IN A NUTSHELL Author's noteDemocracy is commonly defined as a system of government based on popular sovereignty, political participation, free and fair elections, fundamental rights, the rule of law and public accountability. However, these institutional principles do not necessarily guarantee equal opportunities to influence political decisions, equitable access to the conditions required for human dignity, or accountability for the consequences of national power beyond territorial borders. This article examines the United States, the world's dominant military power and one of its leading political, economic and financial actors, through the framework of Sustainable Health Equity. It analyses the contradictions between formal political equality and unequal effective influence arising from campaign financing, wealth concentration, party structures, access to candidacy, political communication and electoral participation. It then considers the relationship between economic inequality, healthcare expenditure and population health, using comparisons with Japan, Greece and Sri Lanka. Finally, it examines the international consequences of US power through military expenditure, the United Nations Security Council, economic sanctions, trade policy, the international role of the dollar and financial information infrastructures. The article is situated in the aftermath of the November 2026 US midterm elections, in which Democrats gained control of both chambers of Congress. This outcome demonstrates the continuing capacity of electoral competition to impose political accountability. Nevertheless, alternation in legislative control does not necessarily transform the structural distribution of political and economic influence. A central contribution of the article is the proposal of Sustainable Equity Democracy, grounded in ethical principles of equal human worth, justice, common good, minimum dignity, equitable participation, solidarity, accountability, intergenerational responsibility and respect for planetary boundaries. The philosophical discussion draws on Plato's conception of the common good, while recognising the historical limitations of his political model. Contemporary planetary science provides an additional ethical imperative: the 2026 Planetary Health Check reports that seven of the nine planetary boundaries have been transgressed. The article argues that democracy cannot be adequately assessed solely through electoral procedures and constitutional rights. Its substantive legitimacy must also be evaluated according to how fairly power, resources, health opportunities and ecological responsibilities are distributed, and whether decisions protect the dignity and freedom of present and future generations
By Juan Garay
Co-Chair, Sustainable Health Equity Movement (SHEM)
Professor and Researcher in Health Equity, Ethics and Metrics
Founder, Valyter Ecovillage
By the same Author on PEAH: HERE
The Pitfalls of the So-Called Democratic System of the World’s Dominant Political, Economic and Military Power
The United States Through the Lens of Sustainable Health Equity
1. Introduction: What should democracy mean in the twenty-first century?
Democracy is one of the most influential political ideals of modern societies. Its legitimacy rests on the principle that political authority derives from the people rather than from hereditary privilege, imposed rule or the arbitrary power of individuals and institutions.
In its contemporary constitutional form, democracy is generally associated with popular sovereignty, universal and equal suffrage, free and fair elections, political pluralism, freedom of expression and association, the rule of law, protection of fundamental rights and accountability of public authorities. These principles are indispensable. Without them, citizens’ capacity to exercise political agency, challenge authority and influence collective decisions is severely restricted.
However, an essential question remains: are these institutional guarantees sufficient to make a society genuinely democratic?
The principle of one person, one vote establishes formal political equality at the ballot box. It does not necessarily establish equality in the capacity to influence which candidates become available, which issues dominate public debate, which interests shape legislation or which groups benefit from public policies. Nor does it guarantee that all people possess the education, security, health, time, information and material resources needed to exercise their political rights meaningfully.
A person experiencing poverty, insecure employment, inadequate housing, poor health or limited access to reliable information -or the capacity to critically analyse unreliable information- may formally enjoy the same political rights as a billionaire, corporate executive or major political donor. Yet their practical capacity to influence public decisions can be profoundly different.
This distinction between formal equality and substantive equality is central to understanding the limitations of contemporary electoral democracy.
A further limitation emerges when democracy is considered only within national borders. Decisions taken by powerful governments can profoundly affect people living in other countries, who have no vote, representation or direct mechanism of accountability within the institutions making those decisions. Military interventions, economic sanctions, trade restrictions, financial policies and international institutional arrangements can influence the availability of food, medicines, employment, public revenue and essential services in societies whose populations have no direct political voice in the decisions concerned.
The democratic question therefore extends beyond the relationship between governments and their own citizens. It also concerns the accountability of powerful states and institutions to people affected by their actions internationally.
1.1. Towards a substantive and equitable definition of democracy
For the purposes of this article, democracy is understood as:
A system of collective self-government in which all people have equal political rights and meaningful opportunities to participate in, influence and hold accountable the decisions that affect their lives, within institutions that protect fundamental freedoms, ensure the equitable distribution of power and resources, and safeguard the social and ecological conditions necessary for present and future generations to live with dignity.
This is a normative definition proposed for analysis, rather than a claim that international law or existing democratic theory has adopted a single equivalent formulation.
It preserves the essential institutional foundations of democracy while extending its assessment to the conditions required for those foundations to become meaningful in practice.
Five interconnected dimensions follow from this definition:
- Political equality: equal rights to vote, stand for election, organise, express opinions and participate in public decision-making, without discrimination or undue barriers.
- Equity in effective influence: safeguards against the disproportionate conversion of wealth, institutional privilege, corporate power or control of communication into political influence.
- Equity in dignity and opportunity: access to the material, educational, social and health conditions that enable people to exercise their freedoms and participate as equal members of society.
- Accountability beyond borders: responsibility for the consequences of national and international decisions affecting populations who may not be represented in the institutions making them.
- Intergenerational and ecological responsibility: protection of the environmental systems and shared resources on which the health, freedom and dignity of present and future generations depend.
These dimensions do not imply that every person must have identical income, identical political opinions or identical social circumstances. They require that differences in wealth and status do not become instruments through which some people acquire disproportionate control over collective decisions or deprive others of the conditions necessary for a dignified life.
