No-Nonsense Guide to World Health

By Shereen Usdin

Here is a clear, wide-ranging introduction to the worldwide state of human health. Starting with a brief history of modern medical progress, Shereen Usdin then untangles the knot created by poverty and globalization to show that where you live, how wealthy you are, and your gender all have a bearing on the diseases you may encounter in your lifetime—and your prospects for prevention, treatment, and ultimately, survival.

Pulling no punches, Usdin also blows the whistle on the political economy of illness and how keeping people sick means more money for the pharmaceutical, tobacco, and food industries. This No-Nonsense Guide is a must-read for anyone who wants a clear sense of how healthy our global family really is.

• Language: English
• Publisher: Between the Lines
• Release date: Oct 7, 2007
• ISBN: 9781771130707

Shereen Usdin

Shereen Usdin is a medical doctor and a public health specialist. She is co-founder of the internationally acclaimed Soul City for Health and Development Communication in South Africa, and works in the areas of development communication, HIV/AIDS, violence against women, and human rights.

Book preview

Introduction

In 1981, as a young medical student at the University of the Witwatersrand in Johannesburg, I attended a conference called ‘Apartheid and Health: History of the Main Complaint’. It joined many dots for me at a time in South Africa when there was little that made sense.

All good doctors begin examinations by asking about ‘the history of the main complaint’. This precedes the physical examination and is designed to get to the bottom of the problem. ‘Where is the pain, when did it start, what makes it worse, what makes it better?’ And so on. A diagnosis follows and treatment is prescribed.

The ‘Apartheid and Health’ conference challenged us to go beyond this history and ask questions that would get to the root cause of disease and death under apartheid.

This questioning would reveal the history of a man whose main complaint was a lingering cough with night sweats and chest pain. The disease was TB but the root cause was his life as a miner exposed to the bacillus while extracting the gold South Africa is famous for. Denied the vote under apartheid, black South Africans were made citizens of arid homelands in far-flung areas. A pool of labor for White South Africa, but unable to live there permanently, people became migrants in their own country. Living in squalid, overcrowded single-sex hostels, lack of decent food and poor working conditions made the miner an easy target for infection.

This interpretation of the history of the main complaint has resonated with many others. My work as a doctor only served to solidify the diagnosis that ill health is inextricably linked to poverty and inequity for which social justice is the cure.

This book was written in the heat of a Johannesburg summer with mosquitoes buzzing around my sleeping child. I imagined what it would be like to be a parent in an endemic malaria area. It would be hard to have a good night’s sleep. And yet, despite a million children dying every year from malaria, the world sleeps.

This book examines what we are sleeping through. It looks at the political economy of health in today’s world. It hopes to answer why in this day and age, where there is so much wealth, there is also so much suffering.

Every attempt has been made to reflect the terrain accurately but new developments on the global health landscape have arisen even in the course of writing this book. The G8 group of richest countries is soon to meet again and new commitments will be made. Or maybe not.

It is an enormous field to traverse and there is not enough space in this book to do it full justice. Many important health-related areas are missing – war and other complex humanitarian emergencies, disability, youth, education, and much else. Some issues, reduced to paragraphs here, are the subject of tomes. The scope of the problem is disheartening on many levels.

But at the same time there is cause for optimism. Not so long ago, books suggesting ‘another world is possible’ were relegated to shelves alongside dusty copies of Das Kapital. Nowadays this view is increasingly mainstream. People are seeing the impact of the current world order all around them. With this has come an acknowledgement that the treatment for the main complaint is a commitment to social justice and the universality of human rights.

Shereen Usdin

Johannesburg, South Africa

Chapter 1

1 No ‘Health for All’ by the 21st century

‘Modern high-tech warfare is designed to remove physical contact: dropping bombs from 50,000 ft ensures that one does not feel what one does. Modern economic management is similar: from one’s luxury hotel, one can callously impose policies about which one would think twice if one knew the people whose lives one was destroying.’

Joseph Stiglitz, former World Bank Chief Economist and Nobel Laureate in Economics, 2001.¹

Spectacular gains in life expectancy have taken place but the benefits have been unevenly distributed. Today’s world is beset with inequities exacting an enormous toll on health. The causes go way back but they have been deepened by macroeconomic policies imposed over the last few decades on the South. Serving the interests of the North they are in large part why WHO’s clarion call of ‘Health For All by the Year 2000’ remains a lofty dream.

If an alien were to land on earth today it would have a hard time explaining things to the mothership. It would flash back photographs of Citizen X, sipping mineral water in his luxury penthouse, followed by Citizen Y’s mother collecting water from a stagnant stream.i

Today, 1.1 billion people do not have access to adequate amounts of safe water and 2.6 billion lack basic sanitation,² making hygiene impossible. Together they make Citizen Y vulnerable to a host of infections. She could be one of the 1.5 million children who die each year from diarrhea because of this.³ Because no health education ever reached her village, her mother does not know about lifesaving oral rehydration therapy. The clinic is too far to walk to and there is no money to pay for transport or the clinic visit.

If Citizen Y recovers, her chances of making it beyond her fifth birthday are slim. If infections don’t kill her, they could leave her blind or undernourished in her critical developmental years, with compromised physical and cognitive functioning. Disadvantaged at school, if she gets to go, what chance does she stand to perform well, graduate, get a job and escape the poverty she was born into? Poverty begets ill-health which begets poverty.

The alien would report that there is some trouble in paradise – living high on the hog makes Citizen X vulnerable to chronic diseases.ii But when he has his heart attack at 70 he will be rushed to a state-of-the-art hospital where the best medical team will work wonders.

