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From the Surgeon General
December 13, 2000

Eliminating Global Health Disparities

JAMA. 2000;284(22):2864. doi:10.1001/jama.284.22.2864

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 health spending.

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.

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