The quest for healthcare equity and a sustainable future for our species (Part 2)

See Part 1 The cruel loneliness of death in isolation, and the enormous stress on healthcare workers

The Covid-19 pandemic has exposed multiple deficiencies in healthcare systems and in governance worldwide, as well as providing a new focus on suffering and the shame associated with long-neglected discriminatory processes contributing to a wide spectrum of human vulnerability. In addition to radically changing all aspects of our lives today, it is reshaping the future to an undetermined extent. 

Given the precipitousness and magnitude of the impact on the economy and on deeply entrenched lifestyles, many lavish and associated with extreme entitlements, a return to the prior status quo is at worst unlikely, and at best will be long delayed. The “new normal” of our future world remains opaque.

It seems uncontroversial that relationships enduringly lie at the core of our lives and that in health settings, mutually respectful interactions, imbued with compassion, empathy and caring can meet some of the needs of fearful patients and the aspirations of those dedicated to providing humane care in life-threatening situations. 

https://www.dailymaverick.co.za/article/2020-07-15-the-cruel-loneliness-of-death-in-isolation-and-the-enormous-stress-on-healthcare-workers-part-1/

Such relationships, and the efficient functioning of hospitals, require that we recognise that “we are all in this together”. This acknowledgement is clearly based in an ethic of care and embodies the virtues associated with the pursuit of knowledge and excellence in healthcare service. This should be a constant in healthcare and not only highlighted as a need during crises. The challenges to achieving this face healthcare services everywhere and are largely being met admirably during this pandemic, often under most difficult conditions. 

Our major local challenge currently is how to be supportive in sustaining and extending such relationships, with a sense of togetherness throughout the healthcare services countrywide. The example of numerous remarkable civil society projects that were mounted during the lockdown to relieve deprivation and dire hunger, especially among children, hints at some potential for achievement of this goal. However, the almost overwhelming magnitude of challenges for many countries must be acknowledged.

As a nation embedded in a world where the global political economy is exploitative and complex power relations are driven by powerful nations with endless expectations for benefit for themselves, there is limited potential for such caring relationships to be extended to international considerations such as equitable access to vaccines that are in development – although such arrangements are being examined.

A divided country and a divided world

South Africa is a microcosm of an increasingly divided, but interdependent world in which many of the benefits of progress are available to only a minority of people globally while the majority struggle to meet basic needs. It is an uncomfortable and seldom-addressed fact that the economic progress we value is deeply linked to exploitation and domination of people and nature in the pursuit of self-interest, with little thought for others or the future. 

A measure of self-interest is understandable as part of human nature, and complete equality can never be possible. However, self-interest becomes grotesque when power is unfairly wielded and corruption at many levels, not least in government, contributes to egregiously wide national and global disparities (in health, wealth and human rights), to social turmoil and to destruction of the natural environment on which we are all deeply dependent. 

The causal forces of this predicament are linked to a global political economy that is increasingly openly acknowledged as fraudulent, corrupt and dysfunctional. It is driven by greed, and a now recognisably obsolete and unethical ideology, with a short-term view that seeks accelerating consumption in the relentless pursuit of economic growth and profit, and little concern for the implications for billions of people and the biosphere. 

The 2008 financial debacle revealed the fragility of even powerful economies, and showed how current policies impair provision of common goods essential for human flourishing. Looming “tipping points” have long portended dire implications for health globally, although at different speeds and with varied distribution of effects in different regions and across socio-economic groups. 

Arising in the context of long-neglected pervasive threats to global health, the Covid-19 pandemic is a major tipping point in an increasingly unstable world. It will have extraordinarily severe short- and long-term adverse effects that will recur and intensify for as long as we cling to old ways of thinking and acting. 

We are thus starkly reminded that, despite major advances in science, healthcare, population health and longevity since the enlightenment, and all the promises of biotechnology and artificial intelligence, our health and the long-term survival of our species are now more than ever dependent on our interconnectedness. 

Healthcare systems and their evolution 

Improvement in the social conditions of life that so powerfully influence health, together with impressive advances in science and technology and their application to medical practice over the past 60 years, have increased lifespans and greatly improved the quality of life. Regrettably, these advantages have accrued optimally to a minority (less than 30%) of both South Africa’s and the world’s populations. 

