Poverty and Inequality

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All people have an equal right to health and health care. That contemporary societies have large health variations is readily apparent (Carroll & Davey Smith, 1997; Wilkinson, 1996). Of major signi"cance in both developed and developing societies is poverty. In pursuit of health-for-all, the health care system must strive to equalize the opportunities of all members of society. This principle requires psychologists to provide their services (whenever possible) to all people regardless of gender, age, religion, ethnic grouping, social class, material circumstances, political af"liation, or sexual orientation. When access is low, or when there is evidence of greater needs, special efforts should be made to target services to those with the poorest access or greatest need (e.g., refugees, the homeless, lower income groups). Policy decisions concerning the allocation of resources to these needy groups both inside and outside of the health care system are about ethics as much as politics.

Economics

The demand for health care exceeds supply. This fact has economic implications for services. First, it is necessary to provide services according to the health needs of all client groups. Second, it is necessary to analyze health care economically. This means that cost-bene"t analyses and evidence of cost-effectiveness should be utilized in making decisions about services. It is likely that some psychological interventions are able to provide more cost-effective options than pharmacological and medical treatments (Sobell, 1995). However, the evidence to provide de"nite support of this claim is often not available. If psychological interventions are to be more widely employed, it is necessary that more effort and resources be devoted to economic analyses of their cost-effectiveness. Third, whether we like it or not, health services have to be rationed. Unless we accept the philosophy that those who receive a service are those who can afford it (or the insurance premiums), the decision about who receives or does not receive a service is both political and ethical in nature. In many countries, psychology services are in short supply and among the least accessible and most rationed. Yet rationing is rarely discussed in the psychology literature.

New Technologies

New scienti"c and medical technologies are having dramatic effects on the cost-effectiveness, ef"ciency, and competence of health care (e.g., microsurgery, organ transplantation, genetic testing/screening, gene therapy, in vitro fertilization). Genetic information and its communication to individuals and families are sensitive issues that have both psychological and ethical implications (Lerman, 1997). Following the production of a sheep clone, »DollyZ (Wilmut, Schnieke, McWhir, Kind, & Campbell, 1997), the cloning of humans is likely soon to become technically possible. In spite of reassurances from a professor of fertility studies (Winston, 1997), this prospect raises profound ethical questions among health professionals, patients, and families (Human Genetics Commission, 2000).

There may be biological, psychosocial, or moral implications that have not yet been adequately conceptualized.

Not only do new technologies increase the need for public understanding and debate, they require medical scientists and health professionals to be completely open and honest about the bene"ts, risks, and possible sequelae of treatments and procedures. Communication, counseling, and informed consent are becoming increasingly vital elements of health care (Marteau & Richards, 1996). However, it is recognized that providing people with genetic information on risk may not increase their motivation to change behavior and in some cases may even decrease their motivation (Marteau & Lerman, 2001). In these areas, psychologists should play a major role.

The Aging Population

Demographic data show that the Western population is aging. In Europe in January 1993, there were 117 million people aged 50 years and over (32%) and nearly 75 million aged 60 and over (20%) in the 15 countries of the European Union. The latter will increase to over 25% by the year 2020. In terms of health policy, the most signi"cant increase is in the numbers of people who are 80 years or more, particularly women, large numbers (48%) of whom live alone, especially in northern Europe (Walker & Maltby, 1997).

An increasingly prevalent combination of frailty, poverty, and social isolation is making older age a time of signi"cantly reduced quality of life. This is particularly true for the increasing numbers of people suffering from Alzheimer's disease, or other forms of dementia, and their informal caregivers (European Alzheimer Clearing House, 1997). A report from the Eurobarometer surveys suggests that poverty, age discrimination, fear of crime, and access to health and social care are signi"cant barriers to social integration among older people (Walker & Maltby, 1997). On the more positive side, the surveys suggest that, 'Just under one-quarter of older people were very satis"ed with their lives, more than half fairly satis-"ed and only one in "ve not satis"edZ (p. 122). Promotion of social integration of older people, particularly those living alone, presents a major challenge for the future. Health psychologists will need to work closely with other professionals to "nd new ways of enhancing social integration and well-being of older members of the population and their caregivers.

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