A more integrative approach to understanding the myriad causes and consequences of inequality is needed, as well as more defined framework of which actors must be involved in tackling inequality.
One of the questions this debate poses is whether inequality should be one of the post-2015 development goals. In my opinion this is a very important issue that should figure on any political agenda. However, a more integrative approach to understanding the myriad causes and consequences of inequality is needed, as well as more defined framework of which actors must be involved in tackling inequality.
Inequality is one of the driving factors of political violence, war and ill health (see our article ‘Stalling growth and development’ on the consequences of inequality for societies). It is astounding to realize that armed conflict and other forms of political violence and ill health share a range of risk factors. This overlap in predictors poses a challenge for key actors in the domains of health, education, economy, governance, the military, and human rights (De Jong, 2010). Table 1 shows the common predictors that are involved.
| Predictor | Consequences Armed conflicts | Consequences Health | |
| Faulty governance/ Lack of democracy | Human rights violation; Criminalization of the state; Corruption; Faulty leadership | Lack of social justice; Low priority of health; Low government spending; Lack of health policy | |
| Inequality/inequity | Widening socio-economic inequalities/struggle over access resources (oil, water) | Impaired access to sanitation, health, education | |
| Marginalization of groups | Political power exercised differentially applied according to ethnic or religious identity | Differential access to services and differential outcomes for minorities, urban/rural residents/immigrants/IDPs | |
| Lack of intersectoral collaboration | Poor interaction international agencies governments and NGO’s; Poor engagement in preventive, rehabilitative, and reconstructive interventions that mayfuel cycles of violence | Lack of interconnection (sub)national policies, inability to address crucial social determinants mostly located outside the health sector | |
| Health and nutritional indicators per se | Important determinants of conflict onset | Further deterioration of public health services and a vicious circle of reduced access to services and increased mortality and disability |
The consequences of these five predictors for violence and health can be summarized as follows:
- Faulty governance, lack of democracy and failed states result in human rights violations, torture, imprisonments, in criminalization or delegitimization of the state, and in corrupt governments and faulty leaders. They prefer the use of violence to social justice to achieve their aims, prefer military expenditures to investing in health policies and the health care system.
- Inequality leads to widening social and economic inequalities, both between and within population groups, to the decline of social safety nets, deprivation, and competition for resources such as oil, water and timber. In health terms it leads to impaired access to water, sanitation, health and education, and increased mortality and disability.
- Marginalization of groups implies that political power is exercised – and differentially applied – according to ethnic or religious identity, possibly resulting in inter ethnic strife. In the domain of health this may result in differential health outcomes for different ethnic or religious groups, for urban and rural inhabitants or for immigrants, internally displaced persons or refugees.
- Lack of intersectoral collaboration results in poor interaction between international agencies like the UN, governments, peace-keepers and NGOs. When political violence and armed conflict are taking place, poor engagement in preventive, rehabilitative, and reconstructive interventions may fuel cycles of violence. Its corollary in the health sector implicates a lack of interconnection between national and subnational policies and the inability to address crucial social determinants of health that are mostly located outside the health sector.
- Finally, health and nutritional indicators per se are and important determinants of conflict onset: child mortality rates are 102% higher, child malnutrition rates are 50% higher, and malnutrition rates are 45% higher than in non-conflict countries (Pinstrup-Andersen & Shimokawa, 2008). This results in a vicious circle of further deterioration of public health services, reduced access to health services and increased mortality, malnutrition and disability (Daar et al, 2007; De Jong, 2010; Collins et al, 2011, WHO, 2011 a, b).
These lines show the importance of collaboration between diplomatic, political, criminal justice, and human rights initiatives with the health and other development sectors to promote peace and prevent the aggravation and continuation of violence. An approach based on preventive principles, involving the economy, governance, diplomacy, the military, human rights, agriculture, health, education and journalism sectors might successfully contribute to reducing and preventing inequality on a global scale.