EDITORIAL THE ETHICAL IMPLICATIONS OF THE SOCIAL DETERMINANTS OF HEALTH: A GLOBAL RENAISSANCE FOR BIOETHICS In this special issue, Bioethics explores the ethical issues that relate to the social determinants of health. As the articles demonstrate, the recognition that social factors help to determine a population’s health offers bioethics new challenges and new opportunities. With this recog- nition, fundamental bioethical concepts, such as cau- sation, autonomy, rights, and justice, take on new meanings. Likewise, mainstay bioethical issues, including the equitable distribution of resources, the duties of pro- fessionals, and the conflict between paternalism and autonomy, become amenable to new perspectives. The realization that social forces help to determine health is hardly new. For millennia people have recog- nized a relationship between the social environment and disease. In the 19th century, sanitarians blamed the rampant filth of growing cities for the incessant outbreaks of disease. Later progressive reformers lambasted both poverty and poor working conditions for disease and premature death. The pioneers of epidemiology docu- mented these relationships. The field of bioethics has never been closed to such concerns. Since its inception in the 1960s and 1970s, however, bioethics has deployed much of its intellectual energy on the moral issues that relate to the development, distribution, and delivery of health care services. In so doing, the field reflected medicine’s eclipse of public health in the 20th century. As medicine became predomi- nant and illness became more and more amenable to individualized medical treatment, ethical discourse came to emphasize clinical encounters. At the same time, as disease and health increasingly came to be seen as result- ing from individual factors, individuals began to be viewed as morally culpable for both their illnesses and the impact of those illnesses on others. Not surprisingly, given the importance that bioethics placed upon individual patients and providers, autonomy surfaced as a key concern. In the early years bioethicists focused on the autonomy of patients. Following the lead of John Stuart Mill, bioethicists revealed the dangers of medical paternalism and explained why and how patient autonomy should be respected. In this they were highly successful, as informed consent became both widely regarded and legally established. Individual autonomy remained of paramount interest in the 1990s. By then, however, the concern widened to include the autonomy of physicians. At least within the USA, physicians criticized managed care for interfering with their ability to make decisions for their patients and infringing upon their professional autonomy. And throughout the developed world, as health care costs rose, market solutions were debated. Patients began to be viewed as ‘consumers’ of medical care instead of as patients in need of treatment and care. Not surprisingly, once patients were.

1. EDITORIAL
THE ETHICAL IMPLICATIONS OF THE
SOCIAL DETERMINANTS OF HEALTH:
A GLOBAL RENAISSANCE FOR
BIOETHICS
In this special issue, Bioethics explores the ethical issues
that relate to the social determinants of health. As the
articles demonstrate, the recognition that social factors
help to determine a population’s health offers bioethics
new challenges and new opportunities. With this recog-
nition, fundamental bioethical concepts, such as cau-
sation, autonomy, rights, and justice, take on new
meanings. Likewise, mainstay bioethical issues, including
the equitable distribution of resources, the duties of pro-
fessionals, and the conflict between paternalism and
autonomy, become amenable to new perspectives.
The realization that social forces help to determine
health is hardly new. For millennia people have recog-
nized a relationship between the social environment
and disease. In the 19th century, sanitarians blamed the
rampant filth of growing cities for the incessant outbreaks
of disease. Later progressive reformers lambasted both
poverty and poor working conditions for disease and
premature death. The pioneers of epidemiology docu-
mented these relationships.
The field of bioethics has never been closed to such
concerns. Since its inception in the 1960s and 1970s,
however, bioethics has deployed much of its intellectual

2. energy on the moral issues that relate to the development,
distribution, and delivery of health care services. In so
doing, the field reflected medicine’s eclipse of public
health in the 20th century. As medicine became predomi-
nant and illness became more and more amenable to
individualized medical treatment, ethical discourse came
to emphasize clinical encounters. At the same time, as
disease and health increasingly came to be seen as result-
ing from individual factors, individuals began to be
viewed as morally culpable for both their illnesses and the
impact of those illnesses on others.
Not surprisingly, given the importance that bioethics
placed upon individual patients and providers, autonomy
surfaced as a key concern. In the early years bioethicists
focused on the autonomy of patients. Following the lead
of John Stuart Mill, bioethicists revealed the dangers of
medical paternalism and explained why and how patient
autonomy should be respected. In this they were highly
successful, as informed consent became both widely
regarded and legally established.
Individual autonomy remained of paramount interest
in the 1990s. By then, however, the concern widened to
include the autonomy of physicians. At least within the
USA, physicians criticized managed care for interfering
with their ability to make decisions for their patients
and infringing upon their professional autonomy. And
throughout the developed world, as health care costs rose,
market solutions were debated. Patients began to be
viewed as ‘consumers’ of medical care instead of as
patients in need of treatment and care. Not surprisingly,
once patients were seen as consumers responsible for
selecting their own healthcare in market transactions,
some ethicists were apt to disavow physicians’ fiduciary
duties. Caveat emptor replaced the duty of beneficence as

3. the invisible hand of the market was viewed as the source
of just outcomes. Frequently neglected in mainstream
bioethical discourse of this era – although well noted by
bioethicists working from feminist and communitarian
traditions – was the fact that individuals are never simply
self-determined but are selves nestled in relationships with
other individuals, communities, and the wider world.
This neglect is vanishing. With globalization and the
rise of pandemics including, HIV/AIDS, and new global
threats, such as global warming, the deep connections
between individuals, communities, and the wider world
can no longer be overlooked. Moreover, although many
empirical questions remain unanswered, voluminous
research has now firmly demonstrated the existence of
significant disparities in health between the rich and poor,
across the globe and within nations. As the World Health
Organization’s Commission on Social Determinants of
Health recently stated: ‘These inequities in health, avoid-
able health inequalities, arise because of the circum-
stances in which people grow, live, work, and age, and the
systems put in place to deal with illness. The conditions in
which people live and die are, in turn, shaped by political,
social, and economic forces.’1 In response, bioethics must
expand its horizons and consider the ethical issues that
arise from the social forces that help to determine health,
as well as the ethical problems that result from interven-
tions that target those forces.2
1 WHO. Commission on Social Determinants of Health. 2008.
Closing
a Gap in a Generation: Health Equity Through Act on the Social
Deter-
minants of Health, Final Report on the Commission on Social
Determi-
nants of Health. Geneva: WHO. Available at:

4. http://whqlibdoc.who.int/
hq/2008/WHO_IER/CSDH_08.1_eng.pdf
2 D. Brock. Broadening the Bioethics Agenda. Kennedy Inst
Ethics J
2000; 10: 21.
Bioethics ISSN 0269-9702 (print); 1467-8519 (online)
doi:10.1111/j.1467-8519.2008.00719.x
Volume 23 Number 2 2009 pp ii–v
© 2009 The Authors. Journal compilation © 2009 Blackwell
Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK
and 350 Main Street, Malden, MA 02148, USA.
http://whqlibdoc.who.int
As this Special Issue attests, bioethics has answered the
call. While the traditional issues and principles that have
dominated the field continue to generate important
insights and discussions, other topics have emerged and
are being analysed from a wide range of new perspectives.
For example, a subfield of bioethics, generally referred to
as public health ethics, has come of age. Focusing on
questions of public health and public health practice,
bioethicists have carried old questions about autonomy
and paternalism to new areas including the state’s power
to limit individual liberty in order to promote public
health. Thus some bioethicists, such as Lawrence O.
Gostin3 and Amitai Etzioni4 have emphasized a commu-
nity’s right to self-protection and the limits that this
places upon individual autonomy. Others, such as
Marion Moser Jones and Ronald Bayer, have questioned
bioethics’ traditional disdain for paternalism while
asserting that perhaps in some instances it is indeed
appropriate for governments to enact laws, such as those

5. requiring individuals to wear seatbelts, that limit indi-
vidual autonomy in order to improve a population’s
health.5 While such discussions seldom consider the role
of social determinants explicitly, these debates arise from
a discontent with the atomistic assumptions that social
determinants dissolve.
In recent years, bioethicists have also paid attention to
the ethics of public health interventions directed at ill-
nesses which are linked to social determinants. In this
issue, the articles by Paula Boddington and David Shaw
exemplify different ways of addressing such questions.
Each article is written with a firm appreciation of social
determinants. And each moves bioethics away from the
clinical encounter to a broader social setting.
In Heart Disease and Social Inequality: Ethical Issues
in the Aetiology, Prevention and Treatment of Health
Disease, Paula Boddington analyzes the ethics of prevent-
ing and treating heart disease. In contrast to traditional
bioethical discussions, which generally focus on the ethics
of clinical research and treatment, Boddington analyses
the ethical issues that arise from broad public health
policies. Her piece begins with two critical observations:
heart disease is distributed unequally and its etiology is
complex and multi-causal. With these observations, she
establishes that a discussion of the ethics of heart disease
prevention and treatment must move not only beyond
clinical medicine, but beyond individually-oriented
solutions. It must consider the possibility, and ethical
implications, of broader social changes. As Boddington
notes, ‘Distributive justice is embedded in debate about
strategies for treatment and prevention.’ (123) Common
interventions, such as those that warn individuals about
‘risk factors’ may help prevent some cases of disease.

