PHA-Exchange> Leadership and health equity

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EL SALVADOR, 24 FEB, 2003. SOME REFLECTIONS BY DR HALFDAN MAHLER.

LEADERSHIP AND HEALTH EQUITY.

I believe that Milos Kundera had it right when he wrote in one of his
books: »The struggle against human oppression is the struggle between memory
and forgetfulness ». For instance, I believe that the many who over and over
again ridicule WHO definition of health in its Constitution that these many
have forgotten this Constitution and its Health Definition. So, let me
remind all of us of the intrinsic beauty and pertinence of this
definition: »Health is a state of complete physical, mental, spiritual and
social wellbeing and not merely the absence of disease or infirmity ». Let
me also remind the forgetful  about the link between the inspirational and
the practical in that this Constitution has only one article defining « The
Objective of The World Health Organization shall be the Attainment by All
Peoples of the Highest Possible Level of Health ».For my personal
enlightment one of the architects of this WHO definition, a partisan during
the 2d World War, explained it to me in the following way : »I have
experienced this complete physical, mental, spiritual and social wellbeing
many times as a partisan when I decided to risk my life for something I
thought was vitally important, namely freedom from occupation. Complete
physical wellbeing, in that I as an individual could make a difference
against a huge army of occupation. Complete mental and spiritual wellbeing,
in that I fully realized my existential freedom by deciding to risk my life
for something vitally important. Complete social wellbeing, in that I knew
that should I not come back alive somebody from my partisan group would take
care of my family. » And so, in facing death this partisan maintained that
he had experienced the innate and transcendental meaning of WHOs Health
Definition!
I am convinced that health is politics and that politics is health as if all
people truly mattered. I am, therefore also convinced that political action
for health-locally and globally-requires moral and intellectual stimulation.
I am, furthermore morally and intellectually convinced that the Health for
ALL Vision and the Primary Health Care Strategy provide significant starting
forces and added impetus for health development all over the world.  Such
development is based on the principle that those who have little in health
and wealth will generate much more for themselves, and those who have much
will have no less, but will have it with a better social conscience.
I see startling patterns of inequities in the health scores throughout our
miserable world. I'm not talking about a first, or second, or third, or
fourth world-I'm talking about ONE WORLD-the only one we have got to share
and care for. And I continue to support the resolve to provide levels of
health that will allow all people of this ONE WORLD to lead socially and
economically satisfying and productive lives.
I have always maintained that peoples own creativity and ingenuity are the
keys to their and the world's progress. People's apathy can turn development
dreams into stagnating nightmares. The transformation of social apathy into
social and economic productivity is the point of embarkation of all
sustainable and cumulatively growing human development. And an adequate
level of health is a basic ingredient that fuels this transformation. What
the billions of people throughout the developing world need and want is what
everyone, everywhere need and wants: the wellbeing of those they love; a
better future for their children ; an end to gross injustice ; and a
beginning of hope. So, development is about the creation and expansion of
opportunities for human beings to realize what they consider to be their
positive destiny. It is a complex, often messy process involving the
interplay of physical, social, economic and political variables. And, we are
not talking about dealing with physical sciences and controlled environments
where quantifiable elements can be introduced and results predicted. We are
talking about human institutions and cultures, ways in which people organise
themselves to effect change in their social environments. We are talking
about human expectations, perceived rights, preference values, and people's
emotions and attitudes about those rights and values.
Equity, especially in ensuring essential health and socio-economic needs,
and particularly as it relates to vulnerable groups such as the poor,
children, women, elderly, disabled remains for me a primordial objective of
all development. Indeed, I consider equity a moral imperative to which all
social and economic activities must be subsumed. I do believe that a greater
degree of equity, to assure a more just and reasonable equality of health
opportunity, is an absolute necessity for the preservation of a sane local
and global humanity. Let us not forget that there are still thousands of
millions of humans caught in the absolute poverty trap-a condition of life
so characterized by malnutrition, illiteracy and ill health as to be beneath
any definition of human decency.
How then, in to-day's largely amoral, if not immoral world is « social
conscience » on the part of leaders generated? Rarely in human history has
this kind of leadership been so essential-so vital ;leadership to propagate
new values in society, particularly values that are concerned with social
progress, leadership of involvement, of responsibility, of objectivity and
of compassion.
It has been said that leaders have a significant role in creating the state
of mind that is the society. They can express the values that hold the
society together. They can bring to consciousness the society's sense of its
own needs, values and purposes. And let us not forget that visionaries have
always been the true realists of humankind's history.