Democracy, in this broader understanding, is not simply the right to choose those who govern. It is also the capacity to influence what governments do, the equitable distribution of the benefits and burdens of public decisions, and the accountability of power to all those affected.
1.2. Why Sustainable Health Equity is central to democracy
Health equity provides a particularly relevant perspective from which to assess the substantive quality of democratic systems.
Health, the most cherished aspiration of all cultures and times, is not determined exclusively by medical services or individual behaviour. It is shaped by the conditions in which people are born, grow, learn, work, live and age, as well as by their access to power, money and resources. The World Health Organization’s work on social determinants of health equity reinforces the importance of these structural conditions in producing avoidable and unjust differences in health and life expectancy.
Political institutions influence these determinants through decisions about taxation, employment, education, housing, social protection, healthcare, food systems, environmental regulation, public investment and international relations.
Consequently, the distribution of political influence can become a determinant of the distribution of health.
The Sustainable Health Equity framework connects these relationships with a wider understanding of human development. It asks whether societies provide the resources and conditions necessary for every person to live with dignity, whether the benefits of development are distributed equitably, and whether excessive accumulation and consumption undermine the rights of others or the ecological foundations of life and should be therefore restricted.
This perspective challenges the assumption that economic growth, national wealth or military strength are sufficient indicators of social progress. A country may possess enormous financial and technological resources while maintaining substantial inequalities in access to healthcare, housing, education and political influence.
Similarly, a country may enjoy considerable international power while exercising that power in ways that constrain the economic choices, political autonomy or health opportunities of other populations.
Sustainable Health Equity therefore introduces an essential question into the assessment of democracy:
To what extent does the political system convert collective resources and decision-making power into equitable opportunities for health, dignity, participation and sustainable wellbeing?
1.3. The United States as a case study after the 2026 midterm elections
The United States is a particularly relevant case for this analysis.
It has a competitive electoral system, constitutional protections, a substantial civil society, powerful media institutions and mechanisms for public scrutiny and political contestation. These characteristics are important and should be recognised.
At the same time, the country is the world’s foremost military power, one of its largest economies, a central actor in international financial markets and a permanent member of the United Nations Security Council with veto power. Its domestic and international decisions therefore have consequences extending far beyond its national borders.
The November 3, 2026 midterm elections provide a timely context for examining these issues. The reported outcome was a substantial Democratic victory, with Democrats gaining control of both chambers of Congress. They won at least seven additional Senate seats and more than two dozen House districts, creating a new legislative counterweight to President Donald Trump’s administration.
The Associated Press reported that voter dissatisfaction with the cost of living, inflation, the Iran war and concerns about corruption contributed to the electoral climate. These factors should be treated as reported explanations and survey findings, not as a complete causal account of individual voting decisions.
Preliminary turnout estimates indicated approximately 124.3 million ballots cast, demonstrating substantial electoral mobilisation compared to previous years, yet only around 50% of adults with voting rights. Final certified turnout and some individual contest results remained subject to the normal counting and certification processes at the time of this manuscript’s preparation.
The elections demonstrate that electoral competition can provide an effective mechanism for citizens to express dissatisfaction and change the balance of institutional power. However, a change in legislative control does not necessarily transform the underlying inequalities in political financing, economic concentration, access to decision-makers or international power.
The central question is therefore not simply which party wins elections, but whether the institutions and policies that follow contribute to more equitable political participation, human dignity, health and ecological sustainability.
1.4. Aim and research questions
The article addresses five main questions:
- To what extent does the US electoral and party system provide equitable opportunities for citizens to influence political decisions?
- How do economic concentration and unequal access to political resources affect representation and public accountability?
- What do comparisons of healthcare expenditure and life expectancy reveal about the relationship between national wealth and population wellbeing?
- How does the international exercise of US political, military, economic and financial power affect the autonomy, development and health opportunities of other populations?
- What ethical principles and measurable dimensions would be required to assess and strengthen democracy through a Sustainable Health Equity framework?
The central hypothesis is that electoral democracy remains incomplete when formal political equality coexists with profound inequalities in effective influence, material dignity and the capacity to shape decisions affecting human and planetary wellbeing.
2. Ethical foundations of Sustainable Equity Democracy
A substantive conception of democracy requires an ethical foundation. Without explicit principles, equity can become a vague aspiration, while indicators can measure institutional performance without clarifying the values by which that performance should be judged.
The proposed framework of Sustainable Equity Democracy is grounded in eight mutually reinforcing ethical principles.
2.1. Equal moral worth and equal political consideration
Every human being possesses equal moral worth. Political institutions should therefore recognise every person as deserving equal consideration, protection and opportunities to participate in collective decisions.
This principle is not satisfied merely by granting formal voting rights. It requires institutions to prevent wealth, social status, gender, ethnicity, disability, educational opportunity or other circumstances from becoming unjust barriers to political voice.
Equal moral worth does not require identical outcomes in every dimension of life. It requires that inequalities should not deprive people of their fundamental rights or their capacity to participate as equals.
2.2. Justice and the common good: the contribution of Plato
The ethical foundations of democracy can be connected to classical philosophical discussions of justice.
In Book IV of The Republic, Plato presents an argument that the purpose of the just city should not be to make one particular group exceptionally happy, but to enable the city as a whole to flourish. In the translation by David Horan, Socrates explains that the city is being founded not to privilege one group but so that “the whole city may be as happy as it can possibly be” (Plato, Republic, 420b).
Plato also discusses the dangers of excessive wealth and poverty, arguing that both can undermine the cohesion and unity of the city (Republic, 421d–422a).
These arguments offer a valuable ethical starting point: the legitimacy of political organisation should be judged in relation to the wellbeing of the community as a whole, not merely the prosperity or power of a privileged minority.
