The authors offer a mechanism under the aegis of the United Nations for more efficiently, effectively, and substantially allocating global health development aid. They note analogies to global carbon permit markets. I have summarised these using the DPSIR framework:

For carbon, lifestyle is the Driver for material consumption, which puts Pressure on the State of environmental carbon dioxide, which in turn has an Impact on physical ecosystems. The Response is to cap and trade as much carbon dioxide production as possible. As a corollary, the MDGs are the Driver for health care, which puts Pressure on the State of DALYs, which in turn has the Impact that ‘donor countries can benefit substantially’. The proposed response is to cap and trade a limited portion of human suffering.

The paper’s analogy fails somewhat in its ethical conviction: Whereas carbon production is directly related to greed (the responsbility for damaging global commons is direct, and free-loading is absolutely wrong), averting DALYs is related to methodology (there is no responsibility for global health inequity, only for imbalanced and inefficient global inputs; free-loading is a relative misdirection).

However, the mechanism which the paper suggests might link health expenditure in over-developed countries to that in developing countries is breath-takingly radical (and I endorse its principles): essentially, it taxes inequitable domestic health spending using globally relevant indicators (what the paper calls ‘compensation for inefficient domestic allocations’).

But the paper only argues for enforcement of methodological excellence in the context of marginally increased global contributions.Why stop at the MDGs? (From the paper’s figures, I calculate that if the USA paid its way to achieving the MDGs under the mechanism, it would still spend 222 times more on domestic health expenditure.) I project that over-developed countries will not take kindly to this proposal, being unwilling to accept the possibility that they are causal to global ill-health through the perpetuation of various forms of global inequity which preferentially benefit themselves. MDGs are only the thin end of a wedge for which such a ‘compensation’ scheme could operate. Furthermore, I hypothesise that doctors and others who have internalised highly inequitable global health systems, actually tend to perpetuate them. (Note for example, the successful pressure from China’s medical elite to ban the training of new ‘bare foot doctors’ despite so few being themselves willing to work in China’s many very poor and remote areas; or the self-justifying encouragement over the years of some of Britain’s health-related Royal Colleges to the development of highly specialist postgraduate training in developing countries, instead of supporting basic primary health initiatives; or globally distorted health research and drug development priorities).

In conclusion, richer country politicians and professionals will not even want to start down this road, for fear of legitimising the argument that inequitable domestic health spending worsens global DALYs. Doing it for MDGs will actually be an admission of much wider culpability: for unfairly causing many of the world’s DALYs (i.e. hurting people) in the first place. Indeed, the MDGs may be missed not simply because of a lack of US$45 billion, but because of underlying, negligently (or even deliberately) perpetuated inequities.