Debt, Financial Speculation and Artificial Intelligence: The Emerging Architecture of Inequity

IN A NUTSHELL
Author's note
Public and private debt, financial speculation and artificial intelligence are converging to reshape the global distribution of wealth, power and opportunity. Debt creates contractual claims on future income; financial markets transform these claims into tradable assets; and increasingly sophisticated algorithms enable capital to be analysed, allocated and mobilised at unprecedented speed and scale. These mechanisms can finance productive investment and improve economic coordination. Yet, when governed primarily by private returns rather than social needs, they can also reinforce wealth concentration, amplify systemic risk and constrain the resources available for health, social protection and ecological transition.

Building on Karl Marx’s analysis of public debt, Thomas Piketty’s work on wealth concentration, contemporary research on financial stability, and Juan Garay’s previous publications on WiSE, algorithmic power, Palantir, “unplugging” and living communities, this article examines the mechanisms connecting debt, speculation and AI-driven decision-making. It argues that the central challenge is not technological progress or borrowing per se, but the concentration of control over financial and informational infrastructures and the unequal distribution of their benefits and risks.

From the perspective of the Sustainable Health Equity Movement (SHEM), the article proposes a framework for assessing financial and technological systems according to their contribution to human dignity, sustainable wellbeing and planetary health. It concludes by exploring how democratic financial governance, fair taxation, shared knowledge and interconnected communities can challenge structural dependency and build alternatives grounded in solidarity, sufficiency and ecological responsibility.

By Juan Garay  *

Co-Chair, Sustainable Health Equity Movement (SHEM)

Professor and Researcher in Health Equity, Ethics and Metrics

Founder, Valyter Ecovillage

Debt, Financial Speculation and Artificial Intelligence: The Emerging Architecture of Inequity

 

1.   Introduction: Three forces, one structural challenge

Debt, financial speculation and artificial intelligence are often discussed separately. Debt is treated as a fiscal or macroeconomic problem, speculation as a feature of financial markets, and AI as a technological revolution. Yet their interaction deserves much greater attention.

Debt creates obligations to transfer future income to creditors. Financial markets allow those obligations and other claims on future income to be traded, aggregated and used as collateral. Artificial intelligence increasingly supports the analysis of these assets, the assessment of risks and the automation of investment decisions.

Together, these processes can increase the capacity to mobilise capital. They can also strengthen the position of actors who already control large financial resources, privileged access to information and the technological infrastructure through which decisions are made.

The result is not necessarily a coordinated conspiracy or an inevitable outcome of technological progress. It is a structural possibility arising from the interaction of incentives, ownership, market concentration and unequal bargaining power.

The central question is therefore not simply how much debt exists or how powerful AI becomes. It is who controls these systems, whose interests they serve, who captures their benefits and who bears their costs.

This question is particularly important for the Sustainable Health Equity Movement (SHEM). In Achieving Sustainable Health Equity, Castro, Marmot, Garay, de Negri and Buss (2022) connect health inequities to the unequal distribution of power and resources, environmental damage and political conflict. Their analysis suggests that the consequences of financial and technological arrangements must ultimately be evaluated against their effects on people’s opportunities to live healthy and dignified lives.

2.   Debt: A liability for one party, an asset for another

Debt is not merely a number on a government’s balance sheet. It is a relationship between a borrower and a creditor, governed by contractual obligations and unequal economic circumstances.

For the borrower, debt means a commitment to make future payments. For the creditor, it represents a financial asset that may generate interest, be sold to another investor or serve as collateral for additional borrowing.

This dual character is essential to understanding the political economy of debt.

Public borrowing can finance hospitals, education, transport, renewable energy and infrastructure whose benefits extend across generations. Private borrowing can help households secure housing and enable companies to invest in productive capacity. Credit is indispensable to many modern economies.

The problem arises when borrowing becomes unsustainable, when its benefits are distributed unequally, or when repayment obligations undermine essential social functions.

Karl Marx examined this historical relationship in Capital, Volume I, Chapter 31, describing public credit as “one of the most powerful levers of primitive accumulation” (Marx, 1867, ch. 31).

His argument connected public borrowing to taxation, colonial expansion and the historical concentration of capital. The contemporary relevance lies not in assuming that every modern debt instrument reproduces the conditions of nineteenth-century capitalism, but in recognising that financial contracts operate within wider structures of ownership and political power.

A government can borrow to improve collective wellbeing. It can also borrow under conditions that transfer a substantial share of public revenue to creditors while limiting its capacity to provide essential services.

These outcomes are not equivalent.

Nor should all creditors be treated as a homogeneous group. Government bonds may be held by pension funds, insurance companies, central banks, investment funds and individual savers. Understanding the distributional consequences of public debt requires examining the actual ownership of financial assets, the terms of borrowing, the tax system and the public expenditure displaced by debt service.

The essential questions are:

  • Who receives the proceeds of borrowing?
  • Who owns the resulting financial claims?
  • What interest and repayment conditions apply?
  • Who pays the taxes or bears the spending reductions needed to service the debt?
  • Does the borrowing expand society’s long-term capacity to provide dignified lives?

Debt should be assessed not only through its financial sustainability but also through its social purpose and distributional consequences.

3.   From borrowing to speculation: When future income becomes a financial asset

Financial markets enable investors to buy and sell claims on future income. Government bonds, corporate debt, mortgages and other financial instruments can be traded in secondary markets or incorporated into more complex investment strategies.

This capacity can improve liquidity, distribute risk and help allocate capital. But it can also create incentives for financial activity increasingly detached from the production of goods and services or the provision of essential needs.

Leverage is particularly important. By borrowing to purchase assets, investors can increase the potential return on their own capital. When prices rise, the gains may be amplified. When prices fall, losses can also multiply, potentially forcing investors to sell assets, reduce lending or seek additional liquidity.

A reinforcing cycle can emerge:

  1. Credit finances the purchase of
  2. Rising asset prices increase the value of
  3. Stronger collateral enables additional
  4. New borrowing increases demand for
  5. Expectations of continued appreciation encourage further

This process may support productive investment for a time. However, if valuations and borrowing rise faster than the underlying capacity to generate sustainable income, the system becomes vulnerable to a reversal.

The same mechanism can affect public finance. When governments face rising borrowing costs, refinancing becomes more expensive. Countries with large external debts, limited access to foreign currency or weak fiscal capacity may find their policy choices increasingly constrained.

Debt does not automatically produce speculation, and speculation does not always create instability. The risk emerges when leverage, concentrated ownership, short-term incentives and interconnected financial institutions reinforce one another.

The critical distinction is between finance that supports productive and socially useful activity and financial expansion that increasingly depends on rising asset prices, refinancing and expectations of future returns.

4.   Inequality and the distribution of financial returns

The distributional consequences of debt depend on the relative positions of borrowers and creditors.

Households with limited income may need to borrow to obtain housing, cover emergencies or meet essential expenses. Their ability to negotiate interest rates and repayment conditions may be limited.

By contrast, institutions and individuals with substantial financial assets may have access to diversified portfolios, professional advice and cheaper sources of credit. They can earn interest, receive dividends, collect rents and benefit from capital gains.

This does not mean that every debtor is poor or every creditor wealthy. It means that unequal initial access to assets and credit can produce unequal opportunities to benefit from the financial system.

Thomas Piketty’s Capital in the Twenty-First Century (2014) draws attention to the capacity of accumulated wealth to reinforce inequality across generations. His well-known relationship between the return on capital and economic growth, expressed as (r>g), highlights one mechanism through which wealth concentration can persist.

Piketty does not present this relationship as an unconditional law. Its effects depend on institutions, taxation, inheritance, economic growth and political choices. Nevertheless, where wealth generates returns that persistently exceed the growth of ordinary incomes, the relative position of asset owners may strengthen over time.

Financialisation can intensify this divergence when returns from asset ownership grow faster than wages or public resources available for essential services.

The result is a potentially self-reinforcing cycle: concentrated wealth provides access to capital, access to capital creates additional investment opportunities, and investment returns expand the capacity to acquire further assets and influence economic decisions.

The issue is not merely the amount of wealth in society, but the concentration of ownership and the ability to convert financial resources into lasting economic and political power.

5.   Artificial intelligence: The acceleration of financial decision-making

Artificial intelligence is changing how financial institutions process information, evaluate risks and allocate capital.

Algorithms can analyse large datasets, model scenarios, detect patterns, estimate creditworthiness and support trading or portfolio management. These tools can improve efficiency and help institutions respond to complex conditions.

BlackRock’s Aladdin platform, for example, provides investment and risk-management technology used to analyse portfolios and market exposures. It illustrates the growing importance of digital infrastructure in the management of financial assets.

The existence of such systems does not mean that a single institution controls the global financial system or that all investment decisions are automated. It does demonstrate that advanced information technology has become an important component of financial power.

Juan Garay’s article, The Progressive Power of Data and Algorithms, and Their Effect on Human Life Loss Due to Geopolitical Tensions, Military Spending, and Global Injustice (2026a), examines the growing interaction between algorithmic infrastructures, financial concentration, military systems and global inequity. It argues that unequal access to data-processing and predictive capabilities can strengthen existing asymmetries of power.

The underlying concern is broader than any single platform. When a relatively small number of institutions control essential financial and technological infrastructures, they can acquire advantages in information, speed, scale and influence.

These advantages may improve investment decisions, but they can also make markets more dependent on concentrated providers and less transparent to regulators, workers and citizens.

The risks include:

  • Opacity: complex models may make decisions difficult to explain or challenge
  • Concentration: the costs of advanced computing and data infrastructure can favour large institutions.
  • Common-model risk: similar algorithms may react to the same signals, amplifying market movements.
  • Unequal access: institutions with better data and computing capacity may gain advantages over smaller participants.
  • Accountability gaps: responsibility may become difficult to establish when human decisions are mediated by automated systems.

AI does not need to possess intentions or independently seek domination to contribute to these outcomes. The relevant question is how its design, ownership and deployment interact with the incentives of the institutions using it.

6.   The feedback loop between debt, speculation and AI

The interaction between debt, financial speculation and AI can create a feedback loop that amplifies both growth and instability.

First, credit expands investment capacity. Borrowers use debt to purchase assets, develop businesses or finance technological infrastructure.

Second, expectations shape asset valuations. Investors assess the future income and potential appreciation associated with those assets. Optimistic expectations can increase demand and raise prices.

Third, algorithms accelerate analysis and transactions. Automated systems process information and respond to market signals at scales and speeds that can exceed conventional human decision-making.

Fourth, rising valuations support additional borrowing. Higher asset prices may increase collateral values, enabling further credit and additional investment.

Fifth, a change in expectations can reverse the process. Falling prices weaken collateral, increase refinancing difficulties and trigger sales. If many institutions react simultaneously, liquidity can deteriorate and losses can spread through interconnected markets.

The outcome depends on leverage, market structure, liquidity, regulatory safeguards and the quality of the underlying assets. It is not inevitable that AI will amplify a crisis.

Well-designed systems and effective oversight may improve risk detection.

Nevertheless, algorithmic speed can become a source of fragility when multiple institutions rely on similar signals, pursue comparable strategies or attempt to reduce exposure at the same time.

This is particularly relevant to investments associated with AI itself. Technological innovation can create substantial productive value, but expectations about future returns may also become excessive. If investment, valuations and borrowing grow faster than the revenue and productivity that eventually materialise, a correction can affect investors, lenders and the wider economy.

The International Monetary Fund’s work on AI and financial stability provides a useful framework for assessing these risks. Its Global Financial Stability Report and research on AI adoption should be read alongside national regulatory assessments and evidence on actual market exposures.

The central issue is not whether AI investment is good or bad. It is whether the financial commitments built around it remain sustainable under less optimistic conditions.

