Like many of you I'm sure, I usually come away from interdisciplinary conferences feeling a mixture of exhaustion and inspiration. This time around was no exception. I feel especially compelled to bring up the topic of universal access to health care- a topic that transpired through many of this year's panels and sessions. We of course are the privileged few in the world who don't have to think twice about medical care- but what about the billions of people who are not so fortunate? What do multilateral policies, development initiatives, and international projects really mean to those living in poverty? What about hidden populations? And what about those who are predisposed to a lower quality of life? Are the social determinants of health really taken into account when designing health and social outreach programs?
So many questions! Questions that mostly bring up even further inquiry. But the fact is that all around the world people from a diversity of disciplines and backgrounds, young people especially, are asking these questions, challenging current paradigms, and holding those in charge of our systems of governance accountable. That was the main message I took home after two days of debate and discussion at the SUNSIH/REGSA/SIHA 1st annual Western Conference.
Are you passionate about global health? Do you have answers to these questions?
Send us your thoughts and project ideas at general@sunsih.ca.
Before signing off I wanted to share an article with you that I came across about a month ago. I think that it is especially relevant to global health as it draws on the importance of the social determinants of health. It is also very topical considering that the Alma Ata Convention, which established the importance of social determinants of health and championed the concept of "health for all", is celebrating it's 30th anniversary this year. Look for related events, such as the Canadian Conference on International Health's review of Alma Ata (Checking In: Health for All or Health for Some?", hosted by the CSIH, October 26th-29th,2008 in Ottawa), which will be taking place throughout the year to celebrate and evaluate this landmark in global health.
And now for the article- hope you enjoy it.
Source: http://www.economist.com/world/international/displaystory.cfm?story_id=12009974
The price of being well
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Which gap, exactly? That the life of a slum dweller in Caracas is generally shorter, nastier and more brutish than the earthly span of a rich person in Cologne or Chicago is hardly surprising. But why, asks the panel, do men born in Calton, a rough part of Glasgow, tend to die more than two decades sooner (see chart below) than men from the dormitory town of Lenzie a few miles away? Why do America’s Asian females live, on average, to 87, while the life expectancy of black males is only 69? The explanation, according to the WHO’s Commission on Social Determinants of Health, is not merely a matter of income. Nor can it be reduced to the varying capacities of health systems. In addition to those factors, says the report, there are social, political and economic forces that ostensibly have little to do with health but can still end up determining “whether a child can grow up and develop to its full potential and live a flourishing life, or whether its life will be blighted.”
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To reduce the risk of the latter, the experts have drawn up a long wish list. They call on governments to improve the quality of everyday life, particularly for women and girls in poor countries, through investment in child care and education, and by insisting on better working conditions. They stress the need to “tackle the inequitable distribution of power, money and resources”—through better governance, support for civil society, and more equitable economic policies. A final element in their proposal to make the world a fairer and healthier place is transparency, and better measurement of progress in tackling inequities in health. The manifesto is a new paradigm for development, claims Sir Michael Marmot, a professor at University College London, who chaired the panel.
Sweeping the proposal certainly is, and the idea of ending health inequality in one generation is ambitious, to put it mildly. But does it amount to anything more than a pious expression of worthy hopes?
At least on a first reading, there are good reasons to take the report with a fistful of salt. First, the authors exaggerate the originality of their ideas; theirs is not an entirely new paradigm. Second, by stressing the “social determinants” of health they may have gone too far to one extreme and underplayed the more obvious link between health and income. And finally, railing against the distribution of power and money may not be much help to anyone who faces practical decisions about how to allocate scarce medical resources.
But for anyone who is willing to look past the report’s ideological slant, there are plenty of things in it that deserve to be taken seriously. Ruth Levine of the Centre for Global Development, an American think-tank, describes the manifesto as imperfect but still useful. On one hand, she notes, the report fails to provide any ranking for its laundry list of laudable aims. But it makes a worthwhile point, in her view, by urging a rediscovery of an earlier view of global health that was more prevalent before 2000. That was the year when a different WHO-inspired panel—convened by Jeffrey Sachs of Columbia University—put a controversial emphasis on the way in which poor health leads to bad economic performances by individuals and nations.
With the latest report, says Ms Levine, “we can see the pendulum swinging back.” In other words, there is renewed stress on the way that poverty and inequality lead to worse health. Julio Frenk, a former Mexican health minister now working with the Gates Foundation, a charity, says the new report offers a way out of a “sterile debate” about whether poor health causes poverty, or vice
versa. What about the other possible flaw in the new report—that it downplays the link between income (as opposed to inequality) and health? Adam Wagstaff, a World Bank economist, says he still believes income “is causal” when it comes to health—so that faster economic growth is likely to benefit the health of society as a whole, even if income inequality is constant. As an example of the benign effects of money, he cites data from South Africa, where the health of older people improved after they started receiving pensions at the age of 65.
Still, Mr Wagstaff credits the reports’ authors with making a nuanced contribution to global-health debates. The authors don’t dismiss the role of growth—which they describe as “without question important”—though they do say it can lead to greater inequity unless there are policies specifically designed to improve public health.
One of the points that emerge from the report has been the subject of a lifetime’s research by the panel’s chairman. Sir Michael argues that even in rich societies people get healthier as they climb the social gradient in ways that cannot be explained by wealth alone. Hence his interest, and the report’s focus, on “social determinants” of health that are non-monetary.
One example: job insecurity, and the resulting stress, have a proven link with mental health (see chart). So does the immunisation of children, even in countries with free and universal access to vaccines. The report lists many reforms—ranging from the extension of social safety-nets to the education of girls and better public information about nutrition—that might boost the chances of better health.
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The structure of a country’s health services plainly matters too. The commission points out that societies with universal medical coverage enjoy better health than places of comparable wealth that choose a different approach. That gives the citizens of, say, Costa Rica an advantage which many uninsured Americans lack.
But whether people are well or sick also depends on factors and policies that lie far beyond the remit of any health minister. For example, a health ministry may try to get villagers to wash their hands before preparing food, but that is unlikely to happen unless there is running water, something the ministry cannot control.
The report may be right to look at the full range of causes, broad and narrow, that determine people’s physical condition. But it seems, at times, to be baying at the moon when it attacks global imbalances in the distribution of power and money. Especially when you recall that health ministers are often weak figures in a cabinet; they can’t hope to change everything.
One other niggle. Amid the report’s musings on the social causes of health problems, what about individual choice? A fat glutton can hardly blame a cruel society, or liberal trade policies, for his predicament—yet the report says too little about people’s responsibility to look after themselves.
Still, Dr Frenk for one believes it is possible to welcome the report without endorsing the nanny state. He recalls that as Mexico’s health minister he successfully made the argument that raising taxes on the sort of cigarettes smoked by the poor would in the long run help the worst off. As he sees it, such a tax need not imply a rejection of choice: diehard smokers can still puff away, but they must pay a price that reflects the cost to society of their habit.
Some people might quibble with his economics. But as Dr Frenk implies, it would be a pity if the new report’s saner ideas were obscured by the authors’ quixotic determination to achieve perfect political, economic and social equity.
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