CLAUDIO SCHUFTAN, MD
cschuftan@phmovement.org
1. The topic of the above title has vividly interested the author for many years. It is fascinating to him that the issues at stake have not changed for the last 25 years. As proof of this –and on purpose– references dug-up and quoted are only those published before 1986. Considerable material was available already then, but the difficulty was to find a unifying thread through the swamps and jungles of the raw data. The end result has been the (re)construction of a scenario that has been stubborn to change and that looks into most of the burning questions of then and now on the issues pertaining to the title of this contribution.
2. The materials are here presented under six headings and are an informal, non-systematic review of the literature on the ethical, ideological and political implications of health as a science and as a praxis. The materials here collected should shed some light upon the major issues at the core of this universal discussion that –whether we like it or not– was and continues to be at the very base of our daily work as health professionals.
Science: Its ethical and ideological implications
Slicing Reality
3. Every age is dominated by what Foucault calls an ‘episteme’ –a way of conceiving and perceiving the world– which brings certain features of existence into view while it blurs or conceals others. If we are to understand history, then, we must come to terms with the episteme of each age. In it, we should find the interplay between knowledge and power [1]. This is said, because half-truths can be dangerous; they can frighten and subdue the uninitiated while legitimizing the interpreters thus deforming the moral discourse [2].
4. Whether a certain development-in-the-way-health-has-gone is interpreted as harmful or as beneficial ultimately depends on one’s ideological position and one’s class interests. To understand and to change the health situation requires a knowledge not only of the internal dynamics of the situation, but also of the nature of the macro-system which provides the parameters for that situation [3]. We thus have to learn to look at totalities, rather than at fragments of reality [4]. Therefore, what counts as a fact depends on the concepts we use, on the questions we ask. There is no neutral terminology. There are really no wholly neutral facts. We cannot say what somebody is doing until we know why s/he does it. Wo/man can neither understand her/his nature nor her/his behaviour until s/he understands her/his motives [5]. Let’s face it, we are often more interested in answering questions of fact not involving values, than answering factual questions about values [6].
5. As said, our intellect tends to divide the indivisible –thought from feeling, form from content. Ambivalence is part of our nature, else we would not have developed a morality. Asking different kinds of questions produces quite different kinds of answers. All you have to remember is that there’s more than one way to slice reality [5]. It is well and good to question why we have so much preventable ill-health and avoidable mortality, but, in so doing, are we using the right questions? That is, do we not obfuscate the problem by avoiding the real issues, i.e., today we would say ‘the social determinants of health’ which are ultimately issues related to wealth and power? [7]
[A quick glance at the present shows us that, as of 2007, ‘ten million children under five die each year in the poor countries from diseases that are easy and inexpensive to prevent’ –Global Monitoring Report, IMF/WB, 2007].
6. There is the naive perception that health interventions are intrinsically good; who can be against feeding or giving Vitamin A to children? But many do not realize the importance of the social and political context in which those programs take place [8].
Moral and Ideological Aspects
7. Intellectual development cannot be separated from moral development. The connection between morality and the sciences may appear indirect, but I do not see how a prejudiced person could be a good research scholar. Who you are and where you stand does make a difference. Intellectual development should never stunt moral growth; they must travel hand in hand. How does one deal with poverty around the world if by our behaviour we abet those who favour an elitist and authoritarian view of society and see left wing subversion in every attempt to change ways when people are treated unjustly? Whether we like it or not, what we are morally depends on the choices we make and the things we actually end up doing.