Pervasive global disparities in health and human rights that were becoming well-recognised more than two decades ago have not been ameliorated. Their persistence is illustrated by the 2015 maternal mortality rates, which ranged from seven per 100,000 pregnancies in Canada to 134 in South Africa, 789 in southern Sudan and 1,360 in Sierra Leone. Many other health statistics reveal similar disparities. These disparities are in part explained by the persistence of poverty and severely deprived living conditions for billions of people and the social structures that sustain this divide. 

With regard to healthcare, explanations can also be linked to the outcome of healthcare system reform globally that over the past 40 years has been shaped by a dialectic between opposing ideological forces, with one ideology trumping the other. At the end of World War II, Keynesian economics-inspired mechanisms in such social democracies as the United Kingdom and many countries in Europe facilitated the rebuilding of war-torn societies. National health goals were broadly guided by a primary-healthcare approach that embraced wide co-operation through shared principles of solidarity and community, with the intention of ultimately achieving greater equity in access to sophisticated healthcare. National Health systems in the UK, Europe and elsewhere confirmed the ability to achieve these goals and continue to be functional.

Since the 1980s, however, such socially supportive forces driving healthcare have been incrementally eroded by the ideology of a neoliberal global political-economic system and the implementation of market forces and market values to achieve today’s market civilisation. These forces favoured competition over co-operation and encouraged privatised services that were oriented towards expanding productivity and consumer choices. Access to healthcare was increasingly determined by free-market principles as the perceived route to optimal progress. Such neoliberal economic policies exacerbated disparities in wealth and health, and contributed to undermining the goals of medicine and healthcare as a social good. 

Attempts to compensate through philanthropic endeavours, for example, in the funding of anti-retroviral medications for a large HIV-infected population that have made a major impact on narrowing health disparities, are necessary, but can never be sufficient.

These global trends are reflected in South Africa, where significant advances in reversing apartheid conditions were made through the removal of previous discriminatory policies and a shift to a constitutional democracy. However, increasingly embedded corruption and associated macro-economic policies have impeded enhanced achievement of social justice by allowing inter-alia, the public health system to wither and the private health system to flourish. 

Threats to healthcare professionalism

In recent years there has been growing global concern that professional ideals and the goals of medical practice are being diluted within a powerful commodification model of healthcare that is not conducive to the provision of equitable healthcare. The erosion of public services is in part accounted for by tensions associated with a changing balance between two powerful drivers of human behaviour: market values and the bureaucracy of healthcare on the one hand, and the less powerful driving force of professionalism on the other. 

This changing balance is having adverse impacts on medical practice and physician morale in both the private and public health sectors. Inadequate development of well-staffed, well-equipped and well-funded public hospitals alongside the expansion of private hospitals and the pharmaceutical industry have been powerfully led by the US. South Africa and many other countries have been co-opted into this process. Under these circumstances, and despite the best intentions of many healthcare professionals to sustain the highest ideals, healthcare has become primarily a profitable enterprise, entrenching the market model of healthcare through an incremental emphasis on the quest for profitable drugs and financial success for investors in healthcare facilities. 

Powerful adverse effects on medical practice and on the independence of private healthcare professionals are aggravated by the expansion of a medical bureaucracy that imposes excessive executive and managerial control over health professionals. Administrative “creep” is ubiquitous, and in the US has resulted in a 3,200% increase in the number of healthcare administrators between 1975 and 2010, with about 10 administrators for every doctor.

Many health professionals who work with dedication in public and private medicine are thus pressured by both market and administrative forces to embrace corporate imperatives. Burnout, one of the potentially serious consequences of these powerful forces that erode professional values and public commitment while reducing professional satisfaction, is increasing. Burnout in the US, with its strong market orientation, has led to many suicides among physicians and is understood as symptomatic of a broken healthcare system in which the complex web of commercialised provider facilities may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience.

Implications for the future of health and healthcare

The future remains unclear, but in the post-Covid-19 world, medical education and practice will likely be very different from what was optimistically anticipated by many in recent decades. Ongoing exciting progress in designing personalised treatments based on the potential of biotechnology and other advances during the Fourth Industrial Revolution are unlikely to be applied widely. The costs of such treatments is increasing and will face a reality check in markedly shrunken economies, even in wealthy countries. Research that could extend the boundaries of knowledge and improve medical practices is also likely to be curtailed.

