Six caveats to start with
1. First, public health cannot only revolve around that which is already ‘evidence-based’. Why? Because this actually colludes with the status-quo. For public health to restrict itself to an ‘evidence-base’ is also naïf. Why? Because knowledge growth and social development have always and will always operate through more than strictly evidence parameters. Public policy in health must work with partial evidence, despite of (or in the face of) it being partial. Often too much is at risk. Yes, it is important to strengthen evidence, but there is no such thing as a perfect state of evidence; there never will be. Public health decisions and actions have always and will always be made and carried out in a context of contested evidence, ignored evidence, rediscovered evidence, right evidence with the wrong theory, wrong theory with the right evidence, evidence gathered without policy consequences or, perhaps the best kind, ‘slow-burning evidence’. (G. Rayner and Tim Lang)
2. Second, progress in public health cannot rely on scientific evidence alone. It also requires thought. Judgments and actions in public health cannot simply be the responsibility of single-issue, expert-led professions either. There must be access to a wide range of different types of knowledge and understanding, including and going beyond the natural sciences. This crucially includes listening to the people who most suffer from bad public health conditions and who, partly for this reason, are unlikely to be well educated. But they suffer the direct experience, and are thus first-hand-knowledgeable. (G. Rayner and T. Lang)
3. Third, the human right to health (RTH) is not a mere declaration. It does not consider preventable ill-health and malnutrition and preventable deaths a marginal-cost-to-be-paid-for-an-assumed-‘progress’ that, among other things, is leading us to the destruction of the planet. (Mario Rovere). This is why the core health obligations of the State are non-derogable/non-negotiable; they represent the minimum essential levels which States are required to meet in order to be in compliance with the RTH. Core obligations establish a funding baseline below which States will be considered in violation of their obligations under the same RTH.
4. Fourth, non-communicable diseases (NCDs) are transmitted, usually not by bugs, but by the viral marketing crime perpetrated by transnational corporations. (Guido Girardi) So, it is pertinent to ask: What is really on trial? Nutrition and NCDs? Or misinterpreted science blind to the power of the marketing media and deaf to the silenced voices of enlightened peers who have this picture very clear? (A. Yngve) Many still think that people suffer from NCDs because they take risks or have risky behaviors, but beware, risks are also imposed!
5. Fifth, and to carry the argument above further, I can perceive some of the same blindness associated with some scholarship on the social determinants of health which often relies too much on descriptive studies showing an absence of an accurate understanding of the political mechanisms underlying the production of disease –as this is imperative for bringing about meaningful effective political action. (C. Muntaner)
6. Sixth, a rigorous understanding of the distribution of health outcomes and opportunities, across socioeconomic groups, is an essential tool for policy-makers to appropriately and effectively tailor interventions that address patterns of health inequality. Effective action to address the social determinants of health requires us all to rethink the dominant understandings of the way in which population health is improved and health inequalities are reduced. *
*: Health inequalities pertain to differences in health status or in the distribution of health determinants between different population groups. For example, differences between elderly people and younger populations or differences in mortality rates between people from different social classes. (Development in Practice) [Note that health equity refers to differences in health that are not only unnecessary and avoidable, but in addition are unfair and unjust. (Ron Labonte et al)
Obstacles to achieving equality in health using the human rights framework
7. Why do most decision makers (often some of us) not assess the causes of preventable ill-health and deaths as being rooted in the violation and neglect of the RTH and on the inequalities this generates? If we do not look at these violations as de-facto causes, we will never devise interventions directed at reversing them for good.
8. Instead, there are endless calls for intersectoral/multisectoral work in health. In my experience, as time passes, inescapably the toughness of the bureaucracy to resist the human rights-based framework pops-up again and again ultimately leading to immobility of the whole. Too bad.# [I ask myself, what is the reason for bureaucrats (with their mostly silo mentality) to see the violation of human rights as only having an ‘opaque’ causal link to preventable ill-health and deaths?].
9. I ask myself further, does the now popular call for Health in All Policies (HiAP) not risk becoming yet another call for intersectoral work –which has such a poor record of success?**
**: HiAP is a policy strategy that purports to target the key social determinants of health through integrated policy responses across relevant policy areas with the ultimate goal of supporting equality in health.
10. Conversely, Health Impact Assessments (HIA) involve a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population. HIA is thus much closer to the RTH and can be adapted so as to use the human rights framework.
11. The important point to note from this is that not all inequalities are inequitable and not all equalities equitable.*** (D+C, 36:2, Oct.2009).
***: This actually relates to the concept of horizontal and vertical equity; horizontal equity occurs when the same resources are used to address the same needs, whereas vertical equity allows different resources to apply to differing needs. For example most people would support the ‘rule of rescue’ that gives priority to treat those with more urgent health needs. (Daniel Tarantola et al)
Health is much more than health systems and health services (Geoffrey Cannon)
One should not have to pay for something that is a fundamental right.
12. When national constitutions do not include health as a human right, but address health as a service, this opens the door for ineffective neoliberal reforms in which the denial of health care is considered as an individual problem so that people are kept in the dark about health being a collective issue that requires their organization and mobilization to demand health for all from the State. (Leslie London)
13. In the words of Ivan Illich: People accept services without questioning values. Regaining health is defined as per the outcome of a series of services and treatments. Subjects are rendered insensitive through coercion. They confuse medical treatment with health care, social work with improvements in community life; police protection with security; military investments with national security; the everyday rat race with productive work. Through these confused approaches, spurious values are institutionalized.
14. Bottom line here is thus a call not to accept only what is possible. (Y)our job is to make what appears to be impossible, possible. That is the challenge…. Conformity pleases the weak in spirit. The future belongs to the bold and courageous. And time is of the essence. To navigate against the wind, is the real challenge. Courage is tested when one swims against the current. If you are convinced enough you have to be willing to go at it alone if necessary. (Ricardo Uauy, www.wphna.org)
Claudio Schuftan in Ho Chi Minh City
cschuftan@phmovement.org