8. When people who hold the fate of health programs in their hands make fine distinctions, semantics become statements of policy. Words have always been ideology and ideology has been policy. It, therefore, becomes important to take a close look at the beneficiaries’ rights and needs, as much as at our moral duties. Are these two interlocked? And what do we really mean by the ‘beneficiaries’ rights’? Is subjective conviction all there is to the concept of a moral obligation? Obviously not, for otherwise any thief who honestly believes that, because he has had a deprived childhood or because he has been wronged by society he has a right to help himself to a piece of someone else’s property. And a Robin Hood, who robs the rich to give to the poor, would be doubly right. The subjective conviction that one is in the right gives one the inner strength to do what one is doing. That is an important thing in itself. But for such a subjective conviction to become a moral obligation, it also has to obtain the sanction of others, even if not of necessarily most or even of all of them. Such a sanction may convert a Robin Hood from a highway robber into a social rebel, a terrorist into a freedom fighter. A subjective claim can become a recognized moral obligation and a legal right by external sanction. But there is another limit to any moral obligation which determines to what extent it will be sanctioned –its possible conflict with another moral obligation. When such a conflict arises, the sanction for one right against the other depends, in terms of morality and justice, on what claim is considered the stronger, the more urgent, the less injurious to the other. In terms of political reality, it depends on whose claim can muster more support based on the real interests of those who have the power to grant the sanction or to deny it. This. then, determines the extent of the moral obligation and legal right the world is prepared to accept. However much we may regret it, the world never accepts more. Not only do the relative weights of conflicting moral claims change –political power interests also change. The question thus is, what sanction (moral, legal and political) one can get for any new position. Morally, might is not right. Politically, it often is. Perhaps if we have the might, our subjective belief that we are doing no wrong would, in time, receive the sanction of some and of time itself. But not only do we not have the might to do something sustainable to get rid of preventable ill-health, not only do we not have the power to rally support, and not only does time work against us, but the very attempt to rely on our moral strength may lead to disaster. It may be good rhetoric to say that we need no one’s confirmation of our rights, that we will in all likelihood win morally. But politically, it may bleed us to death. The question is not our right to fight preventable ill-health, but how –and that, unfortunately, can not easily be imposed unilaterally. To fight preventable ill-health and preventable deaths we have a supreme moral claim, sanctioned by the entire world. For the more comprehensive alternative –the claim for structural social changes– we have no universal sanction. Charity, therefore, is obscurantism, because it really means no solution [9].
9. To be human is to be a moral agent, able to choose freely among alternatives and to engage in consequent action. Moral questions arise as we consider how we ought to act in respect of others –including in health matters. The moral values we draw-upon when choosing certain policies over other are themselves the product of our collective life. Moral values are consensual, and actions based on them are said to be legitimate. It is clear, however, that the moral code of a community also legitimizes established relations of power. An instrument of domination in the hands of the ruling elites, such as a moral code is not only an integrative, but an alienating force; it renders abuse of the people easier; we see that in health all the time Thus, neither moral nor political, the market’s powers are to be seen as purely instrumental, relating means to given ends. By responding more and more to the logic of markets, communities are reduced to the functional requirements of livelihood, while the roles and moral obligations of citizens are often dismissed as irrelevant. Therefore, a system that has no place for a majority of the people has lost the moral authority to prescribe what should be done. It is by participating in the political life of a community that we acquire a sense of who we are. It is through a political discourse that a needs-oriented economy comes into being. The right to equal access to such a discourse in health should be the essence of our demands [10].
10. Conversely, we often find ourselves accepting or supporting ‘ethically-neutral’ although ‘value-biased’ premises. It is in the name of scientific analysis that unemployment, malnutrition, preventable ill-health and poverty are often perpetuated through the impersonal mechanisms of economic policy and of the market [11]. In ‘the-way-things-areness’, society makes disprivilege look right. Governed by myths, things are explained away. It is through ideology that society ultimately explains itself [12].
The health professional: a promoter of status quo or of social change?
Health Professionals as Intellectuals
11. Are health professionals a class apart, responsible only to their own inner urges and their own preconceived visions of their fellow wo/men’s needs? Are they duty-bound to immerse themselves in the society they are part-of to articulate a deeper consciousness? Or are they natural leaders, destined not only to provide better ideas that can reshape health services, but also make sure that they are implemented? Here is Jean-Paul Sartre, arguing the obligation of political engagement and action as the true test of our values [13].
12. The truth is that intellectuals too often bend the rules of discourse to suit their own interests; they argue for what they want to believe. Doctors are no exception. The deterministic theories they use consistently tend to provide a justification of the status-quo and of the existing privileges of certain groups according to class, race or gender. The judgement of our work in health depends on whether it conforms to the political convictions of the judges –who are mostly self-appointed [5]. We are not independent intellectuals floating somewhere above the economic system: we’re part of it [14].
13. Without challenging the ideology many of us find abhorrent, we only perpetuate the passivity that has become our central image [15]. We are prisoners of our own past training and often of somebody else’s thought [16].
14. We also often use statistical illusions devised by our own academic elites which do not fit any real-life cases anywhere in the world [17]. Measuring poverty and its effects on health in detail can often be a substitute for, or an excuse for not acting in response to perfectly visible needs [18]. In that sense, factor analysis, for example has often led us to the cardinal error in reasoning of confusing correlation with cause [19].
15. Moreover, too many of our health economists and too many international organizations are seeking to take the politics out of the political economy of preventable ill-health, as well as of the daily decision-making process just to avoid discord or conflict. Many, if not most, aspects of life should never be decided by the health economists’ yardstick only. The abolition of slavery or child labor laws certainly never would have passed a cost-benefit test [20].
