Editorial: Man-made health

Development Policy30 Jan 2009Frans Bieckmann

‘Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness and their risk of premature death’. So begins a recent report by the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH). It, along with other recent international publications, is the subject of the special report on global health in this issue of The Broker.

These reports make the case for a radical change of approach to achieving universal health. Instead of focusing on specific diseases, the reports argue, comprehensive strategies must be adopted. The authors of the special report in this issue cite ample evidence – listed in the online version of the report found at – showing that social, economic and political injustice are major factors of poor health around the world. Growing inequity, within and between countries, not only affects material wealth, but also health, even though international health budgets have doubled in the last years. It may seem far-fetched to connect health care in developing countries to social and political justice or to how the world economy operates. After all, health care is about doctors and nurses delivering treatment. It is about health professionals changing patient behaviour. It is about improving sanitation. Health care is about helping people get better. It should not be added to an already confusing mix of politics, economics or social relations. Or should it?

The reports argue that health care cannot be adequate without being supported by favourable political, social and economic circumstances. One of its authors forwarded me an email about a Physicians for Human Rights publication that calls Zimbabwe’s ruined health system a ‘man-made disaster’. The director of the Palestinian Medical Relief Society (PMRS) described day 20 of the Israeli attack on Gaza in this way: ‘The Israeli military operation and bombardment is 400 meters away from PMRS head office in Gaza. This will threaten the lives of PMRS teams and jeopardize their efforts in emergency response. UN Relief and Works Agency (UNRWA) head offices and storehouses including fuel main supply were targeted during the last few hours; the main building was hit, and it is on fire now. People living in this neighbourhood are trapped inside their homes while aid organizations and emergency health teams are unable to access these communities’.

The current call for a much more systemic approach to health care harks back to the ‘Alma Ata Declaration of 1978’, when world leaders decided to work toward comprehensive primary health care. The declaration emphasized the need for a New International Economic Order (NIEO) as a prerequisite to ‘health for all’. This idea from the 1970s is back, in other words, but in a less ideological, more practical form. The call for this new-old approach is coming from an extended network of researchers, policy makers and practitioners across the world. During the few months it took to put together this special report, the authors travelled around the world to attend meetings and conferences where the systemic approach to global health was discussed. Not coincidentally the three reports were published at the same time; there is a general feeling of ‘momentum’ for change at the global level.

One of the more concrete proposals is the need for ‘comprehensive’ primary health care that combines basic health services with a broader policy to change the socio-economic circumstances that aggravate poor health at the local level. A similar appeal for comprehensiveness, though from a different angle, is made by the seven-year research project being coordinated at the University of Bath in the UK. The project explores a new concept for development: well-being. The article in this issue by Romesh Vaitilingam explains this well-being concept as one that combines poverty reduction, care for the environment and social and political equity into one comprehensive approach to development.

The great risk of such broad initiatives is that they remain abstract, intellectual endeavours. But that is not the case here. The well-being project has developed a detailed toolkit of methods to analyze specific situations in countries or regions, leading to practical measures and policy proposals.

Time has shown that single-issue approaches in an increasingly complex and interconnected world are too limited. There is a growing conviction that new paradigms are needed that combine an integrated approach – to health or development – with practical strategies and policies. The Broker would like to contribute to this process. We invite experts from all over the world to debate and comment on the ideas expressed in this special report and the reports it summarizes. The Broker welcomes readers to contribute to this discussion by sharing their views and reactions at