Annual Report of the Director 1996

Although there may well be modern versions of the concept of a good that might be at variance with Aristotle's, the view that health may be found among the goods to be created and nurtured by associations clearly remains as one of our working hypotheses. Moreover, health itself may lead to the formation of associations in particular spaces that, in turn, contribute to other equally desirable goods.

My 1995 report was entitled In Search of Equity, and this quest continues to be a major thrust of our work. I intend to keep before us always the importance of equity and the pan-American approach to solving the major health problems of the Americas.

There is no equality of health opportunity in our countries. I say this with no intention to judge; rather, I want to emphasize the necessity for defining where the inequities lie as a first step towards correcting them. National averages, which are the standard way of reporting health data in regional publications, hide differentials within countries. Furthermore, some of the techniques that are being elaborated to describe the burden of disease, which is a prerequisite for directing interventions, fail to discriminate spatially and make it difficult to address inequities within countries.

In 1996, we have pursued methodological advances that would allow us to more clearly show differences among and within countries. This work will proceed hand in hand with our technical cooperation directed at enhancing the countries' capabilities to collect and analyze their basic health data. We continue to improve the nature and quality of our basic health indicators, because we view them as being absolutely necessary for health planning.

The inequalities in health that may indeed be inequities are not the only measure of social differentials. The economic differential in the Americas is a constant cause of concern. And, since we know that this differential is closely related to gradients in health status, it becomes an issue of importance to all sectors. Through associations it may be possible not only to decrease poverty, but also to decrease inequities.

The formation of associations for health has a long history. Take, for example, the "Health of Towns Association" that was formed about 150 years ago in an effort to reverse the deterioration of the public's health that was the consequence of England's Industrial Revolution. It is from that association of residents that much of the sanitary focus of public health sprang, leading to the many important advances in health that preceded the availability of specific cures for disease.

Today, the formation of associations for health finds expression in such efforts as the European "Healthy Cities" movement and, in the Americas, the "healthy municipalities" movement. These efforts concentrate on geographically and politically determined spaces that can focus on health. In this Region, the concept of a space that can be "healthy" also has been extended to schools, workplaces, and even the home. PAHO has promoted the formation of these healthy spaces in the belief that it is in their midst that the basic principles and tenets of health promotion can find concrete expression. Our experience in the Americas has been gratifying, as we have seen community after community transform its external environment, showing one of the first areas where the impact of community action can be demonstrated. This often has been followed by other activities that have led to improvements in health status and a swelling collective pride in being healthy. The chapters that follow include highlights of the Organization's technical cooperation with the countries in this regard.

But my interest in promoting the creation of healthy spaces goes beyond the possibility of developing an environment in which good individual health can flourish. I believe that these spaces present us with a unique opportunity to form or preserve social capital.

The concept of capital--the stock of productive resources held by organizations or individuals--is as it always was, but now it is being appreciated that there are other important resources besides traditional ones. Serageldin and his colleagues at the World Bank, for instance, have applied the concept of capital to various inputs into the wealth of nations. Social capital has been added to the natural, produced, and human capital that have hitherto been considered as the bases for the production of a nation's wealth.

The strict definition of social capital has varied somewhat, as can be expected in a concept that is barely 20 years old. However, its essential features continue to be the relationships between people and groups, which may be formal or informal. The social cohesion that emerges from these relationships is what forms the driving force for various aspects of social action. It is important to recognize that these social relationships have externalities (we usually only consider the positive ones). Because these externalities cannot be directly related to or appropriated by a single individual or agent, there is a tendency to underinvest in this kind of capital. Given its importance, however, it is essential that the State and other actors, external and internal, provide support to build and maintain it.

Social capital will affect health in several ways. For one, it has been shown that social capital has a positive effect on economic growth: if human capital and social capital are combined, they contribute between 36% and 67% of a nation's wealth, the higher the level of development of a country, the higher the percentage. Social capital likely will help to enhance equity in the same way that human capital formation, through education, may accomplish this end. Empirical evidence already exists to show the positive effect of social capital on education, and I would deduce that this would also have an impact on health.

I propose that social capital formation in various places not only will improve health in those places, but that coordination and cooperation for purposes of health would, in and of themselves, favor the interrelationships and social cohesion that are essential for the formation of social capital. We already have experienced this as we have seen health concerns stimulate dialogue and exchange in situations of conflict: witness the situation in Central America, where health was actually described as a "bridge for peace."

However, social capital is known to be fragile, and if destroyed, it often leaves crime, environmental degradation, and violence in its wake. In the face of such social pathology weighing upon the individual's and the community's health, the health sector cannot look the other way.

The fact that social capital encompasses relationships among institutions, not only among individuals, gives PAHO an added reason to enlist the work of other actors in civil society on behalf of health. Their interaction not only helps to create social capital, but it also contributes to enhance health locally. Although the perception of social capital and the quantification of its impact on various human development aspects are relatively new, it already is becoming clear that social capital and various other similar kinds of capital are not only important in themselves, but they also potentiate the effects of other forms of capital investment. Thus, social capital formation will enhance the production of human capital, ultimately benefiting health.

Merely participating in an activity is not sufficient to create social capital; participants must also bond and appreciate their interdependence. Moreover, acts that are essentially and purely individual, neither create nor depend on social capital. Humans are born alone, to a certain extent they ail alone, and they certainly die alone. But the health we aim for is not produced alone, and the integrity of the spaces in which it is developed and maintained depends, in large measure, on the social capital we are capable of creating.

One part of our charge mandates us to seek, at the regional level, the associations of which Aristotle wrote, thus stimulating the kind of pan­american interaction and association that will produce the good that is health. At the national level, we are committed to promote the efforts to enhance social cohesion through and for health. This is one way in which we will reduce the inequities that we are learning to measure.

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