It has long been my opinion that all notions of human equality, other than that of formal equality before the law, are destructive of human intelligence and sensibility. My opinion was confirmed recently when I read an editorial in the Lancet, one of the two most important general medical journals in the world.
The title of the editorial was “Equity in Child Survival.” I could have written the editorial myself from the title alone, so utterly predictable was its drift:
Although Indonesia has reduced child mortality by 40% during the past decade, data from 2007 show that children in rural areas were almost 60% more likely to die than those living in urban ones, while those in the poorest 20% were more than twice as likely to die as those in the richest 20%, and girls were 20% more likely to die than boys.
Note here that even if inequality were the same as inequity, there is nothing in these figures to show that inequity had increased in Indonesia during the decade, or to show that it had not actually decreased; and if equity in this sense were an important goal in itself, it would matter little whether the health of the poorest improved, or the health of the richest deteriorated.
In a country the size and complexity of Indonesia, with hundreds of inhabited islands, some of them very remote, it is hardly surprising that there should be quite wide geographical variations in health, wealth and productivity. It is no more inequitable that there should be these variations than that the French should have so much better health than the Americans, or for that matter than the Bangladeshis.
This is not to deny that it would be eminently desirable for the health of the poor to improve, but it is desirable not for reasons of equity; it is desirable because health for human beings is a good in itself and avoidable suffering ought to be avoided. Furthermore, it is true that it is often easier and cheaper to improve the health of the poor than that of the rich. But this has nothing to do with equity in the Lancet’s sense of the word, and those who are fixated on such equity are often at a loss to give any reason why the poor should be treated when ill other than it would be inequitable not to treat them. On their principles, indeed, it would be illogical to save the drowning child of rich parents because to do so would be to increase inequity. Equity would be increased if he drowned.
Lancet-type inequity lurks everywhere, even unnoticed in its own pages. Inequity can be diachronic as well as synchronic. In the same issue of the journal as the editorial there was an interesting paper from Denmark comparing the cognitive function of those born in 1905 and surviving into their nineties with those born ten years later and surviving into their nineties. Those born earlier had worse cognitive function in their nineties than those born later. Moreover, anyone born in 1915 had a 28 percent better chance of surviving to the age of 93 and a 32 percent chance of surviving to the age of 95. So they lived not only better but longer.
It is almost certain that this tendency, to greater survival with a better quality of life, has continued everywhere since then (give or take a genocide or two). But this is inequitable. Why should people born after me have better prospects just because of the date of their birth? In the name of justice, I demand that they should suffer worse health!