16. Among other, excessive institutional compartmentalization has separated political and social analyses (e.g., those in the social determinants of health) resulting in a passive reluctance to call a cat a cat [21]. There is a tendency to stop the analysis where politics begins, with formulations like: ‘this, however, is a political question…’. Of course, that is where the analysis very often should start. Our task is not merely to reflect the world, but to do something about it. Goals which are not at the same time processes become a dogma (…the MDGs..?). It is the ‘principle-of-recognizing-trends-and-acting-promptly-at-the-right-time’ that mainly differentiates the politically-oriented health professional from the theoretician [22].
17. On the other hand, why do our attempts to be ‘comprehensive’ and ‘multisectoral’ in health matters not achieve the expected results? The complex nature of the problems of preventable ill-health complicates our policy making. The essence of the problem transcends its interdisciplinary, intersectoral nature. Comprehensiveness cannot be obtained by achieving all-inclusiveness of the parts, but by adhering to a new philosophy into which all parts mesh (i.e., the skewer and not the morsels n the shish-kebab). The advocating for such a philosophy has been avoided, because it automatically raises larger issues about the direction of society and challenges the current system. The essence of the matter is the need for new directions in philosophical approaches, methodologies and processes which will help us work towards a society inspired by a different world view. We need tactics, yes, but first we need innovative strategies. It is more necessary than ever to pass from a state of critiquing the current health system to actual concrete actions. Tactics must be shifted from a defensive position to one that offers positive, proactive choices. A positive strategy will be most effective if efforts are made to go beyond the political goal of obtaining the type of lowest-common-denominator that only serves to alleviate our guilt feelings [23].
Our Inherent Obligations
18. We ought not retreat into helpless passivity, watching the biological and social causes of the preventable ill-health all around us deteriorate. We can alter trends and avert catastrophes if we recognize and exercise our own power to make a difference. We all carry around with us a bag of unexamined credos, and this unexamined life is what comes under pressure when we are faced with tough decisions [24]. One of the greatest challenges facing humanity today is the challenge to meet the fundamental rights of poor people –in our case sanctioned by the universally corroborated right to health. In that sense, research, even applied, has acquired an elitist character, with little or no relevance to our concern for the real problems, needs and rights of poor people [25].
19. Moreover, from the effectiveness-in-combating-preventable-ill-health’s-point-of-view, international and national health meetings have too often become exercises in futility, organized and chaired by the same conservative groups year after year [26]. Health professionals should, more than others, leave behind academicism and begin to look at real people and their needs [27].
20. Respecting, protecting and fulfilling the rights of poor people will in most countries hardly require any new knowledge or any new hard technology. However, it will require political solutions which are likely to have a number of technological inputs. But the political solutions are not dependent on first making the technological inputs available [28]. There is no ethical choice here.
[Human rights focus on five clusters of needs (not limited to material needs): (1) access to basic personal consumer goods: food, clothing, housing, tools and furnishings. (2) universal access to basic social services: education (adult and child), clean water, preventive and curative health, environmental sanitation, communications, and legal services. (3) the right to productive employment, (4) an infrastructure (physical, human, technical, institutional) to produce goods and services, and (5) mass participation in decision-making and monitoring].
21. Not everyone supports the above right to health strategic conceptualization. The Roman emperors provided ‘bread and circuses’ for the masses; authoritarian regimes provide modern variants, e.g., ‘football stadia and rice’. Human rights defined in material terms, delivered by a bureaucracy and planned by an elite create client groups, demobilize grassroots groups and create new patterns of dependence. Devoid of a clear ideological orientation, human rights delivered top-down do not liberate but mystify, they do not mobilize but manipulate. On the other hand, technocratic basic needs models assume that the problems are largely due to management gaps in the decision-making together with an inability to grasp opportunities by the poor [18].
22. Clearly, there is no easy or short-term solution to the syndrome of excess-preventable-ill-health. The perniciousness of the statistical and technocratic approach to tackling preventable ill-health is that it has so many non-solutions built-in masquerading as fitting responses. The most serious of these is the implication that, for the poor countries, the salvation lies in obtaining the features of rich countries –doctors, hospitals and staff, specialists’ services, expensive equipment and a rich pharmacopeia of drugs [29]. But disease is not the consequence of a lack of health services, and the provision of primary health care alone will not bring about better health. Ultimately, levels of health, health status and living standards are determined by national development strategies and the international economic order [30]. Traditional public health and health plans, while they may purport they are committed to greater equity, do not per-se contain interventions conducive to attaining the objectives of a more egalitarian society [31].
