Presented in the Distinguished Lecturers Series, University of the West Indies, Kingston, Jamaica, 27 March 1995

Mr. Vice Chancellor, Pro Vice Chancellors, distinguished colleagues,ladies, and gentlemen:

It is said that when we are young professionally,we are generalists, in the sense that we have a very limited andsuperficial knowledge about many things. As we grow, we becomespecialists and devote considerable attention to delving into theintricacies and mysteries of a very few specific areas or fields ofknowledge. We may even be faintly damned as experts. Then, as we mature,we revert to something akin to our early generalism, but we apply ouraccrued expertise and specialization techniques to a wider range ofsubjects that tend, in general, to affect more people; better still, webring a wider vision to bear on a few issues that are of fundamentalimportance to many. The challenge lies in walking the fine line betweenbeing a fully developed generalist or remaining forever a dilettante,flitting and dabbling from here to there. So, if I were accused ofdisciplinary deviance for dealing with a topic such as Health andNational Security, I would plead that I have grown and developed and amnow in the third stage of personal development.

I assure you that this growth is ongoing and that none, or very few, ofthe important thought processes or attitudes acquired along the way evergo to waste. And so I tell myself that there is, indeed, a thread thatconnects the approaches involved in constructing Latin prose, plumbingthe mysteries of renal biochemistry, and unraveling the broad issuesthat must be considered if one is to have some idea of how to addressthat most challenging of avocations, the care for the public's health.

I had no sudden epiphany to illuminate my interest in this afternoon'stopic, but recent events in two of the more important Member Countriesof the Pan American Health Organization provided me with food forthought. First, in December, after years of seemingly spectacularstability and economic growth, the Mexican economy seemed to go intofree fall, and its currency suffered ever-increasing devaluations. I amnot an expert in this field, but I was struck by how deeply the rest ofthe world experienced the aftershocks of the crisis, and I came toappreciate the fact that some fundamental aspects of a nation'swell-being were not in its own hands. The national government and itsattendant State apparatus were less and less able to control capitalflows. In fact, international market forces determined the course of thedomestic economy, apparently wresting from the government the controlover one of the traditional ingredients of a nation's security.

Then I read the Canadian Government's response to the recommendations ofthe Special Joint Parliamentary Committee Reviewing its Foreign Policy.The Canadian Government pointed out clearly that there were new rulesfor foreign policy: the threatening but predictable postwar period wasover, and Canada needed to devise a new approach for protecting itssecurity. The country's foreign-policy actions now would be informed bya concept of shared human security, as the world was too interdependentto retain a narrow view of national security. By the same token, thepolicies that other countries adopted in the fields of health and theenvironment also would affect Canadian security. As the Minister ofForeign Affairs said in the House of Commons:

Mr. Speaker, the hostile environment of the Cold War kept us fromconcentrating our efforts on combatting other threats no less real.While the geopolitical upheavals of recent years have greatly reducedthe immediate threats to our security, we must now, paradoxically,expand our definition of this concept. Today, security is no longerdefined in terms of ideologies or boundaries. Environmentaldeterioration; massive, uncontrolled migrations; international crime;drug trafficking; AIDS; overpopulation; and underdevelopment are thenames of today's threats. Our security requires a deeper awareness ofthem.

As you can see, these events caused me to reflect again on this changingperception of national security and the changing view of health in ourworld today.

There were, of course, simpler times and concepts. When NicoloMachiavelli wrote of how the strength of all states should be measured,he advised the Prince that, "he will not find it difficult to uphold thecourage of his subjects both at the commencement and during a state ofsiege if he possesses provisions and the means to defend himself."

And although the concept of provisions might have changed, the basicpremise remained intact for centuries. Machiavelli was not far distantfrom the definition of national security that held sway even up torecent times. The Maginot Line and the Berlin Wall are but twomodern-day examples of the thinking of nations in this regard. About 20years ago, an author defined national security as:

. . .the condition of freedom from external physical threat which a nationstate enjoys; and this relative security derived from three conditions: First, the deterrent effect of the state's alliances, next theinternational environment that would deter an aggressor and finally thestate's own intrinsic capacity to resist aggression.

But, with the dramatic changes in the political landscape that occurredin the last five years, the concept of national security also changed,coming very close to the Canadian Government's pronouncement. As RobertReich points out in his book, Work of Nations, in which he describes thegrowing interdependence of individual and commercial interests:

. . .a nation sacrifices a bit of security when it becomes dependent onforeigners for anything. Complete security is equivalent to autarky. Butautarky deprives a nation's citizens of all the advantages of economicinterdependence with the wider world.

