Holloway D. Self-interest as motivation for international cooperation toward universal healthcare. Harvard Public Health Review. Spring 2015;5.
According to the World Health Organization, over a billion people lack the healthcare they need, and medical costs drive 150 million people below the poverty line every year. [1. WHO. WHO | Universal Health Coverage (UHC). Fact sheet N°395. September 2014.] In a world where annual GDP tops $500 trillion [2. World Bank. World Development Indicators 2014. (2014). doi:1d0.1596/978- 1-4648-0163-1.], raw financial resources are not the limiting factor for providing universal healthcare (UHC) [3. UHC is defined here as consisting of only a basic level of care, including emergency services, vaccination, access to medicines for both communicable and non-communicable diseases, and access to necessary surgical procedures. For the purposes of this piece, this overarching concept is considered more important than specifics of a particular care package.]: the problem is one of international priority setting and political will. For governments to unite in the common cause of bringing healthcare to all those who need it, citizens and politicians must be convinced that international cooperation for health has more than moral value: it is in everyone’s self-interest.
People as individuals have varying moral justifications to support UHC, but norms around morality are difficult to harmonize across the borders of culture, religion, ethnicity, tribe, and nation state. Without such harmonization, delivering healthcare to the world’s poor is fraught with controversy about its priority, purpose, and merit. In his landmark book, Diplomacy, Henry Kissinger noted that “[n]ations have pursued self-interest more frequently than high-minded principle”, and “[t]here is little evidence to suggest that this… is likely to change in the decades ahead.” [4. Kissinger, H. Diplomacy. 912 (Simon and Schuster, 1994).] Following these ideas, I discuss three reasons, based on self-interest alone, to support the spread of UHC [1.WHO. WHO | Universal Health Coverage (UHC). Fact sheet N°395. September 2014.] to low and middle-income countries.
Social Contract Theory Supports Universal Healthcare
A leading theory in western political thought for the past forty years is John Rawls’ Justice as Fairness. [5. Rawls, J. Justice as Fairness: A Restatement. 214 (Harvard University Press, 2001).] [6. Rawls, J. A theory of justice. 538 (Belknap Press of Harvard University Press, 1999).] Rawls’ theory re-imagines the nation state as founded upon the idea of a social contract, and therefore based on the self-interest of its participants. Rawls saw society as a “fair system of cooperation,”6 but he understood that parties to a contract would be biased according to their political influence, socioeconomic status, religious affiliation, or ethnic background. To guarantee fairness, Rawls invented “the veil of ignorance” as a philosophical tool to shield hypothetical negotiating parties from knowledge of their particular interests, gender, race, and other characteristics. He reasoned that parties behind the veil of ignorance, negotiating to establish the founding principles of society, would choose only those principles that protect all citizens’ basic freedoms and promote a fair distribution of public goods.
Rawls’ ideas in Justice dealt only with the organization of society within the boundaries of a state. In 1999, however, he extended those concepts to international relations in The Law of Peoples.6 The expanded theory recognizes the normative force and practical reality of nation state boundaries, and seeks to establish guiding principles that a diverse collection of societies “would accept as fair in specifying the basic terms of cooperation among peoples.”[7. Rawls, J. The Law of Peoples: With, The Idea of Public Reason Revisited. 199 (Harvard University Press, 2001). at .] He again used the veil of ignorance as an analytic tool to understand what these peoples would agree to if they had no information about their specific national interests (such as GDP, geography, religious majorities, etc.). Rawls articulated a set of principles that could be used as a starting point for more comprehensive international guidelines.
Justice as Fairness could now describe the basic contract of society, and extend from the state to the international level. However, Rawls said very little about healthcare as a social institution. This omission was taken up by Norman Daniels, who argued that healthcare has a special place in justice. “The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly[sic] the distribution of health-care services.”[8. Daniels, N. Just Health: Meeting Health Needs Fairly. 0, 397 (Cambridge University Press, 2007).] Daniels effectively expanded Rawls’ theory to include healthcare as a condition for the implementation of basic justice within a state.
Taken together, these ideas form a philosophical basis for a kind of cooperative UHC that applies internationally. Two of the principles that Rawls originally described in the Law of Peoples have very strong health implications: “People are to honor human rights,” and “[p]eoples have a duty to assist other peoples living under unfavorable conditions that prevent their having a just or decent political and social regime.”8 If we combine these ideas with Daniels’ argument that justice encompasses health, it follows that our duty of assistance to others includes assisting with the establishment of the systems of governance necessary to support an adequate universal healthcare system. This is to everyone’s benefit because it is part of the basic fabric of international cooperation. It also adds weight to the idea that we have a collective duty to assist those living under unfavorable conditions because such assistance is what justice would provide to us if we were in similar circumstances.
Controlling Communicable Disease is a Health and Security Priority
Assuming a foreign policy guided by self-interest, deciding to assist other nations in fighting disease can be a matter of debate. However, the immediate risk posed by acute, communicable diseases (CDs) makes cross-border aid and cooperation worthwhile undertakings. The spread of HIV and multidrug-resistant TB are powerful reminders that CDs travel easily across borders and require a global response.