Economic power, political power and poverty
The Economic and Political Discourse
23. It should come as no surprise that economic injustice is not an accident. When profit governs the day-to-day decisions of business, the health consequences on the ordinary poor person will inevitably be considered secondary. Policy cannot be governed by the profit motive and by love-thy-neighbor at the same time. Currently, the most that can be hoped for are a few compromises that alleviate some misery; but those sick, underfed and underprivileged millions are still among us, suffering [32].
24. An induced commitment to justice, on the other hand, is shakier than a genuine one, especially if ‘frightened into’ by the threat of terrorism [33]. Thus, in the long run, political (ideological) considerations will prove as potent as primarily health considerations when the aim is to achieve those relevant and durable solutions we so sorely need [20].
25. Limited by this underlying discourse, we are left without a more all-encompassing analytical framework capable of accounting for the impacts of the macro-economy on health. Therefore, public health decisions based on the results of efficiency analyses fall way short of what is needed. If public health policy makers have additional objectives they would like to consider in making health investment decisions –such as equity and quality of care considerations– it becomes imperative to incorporate them into a more structural analysis [34]. Moreover, given the current health-economics-state-of-the-art, cost-benefit analyses are about as neutral as voter literacy tests were in the Old US South. They are often ideologically biased documents designed to prove preconceived notions. Or, as somebody said, ‘they tend to support the vested interests of the sponsor of the estimate or to fit the hypothesis of the individual making the estimate’ [35].
The Poor
26. The poorest are the same everywhere. They are poor primarily because their needs are not central to the political priorities of governments [36]. They are prevented from translating their needs into effective demands in the only terms that the market understands: cash [37].
27. Market demand should be substituted by national consumption and production targets on the basis of minimum human needs. A spirit of noblesse-oblige towards the poor is not enough. Public health initiatives must thus be measured as the level of needs-satisfaction of the poorest 25%. [16]. A we-must-do-for-the-poor tone will only engender guilt and defensiveness, not energy for change [38].
The Establishment and Us
28. The Establishment is the people who create and sustain the climate of assumptions and opinions within which power is exercised [39]. The Establishment is thus a pretty clumsy monitor of morality [40]. In any society, the dominant groups are the ones with the most to hide about the way society works [41]. (Was there ever any domination which did not appear natural to those who exercised it? [42])
29. The danger exists that policy will be based on such dominant mythology. When helping to shape policy, public health planners frequently contend that not enough information is yet available to make definitive assessments of the interaction of different variables. The next step is, then: a call for more research… This argument is advanced even though absolute proof is an impossible goal. Political and economic opponents of any advocated changes are, of course, more than happy to espouse this argument that proof is not yet adequate, definite or sufficiently general to dictate policy [43].
30. Here, we need to remember that morality is one of the forms of social consciousness. It changes with each change of social order. The ruling class imposes its morality and puts it into practice in accord with its historical class interests. Politics, science, morality, art and religion are all forms of ideology [44].
31. In the analyses found in the literature, the Establishment is too often left undefined, but its characteristics are clear. Its ideology is based entirely upon commerce; qualitative values are postponed in favor of the quantitative. Everything in everyday life, from our films to our cooking, is dependent upon the notions the Establishment makes us have. Although it takes more than a myth to conquer half the world, the Establishment succeeds in its conquest by infiltrating everyday life with consolatory myths. [45] Modern myths justify and reinforce the power of the haves. But such myths based on false universals are insidious and only dull the pain; they may appear innocent, but in fact, have a stronghold upon our life [46, 47].
Attitudes Towards Poverty
32. No government can do everything. To govern is to choose. But poverty and preventable ill-health will persist and grow if the choice too often favors the peripheral extravagance over the critical need. Even in the poor countries that have enjoyed rapid growth, the poorest income groups have not shared in it equitably; their incomes have risen roughly only one third as fast as the national average. No government wants to perpetuate poverty and ill-health. But not all governments are doing something sustainable about it [48].
33. We cannot probe into the moral core of our societies’ ills unless we make clear that wealth conveys power over others –including political power– and that is the essence of the moral problem. Otherwise, one is left only with a moralistic admonishment –the concentration of wealth is bad, because it reflects greed [38].
34. Therefore, the crucial test of ethics is who defines who is functioning as a true social change agent. Without clear definitions and clear accountability, the search for the true innovator can be the excuse for repressive behavior. Public health professionals have had little to offer in this process of identifying true change agents. What is missing, then, urgently, is for these committed public health practitioners to adopt a new, more proactive political strategy [45].
