5.8: So Who Is Responsible?

The Question We Can No Longer Avoid

We have spent this chapter making health more complicated.

We began with the body, but the walls around it kept moving. Health turned out to be connected to housing, work, income, history, race, gender, migration, pharmaceutical markets, political institutions, infrastructure, climate, food systems, and power. By now, explaining illness entirely through individual behavior should feel a little like blaming someone for getting wet while standing inside a house with no roof. Perhaps they could have moved the chair, but sooner or later we have to discuss the roof.

That leaves us with the hardest question in the chapter: If health is produced by systems, who is responsible for changing those systems?

The easiest answer is “everyone.” Individuals matter. Families and communities matter. Governments, corporations, international organizations, scientists, employers, donors, researchers, and health professionals all matter. That answer is true, but it is not especially useful. When responsibility belongs vaguely to everyone, it can very quickly belong concretely to no one.

A better approach is to connect responsibility to power, capacity, causation, benefit, obligation, and accountability. Instead of asking only who is involved in a health problem, we can ask who actually has the ability to change the conditions producing it, who benefits from the existing arrangement, who bears its costs, and what obligations follow from unequal power.

Individuals clearly make decisions that affect their own health. Food, exercise, medication, smoking, vaccination, sleep, sexual behavior, and medical care all matter. Personal agency is real. But agency is never exercised in empty space. Someone deciding what to eat chooses inside a food system. Someone deciding whether to visit a doctor acts within a health-financing system. A worker deciding whether to stay home sick is making that choice inside a labor market that may or may not provide paid leave. A parent deciding whether to vaccinate a child acts within an information environment shaped by trust, media, education, institutions, and history.

Public-health scholarship has therefore consistently challenged explanations that reduce health inequality entirely to individual choice (Link & Phelan, 1995; Marmot, 2005). Choice matters, but some people choose from a menu while others choose from whatever is left.

That suggests a useful principle: responsibility should increase with the power to shape health conditions.

A teenager cannot regulate pharmaceutical prices. A migrant laborer cannot redesign national labor law. A patient cannot independently build a rural hospital. A village cannot rewrite an international patent regime. Governments, corporations, and international institutions possess forms of power that individuals do not, and their obligations cannot therefore be identical.

Thomas Pogge (2002) pushes this argument further by asking us to consider not only whether powerful actors do enough to relieve suffering, but also whether the institutional arrangements from which they benefit help reproduce that suffering in the first place. That changes the ethical standard. Instead of asking whether wealthy states, corporations, or institutions are generous enough, we begin asking whether the rules themselves are just.

Health has long been connected to this language of rights. The Constitution of the World Health Organization describes enjoyment of the highest attainable standard of health as a fundamental human right, while the Universal Declaration of Human Rights links health and well-being to food, housing, medical care, and social protection. A right to health does not mean that governments can guarantee that nobody will ever become sick. No government can promise immortality, which would be a terrible campaign platform anyway. Rather, the right to health concerns fair and nondiscriminatory access to the institutions, services, resources, and social conditions that make the highest attainable standard of health possible.

Legal scholar Lawrence Gostin (2014) argues that global health justice therefore involves responsibilities that extend beyond voluntary charity, including obligations related to basic health capabilities, public goods, governance, and human rights. The conversation changes from It would be nice if everyone had access to a much harder question: What do governments and institutions actually owe people?

Scarcity makes that question difficult. No health system can provide every possible intervention to every person at unlimited cost. Governments make choices among maternal health, vaccination, mental-health care, sanitation, primary care, chronic-disease prevention, rare-disease treatments, workforce development, and countless competing needs.

A budget is therefore more than a financial document. It is also a moral one. It reveals which needs were considered urgent, which populations were prioritized, and which forms of suffering were allowed to wait.

Norman Daniels (2008) argues that health has special moral importance because it protects people's range of opportunities. Ill health can profoundly restrict what individuals are able to do and become, making fair access to health-producing conditions central to justice. Amartya Sen's capability approach widens the argument further by asking us not simply what resources people formally possess, but what they are actually able to do with them (Sen, 1999).

Two people can receive the same health resource and still possess radically different capabilities. Imagine that everyone is technically entitled to use the same clinic. One patient lives next door, while another travels six hours. One receives paid leave, while another loses a day's wages. One speaks the clinic's language; another does not. One trusts the institution, while another has experienced discrimination there.

