The psychoanalytic theory established the concept of defence mechanisms as unconscious resources used by the Ego to distort the reality and better cope with it. When it comes to the debate on health disparities, for example, psychoanalytical denial, a black-and-white thinking and rationalisation lay behind some common statements that the current scenario is not as bad as you may think, although there is a deep division in very poor and very rich areas, and, ultimately, the world is beautiful because it is varied.
Most of the people believe there is not a single recipe to save the world, no universal principle to address the global needs. It came recently that a pandemic hit the Earth, and a global recipe was outlined by the World Health Organization, when I realized how the world of health disparities perpetuates double standards (Glob Bioeth. 2022 Feb 4;33(1):4-13). This means there are two recipes to cure people: one for rich countries, one for poor countries. I don’t need to clarify which one may imply a sub-standard of care.
Although it is hard to believe, perpetuating the disparities across social and economic disadvantaged groups is boosted by an acknowledgement of the social and economic differences across people. An experiment from the Yale University demonstrated that making wealth inequalities visible in a neighbourhood had a corrosive effect on the social cooperation and inter-connectedness of its inhabitants (Nature. 2015 Oct 15;526(7573):426-9). In a sick society based on the success and wealthiness, the attitude of “I don't get my hands dirty with those people anymore” may sound acceptable – although it is not.
Preambles are not required to remind how the initial commitment to convene for a global partnership in the fair distribution of COVID-19 vaccines to end the pandemic melted like snow in the sun, when it came to wealthy countries to share their benefits. Prioritising rich countries was justified by the high burden of noncommunicable diseases at a local level, compared to many low- and middle-income countries, which are populated by younger and stronger persons. In the debate, the high-income economies with solid and highly-performing health systems became unexpectedly so vulnerable to have the full package of the pandemic control measures granted. I will not stress further that the top three countries with the highest COVID-19 mortality per population are not high-income countries.
How much we endorse equitability - I mean, unconsciously? -- what makes people, groups, countries, regions appreciable is not commonly how fair they are. Here it is where the instrumental rationalisations arise: equalizers are ideal, but in practice the assurance of double standards sounds like a confirmation of life achievements and status obtained with sacrifices, efforts, hard work. We deserve it, don’t we? Double standards are unconsciously unavoidable, because “we are” in a different status than “they are”, because of “our” hard job – in other terms, we deserve a lot!
I learnt from some smart infectious disease specialists (and public health dreamers) that efforts can be canalised toward highly impactful outcomes, if a person works for all people attaining to the same standards. It was the German pathologist Rudolf Virchow who stated that “Medicine is a social science, and politics nothing but medicine at a larger scale” (J Epidemiol Community Health. 2009 Mar;63(3):181-4). I learnt Virchow’s adage from a Brazilian friend, who also introduced me for the first time to the work of Paul Farmer, the theoretician of one standard for all in healthcare (Lancet Glob Health. 2019 Apr;7(4):e410-e411). I found someone in the world who was implementing the Virchowian Verb: that was my first career epiphany! I realised that there is an escape from the obviousness of double standards, that can lead to health for all. Paul was a strong contestant of the double standards in healthcare: having treatment protocols for the rich people and alternative protocols for the poor ones is the ultimate expression of injustice. Without a social justice component, medical ethics risks becoming yet another strategy for managing inequality, was his legacy.
Claimed benefits for double standards mostly are low-value health interventions, which sometimes are just harmful or almost inert illusions (JAMA. 2021 May 4;325(17):1715-1716). However, disparities in the access to (the few and franticly priced) high-value, high-impact interventions can have dramatic consequences. It might be the case of anti-hepatitis C medicines and anti-HIV (PLoS One. 2017 May 25;12(5):e0177770); high-value yet incredibly expensive cancer medicines (Ann Oncol. 2017 Nov 1;28(11):2633-2647; Ann Oncol. 2016 Aug;27(8):1423-43) can save lives, but must surrender to the market-based logics: no matter where we live, the best care should be the only one you can offer, the only one we can get.
We feel the anger and the frustration when a financial barrier, a cultural difference, a social disadvantage is interposing between a person with a serious health condition and the possibility of healing or find alleviation of suffering. I can’t believe we still accept the toll of market logics, and I can’t indulge — we, as a community, must not indulge.
Pragmatists argue that double standards are unavoidable. However, they often miss to recall that the persistence of double standards is the reason of global disparities. The narrative that endures disparities through tricks of rationalisations is malevolent, albeit Ego-protecting for some distressed stakeholders. Progressive universalisms can be reached but only through phases of implementation - and this should not be used to justify double standards.
This is the time to stand up against double standards. Stand up for one, equitable care. Stand up to end the care gaps. There is one standard of care: the best one.