Advancing the people's health
The Director's Message
from the Annual Report of the Director - 2000
I have fond memories of a lovely inn in Dublin where my wife
and I stayed as the guests of the Royal College of Physicians of
Ireland. We came down to breakfast one morning and were regaled
by a fellow guest with stories of great Irish academics. We
were told of a professor of Classics who, when accosted by some
lesser mortal and being asked if he taught Greek, replied
haughtily, "I do not teach Greek. I profess Greek. I advance
Greek and the knowledge of all that it stands for." It is in that vein that I
will address the issue of advancing the people's health. There will be the dual
approach of "professing" health in the sense of examining what must be
done to carry forward or advance the cause of health and the knowledge of
all that it stands for. In addition, I will refer to the more traditional aspect
of examining the advances or improvements in the people's health, what
they signify, and what must be done to see that such improvements are
maintained or accelerated.
Any consideration I make about the need for advancing the cause of
health must begin with an appreciation or conceptualization of health and
what it means to society. I admit that this sort of discussion or debate is
likely to have a philosophical or ethical bent, but I have always maintained
that all health workers, particularly those of us who work in or guide international
or national institutions, must have some sense of the philosophical
underpinnings of our work. I also believe that our ability to advance
the cause of health must be grounded in developing sound advocacy
skills, so we can ensure that health issues are included when major policy
issues are debated.
Without a doubt, "we the people" care about health. The largest public
opinion survey in the world, the one undertaken by Gallup International
in 1999 for the Millennium Report of the Secretary General of the United
Nations, showed that good health and family life ranked first among the
things that people valuedfar outranking material possessions. It is good
for us and our fellow human beings to be healthy, but we are still a long
way away from universal acceptance of the notion that health is an essential
public good that needs appropriate policy focus. Much of the attention
to health still turns around a concern for the nature of the transactions
that take place between individuals and the services that provide care.
Kaul and his colleagues 1 have clearly set forth the thesis that the population's
health may be cast as a public good. In reviewing the notion of
public goods, they characterize them as having two main featuresthey
are "nonrivalrous in consumption and nonexcludable." To explain this,
they use the analogy of traffic light systems, which can be relied on by all
to the benefit of all and to the detriment of no one; they need to be used
by everyone, and their use cannot be restricted to a few.
Population health is similar, in that the health of the population benefits
all and, under most conditions, no one can really be excluded. In considering health as a public good, attention has quite rightly been placed on
communicable diseases and the need for their surveillance, which has itself
been framed as a public good. I would agree with Kaul and his colleagues
that the state of health, in itself, should fall into this category, and indeed
much more consideration is being given now to the relationship of the health
of populations in distant countries to the security and prosperity of others
far away. Health was a public good long before we "discovered" globalization,
but now it has been raised to the state of a global public good, and the
communication that is so much a part of globalization has strengthened that
perception.
The notion of a public good, or of any other good, always raises the question
of how to quantify the nature of the benefit. The measurement of health
status has bedeviled us constantly, which is attested to by the number and
variety of approaches that have been tried, from simply counting final common
eventsdeaths to relying on extremely complicated indicators. In discussions
about measuring phenomena or states that are as multidimensional
as is health, I am always reminded of Bentham's "felicific calculus," which
he would use in measuring the net happiness that resulted from various actions
by the State.
But, regardless of any difficulties with measurement (and I will refer to
this again later), the need to advocate for or advance the concern for the
public's health is based on two concepts that are important for our work.
First, we hold that assuring the necessary means for persons to enjoy the optimum
state of health is a matter of social justice, such as was enshrined in
the concept and practice of Health for All. Health institutions such as ours, which must be qualified as social, have to be concerned with matters of
justice. It is for this reason that I have insisted on making equity one of
our essential value principles. We have discussed this extensively here at
PAHO, and I believe that everyone in the Organization now understands
the concept as referring to the distribution or allocation of the means necessary
to ensure health in a fair manner. The differences or disparities that
may be described as representing inequity must be nonvolitional and
avoidable, in addition to there being some identifiable responsible agent.