7.   Algorithmic power, surveillance and the Palantir question

Financial AI is only one dimension of a wider transformation in the relationship between data, technology and power.

In The Revolution of Harmony Against the Palantir Manifesto: Digital Control, Permanent Warfare, and the Defense of Human Freedom, Garay (2026b) examines the convergence of algorithmic systems, military applications, surveillance and political authority.

The article contrasts technologies that support human autonomy with systems that may strengthen surveillance, militarisation and centralised control. It argues for a different technological orientation, grounded in cooperation, ecological responsibility and the protection of human dignity.

This perspective matters to the debt debate because financial and informational power are increasingly interconnected. Large financial institutions use data to allocate capital and evaluate risk. Governments use digital systems to manage public administration and security. Technology companies provide infrastructure used in both civilian and military settings.

These systems have different purposes and governance arrangements; they should not be treated as interchangeable. Nor does their coexistence prove that they operate as a single coordinated system.

But their interactions raise legitimate questions about the concentration of decision-making power.

Who controls the data used to determine credit access, insurance costs, employment opportunities or public resource allocation? Who can challenge an algorithmic decision? What happens when critical infrastructure is owned by a small number of private providers? How can democratic institutions retain effective oversight when technical systems become increasingly complex?

The answer should not be technological rejection. It should be transparent governance, independent scrutiny, meaningful human accountability and the development of public-interest technological capabilities.

The same principle applies to financial AI: the more consequential a system’s decisions, the stronger the requirements for transparency, oversight and redress.

8.   From financial inequality to health inequity

For SHEM, the ultimate significance of these mechanisms lies in their consequences for human wellbeing.

Debt-service obligations can constrain public budgets. Financial instability can reduce employment, household security and access to credit. Wealth concentration can influence political priorities and the distribution of essential resources. Technological inequalities can determine who benefits from innovation and who remains excluded.

These mechanisms may affect health through several pathways.

Fiscal displacement

When governments devote increasing resources to servicing unsustainable debt, they may have less fiscal space for primary healthcare, education, housing, nutrition and social protection. The impact depends on national circumstances and policy decisions, but the opportunity cost can be substantial.

Household insecurity

High borrowing costs, housing debt and insecure income can increase financial stress and reduce households’ ability to afford nutritious food, healthcare and adequate living conditions.

Unequal technological access

AI may improve diagnosis, health surveillance, research and resource allocation. But where access to computing, data, infrastructure and skilled personnel is unequal, the benefits may accrue disproportionately to wealthier populations and countries.

Ecological harm

Financial incentives that favour environmentally destructive activities can contribute to pollution, biodiversity loss and climate disruption. The resulting health costs may be borne by populations that receive little of the financial benefit.

Political and military expenditure

Financial and technological systems also influence how resources are mobilised for defence and security. Military spending can serve legitimate public purposes, but its scale and allocation should be assessed alongside unmet health, social and ecological needs.

Castro et al. (2022) provide a relevant foundation for this analysis by linking sustainable health equity to the distribution of power and resources and to environmental and political conditions.

From this perspective, financial performance cannot be the sole measure of economic success. A system that generates substantial returns while worsening preventable mortality, undermining public services or accelerating ecological destruction must be evaluated against those social costs.

9.   The opportunity cost of financial and technological priorities

Every allocation of resources has an opportunity cost. Capital, energy, skilled labour, public revenue and institutional capacity used for one purpose cannot simultaneously be used for another.

Some financial activities create substantial social value. Others primarily redistribute existing claims, increase leverage or pursue short-term price movements. Similarly, AI can support scientific research, public health and environmental monitoring, or it can be deployed in ways that intensify surveillance, excessive consumption and financial concentration.

The distinction is not always straightforward, and financial markets cannot be reduced to a simple opposition between productive and unproductive activity. Liquidity, risk management and investment are necessary functions.

Nevertheless, society should ask whether its financial and technological capabilities are aligned with its most urgent needs.

What if more investment and technological expertise were directed towards strengthening primary healthcare, developing affordable medicines, restoring ecosystems, improving energy efficiency, supporting regenerative agriculture and ensuring access to clean water?

Such a reorientation would not happen automatically. It would require public investment, appropriate incentives, effective regulation and institutions capable of identifying and supporting activities with high social value.

The central problem is a possible divergence between private profitability and collective benefit. An activity may be highly profitable without meeting an urgent social need, while another may generate enormous public benefits without offering investors an attractive financial return.

Public policy must address this divergence rather than assuming that market prices alone will determine the most socially desirable allocation of resources.

10.   From financial accumulation to Wellbeing in Sustainable Equity (WiSE)

Garay’s earlier work on Wellbeing in Sustainable Equity (WiSE) offers a normative framework for addressing this challenge.

In Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity (2023), Garay proposes that economic and political arrangements should be assessed according to their capacity to support dignified, healthy lives while respecting ecological limits and intergenerational responsibilities.

This framework challenges the assumption that growth in monetary output is sufficient evidence of social progress. It instead asks whether resources are distributed fairly, whether people can attain good health and wellbeing, and whether present consumption undermines the opportunities of future generations.

The Sustainable Wellbeing Equity Index (Garay, 2025) develops this direction through an ethical approach to wellbeing that considers both individual flourishing and the consequences of excessive accumulation for others and for the natural world.

Applied to debt and AI, WiSE suggests three complementary tests.

The dignity test: Does a financial or technological arrangement expand access to the material and social conditions necessary for a dignified life?

The equity test: Who benefits, who bears the risks and costs, and does the arrangement reduce or reinforce unjust inequalities?

The sustainability test: Are the activity’s ecological consequences compatible with the long-term conditions for human and planetary health?

These tests do not replace conventional financial analysis. They complement it by making explicit the social and ecological consequences that market prices may fail to capture.

They also provide a basis for developing indicators that compare debt service with essential public expenditure, assess the distribution of financial returns and examine who benefits from AI-driven productivity gains.

11.  “Unplugging”: Reducing dependence on extractive systems

In The Health, Equity, Peace, and Planetary Value of “Unplugging” (Garay, 2026c), the concept of unplugging is presented as more than a personal lifestyle choice. It is a potential strategy for reducing dependence on systems characterised by hyperconnectivity, surveillance, financial concentration, ecological extraction and excessive consumption.

The argument is not that people should abandon technology or withdraw from society. It is that individuals and communities can strengthen autonomy by reducing unnecessary dependence on systems that intensify stress, compulsive consumption and social fragmentation.

The concept has an economic dimension. Communities that cultivate food, share tools, repair equipment, generate renewable energy and exchange knowledge can reduce some of their dependence on distant markets and concentrated suppliers.

These practices cannot eliminate the need for national institutions, specialised healthcare, international trade or sophisticated technological infrastructure. Nor should responsibility for structural inequality be transferred to individuals expected to solve it through personal choices alone.

Their value lies in complementing institutional reform with practical alternatives.

Unplugging can mean reducing dependence on systems whose incentives are misaligned with wellbeing while reconnecting economic activity to ecological limits, social relationships and meaningful work.

In this sense, community autonomy and global cooperation are not opposites. Local resilience can reduce vulnerability, while wider networks provide access to knowledge, specialised resources and solidarity that individual communities cannot generate independently.

12.   From individual resilience to networks of ecovillages and flotillas

Reducing dependence on global markets can begin at the individual level, through choices that strengthen self-reliance, sufficiency and mutual aid. People can reduce unnecessary consumption, cultivate food where possible, repair and share goods, use local services, develop practical skills and participate in cooperative forms of production and exchange. These actions do not imply isolation from the wider economy; rather, they can reduce vulnerability to volatile prices, debt, monopolistic suppliers and extractive consumption patterns.

At the community level, the same principle can become institutional. Ecovillages, cooperatives, community land trusts, local energy systems, seed networks, repair workshops, shared transport and solidarity economies can retain more value locally while strengthening social relationships and ecological stewardship. Such communities can experiment with forms of governance in which essential resources are treated as commons rather than merely as commodities.

The objective is not to romanticise localism or suggest that every community can meet all its needs independently. Modern societies require specialised knowledge, healthcare, infrastructure and forms of international cooperation. The aim is instead to build a diversified network of local capacities that reduces excessive dependence on distant and concentrated systems while remaining open to reciprocal exchange.

At the national level, governments can support this transition through public procurement from cooperatives and local producers, decentralised renewable energy, regional food systems, public digital infrastructure, universal basic services, fair taxation and investment in resilient transport, health and education. National policy can also reduce exposure to volatile global markets by strengthening domestic productive capacity and democratic control over essential resources.

Progress towards a network of ecovillages can therefore be understood as a gradual rebalancing between local autonomy and wider solidarity. Connected communities could exchange knowledge, technologies, seeds, medicines, educational resources and emergency support without reproducing the logic of financial dependency. Digital tools, when governed as public-interest infrastructure, could help coordinate these networks while protecting privacy and democratic accountability.

The idea of flotillas extends this vision to the maritime and international sphere. Cooperative flotillas could support ecological restoration, humanitarian assistance, scientific research, sustainable fisheries, ocean monitoring and peaceful cultural exchange. They could connect coastal communities and island societies in networks based on mutual aid rather than military competition or extractive trade. Their purpose would be to demonstrate that mobility, technology and international connection can serve life, peace and ecological care.

Such networks could also challenge the political economy of arms trade and war. By redirecting public attention and resources towards health, climate adaptation, food security, ecological restoration and human development, ecovillages and flotillas could expose the opportunity costs of militarisation. They could create visible forms of transnational cooperation that contest the assumption that security depends primarily on weapons, permanent military expansion and geopolitical domination.

This does not mean that local communities or civil society networks can end wars by themselves. Arms production, military alliances and geopolitical conflicts require national and international political action. However, networks of autonomous and cooperative communities can strengthen peace constituencies, document the human and ecological costs of militarisation, support affected populations and advocate for arms-control agreements, demilitarisation and the conversion of military industries towards socially useful production.

The broader ambition is to move from dependence on global markets organised around debt, speculation and arms competition towards interdependent networks organised around sufficiency, cooperation and shared wellbeing. At the individual, community and national levels, reducing dependency should not mean withdrawing from humanity; it should mean creating the capacities needed to participate in global solidarity on more equal and peaceful terms.

13.   Policy directions: Governing debt, finance and AI for the common good

The preceding analysis suggests a set of practical priorities.

13.1.   Make debt transparent and socially accountable

Public borrowing should be evaluated not only through repayment capacity but also through its purpose, distributional effects and long-term contribution to collective wellbeing.

Governments should disclose relevant borrowing conditions, guarantees and risks, while protecting legitimate confidentiality. Where debt becomes unsustainable, restructuring should be timely and fair, with safeguards against disproportionate harm to essential public services.

13.2.   Strengthen fair taxation and reduce excessive concentration

Progressive taxation, effective action against tax evasion and illicit financial flows, and the review of unjustified fiscal privileges can help finance public goods and reduce the political influence associated with extreme wealth concentration.

The objective is not to discourage all saving or productive investment. It is to ensure that the benefits of economic activity contribute fairly to the societies that make it possible.

13.3.   Monitor systemic financial risk

Regulators should assess leverage, interconnected exposures, liquidity risks and the effects of common algorithmic strategies across financial institutions.

Oversight must extend to relevant activities outside traditional banking where these can generate systemic vulnerabilities. Stress testing should consider not only conventional financial shocks but also sudden changes in AI-related valuations and the concentration of critical technological infrastructure.

13.4.   Require accountability for consequential AI

Financial and public-sector AI systems should be subject to appropriate risk assessment, independent scrutiny, meaningful human oversight and accessible mechanisms for challenging harmful decisions.

Institutions should disclose sufficient information about the purpose and limitations of consequential systems to enable effective supervision without compromising legitimate security or privacy protections.