35. Our acceptance of the established ways has an important consequence. It leads to a belief that those with wealth and power –even if inherited– deserve their good fortune. If the rules are fair –and we seldom question that they are– those who make their way must deserve what they have amassed. But a corolary of the acceptance of good fortunes is the acceptance of bad fortune. A man who is poor deserves to be poor –he must not have tried hard enough; perhaps if he had worked harder, he might have inherited something. Abroad, we doubt that poor nations really deserve the rich countries’ assistance. They must not have tried hard enough or, had they looked harder, they might have found oil. This attitude towards the permanently poor is confused with our attitude towards the temporarily afflicted those faced with sudden disaster. Not many nations are more generous than the G8 countries when disaster strikes. Yet, this generosity is only a natural extension of this same vision. Victims of disaster cannot be held responsible for their plight. This being so, any poor nation should not only be grateful, but permanently beholden to us for any aid, because it should be recognized that the receiving nation really does not deserve the money [49].
36. Therefore, a new relationship between the rich countries and the poor countries is needed. Not one of self-sacrifice and charily, but one of solidarity that leads to harmonize the rich countries’ changing needs with the aspirations of the poor countries [20]. In health, as in other development endeavors, charily cannot do the work of justice [50]. IN terms of the accepted morality, the barriers of class, race, and ethnic and religious prejudice, along with political and economic naivete till separate us from the stark reality out there [51].
37. Moralists would have sent money to a distant Mother Theresa (may she rest in peace), but ignore the poor only a few blocks away. We can look with anger and contempt at the selfishness of the rich in Calcutta who let the poor starve, but how about our own responsibilities for conditions in the ghettos/favelas/shanty towns of our own cities? Are we ourselves perhaps guilty? This is an unpleasant question. Better to think of the poor in Calcutta. The big difficulty arises from the traditional attitudes of the rich people. We are afraid of radical change. How to reduce our fear –transform our cowardice, really, is a mystery that no one has figured out [32].
Where do ‘liberal’ health workers stand?
A Need for Another Commitment
38. Unless ideologically inclined, many of us are content to take life as it comes when things go reasonably well, preferring to evade the troublesome question of life’s purpose or meaning. In times of trouble, however, the problem forces itself on our awareness. The greater the hardship we experience, the more pressing the question becomes for us [52].
39. As health workers and as intellectuals we are restless, often dissatisfied and critical and urgently in need of adopting a more proactive ideology. (…But we are also doing quite nicely: we may have a vested interest in the status quo…). And what is the ideology to be? Just a vague consensus for equal opportunity, but not for equity which ends up with equal access to everything for everybody? We often refer to ‘morality-and-fundamental-values’ and are good at exposing unintended consequences of well-intended measures. But this can be downright dangerous. This position has evolved into an independent force threatening to give legitimacy to a situation where essential conditions are set by corporate elites, where great inequities are rationalized and where democracy becomes an occasional. ritualistic gesture [53].
The ‘Liberal’ Approach
40. ‘Liberals’ are committed to stability as the prerequisite for justice –rather than the other way around. They (we?) have connections in the Establishment. They do address fundamental questions. In short, they are a new cast of experts (technocrats), and ‘reform-professionals’, yet ‘stability professionals’ might do equally well [53].
41. Are they just an example of a depressing genre: powerful diagnosis joined to feeble therapy? When making decisions they often play zero-sum games in which losses and gains are supposed to cancel out. However, in the real (skewed) world, it is much harder to play zero or positive sum games in which everybody or almost everybody wins something. Liberals are good at allocating gains but horrible at sharing out losses. They have acquired the capacity to stall indefinitely on policies and needed changes they oppose –just as organized interests do– showing us how honest rationality and self-interest frequently clash [54].
42. Much of what was called ‘liberalism’ in the last half of the 20th century was merely an accommodation to historical change, i.e., to circumstances. It represented a triumph of circumstance over ideology. Liberals, if sometimes reluctantly, made (and still make) a virtue of ‘adjusting’. Conservatives have a moral commitment to the past: that’s why they are conservatives. What has been called liberalism in the past has, in fact, been a kind of adaptive pragmatism [55].
43. In fact, no conservative thinker –not even Milton Friedman or Alexander Solzhenitsyn– has been fit to provide capitalism with a moral brain, a ‘theology’. And, without a creed, the future can look awfully bleak.
