Health and Equity: Need for a People’s Perspective in the Quest for World Health

David Werner

Too often, in planning strategies to improve health, the people whose lives are most vulnerable have not been consulted. However, the Alma Ata Conference of 1978 was something of an exception. Among its participants were pioneers of community-based health care initiatives from several countries. They emphasized the need, in the pursuit of Health for All, to confront the underlying social, economic and political causes of poverty and poor health. The result was the potentially revolutionary Alma Ata Declaration, which promoted a comprehensive, multi sectoral approach named Primary Health Care. This called for a New Economic Order based on equity and “social justice”, to be achieved through strong community participation.[^1]

But as we know, in most countries Comprehensive PHC was never given a fair trial. It was soon replaced by Selective Primary Health Care, which called for a few vertical, quick-fix technologies, requiring only the weak participation of compliance. Its goal was to reduce mortality rates of high-risk groups such as children, with little emphasis on equal opportunities or quality of life. The socioeconomic causes of poor health went largely unchallenged and unchanged. The gap between rich and poor continued to widen. Poverty and poor health persisted, and in some countries have worsened.[^2]

For the poorer half of humanity, the goal of Health for All seems more distant today than 20 years ago. Structural Adjustment and World Trade agreements have placed the cost of health and foods beyond the reach of millions. Indeed health care and essential food are no longer basic human rights. There are more hungry children in the world now than ever before. According to UNICEF, malnutrition contributes to over half the deaths of young children.[^3] This year more than 6 million children will die because they do not have enough to eat. This is not because of total food scarcity, but because of unequal, unfair distribution. It is because the world’s ruling class has chosen a model of development, whose goal is the economic growth of the already rich, with too little regard for the human and environmental costs.

The well-being of the poorer half of humanity is compromised by landlessness, joblessness, insupportably low wages, cut-backs in health and welfare services, and the resultant pandemic of anger, crime, violence, despair, unrest, with consequent harsh measures of social control—all of which arise from the growing disparity of wealth and power. “Those on the bottom,” know that health is determined more by the fairness—or unfairness—of social structures than by medical or health services, per se.[^4]

What alternatives are there? A study funded by the Rockefeller Foundation in 1985 showed that, at that time, a number of poor countries had achieved “Good Health at Low Cost,” through socio-political commitment to equity.[^5] Rather than making economic growth their chief goal, their top priority was to meet all people’ s basic needs. They guaranteed universal primary education and basic health care, assuring outreach to rural and vulnerable communities. And most important, they guaranteed that every person had enough to eat. The results were rates of longevity and child-survival comparable to those of much richer nations.

Sadly, the countries included in this 1985 study—China, Sri Lanka, Costa Rica, and Kerala State of India—in the 1990s have all seen some reversals in their political commitment to equity, and consequently in their quality-of-life indicators. The globalization of the free market, with its structural adjustment programs and mandates for lop-sided economic growth, has made it increasingly difficult for equity-oriented nations tosustain their humane, basic-needs approach to development.

Recent studies in rich countries and poor alike are showing that the polarization of wealth is a major threat to the well-being and integrity of society. Yet within the current globalized economy, wealth and power have concentrated increasingly in the hands of a small number of giant transnational corporations and speculative investors.[^6] Today over half of the world’s annual income goes to some 450 billionaires. The amount of money that changes hands every day on speculative investment is 240 times the total amount spent on actual production of goods and services, worldwide. It is the gambling manoeuvres of this “Global Casino” economy that go far in explaining the recent crashes in the economies of Mexico, Thailand and the “AsianTigers”—a failing of the global free market system that has had a negative impact on the health of millions.

The oligarchy of the corporate class has made a mockery of democratic process. Politicians are elected whose campaigns are financed by big business. As a result, trade agreements role back policies designed to protect human and environmental well-being. To make the rich richer, humanity has been thrust into a development paradigm that not only perpetuates poverty, but places all life on this planet at risk.

If we are ever to approach “Health for All”—or, indeed, to prevent an eco-disaster leading to “Health for No One,” we must embark very soon on a radically different model of social development. The necessary science, technology, and wisdom now exist to forge a more healthy, humane, and sustainable paradigm. What is missing is the political will.

The main point I would like to make is that the pursuit of World Health is inseparable from global economics, preservation of ecosystems, and social justice. The Struggle for Health is essentially a Struggle for Equity and Compassion, not just in the provision of health services, but in all sectors and aspects of life. Therefore we health planners need to reach far beyond conventional medical and health services. We need to join with social activists, alternative economists, ecologists, grassroots organizers, progressive educators, and other agents-of-change, to advance a multi sectoral strategy that puts the basic needs of all people—especially the disadvantaged—before the myopic power plays of the global rulers.

Health promoters at all levels need to become well-informed about economic issues, and work toward more humane and sustainable alternatives to our current top-down policies. We also must seriously question and challenge the self-appointed role of the World Bank as the dominant health-policy planner for poor countries.

We seekers of world health need to enter into a serious dialogue with the leading advocates of healthier paradigms for development. We must familiarize ourselves with people-centered development strategies such as those proposed by The Other Economic Summit[^7], the International Forum on Globalization[^8], the Eco-economics of former World Bank economist, Herman Daly[^9], and the energy-saving innovations of the Rocky Mountain Institute.[^10]

Perhaps most important of all, we need to become popular educators, helping ordinary people to see through the disinformation of the mass media, to analyze local and world events, to understand the roots of their hardships, and then to mobilize a massive demand for more responsible, democratic, and humane global leadership.

In sum, our cruelly inequitable global economy is the biggest obstacle to “Health for All.” [^11] Only when the prevailing market system is effectively transformed—or at least strongly regulated—to put human need before corporate greed, can we begin to approach to Health for All.

In such a transition, the World Health Organization and UNICEF need to reclaim their mandate as world coordinators for the well-being of the disadvantaged. They need to gain strong enough popular support to stand up to the transnational corporations—the pushers of weapons, cigarettes, and infant-formula—without fear of funding cuts by the US government. Likewise, financial institutions such as the World Bank must be “structurally adjusted” to place basic human needs before unregulated corporate profits (not just in rhetoric, but in practice.)

To this end, non-government organizations, as well as the United Nations and progressive elements within governments, need to work closely together with grassroots movements to build—from the bottom-up—a people-centered globalization to challenge, rein in, and build healthy alternatives to today’s lop-sided globalized economy.

The International People’s Health Council (IPHC) is one of several budding efforts to build a world-wide coalition.” Several representatives of the IPHC, including David Sanders, Fran Baum, and myself, are present at this meeting. We encourage all of you here to help formulate a new, stronger Alma Ata Declaration aspiring to Health for All, as a basic human right, through the pursuit of Equity, Participatory Democracy, and Fairer Social Structures.

 
 

Presented at the Conference: “PHC21–EVERYBODY’S BUSINESS.” Almaty, Kazakhstan, 27-28 November 1998.