The fight against HIV, TB and malaria is very often focused on an exclusively hygienic, therapeutic or biomedical approach. This paper does not question the interest or the relevance of such an approach, but it suggests that we should resolutely broaden the scope of this fight to the borders of social inequalities. Actually, health as well as illness are not strictly random or natural conditions. They do not just depend on biological make-up, environment, individual behavior or medical care. Their distribution is almost always related to socio-professional status or social affiliation. Those at the top of the social pyramid enjoy better health than those directly below them, who themselves are healthier than those just below them…and so on all the way down the pyramid This is what is commonly called the social gradient of health. This implies that the higher up the social hierarchy we climb, the better our health status. What is true internally within the States, is even more so at the international level.
From social inequalities to health vulnerabilities
The following lines show that social inequalities exacerbate health vulnerabilities, perpetuate pandemics and fuel inequality ( length and quality of life) on an international scale. This was seen with the COVID-19 pandemic. It “disproportionately affected hundreds of millions of the most disadvantaged populations, such as those living in low- and middle-income countries, those in socially discriminated groups, or those with informal employment, as well as girls and women “. Above all, it “.reminded us of a harsh reality: unequal access to income and opportunity not only creates unfair, distorted, and unhappy societies, it literally kills people”
The same is true for HIV, TB and malaria. The social gradient of health is also an important explanatory factor here. The diseases are more prevalent at the bottom of the social ladder and decrease as one moves up the ladder.
According to the Global Fund’s Executive Director and the UNAIDS Executive Director, “in the fight to end diseases, inequalities are often the main obstacle.4». Inequalities worsen pandemics and feed on them (bidirectional causation). They uncover the gaps in our societies and widen them. In short, they make diseases and pandemics longer, more deadly and more damaging to developing countries, including many African countries, the region of the world that suffers most from poverty and bears the greatest burden of some diseases.While it is true that with the research and accessibility of antiretroviral drugs (ARVs), the life expectancy of people living with HIV has increased globally, it remains close to the average for each country. Thus, while the life expectancy of a man living with HIV and on treatment is 53 years in Chad and 54.2 years for an HIV-negative person born in 2019, it is 69.4 years in Canada and 82 years for an HIV-negative person born in 2019. The sixteen and twenty-eight year gaps between the two categories of countries mentioned cannot be attributed solely to the natural lottery of life or to a religious determinism such as “it was his day” (understood here as: the day he was bound to die). While it is true that other factors (gender, age, biological makeup, skin color, disability, etc.) affect the distribution of health vulnerabilities, it can nevertheless be argued that socio-economic factors (income inequalities, social fragility, insufficient State resources, a weak health system, etc.) account for the low age that Chadians living with HIV can expect to reach.
On an international scale, there is generally a factual, empirical correlation between the level of income or GDP and vulnerability to diseases and pandemics. The standard of living dictates, determines and structures these vulnerabilities centrally and decisively. “A higher social status, a more stable job, being wealthier and more educated does not only guarantee a better social status, greater financial prosperity and more favorable living conditions, it also leads to a longer and healthier life“.
Global Inequalities Kill in Africa
It is actually domestic and especially international economic structures that generate these deep inequalities. Their effects are particularly glaring in sub-Saharan Africa. Health insecurity – and therefore inequality of lives – which is the daily reality of the continent is above all due to the growing scale of global inequalities.
Let’s take another example to illustrate our point. Let’s imagine a Kenyan woman who has been experiencing the following symptoms for several weeks: physical discomfort, gradual weight loss, fever, prolonged cough, swollen lymph nodes, loss of appetite, shortness of breath and chest pain. She goes to the hospital and discovers after medical examinations that she has TB. Although she received medical care, she died a few days later. A first medical interpretation points to complication linked to a late detection of the active form of the disease. But there are other (complementary) ways to determine the causes of her death. A broader analysis would reveal that the reason why this housekeeper (by profession), widow and mother of 5 children went to the hospital late was that she was faced with a problem of access to care (costs, distance, insurance, etc.) Moreover, she was living in an unhealthy dwelling located in a poor, polluted neighborhood that is extremely conducive to the outbreak of infectious diseases. Actually, for this woman, as for many other inhabitants of this neighborhood, the precarious social or biographical life finally engraved its deadly stamp on her biological life. Using the words of the health anthropologist Didier Fassin, we can say that in this case, as in many similar social circumstances, death is the engraving of the inequalities produced by society in the bodies. It is the culmination of the processes by which the social aspect becomes embedded in the body.
Inequalities do kill, but solutions are within our reach. The fight against HIV, TB and malaria is basically a social justice issue. Despite the scope and complexity of the task, it is on the social levers that we must act to better prevent these diseases.
Prevention is better than cure
Social inequalities are not a matter of chance or fate. They are the result of political and economic decisions that can be corrected. What is socially constructed can be socially deconstructed. To overcome diseases, it is necessary to influence the root cause of the problem, in other words, to resolutely address the social inequalities that fuel and worsen them. To get back on track and end HIV, TB, and malaria as global health threats in general and African health threats in particular, we “need, above all, an ironclad commitment to address the inequalities that fuel them. This is a challenge we can and must meet,” Peter Sands and Winnie Byanyima clearly stated.
Given that such a perspective inevitably requires a reform of the global economic system and a better redistribution of wealth created collectively, this will not come without giving rise to several obstacles or some reluctance. We must bear this in mind, but without ever dampening the drive towards an ideal of social equity. If such an ideal becomes a reality, then, the range of social determinants of health can be broadened and revitalized. For, it can not be overemphasized that reducing social inequalities on a global scale is the key to reducing health vulnerabilities and the related life inequalities.
The interest of such an approach, as you have surely understood, is that it helps to treat the ailment rather than the pain. It is essentially more preventive than curative. It suggests prioritizing systemic and sustainable solutions rather than the occasional “humanitarian trucking”. Problems are not solved in the long run through charity, but through justice and equity. In any case, there is a pragmatic and ethical precedence of the second value over the first. And as the Baham saying in Cameroon goes: “If you want to help your neighbor who is hungry, give him seeds rather than roasted corn”. The more States are divided by social inequalities, the less effective they will be in fighting diseases and pandemics. A global community that is riddled with great disparities cannot remain healthy.
Due to the limited space of such an article, we cannot provide much detail on this specific point. But we can say that there is a great difference between life expectancy, which refers to length, and life expectancy, which refers to quality of life. “On the one hand, how many years can we expect to live? On the other hand, what can we expect from life? Moving from the first to the second formulation radically shifts the perspective. Talking about the inequality of lives is no longer just a matter of questioning the disparities in the length of life, but of considering the differences between what they are and what individuals are entitled to expect from life. We are no longer talking about quantity but about quality, no longer about longevity but about dignity”, Didier Fassin, L’inégalité des vies, inaugural lecture delivered at the Collège de France on Thursday, January 16, 2020.