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This article seeks to contribute to debates on the political economy of global health by offering a ‘planetary’ perspective. We initially sketch contestations concerning improvements, inequalities ...

Globally, there is inequitable access to healthcare. Despite efforts to promote universal access to healthcare, the political and economic conditions that give rise to this are unlikely to be resolved. While a minority of wealthy countries enjoy unlimited privately purchased healthcare, for most, there are limits to what can be accessed. In the few successful high-income, public healthcare systems, limited rationing results mostly in treatment delays or restriction of novel expensive treatments. For the majority of people globally though, there are severe restrictions, and some form of rationing is not so much by design as by default. Given these different levels of healthcare, even defining universal approaches to rationing becomes difficult. While efforts should be made to narrow the wealth gap, the COVID-19 pandemic has highlighted that all populations are vulnerable and that rapidly overwhelming disease pandemics can threaten even the wealthiest of countries.

As the COVID-19 pandemic rages through the world, all aspects of life globally are being disrupted by mounting death rates and governments' responses The first ethical lesson has been the realization that the increasing instability of the world, characterized by diverging trajectories of health and well-being, with a minority (25%) benefiting from spectacular human development and progress, and a majority (75%) suffering from inadequate human and social development, is amplified in South Africa as a failing state, with its even wider disparities and continuing, pervasive poverty, hunger, unemployment and heavy burden of disease The second lesson relates to the complexity of the challenge for the government and people of a middle-income country seeking a balance between efforts to: mitigate and control the pandemic for long enough to prepare already inadequate overall health facilities to save as many lives as possible, and prevent severe damage to our fragile and crumbling economy in order to avoid deaths from starvation and other neglected health needs Here, Benatar discusses the ethical challenges highlighted by the pandemic

Much current global debate – as well as a great deal of political rhetoric – about global health and healthcare is characterised by a renewed emphasis on the goal of universal access throughout the world. While this goal has been achieved to varying extents in the United Kingdom, Canada and many countries in Europe, even within those countries where national health systems have long been in place, the pervasive shift in emphasis from health as a social value to health as a commodity within a capitalist market civilization is eroding the commitment to equitable access to healthcare. Against this background the challenge is much greater in low- and middle-income countries that lag behind – especially if aspirations to universal access go beyond primary care. The challenges of achieving greater equity in access to health and in health outcomes, in a middle-income country like South Africa, illustrate the magnitude of the tensions and gaps that need to be traversed, given the vast differences between healthcare provided in the private and public sectors. Understandably the concept of National Health Insurance (NHI) in South Africa has widespread support. The strategies for how a successful and effective NHI could be implemented, over what time-frame and what it covers are, however, very controversial issues. What tends to be ignored is that sustainable improvement in health in South Africa, and elsewhere, is not determined merely by medical care but more especially by social structures intimately linked to deeply entrenched local and global social, economic and political forces and inequalities. While seldom openly addressed, some of these forces are explicated in this article to supplement views elsewhere, although most have elided emphasis on the pervasive effects of the global political economy on the provisioning and practising of health and healthcare everywhere on our planet.

This article seeks to evaluate the ethical underpinnings of neoliberalism and its associated power relations, and to illustrate the influence of such relationships on the health of people and the planet in the so-called era of the Anthropocene. We seek to reveal the current ethical standing of neoliberalism, and to identify other ethical positions and power relations that could be more conducive to promoting peaceful progress in an era during which all future life on our planet will be increasingly threatened by several organically inter-linked, human-caused crises, including that of the Earth’s biosphere. We conclude that on a planet close to many tipping points, beyond which irreversible entropy may ensue, a shift is needed away from neoliberal and anthropocentric belief systems towards a more ecologically aware perspective on life. Fostering the ethics of greater cooperation, mutual respect, deeper democracy, solidarity and enhanced social justice could facilitate the development of sustainability as a maxim of wisdom and praxis. Ultimately however, such progress requires the transformation of political power, as well as policies that are grounded in new ethical commitments.