However, Plato’s political philosophy was hierarchical and excluded many people from political citizenship, including a large share of slaves at the time. It should not be presented as an early formulation of contemporary democratic equality. The present framework draws on his concern for justice and the common good, while grounding equal political rights in modern principles of human dignity, universal citizenship and human rights.
The contemporary implication is that political and economic arrangements should be evaluated according to whether they contribute to the wellbeing of society as a whole, rather than allowing the interests of powerful groups to dominate collective priorities.
2.3. Minimum dignity and the equitable distribution of resources
Justice requires more than equal formal rights. It requires that every person has access to the minimum material and social conditions necessary for a dignified life.
These include adequate food, safe water, housing, sanitation, education, healthcare, energy, security and opportunities for meaningful participation.
The Sustainable Health Equity framework defines the economic equity space between a minimum dignity threshold and levels of excessive accumulation or consumption that may undermine the dignity and opportunities of others.
This principle is not an argument against all differences in income or wealth and towards egalitarism. It is an ethical argument against arrangements in which extreme deprivation coexists with excessive accumulation, while the resources and productive capacities necessary to secure basic dignity remain insufficiently distributed.
The principle of sufficiency is therefore combined with the principle of equity: societies should guarantee a dignified minimum for all while ensuring that the pursuit of additional wealth does not generate unjust deprivation or ecological damage.
2.4. Equity in effective political participation
A democratic system must protect the capacity of people to influence decisions, not simply their right to cast a ballot.
This requires fair access to candidacy, transparent campaign financing, accountable lobbying, pluralistic media, reliable public information and opportunities for participation between elections.
It also requires attention to the unequal resources that shape political communication and public debate.
The principle is one of effective political equality: no individual, corporation or organised interest should be able to convert economic power into disproportionate control over collective decisions without transparency and accountability.
2.5. Solidarity and responsibility beyond national borders
The consequences of political decisions frequently extend beyond the populations represented by the institutions making them.
Economic sanctions, military operations, trade restrictions, financial regulations and climate policies may affect the health, livelihoods and political autonomy of people in other countries.
An ethical conception of democracy must therefore include responsibility towards populations affected by national decisions, even when they do not possess citizenship or voting rights in the country concerned.
This principle requires international solidarity, transparent impact assessments and mechanisms through which affected populations can be heard and protected.
2.6. Intergenerational justice and responsibility for future life
Democratic decisions should not transfer avoidable social, financial or ecological burdens to future generations.
The interests of people who cannot yet vote must be considered in decisions about public debt, resource extraction, climate policy, biodiversity, infrastructure, technology and environmental protection.
Intergenerational justice requires institutions to consider long-term consequences rather than prioritising immediate political or economic benefits.
2.7. Ecological responsibility and planetary boundaries
Human societies depend on stable Earth systems. Climate regulation, freshwater availability, biodiversity, soil fertility, ocean chemistry and nutrient cycles are not external environmental concerns; they are foundations of human health, food systems, economic activity and social stability.
The Planetary Boundaries framework identifies nine major Earth-system processes that regulate the stability and resilience of the planet.
The 2026 Planetary Health Check reports that seven of the nine boundaries have been transgressed: climate change, biosphere integrity, land-system change, freshwater change, biogeochemical flows, novel entities and ocean acidification. Atmospheric aerosol loading and stratospheric ozone depletion remain within the global safe operating space, although important regional and continuing concerns remain.
This evidence makes ecological responsibility an ethical requirement of political legitimacy, not simply a technical matter for environmental policy.
Planetary boundaries are global Earth-system limits. They do not automatically specify how much each country or individual should consume or emit. The allocation of fair national and individual shares requires additional ethical and political principles, including historical responsibility, capacity to act, basic needs and the right to development.
2.8. Transparency, accountability and precaution
The exercise of political, economic, financial and technological power must be transparent and accountable.
Where decisions may generate serious or irreversible harm, institutions should apply precaution, independent assessment and public scrutiny.
This principle is especially relevant to artificial intelligence, financial modelling, digital political communication, surveillance technologies, economic sanctions and military decision-making.
The ethical legitimacy of a decision cannot depend exclusively on the authority of the institution making it. It must also depend on the evidence supporting it, the proportionality of the action, the transparency of its objectives and the mechanisms available to challenge its consequences.
3. Operational framework: dimensions of Sustainable Equity Democracy
The eight ethical principles can be translated into seven interconnected dimensions for research and policy assessment.
| Dimension | Ethical foundation | Possible indicators |
| 1. Political rights and participation | Equal moral worth and political equality | Electoral participation, registration barriers, access to candidacy, representation |
| 2. Equitable influence | Justice and non-domination | Campaign-finance concentration, lobbying transparency, media concentration, public responsiveness |
| 3. Minimum dignity and health | Sufficiency and distributive justice | Poverty, healthcare access, preventable mortality, housing, education, life expectancy |
| 4. Fair distribution and limits to excess | Common good and social equity | Income and wealth concentration, access to essential resources, ecological consumption by income group |
| 5. Global solidarity and accountability | Responsibility beyond borders | Health impact assessments, sanctions effects, trade impacts, international representation |
| 6. Ecological sustainability | Planetary stewardship and precaution | Greenhouse-gas emissions, material footprint, biodiversity, water and land pressures |
| 7. Intergenerational responsibility | Justice across generations | Long-term debt sustainability, climate commitments, ecosystem restoration, future-generation impact assessments |
These dimensions should be assessed separately before any composite index is calculated. A single score could conceal serious failures in one dimension behind strong performance in another.
A proposed Index of Equitable Political Representation could form one component of the broader framework, while a Sustainable Equity Democracy assessment would incorporate the social, health, international and ecological dimensions.
