Who cares about health for all in the 21st century?
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by Fran Baum *
Journal of Epidemiology and Community Health 2005;59;714-715
This paper regrets the retreat in the 1990s from a focus on
health as a social good that results from good social policy. It
highlights the importance of the People's Health Movement and
the WHO Commission on the Social Determinants of Health as of-
fering a chance to return to a more socially just quest for eq-
uity and health.
It's been a peculiar century so far. It started off with the
great and lofty thoughts that accompany centennial change. Mil-
lennium summits, domes, and plans for a peaceful century in
which human health and wellbeing blossomed. With amazing rapid-
ity, in the wake of 11 September 2001, it deteriorated into a
century of fundamentalisms, acute fear of terrorism, and an un-
provoked attack on a sovereign state that was not backed by the
United Nations or the majority of citizens of the countries go-
ing to war. The aftermath of the war in Iraq has become a public
health nightmare and there are few signs of the flourishing of
democracy that was meant to justify the war .Meanwhile the
deeper causes of global instability persist and the USA spends
more on war than it does on tackling extreme poverty. Sachs es-
timates that eight million people die each year because they are
too poor to stay alive. The 21st century, then, is proving to be
a disaster for Africa and many other postcolonial states who
face economic disaster under the burden of crippling debt and
the onslaught of both old (such as malaria) and new infectious
diseases (most notably HIV/AIDS). Life expectancy in Africa is
going backwards for the first time in over a century. Meanwhile
the populations of OECD countries are experiencing growth in
wealth and prosperity, albeit with increasing inequities between
the rich and poor.
IMPORTANCE OF VISIONARY LEADERSHIP
It is against this background that I pose the question: who ca-
res about Health for All in this century? The answer would have
been easier if we had gone back 25 years to the period around
1980. The World Health Organisation under the charismatic lead-
ership of Dr Halfdan Mahler had launched the Health for All by
the Year 2000 campaign and the target seemed a real possibility.
WHO was widely respected as a lead organisation in global health
with a leader who was visionary and inspiring. Many public
health doctors now in their 50s and 60s remember with affection
the great inspiration they received from the HFA2000 strategy.
Mahler's leadership lasted through to the 1980s when the Ottawa
Charter for Health Promotion inspired more people to adopt a
comprehensive model of promoting health that did not blame indi-
viduals but rather focused on creating environments and making
policies in which people could flourish and make easy, healthy
choices. I remember my own excitement on reading the Ottawa
Charter and seeing that it could move health promotion beyond
simple ineffective behaviour change strategies to whole of com-
munity approaches to improving wellbeing. There was a buzz in
public health then, a palpable feeling that we were on the right
track with Healthy Cities, Healthy Schools, and other such ini-
tiatives, comprehensive primary health care plans, community in-
volvement, and a growing (if fragile) commitment to equity in
health. Sadly, much of this idealism was lost in the 1990s. WHO
lost its ability to inspire and seemed to give up its leadership
in global health to the World Bank. This was most obvious in
1993 with the publication of the World Bank's Investing in
Health. This report saw health as a crucial part of economic de-
velopment but did not see health as a human right. This approach
was consolidated with the notion of disability adjusted life
years (DALYs) that privileged the value of lives of those who
were young and without disability. These approaches to health
were very much in line with the zeitgeist of prescription of
structural adjustment throughout the developing world-completely
without an evidence base or sound justification. The WHO did
nothing to challenge this neoliberalism and seemed to endorse
the general direction with its Commission on Macro-economics and
Health. In fact the main challenge within public health came
from outside governments and international agencies. It came
from grass roots and activist movements who despaired at the di-
rection of global health and came together in December 2000 in
Savar Bangladesh at the People's Health Assembly.
FIRST PEOPLE'S HEALTH ASSEMBLY AND PEOPLE'S HEALTH MOVEMENT
This was truly a civil society movement that had roots in popu-
lar people's organisations from around the globe.
At this assembly the 1500 people attending provided testimonies
of the impact of neoliberalism on their lives, health, and well-
being. These testimonies were combined with analysis of the
global economic trends and the role of major public health in-
stitutions such as the WHO and World Bank. Topics discussed in-
cluded: the ways in which the international regime that governs
global trade is fundamentally unfair and biased against poor
countries; the impact of unsustainable environmental practices;
and the need for a return to people centred primary health care
that focuses on the development needs of communities and not on
disease focus strategies imposed from outside. The People's
Health Movement emerged from this event. Its philosophy and ap-
proach to global health is laid out in the People's Health Char-
ter, which has been translated into 42 languages. In July 2005
the Second People's Health Assembly took place in Cuenca, Ecua-
dor and was a major milestone in the road back to a public
health based on the needs of ordinary people rather than on the
demands of a neoliberal economic fundamentalism. The catchcry of
the Second People's Health Assembly was ''The Voices of the
Earth are Calling!'' This captures the grass roots nature of the
movement. The health of the world's indigenous people received
special focus at the assembly. In so many ways indigenous people
highlight what is wrong with our approach to health. Australia
exemplifies this well. It is one of the world's richest coun-
tries yet the life expectancy of its indigenous peoples is 20
years less than non-indigenous Australians. Instead of being
celebrated as the first peoples of the land and given special
status, colonial and racist ideas have led to systematic poli-
cies that have seen indigenous people deprived of their land and
culture, stolen from their families, excluded from the economic
benefits of the mainstream, and then blamed and vilified when
their health suffered as a result of the cruel and inhuman poli-
cies.