The authors draw on their many decades of combined experience with medical students, observing their maturation into practice in widely differing contexts, to reaffirm some of the essential goals of medical education. They briefly review curricular changes in medical education over the past 100 years, then focus on the dynamic tension in undergraduate medical education (UME) resulting from new pedagogy. Specifically, these tensions arise from the differing trajectories and directions of the 3 traditional pillars of academic medicine: clinical excellence, state-of-the-art education, and cutting-edge research. The authors highlight the role of generalism as an essential foundation of UME, as well as the dilemma of a shrinking cadre of medical students choosing a generalist career path. To address challenges stemming from pedagogical changes, the authors offer 4 observations. First, a more condensed approach to faculty development may be to ensure that bringing teachers up to speed on the new curriculum is not excessively burdensome. Second would be a more gradual introduction of the proposed changes. Third, some discussion about medical education pedagogy and curricular development ought to have a place in UME to prepare the next generation of physicians for ongoing changes in accreditation and in approaches to education. Finally, more appropriate funding of medical education would alleviate some of the burden and anxiety by acknowledging its nonmaterial value.

Ilona Kickbusch’s thought provoking editorial is criticized in this commentary, partly because she fails to refer to previous critical work on the global conditions and policies that sustain inequality, poverty, poor health and damage to the biosphere and, as a result, she misreads global power and elides consideration of the fundamental historical structures of political and material power that shape agency in global health governance. We also doubt that global health can be improved through structures and processes of multilateralism that are premised on the continued reproduction of the ecologically myopic and socially unsustainable market civilization model of capitalist development that currently prevails in the world economy. This model drives net financial flows from poor to rich countries and from the poor to the affluent and super wealthy individuals. By contrast, we suggest that significant progress in global health requires a profound and socially just restructuring of global power, greater global solidarity and the “development of sustainability.”

Freedom of speech and academic freedom are widely recognized prerequisites for the maintenance of national and international freedom to communicate with colleagues in the relentless, objective, scholarly pursuit of knowledge and the advancement of the human condition. The debate on freedom of speech and academic freedom at universities in South Africa is complicated by the cultural and ideological diversity that characterizes a society in which racial discrimination has been entrenched for so long (Benatar The Lancet 335, 1576- 1578 1990a). It is perhaps not surprising that in this context the ‘language’ used does not necessarily have the same meaning to all the participants in the debate. These differences in ‘realms of discourse’ which seem to threaten freedom of speech and academic freedom are in part a reflection of the different ideologies from which they arise and also highlight the challenge to universities in South Africa to become ‘Africanized’. This essay is an attempt to analyze and discuss some of the overt, covert and intertwined strands of thought and the different ‘realms of discourse’, woven into the debate on academic freedom (and academic boycott) with a view to identifying, and briefly describing, the various concepts which influence and determine differing positions and which in part derive from diametrically opposed ideological value systems. The complexity of the issues involved precludes provision of comprehensive arguments for or from each position. I shall endeavor to sketch the basis for conflicting opinions, and illustrate that the difficulty in reaching consensus on ‘rational’ grounds is hampered by the contrasting basic value systems from which reasoned debates may proceed. Without recognition and acknowledgement of these fundamental differences, it is difficult to understand discussions in which the same words are used to describe different concepts and values, or to embark on the de-alienation and negotiation processes required to peacefully reach compromise solutions to the complex challenges facing society and universities in South Africa.