6. They may also respect or even facilitate the choices of
individuals. At the same time, however, they result in an
inappropriate attribution of responsibility to individuals
and may increase distributive inequities, both because
some populations may be in a better position to heed such
warnings and because such interventions decrease the
visibility of socially-determined causal factors.
David Shaw’s paper, Tackling Socially Determined
Dental Inequalities: Ethical Aspects of Childsmile, The
The National Child Oral Health Demonstration Pro-
gramme in Scotland, also engages the ethical dilemmas
that arise from public health interventions. Childsmile is
a multifaceted intervention designed to reduce both the
incidence of and disparities of dental caries among chil-
dren. The program includes both broadly-based and
narrowly targeted arms. By examining Childsmile from a
Rawlsian perspective, Shaw illuminates the tensions that
exist between population-based and more targeted mea-
sures, as well as the tensions between maximizing health
and reducing disparities, prevention and treatment, and
ultimately utility and justice. According to Shaw, by
incorporating both population-wide and high-risk strat-
egies, Childsmile may mitigate some of these tensions,
though only ‘time will tell.’ (131) In so concluding, Shaw
demonstrates fidelity to both context and empiricism,
showing that while a bioethical analysis informed by
social determinants may grapple with broad, population-
wide issues, its conclusions remain contingent upon the
particulars of social facts and very specific programs.
In Justice, Stigma, and the New Epidemiology of Health
Disparities, Andrew Courtwright illustrates how the rec-
ognition of social determinants can raise new questions
about old issues. Bioethicists have long criticized stigma-
tization. But for the most part, they have focused on its

7. violation of the respect due to individuals qua individu-
als. With social determinants in mind, Courtwright
demonstrates that stigmatization both arises from and
constitutes a social determinant of health. That leads him
to ask about society’s obligations to foster conditions
that reduce stigmatization. Like Shaw, Courtwright
utilizes Rawls to build his case; indeed like Norman
Daniels,6 Courtwright attempts to show how Rawls’ con-
struct of justice as fairness can explain why society has an
3 L. O. Gostin. 2009. Public Health Law: Power, Duty,
Restraint.
Berkeley & Los Angeles: University of California Press.
4 A. Etzioni, 1999. The Limits of Privacy. New York: Basic
Books.
5 M. M. Jones & R. Bayer. Paternalism and Its Discontent:
Motorcycle
Helmet Laws, Libertarian Values and Public Health. Am J
Public
Health 2007; 97; 2: 208–217.
6 N. Daniels. 2008. Just Health: Meeting Health Needs Fairly.
Cambridge & New York: Cambridge University Press.
Editorial iii
© 2009 The Authors. Journal compilation © 2009 Blackwell
Publishing Ltd.
obligation to address social determinants. By so doing,
Courtwright not only expands our understanding of stig-
matization as a social determinant, he also suggests the
close relationship between bioethics and political and
moral theory.

8. The close nexus between bioethics and political and
moral theory becomes even more pronounced once we
recognize the global dimension of social determinants.
The medical perspective is naturally bounded by the
human body; the same is not true of social determinants.
They have no simple boundary. So when we look at the
social determinants of health, our focus necessarily
becomes global. In making that shift, we leave behind not
only bioethics’ traditional emphasis on autonomy and
the moral responsibilities of individuals, but also domes-
tic law and well-entrenched norms. We enter less familiar
territory, where political and moral philosophy – and
perhaps human rights – serve as our primary guideposts.7
The global dimension of social disparities is striking.
As Audrey R. Chapman points out in Globalization,
Health, and Human Rights, at the end of the 20th century,
1.2 billion people in the world lived on less than $1 dollar
a day and half the world’s population lived on 2 dollars a
day. Because of the connection between absolute poverty
and poor health, poverty is an international determinant
of health. With additional resources, developing coun-
tries could improve the health of their people.
Chapman argues that, unlike the individual right to
health, the right to development is a collective right that
could address the impact of poverty as a social determi-
nant in a way that individual rights cannot. A United
Nations Declaration recognized the human right to
development in 1986. In the following words:
The right to development is an inalienable human right
by virtue of which every person and all peoples are
entitled to participate in and contribute to and enjoy
economic, social cultural and political development, in

9. which all rights and fundamental freedoms can be fully
realized.8
In this way the duty to fulfill the right to development, a
positive right, is imposed on all peoples for all peoples, a
vision that moves away from the particularism of nation-
alism, and embraces a more cosmopolitan stance. There
is little question that this collective right, if realized,
would go a long way in changing the social, political, and
economic conditions that are responsible for the diseases
of poverty.
In Globalization, Human Rights and the Social Deter-
minants of Health, Ashley M. Fox and Benjamin Mason
Meir cover similar terrain but make a different argument.
They contend that globalization, understood as the inter-
dependence of the world’s people, involving the integra-
tion of economies, culture, technologies, and governance,
and under the influence of neoliberal ideology, has ben-
efitted rich countries much more than poor countries. As
globalization has spread, global injustice has followed.
Fox and Meir argue that a human rights approach would
do a better job of improving health and welfare, globally,
but especially for the global poor. Nonetheless, Fox and
Meir point out that in order for the right to the highest
attainable standard of health to be as effective as it can
be, it must be understood by the legal community as well
as human rights activists to incorporate the social deter-
minants of health. They are also concerned that many of
those who are involved in the creation of government
policy have a narrow understanding of the right to health,
and their country’s commitment to the highest attainable
standard of health globally.
Both of these rights-based approaches to poverty,

10. global disease, and avoidable deaths offer compelling
accounts because they assign responsibility for health and
development to identifiable others. Still, as Fox and Meir
suggest, we are a long way away from a time when such
rights are in fact widely respected and fulfilled. The
source of the problem may be that, even though there is a
universal right to the highest attainable standard of
health and a collective right to development, without a
widely adopted cosmopolitan ethic, few will funnel into
the global social order the resources that are needed to
meet these rights.
Nonetheless, without the help of scientific data about
the causes of disease, including the social determinants, a
cosmopolitan ethic on its own has little chance of having
a significant impact on global health. In Epidemiology
and Social Justice in Light of Social Determinants of
Health Research, Sridhar Venkatapuram and Sir Michael
Marmot underscore the importance of collaboration
between ethics and epidemiology in a bioethics commit-
ted to global social justice. Unless the bioethics conver-
sation includes both epidemiologists and ethicists, neither
can be confident that their work will be as effective as it
could be. Importantly, Venkatapuram and Marmot note
that epidemiology is informed by the moral concern with
human health and its role in social justice. By the same
token, the fact that bioethics is informed by the data of
epidemiology ensures that its insights are not cast away as
mere irrelevant postulations, but help to realize the
7 J. Mann. Medicine and Public Health, Ethics and Human
Rights.
Hastings Cent Rep 1997; 27: 6–13.
8 Declaration on the Right to Development. GA Res/128
adopted 4
Dec. 1986. UN GAOR. 41 Sess. Annex UN Doc. A/Res/41128:

11. 1986.
iv Editorial
© 2009 The Authors. Journal compilation © 2009 Blackwell
Publishing Ltd.
concern for health and human welfare shared by ethics
and epidemiology. Interesting, too, is the fact that many
of the non-biological, psycho-social determinants recog-
nized by epidemiologists to be implicated in health
are themselves objects of morality. The list of possible
psycho-social determinants of health that Venkatapuram
and Marmot identify reads like a litany of moral virtues:
autonomy, dignity, respect, agency, trust and reciprocity.
In the end, it might turn out that ethical conduct is itself
a social determinant of health.
Ultimately, Venkatapuram and Marmot present an
ambitious agenda for a bioethics informed by the pres-
ence of social determinants. That agenda demands
rethinking fundamental premises and reformulating the
boundaries between bioethics and other fields. More
broadly, their paper and the others in this special issue
demonstrate the promise of and the need for a renais-
sance in bioethics. Although its full contours cannot yet
be depicted, the outlines of bioethics’ next incarnation are
discernable. Building upon its unique strengths as
an interdisciplinary field, a re-imagined bioethics will
expand its interdisciplinary reach, drawing more capa-
ciously from political and economic theory, international
politics and law, and theories of global justice. Furthering
its tradition as a field of applied ethics, bioethics will

12. remain open to empirical data, but it will gain its ground-
ing not in the clinic but from social, economic, and
epidemiological research. Continuing its fusion of
descriptive and prescriptive ethics, a bioethics informed
by social determinants will embrace the language of
advocacy, relate to social movements, and connect with
NGOs and other institutions of civil society even though
by so doing, it may need to reexamine the comfort of
its commitment to neutrality, and academic insularity.
In short, the curtain has been pulled open. Bioethics is
no longer ignoring the social factors that influence health,
or the grave disparities that endanger it. Having seen
social determinants, bioethics is confronting a wider and
more complex set of issues and is drawing from and
informing a more diverse array of disciplines. The risks
are daunting. The promises are great.
PATRICIA ILLINGWORTH AND
WENDY E. PARMET
Acknowledgement
We wish to thank Clancy Pegg for her editorial wisdom, careful
eye, and
patient demeanor.
Editorial v
© 2009 The Authors. Journal compilation © 2009 Blackwell
Publishing Ltd.
Essay Question # 1 - Discuss the evolution of business ethics as

