Keynote

HEALTH Finding the right cure

New Internationalist Editor: Debbie Taylor

Justice in Health
Spending on doctors and hospitals is as irrelevant and wasteful
in the rich world as it is in the poor. Debbie Taylor explains why.

DAR ES SALAAM steams and stinks. Everyone has the sheen of sweat on their foreheads, sticky dust between their toes and the stench of sewage in their nostrils. I got food poisoning at the hotel. My friend got malaria from one of the mosquitos that hang over green puddles beside the ocean road.

No sooner had I finished turning my insides out than he began the familiar (if you are used to that sort of thing) round of shudders, groans, fever, pain and hallucinations. Calmly I explained that his symptoms signalled the cunningly-orchestrated break-out of thousands of malaria bugs from his cells where they had been developing. He was not comforted. His neck was stiff, he said, and groaned a bit more.

Having heard ruinous of an occasionally fatal form of cerebral malaria (accompanied by neck stiffness), my calm evaporated into the steamy air. At three in the morning I rushed him to Dar es Salaam’s only private hospital.

We waited while the barefoot queue shrank in front of us and grew behind us and the sun began to rise. Eventually a Pakistani doctor (in Tanzania?) appeared with a syringe which he buried in my friend’s buttock. Having exchanged a handful of Tanzanian shillings for a handful of chloroquine, we left. And caught the next plane home.

On the relief to see the shiny white ambulance that met the plane as it landed. It took him to an isolation hospital where specialist doctors found several species of parasitic worm and the remains of his malaria. Our assignment in Tanzania had been cut short. But my friend survived.

Well, of course he survived. Though it kills a million Africans each year, malaria — like the majority of diseases in the developing world — is eminently curable. Any one of Tanzania’s barefoot doctors —

trained in the basics of primary health care — could have treated him. The private hospital in Dar and the tropical disease specialists in London had nothing new to offer — except reassurance. And the promise that if something rare and dreadful was occurring inside my friend’s body, they would be able to cope.

Few things could have exposed our hypocrisy better. We believe in primary health care. We believe that only by channelling resources away from expensive doctors and hospitals and into simple prevention and cure of the world’s most common killing and disabling diseases can the World Health Organisation’s goal of bringing health to all people by the year 2000 be realised. We believe all this. But when it comes to the crunch and our own lives are at stake, our faith wavers. Primary health care doesn’t seem good enough any more. We want the real thing instead.

Much of our faith in modern medicine comes from its reputation for eradicating major infectious diseases in the industrialised world. Plagues of cholera and Black Death are a thing of the past for us. And tuberculosis — once endemic — is now virtually unknown in the West. But the reputation is false. More money for food, clean water to drink and sewage and drainage systems to flush away disease-ridden filth had cut deaths from infectious diseases by 80 per cent long before medical science discovered ‘cures’ for them.

But the medical profession likes to overlook that embarrassing fact. Robert Koch, for instance, was far more interested in finding a way of combating his newly-discovered tubercule bacillus than he was in pondering why he and his well-heeled colleagues — who had all been exposed to the disease — had not contracted tuberculosis. And this early preoccupation with single disease entities or ‘germs’ — has shaped the whole development of modern medicine.

It is no accident that ‘germ’ — referring to an invading virus, bacterium or parasite — is the same word as ‘germ’ meaning that vital part of a seed that allow-s it to grow into a plant. But, just as a seed will not germinate unless it is planted in suitable soil, so a disease will not develop fully useless it finds a body suitably weakened by stress, exhaustion or malnutrition. People are not killed by germs in any part of the world. They are killed by the conditions that allow- the disease to overwhelm them. Nicasles, for example, is 247 times more likely to kill in Ecuador than it is the US, according to the World Bank.

But concentrating on germs rather than on poverty and squalor suited the scholarly gentlemen founders of modern medicine: they could create a disease-treating monopoly that left the major causes of ill health untouched.

The truth is that doctors and drugs do not bring health today any more than they did in Thomas Koch’s day. What they do bring is the idea that what ails us is disease and that what cures us is medicine. They hold out hope of an end to our pain. But in almost every case that hope is unfounded; the medical profession usually ends up just playing with our poor degenerate bodies while we die. Sixty per cent of US health expenditure goes on people in the last year of their lives: not to ease their deaths but to try to keep life in their disintegrating bodies for a few more days.

