THIS MONTH'S THEME
Public health has never come easy. It has always meant a political fight against the powerful and the complacent with their 'I'm all right Jack' attitude. But organizers and campaigners from Berlin to Bogotá have fought this hard fight and achieved quite a bit.
Way back in 1890s New York City, for example, there was Hermann Biggs, a genius at manipulating the press and public opinion. Biggs it was who in 1894 called a press conference to leverage funds from the reluctant burghers of Gotham. His aim: to create a laboratory which was to become the world's largest diphtheria vaccine producer. Immigrant mothers poured out of the tenements to get their hands on the vaccine for their ailing children. The impact on New York death rates was phenomenal: they fell from 296 per 100,000 in 1875 to just 2.2 by 1912.
On the other side of the Atlantic English public-health reformer Edwin Chadwick had railed against 'Old Corruption' and his Report on the Sanitary Conditon of the Labouring Population of Great Britain was a clarion call for organized public health. He recognized his cause as essentially political; his big success was the establishment of the Medical Officers of Health system which by the 1870s took responsibility for local public health throughout the country.
Public health required a variety of talents and political commitments. There were feminists like Margaret Sanger who published birth-control pamphlets for women and tirelessly exposed the maternal death rate amongst pregnant women who were expected to bear at least five or six children. There were muckrakers like the Danish photographer and writer Jacob Riis whose stunning How The Other Half Lives graphically illustrated life on the other side of the tracks. Or Upton Sinclair who exposed health and working conditions in the meat-packing industry. And, of course, there were scientists like Dr Joseph Lister in the Britain who discovered antiseptics and Paul Erlich in Berlin who figured out the theory of vaccination.
These pioneers passed the torch on to later public-health activists who forced through clean-water and air acts, safety inspections at work and of the food supply.
In the global South the promise of public health through a revolution in primary healthcare has been undermined by the economic bondage of debt and structural adjustment. Africa is reeling under an AIDS pandemic that is wiping out a whole generation, while antibiotic-resistant forms of malaria, tuberculosis and several other infectious killers are taking a savage toll. Even where these hard-won health defences do exist they are being stormed by the economic globalizers with their predatory gospel of deregulation and privatization. The argument of these globalizers, perched in their seats of power at the World Trade Organization or in national Finance Ministries is deceptively simple: the public-health safety net is overbureaucratized and often unnecessary. It stands in the way of rational investment decisions. Where possible its function should be carried out by business itself. This can be done by industries - even potentially dangerous ones such as food-processing, nuclear or chemical companies - engaging in self-policing. Or it can be accomplished by privatizing the regulatory agencies that oversee our well-being.
And the globalizers are gradually getting their way. The US has seen a drop of 25 per cent in money for public health. In many countries budgets for environmental compliance by a range of industries have been gutted. In the former Soviet Union a crumbling system of public health and environmental protection has seen life expectancy plummet for both men and women. In countries as diverse as Bolivia and Britain such core public services as water provision have been privatized. In far too many places the basic building blocks of public health are being degraded - either through neglect or wilful destruction. A perilous industrialism, once made bearable by public-health controls, today threatens to turn malignant.
The effects of these changes creep in slowly. We know public health is working when nothing happens. People don't die from the water supply. Workers are safe in their jobs. The air is breathable. Epidemics don't pack the hospitals. Life expectancy continues to rise with little disparity of class or race. When things do start to go wrong, causes can be elusive. Unless there is obvious contamination from an identifiable water or food supply - such as that exposed by Ibsen's 'water inspector' in his classic drama An Enemy of the People - the sick and the dying devolve on to the medical system and that's that.
So one pretty good hint that public health is not very healthy is the inability of medical systems to cope - overspent budgets, user fees and an obsession with cost controls, shortages of personnel, patients lying for days on stretchers in hospital corridors, long waiting lists for life-or-death procedures. In short a system badly overburdened. Sometimes, as with food-contamination scandals in Belgium and Japan, water pollution that destroyed the health of the Ontario town of Walkerton, the public-health failures are obvious (see Diemer). Most times you can nibble away at the public-safety net, usually to help fund popular tax cuts that end up in the pockets of the already well-off, without anyone taking much notice. But the chickens will eventually come home to roost!
Of course in many places, particularly parts of Asia and almost all of Africa, public-health regulation was never more than a distant promise anyway. Official documents from UN Agencies and fine international agreements have never really delivered the goods. As David Werner clearly shows (see article) the South has had other priorities imposed upon it. Debt repayment, keeping the supply of exported foodstuffs and minerals flowing, the national security obsessions of the state, all come before the provision of basic health needs. In India public health has been downloaded from the federal to state governments who lack the resources and sometimes the will to fill the gap. By the 1991-92 budget year health expenditure was only 0.04 per cent of the national budget, just a tenth of the previous decade's. The following year it was slashed by a further 20 per cent but the state governments only increased their budgets by 5 per cent in order to compensate. State governments ignored a painstakingly established surveillance system and were ill-prepared for the outbreak of plague that swept through the ramshackle slums of Surat in Maharashtra State during the mid-1990s.
Both India and its neighbour Pakistan spend a fortune on military preparations including millions on developing nuclear capacity. When a journalist confronted the Foreign Minister of Pakistan's military government recently over these skewed priorities he was told that feeding people and saving lives would mean nothing if India blew the whole place to bits with its 'Hindu' bomb.