13. a field of study from before 1960 to the present. What
historical event do you think has the most important impact on
the current business environment? (150 Words)
Essay Question # 2 - Define business ethics, analyzes the
benefits of business ethics and the development of business
ethics. (250-500 Words)
Essay Question # 3 – Select a recent ethical breach at a
company. Briefly describe what happened, and the effects on
stakeholders. Why do you think it is noteworthy? (150 Words)
Essay Question # 4 – Why is ethical misconduct more difficult
for a business to overcome than poor financial performance?
(150 Words)
Essay Question # 5 – Discuss how one goes about recognizing
an ethical issue? How do companies respond to ethical issues?
(150 Words)
Essay Question # 6 – List 5 different ethical issues in the
workplace. Then briefly reflect on how they could be prevent.
(150 Words)
Essay Question # 7 - How has the concept of social
responsibility changed? Select an area you think will change
over the next 10 years and speculate on why and what might
happen? (150 Words)
Essay Question # 8 - How do you think managers and business
executives should display ethical principles. Give an example.
(150 Words)
Essay Question # 9 - How can companies secure stakeholder
input during an ethics audit? Why do you think it is important
to do so? (150 Words)
Essay Question # 10 - How do you think ethical actions of
business leaders (positive or negative) effect the actions of
their subordinates. (150 Words)
Essay Question # 11 - What is the Global Reporting Initiative?
What is its goal? Why do you think it has grown in importance?
(150 Words)
Essay Question # 12 - How can differences in two countries'
cultures create opportunities for learning about ethical

14. differences? (150 Words)
Essay Question # 13 - List five aspects of an ethics programs
that you think should considered successful. What do you think
is the most important feature of that program? (150 Words)
Essay Question # 14 - How do you
think sustainability relates to ethical decision making and social
responsibility? (150 Words)
Critical Public Health
Vol. 22, No. 3, September 2012, 267–279
The global financial crisis and health equity: toward a
conceptual
framework
Arne Ruckert* and Ronald Labonté
Department of Epidemiology and Community Medicine,
Institute of Population Health,
University of Ottawa, Ontario, Canada
(Received 5 April 2012; final version received 7 April 2012)
In this article, we identify pathways that link the global
financial crisis to
health equity. We distinguish between direct and indirect
channels of
influence, and develop a conceptual model that builds on the
literature
analyzing the impacts of globalization on social determinants of
health.
The most pertinent direct pathways discussed are economic
contraction,

15. health budget cutbacks, rise in unemployment, and qualitative
transfor-
mations of health systems. We also outline how other indirect
channels of
influence are likely to affect health equity, including cutbacks
to welfare
programs, labor market transformations, the emergence of an
ideological
climate conducive to austerity politics, and reductions in
official develop-
ment assistance. We conclude by suggesting that the current
intensification
of neoliberal policy implementation is likely to undermine
health equity,
and that a different path toward economic recovery is required
to ensure
equitable access to health care.
Keywords: health equity; global financial crisis; population
health; social
determinants of health; health governance
Introduction
Health equity is becoming a central concern in health research
(Östlin et al. 2011),
with the tenacity of health disparities in countries around the
world identified as one
of the most serious public health threats of the twenty-first
century (Edwards and Di
Ruggiero 2011). The WHO defines health equity as the absence
of systematic
differences in health, between and within countries, that are
avoidable by reasonable
action (CSDH 2008, p. 1). Health equity research starts from the
assumption that

16. many of the differences in health outcomes between different
segments of the
population are directly traceable to inequalities in the
underlying social and
economic conditions that are essential for health, or what
recently came to be called
‘social determinants of health’ (SDH) (Labonté et al. 2009). A
rapidly growing body
of literature on SDH surfaced in the 1990, and has gained
momentum with the WHO
Commission on Social Determinants of Health (CSDH 2008)
and subse-
quent national and regional reviews (for a good overview, see
Navarro 2009,
Raphael 2011).
*Corresponding author. Email: [email protected]
ISSN 0958–1596 print/ISSN 1469–3682 online
� 2012 Taylor & Francis
http://dx.doi.org/10.1080/09581596.2012.685053
http://www.tandfonline.com
As a part of this literature, a small branch is focusing on how
global factors and
forces are shaping SDH domestically (e.g. Labonte and
Torgerson 2005, Labonte
and Schrecker 2007a, b, c, Edwards and Di Ruggiero 2011).
However, recent global
developments, in particular the on-going global financial crisis
and the concomitant
austerity drive that it unleashed, present a new set of challenges
for understanding

17. the links between global macro-structural developments and
health equity that
remain largely unaddressed in the literature. There have been
multiple warnings that
the financial crisis will negatively impact on health outcomes
(e.g. Banoob 2009,
Blakey and McLeod 2009, Labonté 2009, Marmot and Bell
2009, WHO 2009; Gill
and Baker 2011, Kentikelenis et al. 2011), with a Lancet
commentary calling the
financial crisis an ‘acute threat’ to population health (Horton
2009). Some studies
have started to analyze the ways in which the financial crisis is
percolating down to
the level of health policy making (e.g. Mladovsky et al. 2011,
WHO 2011). But there
has been little effort to explicitly assess the health equity
implications of the global
financial crisis and subsequent changes to health policy and
governance, and little
emphasis placed in the literature on the indirect health equity
effects of financial
crises. This article attempts to fill this research gap.
This article unfolds as follows: First, we review the existing
literature on the
impact of global forces, in general, and the financial crisis, in
particular, on health
equity, linking the financial crisis conceptually back to the
macro-structural process
of neoliberal globalization. We next develop a generic
framework of the linkages
between the current financial crisis and health equity,
distinguishing between direct
and indirect channels of influence (Figure 1). We then discuss
the most pertinent

18. direct channels of influence, with a focus on economic
contraction with its associated
decline in the tax base, health budget cutbacks, rise in
unemployment, and
qualitative transformations of health systems. We then outline
how other indirect
channels of influence are likely to affect health equity,
including cutbacks to welfare
programs, labor market transformations, the emergence of an
ideological climate
conducive to austerity politics, and reductions in official
development
Figure 1. Health equity-relevant pathways of global financial
crisis.
268 A. Ruckert and R. Labonté
assistance (ODA). This article selectively draws on some of the
early experiences with
and effects of the financial crisis on SDH in a range of different
countries
representing developed, transition, and developing economies.
The article concludes
by suggesting that a different path to that of deep austerity is
required to insure that
health equity goals will not be undermined further in the policy
response to the
global financial crisis.
Globalization, the global financial crisis, and health equity
Financial crises have been a central characteristic of neoliberal
globalization since

19. the beginning of the deregulation of finance in the early 1980s,
with more than
20 financial crises occurring annually since 1986 (Mohindra et
al. 2011). Most of
these financial crises have been contained domestically, with
the exception of the
Asian financial crisis (in the late 1990s) and the global financial
crisis (2007/2008 and
ongoing). All have strongly affected health and wider social
living conditions in the
countries in which they transpired. The wider health equity
impacts of the current
global financial crisis must be situated within the context of the
globalization of
production and finance that has been a key feature of the world
economy over the
past three decades. The liberalization of financial markets has
been identified as one
of the key pillars of neoliberal globalization, with strong
implications for health
equity and SDH (Labonté and Schrecker 2007b). Financial
liberalization refers to
the global integration of financial markets and predominantly
consists of the
deregulation of the foreign sector capital account, the domestic
financial sector, and
the stock market (Arestis 2004). A central element of financial
liberalization since the
early 2000s has been the self-regulation of banking entities,
with risk assessments
performed internally through models developed and controlled
by banks themselves.
The loosening of financial capital from the regulatory
constraints of the nation state
has ushered in a new era of market discipline with concomitant
loss of policy space in

20. the health domain (Bakker and Gill 2006).
1
Loss of policy space is related to the
ways in which investor decisions can influence the policy
making process. Under
globally integrated financial markets, governments require the
confidence of large
international institutional investors to fund their operations
through sovereign debt
markets (borrowing). In the realm of health, this implies that
even governments
committed to improving access to better and more equitable
health care are reluctant
to risk the effects of displeasing financial markets.
Governments may also be
reluctant to implement policies that might be viewed negatively
by sources of foreign
direct investment or foreign sovereign bond investors (Labonte
et al. 2009, p. 118).
This tendency has been intensified with the onset of the global
financial crisis, as
rating agencies have become private actors whose embrace or
rejection of
government policies can have far-reaching consequences. Any
downgrading of a
country’s public (government) bond issues can dramatically
increase the cost of
borrowing in international markets. The higher interest rates
governments pay on
their bonds decrease revenues available for public service
spending and potentially
increase debt, risking a cycle of further bond-rating downgrades
and higher
borrowing costs.

21. Despite the conceptual challenge of connecting the macro-
structural phenomena
of globalization to individual health outcomes, a body of
scholarship has developed
that assesses the health equity implications of globalization. A
comprehensive
Critical Public Health 269
conceptual framework linking globalization to health equity was
presented by
Labonté and Schrecker (2007a, b, c) in their work funded
through the WHO
Globalization Knowledge Network of the CSDH. They propose
seven clusters of
pathways that link various aspects of globalization with SDH
and health equity:
trade liberalization, reorganization of labor markets, debt crises,
financial liberal-
ization, restructuring of cities, environmental impacts of
globalization, and market-
ization of health systems (Labonté and Schrecker 2007b).
Building on this
framework, the financial crisis could be considered a novel
health equity-relevant
pathway, which is linked to previous financial liberalization
efforts, and which
directly impacts the SDH and health equity through the channels
specified below.

