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As for international health the term was coined in by the Rockefeller Foundation, in the United States , it is characterized mainly by actions developed to prevent and control infectious diseases, to combat malnutrition, maternal and child mortality, and to provide technical assistance activities, mainly to the so-called less developed nations Koplan et al.
These conceptions are gradually replaced, in the final decades of the 20 th century, by the "consolidation" of Global Health, a complex and polysemic term and concept. Global Health has been developing simultaneously with the global forces that connect people's daily life to facts that occur in other parts of the planet. This notion guides stances such as those shown by many countries' ministers during a meeting in Oslo, Norway, in , when they expressed that global action is fundamental because many contemporary health problems - like influenza, SARS, drug-resistant tuberculosis, malaria, poliomyelitis and dengue - do not respect national borders and, therefore, the solution needs nations' joint work and action WHO, In addition, Global Health has been concerned about the transnational impacts of globalization on social determinants and health problems that are beyond the individual control of national states and affect diverse dimensions of human life, that is, persistent, emerging and reemerging problems.
Some examples are the access to health care and essential medicines, the emergence of new pandemic diseases, the reemergence or resurgence of infectious diseases like dengue and yellow fever, violence and its consequences, the issue of mental health, and the consequences of socio-environmental disasters. Global Health also deals with forms of international trade and investment and their repercussions on health, problems related to the migration of people and health professionals, international medical tourism, and the marketing of products that are harmful to health, like alcoholic beverages, unhealthy foods and tobacco Franco-Giraldo; Alvarez-Dardet, ; Kawachi; Wamala, ; Frenk; Gomez-Dantes, Values are components of the daily life of human beings and collectivities, and it is "impossible to imagine life without them".
Therefore, we must respect and protect them so that we can have a good and fair social interaction Cortina, They are central in political life and support policies, programs, actions and behaviors, both in neoliberal approaches, which focus on safety, individual freedom, efficiency and cost-effectiveness, and in approaches grounded on social justice, equity and solidarity Steward; Keusch; Kleinman, We can evoke diverse values when we reflect on Global Health issues.
However, this article will approach the values that prevail in the discourses of authors in the field of Global Health: To reflect on social justice and equity, our presupposition is that the orientations provided for Global Health actions by national states, multilateral agencies, non-governmental or private organizations present important differences if health is or is not understood as a global public good Rowson et al.
We believe that being a global public good - a notion that is still marked by theoretical and ideological clashes - means that no person or no collectivity can be excluded from its possession or consumption, and that such possession or utilization by a person or group cannot prevent other individuals or collectivities from enjoying it.
In other words, there must be no rivalry in the possession or consumption of the good. Thus, it is accepted that no person, country, region or population group should be excluded and that all can benefit from this global public good - health ALASAG, ; Stewart; Keusch; Kleinman; ; Buss; Ferreira, ; Smith, We can argue that health is a global public good in the perspective of social justice, equity and ethics. Justice is a secular principle of interaction among human beings that brings the interface between individual ethics and collective ethics.
According to the French philosopher Paul Ricoeur , if good is intuitive, fair is constructed within human relations. The Spanish philosopher Adela Cortina teaches us that we should consider justice as the grounds for interaction among people, the basis for an ethics of minimal things, necessary in each morally pluralistic society so that people can reach their individual and autonomous project of happiness.
Justice brings the notion of mutual obligation among people, and relates individuals to the collective dimension. The term social justice is relatively recent. It dates back to the 19 th century and is confounded with distributive justice. Mainly during the 20 th century, there is a separation from the notion of meritorious justice and the contemporary concept of distributive justice is built. This notion demands intervention on the economic and social fields and aims to guarantee an equitable distribution and the supply of a certain level of interests and material resources to all people Fleischacker, The theme of social justice, approached in Global Health, is extremely relevant because of the contribution, allocation and distribution of human, technical and economic resources across countries and regions.