Equity in health is not restricted to care services.
Daniels and his colleagues 2 have written cogently on the thesis that justice
is, indeed, good for health, and base much of their reasoning on
Rawls's philosophy.3 My introduction to this field came almost 20 years
ago, from reading Campbell's 4 excellent analysis of Rawls's theory of justice
as it applied to health. He added two other principles besides equity
that should be considered in the context of justice. First there was liberty,
in the sense that the provision of health care should enhance liberty "by
ensuring equal access to available health services within a given society,
irrespective of income, social status or political allegiance." The second
was fraternity, in that all society members "should be regarded as
providers of health care and should be given responsibility for assessing
the effectiveness of existing provisions and for formulating policies for the
improvement of local and national services." I would consider these last
two as not being in the same scale as or as important as equity, and I
would extend the reasoning beyond health care to include the other factors that contribute to health and that are even referred to as determinants
of the healthy state.
The concept of liberty is very much related to the need for personal autonomy
in health, a need that has been expressed by many and perhaps
most vocally by Illich 5 almost 25 years ago. Illich's claims that the medical
or health industry was to be reined in, if not abolished, because it reduced
personal autonomy or a person's capacity to care for health were
exaggerated, but the notion of personal autonomy in health is still very
relevant. An important aspect of autonomy deals with the allocation of resources
to specific groups that are disadvantaged and for whom improving
their health will contribute toward enhancing their autonomy. These
groups certainly include the poor, children, the mentally handicapped,
and the elderly who live without family support. Much of the call for attention
to the improvement of health as a mechanism for relieving poverty
turns around the recognition that poverty is not only determined by income,
but also is related to a complex web of factors that essentially reduce
the capability and autonomy of persons.
The concept of fraternity is becoming ever more relevant as the clamor
increases for there to be some societal mechanism that determines the allocation
of resources to health, not only in terms of quantity but also in terms
of technology and geographical distribution. It was this ideal of fraternity
that lay behind the call for community participation that was so much a
part of Primary Health Care. We cannot have fraternity of the type envisioned
by Rousseau, with every citizen participating in decisionmaking.
But there is a real fear that the current mechanisms through which the ple make their wishes known is essentially flawed, and that in fact, the ones
actually making the decisions on resource allocation are the powerful and
vocal interests. The secret may well lie in an equation that is being accepted
more and more in the processes of health sector reform: some powers must
remain centralized to facilitate the steering role of the State and ensure
equity, while others should be decentralized to ensure fraternity.
There is an obvious tension between the need for justice in providing
necessary resources equitably to assure health and an acceptance of distances
or gaps between persons or groups in terms of social attributes.
This is another reason why we have insisted so firmly that the process of
health sector reform in our part of the world should encompass, as a fundamental
principle, the notion of a guiding or steering role for the State,
as exercised through the ministry of health. Because the State is the only
instance that can ensure that the measures necessary for health are equitably
provided, our technical cooperation continues to emphasize the need
for countries to develop the tools to carry out this steering function.
Although I might wish that the attention to considerations of justice
would suffice to guarantee advances in the attention to the public's health,
I know that this is not so. It is essential that we show some instrumental
value of health in that it contributes to other needs or values that humans
hold dear. The area in which there is most current interest is the relation
between health and wealth. It has been known for centuries that the poor
are less healthy than the rich, although the economic historian Fogel 6 has
drawn our attention to an interesting phenomenon that he calls the "peerage
paradox." Until the beginning of the eighteenth century, English ants and peers had similar life expectancies. This was perhaps due to the
remarkable alcohol consumption and poor diet of noble ladies, and the
fact that the nobles were not quite able to distance themselves from the
unfavorable environmental conditions that were the main determining
factors for the health of rich and poor alike.
