The astonishing privilege of living in a high-income country

On the advantages of resources and geography that shape how we think and what we do.

Part of the work of promoting health is engaging with the role of privilege. There are many kinds of privilege, and essentially all forms of privilege influence health. There is the privilege of getting a good education. There is the privilege of being financially well-off. There is the privilege of having regular access to good food. All of this contributes to our health. But, in addition to shaping our health, privilege also shapes our perspectives, the worldviews we bring to the very work of promoting health. That means that if we are concerned with health, we need to be engaged in an ongoing process of acknowledging our privilege, to see clearly the forces that create a better world, to ensure that the resources that support health are not exclusive to a privileged few.

Today, a few thoughts about one kind of privilege that is we do not talk about enough: the privilege of living in a high-income country. I do so mindful that this is indeed just one kind of privilege, and that there are many other levels of privilege worth addressing. Much of the recent academic conversation about privilege has centered around forms of privilege found within US national borders, such as the advantages conferred by factors like race, class, education, and native-born status. This conversation is all to the good, a necessary part of grappling with privilege. However, it is also important to widen our focus to see the tremendous privilege of being able to live, work, and engage in the public conversation in a high-income country. This status affords us comforts and freedoms which are far out of reach for populations in many other countries, and plays a foundational role in shaping our thinking, writing, and the approaches we adopt in pursuit of health. It seems necessary to acknowledge this privilege if we are to see beyond it, to engage with the broader global inequality it reflects. As is perhaps always the case, acknowledging this privilege can be uncomfortable, but I would argue necessary if we are to shape a world that is no longer defined by the privileges some have and some do not.     

I will begin with a story, one which starkly reflects our blinkers, how we do not reflect hardly enough on how our high-income country perspective shapes our global conversation. In June, over 280 people were killed and over 1,000 were injured in a train crash in Odisha, India. The majority of the dead had been traveling in general category coaches, as opposed to the more expensive reserved seats, where poor workers paid the cheapest prices to stand upright for long stretches as they commuted to jobs they likely hoped would provide some economic relief in a country with much poverty. The deaths of these passengers were an outrage and will hopefully lead to a tightening of railway regulations in India. For the families and friends of the dead, the tragedy of the crash will remain an ever-present reality of life, a burden they must now carry. And yet, this tragedy barely registered in the global narrative, which at the time was dominated by another tragedy, a sinking submarine for wealthy passengers. It is not fruitful to try to compare tragedies. But it does not feel unreasonable to note that this, yet again represented a world-view dominated by a high-income perspective, a narrative that values lives in different parts of the world, differently.

This feeling reflects a contradiction at the heart of the work of academic public health today. While we are centrally concerned with supporting the health of all populations, it remains true that much of the writing and leading thinking in public health is done by those who represent a small subset of the global population, namely the part of the population living in high-income countries. Worldwide, this subset is quite small indeed. About 16 percent of the world’s population lives in high-income countries. Yet the populations of these countries are substantially overrepresented in science and academic publishing, with over 90 percent of science and engineering publishing coming from upper middle- and high-income countries. It is important to stress, of course, that this overrepresentation primarily refers to publishing, not to the broader, on-the-ground work of public health. There is much good public health work being done in low-income countries, often led by the communities within these countries. However, it is in high-income countries that we see much academic thinking, writing, and framing of public health issues. This reflects a fundamental distance between the shaping of thinking about health and the lives of the populations affected by our efforts in the low-income world. I am aware that acknowledging this reality can seem paternalistic, a charge to which public health can be vulnerable. Yet it remains a fact that much of the thinking which supports our global health efforts takes place in high-income countries and our efforts are deeply shaped by this high-income-country-centric perspective.

According to the World Inequality Report 2022, the poorest half of the global population makes just 8.5 percent of the income worldwide, while the richest 10 percent makes 52 percent. The gap between haves and have-nots is also evident in global wealth inequalities. The poorest half of the global population controls just two percent of the world’s wealth, while the richest 10 percent of the population controls 76 percent. This global mismatch in material assets is reflected in the resources allocated for the research that shapes public health thinking. The National Institutes of Health, for example, has a budget of $45 billion. More than 84 percent of this money goes to extramural research, supporting around 50,000 grants. This grant money supports over 300,000 researchers in over 2,500 academic and research institutions across the US. We see a similar abundance of resources when we look at global foundations like the UK-based Wellcome Trust, a charitable foundation focused on health research which is supported by an investment portfolio that is currently valued at about $46 billion. These spending profiles reflect vast resources that high-income countries have at their disposal to drive the research that is the intellectual foundation of what we do. Our pursuit of health, then, is to some extent underwritten by the global inequality that allows high-income countries to spend billions each year on the study of health through well-resourced public and private organizations.   

