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Who cares about health for all in the 21st century?
  1. Fran Baum
  1. Correspondence to:
 Professor F Baum
 Department of Public Health, Flinders University, GPO Box 2100, Adelaide 5001, Australia; fran.baumflinders.edu.au

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This paper regrets the retreat in the 1990s from a focus on health as a social good that results from good social policy. It highlights the importance of the People’s Health Movement and the WHO Commission on the Social Determinants of Health as offering a chance to return to a more socially just quest for equity and health.

It’s been a peculiar century so far. It started off with the great and lofty thoughts that accompany centennial change. Millennium summits, domes, and plans for a peaceful century in which human health and wellbeing blossomed. With amazing rapidity, in the wake of 11 September 2001, it deteriorated into a century of fundamentalisms, acute fear of terrorism, and an unprovoked attack on a sovereign state that was not backed by the United Nations or the majority of citizens of the countries going to war. The aftermath of the war in Iraq has become a public health nightmare1 and there are few signs of the flourishing of democracy that was meant to justify the war. Meanwhile the deeper causes of global instability persist and the USA spends more on war than it does on tackling extreme poverty. Sachs estimates that eight million people die each year because they are too poor to stay alive.2 The 21st century, then, is proving to be a disaster for Africa and many other post-colonial states who face economic disaster under the burden of crippling debt and the onslaught of both old (such as malaria) and new infectious diseases (most notably HIV/AIDS). Life expectancy in Africa is going backwards for the first time in over a century.3 Meanwhile the populations of OECD countries are experiencing growth in wealth and prosperity, albeit with increasing inequities between the rich and poor.4

IMPORTANCE OF VISIONARY LEADERSHIP

It is against this background that I pose the question: who cares about Health for All in this century? The answer would have been easier if we had gone back 25 years to the period around 1980. The World Health Organisation under the charismatic leadership of Dr Halfdan Mahler had launched the Health for All by the Year 2000 campaign5 and the target seemed a real possibility. The WHO was widely respected as a lead organisation in global health with a leader who was visionary and inspiring. Many public health doctors now in their 50s and 60s remember with affection the great inspiration they received from the HFA2000 strategy. Mahler’s leadership lasted through to the 1980s when the Ottawa Charter for Health Promotion6 inspired more people to adopt a comprehensive model of promoting health that did not blame individuals but rather focused on creating environments and making policies in which people could flourish and make easy, healthy choices. I remember my own excitement on reading the Ottawa Charter and seeing that it could move health promotion beyond simple ineffective behaviour change strategies to whole of community approaches to improving wellbeing. There was a buzz in public health then, a palpable feeling that we were on the right track with Healthy Cities, Healthy Schools, and other such initiatives, comprehensive primary health care plans, community involvement, and a growing (if fragile) commitment to equity in health.

Sadly, much of this idealism was lost in the 1990s. WHO lost its ability to inspire and seemed to give up its leadership in global health to the World Bank. This was most obvious in 1993 with the publication of the World Bank’s Investing in Health.7 This report saw health as a crucial part of economic development but did not see health as a human right. This approach was consolidated with the notion of disability adjusted life years (DALYs) that privileged the value of lives of those who were young and without disability.8 These approaches to health were very much in line with the zeitgeist of neoliberalism that led to the devastating economic prescription of structural adjustment throughout the developing world—completely without an evidence base or sound justification. The WHO did nothing to challenge this neoliberalism and seemed to endorse the general direction with its Commission on Macro-economics and Health.9 In fact the main challenge within public health came from outside governments and international agencies. It came from grass roots and activist movements who despaired at the direction of global health and came together in December 2000 in Savar Bangladesh at the People’s Health Assembly.

FIRST PEOPLE’S HEALTH ASSEMBLY AND PEOPLE’S HEALTH MOVEMENT

This was truly a civil society movement that had roots in popular people’s organisations from around the globe. At this assembly the 1500 people attending provided testimonies of the impact of neoliberalism on their lives, health, and wellbeing. These testimonies were combined with analysis of the global economic trends and the role of major public health institutions such as the WHO and World Bank. Topics discussed included: the ways in which the international regime that governs global trade is fundamentally unfair and biased against poor countries; the impact of unsustainable environmental practices; and the need for a return to people centred primary health care that focuses on the development needs of communities and not on disease focus strategies imposed from outside. The People’s Health Movement10 emerged from this event. Its philosophy and approach to global health is laid out in the People’s Health Charter, which has been translated into 42 languages. In July 2005 the Second People’s Health Assembly takes place in Cuenca, Ecuador11 and promises to be a major milestone in the road back to a public health based on the needs of ordinary people rather than on the demands of a neoliberal economic fundamentalism.

