Public health rarely works through magic bullets – and public health professionals need what the poet Adrienne Rich has called “wild patience” combining ingenuity, evidence, common sense, passion, a sense of urgency and above all a sense of justice. The two public health revolutions that have changed the face of health and disease in the industrialized countries in the 19th and 20th century were the results of often harsh political and ideological battles spread out over decades which always accompanied the professional and scientific progress and discoveries. And of course the two revolutions: the control of infectious disease through health protective measures and the consequent battle against non-communicable disease are both still on going.
But the achievements of these two revolutions in the developed world stand in stark contrast to the situation in the underdeveloped countries, particularly in rural areas, where the predominant pattern is still that of infectious diseases engendered by the natural environment, such as malaria, tuberculosis and infant diarrhoea, as well as AIDS and high rates of maternal deaths.
We have mounting signals that a new health divide is in the making in the developed world. Indeed it is becoming more and more difficult to define the rich and the poor of this world at the level of the nation state as a large global underclass spreads out around the globe and defies the old definitions of vulnerable groups. HIV/AIDS is only the most visible of the diseases of poverty that undermine the life chances of the poor and in a perverse and unintended consequence – as David Molyneux has shown recently and as the Global Governance Initiative Report also indicates – it might even divert much needed resources from other diseases of poverty that otherwise could be addressed efficiently.
The solutions to this crisis go far beyond the expert based answers (many of which we have). We need not only forceful public health action at nation state level in both the developed and the developing world – we also need nothing less than a new global social contract on health. The drive for such a contract can only be established politically - developed through an ethical and political debate throughout society initiated by outspoken public health professionals, responsible politicians and a concerned civil society at national and global levels of governance.
A new global social contract on health
This means underlining the importance of the state and the public sector; it means translating the do-ability of health into strong public health systems with both a national and a global dimension because they can be separated less and less. Disease maintains poverty and negatively affects growth and security in both developing and developed societies – universal access and efficient managing of health care systems are increasingly important components of good governance. This shift of perspective is central.
Amartya Sen has always insisted that the understanding of health as an end (the right of citizenship) is as important as the utilitarian principle of health as a means – and the public health community must never lose sight of the interface between the two.
In summary let me do a quick revisiting of five key issues:
1. Health as a global public good implies ensuring the value of health, understanding it as a key dimension of global citizenship and keeping it high on the global political agenda. It implies defining common agendas, increasing the importance of global health treaties and increasing pooling of sovereignty by nation states in the area of health.
2. Health as a key component of global security implies an extensive global health surveillance role and expanded international health regulations with interventionist power for the World Health Organization and sanctions (through other bodies such as the World Trade Organization or the International Court of Justice) for countries that do not comply – the financing of a global surveillance infrastructure, a rapid health response force would be ensured through a new kind of global public goods tax.
3. Strengthening global health governance for interdependence means strengthening the World Health Organization and giving it a new and stronger mandate. It must have the constitutional capability to ensure agenda coherence in global health (also vis a vis the development banks), it must be able to strengthen its convening capabilities and it should be able to ensure transparency and accountability in global health governance through a new kind of reporting system that is requested of all international health actors. Indeed recognition of its coordination and leadership role should significantly reduce the transaction costs for countries and for donors and should include a brokering role in relation to the health impacts of policies of other agencies. It should also be the coordinator of health in crises by acting as the intermediate health authority. Finally it should be able to take countries to the international court for crimes against humanity if they clearly refuse to take action based on the best public health evidence and knowledge.
4. Accepting health as a key factor of sound business practice and social responsibility means increasing the capacity of the WHO to develop a new system of access to drugs based on a global public goods model. For example in the area of pricing, joint negotiations by 10 Latin American Countries (together with PAHO) with global players on antiretroviral drugs led to a 92% price reduction. Clearly legally binding / Global Health Conventions such as the Framework Convention on Tobacco Control must be developed and strengthened. Finally there is an enormous scope – as the work on nutrition has shown – for producing and marketing health and safe products to the poor – such new business models should be part of the work of the World Economic Forum. But it is even more important to develop a model package of a Bismarckian type of global health insurance together with the insurance industry and perhaps the ILO, the ISSA and the World Bank. We need to work on a model that ensures access to prevention, care and treatment in developing countries – and it cannot be piecemeal any more. Clearly health and social protection cannot be separated - this falls squarely into the Goal 8 on global partnerships of the Millennium Development Goals.
5. Accept the ethical principle of health as global citizenship. I believe firmly that ethical norms apply to international relations – and as Nigel Dower points out – “If citizens are increasingly motivated by global concerns then cosmopolitan goals enter domestic policy in that way and people can be effective global citizens by being effective global oriented citizens of their own states.” In particular this implies a common notion of social justice and a system of international law where human rights constitute a legal claim. As a German I would like to end with Immanuel Kant’s words: “to act that you treat humanity whether in your own person or any other person never merely as a means but as an end in itself.” (1785)
Kant’s thinking leads us beyond the state towards our obligations of citizens in a global world and highlights our obligations to any human being anywhere in the world. Indeed a guiding phrase for the beginning of a new public health revolution!
*Ilona Kickbusch PhD is known throughout the world for her contributions to innovation in public health, health promotion and global health. She has had a distinguished career with the World Health Organization and Yale University. She is a sought after speaker and advisor on policies and strategies to promote health. She now works as an independent global health consultant based in Switzerland. Contact: www.ilonakickbusch.com. This article is a short extract of Ilona Kickbusch‘s Leavell lectureship of the World Federation of Public Health Associations, Brighton, April 2004. Reproduced with the kind permission of the author.