The concern with national security is perhaps felt most acutely in smallstates because of their vulnerability, which is particularly true in theCaribbean. Griffith, in his analysis of security in the Caribbean, pointsout that the military, political, and economic dimensions are the mostcritical ones. But perhaps of equal importance is the internal politicalclimate that can affect the national security. Of even greatersignificance is the growing realization that national security dependsin great measure on domestic stability which is in turn heavilyinfluenced by human development embracing economic, environmental,health, and political concerns. This wider view of national security ledGriffith to conceive of it as the protection and preservation ofpeople's freedom from external military attack and coercion, as well asfreedom from internal subversion and from the erosion of cherishedpolitical, economic, and social values.

The importance of these social values has been considered in almostevery high-level political meeting. At the subregional level, theCaribbean Heads of State have emphasized the importance of social issueson several occasions. At the Hemispheric Summit held in Miami last year,the Heads of State also underscored the need for a united approach inaddressing social inequity. Although they were primarily concerned withcommerce and economic development, they also gave special attention tohealth and environmental issues. And the recently concluded GlobalSummit on Social Development—to which I will refer again—focused theworld's attention on the main social problems that are important fornational and global security.

One might attempt to outline here a very crude historical sequencing ofthe various issues that are perceived to affect national security. Earlythinking gave primacy to a nation's ability to resist armed aggression,hence the dependence of states on armies and military readiness. In timecame an appreciation of the importance of domestic freedom and ensuringthat citizens could earn a decent living. More recently, the world haswoken up to the need to preserve the environment and its biologicaldiversity as ingredients of national security. Now, as the scourge ofdrugs has come to the fore, I wish to highlight health as another factorthat is important for that security.

I refer mainly to public health, or the health of the public, althoughmy original discipline will not allow me to ignore completely theproblems of the individual. The historical evolution of concern for thehealth of the public is interesting, as it shows some of the cyclicalphenomena that are almost a part of nature.

In the 1920s, the famous public health physician, C. E. Winslow,described three phases of public health concern and, to some extent,practice. The first phase spanned from 1840 to 1890, and saw theflourishing of empirical sanitation and the appreciation that diseasescould be caused by a wide range of social and environmental conditions.Health was improved by building water and sewerage systems, constructingproper housing, and providing adequate food. In Germany there was aparticularly strong perception of the importance of these nonmedicalfactors in disease causation. The famous pathologist, Virchow, who was amember of a government committee charged with investigating an epidemicof relapsing fever that was rampant in Silesia, recommended as means ofcontrol, "prosperity, education, and liberty which can develop only onthe basis of complete and unrestricted democracy."

But this approach to sanitation was not entirely altruistic. As Welch,who was one of the pioneers of American public health teachingexplained:

. . .merely from a mercenary and commercial point of view it is for theinterest of the community to take care of the health of the poor.Philanthropy assumes a totally different aspect in the eyes of the worldwhen it is able to demonstrate that it pays to keep people healthy. [Inhis eyes,] sanitary improvement was the best way of improving the lot ofthe poor, short of radical restructuring of society.

The second phase, which is placed at the turn of the century, witnessedthe introduction and acceptance of the germ theory of disease and thegrowth of bacteriology: the care of the public's health was viewedprimarily in terms of disinfection and killing germs that might affectindividuals or groups.

The third phase, which Winslow dubbed the new public health in 1923,emphasized personal hygiene and the medicalization of preventive care.Public health authorities in most countries were considered as poorrelations within the overall health establishment family.

But over the last 25 years, the concept of what constitutes caring forthe public's health has been intensely reexamined, the value of thehealth of the people has been reassessed, and a serious effort to teaseout the determinants of that health has been undertaken. This has led toa reaffirmation of many of the principles developed and accepted 150years ago. One might be rash enough to call this flurry of activity, thefourth wave.

The seminal work on these determinants of health came out of the UnitedStates of America and Canada, with the work of Blum and the Lalondereport on the health of the Canadian people being the most widely known.Further amplification by Evans and Stoddart questioned the relationshipbetween health care and health status and showed how the public policydebate that focuses on the former needs to be modified.

The health care system often bears little relationship to the perceivedillness of people, being more related to the perception of the diseaseneeds of individuals by health care providers. As these authors claim:

The knowledge of these care providers derives from the triumph ofscientific modes of inquiry in medicine. [It has] increasingly becomedefined in terms of that which emerges from the application ofreductionist methods of investigation applied to the fullest extentpossible in a Newtonian frame of reference.