13.5.   Share the gains from automation

Where AI and automation increase productivity, institutions should consider how the benefits can support better wages, shorter working hours, skills development, social protection and improved public services.

Productivity gains should not automatically accrue to capital owners while workers face insecurity and communities absorb the social costs of economic restructuring.

13.6.   Finance global public goods

Primary healthcare, disease prevention, education, climate adaptation, ecological restoration and scientific research generate benefits that often extend beyond national borders and cannot be adequately financed through private returns alone.

Public finance and international cooperation remain essential to ensuring that these benefits reach populations with the greatest needs and the least purchasing power.

13.7.   Support local and cooperative resilience

National and international policy should support ecovillages, cooperatives, community land trusts, local renewable energy, regenerative agriculture, repair and reuse systems, and other initiatives that reduce unnecessary dependence on volatile global markets.

Funding mechanisms should favour community ownership, open knowledge and democratic governance rather than concentrating infrastructure and data in a small number of private actors. Public procurement, technical assistance and fair access to credit can help local networks become viable without imposing unrealistic expectations of complete self-sufficiency.

13.8.   Redirect resources from militarisation towards peace and wellbeing

Governments and international institutions should assess military expenditure alongside unmet health, social and ecological needs. Greater transparency in arms production and trade, stronger controls on arms transfers, support for conflict prevention and the conversion of military industries towards renewable energy, public transport, health technologies and ecological restoration can help reduce the structural drivers of war.

Civil-society networks, ecovillages and flotillas can complement these measures by building peaceful cooperation, supporting affected communities and demonstrating practical alternatives to militarised security.

13.9.   Measure what matters

Financial indicators should be complemented by measures of health, wellbeing, distribution and ecological sustainability.

Within the SHEM framework, this could include tracking the relationship between debt service and essential public spending, the distribution of financial ownership, access to AI infrastructure, the allocation of productivity gains and the effects of economic policy on preventable mortality and environmental health.

Measurement alone cannot resolve political conflict. But transparent evidence can clarify trade-offs, expose avoidable deprivation and strengthen democratic accountability.

14.   Conclusion: From financial dependency to living communities

Debt, financial speculation and artificial intelligence are not inherently destructive. Each can contribute to productive investment, scientific progress and the coordination of complex societies. Their consequences, however, depend on who controls them, whose interests they serve and how their benefits, risks and costs are distributed.

When debt finances essential capabilities, it can expand collective freedom. When public revenues are increasingly committed to servicing debt held by financial institutions and investors, while essential needs remain unmet, debt can become a mechanism through which taxpayers transfer resources to asset owners. When speculation and leverage reward short-term financial returns over long-term social and ecological value, the result can be greater inequality, instability and environmental destruction. And when AI accelerates these processes without democratic accountability, it risks concentrating economic and informational power even further.

The challenge is therefore not simply to regulate individual financial instruments or technological platforms. It is to reconsider the purpose of the economic system itself.

Who should benefit from humanity’s productive capacity, accumulated knowledge and technological intelligence? Should these resources primarily serve the multiplication of financial assets, or should they guarantee the conditions for dignified lives, equitable wellbeing and the protection of the living world?

The Sustainable Health Equity Movement (SHEM) and its WiSE framework offer an ethical basis for answering this question. Economic progress should be assessed by its contribution to health, dignity and sustainable equity, rather than by monetary growth alone. Valyter, through its commitment to courage and tenderness, ecological regeneration, shared learning and community autonomy, seeks to put these principles into practice.

Communities as a practical challenge to extractive globalisation

In A New Horizon: From Broken Systems to Living Communities, Garay (2026d) develops the vision of a global network of ecovillages, permaculture initiatives and solidarity flotillas. These are not proposed as isolated refuges from the world, but as connected, self-governing communities that can demonstrate different ways of producing, sharing and caring for life.

Such communities can challenge the assumption that wellbeing requires ever-expanding global trade, unnecessary consumption and the constant movement of people and goods over long distances. International exchange remains essential for scientific cooperation, cultural encounter, specialised knowledge and the equitable sharing of resources. The challenge is to distinguish trade that meets genuine needs from trade driven primarily by artificial demand, planned obsolescence, speculative opportunities and the externalisation of environmental costs.

A sustainable economy would encourage durable goods, repair and reuse, local and regional food systems, renewable energy, shared transport and meaningful human mobility. It would reduce unnecessary travel and resource-intensive consumption without restricting people’s freedom to explore, migrate, learn or maintain relationships across borders. The objective is not isolation, but greater autonomy, less waste and more purposeful interdependence.

Communities can also challenge the privatisation of knowledge and resources that should serve as global public goods. Essential medicines, publicly funded research, life-saving technologies, seeds, scientific knowledge and tools needed for ecological restoration raise fundamental questions about the limits of patents and exclusive ownership. Intellectual property can support innovation, but it should not become an absolute barrier to essential goods or prevent humanity from responding collectively to health emergencies and ecological crises. Open science, knowledge commons, fair licensing and technology transfer can help ensure that innovation serves human needs rather than only purchasing power.

The question of taxation and perpetual debt service

A further challenge concerns the use of public taxation. Taxes are essential to finance healthcare, education, social protection, infrastructure and the institutions that make collective life possible. But the legitimacy of taxation is undermined when governments repeatedly ask citizens to contribute while a substantial share of public revenue is committed to debt service, financial rescues or obligations whose benefits are disproportionately captured by creditors and asset owners.

The issue is not that all debt service is illegitimate, or that every creditor represents speculative capital. Public debt is held by diverse institutions and individuals, and borrowing can serve essential social purposes. The ethical question is whether the terms, ownership and consequences of debt are compatible with democratic accountability and the common good.

When unsustainable debt obligations restrict public investment in essential services, while financial returns accrue disproportionately to those who already own wealth, fiscal policy can reproduce the very inequalities it should correct. When capital continues to finance extractive activities whose environmental and health costs are transferred to society, taxpayers and future generations effectively bear costs that are not reflected in private returns.

This calls for transparent public debt, fair taxation, action against tax avoidance and illicit financial flows, timely and equitable debt restructuring where necessary, and scrutiny of the social opportunity costs of debt service. It also requires redirecting public and private finance towards healthcare, education, ecological regeneration, renewable energy, sustainable food systems and other global public goods.

From local autonomy to global solidarity

No ecovillage can solve global inequality alone. Communities cannot replace universal healthcare, international climate agreements, democratic institutions or the political action needed to reform financial markets and prevent war. Nor should local autonomy become an excuse for governments to abandon their responsibilities.

The value of communities lies instead in their capacity to demonstrate, learn and connect. Ecovillages can regenerate ecosystems, share seeds and knowledge, reduce dependence on concentrated suppliers and practise forms of governance based on cooperation. Cooperatives and local commons can retain more value within communities. Solidarity flotillas can connect territories and peoples through humanitarian assistance, scientific exchange, cultural encounter and peaceful resistance to injustice.

Linked through networks of reciprocal support, these initiatives can help create a different relationship between local autonomy and global cooperation. Digital technology, when developed as accountable public-interest infrastructure, can support this network without making it dependent on surveillance, proprietary platforms or the concentration of data and decision-making power.

Such a transformation also challenges the logic of permanent militarisation. Resources devoted to arms races, warfare and geopolitical domination have opportunity costs in lives, health, social development and planetary integrity. Communities and transnational solidarity networks cannot end war by themselves, but they can strengthen peace movements, support affected populations and demonstrate that security can also be built through cooperation, resilience and the protection of essential needs.

The transition must take place at several levels: individuals choosing sufficiency over compulsive consumption; communities building shared capacities and ecological resilience; nations protecting public goods and reforming taxation and debt governance; and international networks ensuring that knowledge, technology and essential resources are shared more equitably.

The ultimate ambition is not to disconnect humanity from the world, but to unplug from systems of dependency and extraction in order to reconnect with one another and with the living planet.

Debt should finance capabilities, not dependency. Finance should serve society, not govern it. Artificial intelligence should expand human autonomy, not concentrate power over our lives. Trade should meet human needs without exceeding planetary limits.

Knowledge should advance the common good, and taxation should sustain collective wellbeing rather than perpetuate unjust financial arrangements.

The measure of economic progress must ultimately be whether humanity can use its knowledge, resources and collective intelligence to prevent avoidable suffering, restore the natural world and ensure that every person has a fair opportunity to flourish.

The horizon is not a world without exchange, technology or institutions. It is a world in which these serve life; where financial systems are accountable to society, global cooperation respects planetary boundaries, and living communities offer practical foundations for a more equitable and peaceful future.

The real alternative to broken systems is not withdrawal from humanity. It is the construction of living communities, connected in solidarity, capable of challenging financial dependency and demonstrating that another way of living together is possible.

 

References

Foundational works and international research

Bank for International Settlements (BIS). (2024). The intelligent financial system: How AI is transforming finance. BIS Working Papers. See BIS publications on AI, financial innovation and stability. https://www.bis.org/

BlackRock. Aladdin: Investment and risk management technology.

https://www.blackrock.com/aladdin

Castro, A., Marmot, M., Garay, J., de Negri, A., & Buss, P. (2022). Achieving sustainable health equity. Bulletin of the World Health Organization, 100(1), 81–83. https://doi.org/10.2471/BLT.21.286523

International Monetary Fund (IMF). (2024). Gen-AI: Artificial Intelligence and the Future of Work. Staff Discussion Note. https://www.imf.org/en/Publications/Staff-Discussion-Notes/Issues/2024/01/14/Gen-AI-Artificial-Intelligence-and-the-Future-of-Work-542379

International Monetary Fund (IMF). Global Financial Stability Report. See current editions and chapters on leverage, financial stability and technological risks. https://www.imf.org/en/Publications/GFSR

Marx, K. (1867). Capital: A Critique of Political Economy, Volume I. Chapter 31, “Genesis of the Industrial Capitalist.” https://www.marxists.org/archive/marx/works/1867-c1/ch31.htm

Piketty, T. (2014). Capital in the Twenty-First Century. Harvard University Press.

Piketty, T. (2015). Putting distribution back at the center of economics: Reflections on Capital in the Twenty-First Century. Journal of Economic Perspectives, 29(1), 67–88. https://doi.org/10.1257/jep.29.1.67

Juan Garay’s related publications in PEAH

These articles develop the ethical, political and practical arguments that underpin the present paper.

