Making progress in global health: the need for new paradigms International Afairs 85: 2 (2009) 347–371 © 2009 The Author(s). Journal Compilation © 2009 Blackwell Publishing Ltd/The Royal Institute of International Afairs SOLOMON R. BENATAR, STEPHEN GILL AND ISABELLA BAKKER Over the past 50 years unprecedented advances in science, technology and medical care, along with spectacular growth in the global economy, have greatly enhanced the lives of many people and contributed to increased human longevity. However, the benefts of such progress are predominantly enjoyed by the less than 20 per cent of the world’s population who consume over 80 per cent of annual global economic output. Almost 3 billion people (44 per cent of the world’s population) live miserable lives on less than $2 per day and beneft little if at all from progress in science and medicine. 1 Estimates indicate that poor countries bear over 80 per cent of the global burden of disease, expressed in disability adjusted life years (DALYs). 2 In addition to inexorably widening disparities in wealth and health, a major threat to human life and security in the twenty-frst century lies in the resurgence of infectious disease—ironically, given the successes of the twentieth century in combating an earlier generation of such diseases. Now HIV/AIDS, multi-drug- resistant tuberculosis and malaria result in millions of premature deaths, and the SARS epidemic took a heavy toll on social and economic life. The continuing prevalence of these infections, along with the possibility of an avian fu or other pandemics, are contributing to global instability. It is time for refection on the current trajectory of progress, and on the need for new ways of thinking and acting that ofer the prospect of greater equity in health. 3 Several steps are required if progress is to be made towards such a paradigm shift. First, much more needs to be known not only about how national political and economic systems afect health and the distribution and general quality of life- chances, but also about how geopolitics and global economic governance (or, more specifcally, transnational economic rules and treaties) serve to entrench extraction of resources from the poor by the rich. The neo-liberal models of governance that pervade such rules and treaties tend to promote particular patterns of global 1 S. R. Benatar, ‘Global disparities in health and human rights: a critical commentary’, American Journal of Public Health 88: 2, 1998, pp. 295–300. 2 It should, however, be noted that the DALY method disadvantages the poor, the very old and the very young and is not an ideal measure of the human burden of sufering and premature loss of life. See H. Bastian, ‘A consumer trip into the world of DALY calculations: an Alice in Wonderland experience’, Reproductive Health Matters 8: 15, 2000, pp. 113–16. 3 S. R. Benatar, ‘The coming catastrophe in international health: an analogy with lung cancer’, International Journal 56: 4, Autumn 2001, pp. 611–31.