Bulletin of the World Health Organization

Denaturalizing scarcity: a strategy of enquiry for public-health ethics

Ted Schrecker a

Why “denaturalizing scarcity”?

In 1995, a heat wave resulted in the deaths of more than 500 people in Chicago, United States of America (USA). Eric Klinenberg’s “social autopsy” of this episode points out that “the processes through which Chicagoans lost their lives followed the entrenched logic of social and spatial divisions that governs the metropolis”.1 People in Chicago’s poorest neighbourhoods, also with some of the highest proportions of African-Americans as the result of a history of racial segregation, were least likely to have, or be able to afford, air conditioning. In particular, realistic fear of crime kept the elderly socially isolated and barricaded into their homes, while a downsized city government failed to link residents with services that could have saved their lives. In 2005, the impact of hurricane Katrina on New Orleans brought to worldwide attention the deadly mix of racial and economic segregation, failure to invest in adequate flood-control measures despite ample warnings, and the presumption that everyone could afford to get in a car and drive to safety. When the storm hit, those who did not have this option, overwhelmingly poor and African-American, were effectively abandoned as refugees in their own country.2,3

The impacts of the heat wave and the hurricane were not natural, any more than the inability of people in wheelchairs to get around buildings without ramps and elevators is natural. Here, I adapt the title of Klinenberg’s study (Denaturalizing Disaster)1 to the study of scarcities of resources to provide health care or to remove causes of illness by addressing social determinants of health. These scarcities are rarely natural, in the sense that they originate in circumstances outside human control. Far more common, in the words of Calabresi & Bobbitt’s Tragic Choices,4 are situations in which “scarcity is not the result of any absolute lack of a resource but rather of the decision by society that it is not prepared to forgo other goods and benefits in a number sufficient to remove the scarcity”. The starting point of my argument is that to conduct responsible policy analysis: “We must determine where – if at all – in the history of a society’s approach to the particular scarce resource, a decision substantially within the control of that society was made as a result of which the resource was permitted to remain scarce. … Scarcity cannot simply be assumed as a given”.4 Denaturalizing scarcity is a strategy for applying this insight to research, policy analysis and advocacy.

On the affordability of saving (and taking) lives

What kinds of scarcities are at issue? In the context of high-income countries, consider the USA’s failure to provide health insurance for more than 40 million people, with predictable medical and financial consequences. On one estimate, providing health coverage for the uninsured would cost US$ 100 billion a year: a huge sum, yet just half the annual cost of the country’s military adventure in Iraq.5 Using a measure designed for cross-national comparisons, the prevalence of child poverty in the USA is 10 times as high as it is in Norway.6 The difference matters for public health, not only because of the long-term importance of early childhood development7 but also because an economic gradient in health status is evident even in the richest societies, although generally less steep in more egalitarian ones.8,9 Such situations direct our attention to national choices and priorities that make resources scarce for some purposes, but abundant for others.

However, this paper concentrates on even more dramatic global contrasts between scarcity and abundance and their implications for public health. Per capita spending on health care varies by two orders of magnitude between rich and poor countries, from US$ 15 per capita in the least developed countries (as defined by the United Nations) where 770 million people live, and US$ 24 per capita in low-income countries (as defined by the World Bank) where 2.4 billion people live, to US$ 3687 per capita in high-income countries.10 In low-income countries, much health-care spending is out of pocket, may not benefit those whose health is poorest or most precarious, and may have catastrophic financial consequences for the household even when it does. The estimated US$ 40 minimum cost of providing basic health care per person per year is out of reach for many low-income countries, and will remain so for some time without major infusions of external resources.11

Another illustration of the impact of scarcity comes from researchers associated with the Bellagio Study Group on Child Survival, who estimate that a package of interventions costing US$ 5.1 billion per year would save the lives of 6 million children per year in 42 countries that account for 90% of the global toll of under-5 child mortality.12 This figure is imprecise (it could be as high as US$ 8 billion) and it is an underestimate because it includes direct costs but not the costs of maintaining, rebuilding or expanding health systems that in many developing countries are fragile or collapsing. Nevertheless, it suggests an affirmative answer to the question: “Can the world afford to save the lives of 6 million children each year”?12

Health-threatening resource scarcities are equally conspicuous with respect to social determinants of health. The World Bank estimates that a billion people worldwide live below its “US$ 1 a day” poverty line and 2.6 billion, or two-fifths of the world’s people, below the “US$ 2 a day” threshold.10 Many commentators argue that these poverty lines substantially understate the true extent of serious deprivation.13,14 Approximately 850 million people suffer from chronically insufficient caloric intake.15 Apart from undernutrition, poverty creates situations in which the daily routines of living are themselves hazardous. More than 850 million people now live in slums, where they are routinely exposed to multiple health hazards;16 rapid urbanization will increase the number to 1.4 billion in 2020 in the absence of effective policy interventions.17 Indoor pollution from cooking fires is a major contributor to respiratory disease among the world’s poor,18 as is lack of safe drinking water and sanitation to infectious diarrhoea and a variety of parasitic diseases.19 These are just selected demonstrations that “many of the most devastating problems that plague the daily lives of billions of people are problems that emerge from a single, fundamental source: the consequences of poverty and inequality”.20

Why care about scarcity in the context of public health?