Garay, J. (2023). Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity. PEAH – Policies for Equitable Access to Health. Introduces the WiSE paradigm as an alternative framework for global wellbeing, equity and ecological sustainability.

https://www.peah.it/2023/12/12800/

Garay, J. (2025). The Sustainable Wellbeing Equity Index: An Ethical Reference to Wellbeing while Respecting Other Lives. PEAH. Develops an ethical approach to assessing wellbeing, inequality, excessive accumulation and ecological responsibility. https://www.peah.it/2025/01/14273/

Garay, J. (2025). Beyond Green Complacency: WISE, SHEM and the Case for Radical Sharing. PEAH. Critiques ecological approaches that leave structural inequality and excessive consumption unchallenged, proposing sufficiency, sharing and common resources.

https://www.peah.it/2025/10/15206/

Garay, J. (2026a). The Progressive Power of Data and Algorithms, and Their Effect on Human Life Loss Due to Geopolitical Tensions, Military Spending, and Global Injustice. PEAH. Examines the interaction between algorithmic infrastructures, financial concentration, military power and global inequity. https://www.peah.it/2026/04/the-progressive-power-of-data-and-algorithms-and-their-effect-on-human-life-loss-due-to-geopolitical-tensions-military-spending-and-global-injustice/

Garay, J. (2026b). The Revolution of Harmony Against the Palantir Manifesto: Digital Control, Permanent Warfare, and the Defense of Human Freedom. PEAH. Explores the relationship between AI, surveillance, militarisation, centralised power and the defence of human autonomy.

https://www.peah.it/2026/05/16031/

Garay, J. (2026c). The Health, Equity, Peace, and Planetary Value of “Unplugging”: Cortisol Dysregulation as a Biological “Plug-Indicator” of Immersion in Extractive Systems. PEAH. Connects hyperconnectivity, financial concentration, chronic stress, planetary health and community resilience.

https://www.peah.it/2026/05/16138/

Garay, J. (2026d). A New Horizon: From Broken Systems to Living Communities. PEAH. Develops a vision of interconnected ecovillages, permaculture and solidarity flotillas as practical alternatives to financial extraction, ecological destruction and systems of concentrated power.

https://www.peah.it/2026/05/a-new-horizon-from-broken-systems-to-living-communities/

SHEM and Valyter resources

Sustainable Health Equity Movement (SHEM). Concept Note.

https://www.sustainablehealthequity.org/concept-note

SHEM. Concepts and Metrics of Sustainable Health Equity.

https://www.sustainablehealthequity.org/concept-and-metrics

SHEM. Webinar Series.

https://www.sustainablehealthequity.org/webnair

Valyter. Latest News and Publications.

https://www.valyter.es/ultimas-noticias

—————————

By the same Author on PEAH: HERE

*  MD, internal medicine, MSc Trop Med, MPH, independent researcher and co-founder of the Sustainable Health Equity Movement (SHEM) and Valyter Ecovillage, a community initiative promoting shared living, care for nature and sustainable development. He has worked for more than three decades in public health, health equity and international cooperation. He served as Coordinator of the European Union Cooperation Programme on Global Health and for Mexico (2013–2017) and Cuba (2017–2023). He is  Visiting Professor at the Latin American School of Medicine (ELAM), the Marta Abreu Central University of Las Villas (UCLV) and the Agrarian University of Havana (UNAH) in Cuba; the Autonomous University of Chiapas (UNACH) in Mexico; Fundação Oswaldo Cruz (Fiocruz) in Brazil; the National School of Public Health (ENS) in Spain; and the University of California, Berkeley, USA. His research focuses on Sustainable Health Equity, global health, human development, international cooperation and the governance of knowledge and global public goods for the common good.

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Derna’s Flood Was a Climate and Health Warning for Libya

IN A NUTSHELL
Author's note
The article reflects on the health consequences of Storm Daniel and the lessons Derna’s recovery holds for climate-informed planning, health services and people affected by displacement.

Derna’s recovery will not be measured only by the speed of construction. It will be measured by whether residents and displaced people are safer, healthier and still able to get care when the next extreme event comes

By Meftah Lahwel 
MD, Master in Sustainability in Health 

 Derna’s Flood Was a Climate and Health Warning for Libya

What a City Rebuilding After Storm Daniel Can Teach Us About Climate Risk, Displacement and Care

 By the same Author on PEAH: HERE

Meftah Lahwel is a medical doctor and public health professional with more than a decade of humanitarian experience, including work with UNHCR, MSF and International Medical Corps. He holds a Master in Sustainability in Health at the University of Turin. His interests include refugee and migrant health, health systems and climate-related health risks

 

In my humanitarian health work, I have learned to ask a practical question: when someone needs care, can they actually reach it? The answer depends on more than whether a clinic is open. It depends on safe roads, clean water, functioning referrals and whether treatment continues when a family has to move. Derna brought all these questions together.

Storm Daniel struck northeastern Libya on 10–11 September 2023. In Derna, the failure of two dams sent floodwater through the city, destroying homes and essential infrastructure. The disaster unfolded in a country with divided institutions and two competing administrations: the Government of National Unity (GNU), based in Tripoli, and another government based in Benghazi. In October 2023, the UN Support Mission in Libya warned that competing recovery initiatives risked undermining reconstruction and called for a unified approach.

Derna’s flood history matters. Wadi Derna is usually dry, but it can carry powerful floodwaters. Historical accounts describe damaging floods in 1941, 1956, 1959 and 1968. Two dams were built upstream between 1973 and 1977. Later floods in 1986 and 2011 showed that the wadi remained a threat. Those events did not make the 2023 catastrophe inevitable. They did make the hazard known.

The climate signal also needs to be stated carefully. In its study, “Interplay of climate change-exacerbated rainfall, exposure and vulnerability led to widespread impacts in the Mediterranean region” the World Weather Attribution group estimated that human-caused climate change had made rainfall as extreme as that observed in Libya up to 50 times more likely and up to 50% more intense than in a climate 1.2°C cooler. The researchers stressed that these estimates carry significant uncertainty. Their analysis also examined how exposure and vulnerability shaped the impact: climate change intensified the rainfall hazard, while dam conditions, preparedness and the ability to communicate and act on warnings influenced the scale of the catastrophe.

The water crisis after the flood was immediate. UNICEF reported that half of Derna’s 18 boreholes were shut down and that damage to the sewage system raised concerns about groundwater contamination. UNICEF and other responders supported water delivery and repairs to water points. The ICRC, together with the Libyan Red Crescent, provided emergency drinking water and water and sanitation equipment. These actions helped meet urgent needs, but they also showed how closely health depends on services outside the clinic.

When water systems fail, the consequences reach households, shelters and health facilities. Safe water, sanitation and proper shelter help prevent illness and protect dignity. When roads are damaged, a referral may fail. When a family is displaced, a course of treatment may be interrupted. These are not separate problems to be solved by separate sectors; they are connected parts of people’s health.

The flood also struck a health system already under strain. WHO assessed 240 health facilities in affected areas in October 2023: 73% were partly functional, 14% non-functional and 13% fully functional. WHO supported the restoration of facilities and the establishment of field hospitals. For patients, these figures meant disrupted access to routine care, medicines, referrals and follow-up at the very time when needs were increasing.

Residents of Derna and other affected locations were displaced, and not everyone faced the same barriers to finding shelter or care. IOM’s November 2023 assessment estimated that 1,715 migrants were also displaced by the floods, most in northeastern Libya. That figure counts people displaced by the flood; it does not mean they had migrated because of climate change.

For public health, this distinction matters. People move for different reasons and have different access to money, documents, language, family networks and services. Displacement can interrupt care for chronic illness, pregnancy, children and mental health. A climate and migration perspective asks who can reach services, who is left out, and how care follows people when they move. Derna’s recovery must include all affected people: local residents, displaced Libyans, refugees, asylum-seekers and migrants, as well as communities hosting them.

The psychological impact was just as real as the physical damage. People faced bereavement, loss of homes and livelihoods, displacement and uncertainty. Health workers and rescuers were exposed to distress as they cared for others and responded to loss.

There was a coordinated MHPSS (Mental Health and Psychosocial Support) response. The government Benghazi established a mental health and psychosocial support committee under the Ministry of Health. WHO worked with local health authorities to provide services from psychological first aid to specialist psychiatric care. By 7 November 2023, the committee had deployed 45 MHPSS professionals to seven flood-affected locations. ACAPS (Assessment Capacities Project) later reported ten health facilities offering MHPSS services in Derna, Al-Bayda and Al-Marj, supported by WHO and partner organisations.

This response showed the value of local professionals working with health authorities and international organisations. It also exposed a longer-term challenge: emergency teams cannot provide continuity if local services are not funded, staffed and supported after the emergency phase. ACAPS called for sustained capacity-building, training and supervision. MHPSS belongs within the health system, not only in the first weeks after a disaster.

The recovery needs were substantial. A joint World Bank, EU and UN assessment estimated US$1.8 billion for reconstruction and recovery and recorded nearly 44,800 people initially displaced. By 2026, rebuilding in Derna is highly visible. New homes, roads and bridges matter to people rebuilding their lives. But reconstruction is not proof that risk has been reduced. A 2026 study “Integrating socio-economic impact assessment into the reconstruction plan for Derna, Libya” raised concerns that parts of the reconstruction reproduced vulnerable spatial patterns without comprehensive flood management or alternative planning frameworks. The question is therefore not only what has been rebuilt, but whether people are safer in the places where they live.

New buildings alone cannot prevent another disaster. Derna needs land-use and reconstruction planning based on flood and climate risk, regular inspection and maintenance of dams, early warnings that people understand and can act on, and evacuation plans designed with communities. Health facilities, water and sanitation systems, roads and shelters need to be treated as one protection network. Clinics need backup water and power, medicines, referral routes and ways to continue care when people are displaced.

My work supporting health services in Libya has taught me that resilience is felt in ordinary moments: when a patient can reach a facility, find safe water, receive a referral and return for follow-up. It is also felt by people on the move, who can lose access to care each time a service or border interrupts their journey. Derna’s recovery will not be measured only by the speed of construction. It will be measured by whether residents and displaced people are safer, healthier and still able to get care when the next extreme event comes.

 

 

 

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Developing a National Framework to Measure Health System Resilience to Communicable Disease Outbreaks: Early Lessons from Iran

IN A NUTSHELL
Author's note
A commentary here on developing a national framework to assess health system resilience to communicable disease outbreaks in Iran.

This article reflects on our experience, while working together with a multidisciplinary team at Iran’s Ministry of Health, of translating the concept of health system resilience into measurable indicators, and considering how resilience can be assessed across different levels of the health system

By Dr. Narges Roohi

PhD. Health in Disasters & Emergencies

Teheran, Iran

Developing a National Framework to Measure Health System Resilience to Communicable Disease Outbreaks

Early Lessons from Iran

 

Introduction

Health system resilience was discussed in the scientific literature before COVID-19 and gained prominence following the Ebola epidemic. COVID-19 further strengthened its place in health policy, management and research. The pandemic demonstrated that effective preparedness and response require coordination across the health system, continuity of essential services and adaptation to changing conditions, alongside disease control and clinical care. Experiences across countries during COVID-19 highlighted the importance of governance, financing, the health workforce, health information systems, service delivery, access to medical products and technologies, and public health functions in absorbing the effects of a shock, adapting and responding effectively.

In Iran, studies conducted during COVID-19 examined challenges in the health-system response, including managerial and organizational issues, and the resilience of healthcare facilities. The involvement of health policy-makers, managers and staff in some of these studies helped clarify implementation challenges. Findings emphasized coordination, resource management, workforce preparedness, health information systems and management capacity, underscoring the need for a health-system-wide approach to pandemic response.

A central question was how to translate the broad concept of health system resilience into components and indicators that could be measured and monitored. This challenge was not unique to Iran. In its 2020 report, Strengthening Health Systems Resilience: Key Concepts and Strategies, the European Observatory on Health Systems and Policies emphasized that resilience assessment should reflect the type of shock and the health-system context, and draw on a range of quantitative and qualitative measures.

In its 2021 position paper on health systems resilience, WHO emphasized linking health-system strengthening, health security, universal health coverage, primary health care and essential public health functions. COVID-19 had shown that addressing these areas separately could limit the capacity to respond to major crises.

In 2024, WHO’s Building Health System Resilience to Public Health Challenges: Guidance for Implementation in Countries provided a clearer pathway for putting this approach into practice. The guidance emphasizes adapting actions to country contexts and the roles of national and subnational actors, helping countries translate resilience into practical health-system interventions.

From global guidance to framework development in Iran

In Iran, this work began with the challenge of translating resilience into capacities that could be identified, assessed and strengthened in practice. In 2025, the Center for Communicable Disease Control at the Ministry of Health and Medical Education initiated the development of a framework adapted to the country’s health-system structure to assess capacities for preventing and responding to communicable disease outbreaks. The aim was to identify priorities for improvement and informed decision-making, with particular attention to the relationship between national policies and their implementation at subnational and service-delivery levels.