Recent data are clear, however, in demonstrating that at the individual
as well as at the national level, wealthier is healthier. What has not been
so clear is that health plays a significant role in the accumulation of national
wealth. It must be intuitively obvious that, provided there is opportunity
to work, the healthier individual will produce more. Strauss and
Thomas 7 have reviewed good evidence that individuals who are healthier,
as shown by anthropometric measures, earn more. In addition, there are
several studies showing the positive effect of disease elimination or reduction
on a nation's wealth.
More recently, PASB has been supporting macroeconomic studies that
show a clear causal relationship between health measures such as life expectancy
and the future economic growth of countries. The mechanisms
by which health should enhance wealth at the macro level are not clear
and therefore need further research. One possibility is that investing in
health permits greater returns from such investments as education. Investments
in health and longer life expectancy may also increase the tendency
to save and, therefore, contribute to increased economic growth. In
terms of advocacy for the people's health, there is no doubt that the experts
on economic growth who formerly thought of matters relating to
health as being exogenous to their models are having to entertain the sibility that health is endogenous. This is one area of inquiry that will require
the active collaboration by health professionals with persons from
other disciplines.
The possibility that the population's state of health may be instrumental
in contributing to social stability and solidarity is attractive, but as yet
lacks the necessary empirical data to confirm it. In a similar vein, it is
plausible to hypothesize that inequality in health status in addition to absolute
status may contribute to the impairment of the social capital necessary
for optimal societal functioning.
The data and the descriptions of programs found in the body of this report
follow the more traditional approaches of describing the advances
made in the people's health. They show changes in traditional health indicators
used to measure health status and refer to the way in which various
factors, including such ones as natural disasters, influence health.
Most measures that are used relate to the health of groups of persons, and
considerable attention is given to our technical cooperation in assisting
countries to collect their data in such a manner that this information can
be disaggregated to show the disparities that exist. More and more emphasis
is being placed on measures of distribution in addition to averages.
These are the first steps towards identifying the disparities that may be
characterized as inequities.
Little attention has been paid to individual health status. This is a reflection
of the traditional tenet of public health, which holds that attention
should be paid to the health of populations rather than to that of individuals.
The health of individuals is held to be the concern of the personal health care system. I have long held, however, that this is not in
keeping with the view that the public, to whose health we are committed,
is comprised of individuals, and that those social institutions that concern
themselves with improving the public's health must at least also take note
of the measures employed to care for the health of individuals. First, there
is the obvious ethical reason for being concerned with the health of individuals,
for it is individuals who become illas C.P. Snow 8 wrote, "each
of us dies alone." And there are other reasons, too. For example, in spite
of claims that medical interventions have played only a small part in the
overall improvement of the health of populations, evidence shows that this
is not entirely true. Medical interventions at the individual level, as in the
case of antibiotic therapy for various illnesses, have had a role in improving
the population's health. Moreover, the steady increase in expenditure
on health that has repercussions on the availability of resources in the
health sector as a whole is related to the individuals' clamor for new technology.
It is the aspirational demands of individuals for technology
cloaked as needs that usually drive expenditure. These issues have to involve
all those interested in advancing the people's health.
While we concern ourselves with the benefits to society from improving
the aggregate of health in the country, we pay little attention to devising
tools to measure the benefits of curing illness, restoring health, or rehabilitating
the ill. As distinguished American physician Walsh McDermott 9 explained
some time ago, we have no measures for assessing the value of individual
care medicine such as we have for assessing the value of population
health. This is a challenge that must be taken up by those of us who are terested in advancing the people's health both from the individual and group level.
Several approaches have been suggested for measuring individual
health, perhaps the most common being the individual's selfassessment of
illness, or some proxy measure such as days of absence from work. The latter
is clearly of limited value in societies in which a high percentage of
work takes place in the informal sector. This is the case in Latin America
and the Caribbean, where up to 50% of workers in a country may be in
the informal sector or may have irregular work because of the high level
of unemployment. Self-assessment has its problems, too, as there may be
wide cultural variations in the appreciation of what constitutes ill health.