Brave new ailments
This kind of threat to public health is something that the crusaders of the early twentieth century could hardly have imagined. Their vision was essentially local as they trudged through the slums of Berlin or London hectoring the local power-brokers in favour of decent drainage or housing conditions that weren't incubators of tuberculosis or smallpox. If they thought on a bigger scale at all it was to develop mass immunization programmes as a prophylactic against particular diseases, or to safeguard the food supply as Louis Pasteur did with his process to make milk safe. But public health has changed. Today the shift, at least in the industrial world but also increasingly in the South, is towards the prevention of chronic rather than infectious diseases. It is predicted that the main causes of human mortality, even in a South still plagued by infectious disease, will soon become cancers, heart disease, strokes, Alzheimer's, diabetes, schizophrenia and many more. Causes can no longer be seen as strictly local but are increasingly global - tied to a toxic development model dominated by corporate hazard merchants who profit, either directly or indirectly, from ill health and our harassed style of work and consumption.
Many people understandably look to the obvious and often impressive achievements of modern medicine when it comes to illness. And there is no denying these achievements - the rollback of smallpox, polio and leprosy for a start. The medical specialist in particular has achieved virtual superstar status with intricate transplant operations, laser surgery and now talk of genetic manipulations to save lives. But there have also been rebound effects as microbes of such diseases as tuberculosis and malaria and a plethora of other infections have developed immunity to widely used - and misused - antibiotics. Medical science has been painstakingly slow in finding 'cures' for the main chronic killers.
Today life-expectancy rates that rose pretty consistently throughout the last century are starting to stall, particularly in places with high levels of social and economic inequality like the US, Britain and Germany. A littleunderstood fact is that the main improvement in the health quality of people's lives, and in the prolongation of those lives, is not due to modern medicine at all. It is due to the patient work of public-health activists in their successful struggle to overcome the conditions in which infectious and other disease thrived: slums, bad ventilation, dodgy water, minimal sewerage, child labour, dangerous work, ignorance about sexually-transmitted diseases. Proper health statistics and a system of food inspection also improved matters. Most of these gains occurred before antibiotics were even invented. In Britain, for example, for example deaths from tuberculosis fell 86 per cent before the age of antibiotics and only nine per cent thereafter.
But with the shift in the burden of disease from the infectious to the chronic, the focus of public health has had to shift as well. Though no easy matter, it was a lot more straightforward to combat the unsanitary conditions of poverty that allowed smallpox or plague to spread. The causes of cancer and heart disease are more diffuse and difficult to pin down. Both are cumulative diseases with the build-up of a condition over a lifetime. Both are closely connected to social inequality - the poorer you are the greater your chances of losing in the chronic disease lottery. Both partly stem from the accumulation of disadvantage - high-stress jobs where workers have little say, material reward or self-esteem, exposures to carcinogens in powerless communities or under-regulated workplaces, a greater tendency towards self-destructive behaviour if people feel their lives are not properly valued. At the World Health Organization there is increasing worry about clinical depression reaching epidemic levels. Public-health advocates have some tricky and controversial questions facing them, questions that cut to the very core of life under contemporary capitalist conditions.
Perhaps this goes some way to explaining the decline in the status of, and resources available to, collective public health in favour of the more individualistic cures offered by the high-tech medical model. But the medical model is simply not delivering the goods. In Britain doctors are puzzled by large increases in cancers - some 50 per cent since 1971. Statistics elsewhere match this trend. The same newspaper (the British-based Independent) that announced this 'baffling' trend ran two revealing but unrelated stories during the following days. One from the Japanese village of Hinode, downwind of where they burn Tokyo's garbage, reported levels of cancer four times the national average. The other from the Italian port city of Brindisi reported charges of 'massacre' against managers of a chemical plant where workers are suffering 'astronomical' rates of lung cancer. Multiply these by the number of stories you will never see in print and skyrocketing cancer rates don't seem so baffling anymore.
The sad fact is that, while these may be particularly egregious examples, profit from risky practice is really just business-as-usual for most private corporations. Some, such as those in the business of tobacco, alcohol, fast food or small arms, create casualties as a direct consequence of the goods they produce. Others, such as the chemical, mining and oil industries, create indirect casualties through polluting by-products. Some, like automobile and agrochemical producers, can get you both ways. While others, like the advertising industry, shil all these goodies while painting a picture of consumer bliss that contributes to depression among those of us who just can't seem to get there. The beneficiaries of the diminishing clout of public health are just these business interests who are being given a freer hand to police their own activities. To draw attention to dangerous business practice, the World Health Organization has coined the brave and politically risky notion of 'hazard merchants'.
Kindling the zeal
The connections between environment and health are by now fairly obvious. Less clear is the social dimension of health. A growing literature shows that not just absolute poverty but all social and power inequalities are determinants of ill health. An unequal and undemocratic society will almost certainly be an unhealthy one. Costa Rica, with a lower per-capita income, is by all conventional measures (life expectancy, infant and maternal mortality) a much healthier society than Brazil. It may be poorer, but it is more democratic and more equal. Similarly Sweden and Holland, whose people spend a fraction of what US citizens spend on their health, are both much healthier societies. They are more equal and arguably more democratic. Some parts of inner-city US (such as Harlem) have male life expectancies lower than rural Bangladesh.
This explosive combination of equity and ecology makes public health an issue that strips the veils of ideology from globalist free-market fundamentalism and reveals an increasingly unhealthy reality. It raises fundamental questions. What is the price of perpetual consumer indulgence? A fractured world where some die of overeating while the rest starve? Highspeed growth that makes us all sick and crazy? Mass petrochemical poisoning that may be undermining the basis of life? A health system that is not a common trust but where only those who can afford it may buy a cure? Surely there are healthier worlds. Let's try to build one.