It is not surprising that modern medicine has so little success against the rich world’s degenerative diseases like cancer and heart disease. Imagine the average American worker on his death bed: every cell thoroughly permeated with food additives, pesticide residues, heavy metal pollution and radiation; his thoughts ricocheting from the pain in his body to worries about his debts to frustration with his marriage. The electron microscopes, infibrillators and lasers of medical science are about as relevant to him as they are to a campesino in Brazil.

Yet Christian Barnard twice filled Brazil’s massive football stadium in Rio, lecturing about heart transplants to a crowd, the majority of whom could not even afford medicine to get rid of their intestinal worms. In Colombia a hospital’s premature -baby unit has achieved survival rates that rival the best hospitals in the US. But 70 per cent of those tiny new-borns die within three months when they are taken home to disease-ridden hovels by their undernourished and ill-educated mothers.

Just as those babies’ lives could have been saved if their mothers had had enough food when they were pregnant and if Colombia’s slums had piped water and an effective sewage system, so the overweight American worker dying of cancer at 52 could have been saved if he had had a diet free of carcinogens and a job providing satisfaction and pleasure rather than frustration and pollution.

Far from being mysterious and unfathomable, the causes of cancer and heart disease — the major killers of the rich world — are as well-known as the causes of tuberculosis. If that comes as a surprise it is largely because we tend to look for cures of illnesses rather than their causes.

We know that cancer — which kills one in five people in the rich world — is an almost totally preventable disease caused by smoking, food additives, alcohol, workplace pollution, environmental pollution and radiation. We know that heart disease — which kills one in three people in the rich world — is caused by poor diet, lack of exercise and stress. We know- that road accidents and accidents at work — which take one in 14 in the rich world — are caused by unrestricted use of dangerous machines -

But even though we know all of this, the search still goes on for the ‘cancer virus’, a search that takes 50 times the amount of money spent on researching all of the diseases of the Third World. There is no cancer virus. Looking for such a thing is about as daft as looking for the parasitic worm that causes unemployment in the North of England. Even the World Health Organisation — a body not famed for its forthright social comment — has commented glumly that ‘environmental hazards have set up a barrier to further improvements in life expectancy’. And even if there was a cancer ‘germ’ to be discovered, that germ would be like any other germ — flourishing in bodies weakened by pollution, bad diet and unhappiness.

The diseases of affluence are not diseases of the rich at all. They are the diseases of a society chasing after affluence at any price. As in the developing world, it is the poor and powerless that are the casualties. Just as a child born into an Indian family earning under 50 rupees a month is ten times as likely to die in infancy than one born into a family with a 250-500 rupee income, so a working class child in Britain is nearly five times as likely to die in the first year of life as a child born to professional parents. And working class adults die an average of five years earlier than professional people.

All of this makes our present health system look like a very expensive talisman — or a sort of high-tech undertaker’s shop. As a talisman it keeps us from facing the real causes of our disease. We keep our fingers crossed that medicine’s chrome-plated safety net will always be there to catch us when we fall because we kept our mouths shut about the gas leak at work, or the funny-tasting tomatoes, or because we failed — yet again — to jog around the block, or get an early night, or refuse a second helping of cheesecake. As a high-tech undertaker’s shop it stands by with its iron lungs and dialysis machines shielding the door of death from our sight.

And, as tidily as the bodies inside a row of coffins at the undertaker’s our health system individualises our diseases. So divided, we can then be ruled by the larger system, designed — not necessarily with the intention of making us ill — but with intentions that make our health utterly irrelevant. Individually we make half-hearted attempts to improve our health. But they are as doomed to failure as Narcissus was doomed to die — languishing alone by the side of a limpid pool gazing at his own reflection.

This is why primary health care is the only sensible health care for all people — in whatever country they happen to be. It is about preventing disease by getting at the root causes and tackling them at source. In the poor world primary health care means standpipes, land reform and, education as well as immunisation and chloroquine. In the rich world it means refusing to be part of a system that makes us eat poison, and breathe poison, and drink poison, and feel powerless, and have too little money to buy fresh vegetables or take a holiday beside the sea.