Framework development combined a review of international documents, including WHO’s health system resilience indicator package, with expert-led adaptation to the country’s structure and priorities. Preliminary meetings and the establishment of a steering committee enabled participation by specialists and operational managers in communicable diseases, primary health care, health-system management, disaster and emergency health, and biostatistics. Group discussions, documented comments and additional feedback supported iterative indicator refinement and expert consensus.

The framework covered six domains: governance, the health workforce, service delivery, health information systems, access to essential medicines and technologies, and health financing. The assessment level and evidence requirements were considered for each indicator. Pilot implementation in the Fardis County Health Network, involving local experts and Alborz University of Medical Sciences, enabled the framework’s application to be examined in practice. Policy and programme documents, administrative records and service-delivery records provided the evidence, which was reviewed collaboratively.

This commentary examines framework development and lessons from pilot implementation. As the project remains ongoing, detailed results, scores and quantitative comparisons are not reported here. The initial assessment was operational and exploratory and was conducted in one local setting. It therefore does not establish national health system resilience or the validity and reliability of the assessment tool.

Early lessons for assessment design and interpretation

First, each indicator requires a clearly defined assessment level and implementation responsibility. Some capacities concern national policy-making, others depend on coordination at provincial and district levels, and others are assessed at service-delivery units. Reviewing national documents within a local pilot does not, by itself, support conclusions about national performance. Comparisons across levels must also account for differences in the sets of applicable indicators.

Second, structural non-applicability must be distinguished from missing data and an unmet capacity. A blank assessment cell does not necessarily indicate poor performance: the indicator may not apply at that level under the framework’s design. Defining this distinction is essential for selecting appropriate denominators and interpreting results correctly, and should be addressed during framework development.

Third, the existence of an approved policy or plan does not, by itself, demonstrate effective implementation. Joint review of documentation can clarify the relationship between formal commitments, organizational responsibilities and local implementation. However, documentation alone cannot establish that essential services will be maintained during an actual shock. Subsequent assessments should complement evidence on capacities with evidence on health-system performance during crises, service continuity and learning after events.

Fourth, relying solely on an overall score may obscure important implementation gaps. An assessment has greater policy value when each priority for improvement is linked to a specific corrective action, a responsible actor, required resources and a follow-up timetable. Assessment findings should therefore inform implementation priorities and the monitoring of corrective actions.

Project continuity amid armed conflict

The project was implemented amid escalating regional armed conflict. Direct conflict between Iran and Israel in April 2024 formed part of the security context preceding the project. The 12-day war began on 13 June 2025, with direct US military involvement on 22 June, followed by joint US and Israeli attacks on Iran on 28 February 2026. According to the implementation team’s experience, hostilities during the project period substantially delayed its progress. This commentary does not quantify the delays or assess the pathways through which the conflict affected implementation.

This experience demonstrates the need to plan for continuity of resilience assessment and strengthening activities during crises. Flexible timelines, systematic documentation of decisions, preservation of records and arrangements for phased implementation could inform future planning. The project delay is reported as an implementation experience; it does not, by itself, provide a basis for assessing the resilience of the entire health system.

Policy implications and next steps

Before wider implementation, the framework requires evaluation of content validity, inter-rater reliability, test–retest reliability, completion time, implementation burden and acceptability across different settings. Completing an assessment in one local setting demonstrates that initial application was possible, but does not establish feasibility at scale or the generalizability of findings. Scoring thresholds should be presented as operational programme benchmarks and, until validated, should not be used to classify a health system definitively as resilient or non-resilient.

Further framework development should incorporate health equity through explicit assessment questions: are essential services maintained for vulnerable groups during crises? Are geographic and financial barriers to access reduced? Does resource allocation reflect the differing needs of population groups? These questions are proposed priorities for future framework development, rather than reported project findings. WHO’s position paper on resilience, universal health coverage and health security provides the conceptual basis for this direction.

Iran’s early experience suggests that developing a national resilience measurement framework requires clearly assigned implementation responsibilities, transparent rules for interpreting evidence and a defined pathway from assessment findings to decision-making, alongside indicator selection. As the project continues, the framework’s practical value should be evaluated in terms of its contribution to corrective action, continuity of essential services and reduced health inequities during crises.

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When People Move, Healthcare Stops: What Libya Reveals About Care Built Around Places Rather Than Patients

IN A NUTSHELL
Author's note
This article looks at continuity of care for refugees and migrants in Libya, particularly across detention centres, disembarkation points, humanitarian services and the public health system. The central argument is that access to healthcare is only part of the story; what often breaks down is the connection between one episode of care and the next

By Meftah Lahwel
MD, Master in Sustainability in Health

 When People Move, Healthcare Stops

What Libya Reveals About Care Built Around Places Rather Than Patients

 

By the same Author on PEAH: HERE and HERE

 

A patient leaves a detention centre in Libya with a prescription and a referral, but no clear idea where the next consultation will happen. A doctor has seen him. Treatment may have started. Yet the next provider may not know what happened before, the medicine may not be available, and the patient may not know which facility will receive him or who is now responsible for the follow-up.

The illness continues. The care may not.

That simple gap between one consultation and the next is one of the less visible problems in healthcare for refugees and migrants in Libya. We are accustomed to asking whether a service was available: Was a doctor present? Was the patient examined? Was medicine provided? Was a referral made? These questions matter, but they describe encounters. They do not necessarily tell us whether care continued.

Migrants, refugees and asylum seekers are not one population. Their reasons for moving, legal situations, vulnerabilities and entitlements differ, and internally displaced Libyans face another set of circumstances. These distinctions should not be blurred. But from the perspective of continuity of care, movement creates a common practical problem: a patient can cross from one place, provider or institution to another while the health condition remains exactly the same.

In Libya, that movement often takes place across a health landscape made up of public facilities, humanitarian services, specialised national programmes and informal networks. None of these components is irrelevant. The problem is that they do not always connect around the patient.

At detention centres and disembarkation points, much of the documented direct healthcare for migrants and refugees has been delivered by international organisations and their partners. IOM’s current Libya response, for example, includes primary healthcare and referrals to secondary and tertiary care at detention centres, disembarkation points and migrant-dense locations. National health structures play a different role: they remain central to the wider public system and to disease surveillance and specialised programmes. Tuberculosis is one of the clearest examples, with diagnosis and treatment embedded in the national TB pathway while international actors support screening, referral and programme capacity.

This division of work has been necessary. It has filled gaps and, in many cases, allowed care to happen where it otherwise might not. But it also exposes the continuity problem. A patient may be seen at a disembarkation point, treated inside a detention centre, referred to a public facility and later need follow-up somewhere else. At each stage, a different actor may be doing exactly what its mandate requires. The patient’s illness, however, does not divide itself according to mandates.

The illness does not recognise the boundary between one mandate and another. The system does.

That is where access and continuity begin to separate. A referral may be correctly issued and still never be completed. A treatment plan may be clinically appropriate and still become impossible to maintain when the patient moves. Medical information may remain with the first provider while the next clinician has to reconstruct the history from memory, a photograph of a prescription or a laboratory paper carried in a bag. Transport, documentation, language, cost and medicine availability can turn a straightforward referral into another point at which care is lost.

For a person who needs one consultation, this fragmentation may be inconvenient. For someone with tuberculosis, diabetes, hypertension, a mental health condition, a complicated pregnancy or another condition requiring follow-up, it can change the course of the illness. Treatment is not only what happens while the patient is in front of the doctor. It is also what happens after the patient leaves.

This matters even more as the direction of policy moves, reasonably, away from permanent parallel humanitarian healthcare and towards greater use of Libya’s national health system. Lately, humanitarian actors advise refugees and asylum seekers to access public primary healthcare centres and hospitals rather than medical assistance through partners or private clinics. That is the right long-term direction. Humanitarian organisations cannot, and should not, become a second national health service.

But integration is not the same as continuity.

The public system people are being asked to use is itself under pressure. WHO has documented shortages of essential medicines and medical supplies and major limitations in facility functionality; in an assessment from December 2024, 84 per cent of assessed facilities were only partially functioning. UNHCR’s own public guidance also reflects practical barriers: identification is generally expected, and secondary and tertiary care usually involves fees. So the patient may leave a humanitarian service and enter a national system that is itself trying to manage shortages, costs and uneven service availability.

The result is an uncomfortable space between two reasonable positions. Humanitarian organisations cannot provide everything forever, and refugees and migrants should, where possible, be included in the national system. Yet neither statement answers the question that matters most at the moment of transition: where does this particular patient go next, and who makes sure the care actually continues?

In practice, that responsibility often shifts quietly onto the patient. People navigating fragmented healthcare become custodians of their own medical histories. They remember medicine names, or sometimes only what a tablet looked like. They keep photographs of prescriptions on their phones, carry laboratory reports with them and repeat the same history to each new clinician. They ask friends, relatives and community members which facility might receive them, where a medicine can be found or whether someone knows someone who can help with a referral.

These informal networks are important. Sometimes they are the reason care continues at all. But we should be careful about calling every act of improvisation resilience. When the patient has to transfer the information, locate the next provider, negotiate the referral and search for the medicine, the patient is doing part of the health system’s work.

That also makes continuity an equity issue. A person with money may buy a missing medicine privately. Someone who speaks Arabic may navigate a facility more easily. Someone with documentation may encounter fewer administrative obstacles. Someone with strong social connections may find a way through a referral pathway that appears closed to somebody else. Another person may simply stop treatment. The same fragmented system therefore produces very different outcomes depending on how much the patient can personally compensate for its gaps.

This is why the discussion has to move beyond access. It also has to move beyond the numbers with which humanitarian and health programmes usually describe success. Consultations, referrals, medicines distributed, facilities supported and people reached are all necessary measures. They tell us what was delivered. But they mostly measure activity, not continuity.

A referral issued is not the same as a referral completed. A prescription written is not the same as treatment maintained. A patient seen today is not necessarily a patient cared for tomorrow.

Libya makes this distinction unusually visible because public services, humanitarian programmes, detention centres, disembarkation points, urban communities and different forms of human mobility all meet within the same health landscape. It is possible for many actors to be present and for the patient still to experience a gap. Several available services do not automatically make one functioning system.

The answer is not to build another separate health architecture for migrants or refugees. Dedicated humanitarian services may remain indispensable in certain settings, particularly at detention centres and disembarkation points. But the long-term task is to make care survive the transition from one provider to another.

That requires less grand language and more practical connection: a medical summary that can move with the patient; a referral the receiving facility understands; communication between the provider sending the patient and the provider expected to receive them; a way of knowing whether an important referral was actually completed; continuity of essential medicines when somebody changes location; and primary healthcare that can reconnect a person with treatment already started elsewhere.

Digital health can help with some of this, but technology cannot solve a problem of responsibility. An electronic record has limited value if the next facility cannot access it, if the medicine is unavailable, if the referral is not recognised or if everyone assumes follow-up belongs to somebody else. Continuity begins when one part of the system accepts responsibility for connecting the patient with the next.

Libya has spent years responding to health needs through public services, humanitarian interventions, emergency arrangements, local initiatives and informal solutions. Much of that work has been necessary, and much of it has saved lives. The next question should not only be whether another service can be added. It should be whether the services already there can begin to behave more like a system.

Patients do not experience healthcare through organisational charts, mandates or funding agreements. They experience it as a sequence: a consultation, a prescription, a referral, a journey to another facility and the hope that somebody there will know what needs to happen next. When that connection fails, the system may still record a successful consultation while the patient experiences an interruption.

The patient should not have to carry the system. The system should carry the care.

Libya cannot remove mobility from its health reality. Humanitarian organisations cannot remain everywhere a patient may eventually go, and a strained public health system cannot simply absorb every additional need because another actor has completed its part. But continuity does not require an impossible promise that one provider will follow every person everywhere. It requires something more basic: that movement should not automatically erase what happened before.

