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One of my goals as surgeon general is to eliminate health disparities
in the United States. Yet, it is essential that we also play a role in eliminating
global health disparities; that is, inequalities in health status, disease
distribution, and access to services.
The World Health Report 2000—available
at http://www.who.int/whr/2000/— notes that health should
be good (the best it can be) and fair (equitably distributed). When health and health services are unfairly
distributed, regardless of how good they are, we
still face disparities.
What are important areas of health disparities in today's world? The
lowest infant mortality is in Iceland, with 2.6 deaths per 1000 live births.
The highest is in Sierra Leone, with nearly 157 deaths per 1000 live births.
The majority of African countries have high rates; Europe and North America
report low ones. Maternal mortality follows a similar pattern. The chance
of dying from pregnancy-related causes for a woman in the developing world
is 38 times that for a woman in the developed world. Additionally, the developing
world bears 99% of the burden of global maternal deaths.
Ninety percent of malaria deaths occur in Africa and most occur in children
under 5 years old. Of the 5.4 million people who became infected with HIV
last year, 4 million live in sub-Saharan Africa. More people are smoking cigarettes
than ever before—with rates in the developed world decreasing while
rates in the developing world increase rapidly. Mental health problems, particularly
depression, affect growing numbers of people everywhere. A total of 89% of
the world's population lives in developing countries that bear 93% of the
world's disease burden. However, they account for only 11% of the world's
I have three "prescriptions" to eliminate global health disparities.
First, we need to keep doing public health measures, but we need to do them
better. Many of our community-based prevention, care, and treatment programs
are highly effective and help millions of people live healthier lives. We
should support and encourage more such programs.
We are already targeting the people who are affected the most, such
as children, mothers, and people with HIV/AIDS. But, we need to seek out other
vulnerable populations. Millions of people are at increased health risk because
they no longer have access to functioning health care systems. There are nearly
25 million refugees and internally displaced people around the world today.
Because of fear, natural events, and economic oppression, these people are
on the move—without regular health care, current and consistent records
of past encounters with the health care system, or assurance of adequate and
appropriate care at their next stopping place.
In public health we focus on prevention, and the lives and resources
we have saved in this approach are incalculable. But, we have more work to
do. Many injuries, which affect children disproportionately, are preventable.
Seldom does injury control appear on health agendas.
Another important public health focus is the use of data to direct developing
programs and policy. However, we should collect, analyze, and share data in
more systematic ways. The World Health Organization's recent report on health
systems performance grappled with data collection and analysis needs for improvement
of health care systems. All countries need adequate data systems to fully
understand and responsibly manage their health programs.
Second, we should engage in a multisector approach. The strides made
during the past 30 to 40 years through collaboration are tremendous. Yet,
we need to draw other partners more deeply into our work. We should collaborate
with the private sector to create powerful, but appropriate, technologies
for developing countries to use in improving their health care systems.
Computer specialists should be encouraged to develop ways to better
collect, analyze, and disseminate data. Scientists should work toward developing
new vaccines and methods to address drug-resistant microbes. Economists can
show the financial benefits of serving vulnerable populations. Social scientists
should be included in all stages of planning and implementation to help explore
the human side of the problems we face. We also need to increase the participation
of patients. Some global health disparities exist because certain people have
been kept at the margins of participation and power. If we give people a voice,
they will speak.
Third, we must advocate. Advocacy is a simple-sounding solution, but
it is sometimes bitter medicine. We must dare to step inside circles that
are unfamiliar to us as public health leaders. We must advocate for a broader
view than our own borders dictate. We must be willing to argue that public
health should take a higher place on political and budgetary agendas. Earlier
this year, Vice President Al Gore and I went before the UN Security Council
to ask that the HIV/AIDS pandemic be considered a security problem, not just
a health problem—that was effective advocacy.
To eliminate global health disparities, we must communicate well, coordinate
our responses, and truly commit to targeting the world's most vulnerable populations.
With such a strategy, we will, I believe, successfully begin to eliminate
the health disparities that divide our globe today.
Satcher D. Eliminating Global Health Disparities. JAMA. 2000;284(22):2864. doi:10.1001/jama.284.22.2864
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