The objective is not to create a universal ranking without adequate evidence. It is to make structural inequalities visible, comparable and open to public accountability.
4. Methodology and limitations
This article uses a multidisciplinary and comparative approach, drawing on electoral statistics, campaign-finance data, socioeconomic indicators, international health statistics, institutional reports, academic literature and Earth-system science.
The analysis is organised around four interconnected levels:
- Domestic political representation and participation.
- Domestic economic inequality and health consequences.
- International political, military, economic and financial power.
- Ecological inequality and the distribution of environmental responsibilities.
The United States is compared with Japan, Greece and Sri Lanka in selected economic and health indicators. These countries do not constitute a representative sample of the world but they are references to best health (Japan), best health under the equity space (Greece) and only economically replicable and ecologically sustainable national reference (Sri lanka). They are included to illustrate how differences in economic resources, health expenditure and social organisation may coexist with different population health outcomes.
Several limitations must be acknowledged.
Electoral participation statistics are not equivalent to measures of political influence. Campaign-finance categories may overlap. Comparable data on the wealth and social backgrounds of candidates, delegates and political office-holders remain incomplete.
Health indicators are influenced by multiple factors, including age structure, disease patterns, social protection, healthcare organisation, lifestyle and environmental conditions. Comparisons cannot establish simple causal relationships between health expenditure and life expectancy.
The international consequences of sanctions, military operations and trade restrictions are also difficult to isolate from other political and economic factors.
Finally, planetary boundaries describe global Earth-system processes. Translating them into national responsibilities requires explicit ethical assumptions concerning historical emissions, capacity, development needs and equitable resource use.
The article should therefore be understood as a critical framework for assessment and future empirical investigation, rather than as a definitive causal evaluation of every dimension of US political power.
5. Inequalities in political representation
5.1. Access to candidacy
The right to stand for public office is an essential component of democratic participation. However, legal eligibility does not guarantee equal practical access.
Candidates need time, financial resources, organisational support, public visibility and access to communication networks. These requirements disproportionately favour individuals with economic security, professional networks and established institutional connections.
Research on the socioeconomic backgrounds of members of the US Congress has identified the overrepresentation of individuals from affluent and highly educated backgrounds.
This does not mean that all elected representatives share identical interests or that social origin determines political behaviour. It does, however, raise questions about whether the composition of political institutions adequately reflects the socioeconomic diversity of the population.
A systematic assessment would require data on candidates’ family wealth, personal income, professional backgrounds, educational trajectories and sources of campaign support.
5.2. Campaign financing and the unequal influence of wealth
Campaign financing is one of the clearest points at which formal political equality encounters economic inequality.
During the 2023–2024 federal election cycle, the Federal Election Commission recorded billions of dollars in receipts and expenditure across presidential candidates, congressional candidates, party committees and political action committees. Independent expenditures alone amounted to several billion dollars.
These figures demonstrate the scale of financial resources mobilised in US federal elections. They do not, by themselves, establish that financial contributions determine electoral outcomes or that every contribution purchases political influence.
Nevertheless, the capacity to finance political communication, support candidates, organise lobbying and sustain long-term advocacy is unequally distributed.
The distinction between the formal equality of individual votes and the unequal capacity to influence the political environment is fundamental. A system may protect one-person-one-vote while allowing substantial inequalities in the resources used to shape the choices presented to voters.
The issue is not simply whether wealthy citizens have the right to participate. They do. The issue is whether the political system provides sufficient safeguards to prevent concentrated wealth from translating into disproportionate political influence.
5.3. Candidate selection and party delegates
Political parties play a decisive role in selecting candidates, defining programmes and determining which political alternatives become electorally viable.
Party conventions and delegate systems are therefore important stages in democratic representation. However, the socioeconomic characteristics of delegates, the distribution of influence among party structures and the role of institutional insiders are not consistently documented in comparable public datasets.
The number of delegates and their formal voting rights are insufficient measures of substantive representation. A fuller analysis would examine their wealth, professional backgrounds, geographical origins, relationships with donors and participation in party decision-making.
5.4. Primary elections and political participation
Primary elections provide opportunities for citizens to influence candidate selection before general elections. Yet participation is generally much lower than participation in presidential and congressional elections.
The preliminary 2026 figures indicated that primary participation remained substantially below general-election participation. This raises questions about the representativeness of the electorate that determines which candidates reach the final ballot.
Low participation does not necessarily invalidate the outcome of a primary. However, it can increase the relative influence of highly motivated voters, organised groups and established political networks.
A more equitable system would seek to reduce barriers to participation and ensure that candidate selection reflects a broader range of social experiences and political preferences.
5.5. Party identification and active political participation
Political identification is not the same as party membership or active participation.
Many US citizens identify as independent, while others identify with one of the major parties without participating in party structures or decision-making. This distinction matters because the political system is often described as a choice between two dominant parties, even though citizens’ political preferences are more diverse.
The existence of independent voters does not automatically imply the absence of meaningful political alternatives. However, the institutional and financial barriers facing smaller parties and independent candidates deserve attention.
The key question is whether the political system enables diverse social interests to achieve effective representation, rather than merely allowing them to express preferences at the ballot box.
5.6. General elections and the November 2026 midterms
The November 2026 midterm elections provide an important contemporary example of the vitality and limitations of electoral participation.
Preliminary estimates from the University of Florida Election Lab indicated approximately 124.3 million ballots cast, corresponding to approximately 49.4% of the estimated voting-eligible population. The estimates were provisional when reported, and should be replaced by final certified data when available.
The elections resulted in Democrats gaining control of both chambers of Congress. This outcome represents an important exercise of electoral accountability and a change in the institutional balance of power.
