Andrew L. Yarrow is a senior research advisor at Oxfam America who studies inequality and low-wage work in the US.

What do high Gini coefficients and diabetes, regressive taxation and cardiovascular disease, and low minimum wages and respiratory ailments have to do with each other? More than most people—even physicians and economists—may think.

It’s not news that economic inequality in the United States has sharply increased during the last 30 years. It’s also not news that super-sized soft drinks, the easy availability of assault weapons, and the lack of health insurance for 49 million people are tragically cutting many American lives short.

What could be big news is that inequality in the United States may be a factor contributing to Americans’ poorer health, especially compared to Western Europeans, Japanese, Canadians, and Australians.  According to a massive new report by the National Research Council and the Institute of Medicine, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” the United States ranks dead last among 17 rich countries in life expectancy and at or near the bottom in nine key health indicators, ranging from infant mortality, obesity, and heart disease to homicides, chronic lung diseases, and sexually transmitted diseases (STDs).

Table courtesy the paper's authors.

These international health rankings look remarkably similar to inequality rankings by the Organization for Economic Cooperation and Development (OECD). Denmark, Norway, and Sweden hover near the top with the best health outcomes and the least social inequality; France, Germany, the Netherlands, and Canada are in the middle of both rankings. The US and Portugal are at the bottom.

Among the 17 countries studied, the United States now has the greatest disparity in wealth between the richest 1 percent of households, whose $16.4 million average net worth is 288 times that of the median household. The US also has the lowest male life expectancy and the lowest probability of its citizens surviving to age 50. Likewise, average incomes of the top 1 percent are more than 70 times higher than those of the poorest fifth of Americans—much greater than in Western Europe or Japan. And finally, the US has the dubious distinction of having the highest rates of infant mortality, STDs, and deaths from car crashes and gun violence.

Table courtesy the paper's authors.

Even fatal illnesses that our state-of-the-art medicine might be controlling, such as heart and lung diseases, are more likely to kill Americans than they are to kill citizens of all but one other country in the study. And the gaps have been widening, as America has been slipping farther behind other developed countries in health outcomes during the last 30 years.

Some might chalk this up to the fact that, prior to Obamacare, the US has had the highest proportion of people without health insurance. Others, pointing to the fact that the poor tend to be less healthy, would be right to note that the US has the highest poverty rate of the countries studied.

Yet, neither lack of health insurance nor poverty fully accounts for America’s miserable health ratings. Even well-to-do, white, college-educated Americans with health insurance fare less well than their counterparts in almost every other rich country.

While the report devotes only a paragraph to the role of high economic inequality, other researchers—notably Richard Wilkinson and Kate Pickett, authors of The Spirit Level: Why More Equal Societies Almost Always Do Better—argue that highly unequal income distribution harms all members of society. They posit that social stress, status anxiety, social competition, and lack of trust born of inequality lead to poorer health.

“Shorter lives and poorer health will ultimately harm the nation’s economy as health care costs rise and the workforce remains less healthy than that of other high-income countries,” concludes the authors of the National Research Council and the Institute of Medicine report.

Moral arguments against excessive inequality have recently been supplemented by macroeconomic evidence that inequality hinders economic growth and contributes to greater economic volatility. Now, we may add that inequality is medically harmful. This, in turn, brings the argument full circle.

Trade can be an engine for development if its benefits reach those living in poverty. Oxfam has argued for this for more than a decade. Philip Stevens of the Emerging Markets Health Network, in a Wall Street Journal Asia op-ed at the end of last year, calls this “NGO scaremongering.”

Stephanie Burgos, Senior Policy Advisor for Trade

Stephanie Burgos, Senior Policy Advisor at Oxfam America, responds in this letter to the editor.

***

The TPP Would Be a Bitter Pill

Philip Stevens’s diagnosis of the Trans Pacific Partnership Agreement and Oxfam’s perspective on it (“Free Trade is Good for Health” op-ed, Dec. 18) is plain wrong.

Oxfam has long been a supporter of trade for development and economic growth, provided rules are fair for rich and poor countries alike. The Trans Pacific Partnership Agreement (TPP), however, only favors multinational drug companies through new intellectual property (IP) rules at the expense of the health of millions in developing countries.

Generic competition, which begins when monopoly protection for medicines expire, is the way countries can reduce medicine prices. New IP rules delay generic competition and thus low-cost medicines in developing countries. Poor people go without treatment or make dire economic sacrifices.

The World Health Organization’s list of essential medicines avoids recommending patented medicines, despite their public health value, because they are too expensive. Mr. Stevens cites the list as evidence that patents don’t matter, when it is precisely a testament to the unfairness of excessive IP rules. Suggesting that developing country patients should be satisfied by access to a limited range of older treatments is outrageously unfair.

Mr. Stevens defends data exclusivity because it generates profits for drug companies, but fails to mention its negative impacts on public health. Oxfam’s research in Jordan, which introduced data exclusivity in 2001 under a U.S. trade agreement, showed the measure significantly contributed to a 20% increase in medicine prices. Other rules demanded by the U.S. will also invite abuse of the patent system by drug companies, tie the hands of governments who want to negotiate prices with drug companies, and distract drug regulators from focusing their efforts on ensuring the safety of medicines.