22. The global financial crisis and health equity: direct channels of
influence
Economic decline and health budget cuts
The most direct link between financial crises and health equity
is the steep decline in
overall economic activity that financial crises induce. The
opportunity costs of
financial crises, understood in terms of lost or forgone output,
are much higher than
those for normal economic recessions (Gill and Bakker 2011),
as financial crises
produce more significant declines in overall economic activity
than ‘normal’
recessions (Reinhart and Rogoff 2009). This puts constraints on
the government’s
ability to maintain social spending, notably but not exclusively
in public health. The
International Monetary Fund (IMF) recently estimated that after
a financially
induced recession, output is about 10% below its previous trend
in the medium term,
which it defines as seven years (Gill and Bakker 2011). This
implies a deeper and
longer economic contraction with more pronounced challenges
to government
budgeting. Such a steep decline in economic activity leads to a
decline in the tax base
and associated cuts in government spending, as the crisis

23. response thus far has
focused on spending cuts and tax increases, mostly by way of
socially regressive taxes
(such as value added and sales taxes), which have the potential
to significantly
undermine SDH. However, if revenues from such taxes are used
to finance
universally accessible health and social programs, they can
function in a redistrib-
utive way; but not in the absence of progressivity in other tax
measures. At the same
time, previous experiences with the impact of financial crises
on health suggest that
health equity impacts can materialize more rapidly than during a
mild recession
(Marmot and Bell 2009).
A WHO commissioned study on the health policy response to
the financial crisis
provides a preliminary picture of how the crisis has affected
health care spending in a
wide range of European countries (Mladovsky et al. 2011).
Although the response
has varied across health systems in Europe, some of the findings
are disturbing and
suggest that health equity impacts of the financial crisis will not
only be felt widely
but will also likely persist over time in many countries. Several
countries reported

24. that steep health budget cuts, in some cases by over 20%,
including in Bulgaria,
Romania, the Czech Republic, Estonia, Ireland, Latvia, Spain,
and Portugal. The
most dramatic case is clearly Greece, where the hospital budget
has been cut by more
than 40%, while demand (partly due to the health hardships
induced by austerity
measures) increased by approximately 25% (Kentikelenis et al.
2011), leading to a
comeback of diseases such as HIV and malaria (Henlay 2012).
It increasingly looks
270 A. Ruckert and R. Labonté
like Greece will represent a blue-print for steep austerity
measure to come in other
parts of Europe, especially the Southern periphery.
Similarly, while most developing countries did not immediately
contract health
spending in response to the global financial crisis, by now, they
have started to follow
the path toward austerity. A comprehensive review of IMF
agreements with low-
income countries commissioned by UNICEF has fueled
criticisms of excessive
austerity in recent IMF programming with low-income
countries, especially
programs agreed upon since 2010 (Ortitz et al. 2011). Although
the IMF initially
showed some flexibility in its crisis response, and allowed

25. marginally higher fiscal
deficits than in past episodes of financial upheaval, by 2010 it
has been back on its
austerity path. The above-mentioned study found that most
governments initially
introduced small fiscal stimuli to buffer their populations from
the impacts of the
crisis during 2008–2009; but that expenditure contraction
became widespread
beginning in 2010 despite vulnerable populations’ urgent and
significant need of
public assistance. The scope of austerity is becoming severe and
widening quickly,
with 70 developing countries (or 55% of the study’s sample)
reducing total
expenditures by nearly 3% of GDP, on average, during 2010,
and 91 developing
countries (or more than 70% of the sample) expected to reduce
annual expenditures
in 2012. The biggest cuts are anticipated in North Africa, the
Middle East, and sub-
Saharan Africa. What is particularly disconcerting is that,
comparing the 2010–2012
and 2005–2007 periods, nearly one-quarter of developing
countries appear to be
undergoing excessive contraction, defined in the study as
cutting expenditures below
pre-crisis levels in terms of GDP (Ortiz et al. 2011, p. v).
In a World Bank analysis of global social spending trends since
the onset of the
financial crisis, Lewis and Verhoeven (2010) confirm that in
developing and
transition economies, social spending levels have declined in
aggregate terms, with
both education and health spending impacted equally. This is

26. not surprising as
developing countries generally display a proclivity toward
procyclical macro-
economic management, especially in the area of public
expenditures for health
(Calvo 2010). This is largely an outcome of the misguided
policy prescriptions and
conditionalities enforced by international financial institutions.
Lewis and
Verhoeven (2010) note that the impacts of the financial crisis
on social spending in
developing and transition economies ‘have generated concern
about continuity of
services when citizens need them most’ (p. 84). However, there
is a notable exception
to this decline as social spending has actually increased in Latin
America (Barcena
2012). Latin American economies have largely been able to
avoid having to rely on
IMF and World Bank lending in the aftermath of the global
financial crisis, which
partly explains the expansionary crisis response compared to
financially dependent
European and African countries.
Rise in unemployment
Another direct health equity pathway is the effect of the
financial crisis on
employment levels, which is itself an after-effect of the steep
decline in economic
output following the rapid (and still ongoing in many countries)
contraction of
credit. The relationship between employment and health
outcomes is well-
established. Employment and working conditions are the origin

27. of many SDH, as
work in its optimal form can provide financial security, social
status, self-esteem,
Critical Public Health 271
personal development, and many other health promoting
attributes (CSDH 2008,
p. 72). Being unemployed is directly associated with various
adverse health
outcomes, as unemployment has been associated with increased
self-harm, suicide,
decreased mental health status, and psycho-social stress (Moser
et al. 1986, Blakely
et al. 2003). Developed and particularly European countries
have seen the steepest
increase in unemployment levels, with some countries reaching
depression-like
unemployment rates exceeding 20%, while most low- and
middle-income economies
were hit less hard. Nevertheless, the International Labor
Organization (ILO 2011a)
has recently noted that unemployment globally has reached
unprecedented propor-
tions, with more than 200 million workers entering the reserve

28. army of unemployed
workers, putting global unemployment at the highest level on
record. In many
countries, a rise in the level of unemployment also has direct
repercussions on the
government’s ability to fund health care expenditure, especially
when government
revenue is generated through social insurance contributions.
Finally, the nature of
the relationship between job loss and health equity is straight-
forward: the health of
people who lose jobs and have poor employment prospects is
affected dispropor-
tionately compared with other population groups in society
(Marmot and Bell 2009,
Suhrcke and Stuckler 2010). Previous experiences with
economic recessions confirm
that the negative distribution of employment impacts is
concentrated amongst those
who are already socioeconomically deprived, and who are part
of ethnic, racial or
other socially disadvantaged minority groups (Blakely and
McLeod 2009,
Phua 2011).

29. Qualitative transformation of health systems
The global financial crisis is also putting pressure on
governments to qualitatively
transform the delivery channels within health systems, arguably
to enhance
efficiency. Such transformations, however, can risk
undermining health equity
goals. Improved efficiency can help reduce the severity of
budget cuts and thus allow
governments to maintain critical health services (WHO 2011).
For example, the
introduction of health technology assessments in several
countries and the
renegotiation of drug prices through public tendering, especially
for generic
medicines, have led to cost savings in a wide range of countries
around the world
(Mladovsky et al. 2011). However, certain qualitative
transformations of health
systems represent formidable challenges for health equity. For
example, several
countries have instituted user charges for specific health
services to address revenue
shortfalls in response to the global financial crisis, including

30. the Czech Republic,
Denmark, Estonia, Finland, France, Greece, Ireland, Latvia, the
Netherlands,
Portugal, Romania, and Turkey (Mladovsky et al. 2011, p. 20).
User charges are
widely known to have negative health equity effects, as low
income groups are
disproportionately affected by them (Gemmill et al. 2008). At
the same time, the
introduction of user charges is likely to worsen overall health
outcomes and can lead
to increased health spending in other areas, such as emergency
care. As the WHO
(2011, p. 34) notes, the poor and less educated population
groups are most likely to
make decisions in response to the introduction of user fees that
lead to delays in
seeking care, which may eventually result in higher costs for the
health system and
worse health outcomes for the individual.
272 A. Ruckert and R. Labonté
Indirect channels of influence

31. Reductions in welfare spending and programs
As is widely acknowledged, individual health, and especially
health equity, is not
solely affected by the prevailing levels of health spending. Two
recent studies have
found a direct link between welfare program expenditure and
health outcomes (e.g.
Stuckler et al. 2010, Bradley et al. 2011). Both studies show
that lower levels of social
expenditure in other areas than health are associated with
deteriorating population
health. Stuckler et al.’s (2010) statistical model demonstrates
that each additional
US$100 in welfare spending is associated with a 1.19% drop in
all cause mortality.
They conclude ‘that the maintenance of social welfare systems
seems to be a key
determinant of future population health’ (p. 77). Similarly,
Bradley et al. (2011)
argue that higher levels of social spending are associated with
improved overall
population health, as the ratio of social expenditure to health
expenditure may
influence health outcomes beyond that which results from health
spending alone.
This implies that cutbacks to welfare programs, even if health
spending is maintained
at pre-crisis levels, are likely to undermine population health.
Given the importance
of social programs for the most vulnerable populations,
cutbacks in social spending
will directly undermine health equity goals.
A recent analysis of the impact of the global financial crisis on

