Equity in Public Health: A Challenge for Disaster Managers
Dr. Abelardo Ramírez Márquez
Dr. Guillermo Mesa Ridel

Many governments have expressed their desire to reduce the unjust, and unjustifiable, inequalities that affect different social groups. While this concern is not new, there has never been such an enormous scientific and technical potential to right this wrong, never such an extraordinary capacity for wealth generation and, hence, redistribution.1

Significant contemporary scholars like John Rawls, Amartya Sen and Margaret Whitehead have attempted to study, define and interpret the concept of equity as it relates to social justice and public health. Some of them, starting out from the premise that good health and a state of well-being is potentially available to all, have claimed that a just society should secure for every one of its members the same basic liberties, the same rights to political participation, and the same opportunities. Seen from this point of view, equity confronts the rule of law with the notion of justice.2

Gender, age, race, ethnic background, and geography—not to mention income—can all affect individuals’ access to healthcare and other vital services that also influence the overall degree of health and wellbeing. In spite of the enormous technological and scientific advances of recent decades, communicable diseases remain the most frequent cause of death in today’s world among those living on the margins of society, underscoring the growing health inequity at both the international and national levels.3 It is another facet of the unequal production, distribution and consumption of goods and services, including education and cultural expression.

The impact, magnitude, and recurrence of disasters in the Americas has less to do with the absolute characteristics of natural hazards—wind speeds, in the case of hurricanes, or rainfall levels in the case of floods—than with the social, economic, environmental, institutional and other circumstances of the victims. In that sense, vulnerability is social. Generally, adverse natural phenomena cause the greatest damage among those social groups living in the most fragile conditions: peasants, indigenous peoples, the urban poor—broadly speaking, the excluded.

There is little reason to hope that the current development model—which is predatory and unsustainable—can right this wrong. As the masses become poorer, they also lose political power and spaces for participation, while increasingly feeble nation-states reduce their social investment and lose their response capacity even as vulnerability grows. International aid, meanwhile, can at best attenuate the impact of disasters once they have already occurred, instead of providing lasting solutions in the form of soft loans to improve poor countries’ capacity to increase their exports, raise employment levels, and obtain the necessary revenue to fund disaster prevention programs.

In this context, it makes little sense to propose policies for improving the health of the general population without addressing the question of equity.4 Efforts must focus on the inclusion of the disadvantaged, including women, children, the elderly, the disabled, and ethnic minorities. While their losses in disaster situations are low in absolute terms, due to their very poverty, relative losses are high given the impact on their standard of living.5 This calls for the institutionalization of citizen participation mechanisms.

However, health inequities cannot be eliminated simply by reducing poverty, since they can still be found in those countries that provide the poorest groups with access to health and medical care, sanitary education and welfare and unemployment benefits. All they appear as a health gradient throughout the social hierarchy, not only among the least advantaged. It is essential to understand that disasters are caused by social and political structures, and are not the result of chance or bad luck. In the field of health and disaster prevention, all countries must work together to introduce the necessary changes. The current world economic crisis is affecting everyone—with one proviso: the rich are less affected; the poor, more. This means that the impact of the crisis is not the same for all individuals or all countries.6

Thus, in addition to medical services, the population must have equitable access to education, culture, sport, and all other ways to improve their wellbeing. And a key part of this must be a carefully crafted, multidisciplinary disaster reduction plan involving all relevant institutions and community organizations.

In our country, Cuba, the foundations have been laid for knowing the hazards that can affect every community and every health facility, based on their vulnerabilities, and a monitoring and training plan has been developed for all relevant human resources. Public health institutions play their role in disaster reduction through teams of multidisciplinary specialists who work closely with all other sectors at the local level, employing a methodology that includes early warning, preparedness and response. The recent infestation by the Aedes aegypti mosquito and the resultant dengue epidemic that affected the country, most severely in Havana, put us to the test, forcing us once again to develop comprehensive interdisciplinary solutions based on health equity—that is, the allocation of resources where they were most needed.

With the valuable assistance of UNICEF, the Pan American Health Organization (PAHO), DIPECHO and other international organizations, and the cooperation of non-governmental organizations, we are perfecting our integral approach to disaster prevention and mitigation, and efforts are underway to make the best possible use of the country’s scientific capabilities with a view to coordinating as a whole all prevention activities, including research and information, the coordination of relief and rescue efforts, and the handling of sanitary and epidemiological concerns—not to mention greater international cooperation, particularly with Latin America and the Caribbean, in fields such as forecasting, emergency assistance and training.

At present, we are involved in the design of a Health Equity Monitoring System for Cuba that should respond dynamically to warnings of possible health inequities and view them not only territorially and in terms of the groups involved, but also over time, so that decisions can be made to ensure the highest degree of health equity. The project benefits from the political will of the State to see it executed, the existence of reliable information, and the quality of the human resources involved in it. The integral approach favored by our National Health System in the field of natural or man-made disaster prevention and mitigation has made it possible to build capabilities for preparedness, early warning and response in connection with this world-wide problem. It also places us in a position to collaborate and provide assistance to the countries of the region and the world, something we are gladly willing to do.

Footnotes

1. F. Castro (2000), Inaugural Speech, South-South Summit, Havana, April.
2. PAHO/WHO (1999), Principles and Basic Concepts of Equity and Health, Division of Health and Human Development.
3. P. Hartigan (1999), Communicable Diseases, Gender, and Equity in Health. Cambridge, MA : Harvard Center for Population and Development Studies.
4. International Strategy for Disaster Reduction (ISDR), Pan-American Health Organization (PAHO/WHO) (2000), Hurricane Mitch: A Glance at Some Thematic Trends in Risk Reduction in Central America. San José, Costa Rica: ISDR.
5. Dr. Abraam Sonis (2000), speech upon accepting PAHO’s Abraham Horwitz Award for Leadership in Inter-American Health. Pan-American Health Review 8(5):359-62.
6. F. Castro (2001), remarks at the 11th Ibero-American Summit, Lima, November.

For more information please contact:

Dr. Abelardo Ramírez Márquez,
Viceminister of Health, President, Latin American Centre for Disaster Medicine (CLAMED)
Calle 23 esquina N, Vedado, Ciudad de La Habana 10400. Cuba
Tel: +53 (7) 553382 / 322131,
Fax: +53 (7) 662537
vicemp@infomed.sld.cu

Dr. Guillermo Mesa Ridel,
MPh, Executive Secretary, CLAMED
Calle 18 No. 710 entre 7ma y 29, Playa. Ciudad de La Habana 11300. Cuba
Tel: +53 (7) 202 3636 / 202 3644;
Fax: +53 (7) 204 8806
mesa@clamed.sld.cu