A restricted mandate and a reversal of logic
- The relationship between health and poverty is two way, but the relationship is not symmetric. Poverty is the single most important determinant of poor health. People suffer from ill-health and malnutrition because they are poor. But poor health is very far from being the single most important determinant of poverty. Poor health exacerbates existing poverty…and poverty is most often a political problem, i.e., people are poor because of structural, man-made situations.
- The neoliberal approach to health has turned this reasoning on its head by asserting that people are poor because they are ill, because there are too many of them, because they place a strain on scarce resources and — to add insult to injury– because they behave irresponsibly.
- But no amount of top-down health interventions delivered to Haitians or Tanzanians today are going to make them or their country prosperous tomorrow if the national economy is strangled by debt, unfair terms of trade and the continued pillage of natural resources. To this, add the destabilization caused by uncontrolled financial outflows, widely fluctuating commodity prices and outside interference in matters of national sovereignty.
Is economic growth the ultimate aim?
- The last 25 years of globalization (1980-2005) have shown clear declines in progress in development as compared with the previous two decades, e.g., income inequality has risen in most countries since the early-mid 1980s and in many cases sharply. Moreover, the higher the levels of inequality, the less impact economic growth has in reducing poverty –for any rate of economic growth. [Oddly enough, the development community frequently offers poor persons ‘micro’ versions of the advantages that the rich enjoy, such as, micro-credit –a micro-life perhaps…?]
- Globalization also gives us ‘doublespeak’: For example, ‘free’ trade is far from being free –it is very carefully set around the interests of private capital and rich nations. It also fosters the privatization of profits…and the nationalization of losses and debt. Worse even, economic liberalization is cynically made synonymous with political democracy, and the creation of decent livelihoods is made incidental to the making of money for those who already have far more of it than they need.
- The main differences that we have with the Sachs Report are that the neoliberal approach to health tends to blame the victims; a social justice/human rights approach to health blames the ‘system’.
- Some of the main thoughts that are of relevance to the right to health and to sustainable development in the alternative economics we put forward are as follows:
- The current system must be brought under democratic control.
- The economic system and structures should be informed by the ethical and political values of social justice and human rights.
- There is an urgent need to democratize the debate on economics and on health to encourage public action on these issues.
- Economic growth must be replaced by a fair distribution and sustainable use of existing and new resources; economic growth, when pursued, must not be achieved at the expense of poor people or the environment.
Health is what you get from health services?
- Health problems are not solved through technical interventions delivered through health services. Scaling up the access of the world’s poor persons to essential health services, including a focus on specific disease-oriented interventions, will not solve their health problems either.
- The Establishment further regards acting on the major determinants of health as ‘complementary and additional actions’ rather than as the fundamental actions in reaching Health For All.
- ‘The major interventions required lie outside the health sector’ –people repeat this over and over. But it is hard to tell if we are dealing with insincere lip service, ignorance or cynicism here.
- The bottom line is that the proportion of diseases attributable to factors lying outside the health sector –and which cannot be addressed through health services– is overwhelming.
- It is, therefore, puzzling to find statements in the Sachs Report urging the international health community to undertake yet more research or to base policy on ‘evidence’ –as if in the past, public health decision makers sifted through policy options selecting at random or even selecting those for which there was no evidence!
- Do we need to say it again? In the context of basic interventions for health, we do have all the knowledge we need to eradicate the major burden of disease and its root cause –poverty.
14 The political will is lacking among those who have the power to eradicate disease and poverty and who have in no small measure contributed to the current state of affairs (or is it a deliberate choice rather than a lack of will…?).
International aid is the only way to finance health?
- Seriously suggesting that there are no ways of distributing income and assets between countries other than through international aid is, we think, a fallacy.
- The Human Rights-based approach to health rejects poverty being ‘a fact of life’ and focuses attention on impoverishment as a process that is inherent to capitalist accumulation and the inevitable and galloping concentration of power and wealth.
- The factors that allow the North to flourish, the South to wither and the disparities to widen are at the centre of inequities in health. It is simply impossible for all nations to benefit from unfair terms of trade.
And international aid is not designed to change the structure and dynamics of relations between North and South. Aid is more an instrument to project power beyond national borders. So we see the globalised economy of today as equivalent and not greatly different from the colonial economy of the past. Moreover, official aid can be considered to function largely as an export subsidy for Northern companies.
- Aid then, inevitably results in undue influence if not outright interference in national public policy. The supposed beneficiaries (the people) are very rarely consulted, but then neither are their elected representatives.
- Because of this, the Human Rights-based approach to health rejects the assumption that international aid is the only way to finance health and proposes an alternative assumption: A fair and rational international economic order so that sovereign and solvent states can meet the needs of their people sustainably and without external interference.
(contd)
Claudio Schuftan, Ho Chi Minh City