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Knowledge Systems for Sustainable Development

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    • Broadening vision and disrupting set ideas...
      • Health: the perspective of knowledge - Amartya SEN

Health: the perspective of knowledge - Amartya SEN

The global health crisis we face today demands fresh reflection and new departures. Central to this encounter is the development and use of social and scientific knowledge. The crisis does, of course, demand dedicated action as well as faith in mankind's ability to overcome monumental adversities. But we need a knowledge-centred approach to make our actions fit the needs...

...I concentrate on the central question: in what ways are better understanding, including clearer knowledge, important for an adequate global health approach? There is, in fact, an embarrassment of riches in answering this question, but I will confine the discussion to eight basic points.

Relative magnitudes and comparative finance:
... Even though the seriousness of the health problem facing the world is widely accepted, the relative magnitudes involved are frequently missed in the presentation of global news. Since the battle against terrorism has become the central motif in world affairs, it is worth noting that there is not a single day in the history of the world in which more people died from terrorism than from entirely escapable fatalities related to avoidable or controllable illnesses. In fact, absolutely the contrary... While terrorism may kill thousands, and sometimes hundreds of thousands, it is estimated that more than 20 million deaths from illnesses each year (out of a total of 57 million total mortality in 2003) are entirely preventable. And yet the money spent on aiding health care in developing countries is a tiny fraction of what goes into military expenditure, including the so-called war on terrorism.

Continued scourge of old-fashioned illness:
The second point concerns the continued toll from traditional diseases, as opposed to new ones. The gigantic health predicament in the world today arises-not just from the new epidemics such as AIDS (alarming though the numbers of people affected by these new epidemics are) but also from traditional killers, such as malaria, tuberculosis and gastrointestinal diseases, which figure much less strongly in the public understanding of the nature of the global health problem. The need to pay attention to the old - and well understood - case for cleaner water, better sanitation, and the elimination of parasites has never been stronger...

Need to reassess the Hippocratic prohibition:
There is also a case, particularly in dealing with old-fashioned diseases, for reviewing and reassessing old priorities. For example the prohibition of the use of DDT and the considerable reluctance to use such chemicals is easy to understand, because of their environmental effects and the health hazards that are involved. DDT does indeed carry some considerable long-term risk, though that risk has not been put on a comparative perspective vis-à-vis its life-saving role, preventing millions of deaths, from malaria in particular, in a largely predictable way! There is an important decisional issue here that needs careful scientific scrutiny. It is not, of course, being presupposed that the odds will come out in favour of resuming the use of DDT: it may or may not. But the decisional issue does deserve serious epistemic scrutiny, rather than being ruled out on the ground of some general deontological proscription...

Health demands health care but other things too:
A wide range of policies and actions have powerful influence on our health, and these must be taken into account in evaluating the use of resources for the pursuit of good health. Indeed, in dealing with policy making, it is important to go beyond health care facilities into general economic and social arrangements, which can have very important effects on health... Educational expansion, for example, is certainly a very important part of the story, and indeed there is some evidence even to suggest that general education in schools may be more effective in advancing health achievements than is specialized "health education"...

Equity is compatible with incentives for medicinal research:
There has been a good deal of discussion recently, not least in meetings of the World Trade Organization, on the conflict between the incentive for drug companies to develop new medicines which requires a higher price, and the usability of the developed medicines, which requires especially lower prices for poorer users. As we know from the marketing of "generic" substitutes of patented medicines, the production cost of an actually developed medicine can be astonishingly low, but drug companies have an incentive to keep the prices high. Does this reflect an unalterable conflict between development of new medicines on the one hand, and their use on the other?... This very serious issue needs to be discussed more thoroughly. What is important to understand is that incentive systems can be organized in pursuit of whatever our objectives are. If equity is an important part of our goals (as it ought to be), then that too can be integrated into an appropriately devised incentive system.

The direct role of equity:
Recent research has brought out the negative effect of inequality of status and decisional power on health. Those at the bottom of the hierarchy seem to suffer disproportionately from bad health and premature mortality, linked particularly with behavioural adaptation (such as excessive drinking, smoking, and lack of exercise) that reflect their frustration and which, at the same time, badly affect their health... An epistemic approach to health care has to cast the net quite wide to have an adequate grip on the causal influences that impact on illness and mortality.

The intrinsic importance of health:
I turn, finally, to two valuational issues which have strong epistemic connections. It has become increasingly common to focus on the fact that good health can enhance economic performance. Human productivity is raised by better health, and the economic loss from illnesses can be reduced by cutting down morbidity... This focus is important, but it would be a mistake to make that connection be the central reason for seeking (and devoting more resources to) the expansion of health care and to improving health. No matter what indirect contribution good health makes, good health is also its own reward. People tend to value, for understandable reasons, the possibility of leading a healthy and long life. Indeed, at a very basic level economics has to be subservient to health - not the other way around.

Health as Capability:
Last but not least, it is important to appreciate that we seek good health not only because it makes our lives more pleasant and less painful -the classic utilitarian focus - but also because having a long and healthy life enhances our capability to do what we would like to achieve... Indeed, good health is sought not just for pleasure, nor only for reducing pain, but also for expanding a person's significantly important capabilities and freedoms... This is one of the reasons why the focus on longevity in many widely used indicators of human achievement, such as the Human Development Index (used by the United Nations), reflects an implicit valuation of human freedom, our capability to do what we value doing. Once this is accepted it is readily seen that any systematic framework for the assessment of health and health care must look beyond just medical excellence, and take note of the kind of lives that people can lead.