Saturday, October 1 2022

The problems associated with some forms of inequity are easier to understand than others. Unequal access to health care or food, for example, clearly harms everyone’s well-being, satisfaction and productivity.

The problem with some other forms of inequity, however, is less clear. For example, not all individuals can have the same “opportunities”.

My colleagues and I were intrigued by the apparent link between income inequality and health. In particular, we were intrigued by the affirmation that income inequality was strongly associated with well-being and stress. Why would knowing that a small proportion of people have ridiculously high incomes necessarily affect someone’s well-being? We wanted answers to the questions of why income inequality is a problem and why it’s been so hard to fix.

To answer these questions, we undertook an extensive search of the published literature. We studied the publications of leading authorities in the field of health inequity and reviewed the sources they had referenced.

One of our first discoveries was the caveats that apply to the apparent link between income inequality and people’s health and happiness. For example, the research behind this link applies only to wealthier countries. In the poorest countries, economic development matters more for well-being than the gap between those who have the most money and those who have the least.

We haven’t started our investigation to find out where income inequality might have the greatest relevance. But our results suggest that income inequality may have limited relevance in African contexts. What might, perhaps, be more important for well-being is the ability to contribute to decisions about how to live in a social group. Therefore, political, economic and governance structures could be more important than income inequality.

Investigate inequalities

We fell on frequent references to concepts such as self-determination, freedom, ability, agency and opportunity. Michael Marmot, professor of epidemiology and public health, is a leading this zone. For example, he writes about the freedom to be and to do. He suggests that it’s not so much how much money you have “but what you can do with what you have” that is important for your health. Joseph Stiglitz, American economist and public policy analyst, propose that dawning iniquity is one side of a coin with shrinking opportunity on the other side.

A recent review historical origins of inequity suggest that the fundamental question is not how equitably people can access material resources. Rather, it is about how equitable the ability is to contribute to decisions about how to live together.

For us, all of these ideas could be captured and accommodated by the fundamental mechanism of individual control of key life priorities. The process of control is the defining characteristic of life. It refers to maintaining a balance at all levels of functioning for all living things. Control explains why the ability to contribute to decisions about how to live and live together has always been so important to people.

Through our efforts to understand inequity more clearly, we have come to the position that inequity itself is not a problem. Compromised control is the problem because it interferes with people’s ability to live as they would like.

Stiglitz, for example, argues that inequity in the United States exists because top 1% (in terms of income) want it. He suggests that the ultra-rich are able to directly influence political decision-making, including taxation systems, so that their wealth is protected. It reminds us that the fate of the top 1% is inextricably linked to the fate of the remaining 99%. But the very wealthy often ignore this fact, at their peril.

Relevance for African countries

Therefore, inequality, and in particular income inequality, might have limited relevance in African contexts. However, the concept of control, encompassing the ability to contribute to decisions about how one can live harmoniously and productively in a social group, may have much greater relevance and application.

Health services could do much more to adapt treatments and interventions to local contexts. For wellness, this might involve developing programs based on dominant culture and belief systems rather than imposing, for example, Western biomedical ideas about psychological illnesses. Rwandan scholar Jean Pierre Ndagijimana describe the development of a psychological healing program in Rwanda based on local concepts like kongera kwiyubaka and kwigira (build us back again).

Governance structures that provide opportunities for people at the local level to contribute to decision-making would also strengthen people’s abilities to control important factors in their lives. Rwanda, for example, is organized into provinces, districts, sectors, cells and villages. At each level are various positions and groups that are responsible for different aspects of governance and decision-making. This transition to more decentralized forms of government started in 2001 and is reported to have increased citizen participation in local decision-making as well as greater equity in the allocation of resources and services.

How things could be different

More attention to control could be useful in a general sense. Corruption is often identified as a problem within government, organizations and industries. Corruption could be seen as nothing more than people in positions of authority using that authority at their own discretion to benefit some people while disadvantaging others. A CEO, for example, can create positions in an organization for family members and remove people who disagree.

Inequity as a concept has not been a topic of interest and investigation for all times and for all peoples. Control is as important as life itself. The important lesson from our very early beginnings is that societal structures and institutions in general, as well as entities such as health systems, must be organized in such a way that the few do not determine the fate of the many.

The sustainability of social life depends on the ability to find ways for all members of a community, a society, a nation, and even the planet, to live their own lives without preventing others from making same.

Timothy A. CareyDirector: Institute of Global Health Equity Research, Andrew Weiss Chair of Research in Global Health, Global Health Equity University


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