It demonstrates that voters can impose political costs on governing parties and alter the legislative environment. It also creates opportunities for congressional oversight and institutional checks and balances.
However, a change in party control does not automatically resolve structural inequalities in campaign financing, lobbying, media ownership, wealth concentration or political access. Nor does it guarantee that the resulting policies will reduce domestic or international health inequities.
The elections should therefore be interpreted as evidence of continuing electoral responsiveness, but not as proof that the political system has achieved substantive equality.
5.7. Political knowledge, education and communication
Effective political participation requires more than the formal ability to vote. It also requires access to reliable information, opportunities for political education and the capacity to assess competing claims.
Educational attainment is associated with differences in electoral participation in US Census Bureau data. However, education alone does not explain political behaviour, and it would be inappropriate to assume that people with less formal education lack political understanding.
The more important question concerns unequal access to the resources that support informed participation.
Political communication is increasingly shaped by digital platforms, targeted advertising, private data systems and algorithmic recommendation. These systems can expand access to information, but they may also fragment public debate, reinforce polarisation and create unequal opportunities to influence political attention.
The democratic implications of these developments require independent research, transparency and public accountability.
5.8. Electoral exclusion and non-citizen residents
The United States includes millions of residents who are not citizens and therefore cannot vote in federal elections. This includes permanent residents and other non-citizen populations.
The distinction between citizenship and residence is legally significant, and the right to vote in national elections is generally linked to citizenship. Nevertheless, many non-citizens contribute to the economy, pay taxes, work in essential sectors and are directly affected by public policies.
The democratic question is therefore broader than the legal right to vote: how can societies ensure that people who are substantially affected by public decisions have appropriate channels for representation, consultation and protection?
The same issue applies to people affected by US foreign policy. Populations abroad may experience the consequences of sanctions, trade restrictions or military decisions without having any direct mechanism to influence those decisions.
6. Economic inequality and its consequences for health
Political representation cannot be separated from the distribution of economic resources.
Economic inequality affects access to housing, education, nutrition, transport, healthcare, environmental quality and social security. These conditions influence health throughout the life course.
The United States combines exceptionally high economic output and healthcare expenditure with persistent inequalities in access to care and health outcomes.
6.1. Healthcare expenditure
In 2023, estimated current health expenditure per capita in purchasing-power-adjusted international dollars was approximately in the follwoing sleceted countries (Japan for best health, Greece for best health under equity curve, Costa Rica for best health under equity curve in the region and Sri Lanka for global reference of good health, economically replicable and ecologically sustainable levels):
| Country or group | Health expenditure per capita, 2023 | |
| United States | $13,473 | |
| Japan | $5,365 | |
| Greece | $3,454 | |
| Costa Rica | $1,163 | |
| Sri Lanka | $507 | |
| World average | $1,891 |
Source: World Bank, World Development Indicators, based on the WHO Global Health Expenditure Database
The United States spent substantially more per person on healthcare than the other countries included in this comparison.
However, higher expenditure does not automatically translate into proportionately better population health. The organisation of healthcare, administrative costs, prices, access barriers, social determinants and distribution of services all matter.
The central equity question is therefore not only how much a country spends, but how effectively and fairly those resources are converted into health and wellbeing.
6.2. Life expectancy
Internationally harmonised estimates for 2023 indicate the following life expectancy at birth in the USA and the comparative countries listed above in the health expenditure discussion
| Country | all | men | women |
| United States | 79.8 years | 77.4 years | 82.2 years |
| Japan | 85.1 years | 82.1 years | 88.2 years |
| Greece | 82.4 years | 79.9 years | 84.7 years |
| Costa Rica | 79.8 years | 76.8 years | 82.8 years |
| Sri Lanka | 78.0 years | 74.9 years | 81 years |
These estimates use the Human Mortality Database and United Nations World Population Prospects 2024, processed by Our World in Data.
The comparison is informative. The United States has substantially higher health expenditure per capita than Japan and Greece, but lower life expectancy in the cited series.
Japan achieves particularly high life expectancy despite considerably lower healthcare expenditure per capita than the United States.
Greece, Costa Rica (borth with lower health expenditure and better health than the USA) and Sri Lanka (a globally replicable model with much lower health expenditure and very close levels illustrate that population health cannot be explained by national income or healthcare expenditure alone. Social organisation, public health, nutrition, education, family structures and other determinants also contribute.
Life expectancy is an important but incomplete indicator. It should be complemented by healthy life expectancy, preventable mortality, inequalities by income and education, access to healthcare and sex-disaggregated outcomes.
6.3. Interpretation: expenditure, distribution and outcomes
The comparison does not establish that the United States necessarily has a less effective healthcare system in every respect, nor that Japan, Greece, Costa Rica or Sri Lanka offer universally transferable models.
It does demonstrate that national wealth and healthcare expenditure alone are insufficient indicators of population wellbeing.
A health-equity assessment must consider:
- Who receives healthcare and under what conditions.
- The distribution of health expenditure across population groups.
- The affordability of medicines and treatment.
- The social determinants of health.
- Preventable mortality and avoidable inequalities.
- Differences in life expectancy by sex, income, education and geographical location.
- The distribution of resources between prevention, treatment and public health.
The central concern is not simply the amount of wealth available, but the extent to which that wealth is converted into equitable opportunities for healthy and dignified lives.
7. The international dimensions of US political and economic power
The domestic political system of the United States cannot be understood independently of its international position.
Its influence operates through military capabilities, diplomatic institutions, trade policy, financial markets, economic sanctions, technological infrastructures and the international role of the dollar.
These mechanisms can affect the economic and political choices available to other countries, including those whose citizens have no direct representation in the US political system.