Under this approach, the body is viewed as a machine that can be fixedby increasingly sophisticated technology at ever-increasing cost. Thehealth care system very often seeks to draw persons into it to satisfythe interests of the care providers themselves.

I must make it abundantly clear that I believe that there must be roomfor the application of care to those individuals who either have anillness or disease—in the sense of not having "ease"—or to those whoare diagnosed as having disease because of the presence of aconstellation of indicators that show some objectively definablemalfunction. This is the pristine role of the healer and should never beminimalized. Indeed, sound reasons have been given for the thesis thatthe individual care physician makes a significant contribution to thepublic's health, but that the effect and impact have been obscured bythe lack of suitable indicators. Indicators currently in use have beendesigned by those who deal with people in groups.

But the current dominant argument is that, for reasons I will detaillater, the public attention has been riveted on care, driving publicpolicy and expenditure in this direction. And yet, in terms of thepopulation, health care contributes only marginally to health conceivedas the absence of disability and the state of ease, or even in the morelofty terms of well-being.

The determinants of health include the physical and social environmentor ecology; biology, which includes genetic endowment; individual andcollective behavior; and health care, which is the least important.This search for the principal determinants of health status is not someabstruse, recondite philosophical enterprise. It is fundamental to thenational understanding of how a large part of social policy isstructured.

These broad determinants of health status are being examined further,and one of the more fascinating enquiries relates to social status andhealth. It has been known from time immemorial that there is somerelationship between health and wealth. Now it is clear that there is amarked social class gradient in relation to health outcomes, and thatthis social gradient persists in population groups followedlongitudinally, even though the causes of ill health and death may vary.It is simplistic to say that poverty causes ill health and that anattack on poverty would banish most of it. Eliminating poverty is amoral and economic imperative; it is necessary but not sufficientin terms of eliminating the health manifestations of the social classdifferential.

The gradient for health outcomes shows up clearly even in strata thatare higher than those that would, by any stretch of imagination, becalled poor. It is all the more fascinating to appreciate that thissocial gradient may have expressions in biological responses that couldthemselves be health promoting or disease provoking. The universalfinding that, in the context of the health/wealth relationship, thehealth of the population depends not so much on the average income buton the equality of income distribution in a country, is relevant to apoint I will later make.

I cannot go into detail here on the mounting evidence of the impact ofthe other determinants on health status. I believe you will accept thatthe physical environment is important. The social environment is alsocrucial, and the domestic and family support systems are obviouscontributors to health. You will be pleased to know, if you did notalready, that marriage is good for a man's health! It is not so clearthat it is so for women!

Having outlined some of the elements of national security and brieflysketched out some of the current thinking of what determines the stateof the nation's health, let me try to establish the linkage between thetwo. First, the health of the population as a resource is essential forthe domestic stability of the nation. Most obviously, a healthypopulation represents the human capital necessary for productivity. Inany discussion of the human resources required for progress, health andeducation stand out as the two most important elements.

There was a time when the benefits of investing in education werequantified in economic terms, but the arguments for investing in healthwere cast as moral and ethical issues. There is now a growing body ofempirical evidence that shows the economic return from improving health.In a seminal study on investing in human resources conducted for theInter-American Development Bank, Behrman demonstrates that suchinvestment can improve productivity and income distribution. Especiallyin poor countries, the economic gains from investing in health andnutrition may well be greater than those from investing in education.Let me quote directly from his paper:

Although schooling is the most emphasized human resource, lifeexpectancy is a better indicator of economic growth. The estimate meansthat, all things being equal, the recent gap between Jamaican andBolivian life expectancy relative to the international experience willbe associated with a difference in future real GNP per capita growthrates of 2.4 percent per year, a considerable effect.

Life expectancy was used to characterize the health and nutritionexperience. Behrman goes on to point out, however, that a country'sepidemiological situation will determine where the investment must bemade. It is now standard dogma that public investment should targetareas with higher social benefits, and that those health interventionswith the highest positive externality content should be the onesprovided by the State. These include most of the activities of healthpromotion and disease prevention.

If governments accept that domestic stability is a matter of nationalsecurity and that economic health is one determinant of that stability;if they accept the logic of the economic returns from healthinvestments; and if there is no evidence to refute the demonstratedrelative importance of the determinants of the population's health, thenone can logically ask why governments continue to place resourcespredominantly in health care. Ministries of Health still concernthemselves primarily with the care of the individual.