32. welfare spending
globally documents the pressure that the financial crisis has
been exerting over the
welfare state (Busch 2010). In Europe, cuts in services, as well
as tax and
contribution increases, are speeding up the process of
recommodification and state
retrenchment which has been under way for years. This process
is more extreme in
countries with high levels of public debt, such as Greece,
Ireland, and Portugal.
Nevertheless, even countries in a solid fiscal position, such as
Germany and Canada,
have started to further downsize the welfare state, generally by
freezing social
assistance rates. In the realm of pension policy, this rolling
back of the welfare state
finds expression in the introduction of the three-pillar model,
through the transition
from defined-benefit schemes to defined-contribution schemes,
cutbacks in pension
payments, and increases to the retirement age (Busch 2010, p.
7). As Busch (2010)
concludes, ‘reforms of the welfare state in the EU exhibit
considerable convergence
in the East and the West. Given the common objective and the
common socio-
political ideal-model (i.e., neoliberalism), this is not surprising’
(p. 8). A similar
tendency is noted in the revamping of unemployment insurance
schemes. In both
West and East Europe, entitlement conditions have been
tightened up, entitlement
periods cut and wage replacement ratios reduced. While most
developing countries
do not generally have comprehensive welfare states in place,

33. targeted transfer
schemes have come under pressure as well in the aftermath of
the global financial
crisis (Busch 2010, p. 9, Ortitz et al. 2011). Given the
precarious situation of people
relying on such transfers, any cutback will have direct health
consequences for the
most vulnerable populations in developing countries, further
undermining the
equitable delivery of health care.
Changes to aid flows
Another major concern related to the long-term health
consequences of the global
financial crisis is the impact that the crisis will have ODA flows
to low-income
countries. The fact that international assistance in health
already accounts for
Critical Public Health 273
roughly 50% of all public health expenditure in low-income
countries reveals how
crucial the role of international assistance has become
(Taskforce on Innovative
International Financing 2008). In the case of Rwanda, donor
funding represent
almost 100% of the total public health budget (Calvo 2010). In
the period 2008–
2010, overall donor funding in the form of ODA has not been
cut. Organization for
Economic Cooperation and Development (2011) notes that ODA
flows have

34. continued to rise in line with promises made by the
international community, with
aid flows from Development Assistance Committee donor
countries totaling USD
129 billion in 2010, an increase of 6.3% over 2009. However,
given a string of recent
announcements in a wide range of countries to cut back on
ODA, this trend is likely
to be reversed. Previous experiences with financial crises also
suggest that in
countries struggling with budget deficits ODA will likely
plateau and then decline as
countries start addressing large fiscal deficits (World Bank
2009). For example,
Canada just announced a 10% cut to its international assistance
envelope in order to
rein in its budget deficit.
At the same time, a preliminary estimate of health aid flows by
Leach-Kemon
et al. (2012) notes that while development assistance for health
continued to grow in
the aftermath of the financial crisis, growth has slowed down
significantly to around
4% from 2009 to 2011 (p. 228), compared to double digit
growth rates before the
financial crisis, with a growth rate of 17% between 2007 and
2008. Disconcertingly,
this limited growth in international assistance for health was
largely driven by the
World Bank’s increased disbursements to middle income
countries, while World
Bank health funding to low-income countries through the
International Development
Association actually decreased since the onset of the global
financial crisis (Leach-

35. Kemon et al. 2012, p. 231). From a health equity perspective,
this reallocation of
health funding away from low income to middle countries raises
significant concerns.
In addition, some multilateral disbursements have already been
negatively
affected by the global financial crisis, with a high-profile
victim: the Global Fund to
Fight AIDS, Tuberculosis, and Malaria. International donors
have started to
drastically reduce contributions to the Fund, despite a recent
infusion of $750 million
by Bill Gates. As a result, in November 2011, the Global Fund
announced that it
would make no new grants until 2014, in large part because of
depressed donations
attributed to the global financial crisis. More than 70% of life-
saving AIDS medicine
in the developing world, and about 85% of TB programs in
Africa, are financed by
the Global Fund (York 2011). Consequently, the cancelation of
the next round of
grants will negatively impact on tens of thousands of
impoverished people living with
HIV who depend on foreign financing for their medicine.
Finally, development
assistance for health from UN agencies has become stagnant.
Stagnation in UN
funding may pose a challenge to several health focus areas in
which these channels
play an important role, including the areas of maternal and child
health (the United
Nations provided 37% of total development assistance for health
for this area in
2009), noncommunicable diseases (25%), and tuberculosis

36. (16%; Leach-Kemon
et al. 2012, p. 232).
Labor market transformation
Another indirect pathway by which the global financial crisis
has already affected
health equity is through a qualitative transformation of the labor
market.
274 A. Ruckert and R. Labonté
Current policy responses to the global financial crisis
emphasize the importance of
‘modernizing’ labor markets, especially in developed economies
struggling with large
budget deficits. In most cases, this means a dismantling of the
protective measures
that have insulated workers from the vagaries of unregulated
labor markets. These
qualitative transformations of the labor market are not entirely
novel as even before
the financial crisis neoliberal reforms noticeably transformed
working conditions,
with deep implications for SDH (Labonté and Schrecker 2007b).
Increased
‘flexibility’ in the labor market has been a corner stone of
neoliberal globalization
which has lastingly transformed the global landscape for
workers (Vosko 2006). In
this context, flexibility can best be defined as ‘reducing the
constraints on the
movement of workers into and out of jobs previously
constrained by labour laws,

37. union agreements, training systems, or labour markets that
protect workers income
and job security’ (Hadden et al. 2007, p. 6). This flexibilization
resulted in an increase
in various contractual forms, such as temporary, part-time, and
self-employed work.
Previously, standard arrangements generally provided social
benefits, security,
modest income, and various other entitlements. However, the
standard employment
relationship is shifting, so that employers are reducing their
‘commitments’ and
entitlements offered to their workers. The responsibility and
costs for benefits such
as training, extended health care, and pensions are being shifted
away from
employees to workers, creating new burdens for them and their
families, and
undermining SDH in the process. Such changes are under way
in a wide range of
European countries, most prominently Greece, Spain, Italy, and
Portugal. Various
studies show that economic recessions, especially when they are
steep, tend to
exacerbate the deviation from the standard employment
relationship (Vosko 2006,
Perry et al. 2007). Workers in precarious arrangements often
share similar
characteristics with the unemployed, with some evidence
suggesting that chronic
job insecurity may be more damaging to health than actual job
loss. In fact,
dimensions which are typically, but not exclusively, related to
precarious work
arrangements, such as job insecurity, have long been linked to

38. adverse health
outcomes such as psychosocial morbidity (Ferrie et al. 2002,
Virtanen et al. 2005).
Studies suggest that workers that are involuntarily involved in
temporary work
contracts are at an increased risk for mortality (Natti et al.
2009), and that unsecure
employment relationships (where future employment is
unknown) are associated
with overall poorer health indicators.
Conclusion
It has been widely acknowledged that the global financial crisis
of 2008 will have
lasting effects on the health of populations (Horton 2009,
Labonté 2009, Marmot
and Bell 2009). These health effects, however, will not be felt
equally or even
similarly by different population segments, as different socio-
economic positions in
the societal hierarchy will lead to different health outcomes
(Blakey and McLeod
2009, Phua 2011). This article attempted to conceptually
sharpen our understanding
of the transmission channels by which the (ongoing) global
financial crisis will
undermine SDH and challenge health equity goals. We proposed
a number of direct
and indirect channels of influence by which the global financial
crisis has already
begun impacting health equity outcomes. Yet, it likely will take
some time until the
full impact of the crisis on health equity can be
comprehensively assessed, especially

39. Critical Public Health 275
in relation to the indirect channels of influence. In this context,
it is important to
highlight that the most challenging years are still ahead. In
many countries, the initial
response to the financial crisis was counter-cyclical and
expansionary, as few
countries engaged in cutbacks to health budgets and welfare
programs in the
immediate aftermath of the crisis. However, the current
ideological climate of
austerity will make it more likely that further cuts to health and
other social
expenditure will be enacted. This can already be seen in a wide
range of European
countries that have started to make draconian cuts to health and
welfare budgets
(Houston et al. 2011, Mladovsky et al. 2011). But even fiscally
sound countries, such
as Canada, have recently started to wield the axe to cut
government programs in
order to close budget deficits. If access to health and other
social services continues
to decrease, this will more strongly affect those that rely on

40. such services for
maintaining their basic health, i.e., groups within society living
in vulnerable
conditions.
However, there are alternatives to the currently hegemonic
neoliberal austerity
agenda as cracks in its consensus are already appearing. As can
be observed in
Greece, deep cutbacks in government spending can actually be
self-defeating as
budget deficits are likely to remain large due to the economic
decline and associated
revenue contraction that are the logical outcomes of austerity
measures. In
contradistinction to the austerity agenda, the global financial
crisis could be seen
as an opportunity to reinforce commitments to equity,
solidarity, and protection
(WHO 2011); this would require a significant redistribution of
power and wealth, for
example, through more progressive systems of taxation that
would ensure that those
at the top of the income spectrum, currently benefiting from
generous bail-outs of
the banking system, at least contribute a fair share to burden-
sharing within society.
Alternate agendas (e.g. enhanced social protection, expanded

41. universal social
protection, new systems of global taxation) are all part of global
discourse at the
moment (e.g. ILO 2011b), if not yet with the national political
or financial institution
traction needed to move from page to policy. Assuming they do,
even if only because
states will need to accommodate such demands to alleviate
increased domestic strife,
there may still need to be some budgetary cuts in the near- to
mid-term. If budget
cuts in certain areas turn out to be unavoidable, health equity
impact assessments
should be given a priority to determine how cuts can be
implemented in such a
manner that health equity will not be undermined further in the
policy response to
the global financial crisis.
Acknowledgments
Arne Ruckert was supported in this study through the Emerging
Researcher Award by the
Population Health Improvement Research Network (PHIRN),
funded through the Ministry
of Health and Long-Term Care, Province of Ontario. Ronald
Labonté is supported through
the Canada Research Chair Program of the Government of
Canada.

