Promotion and Education, Vol.XV, No.3, 2008.
CLAUDIO SCHUFTAN, MD
cschuftan@phmovement.org
Abstract
The topic of the above title has vividly interested the author for many years. Regretfully, 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. 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 pertaining the title.
The materials here presented 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 are, in a way, ‘out-of-the-box’ and, in the author’s view very needed despite this being a commentary piece. The article sheds some light on 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.
HEALTH PROFESSIONALS AS INTELLECTUALS
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? Or are they duty-bound to immerse themselves in the society they are part-of to articulate a deeper consciousness? Or, perhaps, are they natural leaders, destined not only to provide better ideas that can reshape health services, but also make sure that they are implemented? [1]
Intellectuals too often bend the rules of the prevailing discourse to suit their own interests; they argue for what they want to believe. Doctors are no exception. They too often 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 [2]. We are not independent intellectuals floating somewhere above the economic system: we’re part of it. [3]
Without challenging the ideology many of us find abhorrent, we only perpetuate the passivity that has become our central image [4]. We are prisoners of our own past training and often of somebody else’s thought. [5]
We also often use statistical illusions devised by our own academic elites which do not fit any real-life cases anywhere in the world [6]. 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. [7]
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. 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. [8]
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 (…e.g., 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. [9]
The complex nature of the problems of preventable ill-health complicates our policy making. The essence of the problem transcends its 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 in a shish-kebab). The advocating for such a philosophy has been largely avoided. What is needed are 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. [10]
OUR INHERENT OBLIGATIONS
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 [11]. One of the greatest challenges facing humanity today is the challenge to meet the fundamental human 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 [12]. Health professionals should, more than others, leave behind academicism and begin to look at real people and their needs. [13]
Respecting, protecting and fulfilling the human rights of poor people will in most countries hardly require any new knowledge or any new hard technology. However, it will require political solutions. But the political solutions are not dependent on first making the technological inputs available [14]. There is no ethical choice here.
But beware: 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. [7]
Clearly, there is no easy or short-term solution to the syndrome of excess-preventable-ill-health and deaths. The perniciousness of the 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 [15]. 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 [16]. 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. [17]
A NEED FOR ANOTHER COMMITMENT
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. [18]
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 according to need? 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 (voting) gesture. [19]
THE ‘LIBERAL’ APPROACH
‘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 cast of experts (technocrats), and ‘reform-professionals’, yet ‘stability professionals’ might do equally well. [19]
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 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 –just as organized interests do. [20]
Liberals, if sometimes reluctantly, 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. [21]
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. Capitalism evolved towards a strategic position with welfare-liberalism and ‘safety nets’ at its center. 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 [22]. 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 [23]. By the way, liberals seldom see trade unions as institutions to be promoted and backed.
Not surprisingly, liberals have not and cannot become advocates of structural, truly democratic change. [24]
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. [25]
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 here…? Really, when it comes to the question of what, in positive terms, liberals stand for, answers are often fuzzy [20].
OUR LIMITATIONS
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.
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 [26]. We often fail to strike the right balance between academicism and activism.
So many of our colleagues continue to discuss matters to be overcome as problems 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 [27]. 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 [28]. 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 [29]. In our system, colleagues pointing out valid discrepancies between ideology and reality are disciplined rather than rewarded. [30]
Projects dreamed-up in a social vacuum must play themselves out in the real world of injustice and conflict [31]. We need health experts who are strong and flexible enough to ask the right questions rather than sell the wrong answers. [32]
OUR ROLE AND OUR RESPONSIBILITIES
What then is the appropriate role of public health professionals in people’s development in situations where marginalization, 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 ‘reformist’. But can the beneficiaries be easily mobilized for political action for structural changes? Why distracting mass attention from the need for fundamental social change for a more sustained improvement of their lives? Should a combination of economic and political mobilization be pursued [33]? 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. [34]
To many, problems such as inequity, disparity or injustice appear irreducible, because their solutions are not fixable; these kinds of problems mostly generate 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 [35]
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 [36]. 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. [37]
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. Great technological changes 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. [38]
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 [39]. A technocratic utopia is the most banal of all utopias [40].
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. 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. [41]
THE FUTURE CHALLENGE
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 [32]. 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. [42]
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 [12].
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 [33]. New forms of learning, education, awareness creation and consciousness raising need to be pushed in this endeavour. [43]
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. [44]
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 [45]. Where do you and I stand when it comes to promote this transition and to provide rallying points for mobilization in this direction?
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 [46]. But this health development needs to be built from the bottom up. If this does not take place, one has social Darwinism, i.e., the ones who survive are the richest, the most powerful, the whitest and the malest [47].
References
[A number of the quotes from this reference list have been adapted to fit the text, but credit is always given to the source where they originated].
[1] Lewis, F., reviewing: The Intellectual Resistance in Europe’ by J. D. Wilkinson, Intl. Herald Tribune, July 30, 1981, p.12.
[2] Midgley, M., Beast and man: the roots of human nature; in The Sociobiology Debate: Readings on ethical and scientific issues, as reviewed by W. McPherson, Wash. Post E-1, Oct. 15, 1978.
[3] Adapted from Ottman, R., In praise of impertinent questions. Book World, Wash. Post, Jan. 6, 1978, p.32.
[4] Adapted from Brunette, P., Afraid and alone in the dark. Book World, Wash. Post, March 2, 1980.