A change in location should not unnecessarily become a break in healthcare. The health condition continues. The patient continues. Healthcare should too.

 

News Flash 680: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Needlefish (Belone belone)

News Flash 680

Weekly Snapshot of Public Health Challenges

 

From National Power to Sustainable Equity: a critical reading of Donald Trump’s 2026 UN address and a proposal for the refoundation of the United Nations  by Juan Garay

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The Pathology of Health Equity: The Foundation of Equitable Governance  by Fahriba Shahraki Sanavi 

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HRR835. YOU CANNOT PROTECT NATURE WITHOUT UNDERSTANDING THE ECONOMY THAT DESTROYS IT. (Alessandra Prampolini)

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4th Annual Seminar on Racism and Health 08-09 October 2026

The best social prescription is a healthy living environment

Africa Has the Technology to Achieve Food Security—Now It Needs Coordinated Deployment

Worsening El Nino threatens Asia with drought, potentially raising food prices globally

After US Embassy Monitors Went Offline, Air Pollution Spiked

 

 

 

 

 

 

 

 

A Critical Reading of Donald Trump’s 2026 UN Address and a Proposal for the Refoundation of the United Nations: From National Power to Sustainable Equity

IN A NUTSHELL
Author's note
Donald Trump's address to the 81st United Nations General Assembly on 22 September 2026 offers a clear expression of a model of international relations centred on national power, military strength, economic competition, energy production and national advantage.

This article examines that model from the perspective of Sustainable Health Equity. It considers Trump's treatment of war and peace, Iran, Gaza, Venezuela, Cuba, migration, fossil fuels, climate change, international law and the United Nations itself. It also examines several factual claims in the speech that have been challenged by independent fact-checking.

The analysis is placed within a broader body of work developed through the Sustainable Health Equity Movement and published in PEAH, including the concept of Wellbeing in Sustainable Equity (WISE), the estimation of a major global health inequity burden, the projected climate-related mortality of more than 220 million excess deaths during the remainder of the twenty-first century, and the estimated global "dignity gap" of approximately US$7 trillion.

The article argues that these are not separate crises. They are expressions of a global order in which economic, military and political power remains concentrated while the costs of deprivation, ecological damage and conflict are distributed very unequally.

The article therefore proposes a refoundation of the United Nations around sustainable equity: ensuring that every person can achieve a dignified and healthy life while humanity remains within the ecological limits of the Earth

 

By Juan Garay  *

Former Head of European Union Cooperation in Cuba (2017–2023)

Professor of Health Equity (Cuba, Mexico, Brazil, Spain)

Co-Chair of the Sustainable Health Equity Movement (SHEM)

By the same Author on PEAH: see HERE

A Critical Reading of Donald Trump’s 2026 UN Address and a Proposal for the Refoundation of the United Nations

From National Power to Sustainable Equity

 

Introduction

The United Nations was created in 1945 after a world devastated by war. Its Charter sought to establish a system in which sovereign states could cooperate to prevent conflict and promote human rights, development and international peace.

More than eighty years later, the basic architecture of that system remains largely unchanged, while the problems facing humanity have become increasingly global and interconnected.

Climate change, biodiversity loss, pandemics, nuclear weapons, mass displacement, global financial concentration and unequal access to knowledge and essential resources cannot be addressed effectively by states acting only in competition with one another.

Trump’s 2026 address is therefore significant beyond the individual statements it contains. It expresses a particular understanding of how the world should be organised: strong nations protecting their interests through economic, military and technological power.

This raises a larger question:

Can a world facing common existential risks continue to be organised primarily around competition between powerful states?

From the perspective of Sustainable Health Equity, this requires reconsidering what we mean by security, prosperity and development.

Power as the organising principle

Trump repeatedly connects national strength with economic production, military capacity, energy resources and geopolitical influence.

There is nothing new about states defending their interests. The problem arises when national advantage is treated as if it can be pursued independently of the interests of other peoples and of the ecological systems on which all societies depend.

A military can protect territory, but cannot prevent a pandemic.

A larger economy does not necessarily reduce health inequality.

More fossil-fuel production may increase energy supply while increasing climate and pollution risks.

Control of natural resources can strengthen national power while intensifying competition for those resources.

The atmosphere, oceans, biodiversity and many essential resources do not respect national borders.

The security of one population is increasingly connected to the security of all others.

War presented as peace

One of the most striking features of Trump’s speech is the presentation of military action and US power as instruments for achieving peace.

Trump describes several conflicts as having been “settled” and presents American military capacity as a source of deterrence and stability.

But ending active fighting is not necessarily the same as establishing peace.

A ceasefire may stop immediate violence without resolving the causes of conflict, protecting civilian populations, establishing accountability or creating the political and social conditions for lasting peace.

This distinction matters particularly in relation to Gaza and Iran.

Trump presents Iran as a major terrorist threat and warns of extreme military consequences if an agreement is not reached.

A consistent application of international humanitarian law requires the same questions to be asked of every actor: who uses force, against whom, under what legal authority, with what distinction between civilians and combatants, and with what consequences?

International standards lose credibility when the vocabulary of terrorism is applied selectively.

Gaza and the erosion of a moral order

The destruction of Gaza raises a wider question about the credibility of the post-war international order.

The International Court of Justice ordered provisional measures in the South Africa v. Israel case under the Genocide Convention. These measures do not constitute a final judgment on whether genocide has occurred, but they demonstrate the seriousness of the legal allegations and the Court’s concern about the risk of irreparable harm.

The PEAH analysis “Gaza and the End of a Moral Order” argues that Gaza represents more than another regional conflict. It is a test of whether the international system can reconcile its declared principles with its actual behaviour. It describes the growing gap between human-rights language and political action and argues that the crisis exposes the exhaustion of a global order whose legitimacy depends on standards that are not consistently applied.

The question is therefore not whether Hamas’s attacks on civilians should be condemned. They should.

Nor is it whether Israeli civilians have a right to security. They do.

The question is whether the same principles of civilian protection, international law and accountability apply equally to powerful and less powerful actors.

The United States’ longstanding military and political support for Israel therefore forms part of the context that cannot simply be omitted from an assessment of the international order.

The issue is not collective blame. It is universal accountability.

The climate-health burden: an unequal planetary war

The ecological dimension gives this debate an even larger scale.

A 2018 PEAH analysis, “Health and Climate Change: a Third World War with No Guns,” modelled the potential health consequences of continued warming and estimated approximately 216 million excess deaths from temperature increase during the twenty-first century, with the great majority expected in tropical and subtropical populations that have contributed relatively little to cumulative emissions.

Later SHEM work has developed this estimate further, referring to more than 220 million projected excess deaths during the remainder of the twenty-first century, predominantly affecting low-polluting countries, communities and age groups.

These figures are model-based estimates, not observed deaths or certain predictions. Their importance lies in the distribution of the projected burden.

The countries and populations expected to suffer most are not necessarily those responsible for the largest share of historical emissions.

Climate change therefore creates a profound intergenerational and international equity problem.

The PEAH analysis proposed a Universal Ethical Threshold of approximately 1.7 tonnes of CO₂ per person per year in its modelling framework, as an indicative ethical allocation of the remaining carbon space.

Whatever precise threshold is ultimately adopted, the ethical principle is clear: ecological space cannot be treated as an unlimited resource belonging disproportionately to those who reached high consumption first.

Prosperity and the fossil-fuel economy

Trump’s speech repeatedly associates prosperity with energy abundance and increased production.

This reflects a conventional economic model in which prosperity is closely associated with production, consumption, investment and energy use.

But economic activity takes place within a finite ecological system.

The 2025 UNEP Emissions Gap Report estimates that current policies remain consistent with warming of approximately 2.8°C this century, while full implementation of current national climate pledges would still imply approximately 2.3–2.5°C.

The WHO has repeatedly warned that climate change is already affecting health through heat, food insecurity, infectious disease, water insecurity and other pathways.

The central question therefore cannot simply be:

How much can the global economy produce?

It must also be:

How much can humanity produce while maintaining the ecological conditions required for life?

And:

Who receives the benefits and who bears the costs?

Venezuela and resources as the spoils of power

The Venezuela section of Trump’s speech is particularly revealing because natural resources are closely associated with geopolitical victory.

Trump refers to Venezuela’s oil resources and uses the expression “to the victor belong the spoils”.

This language is difficult to reconcile with the idea that natural resources ultimately belong to peoples and future generations rather than to whoever possesses the greatest military or economic power.

There is also a factual problem with his claim that the United States and Venezuela together possess more than 60% of the world’s oil. Independent fact-checking found that their combined share of proven reserves is approximately 22%, not 60%.

The larger issue is whether access to natural resources should be understood as a prize of geopolitical power.

If so, the international system itself creates incentives for competition and conflict over resources.

Cuba: coercion, ideology and the human cost

Trump’s treatment of Cuba is framed largely through the failure of communism.

There are legitimate grounds for criticism of the Cuban political system, including restrictions on political freedoms and political pluralism. But this does not remove the need to examine the consequences of prolonged economic coercion.

The most recent PEAH study, “Cuba Under Economic Siege,” examines the combined effects of the US economic, commercial and financial restrictions, intensified in 2026, particularly through constraints affecting fuel and third-party economic operators. It estimates approximately 14,000 excess deaths in 2024 relative to selected demographic and historical references, while explicitly stressing that these are analytical estimates rather than official counts of avoidable deaths.

The article asks whether the progressive deprivation of essential conditions for life could constitute a “genocide without weapons”, but this is presented as a public-health and ethical question, not as a legal determination of genocide.

The distinction is important.

Cuba has internal political and economic responsibilities for its population’s wellbeing. At the same time, external economic restrictions can have real consequences for access to fuel, medicines, food, water, transport and health services.

A serious analysis needs to consider both.

Migration and the reduction of human beings to security categories

Trump’s treatment of migration reduces a complex global phenomenon largely to questions of borders, illegal entry, crime and sovereignty.

States clearly have the right to regulate entry into their territory.

But migration is also driven by war, poverty, political persecution, economic inequality, family reunification, labour markets and environmental disruption.

A sustainable-equity approach therefore asks not only how borders should be controlled, but why so many people are forced to leave their homes.

If the global system produces radically unequal opportunities for health, security and dignity, migration is partly a symptom of that inequality.

The problem of the numbers

The speech makes extensive use of large numerical claims concerning oil, drugs, migration, investment, military action and wars supposedly ended.

Some have been challenged by independent fact-checking.

For example, PolitiFact found Trump’s claim that US operations had eliminated 97% of drugs entering the United States to be unsupported, because seizure figures cannot establish the total amount entering an illicit market. It also found the oil-reserve claim substantially exaggerated.

The methodological lesson is important.

Numbers in public policy require definitions, denominators, time periods, populations and sources.

Sustainable Health Equity therefore requires not simply more data, but better measurement and greater transparency about what data actually show.

From health inequality to sustainable equity

The health dimension provides a useful way to connect the apparently separate crises of poverty, climate change, war and economic concentration.

The WISE paradigm — Wellbeing in Sustainable Equity — proposes that global development should be assessed by the capacity to achieve the best feasible levels of human wellbeing while remaining within economic and ecological limits.

The starting point is simple: the aspiration for a long and healthy life is universal.

The question is whether the economic and ecological resources needed to achieve this can be distributed fairly.

The WISE analysis estimates a persistent burden of approximately 16 million excess deaths each year associated with global health inequity, while identifying an estimated dignity gap of around US$7 trillion—the additional resources required for countries below the proposed dignity threshold to approach the best feasible levels of health.

This is not simply a call for traditional development aid.

It points towards a much larger redistribution of global resources.