7.1. The United Nations Security Council and veto power
The United States is one of the five permanent members of the United Nations Security Council. Alongside China, France, Russia and the United Kingdom, it possesses the power to veto substantive resolutions.
This arrangement reflects the geopolitical settlement established after the Second World War. It does not represent an equal distribution of political authority among the world’s countries.
The veto can prevent collective action even when a majority of Security Council members support a proposal.
The issue is not that the United States alone possesses this privilege. All five permanent members do. The structural concern is that a small group of states retains a level of institutional authority unavailable to the vast majority of countries.
This raises fundamental questions about the democratic legitimacy and representativeness of global governance.
7.2. Military power and international coercion
The United States has the world’s largest military budget.
SIPRI estimated US military expenditure at approximately 997 billion US dollars in 2024, representing around 37% of global military expenditure.
Military power can serve multiple purposes, including defence, deterrence, alliance commitments and international security operations. However, it can also be used, as it most often does, to support coercive foreign policy, military intervention and strategic influence.
From a Sustainable Health Equity perspective, military expenditure must be assessed not only in relation to national security, but also in relation to its opportunity costs and its effects on human wellbeing.
The relevant questions include:
- What proportion of public resources is allocated to military expenditure rather than health, education and social protection?
- What are the human and health consequences of military operations?
- How do arms transfers and military alliances affect conflict and population displacement?
- What are the environmental costs of military infrastructure and operations?
- Who bears the consequences of decisions made by powerful states?
These questions require careful empirical analysis, rather than assumptions that all military expenditure has identical consequences.
7.3. Economic sanctions and health consequences
Economic sanctions are frequently presented as alternatives to military intervention. They may be designed to influence governments, restrict access to resources or respond to violations of international law.
However, sanctions can also affect civilian populations through restrictions on trade, financial transactions, investment, access to medicines, food security and essential infrastructure.
A 2026 scoping review of research on US international economic sanctions identified 43 original studies, of which 42 reported health-related harms. Reported effects included mortality, reduced access to medicines, food insecurity and infectious disease consequences. The evidence was concentrated in a limited number of countries, particularly Iran, and the quality and attribution of studies varied.
These findings should not be interpreted as proof that every sanction produces the same effects or that sanctions are the sole cause of observed health outcomes.
They do, however, demonstrate the need for systematic health-impact assessments before, during and after the implementation of economic coercive measures.
An equity-based approach would require independent monitoring, humanitarian safeguards, transparent evaluation and effective mechanisms to protect civilian populations.
7.4. Trade policy and the distribution of global economic power
The United States occupies a central position in international trade and has considerable influence over the rules and conditions governing access to its market.
Changes in tariffs can affect exporters, consumers, supply chains and the economic stability of other countries.
UNCTAD analyses published in 2025 and 2026 documented substantial increases in US tariff barriers compared with the pre-2025 period. The exact effective rates vary according to product categories, exemptions and subsequent policy changes.
The wider issue is the asymmetry between countries with substantial economic leverage and those whose development depends heavily on access to external markets.
Trade policy should therefore be assessed in relation to its effects on employment, food security, medicine availability, productive capacity and the fiscal resources available for public services.
The principle of equitable development requires that international trade rules do not systematically disadvantage countries with less bargaining power.
7.5. The international role of the dollar
The US dollar remains the dominant international reserve currency.
IMF COFER data for the fourth quarter of 2025 placed the dollar’s share of disclosed global foreign-exchange reserves at approximately 56.8%, compared with around 20.3% for the euro.
Dollar dominance provides important benefits to the United States, including favourable financing conditions and considerable influence over international financial transactions.
It also creates structural dependencies for countries, companies and financial institutions that rely on dollar-denominated trade, debt and reserves.
Research on international sanctions and dollar dominance has examined how the central position of the dollar can increase the effectiveness of US financial sanctions while also creating incentives for some countries to diversify their financial arrangements.
The equity question concerns the extent to which one country’s monetary and financial position can influence the economic options available to others.
The international monetary system requires institutions that balance financial stability with the legitimate interests and development needs of all countries.
7.6. Financial information infrastructures and Aladdin
The growing role of large financial technology platforms introduces another dimension of global economic influence.
BlackRock’s Aladdin platform integrates investment management, portfolio analytics, risk management, trading, compliance and operational functions. It is used by a wide range of financial institutions, including asset managers, banks, insurers and pension funds.
The significance of such platforms should be analysed carefully.
Aladdin is not itself a speculative investment fund, nor is there sufficient evidence to claim that it directly controls global financial markets or dictates the decisions of every institution using it.
Its relevance lies in the increasing concentration of financial information infrastructure, analytical tools and risk-management capabilities within a small number of large private technology providers.
This raises important questions about transparency of financial models, accountability of risk-assessment systems, concentration of data and analytical capabilities, potential systemic dependence on shared technological infrastructure, and the capacity of regulators and public institutions to assess these systems independently.
The issue is not whether a particular platform is inherently harmful. It is whether financial systems of global importance should depend on infrastructures whose governance, models and operations are not fully transparent to the societies affected by their decisions.
8. Ecological inequality, planetary boundaries and the limits of the dominant development model
Political and economic inequality cannot be separated from ecological inequality.
The global distribution of environmental resources and responsibilities remains highly unequal. Countries and populations with the greatest historical and current ecological footprints have generally benefited from disproportionate resource consumption, while many of the populations most vulnerable to climate change have contributed comparatively little to the problem.
The United States has one of the world’s highest per-capita levels of resource consumption and greenhouse-gas emissions.
The ethical significance of this imbalance becomes clearer when considered alongside the planetary boundaries framework.
The framework identifies nine Earth-system processes that regulate the stability, resilience and life-support functions of the planet:
- Climate change.