44. Not too differently, in the-world-that-liberalism-finally-made –the world of the welfare state and the transnational corporation– liberalism itself has become politically and intellectually bankrupt. Having overthrown feudalism and slavery and then outgrown its own growth pains, capitalism evolved towards a new strategic position: welfare-liberalism and ‘safety nets’. This position absolves individuals of moral responsibility and treats them as victims of social circumstances. Even reformers with the best intentions still condemn the lower class to second rate health care (to take just one example) and thus help to perpetuate the inequalities they seek to abolish. In the name of equity, they preserve the most insidious form of elitism [56]. The disparity between what liberals say in public and what they do in private is actually the reason why it is so easy for young people to unmask the hypocrisy of their liberal parents [57].
45. In the liberal tradition of the West, individual rights are valued more than social rights, and civil and political rights are more important than economic, social and cultural rights. In socialism, on the other hand, the right to work and to minimal levels of health and education outweigh personal freedoms, which are limited by economic and social considerations [58].
46. It is no surprise that liberals believe in the market and in unheeded competition. The market is to save the poor by slaying bureaucratic regulations and manipulative landlords and businessmen who shelter behind them. Just how selective market controls are to be achieved, to benefit the poor, is seldom analyzed or elaborated-on by liberals. Not surprisingly, liberals seldom see trade unions as institutions to be promoted and backed.
47. As can be guessed, liberalism has no operational political economy at its core. On the one hand, it is abstractly economistic and, on the other, its desire to demonstrate a caring interest has resulted in expunging any real perception of the nature of the political/economic conflict perceived in class terms. Unfortunately, the consequences of this are serious.
48. Not surprisingly, liberals have not and cannot become advocates of structural, truly democratic change [59].
49. Conversely, when we think of the left or leftist radicals, we think of people who espouse equity as an absolute and who measure injustice by distribution of wealth. But the right and the left do not occupy two extremes with a middle made up of liberals. Liberalism is another dimension altogether. It remains empty of standards, committed to everything and, therefore, to nothing [60].
50. Some say that the problem with labels (e.g., ‘liberals’) is that, when they are applied too soon or too loosely, they are, while not necessarily despicable, usually not to be trusted; that by trying to encapsulate too much, labels can oversimplify or mislead. Point well taken, but are we so way off…? Really, when it comes to the question of what, in positive terms, liberals stand for, answers are often fuzzy [53].
The Core Issues
51. The above notwithstanding, the time has come, perhaps, to ask the question modern liberalism has always ducked: Why is the wealth of so many self-proclaimed ‘egalitarian’ nation distributed so unfairly? The question itself sounds vaguely Marxists, which is one reason why welfare-state liberals have always ducked. The long march of liberal solutions to social injustice is evasive of the more fundamental questions about wealth and its gross maldistribution. The liberal mindset, honorable and well-intended, cannot confront the limits of a harsh reality that always will stand in its way: in the final balance, the welfare state cares best for the prosperous, not the poor [61]. Paradoxically, this does not necessarily lead to immediate crises; in the USA, for example, because there is more or less enough to go around the system can scandalously get away with no equity [62].
52. Perhaps as a corolary, the fashion of the times dictates that, even in countries that are not fully committed to genuine structural social change, health and health programs have become glamorous, popular subjects. Thus, one can see a political commitment to the ‘ideas-of-better-health-and-nutrition’ without commitment to deal with the concomitant deep-rooted social problems –in modern lingo: the social determinants of health [63].
53. People cannot wail forever: many of us want to do something now (…the danger being that some of us will run the risk of being victimized by repression) [64]. With this risk hanging over us, health planning suffers greatly from the mystification of the issues involved through the language used –perhaps this being a device used to disguise (with a technical cover) issues that are often politically hot. [65]. Technocrats amongst us tend to dodge the moral issues of preventable ill-health and preventable mortality: we are basically afraid to confront the hard-nosed reality of unresolved and lingering health issues, because it comes down to moral questions and these are non-scientific and hard to grapple with; so we slide away from them [62].
54. Our well-known predilection for health education interventions (which, in a way, blame the victims for their ‘ignorance’) is precisely the result of our adherence to a concept of society which derives from functionalist social theory. For the functionalists there are ‘practical difficulties’ and ‘obstacles to desirable changes’, but fortunately there are also ‘various technical solutions’ to overcome them, so in the end everything will be fine.
55. There is also often a total lack of social imagination among us health professionals. We are in for a period of rough and agonizing reappraisal if we are to contribute to a world that is changing with remarkable speed. It is incumbent upon us to make governments conscious of the many unpostponable health problems emphasizing that health interventions alone do not solve the problems at hand and that the answer is not to be found in small projects or with a few experts running around [66].
