Power and politics in global health
Ron Thomas Varghese writes about the impact of power and politics on global health, including personal observations of the role of these factors in his home country, India.
The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The health of every citizen is a top priority for every country irrespective its system of governance. However the question still remains, can such an ideal concept of health be attained by all countries and governments?
Among the systems of governance available today, democracy seems to be the best option through which the goal of health for all can be achieved. Examples of the failure of other systems of governance to achieve this goal of health are many. One stark reminder is the failure of Communism to achieve health in USSR and Eastern Europe, even whilst trying to establish a welfare state with equal rights for all. Also an analysis of political history and health is incomplete without mentioning the unethical and despicable attempts by the Nazi doctors in a fascist form of governance to create a perfect Aryan race. Critics may argue that democracy too has its pitfalls, as the choices of the majority are imposed on the rest irrespective of whether or not they are morally and ethically right. However it must remembered that the majority need not always be right. For example, the Nazis were actually democratically first voted to power in Germany, leading to the worst part of German medical history. In summary, having viewed the pros and cons of democracy, I strongly feel that democracy is the only plausible form of governance that is suited to achieve this goal of health for all
The current major controversy in preventing our achievement of health is the escalating food prices and scarcity of food in poor countries. Such a situation was never contemplated in lieu of the industrial revolution, green revolution and the biotech revolution. These revolutions were thought to be the key to eradicating hunger from the world. Many theories exist to explain the reasons behind these food shortages. According to one un-named president of a developed country is because people (gluttons) from India and China are eating too much nutritious food (1). Others have blamed the crisis on the fact that developed countries are using food grains to produce biofuel in their efforts to achieve energy security.(2,3). Such a policy decision when viewed from the perspective of poorer countries simply lacks sensitivity and humane considerations, especially when millions are starving in Africa. However both these explanations sound bizarre and unconvincing. Yet, despite not being able to identify the cause of global food shortages, we must not dismiss the significance of the situation. In fact regimens have fallen on account of hunger, for example the downfall of Emperor Haile Selassie in Ethiopia and the rise of Khmer rouge in Cambodia. If the crisis is due to the developing countries self-interest, they learn to be more holistic in their policy making. To achieve greater political stability throughout the world, should food security not be a higher priority compared to energy security?
The withdrawal of the governments from the healthcare sector is being viewed with dismay by most people in third world countries. Quality subsidized health care for the poor and needy is an urgent necessity. Leaving this healthcare solely to the private sector is fraught with danger. Hillary Clinton’s statement that 40 million in the USA were not covered by medical insurance came as a shock to many in the third world. The dangers of leaving health care and insurance totally to private firms leaves to many people, especially the poor, being unable to afford even basic healthcare.
The world is truly becoming smaller world, and this is increasingly forcing our doctors to be global physicians. A good knowledge about the global health problems, beyond the confines of the doctors own country, is essential. In fact, I feel that thinking globally and acting locally ought to be the mantra of every doctor. The sacking of many South Asian doctors, who many argue formed the backbone of NHS, was unfortunately a retrograde step in this direction. Every country has to safeguard the rights of its citizens, but such ‘political stunts’ will only serve to work against the ideals of global health.
With the advent of globalization most goods available in the west are now available in developing nations. However, drugs seem to be an exception to this rule. Providing good quality drugs at an affordable cost ought to be given more attention by pharmaceutical companies. Antiretroviral drugs especially must be made available to poor African countries at subsidized rates to battle the epidemic proportion of AIDS. This will ensure equitability in the availability of drugs however strong political will and courage is necessary for such progress to occur.
The flipside of globalization is medical tourism. This is a system in which the relatively well off from developed countries swarm to developing countries in search of low cost health care. In such a scenario it is the poor in these “tourism destinations” that suffer as it draws doctors away from the core basic healthcare system. Third world political leadership needs to address these concerns urgently. If they fail, the health disparity will only widen between the rich and poor of these countries.
Writing from India, which contributes approximately 1/6th of the world population, I feel that the healthcare situation in India deserves a mention. Countries like India, experiencing an epidemiological transition following the economic boom, are now finding it tough to tackle the double burden of communicable and non-communicable diseases. On one hand India has to deal with the malnutrition and poverty affecting the poor and on the other the burden of lifestyle diseases like diabetes and hypertension is reaching epidemic proportions in the middle class. Only strong political will can achieve a more equitable distribution of wealth in health. For an optimal health scenario, the economic growth and prosperity of any country has to be spread equally. The problems in this area come up when arbitrary decisions are taken by the governments without consulting doctors in matters pertaining to health care. For example, the political establishment in India has decided to implement one year of rural service to all fresh medical graduates to serve the rural poor. For such a programme to succeed a programme, it has to get the goodwill and support of the doctors concerned. No doctor would oppose such a programme if they were given a decent remuneration for their services in such difficult rural areas (4). However with the government proposing paltry salary for these doctors, there have been vehement protests. As an Indian doctor I do feel that it is the honor of a doctor that is at stake. No financial or political reasons can justify such a punishment of doctors, paying them peanuts for doing this noble work. On a positive note, the Indian government is contemplating a ban on smoking in public places .This has come across stiff resistance from the tobacco lobby and trade unions, despite both parties possessing strong political clout. The ministry is determined to implement the proposed ban. They view public smoking as an important issue of public health, and are highly concerned about the adverse effect it has on children who view smoking as a symbol of being chic and fashionable.
Politics and health are interrelated to such an extent that they can never be considered separately. Much remains to be done in the area of politics and health, but I have hope that our generation of doctors working together with politicians as a team for global health will greatly improve the situation.
Ron Thomas Varghese is a intern house surgeon at the Government Medical College, Kerala, India.
References
(1) http://www.washingtonpost.com/wp-dyn/content/article/2008/05/07/AR2008050703405.html
(2) http://in.reuters.com/article/topNews/idINIndia-33406820080505
(3) http://www.lk.iwmi.org/press/coverage/pdf/_Guardian%20Unlimited,%20UK.pdf