In many settings, the dedication of healthcare workers (HCWs) to the treatment of tuberculosis exposes them to serious risks. Current ethical considerations related to tuberculosis prevention in HCWs involve the threat posed by comorbidities, issues of power and space, the implications of intersectoral collaborations, (de)professionalization, just remuneration, the duty to care, and involvement in research. Emerging ethical considerations include mandatory vaccination and the use of geolocalization services and information technologies. The following exploration of these various ethical considerations demonstrates that the language of ethics can fruitfully be deployed to shed new light on policies that have repercussions on the lives of HCWs in underresourced settings. The language of ethics can help responsible parties get a clearer sense of what they owe HCWs, particularly when these individuals are poorly compensated, and it shows that it is essential that HCWs' contribution be acknowledged through a shared commitment to alleviate ethically problematic aspects of the environments within which they provide care. For this reason, there is a strong case for the community of bioethicists to continue to take greater interest both in the micro-level (eg, patient-provider interactions) and macro-level (eg, injustices that occur as a result of the world order) issues that put HCWs working in areas with high tuberculosis prevalence in ethically untenable positions. Ultimately, appropriate responses to the various ethical considerations explored here must vary based on the setting, but, as this article shows, they require thoughtful reflection and courageous action on the part of governments, policy makers, and managers responsible for national responses to the tuberculosis epidemic.

The Lancet–University of Oslo Commission Report on Global Governance for Health provides an insightful analysis of the global health inequalities that result from transnational activities consequent on what the authors call contemporary “global social norms.” Our critique is that the analysis and suggested reforms to prevailing institutions and practices are confined within the perspective of the dominant—although unsustainable and inequitable—market-oriented, neoliberal development model of global capitalism. Consequently, the report both elides critical discussion of many key forms of material and political power under conditions of neoliberal development and governance that shape the nature and priorities of the global governance for health, and fails to point to the extent of changes required to sustainably improve global health. We propose that an alternative concept of progress—one grounded in history, political economy, and ecologically responsible health ethics—is sorely needed to better address challenges of global health governance in the new millennium. This might be premised on global solidarity and the “development of sustainability.” We argue that the prevailing market civilization model that lies at the heart of global capitalism is being, and will further need to be, contested to avoid contradictions and dislocations associated with the commodification and privatization of health.

While debate remains about the definition and goals of work on global health, there is growing agreement that our moral starting point is the reality of unjust inequalities in the distribution of the conditions necessary for human health and well-being. With the growth of multi-jurisdictional and multicultural global health partnerships, the adequacy of the prevailing bioethical paradigm guiding the conduct of global health research and practice is being increasingly challenged. In response to ethical challenges and conflicts confronted by decision-makers in global health research and practice, we propose an innovative methodology that could be developed to bridge the gap between polarized systems of ideas and values (metaphysical, epistemological, moral, and political). Our inter-philosophies methodology provides the potential to construct a new, shared paradigm for global health ethics, thereby increasing the capacity for solidarity and shared decision-making in global health research and practice.

This chapter analyses the political influences that shaped reform of healthcare service provision and financing during four decades of neoliberal capitalist dominance, with its emphasis on individualism, consumerism, competitiveness, and the capitalist market in determining social needs and healthcare priorities. New financing sources and market competition, which shaped adoption of reforms, are contrasted with earlier reform efforts that were premised on the socialisation of risk and the universalisation of healthcare provision on an equitable basis for all. Transformation of state forms promoted the market and substantially weakened capacities to provide for basic needs. Controversy over these outcomes has coincided with astounding increases in global inequality, particularly since the 2008 global financial meltdown, with devastating and unequal effects on the health of populations. The chapter concludes by returning to the quest for universal health coverage by reaffirming the “Health for All” principles of social justice and solidarity within a ‘post-Washington consensus’.

A new context for ethics and ethics education is evident in a rapidly changing world and our threatened planet. The current focus on considerations of inter-personal ethics within an anthropocentric perspective on life should be extended to embrace considerations of global and ecological ethics within an eco-centric perspective on global and planetary health. The pathway to understanding and adapting to this new context includes promoting shifts in life styles from selfish hyper-individualism and wasteful consumerism towards cautious use of limited resources within an increasingly interdependent world in which the equal moral worth of all and sustainability are valued. Critical scholarly approaches to global politics and to the global political economy could facilitate such change and encourage iterative interactive processes instead of seeking conclusive definitive ‘scientific’ solutions to all problems. Hopefully this shift in perspective could be achieved firstly through sensitization to new and increasingly challenging ethical dilemmas, and then by encouraging rational thinking and action based on global and ecological considerations rather than on false economic dogma and the distorted workings of a market civilization. Moving ahead with these activities must begin with promotion of education, learning and self-reflection to foster the widespread development of a global state of mind. Such a shift would require an expanded ethical discourse, with consideration of ethical dilemmas beyond human inter-personal relationships. These should include intra-institutional and inter-institutional relationships, as well as relational ethics between nations in a post-Westphalian world, and between humans and nature in an era now called the Anthropocene, to ensure survival on a planet undergoing entropy.

