Global Policy Forum

Uwe Bott

Many people in Latin America — and around the developing world — cannot afford medicines to treat infectious diseases. They also continue to lack the infrastructure to provide the most basic medical treatment.

Inadequate infrastructure

Lest one considers this to be a problem solely of the developing countries, it should be recognized that the United States, too, is dealing with its own health care crisis. For all its riches, 41 million Americans are still without health insurance. And even though the U.S. House of Representatives and the U.S. Senate are competing these days over providing a prescription drug benefit for the nation's elderly, it is unclear whether the money will be there in the future to pay for this new benefit.

In addition, in light of the difficult economic environment, U.S. corporations — which provide group health coverage to their employees — increasingly limit access to health insurance. Instead, they ask their employees to rely on the "invisible hand" and allow the free-market to take care of health care.

Exponential costs

And lest one thought that America's health care crisis is unique in the industrialized world, it ought to be noted that countries which recognized decades ago that health care was a social responsibility, are faced with their own dilemmas.

Their universal health care systems are overwhelmed by exploding costs and demographic trends that seriously put into doubt their long-term financial viability. The chart below shows the demographic challenges of three selected economies by the year 2025, compared to their historical data in 2000.

Infectious problems

Over the next 2 decades, the U.S. population will be ageing, but its situation pales in comparison to that of Germany and Japan.

In the latter case, the relationship between Japan's economically active people and those over the age of 65 will have fallen to just over a ratio of 2:1. The numbers are not much better for most of Western Europe (based on data from the U.S. Census Bureau).

These frightening statistics are leading to intense debates around the world. The respective points of departure, however, are slightly different. Many developing countries are engaged in a struggle of national survival as vast portions of their populations are inflicted with infectious diseases, especially HIV/AIDS.

A scarce commodity?

Meanwhile, Japan's system of socialized medicine has contained costs, but at a heavy price. For example, 26,200 patients in the United States were reported to have received implantable defibrillators in 1996 — compared to only 100 in Japan. In most of Europe, it has become clear that health care is a scarce commodity and that blanket coverage will bankrupt the system.

Staggering consequences

In the United States, two government-sponsored programs — Medicare for the elderly and Medicaid for the poorest of the poor — are facing the same fate. But America is also staring at the immediate — albeit chronic — condition that 15% of its people, surprisingly many of them in the middle class, are indeed uninsured. The main reason is that their employers simply cannot afford the staggering costs of group health insurance.

The severity of this global crisis opens the door to proposals that are on the fringe of lunacy. In the spring of 2003, Germany for example was engulfed in public uproar over a study by two university professors.

Germany's desperate proposal

They recommended that medical treatment for German citizens over the age of 75 should be limited to pain relief — and should not involve expensive life-saving or life-extending measures.

It did not help that one of the authors of the study teaches catholic theology at the University of Bochum. Given Germany's history of genocide, the study caused an almost physical revulsion throughout all political parties in the country.

Voluntary euthanasia

As reprehensible as the proposal was, it highlighted the desperate state of health care in Germany. After all, the idea was not a new one — and not one to be described as "typically" German.

Former Colorado Governor Richard Lamm stated as far back as 1984: "We've got a duty to die and get out of the way with all of our machines and artificial hearts — and everything else like that and let the other society, our kids, build a reasonable life".

In 1996, the same Richard Lamm challenged Ross Perot for the Reform Party nomination for President of the United States. Nearly 20 years later, Governor Lamm's recommendation of voluntary euthanasia still has its defenders, such as John Kane, former Chief Operating Officer of Cardinal Health, who — in a public speech in 2002 — suggested that Governor Lamm "was exactly correct in his diagnosis."

Global health — too complex to cure?

As these dramatic, if not offensive, proposals indicate, the issues at stake in the global health care crisis are complex and intertwined — and they are country-specific.

Yet, we may make some generalizations: First, it should be acknowledged that health care is a public good. All citizens have a fundamental right to health care. Health care must have the same priority as national security.

Just say no — to free markets

Second, the free market does not sufficiently or effectively provide our citizens — and citizens around the world — with the means and tools to be as healthy as they can be. The first two points, therefore, lead to the third: Government must intervene.

Fourth, health care is a public, yet also scarce, good. And fifth, this should lead us to publicly guaranteed minimum standards of health care. But it cannot lead to blanket subsidies that will fully cover the most advanced technologies in all cases. Cost-control mechanisms — both private and public sector-based — must be deployed.

In practice, this means that we must find ways to subsidize medicines in the developing countries in order to make them affordable to the sick, if for nothing else than to prevent the spread of infectious disease.

Prevention pays

Viruses don't stop at borders, as the recent SARS health scare has demonstrated. Developing countries must be enabled to provide for the human and physical infrastructure to allow for basic medical treatment.

The costs of these efforts are manageable, especially because self-supporting systems in most of these countries are favored by very advantageous population pyramids.

Reassuring amendments

Western Europe, meanwhile, has to find ways to amend its systems without destroying them.

The United States, for the benefit of its poor, must eliminate the stigma of having a large chunk of its people uninsured, and many underinsured. That is a stigma no decent country can desire to carry.

Maybe "Health for All" is too aspiring and unrealistic, but we surely can do better than Admiral James Stockdale, Ross Perot's running mate in the presidential elections of 1992, who famously stated, when asked about his position on health care: "I'm out of ammunition on this."

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