The catchcry of the Second People’s Health Assembly is “The Voices of the Earth are Calling!” This captures the grass roots nature of the movement. The health of the world’s indigenous people will receive special focus at the assembly. In so many ways indigenous people highlight what is wrong with our approach to health. Australia exemplifies this well. It is one of the world’s richest countries yet the life expectancy of its indigenous peoples is 20 years less than non-indigenous Australians. Instead of being celebrated as the first peoples of the land and given special status, colonial and racist ideas have led to systematic policies that have seen indigenous people deprived of their land and culture, stolen from their families, excluded from the economic benefits of the mainstream, and then blamed and vilified when their health suffered as a result of the cruel and inhuman policies.12 Blatant injustices such as this provide the fuel and passion for the People’s Health Movement.

GLOBAL CIVIL SOCIETY CARES

The other signs of caring about achieving health for all in the 21st century come from the “Make Poverty History” campaign with the goals of “trade justice, drop the debt, more and better aid”.13 The campaign focuses on the 2.8 billion people (nearly half the world’s population) who live on less than US$2 per day. It is driven by a range of non-government organisations and global campaigners such as Sir Bob Geldof and calls directly on the G8 countries to drop debt for the most heavily indebted nations and for aid to be increased to 0.7% of GDP as recommended by the UN Millennium Summit.13 Achievement of these aims has the potential to make our world healthier and more equitable. But this will only happen if what follows is an approach to health and wellbeing that builds on the early, visionary history of the WHO that recognised that health is not just about the absence of disease but about improving the quality of everyday life in terms of our relationships with each other, the safety and satisfaction of our schools and workplaces, the quality and sustainability of transport and housing, the availability of education, sustainability of the environment, and freedom from violence and war.14 So often those who want to do good do not act on this knowledge. Rather they focus on the diseases and believe that tackling them will do the job of creating more health and equity. So we have seen the flourishing of bodies such as the Global Fund and Gates Foundation that, with the best of intentions, set out to tackle a range of infectious diseases. Yet they do very little to tackle the broad social and economic determinants of health that dictate who gets what disease. Healthy people are mainly healthy, not primarily because they have access to good health services (although this helps), but because they have good food, comfortably homes, live in a peaceful environment, have good social support, adequate income, and a satisfying job. The global public health community has to understand and act on this crucial knowledge about what creates health. Are there any signs this may be happening?

SIGNS OF HOPE: SECOND PEOPLE’S HEALTH ASSEMBLY AND WHO COMMISSION ON THE SOCIAL DETERMINANTS OF HEALTH

It just could be that 2005 may be remembered as the year the social and economic determinants of health began to be taken really seriously globally, nationally, regionally, and locally. In July 2005 the Second People’s Health Assembly will take this knowledge as central to its deliberations about how to make the world healthier and more equitable. In March 2005 the WHO launched its own Commission on the Social Determinants of Health (CSDH).15–17 This commission will place a primary emphasis on the underlying factors that determine how healthy populations are and how equitably health is distributed within populations. It will emphasise that health services, while crucial, are only one of the determinants of health and that most health gain will come from going upstream to focus on those factors such as employment, housing, quality of living environments, social relationships, and education that are the main determinants of how healthy we are. The commission works on the assumption that creating healthy societies and individuals largely results from action outside the health sector.

The CSDH will use three key strategies to achieve its aims. Firstly, it will establish knowledge networks preliminarily entitled: Priority Public Health Diseases; Child Health and Education; Financing; Human Settlements; Social Exclusion; Employment; Globalisation; Health Systems, Measurement, Gender and Women’s Empowerment. Secondly, it will work with countries to ensure action on the social and economic determinants of health. Thirdly, it will work to reform the WHO by ensuring that awareness of the importance of the social and economic determinants of health informs all its work and becomes evident in its response to health issues. The commission has great potential to assist Dr J W Lee, the current director general, to leave as his legacy a reformed WHO that is imbued with a strong understanding and determination to act on the social and economic determinants of health and a public health community that accepts the inevitable logic and sense of designing all interventions based on this understanding.

MAKING SOCIAL DETERMINANTS OF HEALTH CENTRAL

The path taken by the People’s Health Movement and the CSDH is not going to be easy. While more funding has gone into global health in recent years the overwhelming amount of it has gone into disease initiatives that do not tackle the underlying social and economic determinants of health. However, if the People’s Health Movement and the CSDH are successful in picking up the baton from the earlier Health for All 2000 movement they may form the vanguard of a successful movement for a socially just and healthier world in which policy decisions are driven primarily by this vision rather than by decisions that maximise profit for a small elite. If the public health community does care about health for all in this century then it must put its full support behind the People’s Health Movement and the Commission on the Social Determinants of Health.

This paper regrets the retreat in the 1990s from a focus on health as a social good that results from good social policy. It highlights the importance of the People’s Health Movement and the WHO Commission on the Social Determinants of Health as offering a chance to return to a more socially just quest for equity and health.

REFERENCES

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Footnotes

  • Funding: none.

  • Conflicts of interest: Fran Baum has been a member of the Global Steering Group of the People’s Health Movement since 2000 and was appointed as a Commissioner on the WHO Commission on the Social Determinants of Health in March 2005.

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