The poor in less developed countries have a much higher threshold for self-reporting
of ill health, given the serious economic consequences of lost
work as a result of sickness. The frequency of symptomatology will also affect
the reporting if almost every child has a nasal discharge, this symptom
may be regarded as the norm, rather than as an indication of illness.
In the final analysis it will be the countries themselves that will be the
principal actors in advancing the people's health. The efforts in the countries
will be the result of action by all the social partners, but this is not
the place to elaborate on the relative roles of these partners. Our only
premise is that whatever the mix of partners, it will be the State, as the expression
of popular will, that will have the ultimate responsibility for the
determinants that fall outside the range of those related to individual behavior
or biological determination. Even in the case of individual behavior
the State has a role, the classical example being tobacco use, where the State's role in preventing exposure is clear. Many determinants that were
thought previously to be immutable because of biology are now known to
be the result of nutritional or other social influence in early life, and as
such may well fall under the purview of the State.
But having said that some responsibility lies with the State, I must emphasize
that I am uncomfortable with the common assertion that many
failures in the application of the technologies that are of proven usefulness
are due to lack of political will. I am increasingly convinced that this is a
new vein of rhetoric that national and international technical advisors
have found and that allows them to evade or renege on their responsibilities.
It is true that the political process involved in making decisions in relation
to health sometimes seems strange, but I have never found that
these decisions are based on some deliberate or devious assault on the people's
health. The unfortunate truth is that many of us have not taken the
trouble to understand the nature of political decision-making. In addition,
once we have laid blame on "the lack of political will," there is little incentive
to put forward good solutions with alternatives that can satisfy the
acid test of being financially practicable, technically sound, socially acceptable,
and politically feasible.
It is not given to many to participate in so noble an effort as advancing
the people's health. It is a trust that we at PAHO hold sacred and we have
committed ourselves to the proper use of all the resources entrusted to us
to that end. It is for this reason that no report is complete without some
statement of the manner in which our resources are applied.
To those of us who are intimately involved in and committed to the efforts
to advance the people's health, progress sometimes seems painfully
slow. But we forge ahead, correcting the correctable with the instruments
that we know do work, seeking and applying appropriately the new technology
that will undoubtedly appear, and using every possible means to
reduce the disparities so that there is more of a common front to the advance.
And we must take comfort in the knowledge that the people's
health is advancing and we are increasingly acquiring the skills and tools
for "professing" health more successfully.
References:
1. Kaul I, Greenberg I, Stern MA. Global public goods. International
cooperation in the 21st Century. New York, Oxford:
Oxford University Press; 1999.
2. Daniels N, Kennedy BP, Kawachi I. Why justice is good for our
health: The social determinants of health inequalities. Daedalus.
Journal of the American Academy of Arts and Sciences; Fall 1999.
3. Rawls J. A theory of justice. Cambridge, Massachusetts: Harvard
University Press; 1971.
4. Campbell AV. Medicine, health and justice. The problem of priorities.
Edinburgh, London and New York: Churchill Livingstone; 1978.
5. Illich I. Medical nemesis. London: Calder Boyars; 1974.
6. Fogel RW. The conquest of high mortality and hunger in Europe and America: Timing and mechanisms: In Hagonnet P, Landers DS, and Rosorsky H, eds. Favorites of fortune: Technology growth and economic development since the Industrial Revolution. Cambridge, Massachusetts: Harvard University Press; 1961.
7.Strauss J, Thomas D. Health, nutrition and economic development. Journal of Economic Literature 1998;36(2):766817.
8. Snow CP. Human care. Journal of the American Medical Association 1973;225:617621.
9. McDermott W. Medicine: The public's good and one's own.
Perspectives in Biology and Medicine 1978;21:167186.
Annual Report of the Director - 2000
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