Moral Imagination: The Missing Component in Global Health

DOI: 10.1371/journal.pmed.0020400.g001 Moral Imagination: The Missing Component in Global Health Solomon R. Benatar 0 0 Solomon R. Benatar is Professor of Medicine and Director of the Bioethics Centre, University of Cape Town , Cape Town , South Africa , and Visiting Professor in Medicine and Public Health Sciences at the University of Toronto , Toronto, Ontario , Canada Citation: Benatar SR (2005) Moral imagination:The missing component in global health. PLoS Med 2(12): e400. - Thealth and the failure to he deplorable state of global improve this state have been debated extensively. Recent editorials in the Lancet in relation to the failure of Roll Back Malaria and the potential failure of the 3 by 5 programme [1,2] illustrate how disappointment, surprise, and admonitions about such failures are usually followed by optimism about the success envisaged from future efforts [1,3]. There are several possible reasons for our failure to make adequate progress in improving global health. First, it seems that there is generally more interest in doing research to acquire new knowledge than in using existing knowledge, unless it is commercially profitableillustrating how market forces are a more powerful influence on the practice of medicine than health needs [4]. Second, concern for those who are most severely affected by ill health seems to be generally transient, perhaps because they are anonymous and out of sight, but maybe also because their lives are less highly valued [5,6]. Third, there is a tendency to focus on new technologies through silo (narrowly contained) approaches to improving global health [79]. Fourth, there is insufficient attention to the social determinants of health [10,11]. Finally, while many are concerned about the plight of others, collective action through nongovernmental organisations can only achieve limited results, and there is reluctance to acknowledge and more explicitly address the indirect, causal, complex global system forces that underlie poverty and many fatal diseases [5,11 15]. Fortunately, there is now growing recognition that new infectious diseases pose a major threat to human health and security worldwide [16,17], and that imaginative new solutions are The Essay section contains opinion pieces on topics of broad interest to a general medical audience. Global distribution of wealth (Figure adapted from [68]) needed to improve global health [18,19]. While it is entirely appropriate to consider scientific and technological advances and economic growth as necessary for social progress, it is arguable that these will not be sufficient to ensure movement towards a more just world in which the health of whole populations could be improved. The controversy about globalisation versus antiglobalisation will not be revisited here, except to say that the debate should rather be about how globalisation can be modified to extend the benefits of progress more widely [20,21]. In this essay, I begin by suggesting that achieving substantial improvements in global health will depend on acknowledging that poor health at the level of whole populations reflects systemic dysfunction in a complex world. I then address why development aid is a necessary but not a sufficient solution for improving global health. I conclude with the idea that greater moral imagination (the ability of individuals and communities to empathise with others) and innovative 21st century approaches Copyright: 2005 Solomon R. Benatar.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Competing Interests: BSR is on the editorial board of PLoS Medicine. He declares that he has no competing interests. are required to break the impasse we currently face in improving global health. In the domain of economics, there is a disjunction between massive economic growth over the past 50 years and fair distribution of new wealth [22]. The global economy has increased 7-fold since 1950, yet the disparity in per capita gross domestic product between the 20 richest and the 20 poorest nations has more than doubled between 1960 and 1995 [23]. As a result, there are ever-widening disparities between rich and poor (Figures 1 and 2), and almost half the worlds population lives on less than US$2 per day [24]. Disproportionate pursuit of short-term self-interest, fostered by market fundamentalism, emphasises production of goods for consumption by individuals, corporations, and governments, while long-term interests and the production of public goods for whole populations are undervalued [25]. Economic stability is threatened when aggregate economic growth is valued as an end in itself rather than as a means to improving human lives, and consequently, there is a failure to achieve a more just distribution of economic and social benefits [26]. Economic dysfunction persists when conventional economic theory continues to be revered and applied despite its many failures [2629], and thus reduces the potential for improving global health and increasing human security worldwide [30]. In the domain of political and social life, instability is revealed by ongoing wars, ethnic conflict, fundamentalist attitudes, failed responses to genocide in many countries, large-scale disruption of communities, refugeeism, terrorism, fragmentation of health services, and attrition of public healthcare servicesall reflecting a lack of global leadership and a failure to achieve basic human rights for more people in the world [5,13,14,26,30,31]. Moreover, the full potential of the human rights approach is greatly diminished by a predominant focus on civil and political rights. Insufficient attention is paid to the social, cultural, and economic rights that are essential for human flourishing, and which are part of the indivisible human rights package described in the Universal Declaration of Human Rights, which most human rights activists use as their source of authority. It seems that higher value is placed on the rights and lives of those with resources than on the common good and the lives of the poor, and inadequate attention is given to identifying and motivating those who have duties to uphold a broad spectrum of rights [32,33]. These shortcomings, together with ecological instability from environmental degradation, global warming, and ongoing loss of biodiversity, arguably facilitate the creation of niches for the emergence and propagation of new infectious diseases, promote the development of multidrug resistance [34], and make it more difficult to maintain the social structures required to provide care and support for so many in need [35]. Development Aid: A Necessary but Insufficient Solution Greenwoods call for increased development aid to provide the US$2 US$5 needed for each year of life that could be saved through an eff (...truncated)