The Perspective of Socioeconomic Inequalities and Infectious Disease in 21st Century

At the turn of the new century, the United Nations set a series of global health goals to be achieved by 2015. Amongst the eight Millennium Development Goals (MDGs), goal six aimed to combat HIV, malaria and other diseases [1]. Whilst progress has been made towards addressing MDG 6, improvement has been slower than anticipated and both communicable and non-communicable diseases have risen to prominence in the minds of health planners in the last few years. In recent times, attention has been focused on addressing non-communicable diseases, as statistics indicate they are the major threats to health. However, the notion that infectious diseases could be eradicated, which came to prominence in the 1960s and 70s, has proven to be false and the need to address the growing threat from infectious diseases has become clear. Since the turn of the century it has become apparent that we are losing the fight against infectious diseases, and many of the diseases we thought under control are now a threat once again. Additionally, several new forms of infectious disease have been recorded, many of which threaten human health as we have little or no resistance towards them [2].

The greatest advances in the health of people have come from equitable access to basic essential resources such as clean air, soil and housing, clean water and nutritious food [3]. Environmental and economic factors, such as global warming, are creating shortages in essential resources and leading to increased human habitation in urban areas. Similarly, war and civil unrest have led to mass migration. Urban living especially for socially disadvantaged groups creates the conditions in which infectious diseases can thrive, adapt and spread quickly [4]. Infectious diseases do not recognize borders, and increased speed of travel and the reduction in restrictions on travel have heightened the possibility of pandemics [2]. Changes in animal husbandry have led to the emergence of new infectious diseases as microorganisms have the ability to adapt to environmental changes quicker than humans do. Antimicrobial resistance to drugs is on the rise, the supply of antimicrobials is reducing and the effectiveness of those we have is on the decline; traditional health care with its reliance on the biomedical model therefore faces an imminent crisis. It is becoming apparent that the biomedical approach to health care has run its course, and that new and sustainable models of health care require development [5]. Furthermore, advances in vaccination and medical treatments translate into a bigger pool of older individuals who are increasingly susceptible. The predominantly biomedical approach to health care, which has led to significant improvements in health for many, is a double edged sword as it has created large sections of society who are vulnerable both to health care and from a lack of access to health care commodities [5].

Humans are becoming increasingly vulnerable to natural and socially constructed environments, and perceptions of vulnerability are traditionally discussed within the concept of health inequalities. According to Davies [5] health inequalities refers to the idea that individuals, groups, regions, nations or geographical areas are exposed to a range of socially constructed differences in health experience and health status; the individuals and groups who suffer from health inequalities suffer a deficit both in comparison with better-off groups and in comparison with the life that they might have lived under more favorable constructions [5]. In terms of morbidity and mortality there is a clear disparity between rich and poor people and rich and poor countries [2]. However, in her address to the World Health Summit in October 2015, Dr. Margaret Chan indicated that emerging threats to health are changing our understanding of health inequalities [3]. No longer can we think of health inequalities as the differences between rich and poor, developed and developing countries, etc. Events such as the Ebola and Syrian refugee crises demonstrate that health inequalities are now a global phenomenon. Increasing global interdependence means that the re-emergence of infectious diseases needs to be dealt with in a coordinated manner. No longer is it simply individuals and communities who are vulnerable to the re-emergence of infectious diseases; it is also nation states. However, sovereign states no longer have the capability to protect themselves from the growing risks to health [3]. The imperative therefore must be to build sustainable and robust health care systems across the globe for the betterment of all. In seeking to highlight the changing nature of vulnerability Chan [3] asks us to consider that today 70% of the world’s socially deprived live in middle-income countries. Schlipköter and Flahault [6] indicate that within these countries the leading causes of death are lower respiratory infections, diarrheal diseases, tuberculosis and malaria. They go on to point out that in low income countries the major threats to health remain infectious diseases, and in particular vaccine preventable deaths in the young. Chan [3] is clearly indicating that within the modern interdependent world there is an economic, ethical and protective necessity to introduce universal health coverage and to focus on proven public health measures.

Karanikolos et al. [7] identify that the global economic recession has meant that most governments, rather than look outwards towards global health sustainability, universal provision and the implementation of public health systems based on addressing the determinants of health, have introduced budgetary constraints on health systems; and that these restrictions have led to increasing health inequalities due to the reduction of provision or removal of universal health systems. As this has happened in conjunction with the drive for neoliberal governance based on the principles of stewardship, then at a time when health systems need to be supportive, robust and sustainable, large sections of the world’s population have seen reductions in health care provision. Within the stewardship approach to health care, governments seek to transfer the cost of health care from health systems to individuals and households [7]. Concepts such as increasing personal responsibility for health, increasing autonomy, increasing choice and victim blaming for poor health choices are commonplace, and should be rejected by those who support the public health agenda [8]. However, at a time when advocates for public health should be voicing their concerns stridently, there has been an absence of a coordinated response, leaving those who are vulnerable without a voice.

It is well established that sociological and psychological responses to increased stressors, such as a lack of resources, lead to poor personal health choices and so-called irresponsible behavior by those who are vulnerable [8]. The recent economic crisis has been used as an excuse to shift responsibility of population health and wellbeing to individual. This reflected in heavy slicing of health care expenditure and shifting of focus from population health to treating the outcomes of poor health choices, which those in the socially disadvantaged groups tend to adopt to cope with the reduction in their basic resources for living. A self-defeating cycle is created in which the maladies of the developed world become the focus of research and expenditure: for example, whilst anti-depressant research thrives, research into treatments for non-communicable and the emerging and returning infectious diseases remains static. At the recent World Health Summit, Chan indicated that this practice could no longer continue. One positive element of the MDGs is that evidence is emerging that coordinated action can lead to sustainable improvements in health. It is clear that health systems alone can no longer address the complex environmental, social and biological threats to health. The biomedical model, with its over-reliance on the preventative medicines approach, is slowly being replaced by a multidisciplinary approach in which all sections of the environment are addressed in an attempt to improve health. Addressing the determinants of health requires a multidisciplinary approach and the development of a public health infrastructure. Dr. Chan’s keynote address is noteworthy as it shows that the conceptual infrastructure for a public health approach to the complex global health issues facing us today is at last taking shape [3].