A critical look at our profession and ourselves
Our Limitations
56. Is it fair to say that we keep diagnosing the obvious and giving prognosis of a tragedy? Why do we keep emphasizing sectoral solutions that deal with what is deemed important and not with what is fundamental? Everything is important. But what is fundamental? Important is the help given to some needy groups, but fundamental is the promotion of more permanent structural social changes.
57. We keep making projections of trends of what we do not want to be continued. Trends are not destiny. The destiny is in our hands. When dealing with health problems, it is important to act on all their causes, as well as on the effects. It is useless to take care of the sick and malnourished while the social determinants of preventable ill-health and malnutrition are not tackled. We can propose steps to avoid those social causes from exerting their effects, or we can concentrate on solving the more immediate, non-structural existing problems. The greatest waste in this latter approach is time. Time wasted on diagnoses that actually check easily verifiable tendencies; time wasted on excess methodology. Decisions are thus delayed by a system without any synchronization with the speed of happenings [67]. We often fail to strike the right balance between academicism and activism.
58. What is ultimately bothersome is that all the elements needed to study preventable ill-health in its wider social and political context are there (i.e., unequal income and wealth distribution between the various sectors of society, the role of state and private interests and the conflicts between them) but, in spite of this, our colleagues continue to discuss matters to be overcome within a framework of cultural habits and ignorance. Their implicit social model (ideology) does not enable them to handle the complexity of social and economic phenomena they themselves witness [3]. They (blamingly) focus their analysis on the poor, not on the economic system that produces poverty. Thus, not paradoxically, most of the strategies for eradicating poverty have been directed at the poor themselves, but not at the economic system that produces it [68]. Problems are thus ‘solved’ in an isolated and totally a-political way, because there is still a lack of understanding of what determinants are really fundamental and how they need to be approached [4]. In our system, colleagues pointing out valid discrepancies between ideology and reality are disciplined rather than rewarded [69].
59. Projects dreamed-up in a social vacuum must play themselves out in the real world of injustice and conflict [70]. Their objective consequences may turn out to be different from the original subjective intent [71]. We need health experts who are strong and flexible enough to ask the right questions rather than sell the wrong answers [82]. In this context, intervention strategies can, therefore, be classified in three categories according to the principles that govern them: comprehensive strategies that are multidisciplinary in nature and call for multisectoral cooperation assuming that this meeting of minds will solve all problems; improvement strategies that ‘put the needed spare-parts to the system’ by assuming that only some things can be changed now, and transformation strategies that call for radical changes of the environment and/or the social system [73]. The idea is that only those strategies that somehow (and at some point in time) include the latter optic have any long-term potential.
Our Role and Our Responsibilities
60. What then is the appropriate role of public health professionals in people’s development in situations where exploitation and oppression are still a fact of life , but room still exists for economic and technological initiatives to improve the material status of the poor –at least up to a certain point? Many persons will deride such initiatives as ‘reformism’. But can the beneficiaries be easily mobilized for political action for structural changes if space for economic improvement within the existing structure still exists? Should progressive forces stand aloof from such space and leave them to be filled by real reformists thereby distracting mass attention from the need for fundamental social change for a more sustained improvement of their lives? Or should a combination of economic and political mobilization be pursued [74]? The answers to these questions are surely not easy. We can occasionally mobilize formidable coalitions generating a potentially irresistible ‘politics of outrage’. But public indignation is difficult to sustain; it can be dissipated by token, merely symbolic palliative responses [48].
61. We just need to confront the fact that there are two kinds of problems: reducible and irreducible. The difference between them is simple: reducible problems have clearly definable solutions while irreducible ones do not. You know when you have got the answer to a reducible problem –it fits like the right piece in a puzzle. But problems such as inequity, disparity or injustice appear irreducible, because their solutions are not fixable; this kind of problem mostly generates only vague, complex and temporary solutions. The problem with developments in public health is that too often we are trying to find reducible solutions to irreducible problems. Technological advances are the answer to reducible problems, but many hoped they would solve the irreducible problems as well. Misjudgement of the kind of problem and type of solution actually only compounds the problem [75].
62. When the world is messy, one falls back either on ideology or technology. Good young people respond to the seduction of technology. It’s more independent of experience and you do not have to know much [76]. But technology is not the origin of change; it merely is the means whereby society changes itself. Technology comprises not just tools and machines, but also skills and motivation. The wrong technologies have for too long been destroying genuine community life and have thus led to maldevelopment –prominently so in health [77].