Wide disparities in health and in access to healthcare will be even more difficult to rectify in the wake of a pandemic that has caused such serious damage to the economy. The notion of universal access to healthcare, promoted by the World Health Organisation (WHO), has become more largely rhetorical. With 70% of the world’s population living on less than $10 a day and 50% on less than $4 a day, credibility for the WHO requires that it should describe the levels of universal access that could be achieved within specified time frames and the required strategies to do so. 

Regrettably, South Africa’s economy has deteriorated in recent decades, with the government debt-to-GDP ratio rising to more than 80%. Mismanagement and State Capture of our economy alongside pervasive corruption have led to the unaccounted for “disappearance” of billions of rands. This, with the estimated loss of R285-billion in tax revenue during South Africa’s extended lockdown (an amount that is more than the R200-billion 2020/21 annual budget for healthcare in the public sector) threatens to cause the total collapse of our economy, making the successful achievement of equitable healthcare goals much more difficult and probably impossible.

It has also long been clear that threats to billions of marginalised people can only be addressed by acknowledging that the long-term self-interest of all would be optimised through the pursuit of policies that foster global human well-being and protect our ecological environment. Despite this knowledge and the increasing tide of emerging new zoonotic diseases over recent decades – HIV, SARS, MERS, Ebola, Zika and others – intimately related to the cruel treatment of animals, and other disturbances to our ecosystem, nothing has been done to prevent the predictable emergence of a Covid-19-like pandemic or to implement well-conceived pandemic planning capable of reducing the impact of such an eventuality. 

Global implications

By the late 20th century it was clear that aberrations of human behaviour were leading to tipping points that if reached would jeopardise health globally through increasing poverty and deprivation, continuing conflict, escalating mass migration from war-torn and poor countries to rich countries, the spread of new and recrudescing infectious diseases, climate change and ecological damage. This would harm all, individually and the world collectively, as well as reducing biodiversity and endangering the long-term survival of our species. 

It was also understood then that failure to respond to such challenges could only increase global/planetary dysfunctionality. Awareness was growing that this was not a tenable prospect and that global challenges at the millennium’s end called for deep introspection by those privileged to benefit from scientific and economic progress. The implications of the limited progress for the marginalised majority raises additional levels of complexity for humanitarian activities .

It is clear that our predicament is related to an excessively competitive global paradigm in which institutional and international relationships are characterised by exclusion, confrontation, domination and enmity, with power being used to maintain superiority through coercion. Added to this are conceptions of security based on an obsession with deterrence, coercion and narrow national interests by demagogic leaders. Why else would we have allocated such massive resources to militarisation including to creating a vast stockpile of nuclear weapons with the combined capability of destroying over 100 planet Earths? 

What should be done?

With increasing acknowledgment that as a global community we are destroying the natural environment on which human health and life are critically dependent, there is some hope that sufficient existential angst might generate constructive global health responses. However, given the nature of the entrenched dogma of the global political economy, shortcomings in global governance and current geopolitical complexities, a shift towards a new paradigm would require changes in the global state of mind and co-operation on an unprecedented scale. Our focus would need to shift from an entirely anthropocentric to an ecological perspective. National and international relationships would also have to be transformed towards inclusiveness; through peaceful engagement through compromise; multilateral, magnanimous co-operation; and new attitudes to power that would foster a long-term, more embracing state of global human security. 

While this ambitious goal is probably beyond our reach, this should not deter us from attempting to use our remarkable human capacities to embark on new, socially innovative activities. If inspiration by transdisciplinary integration of ideas and research by the world’s best intellectual and imaginative minds were to be linked to effective economic and political agency with honest and wise leadership and community spirit, it might be possible to catalyse a peaceful, ecologically safe trajectory towards a more sustainable future with progressive reduction of global inequities in wealth and health. 

Meanwhile, we should retain a commitment to excellence in the technical and humanistic skills in caring for patients as unique individuals at the heart of healthcare services, while extending our national societal obligations to narrowing health disparities through improving the local social determinants of health. It is to be hoped that greater co-operation in reversing the structural fault lines in our society might inspire action towards some essential global changes. After all, we are all in this together. DM

Solomon Benatar, Emeritus Professor of Medicine, University of Cape Town. Adjunct Professor, Dalla Lana School of Public Health, University of Toronto.