42. Note
1. Policy space can be defined as the freedom, scope, and
mechanisms governments have to
choose, design, and implement public policies to fulfill their
aims (Koivusalo et al. 2008).
276 A. Ruckert and R. Labonté
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Attention to Local Health Burden and the Global
Disparity of Health Research
James A. Evans1*, Jae-Mahn Shim2, John P. A. Ioannidis3

52. 1 Department of Sociology, Computation Institute and Center
for Health and the Social Sciences, University of Chicago,
Chicago, Illinois, United States of America,
2 Department of Sociology, University of Seoul, Seoul, Korea,
3 Departments of Medicine, Health Research and Policy, and
Statistics, Stanford Prevention Research Center,
Stanford University, Stanford, California, United States of
America
Abstract
Most studies on global health inequality consider unequal health
care and socio-economic conditions but neglect inequality
in the production of health knowledge relevant to addressing
disease burden. We demonstrate this inequality and identify
likely causes. Using disability-adjusted life years (DALYs) for
111 prominent medical conditions, assessed globally and
nationally by the World Health Organization, we linked DALYs
with MEDLINE articles for each condition to assess the
influence of DALY-based global disease burden, compared to
the global market for treatment, on the production of relevant
MEDLINE articles, systematic reviews, clinical trials and
research using animal models vs. humans. We then explored
how
DALYs, wealth, and the production of research within countries
correlate with this global pattern. We show that global
DALYs for each condition had a small, significant negative
relationship with the production of each type of MEDLINE
articles
for that condition. Local processes of health research appear to
be behind this. Clinical trials and animal studies but not
systematic reviews produced within countries were strongly
guided by local DALYs. More and less developed countries had

53. very different disease profiles and rich countries publish much
more than poor countries. Accordingly, conditions common
to developed countries garnered more clinical research than
those common to less developed countries. Many of the health
needs in less developed countries do not attract attention among
developed country researchers who produce the vast
majority of global health knowledge—including clinical trials—
in response to their own local needs. This raises concern
about the amount of knowledge relevant to poor populations
deficient in their own research infrastructure. We recommend
measures to address this critical dimension of global health
inequality.
Citation: Evans JA, Shim J-M, Ioannidis JPA (2014) Attention
to Local Health Burden and the Global Disparity of Health
Research. PLoS ONE 9(4): e90147.
doi:10.1371/journal.pone.0090147
Editor: Mohammed Shamji, Toronto Western Hospital, Canada
Received January 2, 2014; Accepted January 29, 2014;
Published April 1, 2014
Copyright: � 2014 Evans et al. 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.
Funding: This study was funded by a health and health policy
research for disadvantaged populations seed grant, Center for
Health Administration, and by a
Research Opportunity Seed grant, both from the University of
Chicago. The funders had no role in study design, data
collection and analysis, decision to publish,
or preparation of the manuscript.

54. Competing Interests: The authors have declared that no
competing interests exist.
* E-mail: [email protected]
Introduction
Poor and minority persons, as well as those living in resource
restricted regions, are more likely to live shorter, less healthy
lives
[1,2,3]. A long tradition in medicine has sought to reduce these
inequities and realize universal, global health through socio-
economic development, improved public health measures and
affordable health care [4,5,6,7]. Despite successes, there remain
concerns about the relevance and effectiveness of these efforts
for
disadvantaged populations. Target populations are sometimes
resistant and non-adherent to medical intervention. This has
inspired educational projects to enhance the public
understanding
of medicine [8,9] and practitioner understanding of diverse
patient
cultures.
Doubts persist, however, about whether we produce sufficient

55. medical knowledge to provide medical care for certain
conditions
in certain contexts [10,11,12,13]. Counter-intuitive findings
about
emergency care for African children suffering from malaria,
septicemia, meningitis and similar infectious diseases suggest
that
we know much less about diagnosis and treatment for poor
populations [14,15,16]. Moreover, effective therapies for
pandem-
ics such as HIV can create unforeseen knowledge needs like
how
to provide long-term medical care among HIV survivors
[17,18].
Here we examine whether the global research community has
given sufficient attention to medical conditions prevailing in
globally disadvantaged populations. We demonstrate how this
concern follows from the misalignment of global disease burden
and global research attention. Specifically, we reveal the global
inequality of health research by estimating the relationship
between the health burden imposed by many important diseases

56. and subsequent publication of biomedical articles relevant to
those
diseases. We also explore possible causes for this inequality of
health research.
Our findings highlight how poor populations not only face the
greatest burden from disease and disability, but that burden is
given the least medical research attention. We show that this
global inequality of health research follows from two processes.
First, medical research activities are guided by local health
needs
specific to each country rather than global health needs, and
health needs vary greatly across rich and poor populations.
Second, as medical research requires resources, a few developed
countries disproportionately produce the vast majority of
biomed-
ical research. As a result, global research attention to diseases
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57. tracks the global market for treatment and the ability of patients
to
pay for care. This has resulted in the current global inequality
of
health research. To reduce this inequality of research, our
analysis
recommends efforts that not only globalize the research
attention
of wealthy countries [19], but also support local research in
those
impoverished contexts where health knowledge is needed most.
Materials and Methods
Study Design and Key Measures
We assessed the total number of biomedical articles and also the
specific number of systematic reviews, randomized controlled
trials
and animal research relevant to a wide range of specific
diseases
and disabilities, and then explored how much of these
distributions
could be explained by 1) the global health burden imposed by
these conditions, 2) the global market for medical treatment,

58. and
3) the local health burden. We investigated these relationships
further by assessing differences in the health profiles of
developed
and less developed countries, and by measuring the association
between a country’s GDP and its production of biomedical
science.
To measure the amount of disease-specific biomedical research,
we used the total number of articles published on each disease
in
MEDLINE. We also calculated the precise number of systematic
reviews, randomized controlled trials, and research performed
on animal
subjects devoted to those same conditions. Each abstract in
MEDLINE is indexed with NLM Medical Subject Headings
(MeSH) [20,21]. We defined MEDLINE papers as relevant to
one
or more diseases if annotated with related MeSH clinical and
disease terms. We assessed this for each country by linking
MEDLINE with Thomson Reuters’ Web of Science, which

59. provides full institutional information for most MEDLINE
articles.
We then coded the countries of the institutions that hosted each
article author. See File S1 for details.
Number of total research articles is a reasonable indicator of
health research, but an imperfect proxy for biomedical
knowledge
more generally: some diseases are harder to understand,
prevent,
diagnose, and treat than others. For this reason, we also
assessed
the number of different types of articles: systematic reviews,
randomized controlled clinical trials, and animal subjects
research
associated with each disease. The number of systematic reviews
indicates that the biomedical community deems research on a
disease of sufficient size, and relevance that it merits secondary
evaluation and organization. The number of clinical trials is a
marker of organized research assessing the merits of
interventions
for a condition across many patients in one or multiple centers.

60. Finally, the number of research papers performed on animals
suggests an interest at fundamental aspects of each disease.
It should be noted that medical science can possess deep
knowledge of a disease that continues to cause harm because
that
knowledge has not yet disseminated to places where it is needed
most. Nevertheless, recent studies that demonstrate our limited
knowledge about treatment in resource poor environments [22]
suggest that even for diseases about which we have extensive
biological understanding, additional research into their distribu-
tion, acquisition, prevention and treatment among different
populations and in different contexts would likely produce
further,
much needed medical insight. Following this, we believe that
number of total articles provides a useful purchase on relevant
health knowledge as those articles cover the range of health
research, taking biological but also behavioral, social,
economic,
political and cultural factors into account, as many do here.
Number of systematic reviews, randomized control clinical

61. trials,
and disease-relevant research performed on animal models
provide more fine-grained insight about the relationship
between
health burden, research and treatment.
We used World Health Organization (WHO) data to measure
the burden of disease. The WHO introduced global and regional,
but
not country-level, estimates of the disability-adjusted life years
(DALYs) for an array of common conditions through its Global
Burden of Disease (GBD) project in 1990 [23]. In 2002 and
2004,
the WHO re-estimated DALYs for 192 countries as well as
globally [24]. One DALY refers to one healthy life year lost to
disease or disability. By converting time spent in various states
of
health to their ‘‘healthy-year equivalents,’’ [25] DALYs
incorpo-
rate cultural values placed on different aspects of physical,
mental
and social function [26]. The WHO estimates DALYs for 136

62. health conditions. We used 111 of the 136 conditions in our
analysis, excluding residual categories like ‘‘other infectious
diseases.’’ GBD codes for these conditions are organized into
19
categories, and 3 high-level classifications (see Table S1 in File
S1
for all codes).
We matched GBD codes to MeSH terms through the mediation
of ICD-9 (International Statistical Classification of Diseases
and
Related Health Problems) codes. ICD-9 codes are sufficiently
general that we mapped them onto GBD codes with very little
ambiguity. We then linked ICD-9 codes to MeSH through
NLM’s
Unified Medical Language System (UMLS) metathesaurus.
Following this approach, we regrouped MeSH disease terms
according to the 111 GBD codes and so estimated the number of
articles in MEDLINE relevant to a particular disease category
(see
File S1 for alternate linkages).
We measured the global market for treatment associated with

