make a difference in the long
term? What are the benefits and limitations of social activism?
 C H A P T E R 4 G L O B A L P U B L I C H E A LT H 77

DISCUSSION QUESTIONS
1 What are some of the major indicators of global 4 What are the benefits and limits of aid in addressing
health inequality? global health inequality?
2 What are some of the underlying causes of world 5 What is medical pluralism? Give examples in your
hunger? answer.
3 Why is aid political? 6 In what ways can CAM assist in addressing health
inequality?

FURTHER INVESTIGATION
1 Consult the further reading and web resources listed below and investigate some of the causes and proposed
solutions to global poverty and hunger. Given the abundance of wealth that exists today, why is there a lack
of substantial progress to address global health inequality?
2 Examine the evidence on progress (or lack thereof) towards the MDGs.
3 Examine the impact of the Paris Declaration on improving the amount and effectiveness of aid.

FURTHER READING
Baggott, R. 2010, Public Health: Policy and Politics, Lappé, F.M. 2008, ‘World hunger: its roots and
2nd edn, Palgrave Macmillan, Cambridge. remedies’, in J. Germov & L. Williams (eds), A
Sociology of Food and Nutrition: The Social Appetite,
Baum, F. 2007, The New Public Health, 3rd edn, Oxford
3rd edn, Oxford University Press, Melbourne,
University Press, Melbourne.
pp. 27–57.
Beaglehole, R. & Bonita, R. (eds) 2009, Global Public
Taylor and Francis Online 2013, Global Public Health:
Health: A New Era, 2nd edn, Oxford University Press,
An International Journal for Research, Policy and
Oxford.
Practice, vol. 8, no. 3: <www.tandfonline.com/toc/
Cockerham, G.B. & Cockerham, W.C. 2010, Health and rgph20/current>.
Globalization, Polity, Cambridge.
Wilkinson, R.G. & Pickett, K. 2009, The Spirit Level:
Commission on the Social Determinants of Health Why More Equal Societies Almost Always Do Better,
(CSDH) 2008, Closing the Gap in a Generation: Health Allen Lane, London.
Equity through Action on the Social Determinants
World Health Organization (WHO) 2012, ‘Global
of Health, Final Report of the Commission on Social
Burden of Disease Study 2010’, The Lancet,
Determinants of Health, World Health Organization
vol. 380, no. 9859: <www.thelancet.com/themed/
(WHO), Geneva: <www.who.int/social_determinants/
global-burden-of-disease>.
thecommission/finalreport/en/index.html>.

WEB RESOURCES
Focus on the Global South: <www.focusweb.org>.
Food and Agriculture Organization of the United Nations (UN): State of Food Insecurity in the World 2012:
<www.fao.org/publications/sofi/en>.

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78 P A R T 2 T H E S O C I A L P R O D U C T I O N A N D D I S T R I B U T I O N O F H E A LT H A N D I L L N E S S

Food First: Institute for Food and Development Policy: <www.foodfirst.org>.

Global Call to Action against Poverty (GCAP): <www.whiteband.org>.
OECD: Aid Effectiveness: Paris Declaration and Accra Agenda for Action: <www.oecd.org/dac/effectiveness/paris
declarationandaccraagendaforaction.htm>.
ONE: Fighting Extreme Poverty: <www.one.org/international>.
United Nations Development Programme (UNDP): Human Development Reports: <http://hdr.undp.org/en/
reports>.
United Nations (UN): The Millennium Development Goals: <www.undp.org/content/undp/en/home/
mdgoverview.html> and <www.un.org/millenniumgoals>.
US Global Health Policy: <http://globalhealth.kff.org>.
World Health Organization (WHO): <www.who.int/en>.
World Health Organization (WHO): The World Health Report: <www.who.int/whr/en>.

DOCUMENTARIES/FILMS
The Global Banquet: Politics of Food (2000): 56 Silent Killer: The Unfinished Campaign against Hunger
minutes. (2005): 60 minutes.
A documentary examining the links between globalisation and A documentary examining the causes of global hunger and
world hunger. effective strategies to combat it. Information, interviews, and
clips available online: <www.silentkillerfilm.org>.
Life and Debt (2001): 86 minutes.
Focusing on Jamaica, this documentary provides a critique of the
impact of assistance from the World Bank and the International
Monetary Fund (IMF). Information available online:
<www.lifeanddebt.org>.

Rx for Survival: A Global Health Challenge (2005): 336

minutes (six parts).
Narrated by actor Brad Pitt and filmed in over 20 countries, this
documentary examines the causes and solutions to global health
problems.

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