The same analysis proposes a threshold beyond which additional income no longer corresponds to further gains in life expectancy while being associated with increasingly unsustainable ecological consumption. It estimates that a large share of global GDP lies above such an “excess” or “hoarding” threshold.

The implication is uncomfortable but important:

Global justice requires both ending deprivation and reducing excessive accumulation.

The US$7 trillion dignity gap therefore needs to be considered alongside the resources currently accumulated or consumed above levels compatible with sustainable equity.

Restoring the broken human deal

The 2024 PEAH paper “Restoring Broken Human Deal” develops this argument further.

It describes the present system as a broken deal both among human beings and between humanity and nature. It links persistent health inequity, ecological destruction, financial concentration, military power and weak global governance to a common failure of international cooperation.

The paper argues that the problem cannot be solved simply by increasing conventional development assistance.

It calls instead for a new societal paradigm based on empathetic local governance, ecosystem-friendly production and consumption of essential needs, and collaborative innovation directed towards global public goods.

This changes the meaning of redistribution.

It is not simply transferring money from rich to poor.

It means restructuring the global economy so that resources currently absorbed by excessive consumption, speculation, military expenditure and ecological destruction can instead support health, knowledge, essential services and the transition to sustainable production.

The missing denominator: planetary limits

Perhaps the largest omission in Trump’s speech is the absence of a meaningful ecological denominator.

Economic and military power are discussed as if they could continue expanding without reference to the Earth’s capacity to absorb emissions, regenerate ecosystems and provide resources.

The planetary-boundaries framework provides one scientific way of approaching this problem.

Humanity has already crossed several proposed Earth-system boundaries.

This changes the meaning of development.

The question can no longer simply be:

How much more can humanity produce?

It must be:

How much can humanity produce and consume while preserving the ecological systems required for life?

And:

How can the remaining ecological space be shared fairly?

These questions form the basis of sustainable equity.

International law and exceptionalism

International institutions are imperfect and should be reformed.

But the alternative cannot be a system in which powerful states accept international rules only when those rules coincide with their interests.

International law depends on universality.

No state should be above accountability because of its military capacity, economic influence or permanent position in an international institution.

The tension is particularly visible in the Security Council, where five states—China, France, Russia, the United Kingdom and the United States—possess permanent seats and veto power.

This was a political arrangement designed in 1945.

It is increasingly difficult to reconcile with the principle of sovereign equality among UN members and with the global nature of contemporary problems.

From United Nations to United Peoples

The UN Charter begins with the words:

“We the peoples…”

Yet the organisation remains primarily structured around sovereign states.

A refounded UN should explore how to give stronger representation to peoples, regions, civil society, future generations and the global commons while retaining states as essential political actors.

The objective would not be world government.

It would be a more democratic system for managing problems that no country can solve alone.

Climate change is one example.

Pandemics are another.

So are nuclear weapons, artificial intelligence, global financial instability, biodiversity loss and access to essential medicines and scientific knowledge.

A proposal for the refoundation of the United Nations

A refounded UN could be built around the following principles.

1. Sustainable equity as a central global objective

Every person should have the conditions necessary for a dignified and healthy life, while humanity remains within planetary boundaries.

2. A global dignity floor

Countries and communities below an agreed dignity threshold should have access to the resources necessary to reach the best feasible levels of health and wellbeing.

The WISE analysis estimates the present global dignity gap at approximately US$7 trillion annually.

3. An excess-resource threshold

Above a level at which additional accumulation no longer contributes significantly to human wellbeing while increasing ecological damage, resources should progressively be redirected towards global public goods.

This is the economic counterpart of the dignity floor.

4. Recognition of global commons

The atmosphere, oceans, biodiversity, major freshwater systems and other essential ecological systems should be treated as shared responsibilities of humanity.

5. Rights of future generations

Future generations should have recognised rights to the ecological conditions necessary for life and health.

6. Universal application of international law

No state should enjoy effective exemption from international law because of its political or military power.

7. Reform of the Security Council

The permanent veto should be substantially reformed, with greater representation and mechanisms allowing the wider UN membership to act when the Council is paralysed.

8. Progressive demilitarisation

Nuclear weapons and other weapons of mass destruction should ultimately be eliminated, while military expenditure is progressively redirected towards human security and global public goods.

9. Health and knowledge as global public goods

Essential medicines, vaccines, scientific knowledge, health technologies and other life-saving resources should not depend primarily on purchasing power.

10. A fair system of human mobility

The causes of forced migration should be addressed alongside the protection of the rights and dignity of migrants and refugees.

11. Ecological transformation

Global economic governance should support rapid transition away from fossil fuels while ensuring that lower-income countries have sufficient resources to achieve dignified development.

12. Democratic global financing

The UN and other global institutions need predictable and sufficiently independent financing rather than excessive dependence on voluntary contributions from powerful states and private interests.

From competition to cooperation

The alternative to a power-centred international order is not the absence of power.

It is the democratisation and redistribution of power.

Nor is it the rejection of economic development.

It is a different understanding of development: improving human health, dignity and capabilities while reducing unnecessary material consumption and protecting the ecological systems on which future generations depend.

This also changes the meaning of security.

Security should include food, health, water, energy, climate, peace and ecological stability—not simply the military capacity of states.

It changes the meaning of prosperity as well.

Prosperity should not be measured only by how much a country produces, consumes or accumulates, but by whether people can live long, healthy and meaningful lives without undermining the ability of others and future generations to do the same.

Conclusion: a call for a new global settlement

Trump’s 2026 UN speech provides a particularly clear expression of one possible future: a world of strong states competing for security, resources, markets, technology and geopolitical influence.

But this is not simply about one president or one country.

The deeper problem is the persistence of an international system in which military power, economic wealth and control of resources determine whose interests prevail.

The evidence and analysis developed through Sustainable Health Equity point towards another possibility.

The projected burden of climate-related mortality falls disproportionately on populations that have contributed least to historical emissions. Global health inequity continues to generate millions of preventable deaths every year. At the same time, the WISE analysis identifies a substantial global dignity gap alongside enormous concentrations of resources above levels compatible with sustainable equity.

Gaza and Cuba provide two contemporary examples of a broader problem: the distance between the universal principles proclaimed by the international system and the way power is actually exercised. The PEAH analyses of Gaza and Cuba argue, from different perspectives, that the consequences of geopolitical power increasingly reach directly into the conditions of life, health and survival.

The response should therefore be larger than opposition to any single government.

It should be a new global settlement.

A refounded United Nations could place sustainable equity at the centre of international cooperation:

a dignified life for every person; ecological limits for everyone; greater redistribution from excess to deprivation; global public goods; universal accountability under international law; peace instead of permanent military competition; and democratic institutions capable of representing humanity as a whole.

This would give new meaning to the opening words of the UN Charter:

We the peoples.

The challenge is no longer to decide which country should dominate the twenty-first century.

It is to build institutions through which humanity can learn to share the twenty-first century—and protect the living Earth on which all of us depend.

References
  1. Garay JE, Chiriboga DE, Kelley N, Garay A, Garcia-Carmino E. Health and Climate Change: a Third World War with No Guns. PEAH, 2018. The analysis modelled approximately 216 million excess deaths from temperature increase during the twenty-first century, predominantly in tropical and subtropical populations.
  2. Garay J. Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity. PEAH, 2023. The article develops the WISE paradigm, the dignity threshold, the estimated US$7 trillion global dignity gap and the concept of an excess/hoarding threshold.
  3. Garay J. Restoring Broken Human Deal. PEAH, 2024. The article develops the analysis of global governance failure, health inequity, ecological destruction, economic concentration and the need for a new societal paradigm.
  4. Garay J. Gaza and the End of a Moral Order: Energy, Power, and the Emergence of a Post-Hegemonic World—and the Prospect of a New Global Life Expectancy Decline. PEAH, 2026.
  5. Garay J. Cuba Under Economic Siege: Evidence of the Humanitarian and Health Consequences of United States Coercive Measures and Arguments for an Equity-Based Response. PEAH, 2026.
  6. United Nations. Charter of the United Nations. San Francisco, 1945.
  7. United Nations. Universal Declaration of Human Rights. Paris, 1948.
  8. International Court of Justice. Application of the Convention on the Prevention and Punishment of the Crime of Genocide in the Gaza Strip (South Africa v. Israel). Provisional Measures, 2024.
  9. United Nations Environment Programme. Emissions Gap Report 2025. UNEP, Nairobi, 2025.
  10. World Health Organization. Climate Change and Health. WHO, Geneva.
  11. Richardson K, et al. Earth beyond six of nine planetary boundaries. Science Advances. 2023;9(37):eadh2458.
  12. United Nations Security Council. Voting System and the Right to Veto.
  13. United Nations Security Council. Vetoes since 1946.
  14. PolitiFact. Fact-check: President Donald Trump misleads on Iran war, AI in speech to UN. September 2026.
  15. Associated Press. FACT FOCUS: Trump made multiple false and misleading claims in front of the UN General Assembly. September 2026.

 

 

*  MD, internal medicine, MSc Trop Med, MPH, independent researcher and co-founder of the Sustainable Health Equity Movement (SHEM) and Valyter Ecovillage, a community initiative promoting shared living, care for nature and sustainable development. He has worked for more than three decades in public health, health equity and international cooperation. He served as Coordinator of the European Union Cooperation Programme on Global Health and for Mexico (2013–2017) and Cuba (2017–2023). He is  Visiting Professor at the Latin American School of Medicine (ELAM), the Marta Abreu Central University of Las Villas (UCLV) and the Agrarian University of Havana (UNAH) in Cuba; the Autonomous University of Chiapas (UNACH) in Mexico; Fundação Oswaldo Cruz (Fiocruz) in Brazil; the National School of Public Health (ENS) in Spain; and the University of California, Berkeley, USA. His research focuses on Sustainable Health Equity, global health, human development, international cooperation and the governance of knowledge and global public goods for the common good.

The Pathology of Health Equity: The Foundation of Equitable Governance

IN A NUTSHELL
Author's note
…Health equity cannot be achieved simply by increasing resources, expanding services, or improving average health indicators. It depends fundamentally on how health-related resources, opportunities, risks, costs, and benefits are distributed across different groups within society.

The pathology of health equity shifts attention from merely measuring inequalities to identifying the mechanisms that create and reproduce them. Such an approach requires simultaneous consideration of access, quality of care, financing, resource allocation, governance, power, social participation, intersectoral policies, health-system reforms, digital technologies, and multidimensional vulnerability… 

By Fahriba Shahraki Sanavi 1, 2

1.Associate Professor, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran. Orcid No: 0000-0002-6937-0793. Email: faribasanavi@gmail.com

 2.Center for Development and Studies, Academy of Medical Sciences of the Islamic Republic of Iran, Tehran, Iran

The Pathology of Health Equity: The Foundation of Equitable Governance

 

Introduction

Health equity is a fundamental component of fair and effective health systems. Despite remarkable advances in medical science, health technologies, and access to healthcare services, unjust differences in health outcomes persist across societies and, in some contexts, have even widened. These differences are not merely reflections of variations in individual health status; rather, they reflect how opportunities, resources, power, and responsibilities are distributed across society.

Health equity cannot be reduced to equal access to healthcare services or the provision of identical care to everyone. Equity requires that all individuals, regardless of their social, economic, geographic, cultural, or political circumstances, have a fair opportunity to attain and maintain good health. From this perspective, health policies and programmes should consider not only their overall effects but also how their benefits, costs, and risks are distributed across different population groups.

The fundamental question, therefore, is not simply how successful a health system is, but who benefits from its achievements, who remains excluded, and what mechanisms create or reproduce these differences. This perspective shifts health equity from a broad normative aspiration to a subject of systematic analysis and pathology.