Given the realities of inequality, and the sheer scale of global economic precarity relative to the parts of the world that enjoy high-income status, I have long felt it is a tremendous privilege to be based as I am now in a high-income country, and as such, regularly ask how this privilege might be influencing how I think and what I do in my work. For example, I am writing this essay on a computer which has access to a reliable internet connection, something we often take for granted in the high-income world, but which is far less accessible in less wealthy countries. I have the peace of mind of knowing I will drive home from work on safe, well-maintained roads. This allows me to better focus my thoughts on the world of ideas I am privileged to inhabit, reflecting Maslow’s Hierarchy of Needs, in which the fulfillment of basic physiological needs frees us to focus on more emotional and intellectual considerations. I am also privileged to do my research in an institutional setting which allows me access to the resources necessary for quality work.

While we may like to imagine such privilege does not unduly influence how we think about health, this does not align with the realities of human nature. I grew up and was raised in far less privileged circumstances, but I have worked in high-income country-based population health science for decades and it is certainly true that my perspective has been shaped by being able to call a high-income-country home. Just as this perspective allows us to read of a train crash in India and feel it is happening somewhere far away, it can cause us to engage with the work of promoting health at national and global level differently than we likely would if we did not live in the high-income world.

In recent years, there has been an effort to grapple with what this perspective has meant for what we have historically called “global health.” Much of this has coalesced around the notion of decolonizing global health. This has meant looking at how global health has often been characterized by health workers from high-income countries working in low-income countries to pursue a vision of public health with little input from the communities whose health they are there to support. This ongoing reappraisal of global health has been, I think, a positive influence, shaping a more equitable approach to our work by acknowledging where we have historically fallen short.

Yet as critical as this decolonizing work is, it is possible for us to engage in it while failing to grapple with the arguably more foundational challenge of the privilege imbalance which underlies so much of what we do. As we look to shape a new, practical philosophy of health in this post-war moment, we have a chance to engage in a process of self-reflection, to really look at why we see the world the way we do. This includes looking at the privilege that shapes how we think and what we do in pursuit of health.

This begins, I would suggest, with the simple importance of acknowledging this privilege as a fundamental force which shapes how we see the world. That is in large part why I am writing this piece. My privilege on this is as much a central part of my perspective as my identity as an immigrant, as a doctor, as a husband and father. Keeping this understanding in view is akin to trying not to forget about one’s glasses as one is wearing them. It means saying, always, “There are lenses over my eyes, and while they can give me the advantage of accessing all the places that are open to people with good vision, they are also giving me a forced perspective, sitting as they do between my eyes and the world as it is.” In practical terms, this means that every time I am about to write or speak, I try to ask myself whether what I am about to express is somehow distorted by my privileged perspective. Would I express it differently if I were engaging from a place of less privilege?  Am I mis-aligning priorities based on my own circumstance?   Asking these questions should push us in high-income countries to look beyond our privilege, keeping our eyes open to the whole world, not just the part of it we inhabit. In this, we are helped immeasurably by working in diverse environments, by the perspectives of other people, by the friends and colleagues who bring to our networks a range of experiences, opinions, and priorities, helping prevent the myopia of mistaking what is in front of one’s nose each day for all there is.

Finally, the reality of privilege—the undeniable advantages that come from living and working in a high-income country—means there is little we can do that is more important than shaping a healthier world by addressing the structural drivers of global inequity. The fact that the world can be divided into high- and low-income countries at all reflects how far we still have to go to create a healthier world founded on a basis of equity. Creating such a world is the central goal of public health. This means using our privilege to build a future where notions of privilege are no longer a factor in deciding who gets to be healthy. And that is worthy work indeed. 

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Also this week.

A Dean’s Note on the values that shape our community, as we look ahead to the coming year.