Public Health Challenges

In the words of Sen, health (like education) is among the basic capabilities that gives value to human life. For individuals and families, health brings the capacity for personal development and economic security in the future. Health is the basis for job productivity, the capacity to learn in school, and the capability to grow intellectually, physically, and emotionally. This point is widely acknowledged by analysts and policy makers, but is greatly underestimated in qualitative and quantitative assessments.

As with the economic well-being of individual households, good population health is a critical input into poverty reduction, economic growth, and long-term economic development at the scale of whole societies. An econometric study (Bloom and Sachs 1998) found that more than half of Africa’s growth shortfall relative to the high-growth countries of East Asia could be explained statistically by disease burden, demography, and geography, rather than by more traditional variables of macroeconomic policy and political governance.

The world is now experiencing a serious public health challenge, facing with the appearance of diseases such as Ebola, SARS, Bird flu and in particular, AIDS, combined with the alarming resurgence of diseases previously thought to have been under control. In order to understand better the political dynamics behind public health we need to recognize that the development of modern forms of governance has emerged simultaneously with new approaches toward the administration of human populations.

Improvements in health care were perceived as part of a nexus of reforms that ranged from better housing and nutrition to an extension of voting rights to ensure that the poor had adequate political representation. The contemporary politics of public health needs to be considered, however, in relation to wider discourses on security and human welfare that are quite different from those of the past centuries.

The contemporary exclusion of the world's poor from adequate medical care is a form of state-sponsored hostility, in which millions are denied even the most basic human rights. These “wasted lives”, the marginalized, the excluded have no value within the global economy. The needs of the global poor are less likely to be addressed effectively. Since most people threatened by AIDS, tuberculosis, unsafe drinking water, and other health threats are poor, they have little or no influence over the global politics of public health.

Existing primary health care services in much of the developing world have been drastically cut back, and services that were once freely available are now increasingly beyond the reach of the poor. And these harmful trends also extend even to the wealthiest global cities where a combination of poverty, homelessness, and cutbacks in primary health care since the 1980s has contributed toward the spread of tuberculosis and other diseases [1,2].

Studies show, people in lower social-economic classes are more likely both to be, and to become disabled, and disabled people are more likely either to be or become lower class. Figures from 2001 ESRC Study show that 8 per cent of people in Social Class I are disabled, compared to 24 per cent of people in Social Class V [3]. In a further survey, it was discovered that 73 per cent of disabled people with mobility and sensory impairments have difficulty accessing goods and services.


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What will happen to my boy after I die?
My husband was ill for a long time since doctors were unable to discern his illness. Finally it came out that he was infected by AIDS. One of my children with myself had been infected. After his father died the school shut my boy out and allowed only to appear for the exams. Close family and friends who had no knowledge of the disease all were avoiding me, while those who were aware had mixed feelings filled with watchfulness and pitying. My only worry now is about the future of my child after I die. I have gained more knowledge about the disease and have come to terms to live with it (Iranian local paper, 2006).
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An examination of the social impact of the global public health crisis shows that women and children have been most badly affected by HIV/AIDS. It is married women in southern Africa and south Asia who make up the largest and most vulnerable group of women, since they are at risk of being infected by their husbands. A new generation of HIV-positive women activists, such as the Nigerian journalist and AIDS campaigner Rolake Odetoyinbo Nwagwu, are now engaged in a vital struggle to challenge the social attitudes and economic inequalities that have driven the devastating impact of AIDS on women and children in developing countries.

Generic drug production in countries such as India, Brazil, and Thailand has succeeded in bringing down treatment costs per patient from $10,000 to $300 per year, yet the WHO has revealed that less than one in 20 people who need antiretroviral treatment in the developing world are currently receiving it. The lobbyists claim that generic drugs undermine profitability, and hence, the incentive for new research.

The production of Knowledge in the fight against disease as public goods, are products that require public provision and financing. When public goods are local (such as police and fire protection) or national (such as public defense), local or national governments, respectively, are the key providers. The fight against disease requires important investments in public goods beyond the means or incentives of any single government and beyond the sum total of national-level programs.

The most important kinds of public goods are those that involve the production of new knowledge, especially through investments in research and development (R&D). Since knowledge does not have consuming quality it makes sense to be openly accessed by all. Yet if research outcomes are freely available, it is difficult to draw funds to invest in R&D in the first place. The combination of public financing of R&D in combination with patent protection for private investors in R&D must have logical for furtherance of research projects.

Thus, public support for R&D for basic scientific research is absolutely essential and there is strong support for this kind of public spending in most market oriented economies. Patent protection gives the incentive for product development and testing, which is both risky and expensive. Public financing should cover risk of the initial stages while patent protection should provide incentives for the later stages of the process. In the case of diseases specific to the poor countries, the incentive mechanisms fail at both ends. Poor-country governments lack the means to subsidize R&D, and patent protection means little when there is no significant market at the end of the process.

