-So many people have no other teacher than the street and no other doctor than death. (Eduardo Galeano, Apuntes para Fin de Siglo)
1. You have to be aware that there are options to tackle right to health shortcomings, deficits and violations. What I mean is made clear in the table below.
Risk approach Social Determinants of Health approach Social Determination of Health approach
Offers a merely descriptive approach, without social mobilization. Faces the expressions of the health-disease process, but singularly, confronting them in isolation from each other. Stimulates an analysis of structural causes and reveals the shortcomings of the development model.
Does not address the causes of inequality. Uses statistical models described in terms of time, place and person. Incorporates into the health discourse the concept of social determinants, but relegates them from the social context and from existing inequalities. Analyzes social injustices that translate into health inequalities originating in the inequitable accumulation of wealth and power.
Risky lifestyles are defined as unhealthy conditions, poor environmental sanitation systems, precarious housing and lack of health education for the population. The determinants are water, housing, employment, education, etc. seen in isolation. That is to say, the old risk factors are kept unrelated to the hegemonic model of development and the relationship between social processes and nature. Does not consider living in these conditions as ‘elected lifestyle.’ Links the social, political, historical, cultural and ethnic conditions and contexts of the population in question.
Expressions of this ‘bad way of life’ (illness and death) should be addressed with greater access to health services, preventive care such as educational programs and medicines and health technologies provided through basic health packages. This is only a more advanced developmental conception of the risk approach. As a consequence, public policies are still focused on disease. This approach includes community organization, community leadership, spaces for participation, the HR to health and universal health coverage, as well as access to unified and strong public systems, financed by general taxes, without copayments and free of charge for the population.
Underlying the non-adoption of the approach in the right column above is the fact that global politics (and health policies) has (have) a false perception of reality.
2. I see no other way to describe what is happening in health. We are celebrating 40 years of the Alma Ata Declaration, a political document pertaining the bases of primary health care. Many consider that, in Alma Ata, a-politics-of-health-of-global-key-relevance was put forward. Such a politics had (and has) three components:
• a definition of the problems based on an assessment of the reality,
• the outcome towards which one wants to strive for, and
• the strategy to achieve this.
3. The definition of the problem is well summarized in the Declaration (…and it has changed little since, if at all…). The more serious problems to be resolved the world over hardly need to be highlighted again, i.e., inequality between the privileged and the dispossessed; the lack of access to healthcare of at least 1/5 of the world’s population; unhappiness about the services by those who do access services; doubtful efficacy of the medical technology imposed by the medical-industrial complex; patients having become depersonalized in clinical and preventive services; and globalization creating health problems that escape to mere health solutions.
4. What would we say additionally today? Among other, we would have to refer to the scandalous inequalities, to the myriad armed conflicts, to the threat of re-nuclearization… We probably would also have to emphasize the aggressions against the planet [deforestation, extractive industries, GMOs; the use of agro-toxics; contaminations of all types (plastics gaining more and more recognition); the loss of biodiversity; global warming] …all just but some of the manifestations of the prevailing system’s aggressiveness that jeopardizes humanity’s survival.
5. Far from discouraging us, we have to enthusiastically fall back and appeal to our creative imagination so that a spark of hope feeds the fire of life within us and we all become the stewards of a healthy world. (Julio Monsalvo)
Universal Health Coverage: Will we end up hitting the targets, but missing the point? (Robert Wachter)
6. Even in prevailing UHC models, vertical interventions based on technological fixes for specific diseases are to continue rather than promoting the needed horizontal enhancements of the public health infrastructure. This old ideological wine continues to produce a familiar euphoria as it appears in new bottles. (Rebeca Jasso-Aguilar)
7. So, even when the aim is to create a strong system of public health care, class interests and elite policy actors will often seek its dismantling. The fate of UHC is not predetermined, true, but depends on the outcome of ongoing political struggles at the grassroots and electoral levels. (Adam Gaffney)
8. Yes, there is a diminishing tolerance among the world’s peoples for the imperial public health policies of the Global North (including the UHC model most current literature is putting forward). At the same time, there is a forceful demand for public health systems grounded in solidarity rather than profit. This shows us how popular struggles for health can and do expand popular participation in policy decisions previously controlled by economic and political elites and thus unleash the values of public service rather than those of the market to build a system that values quality over profitability. (Howard Waitzkin, Matthew Anderson)
9. A caveat here: We tend to mystify the notion that adjusting disparities in income can/will produce more favorable health outcomes. But it is more than that: We have to, at the same time, emphasize the struggles that directly confront the social determination of health, that is, make changes in the broad social policies realm as depicted in the table above. (Carles Muntaner)
And then there is the issue of resilience becoming fashionable
10. Resilience is defined as the ability to recover or adjust quickly from or adapt to the consequences of a catastrophic failure, an adversity, a misfortune or a ‘life difficulty’ –in our case a health occurrence or a public health deficit. Three concerns regarding the application of the concept of resilience to health systems need discussion here:
• The resilience narrative overrules certain democratic procedures and priority settings in public health agendas by ‘claiming’ to place itself at the very center of policy making in health.
