Bridging the health divide

More information, better health?

Dr Sally Wyatt President, EASST and Associate Professor, ASCoR, University of Amsterdam, The Netherlands

“The world today is divided between those who have access to health services and those who do not. A similar divide affects the flow of information and communications.”

Health Inter Network (HIN), a major WHO initiative launched by the Secretary-General of the United Nations in September 2000 aims to bring together international agencies, the private sector, foundations, non-governmental organizations and local or country partners to ensure equitable access to health information and to improve public health by facilitating the flow of health information, using the Internet. This is very laudable, and already, in order to address one aspect of the information gap, more than 2000 health and medical journals have been made available, free to countries with a per capita GNP of less than US$1000, and on a sliding scale for countries with a higher per capita GNP. In order to gain access to this wealth of information, eligible institutions need a computer connected to the Internet with a high-speed link, and therein lies just one of the problems implicit in this initiative. There is certainly a global digital divide.

We live in a world with massive inequalities in terms of access to new information and communication technologies including the Internet, as seen in Tables 1 and 2. At the simplest level of technical infrastructure, there is a very uneven geographical distribution of high speed links. In terms of use and access, high income OECD countries have 400 Internet users per 1000 people while South Asia has only 6.3 and sub-Saharan Africa has 7.8 users per 1000 people.
Table 1: Access to technologies, per 1000 people, 2001

Country	Telephone Mainlines	Cellular subscribers	Internet
India	38	6	7
Netherlands	621	767	491
United States	667	451	502
Zimbabwe	22	29	9

Source: UNDP 2003

Table 2: Inputs to innovation, 1996-2000

Country	R & D expenditures as % of GNP	Scientists & engineers in R&D, per million people	Health expenditure per capita, 2000,US$
India	12	157	71
Netherlands	2.0	2572	2216
United States	2.7	4099	4499
Zimbabwe	Not available	Not available	170

Source: UNDP 2003

We also live in a world marked by massive health inequalities, as Tables 1-4 demonstrate. People in countries like the Netherlands and the US can expect to live twice as long as someone born recently in Zimbabwe. Some diseases, such as malaria, are practically unknown in western countries; others, including HIV/AIDS are much less of a burden in richer countries.
Table 3: Selected health problems for four countries

Country	1	2	3	4	5
India	24	0.79	7	199	112
Netherlands	0	0.21	0	3	2775
United States	0	0.61	0	2	2092
Zimbabwe	38	33.73	5410	291	493

Source: UNDP 2003

Table 4: Health indicators, for four countries

Country	1-Men	1-Women	2	3%	4%
India	60	61.7	48	28	0-49
Netherlands	75.8	80.7	251	100	95-100
United States	74.3	79.5	276	100	95-100
Zimbabwe	37.1	36.5	14	62	0-49

Source: UNDP 2003

Of course, people in richer countries have to die sometime and of something. Table 5 summarises the major risk factors facing developed countries and those developing countries, including India, with particularly high mortality rates. One interesting feature of Table 5, and also Column 5 in Table 3, is about the risks of tobacco, a leading cause of illness and death in developed countries. People in developed countries are aware of the risks of smoking. There have been public health campaigns for many years. There are also high levels of tax on tobacco as well as increasingly stringent laws to restrict smoking in public places. Despite all of these measures, many people in rich countries continue to smoke. Clearly, more information is not always the solution. Sometimes people want to engage in risky behaviour.
Table 5: Leading risk factors, as causes of disease burden

Developing countries – high mortality, incl. India	Developed countries
Underweight	Tobacco
Unsafe sex	Blood pressure
Unsafe water, sanitation, hygeine	Alcohol
Indoor smoke from solid fuels	Cholesterol
Zinc deficiency	Overweight
Iron deficiency	Low fruit & vegetable intake
Vitamin A deficiency	Physical inactivity
Blood pressure	Illicit drugs
Tobacco	Unsafe sex
Cholesterol	Iron deficiency

Source: WHO 2002

Problems Undernourished people as % of total population, ’98/’00 People living with HIV or AIDS, % aged 15-49, 2001 Malaria cases per 100,000 people, 2000 Turberculosis cases per 100,000 people, 2001 Cigarette consumption per adult, 1992-2000, average Note: Recent press reports (Frith, 2003) suggest that the proportion of the population infected with HIV/AIDS is much higher in India than admitted by its government. Indicators Life expectancy at birth, 2001 Physicians per 100,000 people, 1990-2002 Population with access to improved sanitation, 2000 Population with sustainable access to affordable essential drugs, 1999

Sources: WHO 2002; UNDP 2003

There is certainly no reason to believe that addressing the problem of unequal access to information will necessarily or automatically help in dealing with the very pressing problem of the global health divide. This assumption that removing the digital divide will reduce the health divide is implicit in the quote above from the Health Inter Network initiative.

There is no obvious similarity between the health divide and the ICT divide, apart from an unequal distribution of income and wealth. Another similarity is that both the digital and health divides are characterised by gender inequalities. Moreover, there is no a priori reason for thinking that a reduction in the digital divide will lead to a lessening of the health divide. In fact, more digital equality could make things worse as new technologies pose threats as well as opportunities.

First, what about the opportunities? In what ways could ICTs and the Internet help to solve health inequalities? Providing people with information about, for example, how to obtain clean water or how to practise safe sex, is important although local radio might well be more effective than the Internet in delivering such messages to large numbers of people. Faster and better communication between health workers in rural areas and experts in urban centres or centres of particular expertise could be valuable. The Internet also provides the means for activists around the world to co-ordinate lobbying for cheaper drugs, more appropriate research and better access to contraception.

What about the threats? It must also be remembered that ICTs pose their own health risks, especially as they are so deeply implicated in the neo-liberal project of globalisation. ICTs help transnational corporations export pollution and hazardous work to those parts of the world which are least able to resist them. ICTs also facilitate the growing and dangerous trade in human organs.

The conclusion has to be that most health inequalities in our world can be addressed more directly than via investment in ICTs. The UNDP recognises that gender equality and universal primary education for girls would go a long way in helping to improve people’s health. Health inequalities can also be directly addressed by, for example, direct investment in clean water; medical research into problems such as malaria; free and confidential access to contraception; and the provision of cheaper drugs, especially for people suffering from HIV/AIDS.

References

• Goyal, M et al, (2002). ‘Economic and health consequences of selling a kidney in India’, Journal of the American Medical Association (October 2), pp.1589-93.
• Health InterNetwork, (no date). ‘United Nations Millennium Action Plan: Health InterNetwork’ URL: www.healthinternet.org/src/millenium.php
• i4d, (2003). ‘Can ICT cross the gender barrier?’ Information for Development 1(3).
• Lupton, Deborah, (1999). Risk, London: Routledge.
• Senker, Peter, (2003). ‘Editorial, Special Section: Science, Technology and Inequality’, Science, Technology & Human Values 28(1), pp.5-14.
• UNDP, (2003). Human Development Report 2003 Millennium Development Goals, A Compact Among Nations to End Human Poverty, Oxford: Oxford University Press.
• WHO, (2000). United Nations Millennium Action Plan, Health InterNetwork, URL: www.hin.org.in
• WHO, (2002). World Health Report 2002, Geneva: WHO.
• Wyatt, Sally; Henwood, Flis; Miller, Nod and Senker Peter, (eds) (2000). Technology and In/equality. Questioning the Information Society, London: Routledge.