The answer is complex and I will touch on only two of its aspects.First, health, as such, does not rank high on the public agenda.National governments that, quite properly, are the result of a politicalprocess, react to the popular agenda, and this agenda does not perceivethe health of the public as a positive resource for its living. It seeshealth primarily through the eyes of traditional care givers, who forthe most part are wedded to the mechanical model of care and repair.Contemporary social forces, including the media, react to the perceiveddeficiencies in individual care, and are often supported by havinginfluential persons "wave the shroud." This phenomenon paintsgovernments as hardhearted villains if they do not provide one or otherfacility that will prevent individuals from dying unnecessarily orprematurely.

The second and thornier aspect is that the discussion about investmentin care often centers on the perception that it is the salaries ofhealth professionals that drive expenditure in care. This introducesclass arguments that are seldom helpful in trying to fashion logicalnational policy.

There is one other facet of health expenditure and national securitythat is of increasing importance to all countries. As the cost of thehealth establishment rises, we see much of the debate in the UnitedStates of America, Canada, and other OECD countries framed in terms ofthe increasing fraction of the national wealth that is being spent onhealth care. For example, the data for the United States show anexpenditure of 14% of GNP and rising. Most countries now accept thatthey cannot sustain increases in health care expenditure that risefaster than the rate of inflation. The consequences of this over thelong term for the national economy and internal stability are obvious.

I will end this section by referring to one aspect of national healththat is important for national wealth. Travel is one of the world'sfastest growing businesses, and tourism has become vital for theeconomic survival of many countries. There is now very good evidencethat the health both in physical and environmental terms of the peopleand their place is a major factor in drawing visitors to a particularspot. We have examples of epidemics or fear of epidemics that havedevastated the economies of tourist areas.

Many countries have been riven and rendered insecure by the ill health,poverty, poor environmental conditions and general socialmarginalization of large segments of their people. The specter of thesefour grim, galloping horsemen frightens the rulers of many ofthe countries; the fact that the horsemen ride in unison is an evengreater source of fear. Ill health is linked with poverty, as I havementioned above. And environmental degradation, ill health, and povertyare interwoven. Proof of the vicious circle of poverty and thedestruction of the physical environment comes from every corner of theworld.

History offers us plenty of examples of how ill health can lead to anation's fall—my favorite example is the conquest of the Aztec empireby the Spaniards. As I wrote in an article about the interface of thetwo worlds in the area of health, which I called "Of Measles and Men,"

History showed disease as the fifth column of the Spanish conquest. Itwas germs and not guns which made Tenochtitlan fall before Cortés: inspite of his technological advantage he was on the verge of defeat untila massive epidemic, probably of smallpox, decimated the Aztecs, and heentered a capital city reeking with the stench of death his musketeersand bowmen had not caused.

National security also depends on a state's alliances, on how it treatsand is treated by other states. It is a foreign-policy canon that thesealliances are driven by interests, and health and concerns about healthrepresent one of these mutual-interest areas that bring states together.The history of my own Organization shows that the countries of theAmericas have acted in concert to address common health problems. Jointefforts in disease control have given brilliant results, the most recentof which have been the elimination of smallpox and now the interruptionof transmission of the poliovirus in the Americas. But there is oneexample that comes closer to the popular concept of nationalsecurity—the success of the use of health concerns as a platform forpeace and understanding among peoples. We believe that the HealthInitiative of Central America—which was called "Health, a Bridge forPeace"—was a major factor in reducing tensions and conflict in thattroubled area. The national security of those countries was strengthenedor enhanced by the peace that was, in some measure, favored by thenon-conflictive interactions that took place in the name of health.

I began by referring to Canada's perspective that national security hadto be seen in relation to global security. Futurologists differ aboutthe scenarios that will unfold, a difference that is, of course,intrinsic to their discipline. There is no shortage ofneo-Malthusianism. In 1972, the Club of Rome, as it sought to determinethe conditions that would limit growth, declared itself pessimisticabout mankind's predicament. More recently, Kaplan, in a widely quotedarticle, predicted global decay and a world "riven by disease—withincreased erosion of nation states and international borders."

He predicted a complete collapse of national security. One of thefrightening consequences of such a scenario for developed countries wasthe prospect of hordes of immigrants from the overpopulated, decayingnations pressing upon their borders. Not everyone shares thatapocalyptic view. I believe we can show substantial progress in manyareas such as health, and that many of the models predicting societalcollapse do not take full account of the world's social and humanresources. But this general concern has been strong enough to spur theconvening of the World Summit on Social Development, which met earlierthis month in Copenhagen. It was billed as a summit of hope andcommitment; the words of the opening paragraph of the Declaration setthe tone:

For the first time in history, at the invitation of the United Nations,we gather as Heads of State and government to give social developmentand human well-being the highest priority both now and into the twentyfirst century.