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.

The improvement of health globally is arguably one of the most significant health policy and global strategic issues of the twenty-first century. What resources should be allocated to improve health and access to health care is contentious. Resource allocation choices are inevitable and those choices are complex, difficult, and morally problematic. Distributive justice, a primary moral concern of health systems, requires that the benefits and burdens of health-related services be prioritized according to morally relevant criteria. Knowing what resource allocation decisions to make would be quite simple if we could agree on both the need to do so and the criteria to guide allocations. However, examination of international experience has shown that there is no consensus about what and how allocation decisions should be made.

In response to the call from an international panel for ‘much needed rethinking’ about the goals and purposes of the education of healthcare professionals, we suggest that there must be an explicit account of the virtues and values that will inform healthcare practice in the 21st century. We propose that a renewed emphasis is needed on reviving the well-honed clinical skills and humanistic attributes in medicine as crucial for optimum affordable (and sustainable) care of individual patients. Analogous virtues should be linked to the quest for improving the health of whole populations, nationally and globally.

The last fifteen years have witnessed a significant increase in investment in research ethics capacity development throughout the world. We examine nine research ethics training programs that are focused on Sub-Saharan Africa and supported by the US National Institutes of Health. We collected data from grants awards' documents and annual reports supplemented by questionnaires completed by the training program directors. Together, these programs provided long-term training in research ethics to 275 African professionals, strengthened research ethics committees in 19 countries in Sub-Saharan Africa, and created research ethics curricula at many institutions and bioethics centers within Africa. Trainees' leadership resulted in new national systems and policies on research ethics, human tissue storage and export, and methods of monitoring compliance with research ethics guidelines. Training programs adapted to challenges that arose due to varied trainees' background knowledge in ethics, duration of time available for training, spoken and written English language skills, administrative obstacles, and the need to sustain post-training research ethics activities. Our report showcases the development of awareness of research ethics and building/strengthening of basic research ethics infrastructure in Sub-Saharan Africa. Nevertheless, the increasing amount and complexity of health research being conducted in Sub-Saharan Africa suggests the need for continued investment in research ethics capacity development in this region. This paper is part of a collection of papers analyzing the Fogarty International Center's International Research Ethics Education and Curriculum Development program.

Widening disparities in health within and between nations reflect a trajectory of 'progress' that has 'run its course' and needs to be significantly modified if progress is to be sustainable. Values and a value system that have enabled progress are now being distorted to the point where they undermine the future of global health by generating multiple crises that perpetuate injustice. Reliance on philanthropy for rectification, while necessary in the short and medium terms, is insufficient to address the challenge of economic and other systems spinning out of control. Innovative approaches are required and it is suggested that these could best emerge from in-depth multidisciplinary research supported by endeavours to promote a 'global mind-set.'

One hundred years after the Flexner Report recommended major changes to medical education, an international panel has released a vision of medical education for the 21st century. Two major features of this detailed report that were not adequately articulated or developed were (1) the values that underpin care of individual patients and how these could be sustained and promoted, and (2) the values required to promote global health at a time when health disparities are widening. After reviewing the timeless scientific and humanistic foundations of clinical medicine that are essential for the care of individuals, we consider the role of virtue both in relation to individual patient care and in promoting an ethical framework for population health within a cosmopolitan global health perspective, and suggest that many organs of society should contribute to promoting such progress.

