economics

Environmental changes are adding additional strains to the already imperiled lives of the world's poorest people. "Droughts will worsen. We will see deforestation, forest fires, a loss of diversity, and degradation of the environment" according to Michel Jarraud, secretary general of the World Meteorological Organization" (Stevenson, 2006). Not surprisingly, the poorest — and hence most vulnerable — people are often the first victims of the severely declining standards of health in much of the developing world. As Paul Epstein of Harvard Medical School said, "Today climate instability and the exhaustion of resources (forests, soils, water, biodiversity), together with the growing inequity and deepening poverty, are resulting in the emergence, resurgence and redistribution of infectious disease, stalking humans, plants and animals. The conditions are not sustainable, and the mounting social and economic costs are creating convergent agendas among members of civil society, international institutions and the economic sector."

Why are things different today? For one thing the sheer number of people on the planet seems to be approaching the limits to the world's capacities. Unfortunately the trends are all heading in the wrong direction. Furthermore people everywhere are more tightly connected. It is no longer true that we live in isolated communities. The tight connections, although remote, give rise to "causes" (although diffuse and multiple) that are often far away from the person who ultimately falls ill.

Clearly humankind has a moral obligation to establish health as a human right. That is a reasonable first step. More importantly, humankind has the obligation to act forcefully and diligently as if it actually believed that health was an inalienable human right. However, as Garrett and Rosenstein report, global health as an issue is "not only for do-gooders." They go on to say that, "A self-interest component to the global health debate has clearly emerged — thankfully, because purely altruistic efforts often fall short of international support and sustainability. The interconnected nature of the world makes ignorance of issues such as deadly infectious diseases not only immoral, but self-destructive."

Health must not, however, be viewed solely as providing medical care after disaster or disease strikes. While it's true that a pill or injection can save a life, the person whose life has just been saved will soon find him or herself back in an environment that leads inexorably to poor health, compromised ability to work gainfully, and a diminished life-span. Nor is health something that can be attained solely through research. A focus on "the cure" for this disease or that disease is a typically a type of welfare program for western researchers. It's a search for a magic" silver bullet" or technocratic approach that, while often very important, will be only effective in conjunction with other approaches.

Extreme and persistent poverty is the primary cause of ill-health and premature death around the world. If people weren't in desperate poverty, if they earned an adequate living, the incidence of disease would plummet. Especially today health is linked to poverty. This poverty is not confined to individuals, but covers large sections of the world's rural areas, towns and cities and, indeed, entire countries. If, for example, a person enters the hospital in many parts of the world he or she is likely to find infection, unsanitary conditions and a scarcity of drugs, bandages, surgical equipment and other vital medical supplies.

Paul Farmer is one the most articulate and hardest-hitting advocate for health care for all of the world's inhabitants, especially those who are the poorest and most vulnerable. He identifies structural inequalities that often originate in the first world as sources of great of the misery that now exists in the third. The "roots" of the problem are likely to lead further upstream than exposure to a microbe in polluted water to a bank in London, an energy company in Houston, or a government office in Washington, D.C. As part of his work and study, Farmer traveled to prisons in the former Soviet Union and to Chiapas, Haiti, and other marginalized locations around the world to work with people in need of medical care and to witness firsthand how health conditions were being met — or not met — around the world. In his book, Pathologies of Power (2003), he proposes a "new agenda" for health and human rights" that includes the following five facets:

• Make Health and Healing the Symbolic Core of the Agenda
• Make Provision of Services Central to the Agenda
• Establish New Research Agendas
• Achieve Independence from Powerful Governments and Bureaucracies
• Secure More Resources for Health and Human Rights

Farmer's "new agenda" is comprehensive, holistic and ambitious. At the same time, it seems that anything less would be insufficient. NGOs and philanthropists, no matter how well-heeled, will not be able to do this work by themselves. The multi-pronged approach resembles the Open Research and Action Network pattern — but writ very large. He is not unrealistic about the chances for success. He lists a number of significant challenges to this agenda including the possibility that increasing the involvement of NGOs will help hasten, "the withdrawal of states from the basic business of providing housing, education, and medical resources usually means further erosion of the social and economic rights of the poor."

The "new agenda" would take a mammoth effort that would integrate direct care, research, and popular mobilization. Ultimately Farmer's recommendations could provide an umbrella for many types of efforts. Health care professionals could take Sabbaticals in developing countries to assist with health care. Religious people could put renewed vigor into projects to alleviate human suffering. The 400+ billionaires in the US (and everybody) could follow the lead of Bill Gates and others and donate substantial amounts of their amassed riches to the effort. At the same time, the rest of us could agitate for health-related initiatives including cheaper drugs from multi-national pharmacuetical companies and authentic foreign aid that wasn't based on arms or oil.

Garrett and Rosenstein (2005) point out that, "with very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. ... exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridded environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on vulnerable populations. Yet it would be short sided to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision."

The commons insists that certain things should not be alienated that is, sold and converted into money. Thus, it is inappropriate to express the value of a worker's life or an endangered species as a dollar sum, in a cost-benefit analysis. It may be morally repugnant to sell off the "naming rights" of public institutions much as it is considered unacceptable to allow people to sell their bodies, babies, ova or genes. The commons gives us a language for talking about extra-market values and their importance. The commons, for example, allows us to talk about the human necessities of life food, water, fuel, medicine that may otherwise be seen as market commodities alone. The commons allows us to talk about the need for open, non-propertized spaces available to all; if too much of that space for example, scientific knowledge, musical works, cultural symbols is "locked up" through copyrights, patents or contracts, it can greatly impede future creativity and progress. We are already seeing the effects of such enclosure in medical research as a result of overly broad patents on "upstream" research. By contrast, when information and creativity are non-propertized and non-monetized as we see most frequently on the Internet the resulting collaborations and exchanges generate a huge surplus value that can be enjoyed by everyone, and not be privatized. This is one reason there is such an epic struggle underway on the Internet non-market modes of creativity and production are frequently more efficient in a strict economic sense, compared to conventional "real world" markets. There is a cornucopia of the commons, not a tragedy, as economists otherwise claim. Despite the different ways in which commons and market create value, the two do not necessarily operate in separate and distinct spheres, but are interdependent. The point is to strike an appropriate balance between the two so that the value-creating capacities of each can be optimized. There are a wide variety of effective commons-management models that belie the tragedy of the commons metaphor invoked by Garrett Hardin in his famous 1968 essay. While Hardin was talking about an open access regime in which no one owns or manages a shared resource, an actual commons has specific rules and social norms for preventing over-use, excluding outsiders, and managing the resource in long-term, sustainable ways. Increasingly, the Internet is the host for countless self-organized commons such as free and open source software, social networking communities, Wikipedia, Craigslist, and websites for sharing photos, videos and other creative works. One useful tool in creating these commons are Creative Commons licenses, which enable ordinary people to freely share their creative works while retaining copyrights for commercial purposes. The public library and the land trust are familiar, highly effective types of commons. More people are starting to realize that public spaces like parks, community gardens, farmers' markets and festivals are also important to the economic and social health of a community. There is a dawning awareness that commons-based infrastructure like wireless Internet access is a great way to use a public resource, the airwaves, to help people connect with each other. There are many other types of legal and institutional solutions for managing the commons, although most are not mentally grouped with other legal or institutional models as commons solutions. It is time for more people to see the kinship of these solutions and their holistic advantages over so-called free market.