- Biosphere integrity.
- Land-system change.
- Freshwater change.
- Biogeochemical flows, particularly nitrogen and phosphorus.
- Ocean acidification.
- Atmospheric aerosol loading.
- Stratospheric ozone depletion.
- Novel entities, including synthetic chemicals and other human-made substances.
The 2026 Planetary Health Check reports that seven of these nine boundaries have been transgressed. The two remaining global boundaries are atmospheric aerosol loading and stratospheric ozone depletion, although regional aerosol pressures remain significant.
This is not simply an environmental warning. It is evidence that the ecological conditions on which human health, food security, economic activity and social stability depend are being placed under increasing pressure.
Planetary boundaries describe global Earth-system limits; they do not by themselves determine how much each country should consume or emit. A fair allocation requires ethical consideration of historical responsibility, current capacity, basic needs, population size and legitimate development requirements.
This is where Sustainable Health Equity becomes essential.
A country cannot claim to advance sustainable human development if its prosperity depends on ecological consumption that undermines the health and dignity of populations elsewhere or transfers environmental costs to future generations.
The ethical question is not whether all countries should have identical ecological footprints. It is whether every person can attain a dignified standard of living while the global community remains within a safe operating space.
The Sustainable Health Equity framework has proposed an ethical reference of approximately 1.6 tonnes of CO₂-equivalent emissions and 1.5 Ha of ecological footprint (global average biocapacity) per person per year as a benchmark for exploring equitable ecological responsibility. The USA has levels of 14.2 tonnes of CO2 equivalent emissions per capita (8.9 times higher than the ethical threshold) and 10.6 Ha ecological footprint per capita (7 times higher). This should be understood as a normative reference for analysis, not as an internationally agreed legal threshold. Any comparison with national emissions must use compatible accounting boundaries and distinguish territorial from consumption-based emissions.
Military expenditure and environmental impact should also be considered together. Military operations, infrastructure, weapons production and global military networks require substantial material and energy resources. Their environmental consequences are not always fully reflected in national emissions reporting.
From a health-equity perspective, climate change and ecological degradation affect nutrition, infectious disease patterns, heat-related mortality, displacement, livelihoods and the resilience of health systems.
The author has previously described climate change and ecological destruction as a form of global conflict without conventional weapons, in which the consequences are distributed unequally across populations and generations.
A sustainable political system must therefore address not only the distribution of income and political influence, but also the distribution of ecological responsibilities and environmental harms.
9. Discussion: the contradictions of the so-called democratic model
The evidence examined in this article points to a central contradiction.
The United States has a competitive electoral system, constitutional protections, political pluralism, a substantial civil society and institutions capable of public scrutiny and contestation. These are important democratic characteristics and should not be dismissed.
The November 2026 midterm elections demonstrate that electoral competition can produce a significant change in legislative power and provide an institutional mechanism for voters to express dissatisfaction with government performance.
Yet electoral responsiveness is not equivalent to equitable political influence.
The capacity to finance campaigns, influence public communication, access decision-makers and shape economic policy is unequally distributed. The social composition of political institutions does not fully reflect the diversity of the population. Millions of residents are excluded from federal voting because they are not citizens, while populations abroad affected by US decisions have no direct political representation in the system responsible for those decisions.
The contradiction becomes more significant when domestic inequalities are considered alongside international power.
A country may defend democratic principles while retaining disproportionate influence over global institutions. It may promote market freedom while using economic sanctions and trade restrictions to influence other countries’ policy choices. It may advocate human rights while supporting military and economic arrangements whose consequences require more systematic evaluation.
These tensions are not unique to the United States. Other powerful states also exercise unequal international influence, and global institutions themselves reproduce historical inequalities.
However, the scale of US economic, military and financial power makes the consequences particularly important.
The central criticism is therefore not that the United States lacks democratic institutions, but that the concept of democracy remains incomplete when it is assessed without considering the distribution of effective power and the consequences of that power for other populations.
The philosophical foundations proposed here provide a way to move beyond a narrow procedural understanding.
Plato’s concern for the common good, modern principles of equal moral worth and human rights, the ethical requirement of minimum dignity, and the scientific evidence on planetary boundaries all point towards a broader criterion of political legitimacy: the wellbeing and freedom of the whole community, including those beyond national borders and future generations.
The 2026 planetary assessment makes the ecological dimension particularly urgent. Seven transgressed planetary boundaries mean that political and economic systems must be evaluated against the capacity of Earth systems to sustain life. A democratic majority cannot ethically justify policies that systematically undermine the basic conditions of life for other populations or future generations.
The concept of Sustainable Equity Democracy therefore extends the assessment of political legitimacy across three interconnected domains: the equitable distribution of power, the equitable distribution of the conditions for dignity and health, and the equitable distribution of ecological responsibilities.
10. Research agenda: towards an Index of Equitable Political Representation and a Sustainable Equity Democracy assessment
The evidence gaps identified in this article suggest the need for a systematic research programme.
An Index of Equitable Political Representation could complement conventional measures of democracy by examining not only electoral procedures but also the distribution of effective political influence.
Potential dimensions include:
- Access to political candidacy
- Socioeconomic background of candidates.
- Personal wealth and income distribution.
- Educational and professional diversity.
- Financial and organisational barriers to candidacy.
- Equity in campaign financing
- Distribution of contributions by income and wealth groups.
- Dependence on large donors and organised interests.
- Public financing and campaign expenditure limits.
- Transparency of independent expenditure and political advertising.
- Representation within political parties
- Social composition of party members and delegates.
- Participation in candidate selection.
- Transparency of internal decision-making.
- Representation of marginalised communities.
- Electoral participation
- Turnout by income, education, age, sex and geographical area.
- Registration and voting barriers.