The most common response to the challenge of protecting health through law is to focus on protecting the rights of vulnerable individuals and to enhance their access to health care. Each one of us is vulnerable or potentially vulnerable because of the fragile, existential nature of the human condition. Catastrophic and unexpected events could instantaneously transform us from a state of total independence and potential vulnerability to one of extreme vulnerability and complete dependence. Some legal provisions have the potential to provide a modicum of protection when we find ourselves in those situations (for example, through legislation, effective emergency health services can be created to reduce the impact of our potential vulnerability). There are also legal provisions that contribute to beneficial social circumstances; for example, legislation enabling universal access to medical care, and operationalizing respect for the individual’s right to health care, as advocated for by other authors in this issue.

As interconnections between health, ideology and politics become increasingly acknowledged, gaps in the literature also become visible in terms of analytic frameworks to engage these issues and empirical studies to understand the complexities. 'Critical public-health ethics' provides such an analytic lens. This article presents the results of a critical public-health ethics analysis of the government of Canada's international response to HIV. This qualitative study involved in-depth, semi-structured interviews with 23 experts on Canada's international response over time. Descriptive, thematic and theoretical analyses revealed an underlying dilemma between Canada's philanthropic desire to 'do the right thing' for the broader public good and Canada's commitment to its own economic growth and other forms of self-interest. Related to this tension were four conspicuous areas of silence in the data: (1) The relative absence of moral vocabulary for discussing Canada's duty to respond to the global HIV pandemic. (2) Scant reference to solutions based on poverty reduction. (3) Little awareness about the dominance of neoliberal economic rationality and its impact on HIV. (4) Limited understanding of Canada's function within the international economic order in terms of its role in poverty creation. Our study has implications for Canada and other rich nations through its empirical contribution to the chorus of calls challenging the legitimised, institutionalised and normative practice of considering the economic growth of wealthy countries as the primary objective of global economic policy.

Although the resources and knowledge for achieving improved global health exist, a new, critical paradigm on health as an aspect of human development, human security, and human rights is needed. Such a shift is required to sufficiently modify and credibly reduce the present dominance of perverse market forces on global health. New scientific discoveries can make wide-ranging contributions to improved health; however, improved global health depends on achieving greater social justice, economic redistribution, and enhanced democratization of production, caring social institutions for essential health care, education, and other public goods. As with the quest for an HIV vaccine, the challenge of improved global health requires an ambitious multidisciplinary research program.

The corrections for four minor errors are shown below. In the paragraph at the top of page 6 the words (mathematical calculation of the most economical means to ends, and loss of the sense of sacredness), should be bracketed as shown below and the quotation marks around the words total freedom for the wolves meant death for the lambs should be removed.

Conventional and well-established guidelines for the ethical conduct of clinical research are necessary but not sufficient for addressing research dilemmas related to public health research. There is a particular need for a public health ethics framework when, in the face of an epidemic, research is urgently needed to promote the common good. While there is limited experience in the use of a public health ethics framework, the value and potential of such an approach is increasingly being appreciated. Here we use two examples of adolescent women as potential candidates for participation in microbicide trials to illustrate how ethical decisions for public health research can be enhanced by drawing on both traditional research ethics guidance, and the emerging framework for public health ethics.

This article takes the state of health in the world today as the starting point for a backward look at the trajectory that has led to our current position and speculation about prospects for improved global health in the future. Our model of social development and its dominant value system, which has promoted scientific progress but has also brought about great social, economic and health instability, is interrogated. This leads to questions such as what it means to be healthy and what the practice of medicine is about. Three potential scenarios for global health in the future are outlined. It is suggested that deep introspection about our current value system is required to achieve a paradigm shift that could reverse current trends and lead both to improvements in health globally and to less human insecurity. The authors conclude that while we have the material resources to achieve ambitious goals we may lack the moral and political will to do so. An expanded discourse on ethics and human rights—as well as on the limits of what is politically possible— may provide the impetus to drive change towards an improved global economic system and better health globally.

people living on less than 1% of the annual global economy. Global health emergencies declared by the WHO, the Global Fund and through the Millennium Development Goals reflect acknowledgment of the challenges posed. Sadly, little has been done, and it is unlikely that in the absence of paradigm shifts in thinking and action any major progress will be made in narrowing global health disparities.

