Is the world flat?

Is the world flat?

Inequality: a mean kind of variation

Twin peaks: the unequal world

Berlin 9 November 1989

The Cold War's final frontier

Infant mortality/1000 North 42 South 6 Years lost to chronic illness (%) North 46 South 72

Friedman's flatteners

#1 No boundaries #2 Netscape #3 Workflow software #4 Open sourcing #5 Outsourcing #6 Offshoring #7 Supply chaining #8 Insourcing #9 In-forming #10 Digital "Steroids"

Representing one's country?

Bangalore: the poverty gradient runs steeply down from

Infosys

6000 5000 4000 3000 2000 1000 0 Divergence, Big Time!

Lant Pritchett 1995 1820 1870 1950 1.29

Annual % growth 0.03

-0.11

India China 1.03

Mexico W Europe

The Great Divergence, 1800-2000

Growing differences in income per person arise because: 1. Variable efficiency of production per worker 2. Medicine lowers subsistence wage 3. High technology raises wage premium for skilled labour

The World is not Flat: Inequality and Injustice in our Global Economy

Nancy Birdsall

"Inequality in developing countries… stalls [economic] growth… vicious circles inhibit the creation of effective social and political institutions"

Gini: a digression on measuring inequality Gini index Equality = 0 Inequality = 1

GINI

Cumulative share of people from low income

10 8 6 -2 -4 -6 4 2 0 Gini: out of the bottle rich-poor income gap widening in most countries

60 50 Increasing inequality among countries within different regions of the world E Europe E Asia OECD SS Africa S Asia L America 40 30 20 1970 1975 1980 1985 1990 1995 2000

Birdsall: failing markets, failing health?

14 12 10 8 6 4 2 0 30 Income inequality slows economic growth Korea Singapore Hong Kong Thailand Chile Indonesia Colombia Brazil Mexico Philippines Venezuela Peru Bolivia 35 40 45 50 55 Average income Gini 1960s-90s

Income inequality without opportunity or mobility, also: Undermines public policy Inhibits collective decision-making

60

Disfavours those without assets Raises costs for poor

The Bottom Billion

Paul Collier

58 countries, mostly in Africa, persistently low income, trapped by: Conflict 73% Valuable natural resources 29% Geography (landlocked) Bad governance 30% 76% Health at the mercy of economics?

Convergence, Period!

Health in an Unequal World

50 40 30 80 70 60 Life expectancy is converging in low and high-income countries Low-middle income High income 1960 1990 2002

80 Life expectancy increased most in Asia and L America, least in Africa and OECD 1970-75 2000-05 70 60 50 40

10 8 -2 -4 2 0 6 4 Life expectancy gains and losses worldwide since 1960 1960-1990 1990-2002

-10 -20 -30 -40 -50 -60 -70 -80 0 1970 Slow fall in child deaths in low-income countries, widening gap 1975 1980 1985 1990 1995 High Upper middle Lower middle Low 2000

Maternal mortality: widening gap between Africa and the rest 1000 900 800 700 600 500 400 300 200 100 0 S S A fr ic a -1.8

O ce an ia % reduction 1990-2005 -22.2

A si a -19.7

-36.3

N A fr ic a La tin A m er ic a -26.3

E E ur op e -12.5

D ev el op ed 1990 2005 -23.6

40 30 20 10 0 poorest 1 Children in Thailand: fewer deaths, more equality 1990 census 2000 census 2 3 Wealth quintiles 4 richest 5

Gorbachev, Glasnost & Green Cross "cultivating a new sense of global interdependence"

60 55 50 45 40 1980 Soviet collapse widens health gap men & women by education level women - university women - primary men - university Berlin Wall 1985 1990 1995 men - primary 2000

160 140 120 100 80 60 40 20 0 0 Infant mortality is lower in urban areas 20 40 60 80 Urban 100 Sub-Saharan Africa Asia Pacific Arab States Latin America C&E Europe, C Asia 120 140 160

4 3 2 1 0 0 But child mortality is more unequal in urban areas 1 2 3 Mortality poorest/richest, rural Under 5 Infant 4

Health in Unequal Britain

"Riven by class and no social mobility"

• • • • •

The Guardian No change in 10 years of Labour rule 89% say they are judged by class Poll shows deep North-South gap North-south divide will narrow but not rich-poor gap Wide life expectancy gap between rich and poor

Variation in life expectancy in England from northern uplands to southern lowlands

Smoking deaths are higher in northern England and London

30 20 10 0 60 Much of the variation in mortality betwen social classes is due to smoking England & Wales Poland 50 40 Other causes Smoking high middle low high middle social class education low Source: P Jha Lancet 2006

Obesity in England

highest in midlands and north

Lowest in: London South east South west

<£100 £200+ £300+ £400+ £500+ £600+ £700+ >£770 0 Mental illness is more frequent in children of poorer British families Prevalence of mental disorder, 2004 (% ) 5 10 15 20 boys girls

Whitehall civil servants: lower grades die younger

80 70 60 50 40 30 20 10 0 Admin Professional Clerk Other 40-64 yr 65-69 yr 70-89 yr

"The attainment by all peoples of the highest possible level of health"

Who wants to fix it?

"a common consensus to invest in the future"?

The post-war health agenda

1946 1946 1947 World Health Organization Marshall Plan UK National Health Service (welfare state) ------------------------------------------------------- 1950s "Vertical" eradication programs 1960s Barefoot doctors - community 1978 1979 care Primary Health Care (Alma Ata) Children's Revolution

"Health for All"

Halfdan Mahler (WHO 1978) Moral leadership for social justice Primary Health Care Appropriate technology Care in the community Link health and social development

Critics: too costly, politically threatening

"Children's Revolution"

Jim Grant (UNICEF 1979) Finite resources, brief political opportunities GOBI Growth monitoring Oral rehydration Breast feeding Immunization

Critics: narrowly technocentric

1980s: the neo-liberal consensus

"Health sector reform"

limit public expenditure, decentralization, economic efficiency

"Structural adjustment"

trade liberalization, privatization of public services, export economy

Clinical economics

The end of poverty by 2025 You two?

"I am a Jeff Sachs groupie" (Bono)

Incentives

William Easterly

Bottom Billion

Paul Collier "The grievous truth is that… the bottom billion will not —and cannot—be freed from poverty in our lifetimes." • Targeted AID • Military interventions • Anti-corruption laws • Concessional trade agreements • Help your local hero "international welfare for a long time…to bring minimal decency to standards for living"

Technological fix

Bill Gates

World Economic Forum, Davos 2006 Bill Gates pledges another $900m for TB control

Social fix

Michael Marmot

The world is getting flatter

but deep troughs remain • Poverty gap -- inequality – sometimes puts a brake on economic growth, and on health gains • Health is getting better on average in most parts of the world – globalization?

• Health gaps (life span) have narrowed with poverty gaps, perhaps even faster but… • Some countries and populations have been left behind, mostly Africa+ • Technical solutions to promote health equality easier than social and economic solutions