It belongs to the field of distributive justice, as it relates individuals to the collectivity and political authorities. In many international declarations and documents on Global Health, the sense of justice is closely related to the value of equity. As Amartya Sen argues, it is important not only to consider institutions as fair; they should also act to promote justice. We can cite some renowned authors who deal with the theme, like Koplan et al.
Kickbusch , an author who is strongly identified with the WHO, states that the main objective of Global Health is the equitable access to health in all regions of the world. Furthermore, other authors argue that the aim of Global Health is to reduce the social and health inequalities and inequities found in the world, and to propose to the field an orientation based on the value of equity Fried, ; Macfarlane; Jacobs; Kaaya, ; McMichael; Beaglehole, ; Brundtland, It is known that equity is a polysemic term.
However, as Almeida emphasizes, the option for a definition to be operationalized reflects the values and choices of a society. Unlike the principle of equality, equity deals with differences, like, for example, the avoidable and unnecessary social and health inequalities, in the search for what is fair. Equity can be understood as the effort of treating the unequal unequally according to their needs.
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This interpretation has diversified bases and defends that the treatment given to people should be different when it is grounded on each person's needs. Egalitarian theories founded on meeting people's needs accept that the State, through public policies, should guarantee, with justice, the distribution of goods and services to minimize the effects of the biological and social lotteries. An example are the Brazilian government's equity promotion policies, which state that their objective is to reduce persistent inequalities, the vulnerabilities to which certain population groups are exposed, which result from social determinants of health Brasil, Without aiming to make value judgements about the different concepts of equity, we can say that the discourses of authors in the Global Health field show a strong trend towards the presupposition of "justice as equity", formulated by John Rawls , in the s.
This presupposition defends that equity is a priority in the development of a theory of justice that, treating the unequal unequally, considers that fair actions must be conducted to prioritize society's less favored individuals, those who are in social disadvantage. The philosopher's thought defends a contractarian procedure in which the action that has different and unequal consequences to the diverse social actors involved in a certain situation is fair only when it results in compensatory benefits to each one and, particularly, to society's less favored members, that is, those who are in social disadvantage.
This would lead, within the Global Health field, to the prioritization of countries, regions or social groups that are considered less favored, with larger social, economic and health disadvantages. That is why, for example, the region of Sub-Saharan Africa, which has the worst sanitary levels of the planet, received in the largest part of the international financial resources allocated to health care development, corresponding to Following Rawls's thought, we can see that it is not the population's magnitude that should guide the actions, but the needs of the less favored.
Thus, Global Health guided by equity should be developed in order to eliminate, or at least reduce, as much as possible, the unnecessary, avoidable and unfair inequalities that exist among human groups with different social levels. Equity can confront the maximalist principle of social utility, defending more benefits to the largest number of people. The principle of social utility, formulated by the English philosophers Jeremy Bentham and John Stuart Mill in the 19 th century, establishes that we should search for the greatest happiness of all those whose interests are at stake, and this would be the fair and adequate purpose of human action.
If we accept that the objective is to protect the needs of the collectivity, that is, maximalist needs, even at the expense of minority individual interests, criteria like magnitude, productive force, transcendence and cost-benefit would be validated, and not equity. This would be against the investment of resources in expensive activities with low population coverage, which is not explicitly present in the Global Health discourse. However, a few authors disagree with the view mentioned above, as they believe that equity is a notion significantly loaded with ideological content, and this can exclude from the field of Global Health those who do not share this value Rowson et al.
One of the most important and frequent areas of action in Global Health is related to international solidarity actions - assistance or cooperation. However, solidarity is also a complex and polysemic term influenced by theoretical lines from diverse orientations.
Its etymological root is the reference to a behavior in solidum , that is, the "reciprocal bond of independent people or things; moral meaning that bonds the individual to life, to the interests of a social group, a nation, or humankind" Ferreira, We do not have the intention, here, to exhaust the theme, nor to list all the theoretical lines that deal with solidarity. When it is evoked in the field of Global Health, we understand it as social solidarity, with a collective reach and a concern that extrapolates borders.
