How do we manage disparity?
I’m not talking about the recommendations we make in our reports on the social determinants and how to address healthcare inequality. I’m talking about how we live our lives.
Our work is full of accounts of injustice. While there are success stories, policy victories and research breakthroughs, our work is often sad and infuriating. We read of and speak to marginalized people denied healthcare, financially ruined by illness, disrespected in health care facilities, and struggling to access the food, employment, housing, water and sanitation needed to live well. And when we’re not working, injustice remains ubiquitous. It is particularly visible in low and middle income countries where many of us live or visit. I’m sure we’ve all experienced the anguish of a child begging us for change, or the dissonance of passing a slum on the way to a secure and comfortable home. The disparities in high income countries may be less stark but are nonetheless visible. Moreover, the international dealings of high income countries often support deepening global disparity. Whether we see it or not, disparity is there.
We work in public health; being confronted with injustice is a part and parcel of our jobs. We want to develop strategies and critiques that contribute to better health systems for all and ultimately achieve health for all.
But beyond our official capacity, how do we reconcile our broader lives with our professional ethics? And what about that grey-zone in between: our offices, salaries and official travel?
How lavish should our conferences be? What kinds of hotels should we book for our visitors and ourselves? For that matter how expensive should our own homes be? Our clothes and gadgets? What kind of healthcare should we secure for our loved ones?
Some find it easy to sneer at the “Development Set”, satirizing those who “discuss malnutrition over steaks” and live in posh homes decorated with ethic knick-knacks picked up from field visits. Then there are passionate activists who live with only the most basic belongings and give away all their money.
Others suggest there is no inherent conflict between tackling social issues and earning like your friends in banking or similarly lucrative professions. Why shouldn’t travel for work be comfortable and why can’t one seek financial stability? Impoverishment is not a pre-requisite to do good research on the social determinants of health. In fact, attracting more bright minds to socially oriented work and motivating them with payments and perks may go a lot further to change the world than expecting a few selfless saints to move mountains on their own.
Many fall somewhere in the middle. It’s not feasible to give away everything and live like Mother Theresa—and probably not that useful either if we end up burnt out. We may tell ourselves that we are trying to change policies and systems that will have broad positive implications, not toss around charity that eases our discomfort. We may note that our motivation to solve issues of disparity is grounded in a belief that everyone should have access to the good quality healthcare and broader opportunities and safety that we enjoy. We may each rationalize our comforts by saying we’re trying to bring the quality of life for the poor up, not drag the quality of life for everyone else down to an unacceptably low level.
It still feels wrong to interview a woman in rural poverty about her daily struggle to survive and then eat a meal that costs more than she earns in a week.
It still feels wrong to discuss the poorest of the poor surrounded by opulence at international conferences.
The poem “The Development Set” certainly still stings.
Can everyone really live like us? Are we really going to win a war on poverty without fighting a war on wealth? How much does our own expenditure and resource consumption, at home and at work, have to go down to sustain a fairer standard of living for all?
Perhaps we need to set a common maximum in our field, to match the common minimums we seek for the poor. Place a cap on aspects of expenditure and compensation that allows for a good life without contributing to widening the gulf between the haves and have-nots. However the logistics of doing such an exercise—of essentially defining “enough”—are complex, difficult and subjective. But I think it’s a conversation we need to have.
In the short term, in our own lives, what do we do?
Ultimately, I guess we all need to make peace with this messed up world in our own way.