Why should we care about resource scarcities that distribute the chance to live a long and healthy life unequally within and among societies? In oversimplified terms, two lines of reasoning, which are not mutually exclusive, can be identified.

First, widespread persistence of unmet basic needs related to health may be regarded as creating at least a prima facie case for allocating resources in a way that gives priority to meeting those needs. Henry Shue21 captured the essence of this argument with the observation that: “One person’s desire for an additional jar of caviar is not equal in urgency to another person’s need for an additional bowl of black beans”. If the quantum of resources available were such that reducing the availability of caviar to a few would not have a meaningful effect on access to black beans (or basic health care, or other social determinants of health) for all, then Shue’s observation would have limited relevance. However, this is not the case. The US$ 5.1 billion annual cost of child-saving interventions referred to above corresponds to less than four days’ US military spending, and is less than the personal incomes of the United States’ two highest-earning hedge fund managers in 2007.22 Redistributing just 0.9% of the global economic product would be sufficient to raise the income of all the world’s poor above the World Bank’s US$ 2 a day threshold.23 Such comparisons can be dismissed as polemical, but in addition to serving as a resource for ethical reflection they underscore an observation by economist Jeffrey Sachs, who directed a multinational research effort on how to achieve the United Nations’ Millennium Development Goals24: “[I]n a world of trillions of dollars of income every year, the amount of money that you need to address the health crises is easily available”.25

The position that priority should be given to meeting basic health-related needs gains force from the moral arbitrariness of accidents of birth26 that determine (for instance) whether one will be born in Canada, where life expectancy at birth is 80 years, or in Zambia, where it is 38 years. It loses force, for some, because it fails to specify the basis for an obligation to mitigate the consequences of such accidents, especially across national borders. A second line of reasoning, which responds to this challenge, starts from factual evidence of multiple causal connections that link the situations and futures of rich and poor. This position is most closely associated with the work of Thomas Pogge,23,27,28 for whom moral responsibility follows causal responsibility (for poverty and other deprivations) within and across national borders, so long as a plausible alternative set of social arrangements or institutions that would be less inimical to poverty reduction and meeting other basic needs is available.

As shown in the next section of this paper, such plausible alternative arrangements can readily be imagined. The strategy of enquiry is important because unless one rejects a priori the position that remediable health-threatening scarcities of resources are a matter of ethical concern, denaturalizing scarcity is in some respects at least logically prior to the effort to construct an ethical argument in support of obligations to reduce or eliminate scarcities, within or across national borders. Only after resource scarcities have been identified as the consequence of either specific policy choices or more general social arrangements can appropriate ethical arguments be constructed.

Denaturalizing scarcity and globalization

Denaturalizing scarcity in the international frame of reference starts with understanding globalization: the increasingly dense web of trade and investment flows and institutional relationships that connects people in rich and poor countries.29 Those flows and relationships are “asymmetrical” in multiple dimensions.30

Trade policy provides the most familiar example. Because the relative size of industrialized- and developing-country markets creates major disparities in bargaining power, developing countries may have to give up a great deal in return for market access, especially in the context of bilateral and regional agreements;31 for instance, the United States is trying to incorporate provisions that undermine hard-won flexibilities with respect to patent rights and access to essential medicines.32 More generally, global reorganization of production across multiple national borders – facilitated by trade liberalization, but long predating the establishment of the World Trade Organization – has created a situation in which countries must compete for foreign direct investment and outsourced contract production. Although effects on health are not always or unequivocally destructive, the World Bank’s observation that global reorganization of production “mercilessly weeds out those centers with below-par macroeconomic environments, services, and labor-market flexibility”33 is indicative of the constraints involved.

Many developing countries found themselves unable to service their external debts starting in the early 1980s, for reasons largely outside their control. The International Monetary Fund (IMF), along with the World Bank, offered “structural adjustment” loans to facilitate rescheduling these debts, but the loans were predicated on a package of macroeconomic policies designed primarily to protect recipient countries’ ability to repay external creditors.3436 Structural adjustment also had the effect, probably intentional, of promoting the broader, market-oriented agenda of key Group of Seven (G7) nations at the time.36 The resulting economic dislocations and austerity measures often had destructive effects on health-care spending and social determinants of health – noted as early as 1987 by a United Nations Children’s Fund (UNICEF) study calling instead for “adjustment with a human face”37 – and were often met with widespread popular resistance.