- Differences between primary and general elections.
- Participation among people with disabilities and other groups facing structural barriers.
- Political information and public deliberation
- Access to independent and reliable information.
- Media concentration and ownership.
- Transparency of digital political advertising.
- Algorithmic accountability and political communication.
- Accountability and responsiveness
- Relationship between public preferences and policy outcomes.
- Transparency of lobbying.
- Legislative responsiveness to different socioeconomic groups.
- Mechanisms for public consultation and oversight.
- International democratic accountability
- Distribution of decision-making power in international institutions.
- Accountability for sanctions and military operations.
- Participation of affected populations in international decisions.
- Transparency of global economic and financial governance.
- Health and ecological consequences
- Distributional health impact assessments of major policies.
- Preventable mortality associated with economic and political decisions.
- Distribution of ecological footprints and carbon responsibilities.
- Effects of international policies on health equity in other countries.
A complementary Sustainable Equity Democracy assessment would include the ethical principles and seven dimensions described in Section 3.
The index would need to avoid reducing complex political systems to a single numerical score without adequate methodological transparency. Its purpose should be to identify inequalities, make them comparable where possible and support institutional reform.
Such work could be developed in collaboration with public health institutions, universities, international scientific networks and civil society organisations.
The World Federation of Public Health Associations, the InterAcademy Partnership and the Planetary Health Alliance offer relevant conceptual and scientific frameworks for connecting governance, health, equity and planetary sustainability. Their work is cited as a source of scientific and policy perspectives, not as institutional endorsement of the arguments presented in this article.
11. Conclusions: democracy must be measured by sustainable equity
The United States illustrates both the strengths and the structural limitations of contemporary electoral democracy.
Its institutions provide important mechanisms for political competition, representation and public accountability. The 2026 midterm elections demonstrate that voters can alter the balance of legislative power and impose political consequences on governing parties.
Nevertheless, the existence of these mechanisms does not ensure equal access to political influence or equitable outcomes.
The analysis identifies inequalities in access to candidacy, campaign financing, party participation, political communication and electoral representation. It also highlights the relationship between economic concentration and unequal opportunities for health and wellbeing.
The comparison with Japan, Greece, Costa Rica and Sri Lanka demonstrates that higher national income and greater healthcare expenditure do not automatically produce better population health. The distribution of resources, social protection, public health and other determinants are equally important.
At the international level, the concentration of military, economic, financial and institutional power raises questions about the democratic accountability of decisions affecting populations beyond national borders. The international role of the dollar, the use of economic sanctions, tariff policies and the distribution of authority within global institutions deserve scrutiny.
The ecological dimension reinforces the argument. The 2026 Planetary Health Check reports that seven of the nine planetary boundaries have been transgressed. This evidence establishes that the dominant development model cannot be assessed solely through economic growth, national wealth or political power. It must also be evaluated according to its contribution to the stability and resilience of the Earth systems that sustain life.
The ethical foundations proposed in this article bring together the common good, equal moral worth, minimum dignity, equitable participation, solidarity, accountability and intergenerational responsibility. They translate these principles into a framework for assessing the substantive quality of democratic systems.
The limitations identified in this article should not be used to dismiss the evidence of inequality. Rather, they should guide the development of more comprehensive indicators and stronger research. Where data are missing, the appropriate response is to improve transparency and measurement, not to assume that equality exists.
The central conclusion is that democracy should not be measured exclusively by the procedures through which governments are elected. It must also be assessed by the extent to which people can participate meaningfully in collective decisions, exercise their rights under conditions of dignity, influence the distribution of public resources and hold power accountable for its consequences.
Democracy without equitable political influence remains incomplete. Economic prosperity without equitable dignity remains incomplete. National power without international accountability remains incomplete. Development without ecological sustainability remains incomplete
Sustainable Equity Democracy offers a way to connect these dimensions. It does not diminish the importance of freedom, pluralism, elections or constitutional rights. It argues that their full value can only be realised when political institutions also protect equitable participation, health, human dignity and the ecological conditions of life.
The challenge is therefore not merely to improve the electoral system of the world’s dominant political, economic and military power. It is to move beyond a narrow understanding of democracy as the periodic selection of governments and towards a system in which the legitimacy of power is measured by its contribution to the wellbeing and freedom of all people, including those beyond national borders and those of future generations.
A genuinely democratic international order would require institutions in which power is more equitably distributed, decisions are transparent and accountable, the minimum conditions for a dignified life are secured for everyone, and the use of shared resources respects the limits of the planet.
The ultimate measure of democracy should not be how effectively a country concentrates and exercises power, but how equitably that power contributes to the freedom, dignity, health and sustainable wellbeing of humanity
References
Political philosophy, ethics and democracy
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Electoral participation and political finance
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Previous publications by the author on Sustainable Health Equity
Author. (2018). Health and climate change: A third world war with no guns. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2018/07/5498/
Author et al. (2021). Global health inequity 1960–2020: Equity vs equality, dignity vs poverty, equitable and sustainable wellbeing vs Human Development Index. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2021/04/9658/
Author. (2023). Towards a WISE – Wellbeing in Sustainable Equity – New Paradigm for Humanity. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2023/12/12800/
Author. (2024). Restoring Broken Human Deal. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2024/04/13164/
Author. (2024). Enough is enough, and more is too much: Between basic dignity and excess/hoarding thresholds. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2024/11/enough-is-enough-and-more-is-too-much-between-basic-dignity-and-excess-hoarding-thresholds/
Author. (2026). Cuba under economic siege: Evidence of the humanitarian and health consequences of United States coercive measures and arguments for an equity-based response. PEAH – Policies for Equitable Access to Health. https://www.peah.it/2026/09/16432/