Infectious diseases, through their lethality and rapid spread, can transcend the label of health risk to precipitate acute crises of national security. The ongoing Ebola outbreak in West Africa underscores this point. Global coordination is needed not only to help local populations, but also to prevent the international spread of disease [9. WHO Ebola Response Team. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections. N. Engl. J. Med. 371, 1481–1495 (2014).] and maintain regional stability. President Obama voiced these ideas in his address last year to the Global Health Security Agenda Summit at the White House when he noted that the Ebola outbreak was not just a human disaster, but a U.S. national security issue. He highlighted self-interest as an important factor, saying: “[i]t is our moral obligation and it is in our national self-interests to see this work through, to help them, to help ourselves.” [10. Obama, B. Remarks by the President at Global Health Security Agenda Summit | The White House. White House Office of the Press Secretary (2014).]
To limit the risks of CDs, it is critical to develop international capacity to detect and respond to disease, especially in countries that lack adequate capabilities and hold major population centers or transportation hubs. [11. Katz, R., Sorrell, E. M., Kornblet, S. A. & Fischer, J. E. Global health security agenda and the international health regulations: moving forward. Biosecur. Bioterror. 12, 231–8 (2014).] [12. Marinissen, M. J., Barna, L., Meyers, M. & Sherman, S. E. Strengthening global health security by developing capacities to deploy medical countermeasures internationally. Biosecur. Bioterror. 12, 284–91 (2014).] [13. Hickey, J., Gagnon, A. J. & Jitthai, N. Pandemic preparedness: perceptions of vulnerable migrants in Thailand towards WHO-recommended non-pharmaceutical interventions: a cross-sectional study. BMC Public Health 14, 665 (2014).] Creating such capabilities in less developed countries can only be accomplished within a larger effort to bolster struggling health systems. When such serious health and security threats are possible and the solutions so well understood, we should all be motivated to provide assistance to countries with challenged health systems. Doing so will make it possible to detect, treat, and contain infectious diseases wherever they arise.
Advancing Universal Healthcare is Good Economic Policy
While communicable disease may pose a rare existential risk, non-communicable and behaviorally driven diseases have deep and growing economic costs, many of which are avertable with modern care. A recent report by the World Economic Forum and the Harvard School of Public Health noted that, with respect to major non-communicable diseases, “macroeconomic simulations suggest a cumulative output loss of $47 trillion over the next two decades.” [14. Bloom, D. E. et al. The Global Economic Burden of Noncommunicable Diseases. PGDA Work. Pap. (2012).] This staggering figure makes obvious the need for effective interventions to treat non-communicable disease.
However, the world’s stake in public health goes beyond the basic management and prevention of disease. Universal care, including maternal care, childcare, family planning, and educational initiatives are critical for maximizing health and productivity. The economic impact of health can be seen in historical observations of the demographic transition. The demographic transition is a phenomenon that occurs as the death rate in a country declines while a correlated decline in birth rate lags behind by several years. The result is a population boomlet that produces a burst of productive activity known as the demographic dividend, when the ratio of working age adults to non-working dependents increases. The demographic transition can establish a new middle class to buoy the world economy via consumption, creativity, trade, and travel. However, these associated benefits are not guaranteed, and rather depend upon the policies in place at the governmental level, including improved access to health care, family planning, adequate schools, and supportive economic policies. [15. Canning, D. The causes and consequences of demographic transition. Popul. Stud. (NY). 65, 353–61 (2011).][16. Bloom, D., Canning, D. & Sevilla, J. The Demographic Dividend – A New Perspective on the Economic Consequences of Population Change. 126 (2003).]
The demographic transition and subsequent dividend have been realized in many Western countries, many of which have universal (or near universal) healthcare. In the future, a critical question will be whether South Asian and African countries can take advantage of their own transitions. Adequate care is central to helping African and South Asian countries to accelerate and capitalize on their demographic transitions. As noted above, the economic case for UHC is clear. Rich countries should be motivated to provide help in order to partake in the vast economic expansion that is possible in underdeveloped nations and also because of their obligations in the international order. Because such a wealth expansion cannot take place without significant efforts to curb the rising tide of non-communicable and chronic disease, early efforts must be focused on building sustainable health systems that can meet this challenge.
World communities have a fundamental obligation to assist each other to develop the governance structures needed to implement UHC. This obligation, grounded in self-interest, is articulated by modern theories of the social contract as proposed by John Rawls and expanded by Norman Daniels. Beyond obligation, the dangerous spread of pathogens and the enormous economic burden of disease should provide ample inducement for nations to cooperate to create systems that establish and support robust universal healthcare. Furthermore, the enormous economic potential of a rising Africa and Asia is a tangible incentive to align the interests of world governments in favor of the universal health policies necessary to take advantage of the demographic transition in those emerging economies. Armed with moral force, justice theory, and a strong economic incentive, there is a convincing basis for persuading wealthy nations to act in support of universal health care, and the WHO should retain UHC as a central element of the Sustainable Development Goals as they are finalized in the coming year.