[DEBATE] : (Fwd) More on WHO "wish list"

[Patrick Bond]

(The Economist on WHO's left turn: "baying at the moon when it attacks 
global imbalances in the distribution of power and money").

http://www.economist.com/world/international/displaystory.cfm?story_id=12009974 


THE PRICE OF BEING WELL
Aug 28th 2008 From The Economist print edition

Is it time for a new paradigm for health and development? A heavyweight 
panel with an egalitarian ideology claims to have found one

"SOCIAL justice is a matter of life and death." Thus begins a long, 
provocative report released on August 28th by a group of grandees with 
an impressive range of expertise in health and development. The pundits, 
who include Amartya Sen, an Indian-born economist and Nobel laureate, 
were asked by the World Health Organisation (WHO) to take a broad look 
at the question of inequality and health. After more than two years' 
work, the panel has issued a call to arms with a sonorous title: 
"Closing the gap in a generation".

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."

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.

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.