We believe it is a value grounded on the bond of reciprocal recognition among people, that is, on people's need, as social beings, of co-existing socially, having interdependent relations. However, we can question whether there is a moral obligation, a requirement, which would lead people to do or to prevent themselves from doing something - in this case, of being supportive in an autonomous way.
What would make a State, or a multilateral institution, either public or private, be ethically supportive? Why should public or private international organizations be supportive towards the poor, the vulnerable, the disadvantaged? How can we justify and explain solidarity and, for example, the South-South cooperation among developing countries? The answers given by some authors are based on the notion that solidarity can profit from an ethics of closeness. This means that we worry and care for those who are close to us, with whom we interact, for affective and family reasons, or because we belong to the same social or religious group, or to the same community Wilkinson, ; Furrow, ; Cortina, Along this line of thought, Sandel argues that, in the liberal conception, although we must not commit injustice considering the various possible meanings of the term , we are not morally obliged to do good.
However, the author defends the thesis that solidarity is the moral obligation of acting in relation to people with whom we share a certain history.
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Other authors, whose conceptions differ from the liberal model, although they are also based on the ethics of closeness, argue that solidarity would be the willingness to help others in whom we recognize similarity and identity, at least in a biological or social aspect, and to whom financial, social, emotional and other costs would be allocated. This can be easily noticed in self-help groups and organizations of patients defending resources and health care to specific problems or pathologies, such as AIDS Illingworth; Parmett, ; Prainsack, Buyz, However, what about the distant and unknown individual, the stranger with whom we do not have a direct relationship and we do not recognize a possibility of immediate reciprocity?
Is there a moral obligation to be responsible for their health? How do we justify the obligation to assist them? An ethics of closeness would not apply to this case. In a line of thought that is closer to the Kantian conceptions, we might argue that the fact that we belong to humankind, transcending national borders, is what makes us equal and close. Belonging to humankind induces us to solidarity with those who are distant, those we do not know and have only heard of their misfortunes - for example, through the global means of communication, like what happened recently in Haiti, the poorest country in the Caribbean region.
Our human identity cannot be reduced to national borders, as it can be related to religion, gender, race, profession or political convictions. This notion would help us explain the efforts of public and private international agencies, like the organizations Doctors Without Borders and Doctors of the World, to act in situations of socio-environmental catastrophes, as well as in the prevention, diagnosis and treatment of diseases that are called neglected, in which the pharmaceutical companies do not have any commercial interest, such as malaria, dengue and tuberculosis.
Regarding this matter, Sen tells us that human identity is, perhaps, our "most basic" identity. The author states that "the imperatives that can be associated with our humanity may not be mediated by our condition as specific peoples and nations", but fundamentally as human beings.
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We can add that our interdependence as human beings to live in society, be it economic, political, social, ethical or religious, has been growing, mainly in this globalized world, which reduces distances. Furthermore, our human condition and our condition of ecological subjects that share one single world impel us to decide, in order to maintain social cohesion, to be concerned about and protect the other, due to a bond that is not personal; it emerges due to our belonging to humankind Eckenwiler; Straehle; Chung, In addition, it is understood that the basis of solidarity is human dignity, one of the few common values in our world of philosophic pluralism, which expresses that all human beings have a unique and unconditional value, and creates a moral obligation to protect it.
Human dignity would involve the notions of vulnerability and fragility, which would correlate with the principle of equity, in the protection of the most vulnerable, while solidarity is the point of view that complements the principle of egalitarian treatment Conill; Cortina, ; Andorno, ; Cortina, Moreover, it is important to reflect on Furrow's argument: In addition, one can argue that the needs of a national State lead it forcibly to act through strategic obligations, maximizing the interests of its citizens, its national and sanitary security, based mainly on ethical references of a utilitarian nature.