PHA-Exchange> Health for all

[pamzinkin]

BMJ 1996;313:316 (10 August)
Editorials
Health for all by the year 2000?
No, and not for many generations without concrete and credible actions to 
alleviate poverty
"No child in the world will go to bed hungry by the year 2000." This was 
one of the final statements at the closing of the Food Security Conference 
in Rome in 1974. According to the United Nations Development Programme, 
hunger now prevails among at least a quarter of the world's inhabitants.1 
Every day there are 30 000-40 000 child deaths in the world, most of these 
from diseases related to malnutrition.2 This means that there are 12 to 14 
million child deaths associated with hunger each year. Can we expect this 
figure to have improved by the year 2000?
The well known phrase "Health for all by the year 2000" was coined at the 
United Nations Alma Ata conference in 1978. Only four years are left for 
hunger and disease to be defeated. Objectives are natural when setting 
targets and are often linked to a change of century or to a historically 
important date. But what is the use of wishful thinking far away from the 
bitter reality of widespread poverty? And what are the risks of indulging 
in lip service--some would call it claptrap--reflected in statements of the 
kind above, which serve only to undermine people's confidence?
"Health for all by the year 2000" seems less probable today than it did in 
1978. The vulnerability of the poorest has increased, as has their number. 
According to the World Bank, almost 65% of the inhabitants of Africa live 
in "absolute poverty,"3 a term used by former World Bank president Robert 
McNamara to describe a condition of total deprivation of the minimum living 
conditions essential for human dignity.4
One of the foremost mechanisms in this impoverishment is servicing and 
paying interest on national debt. The "debt trap" is arguably the single 
most important causative factor in the prevailing morbidity and mortality 
among women and children, the most vulnerable groups. This "pathology of 
poverty" in the Third World is associated with increasing scarcity of 
resources, more hunger, and increasing death rates.5 The poverty gap has 
increased by 30% during the past decade.5 Every year there is a net drain 
from the Third World to rich countries amounting to $150bn, most of it as 
debt servicing.6 From sub-Saharan Africa alone, more wealth is extracted 
each year than is invested by governments in health and education for 
Africans.6
This is happening in an era in which HIV infections and AlDS related deaths 
are dramatically increasing, a trend which is only beginning. In parts of 
central, eastern, and southern Africa today, 30-40% of pregnant women 
attending antenatal care are seropositive for HIV.5 Most of them will have 
died within the next 10 years, as will most of their husbands, leaving 
behind grandparents without support and orphans without care. We know that 
the only defences against this disaster are literacy, knowledge, and 
understanding of measures to decrease transmission among the population at 
risk. But schools and education cost money, and meanwhile the poverty gap 
widens and disempowerment increases.
Two mechanisms seem to be prominent as threats to the objective of "health 
for all," particularly for the two thirds of the African population that 
live in absolute poverty. The first is the debt trap, reinforced by the so 
called structural adjustment programmes that the World Bank and 
International Monetary Fund have devised. The second is the increasing 
privatisation of health care that has resulted from shrinking public 
service budgets. If a country is to be "free" to determine its own health 
policy, it has to accept the shackles of harsh loan stipulations and 
budgetary constraints, making it impossible to allocate resources for 
health services to those most in need and most at risk. During 1978-88 
Ghana was forced to reduce its health budget by 47%, with corresponding 
reductions of 43% in the Ivory Coast and 50% in Mozambique.7 In nearly all 
the African countries health budgets do not allow for more than symbolic 
wages to most professional workers. To avoid massive brain drain, these 
countries must permit doctors to supplement their incomes by private 
practice. It has been calculated that more than 30 000 university trained 
staff have left Africa during the 1980s as a direct consequence of 
vanishing government support for education and research.7
It can be argued that it is sound policy that all citizens understand that 
health care costs money. But the effect can be devastating. In some 
countries a pregnant woman urgently in need of a lifesaving caesarean 
section has to buy surgical gloves, suture material, and drugs before a 
doctor will consider operating. In Zimbabwe the number of hospital visits 
declined drastically after the introduction of fees for patients.8 There 
was no evidence that morbidity had decreased or that there was unnecessary 
consumption of care that could have been avoided. In fact, an increase in 
maternal mortality parallelled the introduction of fees. The same sequence 
of events, with rising numbers of maternal deaths accompanying the 
implementation of structural readjustment programmes, has been reported in 
Nigeria.9
As medical doctors, we have a responsibility to describe, in medical terms, 
what happens when impoverishment takes its toll among the most vulnerable 
groups in society. We must make the "pathology of poverty" understandable 
and show that the widening poverty gap is directly associated with disease 
and death. This responsibility is a question of medical ethics, unrelated 
to political beliefs or creed.
Development programmes should focus more on the quality of human resources, 
on human wellbeing, and on productivity. Access to health services, 
education, food, security, and safe drinking water are basic prerequisites 
in this regard. But health for all is a distant dream, and, without 
concrete and credible actions to alleviate the pathology of poverty, we 
must expect it to remain a dream for many generations to come.
Professor Division of International Health Care Research, Karolinska 
Institute, S-17177 Stockholm, Sweden
Prime minister, Mozambique
Staffan Bergstrom, Pascoal Mocumbi
United Nations Development Programme. Human development report, 1991. 
Oxford: Oxford University Press, 1991.
Grant JP. The state of the world's children. Oxford: Oxford University 
Press, 1992.
Durning AB. Poverty and the environment: reversing the downward spiral. New 
York: Worldwatch Institute, 1989.
McNamara RS. The McNamara years at the World Bank: major policy addresses 
of Robert McNamara 1968-1981. Baltimore: Johns Hopkins University Press, 1981.
Bergstrom S. The pathology of poverty. In: Lankinen KS, Bergstrom S, Makela 
PH, Peltomaa M, eds. Health and disease in developing countries. London: 
Macmillan Press, 1994:3-12.
Bergstrom S, Syed SS. Population control: controlling the poor or the 
poverty? In: Lankinen KS, Bergstrom S, Makela PH, Peltomaa M, eds. Health 
and disease in developing countries. London: Macmillan, 1994:25-36.
Werner D. The life and death of primary health care. Third World Resurgence 
1992;42:10-4.
Logie D, Woodroffe J. Structural adjustment: the wrong prescription for 
Africa? BMJ 1993;307:41-4.
Ekwempu CC, Maine D, Olorukoba MB, Essien ES, Kisseka MN. Structural 
adjustment and health in Africa. Lancet 1990;336:56-7.



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Pam Zinkin                              tel:44 (0)20 7609 1005
pamzinkin at gn.apc.org            fax:44 (0)20 7700 2699
45 Anson Road
London N7 OAR
UK
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