The formal resource may be equal. The meaningful opportunity is not.

Martha Nussbaum (2011) similarly identifies bodily health as central to human flourishing. Taken together, these approaches demand more of equity than simply providing everyone with the same service. The real question is whether people possess a meaningful opportunity to live healthy lives.

This is also why charity and justice are not the same thing.

Suppose a wealthy country donates vaccines to a lower-income country. The donation is useful and may save lives. Justice nevertheless asks an additional question: Why was donation necessary in the first place? If the global system governing vaccine production, purchasing, financing, and intellectual property made it extraordinarily difficult for some countries to obtain vaccines independently, generosity can be genuinely valuable while the underlying arrangement remains unequal.

Charity asks, How can I help?

Justice asks, Why are you in this position, why am I in mine, and what system connects those facts?

Global health needs generosity. It also needs the second question.

Paul Farmer's (2004) work on structural violence makes that distinction especially clear. Poverty and illness cannot always be treated as unfortunate circumstances floating free from history when contemporary patterns of suffering have been shaped by political and economic relationships built over generations. Sometimes helping means delivering medicine. Sometimes it means asking why the medicine was inaccessible. Often it means doing both.

Governments remain especially important because states possess powers that almost no other actor has. They can tax, regulate, finance hospitals, train health workers, negotiate medicine prices, enforce labor standards, build water systems, control pollution, provide insurance, and establish social protections. That capacity creates responsibility.

Yet states themselves are profoundly unequal. Some governments possess enormous tax bases, scientific capacity, effective bureaucracies, and substantial bargaining power. Others govern amid debt, war, colonial legacies, limited revenues, weak infrastructure, or vulnerability to economic forces originating beyond their borders. A country's health outcomes can therefore be shaped by international trade, commodity prices, debt, migration, climate change, pharmaceutical supply chains, and global financial institutions.

If causes cross borders, obligations may have to cross them too.

This is where global solidarity becomes more useful than a simple charity model. Solidarity does not erase differences in wealth or power; it begins by acknowledging them. During a pandemic, solidarity can mean sharing scientific information, expanding manufacturing capacity, financing vaccines, strengthening health systems, and supporting health workers. In climate policy, it can mean countries with greater historical responsibility and greater financial capacity contributing more toward adaptation and resilience.

Solidarity changes the grammar of responsibility. The problem is no longer simply yours. It becomes a question of our relationship to the conditions producing it.

Corporations belong in this ethical conversation as well. Pharmaceutical companies develop medicines and vaccines. Food companies shape diets and consumer environments. Technology platforms influence health information. Energy firms affect environmental exposure. Employers determine working conditions. Insurance companies influence access to care. Corporations can improve health enormously, but they can also create, intensify, or redistribute health risks.

Scholarship on the commercial determinants of health therefore treats corporations as active participants in health governance rather than neutral economic scenery (Kickbusch et al., 2016; Gilmore et al., 2023). The interesting question is not whether profit is inherently immoral. It is what society permits profit to override.

That leads to an important distinction between legal responsibility and ethical responsibility. A company may legally sell a harmful product. A government may legally design a policy with deeply unequal consequences. A wealthy country may legally purchase much of the early supply of a scarce medicine. “We followed the rules” may be factually correct, but it does not necessarily answer whether the rules themselves were just.

Sometimes the most important political question is not Who broke the rules?

It is Who wrote them?

Responsibility also requires more than technically competent decision-making. Powerful institutions have often assumed that responsibility means knowing what is best for other people. That can reproduce hierarchy rather than dismantle it. Communities possess knowledge institutions need: knowledge about trust, language, culture, transportation, family structures, local history, political dynamics, and whether an intervention is actually likely to work.

Meaningful participation therefore cannot mean inviting people to a meeting after the major decisions have already been made. Otherwise, “community engagement” becomes a polished way of saying, We already decided.

Real participation redistributes some authority.

This brings us to accountability, perhaps the most practical concept in the chapter. When an actor possesses power over a health outcome, we should ask what that actor can control, what obligations follow from that control, and what happens when those obligations are ignored.

