Sunday, June 10, 2012

Improving health in poor countries -- and reducing it in the rich

I have recently published the text of my “Withers Lecture” on Social Justice and Health, given at the University of Texas at Houston. In its May 16, 2012 issue, . JAMA published two important “Viewpoint” articles: “Policy making with equity at its heart”,[1] by Michael Marmot, FRCP, and “Primary Health Care in Low-Income Countries: Building on Recent Achievements”,[2] by Jeffrey Sachs, PhD. It is gratifying that these two major figures are writing about the same issues that I am; after all, I cite Dr. Marmot (Sir Michael) in my talk, both for his seminal work on the impact of social class on health (the “Whitehall studies”) and his more recent work as President of the British Medical Association in taking the lead on involving the medical community in addressing the social determinants of health. Dr. Sachs, of the Earth Institute at Columbia, is one of the most important thinkers and actors in the field of international health.

But, in another sense, I am sobered by this, because it is often true that an outpouring of articles citing the evidence for the importance of social action, whether from leaders such as Drs. Marmot and Sachs in JAMA or by bloggers such as myself, are stimulated by attacks and cut-backs in these areas which have already resulted in pain and suffering. Dr. Sachs’ piece is, in this sense, more positive; he reviews successes that have been achieved in poor countries by the use of primary health care strategies. Much of this success has been in “Group I diseases [which] include communicable, maternal, perinatal, and nutritional diseases”, and which he points out are very susceptible to improvement with quite low levels of investment. The successes he points to include reducing the infant mortality rate in many countries (“In the least developed countries, approximately 112 of every 1000 children die before their fifth birthday, as opposed to 8 per 1000 in the developed countries. With a concerted science-based effort, the under-5 mortality rate of the least developed countries could be reduced to less than 30 per 1000 by 2020. Such low under-5 mortality rates have already been achieved, for example, by the Dominican Republic (28 per 1000), Mexico (17 per 1000), and Thailand (13 per 1000).”) He also addresses the issue of malaria, one of the world’s great killers: “Malaria deaths in Africa have declined an estimated 30% from their peak around 2004 with the partial deployment of this new and evolving system.” His article is positive and optimistic, particularly when examining the relatively low cost of interventions that will have such great impact: “Small investments in improved health of the poor have a remarkable return in reduced morbidity and mortality.”

Whether those small investments will continue to be made, however, is an open question. The flamboyant, aggressive, and unabashed attacks on people demonstrated in many laws passed on both the Federal and state level in the US, and the dramatic cuts in social services that have occurred here and in Europe as a result of “austerity” policies”, challenge our ability to maintain health even in developed countries. This is a focus of Dr. Marmot’s article. In a pointed and engaging opening, he writes “In India, there is a cabinet minister for social justice. Would that it were catching, and spread to all government ministers. What a thought: social justice at the heart of all government policy. It would be a radical change from the current set of arrangements, in which many governments are unashamed apostles of self-interest—of their countries, of their partisan supporters or, indeed, of self-interest as a political creed. Given the link between social and economic policy and the health of populations, all ministers should see themselves as ministers of health.”

What a thought, indeed! Dr. Marmot, like Dr. Sachs, cites a list of health problems that could be largely addressed by social intervention and a concern for equity. Unlike those on Dr. Sachs’ list, however, these are interventions are being curtailed rather than expanded. He cites the report “Closing the Gap in a Generation” from the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH) and emphasizes that “…although traditionally efforts to prevent ill health have focused on causes—such as inadequacies in sanitation, nutrition, and shelter in deprived populations, and on unhealthy environments and behaviors among those not deprived—focus should shift to the causes of the causes.” And the cause of the causes is social and socioeconomic inequity – not inequality, because it does not require that everyone be equal – but inequity, which he defines as “systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means.” He challenges the international focus on solely achieving growth of GDP, which has generated the austerity measures that have already caused so much suffering, and instead suggests considering the “…report of the Commission on the Measurement of Economic Performance and Social Progress (established by the French government and led by Joseph E. Stiglitz, Amartya Sen, and Jean-Paul Fitoussi) that argues for broader measures of social and economic progress than simply GDP.” And, as argued by another Nobel Prize winner, economist Paul Krugman, austerity policies don’t even do much for growing GDP!

So, while progress in health has been made with small investments in developing countries, developed countries are seeing both their health and social structure degraded as “solutions” to a financial crisis brought on by the greed of multi-billionaire bankers and investors. These “solutions” are implemented in a way that ensures that the prosperity of those perpetrators is guaranteed while the price is paid by the middle and lower income groups. These “solutions” have neatly dovetailed with radical right-wing (often incorrectly labeled “conservative”) social agendas. This is true not only of cutbacks in direct support for social programs, but in union rights, and most profoundly in the rights of women to protection from violence, opportunity for education, and control of their reproduction. The systematic and hypocritical character of these attacks in the US is well-documented in a New York Times editorial from May 20, 2012, “The Campaign Against Women”.  

While Sachs may be correct in noting that the in developing countries improvement is low cost, his concern that this is not happening sufficiently “While the developed economies grapple with health systems that cost several thousand dollars per person per year and often spend hundreds of thousands of dollars on a treatment to eke out an additional few months of life,” may also miss the point. In developed countries, we spend on this high-tech, high-profit, low-yield medical interventions but we still do not spend on the social interventions that would truly make a difference in health.

Perhaps progress in the developing world can be a model for the rest of us. 

[1] Marmot MG, “Policy making with equity at its heart”, JAMA. 2012;307(19):2033-2034. doi:10.1001/jama.2012.3534
[2] Sachs J, “Primary Health Care in Low-Income Countries: Building on Recent Achievements”, JAMA. 2012;307(19):2031-2032. doi:10.1001/jama.2012.4438

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