(Gwynne Dyer is a London-based independent journalist)

Perspectives

Pull Quote: ‘…notwithstanding a 34% reduction in global infant death rate between 1975 and 1995, a 20% to 80% increase in immunization coverage for children under age one between 1980 and 1990, and great improvement in access to safe water and sanitation, huge health inequities still prevail. And the poor remain the victims of these inequities’

TODAY, people are healthier and live longer than 30 years ago; so says the World Health Organization (WHO). And if we applied the 1978 death rates for children globally in 2006, we would have had 16.2 million deaths; but we had only 9.5 million deaths, a difference of 6.7 million, equivalent to the saving of 18,329 children’s lives.

In the Americas over the last 25 years, the following significant improvements in health and human growth occurred: Infant mortality plummeted by a third; all-cause mortality dropped by 25 per cent; life expectancy improved by an average of six years; mortality from communicable diseases and diseases of the circulatory system decreased by 35 per cent. But tuberculosis, HIV/AIDS, and non-communicable diseases remain as challenges to the region, according to the Earth Institute.

And notwithstanding a 34% reduction in global infant death rate between 1975 and 1995, a 20% to 80% increase in immunization coverage for children under age one between 1980 and 1990, and great improvement in access to safe water and sanitation, huge health inequities still prevail. And the poor remain the victims of these inequities.

Again, Arraigada, in an ECLAC report, points to the health impact of economic and social changes in the region as: Aging populations; diet changes; urbanization; declining support structures. These changes are responsible for obesity; hypertension and cardiovascular disease; increased injuries and violence; associated problems with tobacco, alcohol, and drugs, including natural disasters and on-the-rise infections. In fact, these social and economic changes necessitate a radical transformation of the current healthcare system which carries several shortcomings, according to the WHO Report 2008.

These shortcomings are: Inverse care where the poor consume the least health care, compared to those with the most means; impoverishing care where 100 million people become poor because they have to pay for health care; fragmented and fragmenting care, where care for the poor is fragmented and greatly under-resourced; unsafe care, where poor safety and hygiene standards produce hospital-acquired infections; and misdirected care, where resources revolve around curative services, and so neglect the potential of primary prevention to avert 70 per cent of the disease load.

I saw an enormous focus on clinically curative services in my previous roles as Associate Public Health Epidemiologist at the Bureau of HIV/AIDS Prevention and Control at the New York City Department of Health and Mental Hygiene; and as Coordinator of Primary Health Care at the Interfaith Medical Center of the State University of New York. And so, the argument for some time now is that a Primary Health Care (PHC) system would thwart a good number of these shortcomings; and PAHO/WHO concluded that PHC constitutes the best-practice method for turning out sustained and equitable health improvement for all.

Well, what is this PHC? PAHO/WHO sees a PHC-based health system as a system that (1) is holistic (2) provides the person with the right to reach the highest possible level of health (3) enables the person to get the full benefit from equity and solidarity, and (4) applies the principles of responsiveness to people’s health needs, quality orientation, governmental accountability, social justice, sustainability, participation, and intersectoriality.

More than 30 years ago, The Declaration of Alma-Ata pioneered the strength of PHC, advocating an expansion of the medical model to include social and economic factors, including equity in access to health care, and efficiency in delivery of health care. Then later, PAHO/WHO approved the Declaration of Montevideo that calls for a renewal of PHC that largely has to address the growing health inequities that devastate the poor. Wagstaff makes the point that ill-health breeds poverty, and poverty triggers ill-health, as the Figure below demonstrates.

Source: Wagstaff, Adam. 2002. ‘Poverty and health sector inequalities’, Bulletin of the World Health Organization, 80 (2).

We, therefore, really need to aggressively install a PHC system to deal with the cycle of poverty and health, especially as the evidence of inequities between the poor and non-poor is so glaring, and well-documented by Wagstaff as follows: Health inequities weigh heavier on the poor and non-poor, as the poor die earlier and carry a higher morbidity rate; the poor suffer more with chronic illness and self-assessed health; huge variations in health inequities across countries; and health inequities are increasing.

Next week: The epidemiology of ill-health among the poor.