Although the IMF is now less important as a lender, its influence remains pervasive. Private investors view IMF approval of a country’s macroeconomic policies as an indispensable endorsement, and the IMF and World Bank must sign off on a country’s policies as a condition for many forms of development assistance, including debt relief under the Multilateral Debt Relief Initiative. This process appears to reproduce many earlier forms of conditionality, with an emphasis on rapid integration into the global marketplace.3840 Recently, the IMF’s demand for public-sector wage expenditure ceilings has been criticized for preventing the hiring of badly needed health personnel and teachers, even when the funds are available from development assistance. The IMF first disputed these criticisms, but internal and external assessments confirmed in 2007 that public-sector wage-bill ceilings were often recommended; that IMF projections of future development assistance were consistently low, leading to excessive caution with respect to public expenditure; and that in 29 sub-Saharan countries, IMF strictures meant that just 27 cents of every incremental US dollar in development assistance was budgeted for new programmes, with the balance being used for repaying domestic debt and accumulating foreign-exchange reserves.41,42 This is correct as textbook public finance, but potentially destructive of health and education systems that are already fragile.

A more subtle dynamic of “implicit conditionality”43 operates when governments are constrained by capital hypermobility in global financial markets. Economic crises that reduce the value of national currencies by 50% or more, and spread unemployment and economic insecurity, exemplify what a former managing director of the IMF has called the “swift, brutal and destabilizing” consequences that ensue when policies are not “deemed basically sound” by investors.44 Less dramatically, financial markets’ anticipation of redistributive domestic policies can lead the governments in question, e.g. Brazil’s during the first term of the Workers’ Party and South Africa’s post-1994, to accept high unemployment and limited social expenditure45,46 – “dismal development and excellent macroeconomic outcomes”, in the words of one observer of South Africa.47 Thus, a sophisticated researcher warns that “those societies most in need of egalitarian redistribution may have, in terms of external financial market pressures, the most difficulty achieving it”.48 The global financial marketplace further facilitates patterns of capital flight that contribute to shortages of resources for development in entire regions, such as sub-Saharan Africa.49,50

These dynamics, and many others described more extensively elsewhere,29,51 suffice to demonstrate that in today’s global economy, resource scarcities that threaten health are – like those in the specific contexts of the Chicago heat wave and the New Orleans hurricane – anything but natural. They are the outcomes of decisions that could have been made differently and, in particular, of social institutions that could be designed differently.23

Informing philosophy and practice

Some philosophers concede that health-related resource scarcities give rise to ethical obligations within national borders, yet argue that despite the moral arbitrariness of the accidents of birth referred to earlier, obligations that would entail global redistribution of resources can only exist within a previously established framework of institutional associations and political accountabilities analogous to the nation-state. They further assert that no such framework exists on a global scale.52

Moellendorf counters persuasively that both the historical record (for instance of colonialism and its legacies) and today’s multiple cross-border economic connections, such as foreign direct investment flows and the reach of the IMF, constitute a “global association” sufficient to give rise to claims of distributive justice across borders.53 Indeed, it is perverse in the extreme to reject the existence of health-related ethical obligations that cross national borders simply because no mechanisms exist to hold powerful social institutions, and the key actors within them, accountable for scarcities they cause or perpetuate, perhaps half a world away. The situation would seem, rather, to call for an intensified effort to create such mechanisms where they do not exist, and improve the effectiveness of the imperfect institutions of international governance (such as the framework of human rights law)54 that are available. Expanding on these possibilities would require a separate paper.

Certainly, accepting the existence of duties of international justice related to the causes of health disparities does not define the scope of the relevant obligations. Denaturalizing scarcity will not resolve that debate, but can contribute usefully in the context of increased policy attention to health equity: the absence of disparities in health that are unfair, unavoidable and systematically related to social (dis)advantage.55 Critical and informed study of policies and institutions that affect the distribution of opportunities to lead a healthy life, both within and across national borders, lends strong support to the position of the Commission on Social Determinants of Health that: “The vast majority of inequalities in health, between and within countries, are avoidable and, hence, inequitable”.56 Mainstream health ethics usually accept scarcity as given and adaptation as imperative: for instance, by proposing substantive criteria or procedural algorithms for setting priorities in “resource-poor settings”. Denaturalizing scarcity asks, instead, why some settings are consistently and fatally resource poor and others are not. It is therefore an indispensable foundation for a public-health ethics that lives up to the historical tradition of public-health practice by searching for the root causes of illness and injury. ■

Funding: Partial funding was provided by a grant from the Canadian Institutes of Health Research to a research team addressing Health in an Unequal World: Global Ethics and Policy Choices. The author is one of the principal investigators.

Competing interests: None declared.



  • University of Ottawa, Ottawa, ON, Canada.