• Positioning resilience at the center actually calls for accepting and maintaining the status-quo and excluding alternative more democratic and human rights-based scenarios of fair and equitable health systems –including the socio-political struggles required to attain them, and
• Being closely related to decreasing vulnerability, resilience does not provide us with a real solution to develop a stronger health system.
11. In conclusion here, if the normative aim of health policies is to build sustainable, universally accessible health systems, then focusing on resilience is not the answer. The current threats that health systems face demand us to think beyond seeking resilience and instead exploring possibilities for global solidarity* and justice and fairness in health. (Remco van de Pas et al)
*: To cover everyone, solidarity is more important than competition! (Zafrrullah Chowdhury)
And this, you probably have heard before
12. The intellectual property (IP) standards that rich country governments insist-on have never really been intended to maximize scientific progress and technological innovation. Rather, the prevailing IP regime serves to maximize the profits of influential pharmaceutical and other companies by conferring them with exclusive monopoly rights. Despite a lack of evidence, the IP advocacy argument has been that market forces ‘undersupply’ knowledge owing to the poor incentives for research and innovation. The usual claim is that this ‘market failure’ is best corrected by providing a private monopoly through property rights for new knowledge, e.g., through enforceable patent rights.
13. Private IP protection is presumed to be the only one way to reward –and thus encourage– research and innovation. The current patent system, therefore, rewards legal ownership of innovation. But by doing so it effectively impedes the use of that knowledge by others, hence reducing its enormous potential benefits. Payments to lawyers and patent investigators typically exceed those to scientific researchers in such cases –with research often oriented to merely extend, broaden and leverage monopoly rights due to patents. Powerful corporate and developed economy government lobbies have influenced the IP regime, among other, by opposing competing rights associated with nature, biodiversity or even traditional knowledge.
14. In sum, over the last few decades, the evolving IP regime has erected more and more barriers to more widespread use of new knowledge. The current IP regime serves to maximize profits for a few monopolies, that is ‘Big Pharma’**, rather than serving the progress and welfare of the many. (Jomo Sundaram)
**: Also rightly called ‘corporate vectors of disease’ (Lucy Gilmore) or ‘harm industries’. (M. Welker) These industries talk about the moral high ground, but do not occupy it. (Kelly Burnell)
15. But mind you, the above is only part of the equation. For health to become a human right (HR) it is not enough to have available cheaper medicines, on top of more health professionals and more infrastructure. For it to become a right, many other HR have to be actively reclaimed, because they are being taken away from us –without our consent. (Juan Manuel Pericas)
Bottom line
16. We are told we need to move away from health-care-based-on-expert-opinion toward evidence-based practice. But the prevailing corporate model’s practices that have taken over our every day health care, rarely –if ever, are evidence-based. It is striking that these for-profit corporations, whose scientific bases have been severely questioned, are now running the show. (M. Anderson)
17. It is the transnational dynamics that underscores the importance of movements of international solidarity in the protection and advancement of health care systems. Though divided by political borders, throughout the globe we are all facing similar, albeit not identical challenges from the neoliberal health care agenda.*** There is no doubt much is to be gained from working collaboratively as internationalists, as we struggle towards health care systems based on solidarity rather than profitability. (C. Muntaner)
***: The five axes of health care neoliberalism you must consider in your analyses are:
• austerity health spending,
• a rollback of universalism,
• a rise in payments required at the time of use,
• the extent to which the health system receives adequate public funding, and
• the degree of privatization of the delivery system itself. (A. Gaffney)
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
www.claudioschuftan.com