63. each
disease. First, we multiplied the number of disability-adjusted
life
years (DALYs) for each disease in each country by gross
national
income per capita (GNI) at purchasing power parity (PPP) in
that
country. This product equals the value of the revenue that could
be generated if everyone afflicted by the condition in question
was
restored to full health, or the size of a national market for
treatment, if people in that country were willing to spend all
money that could be gained from health on health. With the
same
disease profile, different countries have different markets,
depend-
ing on their GNI. We used the World Bank’s World
Development
Indicators for GNI (PPP) data for each country [27]. By
summing
all national markets for treatment for a given condition, we
computed the global market for treatment for that condition.
The

64. global market for a condition common in developed countries is
much greater than the market for a condition prevalent only
among less developed countries.
Statistical Analysis
We used regression-based analyses to estimate the association
between the burden of disease and the market for treatment on
the
quantity of medical research produced. Counts for each type of
disease-relevant article are not normally distributed: they are
discrete and widely skewed with a few diseases like breast
cancer
and AIDS attracting a disproportionate share of research
attention
while others like Chagas disease and leishmaniasis attracting
little
[19]. This recommended the use of negative binomial regression
models.
First, we analyzed the relationship between the global burden of
disease for 111 diseases and disabilities in one year (2002 and
2004) and the global number of articles published relevant to
those

65. conditions in the subsequent year. We subsequently analyzed
the
relationship of the market for treatment on the quantity of
subsequently published science. This analysis involved
4,703,021
disease and disability assignments to 3,771,604 distinct articles.
Local Health Burden and Global Research Disparity
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Our next analysis evaluated the correlation of burden of disease
within countries on the number of subsequently published
medical
articles, systematic reviews, randomized-controlled clinical
trials,
and animal model studies relevant to each disease by
researchers
from those countries. We estimated these models with data from
the 167 countries for which total article information was
complete
and 155 countries for which information about systematic
reviews,

66. randomized-controlled clinical trials and animal models studies
was complete.
Finally, we explored the relationship between poverty, disease
and disease-relevant science revealed by our regression
analyses.
We examined the difference in disease distribution between
developed and less developed countries by calculating the
relative
burden of disease for each country and then graphing and
modeling its relationship with that country’s gross domestic
product (GDP). We also assessed the relationship between
wealth
and the amount of research published by researchers in each
country.
Results
Our world-level analysis reveals that the global burden of
disease accounts for none of the distribution of total health
research
or the controlled trials published in the subsequent year (see
Table 1). For randomized controlled trials and animal model

67. studies, more global need is actually associated with less global
research. Systematic reviews responds positively to global
DALYs,
but only when the 19 broad disease and disability categories are
statistically controlled for. Figure 1 summarizes the alignment
of
health burden with health research, as grouped by broad disease
and disability category. This illustrates how malignant
neoplasms
(cancers), endocrine disorders (including diabetes), and skin
diseases are overrepresented in biomedical research, dispropor-
tionate to the global health burden they exact. In contrast,
infectious parasitic disorders, respiratory infections and
perinatal
conditions are underrepresented in the research relative to their
burden.
In contrast, the global market for treatment significantly
impacts
health research. Table 1 shows that for every $10 billion lost to
a
disease or disability, which might have been put toward care,

68. biomedical articles of all types of controlled trials devoted to
that
disease increased by approximately 3–5% in the subsequent
year,
controlling for health burden. Randomized control trials, which
are most expensive and closest to marketable health products,
increase most—by 5.2% the following year. These statistical
relationships between the number of articles of various types,
the
burden of disease, and the global market for treatment persist
when we controlled for the total cumulative number of articles
relevant to each condition and the proportion of those articles
published in the prior five years, but they attenuate when we
include indicator variables for 19 coarse disease and disability
categories. This means that much of the positive effect of
market
size on published research is attributable to different categories
of
disease, which are associated with larger and smaller markets.
These patterns remained unchanged in a supplementary analysis

69. using global DALY data from 1990 and 2004 (eTable 2). In this
analysis, disease burden remains insignificant, but growth in
market size (by $10 billion) leads to an increase of relevant
articles
by more than 10%, which attenuates when controlling for
disease
categories. These results together show that diseases prevailing
in
poor populations are given less overall research attention than
those common in wealthy populations. Although market forces
appear to be implicated in the publication of research articles of
all
types, in the following analyses we show how they are likely
not the
root cause of unequal health knowledge, but themselves a
consequence of global health and wealth inequality.
Our next analysis shows that within countries, disease burden
has a strong, significant association with many forms of health
research. For each 10 million DALYs lost to a disease within a
country, the number of articles published by researchers in that
country increased by 73.9% (see Table 2). The effect of local

70. burden is highest for randomized controlled clinical trials,
where a
million DALYs lost to a disease results in 367.9% more such
trials
in that year. Only the number of systematic reviews on a disease
do not vary significantly with recent DALYs lost to that disease
within country. Interestingly, systematic reviews do not respond
more to the amount of previous national or global research than
other kinds of research.
Global burden of disease has a small, independent association
with the publication of all research articles within countries,
and
with review articles and all clinical research when controlling
for
broad disease categories. This suggests that whether or not
researchers and funding agencies factor global health needs into
their research, the influence of local needs exerts much more
influence on their work. Alternative specifications of country-
authorship produced the same pattern of results (i.e., all
countries

71. with participating authors are assigned the article versus only
the
wealthiest country, which restricts the measure to indigenous
research; see File S1.
In order to reconcile the presence of a national association
between health burden and health research with the absence of a
global one, we explored how disease profiles and health
research
are correlated with national wealth.
Figure 2 illustrates the striking difference in disease profiles
among populations of rich and poor countries. These are evident
at the level of coarse disease classifications, but the differences
are
much larger at the level of individual conditions (see Table S3
and
Figure S1 in File S1). For example, consider the relative burden
of
infectious and malignant neoplasms (cancers) in rich and poor
countries. Infectious diseases like diarrheal diseases, malaria
and
HIV naturally levy a much higher toll in less developed
countries,

72. while cancers incur a larger burden in more developed countries
with longer life spans. Respiratory infections, perinatal
conditions
and injuries disproportionately afflict less developed countries,
while neuro-psychiatric conditions like depression and
schizophre-
nia and musculoskeletal diseases like arthritis and back pain
represent a greater burden in wealthy countries. Note the
conditions that most afflict poor populations only lightly affect
the rich (e.g., infectious diseases, respiratory infections,
perinatal
conditions), while diseases that most afflict rich populations
also
levy a substantial toll on poor ones (e.g., cancers, neuro-
psychiatric
and musculoskeletal disorders). Figure 2 also shows the
regional
dispersion of these health burden differences. The world’s least
developed countries are located in Africa, and to a lesser extent
South Asia and South America: so also disease burden clusters
regionally, largely correlated with country wealth.

73. There are, however, striking disparities among countries in the
capacity to produce health research. Figure 3 plots the
relationship
between country wealth and the publication of biomedical
research. This figure illustrates how wealthy countries publish
much more biomedical research than less wealthy countries.
National disparities in research are not surprising, as biomedical
research requires substantial resources. Nevertheless, combined
with the responsiveness to local health needs demonstrated
previously, research disparities result in the overrepresentation
of
conditions burdening developed countries and the
underrepresen-
tation of those afflicting less developed countries in the
research
literature. The inequality of research limits current quality of
care
Local Health Burden and Global Research Disparity
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74. Figure 1. 2004 global disability-adjusted life years (DALYs)
and 2005 research articles categorized by 19 broad WHO
disease and
disability categories. This correspondence suggests the loose
relationship between burden of disease and health knowledge
(see Figure S1 in File
S1 for the distribution of different types of articles by disease).
doi:10.1371/journal.pone.0090147.g001
Table 1. Estimated Association of Global Biomedical Articles
with Global Health Burden (2002, 2004)
a
.
Model 1: All research articles % change 95% C.I. % change
95% C.I. % change 95% C.I.
Global DALYs (10 millions) 25.1 210.7–1.0 23.9 29.3–1.7 3.3
23.1–10.2
Market size ($10 billions) 3.6** 2.2–5.0 3.0** 1.6–4.4 1.3
{
20.1–2.8
Cumulative Global articles (10
thousands)
3.0** 2.2–3.8 10.3** 7.0–13.6
Model 2: Systematic reviews
Global DALYs (10 millions) 20.9 210.3–9.4 0.8 28.6–10.2 11.6
{

75. 21.8–25.1
Market size ($10 billions) 2.7** 0.8–4.6 2.0* 0.1–3.9 0.4 21.8–
2.7
Cumulative Global articles (10
thousands)
23.5** 14.0–33.8 12.5** 5.5–19.9
Model 3: Clinical trials
Global DALYs (10 millions) 211.2* 220.9–20.3 27.1 213.1–8.1
6.6 26.0–20.9
Market size ($10 billions) 5.2** 2.5–7.9 3.2* 21.6–3.0 1.1
21.5–3.8
Cumulative Global articles (10
thousands)
561.8** 275.8–1065.7 341.2** 142.2–703.6
Model 4: Animal subjects
Global DALYs (10 millions) 28.0{ 215.8–0.5 24.7 214.0–3.6
1.1 27.4–10.2
Market size ($10 billions) 3.8** 1.1–6.5 1.9
{
20.4–3.0 1.0 21.3–3.3
Cumulative Global articles (10
thousands)

