Social and economic justice: the road to health.

I with Prabhat Jha and James Lavery that technological advances, rather than improvements in income and education, have been responsible for improvements in health care in the developing world. Sri Lanka and the state of Kerala in India have made rapid advances in health care through their investment in primary care and education and measures to reduce social and health inequities. Despite a civil war, Sri Lanka has the best health indicators in South East Asia, with average life expectancy of 73 years, infant mortality of 16 per 1000 and maternal mortality of 30 per 100 000 live births. This country does not have a single MRI scanner in the public sector, which highlights an emphasis on primary care. Similarly, Kerala has achieved health and demographic indicators far ahead of Indian national averages. The greatest health hazard is in fact the economic gap between the rich and the poor. According to population health studies, the primary determinant of health within a country is societal structure, especially the degree of hierarchy as measured by income distribution. Not only is the health of a population related to income, but at any given level of overall economic development for a country or a region within a country, the populations of countries and regions with smaller gaps between rich and poor are, in general, healthier than the populations of countries and regions where the gap is larger. A case in point is the United States, which spent the most on health care but ranked only 26th in life expectancy in 2003; Japan was the top country in this ranking. Among the developed countries, the United States has the greatest gap between rich and poor, whereas Japan has the smallest gap. The road to health for developing countries lies not in blindly emulating the West in terms of sophisticated medical care but in making sound investments in primary care and education as well as promoting social and economic justice.