It is my firm personal conviction that leadership is nothing if it is not
linked to the collective purposes of the society. The effectiveness of the
leaders must be gauged, not by their charisma, or their visibility, or the
so-called power they hold, but by the actual social change they create,
measured by the satisfaction of human needs and expectations. I do speak of
moral leadership, where values have a decisive place, where leaders assume
consummate responsibility for their commitments, and thereby produce social
change that is truly relevant to the needs, aspirations and values of the
society.
And the vision of a commitment to remove social inequities cannot be
introduced as a one-shot piece of magic. It must be introduced time after
time. It must be incorporated in the political system and supported through
the strategy and decision making processes. It must be reinforced
continuously through the diligent pursuit of facts and the fearless exposure
of the facts that cry out for social justice.
A question often raised is , »Can health truly form a leading edge for
social justice, especially when we are dealing with situations where the
basic issue is survival ;where people are trapped in the vicious circle of
extreme poverty, ignorance and apathy. ? ».
I can best answer this question by referring to the events that lead to the
creation of the Health for All movement and to this movement, in my opinion
becoming a leading edge in the promotion of equity and social justice.
The World Health Assembly decided in 1977 that the main social target of
Governments and WHO in the coming decades should be the attainment of what
is known locally and globally as «  Health for All « . And the World Health
Assembly described that as a level of health that will permit all the people
of the world to lead socially and economically satisfying and productive
lives. Please note that the World Health Assembly did not consider health as
an end in itself, but rather as a means to an end. That end is human
development as characterized by social and economic productivity and
wellbeing. You will also note that the social aspect preceded the economic
aspect. That is also as it should be. When people are mere pawns in an
economic growth and profit game, that game is so often lost for the poor.
But when people themselves can contribute actively and voluntarily to the
social development of the society in which they live, whether in such fields
as shaping public policies, providing social support to others, undertaking
voluntary action for the health and education of society, or through all
kinds of cultural activities, in other words when people are socially
productive there is much hope for economic productivity too.
This morally binding contract of Health for All was the basis of The Primary
Health Care Strategy which implied a commitment not only to a reorientation
of the conventional health care systems- which rather should be called «
medical repair systems »-but to a shift towards people `s own control over
their health and wellbeing to the extent that they would be willing to
handle in fact profound social reforms in health. This implies a continuous
empowerment process whereby people acquire the skill and will to become the
social carriers of their own health and wellbeing.
Therefore, I do believe that the fundamental values of social justice and
equity are firmly embedded in the vision of Health for All and the strategy
of Primary Health Care. And this vision and strategy can, indeed be a strong
force and leading edge for achieving social justice and equity. Health may
not be everything, but without health there is very little to wellbeing.
The question is often asked: »Can we afford the cost of social justice and
equity? ». I would propose a counter question: »Can we afford the cost of
social and economic destabilization inherent in to-day`s pursuit of profit-
maximization? ». The costs generated through the creation of a just and
equitable health care system may indeed cause some economic turbulence. But
equitable cost containment can be introduced and resources can be
reallocated. Justice and fiscal responsibility do not have to be
incompatible. They will be only so if there is a breakdown of political
nerve. While there has been solid progress in a few countries towards Health
for All, progress towards social justice and health equity remains strictly
limited. A major reason-in my opinion- for this limited progress in the
application of the HFA Vision through the PHC Strategy has been the lack of
politically sensitive ammunition generated through epidemiological,
sociological and operations research. Therefore, much more leadership must
be generated as a collective force from all levels of the local and global
society towards accelerating the abatement of to-days gross health
inequities.
I believe it is obvious, if present inequity trends continue undimished,
that our world will become more crowded, more polluted, less stable
ecologically and much more vulnerable to socioeconomic and political
devastation. I believe the most turbulent transition will be that associated
with the establishment of equity between all earth citizens.
Health for All leadership-locally and globally- is moved by a vision which
can not tolerate the unacceptable inequities of life, and which has faith in
the potential of people, in their inherent ability to develop and to take
responsibility for their own destiny.
I do believe that the leaders are there, who are willing to take up these
challenges. They are those in leading political positions, who can emphasize
social values and be politically sensitive to them, who feel strongly about
equity issues, and who can find ways to motivate and mobilize others. They
are the leaders in the communities-able to take up the cause of justice and
equity more strongly, prepared to adjust their own traditional values and
approaches and willing to take risks. They are the leaders of thousands of
civil society organizations at local and global level already fighting for
equity in health. They are the leaders in educational and scientific
institutions-able to visualize the scope for improving human conditions and
thus willing to focus their intellectual energies accordingly-and also
willing to motivate future generations towards social values promoting
equity. Last, but not least they are potentially among the leaders of all
the world's religions willing to add the spiritual dimension in the fight
for justice and equity.
Those who are fighting for social justice and equity must be even more than
ready to look, to listen, to probe and to learn; must be brave enough to
fearlessly evaluate progress or lack of progress in abating inequities. Only
by highlighting inequities is it possible to re-dress them. This struggle
for equity can often be frustrating, since development knows no limits. The
more you move along its road the more you want to move. You cannot blame
people if they strive to join up with those who are further along the road
than they are. That is only human nature. Injustices however have to be seen
through the eyes of those who are farthest behind on that road. But, we must
not let the injustices take over. Indeed we must not!
I am convinced that this Centro de Investigación y Desarrollo en Salud which
we are inaugurating to-day will provide essential ammunition in the fight
against the growing inequities in local and global health!

Thank you.