And if making those sorts or change means we have to do without our safety net of intensive care units, kidney machines and brain scanners — then so be it. As Michael Wilson — doctor, theologian and author of Health is for people — has argued: ‘only when we are prepared to let some people die will we be free to make more humane decisions in the distribution of resources.’

Hospitals without walls Halfdan Mahler – doctor, tuberculosis specialist, development expert – has been Director General of the World Health Organisation for ten years. In a rare and outspoken interview, he gave New Internationalist his views on primary health care. Illustration: David Smith Thirty two years ago I went to India as part of a vaccination crusade against tuberculosis. ‘This Is good for you’, we told people, ‘because in 25 years there will be less TB in India.’ What outrageous arrogance to think that a woman whose daughter has TB should care about India in 25 years’ time. I learned then that health comes form people’s own understanding of their problems. That is 90 per cent of primary health care. As outsiders, our greatest difficulty is having the energy, the imagination and the faith to support people when they say ‘this is what we want.’ The temptations to submit to the difficulties of comprehensive development and put in vertical, top-down programmes. So we send in our teams of technocrats saying ‘we will put a well here and a pump and latrine there. We have done our job’, we say. ‘People just have to learn to use the latrine properly and maintain the pump.’ But if people have not been given the chance to understand why they should use water, then things don’ work. The health landscape is strewn with examples: often 70 per cent of pumps are out of order within a year. It is the same with national immunisations campaigns. I have been one of the great circus directors involves in such a show. As a shoe it works beautifully for a while. But you can’t keep up the enthusiasm unless people understand and demand that their children are immunised. Or take the example of an experiment in Africa to discover the effects of anti-malarial drugs on a certain tumour. It was brought to the village for mothers to give their children. But the women just put the tablets aside for a rainy day. ‘Aha, you can’t trust people to so even the simple things for themselves’, say the experts. But I submit that those mothers were being very shrewd. Because they had no trust that the government would give them chloroquine when there actually was malaria, they took the chance to save some. We are too ready to say ‘ look, they can’t even do that, so let us manage for them, let us put in vertical programmes’. But primary health care is not about the vertical consumption of medical goodies. It is about supporting people having faith in their own ability to do something about the mess they are in. We have to swing health away form the paternalistic medical wisdom that leads to dolling things out and creating dependence. Nothing makes me scream more than people calling primary health care primitive medicine for primitive people. What they are really saying is: Let’s continue giving good, hospital based medical care to five to ten per cent of the population – and let that syphon off 80 to 90 per cent of the health budget.’ But in the overwhelming majority of cases the hospital is an ingrown toenail – just waiting passively for patients to come for repair. What is needed are hospitals without walls supporting primary health care. But since hospitals are full of doctors, an since doctors are so sceptical about primary health care, then you have tremendous problems in opening up the hospital’s walls. And in many places there is a strong reaction against it. The Dean of the medical school goes to the Prime Minister and says: ‘You are completely ruining our medical school. Until now we were producing physicians with scientific pride who really knew about medicine. Now you want students to learn about nutrition and water and sanitation. This is outrageous’. So the Prime Minister starts getting scared and calls his Minister of Health, saying; ‘What’s going on? We’re losing our national prestige.’ And the result is that, if you take a group of doctors from medical schools throughout the developing countries and put them through an exam on primary health care, then the overwhelming majority would fail. In theory you can have primary health care in spite of doctors. But in reality we, the doctors, will win if we decide to fight ptimary health care. Because we have representatives on earth. You see, in virtually all countries primary health care implies a very fundamental social revolution (whoever wants to misunderstand that word can do so). And there is still a lack of conviction that we can introduce the reforms that are absolutely indispensable to support a primary health care movement. But I also believe – and I know this is outrageous – that health is a marvellous instrument for giving leverage to people – because it is less politically sensitive than agriculture, for instance. This puts a special responsibility on us in the health field to make maximum use of that leverage. Health can then give people the energy to tackle other development problems, like land reform. I believe that what ever resources you have, if they are being used in the spirit of social equity, then you have health for all. It is the feeling that I am just as important sitting out in the village as the Prime Minister. Market forces, political apathy, lack of courage – these kinds of countervailing forces, are rampant throughout the developing world. Nevertheless, if you ask 'has primary health care penetrated in the past five years to a significant proportion of professionals, and made them uneasy about the present health system?’. Then, yes, I definitely think so.