GLOBAL CIVIL SOCIETY CARES
The other signs of caring about achieving health for all in the
21st century come from the ''Make Poverty History'' campaign
with the goals of ''trade justice, drop the debt, more and bet-
ter aid''. The campaign focuses on the 2.8 billion people
(nearly half the world's population) who live on less than US$2
per day. It is driven by a range of non-government organisations
and global campaigners such as Sir Bob Geldof and calls directly
on the G8 countries to drop debt for the most heavily indebted
nations and for aid to be increased to 0.7% of GDP as recom-
mended by the UN Millennium Summit. Achievement of these aims
has the potential to make our world healthier and more equita-
ble. But this will only happen if what follows is an approach to
health and wellbeing that builds on the early, visionary history
of the WHO that recognised that health is not just about the ab-
sence of disease but about improving the quality of everyday
life in terms of our relationships with each other, the safety
of and satisfaction with our schools and workplaces, the quality
and sustainability of transport and housing, the availability of
education, sustainability of the environment, and freedom from
violence and war. So often those who want to do good do not act
on this knowledge. Rather they focus on the diseases and believe
that tackling them will do the job of creating more health and
equity. So we have seen the flourishing of bodies such as the
Global Fund and Gates Foundation that, with the best of inten-
tions, set out to tackle a range of infectious diseases. Yet
they do very little to tackle the broad social and economic de-
terminants of health that dictate who gets what disease. Healthy
people are mainly healthy, not primarily because they have ac-
cess to good health services (although this helps), but because
they have good food, comfortably homes, live in a peaceful envi-
ronment, have good social support, adequate income, and a satis-
fying job.
SIGNS OF HOPE: SECOND PEOPLE'S HEALTH ASSEMBLY AND WHO
COMMISSION ON THE SOCIAL DETERMINANTS OF HEALTH
It just could be that 2005 may be remembered as the year the so-
cial and economic determinants of health began to be taken
really seriously globally, nationally, regionally, and locally.
In July 2005 the Second People's Health Assembly took this
knowledge as central to its deliberations about how to make the
world healthier and more equitable. In March 2005 the WHO
launched its own Commission on the Social Determinants of Health
(CSDH). This commission will place a primary emphasis on the un-
derlying factors that determine how healthy populations are and
how equitably health is distributed within populations. It will
emphasise that health services, while crucial, are only one of
the determinants of health and that most health gain will come
from going
upstream to focus on those factors such as employment, housing,
quality of living environments, social relationships, and educa-
tion that are the main determinants of how healthy we are. The
commission works on the assumption that creating healthy socie-
ties and individuals largely results from action outside the
health sector.
The CSDH will use three key strategies to achieve its aims.
Firstly, it will establish knowledge networks preliminarily en-
titled: Priority Public Health Diseases; Child Health and Educa-
tion; Financing; Human Settlements; Social Exclusion; Employ-
ment; Globalisation; Health Systems, Measurement, Gender and
Women's Empowerment. Secondly, it will work with countries to
ensure action on the social and economic determinants of health.
Thirdly, it will work to reform the WHO by ensuring that aware-
ness of the importance of the social and economic determinants
of health informs all its work and becomes evident in its re-
sponse to health issues.
The commission has great potential to assist Dr J W Lee, the
current director general, to leave as his legacy a reformed WHO
that is imbued with a strong understanding and determination to
act on the social and economic determinants of health and a pub-
lic health community that accepts the inevitable logic and sense
of designing all interventions based on this understanding.
MAKING SOCIAL DETERMINANTS OF HEALTH CENTRAL
The path taken by the People's Health Movement and the CSDH is
not going to be easy. While more funding has gone into global
health in recent years the overwhelming amount of it has gone
into disease initiatives that do not tackle the underlying so-
cial and economic determinants of health. However, if the Peo-
ple's Health Movement and the CSDH are successful in picking up
the baton from the earlier Health for All 2000 movement they may
form the vanguard of a successful movement for a socially just
and healthier world in which policy decisions are driven primar-
ily by this vision rather than by decisions that maximise profit
for a small elite. If the public health community does care
about health for all in this century then it must put its full
support behind the People's Health Movement and the Commission
on the Social Determinants of Health.
Correspondence to: mailto:fran.baum@flinders.edu.au
(*): Fran Baum has been a member of the Global Steering Group of
the People's Health Movement since 2000 and was appointed as a
Commissioner on the WHO Commission on the Social Determinants of
Health in March 2005.