Intellectual property rules must be calibrated to ensure incentives for innovators are balanced with broader public interests. The IP rules proposed by the US in the TPP upset this balance. This is not a matter of perception. It is right there on paper at the negotiating table.

Five years ago, the U.S. revised trade agreements with Peru, Panama and Colombia to limit the damage the agreements could wreak to public health, but deep-pocketed special interests are now holding the U.S. back.

Here’s to hoping that won’t be the case in 2013.

Rohit Malpani is a campaigns advisor at Oxfam and leads the organization’s access to medicines campaign. Oxfam’s response to Progressive Economy’s “Trade Fact of the Week” 11/28/12 is cross posted from the Progressive Economy blog.

Oxfam disagrees with the analysis set out in your November 28 article about patent protection for medicines. The article incorrectly explains the TRIPS Agreement, and we do not believe there was ever a global consensus in support of the intellectual property (IP) approach promoted by USTR, as implied in your article.

The TRIPS Agreement sets out minimum standards for IP protection, and explicitly includes a series of exceptions and limitations to IP rights that may be used by governments in order to achieve public policy objectives, including improvement of health outcomes. We have long been puzzled by efforts to portray compulsory licensing as a legal tool that may only be used during health “crises” or “emergencies”. Put simply, this interpretation is unsupported by the text of the Agreement itself. Similarly, the Doha Declaration confirms the right of countries to use all IP flexibilities in TRIPS “especially”—not “only”—in relation to health emergencies and pandemics.

We question the “policy calm” that you state has existed for 10 years in relation to patented medicines. In fact, that “policy calm” has never existed. Instead, there have been on-going tensions due to the endless efforts of the USTR, under pressure by the multinational pharmaceutical industry, to renegotiate the terms and conditions of the TRIPS Agreement through other means, and especially to strip away the public health limitations and exceptions that were included in the TRIPS Agreement in 1994. Developing countries are finding increasingly that they must endure against these tensions and challenge the pressure because many patients in their countries cannot obtain the medicines they need – especially newer treatments that are still under patent protection, which tend to be out of reach. Certainly governments in poor countries should allocate more money to health care, but the exorbitant prices of many patented medicines, an increasingly familiar problem in the United States, are an absolute barrier to health care coverage in resource-deficient countries.

Together with other humanitarian groups, we have documented a persistent, severe lack of access to new treatments and quality health care across developing countries, with the lowest income groups most affected. Upgrading health infrastructure is a crucial part of the solution, as is use by governments of all the policy options available to them, including IP flexibilities, to promote the availability of quality, low-cost versions of new treatments for their populations.

Medicines, including but not only “essential medicines” as identified by the WHO, are an important component of healthcare. Depending on their affliction, patients need access to quality, effective treatments regardless of whether these are on the WHO essential medicines list (EML). Moreover, medicines are selected for inclusion in the EML based on a range of factors, including affordability; because patent-protected treatments are more expensive, they are generally not included in the list. This is a critical flaw in the papers cited in your analysis, which found—unsurprisingly—that many medicines on the EML are off-patent.

Health care also does not only refer to AIDS, TB and malaria. To say that India has a “relatively small patient population” with cancer and other non-communicable diseases is wrong. Today, the World Health Organization notes that 80 percent of all non-communicable diseases (cancer, heart disease, diabetes) are in low-income countries, especially as life-styles and eating habits undergo a dramatic shift. By some projections, there are up to 2.5 million cases of cancer in India today. Likewise, by 2025, India will have over 75 million cases of diabetes. These are not problems which can be addressed through charity and insurance. They require serious, Marshall-Plan like investments by governments to both prevent development of these diseases and, inevitably, to provide treatment to ensure that their own citizens can lead healthy lives.

Improving health outcomes in the developing world will require substantial investments in health infrastructure, services, and medicines. At the same time, we urge governments to use policy tools available to them to promote availability of quality, effective treatments at the lowest possible cost.

Today’s guest blog is written by Porter McConnell, senior policy advisor and Aid Effectiveness Team member.

Today is World Health Day. And the world is on the brink of eradicating polio. It’s hard for most of us to remember that before the polio vaccine, the disease crippled an average of 1,000 children every day. My own father was one of those children. He recovered full use of his legs, thanks to treatments at the Roosevelt Warm Springs Institute in Georgia, one of the earliest rehabilitation centers in the country.

But few children in developing countries have access to the kind of health facilities my dad did in the rural US. And vaccines are a tricky thing. They need an accessible primary care system to prevent resistance and keep the disease at bay for good. Diseases like polio that we have nearly eradicated have a tendency to reappear again when the global “big push” programs are over.

But there’s good news: five million people are now walking thanks in part to polio vaccine support from the US. The polio vaccine has not only saved lives, it has saved US taxpayer dollars: an estimated $180 billion that would have been spent treating polio victims has been averted. The US really stepped up its game with President Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). The trend continues under President Obama. In 2009, the Global Health Initiative (GHI) was launched. The GHI redoubles US efforts to strengthen health systems, so countries can ultimately care for their own. GHI makes all this progress on HIV, TB, malaria, polio, and other infectious diseases sustainable by strengthening local health systems, and training health workers to manage routine care and prevention. The US is shifting from emergency mode to working with governments and civil society to determine the long-term health needs of their country.
Read the rest of this entry »