[5] Ul Haq. M., The fault is ours, New Internationalist, No.32, Oct., 1975, p.19.
[6] Henderson. H., The politics of the solar age, Doubleday, New York, 1981.
[7] Green, R.H., Basic human needs: a strategic conceptualization toward another development, IFDA Dossier 2, Nov.. 1978.
[8] Exact reference to these quotes lost to the author.
[9] Galtung, J., What is a strategy?, IFDA Dossier 6, April, 1979.
[10] Hetzel, N., A sustainable development strategy, IFDA Dossier 9, July, 1979.
[11] West, M., Wash. Post, E-2, Jan. 14, 1979.
[12] Mattis, A., Science and technology for self-reliant development, IFDA Dossier 4, Feb.,1979.
[13] Adapted from Kirkpatrick, J., De-westernizing medicine: concepts and issues in the literature, mimeo. Proc. 10th Intl. Congress of Anthropology and Ethnographical Sciences, Poona, 1978.
[14] Sigurdson, J., Better analytical tools and social intelligence, The Lund Letter on Science, Technology and Basic Human Needs, Letter No.6, July, 1978.
[15] Senevirante, G., Can statistics lie? World Health, June, 1982, pp.8-11.
[16] Tursher, M. and Thebaud, A., International medical aid, Monthly Review, December, 1981, pp.39-50.
[17] Mangahas, M., Why are we reluctant to set numerical equity targets?, Nutr. Plng., Vol.3, 1980, p.102.
[18] Adapted from Bettelheim, B., Surviving and Other Essays, Knopf, New York, 1979.
[19] Adapted from Geyelin, P., Book review of ‘The Neo-conservatives’ by P. Steinfels, Book World, Wash. Post, April 27, 1980.
[20] Adapted from Lekachman, R., Book review of ‘The Zero-sum Society’ by L. Thurow, Book World. Wash, Post, April 27, 1980.
[21] Galbraith, J.K., Liberals under the circumstances, Intl. Herald Tribune, Jan. 15, 1981, p.4.
[22] Lasch, C., The culture of narcissism: American life in an age of diminishing expectations, as reviewed by W. McPherson, Wash. Post, E-1, Feb. 4, 1979.
[23] McWilliams, W.C., Liberal dialogue: Do you want to talk about it?, Book World, Wash. Post, Dec 21, 1980, p.9.
[24] Adapted from Green. R.H., The international market will save the human race (with a little help), The World Bank’s 1979 development report, IFDA Dossier 14, Dec., 1979, p.119.
[25] Lowi, T.J., Where is liberalism, now that we really need it?, Wash. Post, C-8, Oct. 31, 1982.
[26] Lerner. J., A new strategy for urban development, IFDA Dossier 7, May, 1979.
[27] Bantje, H., Constraint mechanisms and social theory in health education, mimeo, BRALUP, University of Dar Es Salaam, Tanzania. Proc. 11th Intl. Congress of the IUNS, Rio de Janeiro, 1978.
[28] Navarro, V., The industrialization of fetichism or, the fetichism of industrialization: a critique of Ivan Illich, Soc. Sci. and Med., Vol. 9, 1975, p. 360.
[29] Barth-Eide, W. and Steady, F., Evaluation in an African context: with special emphasis on the women producer and reproducer. Some theoretical considerations, mimeo. Proc. Symposium on Anthropology and Health, 11th Intl. Congress of Health, Rio de Janeiro, 1978.
[30] Andrews, O., The perils of bureaucracy, Development Forum, March, 1986, p.2.
[31] Collins, J. and Lappe. F.M., The World Bank, IFDA Dossier 5, March, 1979.
[32] Moore Jr., B., cited by G.A. Karlsson in [84].
[33] Rahman A.:, Science for social revolution, IFDA Dossier 4, Feb., 1979.
[34] Schuck, P.H., Reviewing ‘Revolt Against Regulation’ by M. Pertschuk, Book World, Wash. Post, Dec. 12, 1982, p.5.
[35] Adamson. A., The decade that limped, New Internationalist, No.83, 1979.
[36] Bell, D., cited by B. Nossiter, Wash. Post, B-5, May 20, 1979.
[37] Wilson, S.S., Debate. The Lund Letter on Science, Technology and Basic Human Needs, Letter No.6. July, 1978.
[38] Boorstin D.J., The Republic of Technology: Reflections on our Future Community, reviewed by F. Mankiewiez, Wash. Post, E-6, Aug. 13, 1978.
[39] Adapted from Omo-Fadaka. J., Water planning and management – an alternative view, IFDA Dossier 7, May, 1979.
[40] From a speech by Erhard Eppler, former Minister of Economic Cooperation, Fed. Rep. Germany.
[41] Green, R.H., The IBRD world development report, IFDA Dossier 2, Nov., 1978.
[42] Fendall, R., Health development in Southern Africa, mimeo, SADAP, USAID, Washington DC, 1978.
[43] Development: A long moment of doubt. An interview with Ponna Wignaraja, Development Forum, Vol.X, No. 5, p.10, 1982.
[44] Karlsson, G.A., The richest 640 million, New Internationalist, Vol.32, No. 30, 1975.
[45] Bishops Institute for Social Action IV, Manila, Development Forum, No.7, 1980.
[46] Tanzanian National Union (TANU), Mwongozo (Guidelines), Tanzania.
[47] Perlman, J., SID Meeting, Horizons, USAID Washington, 1982, p. 36.
Claudio Schuftan, Ho Chi Minh City.