It is clear that the World Bank definition of poverty is outdated and requires revision. A brief review of how poverty and income levels are defined is offered to provide insight into the shortcomings of such definitions and into what ‘eradicating poverty in all its forms’ would mean if considered within more realistic boundaries.

The health of whole populations within nations and globally and the implications of climate change are two of the most important challenges facing humanity in the 21st century. Both are components of a complex global crisis that must be acknowledged and addressed. Here we draw the attention of health professionals to some emerging threats and insights from key works of environmentalists in the hope that these may catalyze reflection on the broader challenges facing human health at a time of deep planetary malaise.

In the 12 years since publication of the previous issue of this volume, the world has changed significantly. In addition to further widening of many of the disparities in health previously described, the impact and implications of the still evolving global economic crisis and of climate change have led to increasing recognition of how the ‘development’ agenda has failed, and that global health is one of the major challenges for the twenty-first century (Benatar and Brock, 2011). World population has increased to 7 billion people, half of whom continue to live in severe poverty (on less than US$2–3 a day), most in constant hunger and under squalid conditions, with little prospect of significant improvement unless new solutions are envisaged. This article discusses the health of citizens of very poor countries and the global interdependence of the health of all peoples, including the privileged.

In this paper, we propose a new model for development, one that transcends the North-South dichotomy and goes beyond a narrow conception of development as an economic process. This model requires a paradigm shift toward a new metaphor that develops sustainability, rather than sustains development. We conclude by defending a 'report card on development' as a means for evaluating how countries perform within this new paradigm.

Although the application of major biomedical advances has yielded spectacular results for individual health, there has been little improvement in the health of whole populations. There is a "back to the future" irony in the fact that at the inception of the 21st century, the eruption and spread of a multitude of "old" and "new" infectious diseases has become the most serious global threat to the health of humankind. At this historical juncture, the United States is the country with the most potential for favorably influencing global health and health care. Although there are historical, cultural, economic, and political factors that impede the United States from rising to this challenge, there is both a moral imperative and a rational long-term self-interest basis for the U.S. medical profession and government to exercise leadership in facing the health challenges of tragic and genocidal proportions that threaten everyone in an increasingly interdependent world.

Interest in the ethics of research on human subjects, stimulated by atrocious human experimentation during WWII and the resultant Nuremberg Code, has been sustained by examples of unethical research in many countries and by proliferation of codes and guidelines. Such interest has intensified in recent years in association with expanding international collaborative research endeavors. The ongoing controversy in international research ethics takes place at two levels. At the practical level it is about the competing concerns of those predominantly interested in doing research to advance knowledge and those who, while supporting the need for research, are more acutely aware of the potential to exploit vulnerable participants, especially in developing countries. At the level of theory the controversy pits ethical universalism against moral relativism.In her recent review of agreements and controversies in international research ethics, Ruth Macklin has concluded that, despite seeming agreement on several issues, many different viewpoints persist. In her view it is unlikely that these will be resolved easily.

A major focus within the modern bioethics debate has been on reshaping power relationships within the doctor-patient relationship. Empowerment of the vulnerable has been achieved through an emphasis on human rights and respect for individual dignity. However, power imbalances remain pervasive within healthcare. To a considerable extent this relates to insufficient attention to social injustice. Such power imbalances together with the development of new forms of power, for example through new genetic biotechnology, raise the spectre of increasing social injustice. Attention will be drawn to the need to extend the bioethics debate to include ethical considerations regarding public health. Changes in political philosophy will also be required to reshape international power relations and improve population health.