There fore, diseases such as malaria tend to be grossly underfinanced. The poor countries benefit from R&D mainly when the rich also suffer from the same diseases! It is helpful to distinguish between three types of diseases.

- Type I diseases are incident in both rich and poor countries, such as measles, hepatitis B, and Haemophilus influenzae type b (Hib), and examples of noncommunicable diseases abound (e.g., diabetes, cardiovascular diseases, and tobacco-related illnesses). Many vaccines for Type I diseases have been developed in the past 20 years but have not been widely introduced into the poor countries because of cost.
- Type II diseases are incident in both rich and poor countries, but with a substantial proportion in the poor countries. R&D incentives exist in the rich country markets but not in proportion to global need; HIV/AIDS and tuberculosis are examples: In the case of TB the situation is worse with very little R&D underway for new and better treatment.
- Type III diseases are overwhelmingly happening in the developing countries, such as African sleeping sickness (trypanosomiasis) and African river blindness (onchocerciasis). Such diseases receive extremely little R&D, and essentially no commercially based R&D in the rich countries.

Some diseases straddle two categories, particularly if treatment and/or prevention is sensitive to distinct strains in rich and poor countries. AIDS falls between Type I and Type II, and malaria falls between Type II and Type III. Still, the basic principle that R&D tends to decline relative to disease burden in moving from Type I to Type III diseases is a robust empirical finding. Type II diseases are often termed neglected diseases and Type III diseases very neglected diseases.

The imbalance of research between diseases of the poor (Type II and especially Type III diseases) and of the rich has been recognized and documented for more than a decade. In 1996 the Global Forum for Health Research was created to document the profound insufficiency of research effort on diseases of the poor. Many initiatives have been launched or continued to address the imbalance, but they remain profoundly under funded.

Just as the rich countries rely both on the combination of R&D subsidies and market forces (albeit based on patents) to deliver new knowledge all the way from basic science to product development, so too the increased subsidization of R&D should be combined with market forces to help ensure that scientific breakthroughs find their way out of the laboratory and in to the clinics. The closest analogy to patent protection would be a mechanism to ensure a producer of a new product that a sufficient market exists to earn a return on product development (including the clinical trials). Another mechanism would be the existing inadequate drug laws in the rich countries, which give added financial incentives (e.g., tax breaks or favorable intellectual property rights provisions) to R&D on diseases with low incidence, such as unusual genetic disorders; this legislation could be extended to provide similar incentives for diseases of high incidence in poor countries and low incidence in the rich countries.

We need to harness the new information technologies to this cause as well. The internet now makes it possible to distribute medical and scientific journal articles and other information in a low-cost, rapid manner to all places with basic hardware and connectivity. Provision of such equipment should be an important element of any donor-supported plan for improving health care based on modern information.

There has been calls for increasing R&D in following major ways: (1) increase funding for basic biomedical and health research; (2) increase funding for existing institutions that aim at new vaccine and drug development, such as TDR, IVR, and HRP, and the public-private partnerships for HIV/AIDS, malaria, and TB, and other diseases of the poor; (3) increased outlays for operational research at the country level in conjunction with the scaling up of essential interventions (4) expanded availability of free scientific information on the internet to increase the connectivity of universities and other research sites in the low income countries; (5) modification of the inadequate drug legislation in the high-income countries to include the diseases of the poor; and (6) precommitments to purchase targeted technologies (such as vaccines for HIV/AIDS, malaria, and TB) as an incentive, especially for later-stage product development.

In addition to R&D, there are other kinds of health public goods activities that require public subsidies, such as standard setting for public health, disease surveillance, and the promotion of best practices in health interventions, data gathering and analysis, disease surveillance, and the promotion of best practices in public health through the dissemination of best international practices.



1) Farmer P. Social scientists and the new tuberculosis. Soc Sci Med.
1997;44:347–358. [PubMed]
2) Gandy M, Zumla A. , editors. The return of the White Plague: Global
poverty and the “new” tuberculosis. London: Verso; 2003. 320 pp.
3) Disability Rights Commission
http://www.drc-gb.org/whatwedo/aboutus.asp


Extracts from:

OXFAM Technical Brief – Vulnerability and socio-cultural
considerations for PHE in emergencies, 2004

Gandy M (2005) Deadly alliances: Death, disease, and the global
politics of public health. PLoS Med 2(1): e4

Sachs, J., D., Macroeconomics and Health: Investing in Health
for Economic Development, WHO, 2001

UN Human Settlements Programme (Habitat). The challenge of
slums: Global report on human settlements. London: Earthscan;
2003

World Health Organization. Treating 3 million by 2005:
Making it happen.

References:
Barnett, T. AIDS in the twenty-first century: Disease and
globalisation. London: Palgrave; 2002.

Garrett, L. Betrayal of trust: The collapse of global public
health. New York: Hyperion; 2000.