As the debates, discussions and documents showed, the people's healthmust be at the center of that well-being and must be one of its majordeterminants. The attention to health and well-being will be key forensuring the global security that is essential for the security ofmodern states. It is a concern that goes beyond that engineered by theever-present threat of rapid spread of communicable disease from onecountry to another.

I have deliberately not presented the case for health in terms of thebenefits that might accrue to the public if money currently spent onarms as a means of ensuring national security were diverted to thehealth sector. Experience has shown the futility of such arguments. Evenif expenditure on arms were reduced, this money would not necessarily goto health. Swords are turned neither into ploughshares nor scalpels:there is simply not a strong enough public constituency for thisapproach. The evidence that the health sector is not protected whenthere is general reduction of government expenditure would indicate thelevel of indifference to the concept of health as an essential publicgood.

I wish to deal briefly with a question that might still be troublingyou. Why should the Pan American Health Organization be concerned withhealth and national security?

PAHO has a constitutional responsibility to assist the countries of thishemisphere in their efforts to combat disease, lengthen life, and promotethe physical and mental health of the people. We were created out of adesire of the nations of the Americas to try to work together to solveproblems that might be common. When one looks at the mosaic of problemsthat affect the health of our people, one is struck not only by thediseases themselves, but also by the inequalities that exist among andwithin countries. This inequity has its expression in disease burden andin the access to the means to promote health and prevent disease.Inequity in health is only one facet of the inequity in other spheresthat threaten national security.

Over the years, many approaches have been pursued to solve the healthproblems of the Americas, and we can cite several successes. There havebeen various plans and policies and we, like the rest of the world,embraced the great cry for "Health For All" and tried to put in placethe elements of the strategy of primary health care that was seen to bethe most appropriate approach for tackling the basic problems.

In September 1994, at the XXIV Pan American Sanitary Conference thatelected me as Director, the assembled Ministers of Health approved a setof Strategic and Programmatic Orientations that should steer our work.There are five such orientations: Health and Human Development, HealthSystems and Services Development, Health Promotion and Protection,Environmental Health, and Disease Prevention and Control. Our technicalcooperation with our countries will be guided by these orientations andthe countries and the Bureau will monitor what is done over the nextyears. As I said in my inauguration address, we must seek allies in ourefforts to give health its proper place nationally and internationally.

Certain requirements must be met if health is to be recognized asimportant to well-being and if this acknowledgement is to be reflectedin the public agenda. First, we need an informed citizenry. The currentpublic understanding of health is inadequate. We inevitably link healthwith expenditures, when in reality most of the costs in the systeminvolve repair and rehabilitation. I have begun efforts to have Heads ofState dedicate time to discuss health in their Cabinet deliberations, sothat government can be seized of the real importance of health to thebody politic. The Minister of Finance and the Minister of Culture mustunderstand and appreciate their roles in securing the public's health.

Perhaps the allies whose help I need most of all are those in my ownprofession. Paul Starr, in his book on the social transformation ofAmerican medicine, describes the foundation of the authority of themedical profession based on its scientific knowledge and its peculiarrelationship to people in their most naked state. He writes:

The dominance of the medical profession, however, goes beyond thisrational foundation. Its authority spills over its clinical boundariesinto arenas of moral and political action for which medical judgement isonly partially relevant and often incompletely equipped.

I would like to see the profession take the lead in advocating a newvision of health, a vision that is framed in the context of health beinga positive resource, a resource at the very heart of well-being. I wouldlike to see my colleagues promote fearlessly the discussion about thekind of public policy and people involvement that would guide nationalresources into those channels that are most appropriate for promotingand maintaining the public's health. It is a worthy effort—one thatis critical to the preservation of national security.

My Organization and I, personally, will do everything possible tostimulate that debate—part of our technical cooperation must be drivenby these concerns. But apart from being a responsibility of my work, Iget pleasure out of promoting these lines of thinking. Sometimes Ithink, as Shaw says:

This is the true joy of life, the being used for a purpose recognized byyourself as a mighty one; the being thoroughly worn out before you arethrown on the scrap heap; the being a force of nature instead of afeverish selfish little clod of ailments and grievances, complainingthat the world will not devote itself to making you happy.

I wish for all of you the same joy of life and the same prospect ofbeing happy.

I thank you.

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