63. There are, therefore, two kinds of revolution –technological and political. It is technology which is flattening differences around the world. Cultures which took centuries to build and sustain have been transformed by ‘development’ in a few decades. Technology dilutes and dissolves ideology. While political revolutions are almost always successful in response to a felt need –more liberty, a different racial division, or simply more bread– technology invents needs and exports problems. Political revolutions always have motives –a why– such as grievances, and the need for redress. Most of the times, these are neither light nor transient, but involve a long history of abuses and usurpations (Thomas Jefferson). Great technological changes, on the other hand, do not have a why. Technology, unlike politics, is irreversible. We may be able to develop a new strain of wheat and so address starvation somewhere. But it may not be in our power to cure injustice anywhere, even in our own country, much less in distant places [78].
64. The obvious question, then, is: Why not changing our order of thinking rather than trying to conquer preventable ill-health and malnutrition by the use of technology? Technology is basically improvisational. It treats the symptoms; it provides no lasting cures. Moreover, technology is part of the problem. New policies will thus require a patient and possibly painful reeducation of us all [79]. A technocratic utopia is the most banal of all utopias [80].
65. Technical pragmatism by men of good will can build national. regional and global strategies with no political sensitivity, appealing to all reasonable wo/men and purportedly capable of being implemented. Technocrats shore up fragments wrenched from ‘incomplete’ alternatives, often resulting in a pastiche and not a real synthesis. If this is the best that the best applied thinkers of the international public health Establishment can produce, then indeed public health thinking is a burnt-out case wandering in a desert. Nevertheless, faith in technocratic platonic warriors developing the world, remains unshaken. This leads an outsider to see a picture of general harmony of interests. It also leads to incoherence and to Western development aid not with a human face, but with bleary eyes and a nagging headache. We need to drop the fallacy of this universal harmony of interests so that areas of real parallel interests and negotiable compromises can be identified and promoted [81].
The future challenge
66. The real challenge in our present world is not to maximize happiness (in practice interpreted as maximizing economic growth, GNP, or the quantity of goods), but to organize our society to minimize suffering. Human happiness is undefinable; human suffering is concrete; it manifests itself as preventable sickness, unemployment, poverty, illiteracy and ignorance [82]. Western civilization will, therefore, not be judged so much on its vast accumulation of scientific knowledge on health, as on its trusteeship of that knowledge and its efficient application to the betterment of living and the minimization of suffering [83].
67. A program of consciousness raising directed at the public health community should perhaps then be undertaken as an initiative to apply science, technology and ideology to ‘another development’ in the sense described above [25].
68. The role of public health in raising mass consciousness is critical. It can uniquely generate an attitude of inquiry among the beneficiaries so that they can move from fatalistic preconceptions to a realization of their own power to change reality in their favor. Public health professionals can bring to them systematic knowledge of the wider social structure and its working (i.e., the social determinants of health), a knowledge that is critical in the choice of strategies for sustainable change in health. They need to bring to their attention successful initiatives to change health systems taken elsewhere, so that they may learn from those experiences [74]. The power of new ideas needs to be turned-on using the tools of the communications revolution which is upon us. New forms of learning, education, awareness creation and consciousness raising need to be pushed in this endeavor [7].
69. Even as health professionals, we do have a responsibility to abolish absolute poverty wherever it exists. Relative poverty (dissatisfaction with one’s relative position in the income pyramid) is important, but not morally important as a priority. We cannot keep enjoying our affluence, while most have not even gotten their essentials. The affluent 700 plus million people in the world must pay for the minimum income reforms needed. This will require a new ethos, a discouragement of consumerism –and experience shows that this cannot be done without a substantial change in power relations [84].
70. Conflict is common where there are competing interests. Therefore, avoiding it –as we often do– is no solution. Conflict is not necessarily violence. Conflict is a necessary means to attain true dialogue with people in authority. The poor do not achieve this until they have shown they are no longer servile and afraid. They need to move from the culture of silence to a position of dignified persons [85]. Where do you and I stand when it comes to promote this transition and to provide rallying points for mobilization in this direction?
71. Development in health has to lead to liberation. Any action that gives the people more control over their own health’s affairs is an action for development [86]. But this health development needs to be built from the bottom up. If this does not lake place, one has social Darwinism, i.e., the ones who survive are the richest, the most powerful, the whitest and the malest [87].
References
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[85] Bishops Institute for Social Action IV, Manila, Development Forum, No.7, 1980.
[86] Tanzanian National Union (TANU), Mwongozo (Guidelines), Tanzania.
[87] Perlman, J., SID Meeting, Horizons, USAID Washington, 1982, p. 36.
Claudio Schuftan, Ho Chi Minh City.