76. 35.9** 26.7–45.8 29.1** 19.1–39.9
Controlling for disease
`
a
Models in 1A contain 222 cases (111 diseases in 2002 and
2004).
`Models control for the 19 broad disease/disability categories
listed in Figure 2 (including the 2 in the footnote).
{
p ,.10;
* p ,.05;
** p ,.01
doi:10.1371/journal.pone.0090147.t001
Local Health Burden and Global Research Disparity
PLOS ONE | www.plosone.org 4 April 2014 | Volume 9 | Issue
4 | e90147
in less developed countries, but it also limits the next
generation of
care there, as the science and technology that could be
transferred
to developing countries are less relevant to their most pressing
health needs.
Discussion

77. Our analysis demonstrates that the production of health
research in the world correlates with the market for treatment
and not the burden of disease. While we expected to find a weak
relationship between global health and medical research, we
find
no relationship. One prior study that found a modest correlation
between the amount of systematic review papers and global
burden of disease [11], our research reveals the fragile nature of
this relationship. Clinical trails and case reports have no
relationship to global burden, and systematic reviews only post
a
small influence when disease categories are held constant. This
means that existing global health research is less relevant to the
needs of poor populations.
More importantly, we show how this global pattern is related to
the local processes of health research: 1) local health needs
within a
country draw the attention of researchers and research resources
of the country more than global health needs [13,19], 2)
developed

78. countries and less developed countries have divergent health
profiles, and 3) developed countries produce much more health
research of all kinds than less developed countries [10]. In
short,
health needs from less developed countries do not attract much
attention among rich country researchers. Ultimately, this
article
stresses that poor populations are in double jeopardy: they
experience the greatest health burdens but their diseases have
been studied least and even researchers from wealthy countries
often lack secure knowledge for context-relevant treatments.
Systematic reviews, which are not driven by local needs, attend
to research slightly more relevant to global health needs, but
this
correction is very small.
These findings have relevance for international development
and health policy. The primary focus of international health
efforts
has been to extend health care innovations from developed
countries to less developed and comparatively less healthy

79. countries. This is good policy: as we demonstrate, conditions
that
incur the highest health burden in wealthy countries like cancers
and musculoskeletal disorders are relevant also to poor
countries.
They are, however, not the most burdensome health challenges
for
those countries. Even global health initiatives, which often
target
specific diseases relevant to less developed countries and have
succeeded in reducing some health inequities, are not always
sufficiently aligned with country priorities or countries’
burdens of
disease [28,29].
Others argue that the biggest health challenges are the result of
inferior environmental contexts (e.g., increased air and water
pollution or sanitation), and so efforts to reduce global health
inequity should focus on economic development and public
health.
This position is not unreasonable, but understates the possibility
that we lack appropriate knowledge to intervene in
impoverished

80. environments or those simply different from rich countries. For
example, recent research demonstrates that child hydration, a
long-promoted emergency care measure for children suffering
from infectious disease in resource poor sub-Saharan Africa
Table 2. Estimated Association of National Biomedical Articles
with National Health Burden (2002, 2004)a.
Model 1: All research articles % change 95% C.I. % change
95% C.I. % change 95% C.I.
National DALYs (10 millions) 73.9** 17.4–130.5 72.4** 18.0–
126.7 68.4** 15.1–121.7
Global DALYs (10 millions) 1.0* 20.9–2.8 0.7** 21.1–2.5
5.0** 3.0–7.0
Cumulative National articles (thousands) 1.1** 0.8–1.3 1.2**
1.0–1.4
Cumulative Global articles (thousands) 0.3** 0.2–0.3 0.3**
0.2–0.3
Model 2: Systematic reviews
National DALYs (10 millions) 27.4 241.6–96.4 23.9 241.4–89.2
23.5 241.7–88.7
Global DALYs (10 millions) 0.2 23.0–3.4 20.1 23.2–3.0 7.5**
3.9–11.1
Cumulative National articles (thousands) 7.3** 5.0–9.5 8.9**

81. 6.6–11.2
Cumulative Global articles (thousands) 2.5** 2.0–2.9 1.7**
1.1–2.3
Model 3: Clinical trials
National DALYs (10 millions) 367.9** 92.3–1038.6 297.6**
80.8–774.6 285.6** 81.7–718.3
Global DALYs (10 millions) 3.1
{
20.1–6.3 1.9 21.1–4.9 7.9** 4.5–11.5
Cumulative National articles (thousands) 57.7** 41.7–75.5
73.9** 56.0–93.8
Cumulative Global articles (thousands) 26.9** 23.2–30.7 16.9**
11.9–22.0
Model 4: Animal subjects
National DALYs (10 millions) 90.8** 242.5–90.4 87.1** 20.3–
190.9 81.1** 17.0–180.3
Global DALYs (10 millions) 0.6 22.9–3.4 0.4 21.8–2.6 1.4
21.1–3.9
Cumulative National articles (thousands) 10.7** 9.3–12.2
11.1** 9.6–12.5
Cumulative Global articles (thousands) 1.4** 1.1–1.7 1.2**
0.7–1.6
Controlling for disease`

82. a
Models in 2B contain 8102 cases (up to 111 diseases and 192
countries in 2002 and/or 2004).
`Models control for the 19 broad disease/disability categories
listed in Figure 2 (including the 2 in the footnote).
{
p,.10;
* p,.05;
** p,.01.
doi:10.1371/journal.pone.0090147.t002
Local Health Burden and Global Research Disparity
PLOS ONE | www.plosone.org 5 April 2014 | Volume 9 | Issue
4 | e90147
Figure 2. Broad disease categories, the global DALYs they
exact, and the relationship between country health burden and
wealth
for broad disease categories. Disease subcategories (e.g.,
HIV/AIDS) are listed in order from those that incur the largest
global health burden.
Scatter plots graph country DALY rate (DALYs per 1000
people) of conditions by GDP per capita, plotted on a log scale;
slopes represent this as a
linear relationship (the estimated OLS coefficient of logged
GDP per capita regressed on logged DALY rate). The global
map illustrates country
differences in disease burden by plotting the difference between
DALY rate for infectious diseases and cancers, categories with
the most negative
and positive relationship with country wealth.

83. doi:10.1371/journal.pone.0090147.g002
Local Health Burden and Global Research Disparity
PLOS ONE | www.plosone.org 6 April 2014 | Volume 9 | Issue
4 | e90147
increases short-term mortality [22]. One conclusion voiced by
Ugandan doctor Peter Oluput-Oluput is that ‘‘we need to do
more
research in Africa for Africans.’’ [30] This suggests the
importance
of transferring not only health technology like tertiary care
facilities to the least developed countries, but also helping to
transfer health research technology to impoverished locations
with
health burdens that differ most from wealthy countries. These
recommendations do not presume what less developed countries
should want or how they should spend their limited resources
and
balance urgent with long-term health needs. Neither do they
address the material inequalities that lie behind inequality in
both

84. health and health knowledge. Our research simply highlights the
potential impact of more health research relevant to the needs of
the poorest populations.
Not only environmental but the biological context of disease is
likely to be different in less developed countries. Research
suggesting that treatment for some cancers may be less effective
in certain U.S. minority populations suggests that current
therapies may have been ‘‘overfit’’ to a biased sample of genes
and bodies [31]. A growing collection of related findings have
been
framed as evidence that biological factors play a role in health
disparities [32,33,34,35,36], but they also implicate the
differential
relevance of health knowledge produced by biomedical research
for the health of different groups [37]. In short, the same care
may
not always be equal. In this way, the inequality of biomedical
research that our analysis demonstrates likely understates its
true
inequality.

85. By estimating the particular inequality of health conditions in
relation to national wealth (see Figure S1 in File S1), our study
highlights those most likely to be underserved given the
national
focus and global inequality of research funding. For example,
malaria, tetanus, Chagas disease, measles, Vitamin A
deficiency,
lymphatic filariasis, schistosomiasis, and diphtheria most
dispro-
portionately afflict poor populations. Other conditions also
inflict a
greater burden in less developed countries, including fires,
violence, drowning, and poisoning, as also glaucoma, peptic
ulcers
and ear infections.
Our study has several limitations. The national-level burden of
disease data are only for two years, two years apart, which does
not provide sufficient change to isolate a causal effect of health
burden on research (see File S1). The lag between burden of
disease and disease-relevant publication may also not be long
enough to demonstrate the total influence—we had only one

86. year
of subsequent citation data available to us. Moreover, we did
not
have data on the economic value of diseases within countries,
and
so we were unable to explore to what degree the same dynamic
that occurs across countries occurs inside them. Finally, we
neglect
several other institutions that likely influence health research,
independent of global health needs. These include national
funding priorities, activism in disease communities, the
scientific
maturity or generality of research on some disorders over
others,
etc. Nevertheless, we believe that our analysis sheds light on
the
global inequality of health research and suggests that attention
to
local disease is likely a primary influence. To address global
health
Figure 3. Relationship between the national GDP per capita in
2004 and the quantity of research published by researchers in
2005,
by country, plotted on a logarithmic scale (to spread out