Health Equity: Beyond Equality

Equality and equity in health are closely related but conceptually distinct. Equality refers to the uniform distribution of resources, services, or opportunities, whereas equity takes into account differences in needs, living conditions, and the barriers faced by different population groups.

Consequently, providing identical services to groups with different needs, resources, and social circumstances does not necessarily produce equitable outcomes. Advancing equity may require allocating greater resources to populations experiencing greater deprivation, vulnerability, or structural barriers.

From this perspective, assessing equity requires moving beyond population averages. National or regional averages may indicate an overall improvement in health while substantial gaps between social groups remain. Examining how health-related opportunities, resources, benefits, and costs are distributed across populations is therefore an essential component of equity assessment.

Social and Structural Determinants of Health

Health does not develop in a vacuum. The economic, social, environmental, and political conditions in which people are born, grow, work, and live fundamentally shape their opportunities to achieve good health.

Income, education, employment, housing, food security, the physical environment, social support, and access to resources are among the factors that can produce divergent health trajectories across population groups. Yet these factors themselves are shaped by broader structures of power, policymaking, and decision-making.

Consequently, analyses of health inequalities are incomplete without considering their structural and political determinants. Economic policies, tax systems, labour-market policies, social protection programmes, resource-allocation decisions, and governance structures can directly or indirectly influence the distribution of opportunities for health.

Recent research on the political determinants of health further demonstrates that governance, decision-making processes, power relations, political discourse, and structures of democratic participation are important forces shaping health equity (Duric et al., 2026).

The Pathology of Health Equity

The pathology of health equity can be understood as an approach to identifying, analysing, and explaining the mechanisms through which avoidable and unjust differences in health are created, sustained, or reproduced.

Within this approach, equity is not merely an anticipated outcome of health policies; it becomes an explicit object of systematic assessment. It is necessary to determine which components of the health system or broader social structures generate unjust gaps, where these gaps become amplified, and which population groups bear the greatest burden of disadvantage.

The pathology of health equity can be examined across several major domains.

  1. Equity in Access to Healthcare Services

Equitable access extends beyond the physical availability of services. Geographic distance, direct and indirect costs, waiting times, service capacity, cultural and linguistic barriers, and access to health information can all influence people’s actual ability to use healthcare services.

The presence of a healthcare facility in a particular area does not necessarily guarantee equitable access for its residents. If low-income populations, people living in deprived areas, older adults, or specific social groups are unable to use services because of cost, transportation constraints, or cultural barriers, nominal availability has not translated into meaningful access.

  1. Equity in Quality and Care Experience

Equity concerns not only whether people receive care, but also the quality of the care they receive.

Two groups may have access to the same type of service while experiencing differences in quality of care, communication with healthcare professionals, respect for patient preferences, time devoted to care, involvement in decision-making, and overall care experience.

From this perspective, quality and equity are not separate concepts. High-quality care has meaning from an equity perspective only when it is attainable across population groups. Research on diversity-sensitive care likewise highlights the importance of responding to cultural, social, and individual differences and taking patients’ experiences into account (Lauwers et al., 2024).

  1. Equity in Health Financing

The way healthcare is financed is one of the major pathways through which inequalities can either be created or reduced. Financing arrangements may place a disproportionate economic burden on groups that are already financially vulnerable.

Out-of-pocket payments, co-payments, and other direct payments may restrict the use of essential services among low-income households and increase the risk of financial hardship associated with healthcare expenditure.

Recent systematic reviews indicate that the distribution of healthcare payments across socioeconomic groups can be highly unequal and that financing systems should explicitly consider their distributional consequences (Luyten & Tubeuf, 2025; Shaltynov et al., 2024).

  1. Equity in Primary Care Financing

Primary care occupies a central position in reducing health inequalities because it is often the first point of contact with the health system and can play an important role in prevention, early diagnosis, and the management of chronic conditions.

However, the allocation of resources to primary care does not always correspond to population need. Areas experiencing greater socioeconomic deprivation may have greater health needs while receiving fewer financial and human resources.

Evidence from an umbrella review indicates that primary care funding arrangements can influence health inequalities and that resource-allocation mechanisms should account for differences in population need and deprivation (Holdroyd et al., 2025).

  1. Resource Allocation and Equity

Resource allocation in health systems inevitably involves choices among competing needs under conditions of limited resources. Decisions concerning budgets, workforce, infrastructure, technologies, and services should therefore be assessed not only in terms of efficiency but also in terms of their distributional consequences.

A policy may be highly effective on average while widening health gaps if its benefits are distributed disproportionately. Thus, policy effectiveness does not necessarily imply policy equity.

An equity-oriented analysis requires examining which groups derive the greatest benefits from resource allocation and which groups are less likely to benefit.

  1. Governance and the Distribution of Power

Health equity is closely linked to who holds decision-making power, whose voices are heard, and which groups are less visible in policymaking processes.

Political, economic, and institutional power can shape health priorities, resource allocation, and policy design. Accordingly, an analysis of equity that does not examine power remains incomplete.

Evidence from systematic research on the political determinants of health indicates that governance structures, decision-making processes, and power relations play important roles in defining and shaping health equity (Duric et al., 2026).

Social Participation: From Presence to Influence

Social participation is an important principle of equitable governance; however, the presence of people in decision-making processes does not, in itself, constitute meaningful participation.

Participation can contribute to equity when individuals and communities have not only opportunities to express their views but also genuine capacity to influence decisions and policy priorities.

A distinction should therefore be made between presence, being heard, and having influence. Tokenistic participation, without meaningful transfer of power or influence over decision-making, may even contribute to reproducing existing inequalities.

A systematic review of social participation in health likewise highlights the importance of assessing the quality and degree of influence in interactions between communities and policymakers (Gupta et al., 2023).

Intersectoral Governance and Health in All Policies

Many important determinants of health lie outside the health sector. Education, transport, housing, employment, the environment, agriculture, and social policies can all influence health and its distribution across society.

Responsibility for achieving health equity therefore cannot rest solely with ministries of health or the healthcare system. The Health in All Policies approach seeks to incorporate the health implications of decisions made across sectors into policymaking processes.

However, effective implementation requires mechanisms for intersectoral coordination, accountability, political commitment, and institutional capacity. Evidence suggests that policymaking processes, relationships between organisations, and interactions among political actors can influence the implementation of Health in All Policies (Lilly et al., 2023).

Equity in Health-System Reform

Health-system reforms are often undertaken to improve efficiency, control costs, enhance quality, or expand access. Yet any reform may have different consequences for different population groups.

Equity should therefore be considered from the design stage through implementation and evaluation, rather than treated as a secondary outcome to be examined after a policy has been implemented.

A recent scoping review indicates that systematically incorporating equity into the design and implementation of health-system reforms can help identify and mitigate unequal consequences of reform initiatives (Bouckley et al., 2025).

Assessing the Distributional Consequences of Policies

Health-policy evaluation should not focus exclusively on average or aggregate outcomes. It is essential to determine how a policy affects different social, economic, and geographic groups.

This requires disaggregated analyses according to income, sex, age, place of residence, social position, and other characteristics associated with vulnerability.

Within such a framework, the central question is not simply, “Is the policy effective?” but rather:

For whom is it effective, who benefits from it, who bears its costs, and does its implementation reduce or widen existing health gaps?

Digital Equity and Health Technologies

The expansion of digital technologies, telemedicine, health-information systems, and mobile health applications has created new opportunities to improve access to and the quality of care.

However, technology does not automatically produce equity. Differences in access to the internet and digital devices, digital literacy, financial capacity, technological skills, and infrastructure quality may result in those with the greatest needs benefiting least from digital innovations.

Digital equity should therefore be considered from the earliest stages of technology design. Evidence from assessments of digital-health interventions also indicates that socioeconomic differences in intervention effectiveness remain insufficiently addressed in many studies (Abdelmalak et al., 2024).

Multidimensional Vulnerability and Intersectional Equity

Vulnerability is rarely attributable to a single factor. Individuals may simultaneously experience multiple forms of disadvantage, including poverty, older age, migration, social isolation, or limited access to services.

These factors can interact and reinforce one another, producing disproportionate health consequences. Equity analysis should therefore move beyond single-dimensional approaches and consider interactions among different social and economic factors.

An intersectional approach to health equity can help identify groups located at the intersection of multiple dimensions of vulnerability who may remain invisible within conventional analyses and policymaking processes (Conduah & Ofoe, 2025).

Equity, Diversity, and Quality of Care

The social and cultural diversity of populations requires health systems to recognise and respond to differing needs.

Equitable care requires respect for cultural, social, and individual differences, effective communication with patients, and the creation of conditions in which all people can receive high-quality care without discrimination.

From this perspective, attention to diversity is not a peripheral concern but an integral component of quality of care. A system that provides inappropriate or discriminatory care experiences to particular groups cannot be considered equitable merely because it meets high technical standards (Lauwers et al., 2024).

Equity, Economic Evaluation, and Resource Decision-Making

Health-system decisions are often made under conditions of resource scarcity, and economic evaluation can support the selection of efficient interventions. However, a narrow focus on efficiency may overlook the distributional consequences of such decisions.

An intervention may be highly cost-effective while delivering most of its benefits to groups that are already socially and economically advantaged.

Efficiency and equity should therefore not be treated as entirely separate objectives. Where possible, economic evaluations should also consider the distributional consequences of interventions, and decision-makers should understand which groups benefit from a policy choice and which groups may bear its disadvantages (Muir et al., 2024).

A Proposed Framework for the Pathology of Health Equity

Based on the preceding discussion, the pathology of health equity can be conceptualised as a multidimensional framework through which equity is examined across different levels of the health system and policymaking.

The framework comprises six major domains:

  1. Identifying inequalities: Identifying populations and groups experiencing disadvantage in health outcomes, access, quality, or resources.
  2. Identifying mechanisms that generate inequalities: Examining the social, economic, organisational, political, and structural factors that create or reproduce inequalities.
  3. Analysing the distribution of resources and opportunities: Assessing how health-system resources, services, benefits, and costs are distributed across different population groups.
  4. Analysing power and participation: Identifying actors who influence decision-making and assessing the extent to which different groups have meaningful participation in setting priorities and shaping policies.
  5. Assessing the distributional consequences of policies: Examining how health policies and reforms affect different population groups and whether they reduce or widen health gaps.
  6. Continuous equity monitoring: Establishing mechanisms for ongoing measurement of health gaps and assessment of the health system’s response to them.

This framework can transform equity from a broad normative principle into an operational dimension of analysis, decision-making, and accountability. Within such an approach, equity is not a secondary outcome but a core criterion for evaluating the performance of health systems and public policies.

Conclusion

Health equity cannot be achieved simply by increasing resources, expanding services, or improving average health indicators. It depends fundamentally on how health-related resources, opportunities, risks, costs, and benefits are distributed across different groups within society.

The pathology of health equity shifts attention from merely measuring inequalities to identifying the mechanisms that create and reproduce them. Such an approach requires simultaneous consideration of access, quality of care, financing, resource allocation, governance, power, social participation, intersectoral policies, health-system reforms, digital technologies, and multidimensional vulnerability.

Within this framework, an analysis of health equity without an analysis of power is incomplete, and an effective policy is not necessarily an equitable policy. Likewise, quality and equity should not be regarded as entirely separate objectives, because genuine quality of care is achieved only when all population groups have a fair opportunity to benefit from high-quality services.

From this perspective, efficiency and equity should be considered together in decisions concerning health resources and policies. Evaluation of health-system performance should also move beyond population averages and demonstrate how health gains are distributed across society.

Ultimately, an equitable health system is one in which no population group is systematically denied a fair opportunity to attain and maintain good health because of its social, economic, geographic, cultural, or political position.

References

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