We live in an era where spectacular things are possible. We’ve mapped the Human Genome, grown organ tissue from embryonic stem cells and may be close to cloning a human being. We can replace the human heart with an artificial one and do intricate surgery via computer. These are the days of ‘miracles and wonder’. But this offers little relief from the grinding poverty and ill-health experienced by almost half the world. They are the 2.8 billion people who live on less than $2 per day. In Ethiopia they are called wuha anfari – ‘those who cook water’.

i In UNICEF-supported research in 23 countries more than a fifth of households surveyed spend more than an hour per trip to collect water and in areas with taps, irregular or interrupted supplies cause delays of hours.

ii Ironically chronic diseases are also on the rise amongst the poor (see Chapter 6).

Spectacular gains, spectacular inequity

Our hunter-gathering ancestors roamed the earth for 25 years on average. Major gains were only made in the mid-19th century and by the 1950s we were roaming on average for about 20 to 30 years more. Improvements in socio-economic conditions with better living standards (including water and sanitation provision) and nutrition were largely responsible for the dramatic gains in life expectancy in the mid-19th century. While these gains pre-dated larger public health interventions including oral rehydration therapy and immunization, some argue that the role of these technological interventions is understated.

Life expectancy shot up in the last half of the 20th century, spiking today at 80 years in some parts of the world.⁴ Continuing improvements in socio-economic conditions and better medical interventions, notably treatment of infections and prevention and control of non-communicable diseases such as diabetes and cardiovascular disease, have been largely responsible for gains post-1950.

What’s in a name?

Terminology describing countries’ varying degrees of ‘development’ is highly contested. This book tends to use ‘North’ and ‘South’, ‘Western’ and ‘Majority World’, ‘rich’ and ‘poor’, although they are all imperfect. For example, in 1990, the Fortune 500 included 19 transnational companies from the South. This rose to 57 in 2006. Journalist Thebe Mabanga quips: ‘World domination is now as likely to be plotted from an air-conditioned office in Mumbai as it is from New York’.

While the majority of the world is better off today than a century ago, these gains have been unequally distributed both between and within countries. In some parts of the world you would be lucky to make it to 40. Life expectancies have decreased in sub-Saharan Africa (largely because of HIV) and in the former Soviet Union (largely because of social disruption, increased poverty and the collapse of social services). In industrialized countries only 1 in 28,000 women will die from causes related to childbearing, while in sub-Saharan Africa the risk is 1 in 16. In wealthy Australia there is a 20-year gap in life expectancy between Aboriginals and the Australian average. Premature death in African-American men is 90 per cent higher than in whites.⁵

Inequitable and iniquitous

According to the UN Millennium Project’s Jeffrey Sachs the gap between rich and poor nations has been widening steadily from 12-fold in 1961, to 30-fold in 1997 with simultaneous disparities in life expectancy and infant mortality rates between and within countries.

While under-5 mortality rates (the number of children dying under 5 years per 1,000 live births per year) declined overall, the rate of decline differed. Between 1990 and 2002 rates declined by 81 per cent in industrialized countries, 60 per cent in developing and 44 per cent in the poorest countries. This decline has stagnated and is reversing in some countries, particularly in Africa.

Under-5 mortality rates by country income level (per 1,000 live births)

Under-5 mortality rates by country income level (per 1,000 live births)

Adapted from: UN Millennium Project 2005. Who’s Got the Power? Transforming Health Systems for Women and Children, Task Force on Child Health and Maternal Health. Data source: UNICEF 2004.

According to UNICEF global access to water increased from 78 to 83 per cent between 1990 and 2004. But this masks wide inter- and intra-country disparities particularly between urban and rural communities. In West/Central Africa for example, about 49 million people living in urban areas gained access to improved drinking-water sources during this period, but only 26 million people living in rural areas did so. In some countries the discrepancies are very high. For example, in Mongolia, 87 per cent of urban dwellers have access to safe water supplies while only 30 per cent of rural dwellers do.

Today’s global averages look less rosy when disaggregated by gender, race, geographical location or bank balance. These factors, plus others, are referred to as ‘the socio-economic determinants’ of health. Reflecting differing levels of social privilege, they determine your exposure to risk, your access to life opportunities and resources (including safe water and sanitation, education, and health services). They determine how long and how healthily you live.

It is no surprise that absolute deprivation has negative health outcomes. This is why more than 10 million children die of hunger and preventable diseases every year – astoundingly, one every three seconds. They die largely from a few poverty-related conditions: pneumonia, diarrhea-related diseases, malaria, measles, HIV/AIDS, under-nutrition and neonatal conditions. Most of these deaths happen in the South.

But inequality per se within societies is also thought to result in negative outcomes through perceptions of social deprivation, even when relatively small. Lack of social cohesion and inadequate political support for redistributive policies in such societies are also thought to be responsible.

Economic growth and good health are not automatically synonymous

Once a minimum per capita income is achieved, education and other socio-political investments have greater health impacts than economic growth.* This is why poorer countries with less inequality often score better on health measures than wealthy counterparts with greater inequality. Sri Lanka for example scores higher on the Human Development Index* than South Africa which has a 4-fold higher per capita GDP but is one of the world’s most unequal countries.

*R Beaglehole, R Bonita, Public Health at the Crossroads: Achievements and Prospects (Cambridge University Press, 2004).

GDP vs HDI

GDP vs HDI

http://hdr.undp.org/hdr2006/statistics/indicators/

In fact poorer countries with less inequity often have equal or better health measures than wealthy countries with large disparities. For example,