Despite spectacular twentieth century scientific and technological progress, the world is more inequitable than it was fifty years ago. This is evident both in terms of access to health care for individuals, and in relation to the health of whole populations. Disparities in wealth and health within and between nations are widening inexorably and the rapidly expanding global economy has failed to reduce poverty among those with little if any access to health care. In this context the Universal Declaration of Human Rights remains an unrealized aspiration for the majority of the world's people. Given these realities, no single discipline, or body of knowledge is likely to make much difference. For example, approaches based only on neo–liberal economics, as exemplified by the structural adjustment programmes of the World Bank, have not been successful in promoting health equity. The authors believe that an interdisciplinary approach is required, and that bioethics, an interdisciplinary field, can make a contribution towards improving health globally. To do this, the scope of bioethics should be expanded towards a results–oriented global health ethics, based upon widely shared and foundational values that could be carried forward through five transformational approaches.

Intense scientific work on HIV/AIDS has led to the development of effective combination drug therapies and there is hope that effective vaccines will soon be produced. However, the majority of people with HIV/AIDS in the world are not benefiting from such advances because of extreme poverty. This article focuses on the pandemic as a reflection of a complex trajectory of social and economic forces that create widening global disparities in wealth and health and concomitant ecological niches for the emergence of new infectious diseases. While the biomedical approach to HIV/AIDS is necessary, has prolonged the lives of many individuals and could offer much at the level of population health, it cannot, in isolation, improve the health of populations. To achieve the latter will require understanding and addressing the deeper social causes of pandemics. Broadening the discourse on ethics to include public health ethics and the ethics of international relations could contribute to reducing the impact of the pandemic and to preventing the emergence of new infectious diseases in the future.

The debate on the ethics of international clinical research involving collaboration with developing countries has achieved a high profile in recent years. Informed consent and universal standards have been most intensively debated. Exploitation and lack of adequate attention to justice in the distribution of risks/harm and benefits to individuals and communities have to a lesser extent been addressed. The global context in which these debates are taking place, and some of the less obvious implications for research ethics and for health are discussed here to broaden understanding of the complexity of the debate. A wider role is proposed for research ethics committees, one that includes an educational component and some responsibility for audit. It is proposed that new ways of thinking are needed about the role of research ethics in promoting moral progress in the research endeavour and improving global health.

1 Lawn JE. The child survival revolution: what next? Lancet 2014; 384: 931–33. 2 Barros AJ, Ronsmans C, Axelson H, et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012; 379: 1225–33. 3 Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. 4 South Centre. Capital fl ows from South to North: A new dynamic in global economic relations. Geneva: South Centre; 2008. 5 Klein N. This changes everything: capitalism vs the climate. New York: Simon & Shuster; 2014. 6 Bensimon CM, Benatar SR. Developing sustainability: a new metaphor for progress. Theor Med Bioeth 2006; 27: 59–79. 7 Horton R. Offl ine: Why the Sustainable Development Goals will fail. Lancet 2014; 383: 2196. issues in the next 15 years—namely inequity and climate change. Reduction of the neonatal mortality rate, for example, from 70 to 30 might be achievable through biomedical interventions, technological changes coupled with health systems change, female education, and nutritional interventions. Decreasing it further however, is going to depend less on these factors and issues of governance than it does on paradigm shifts in global political and economic thinking. The global system is driven by inequity, by capital outflows from low-income countries that dwarf infl ows by more than six to one, and a global system with increasing numbers of what Klein calls “sacrifi ce zones” (poor out of the way places that are being destroyed by the consequences of global warming). Biomedical and health system change will not aff ect these “sacrifi ce zones” and as such, are likely to hinder further improvements in child survival in the coming decades. This has particular resonance in view of the imminent release of the Sustainable Development Goals for the post-2015 era. The very phrase ”sustainable development” has been criticised as unachieveable when development is defined in economic terms (in the context of hyper consumption and depletion of the earth’s resources), and there is a need to think about ”developing sustainably”. If we link this to the six dimensions of sustainability outlined by Horton (wellbeing, capability, intergenerational equity, externalities, resilience, and strength of our civilisations) and, more specifi cally, the last one, we have to then situate ourselves firmly in the realm of the political. Location of future gains in child survival squarely within what has gone before, largely biomedical and for the most part apolitical, runs the risk of simply doing business as usual and masking the real social and societal changes that are needed to achieve ambitious goals.