That final question matters because a right without accountability can become an aspiration. A corporate promise without accountability can become marketing. An international commitment without accountability can become conference language. A government target without accountability can become a PDF.

Lovely PDF.

Still no nurses.

Accountability is where values become institutions.

At this point, the scale of global health can understandably feel overwhelming. History matters. Economics matters. Corporations matter. Governments matter. Climate matters. Apparently the forest has entered the syllabus too. A student might reasonably conclude that they are personally expected to restructure global pharmaceutical markets before Thursday.

Good news: no.

The purpose of structural analysis is not to make individuals responsible for everything. It is almost the opposite. Structural analysis helps us identify which level of action actually matches the problem.

Individuals can organize, vote where political systems permit it, challenge misinformation, work in health professions, conduct research, advocate, support community organizations, and help build better institutions. But individual action becomes most powerful when it targets systems capable of producing structural change.

The point is not: You are responsible for everything.

The point is: Stop asking individuals to solve problems that institutions were built to solve.

And this is where the chapter becomes more hopeful.

Global Studies can occasionally make humanity look like a group project where half the members did not read the instructions. Fair enough. But this chapter has also shown what happens when people successfully change systems. Smallpox was eradicated. Sanitation transformed urban health. Vaccination changed childhood survival. HIV activists reshaped research priorities and drug-access politics. Governments created universal health systems. Communities forced institutions to listen. International collaboration has repeatedly mobilized scientists, health workers, governments, and ordinary people across national borders.

None of those changes occurred because humanity suddenly became perfect. They happened because laws changed, budgets changed, infrastructure changed, knowledge changed, institutions changed, and expectations changed.

That matters because it tells us something fundamental about inequality. If health outcomes change when institutions change, then inequality is not simply something societies have to describe or endure.

It is something they can contest.

Return, then, to where this chapter began. WHO's 2025 report described a global difference in average life expectancy of roughly 33 years between countries at opposite ends of the distribution (WHO, 2025a).

We could memorize the statistic, put it on an exam, circle the correct answer, and move on.

But statistics become intellectually useful only when they make us curious about what produced them.

Behind a life-expectancy number are water systems, vaccines, wars, wages, roads, hospitals, food, pollution, medicine prices, education systems, discrimination, care, public budgets, and political decisions.

A health statistic is often a compressed history of a society.

So who gets to be healthy?

People whose environments protect them. People whose governments invest in functioning systems. People whose workplaces do not routinely expose them to danger. People whose medicines exist and are accessible. People whose communities possess political voice. And, uncomfortably, people who happen to be born into systems that make survival easier.

That last one should bother us, because birth is not an achievement.

A child did not earn clean water, and another child did not fail to earn it. A newborn did not choose a health system. A pregnant woman did not design the road to the hospital. A worker did not write the occupational-safety law. A patient did not negotiate the pharmaceutical patent.

This is why health inequality becomes a question of justice. Not every health difference is necessarily unfair, but many are avoidable, patterned, and connected to distributions of power that people did not choose.

And that brings us to the final Global Studies move.

When confronted with suffering, begin by asking what happened. Then ask why it happened more often to some people than others. Push farther: What system produced the pattern? Who benefits from it? Who bears its costs? Who has the power to change it? What would justice require?

That last question is the one worth keeping.

Because studying global problems without asking what should change risks turning other people's suffering into interesting course material. The goal is not simply to know more.

It is to see more clearly.

A virus is microscopic. A hospital is local. A government has borders. A corporation has shareholders. A climate has none of those things.

And somehow a human body sits at the intersection of all of them.

That is global health.

The body is where enormous systems eventually become personal.

Trade becomes diet. Policy becomes medicine. Pollution becomes breath. Labor becomes injury. Housing becomes exposure. History becomes risk. Inequality becomes life expectancy.

And sometimes justice becomes survival.

So the next time you encounter a statistic about maternal mortality, vaccination, cancer, hunger, extreme heat, tuberculosis, or life expectancy, do not stop at How many?

Ask why them. Ask why there. Ask who decided. Ask who could have prevented it.

And then ask the question that turns information into responsibility: Now that we know, what are we going to do with that knowledge? Because health is never only a story about who becomes sick. It is a story about the kind of world we have built, and the kind we are willing to build next.