TCS Daily

Beyond Bad Bureauspeak: Something Quite Menacing

By John Luik - August 12, 2005 12:00 AM

According to the World Health Organization (WHO), about a billion people lack access to safe drinking water, while 80% of all illness in the world's poorest regions is linked to water-bred diseases. Poor water and sanitation annually kills about five million people, and 50% of people in the developing world suffer from a disease associated with poor water quality and inadequate sanitation. These are shocking statistics and you would think that in the normal course of things they and others like them would set the agenda and determine the direction of a five day conference organized by WHO on health promotion. But you would have to look very hard to find something as pedestrian as safe drinking water on the agenda of WHO's Sixth Global Conference on Health Promotion which has been meeting this week in Bangkok.

That's because the delegates have been concentrating their attention on the far more urgent and important issues of " raising awareness of determinants of health" and "fostering health-inducing environments and strengthening capacity at national and local levels for planning and implementing comprehensive health promotion that is sensitive to gender, culture and age..." And when they're not busy with all of that delegates have been asked how best to address such major developing world problems as "unhealthy diet and behaviours". They will, of course, have all of the resources of WHO to "promote intersectoral collaboration and coordination" and to "strengthen national capacity for health promotion".

The first response to all of this is to dismiss it as some inelegant, international, bureaucratic nonsense that must have been conceived in German, written in French and poorly translated into English. But this would be a mistake. For beneath the surface of what looks like simply bad bureauspeak is something that is actually quite menacing. Now even the sharpest critic of WHO might find this overly alarmist. After all, how could anyone actually object to health promotion which is surely only the modern embodiment of that old saw that "an ounce of prevention is worth a pound of cure"? After all, isn't this a large part of what modern medicine is supposed to be about -- preventing people from getting sick rather than simply curing them when they do?

If you look at WHO's Health Promotion website there appears to be little to quibble with, let alone be alarmed about. Health promotion conferences go back to 1986, where the health promotion world first met in Ottawa to give official shape to health promotion. Ottawa was the chosen venue since the idea of health promotion was largely the idea of Canadian Marc Lalonde, who served in the 1970's as minister of health. Alarmed even then about the rising costs of health care in Canada's publicly funded national health system, Lalonde argued that health care costs could be constrained if not reduced if significant attention was directed to preventing people from getting sick in the first place. For Lalonde the key to preventing illness was for people to change the way they lived. Preventing a good many diseases was a matter of getting people to eat not only less but differently, drink little if at all, stop smoking and exercise more. If the government could persuade the population to do these things, then dramatic reductions in illnesses like heart disease and cancer should be possible. The government's role, however, was crucial. Without the government defining and promoting healthy lifestyles, the promise of preventing illnesses would never be realized.

Beginning in 1986 and through subsequent Global Conferences on Health Promotion these ideas have gradually hardened into the official religion of health promotion. At the core of this faith are two tenets. First there is the belief that the diseases of longevity, things like heart disease and cancer, are largely the product of "unhealthy" lifestyles -- lifestyles too rich in the pleasures of the table, like food and drink, and too steeped in sloth. Second, if the diseases of longevity are to be prevented, then people need to be told clearly and repeatedly by the government and organizations like WHO, about the ways in which inappropriate lifestyles lead to early and messy deaths. The government's role along with the medical community is to "convince" people to accept the imperative of health and get on the prevention bandwagon even if this means giving up a good many of life's little pleasures.

So just what is menacing about health promotion? After all WHO may have spent a small fortune on the Bangkok bash, but what's a little money in the aid of something as important as getting "intersectoral collaboration and coordination" right? The first and perhaps most significant problem, at least in terms of being both fair and effective in dealing with the health problems of the developing world is that WHO's health promotion has very little if anything to do with actually promoting and indeed improving the health of the world's unhealthiest people. In effect there is a fundamental disconnect between WHO's first world conception of health promotion and the sort of health promotion that might actually improve the health of those in the developing world.

This is because health promotion for WHO is largely about preventing non-infectious diseases of old age -- diseases of longevity and affluence that, while widespread in the first world, are statistically insignificant in the poorest of the developing world. WHO appears not to have noticed that few of the unhealthiest people in the world, to be horribly blunt, live long enough to get either cancer or heart disease. That's because a good many of them will die of foreseeable and preventable diseases before their third birthdays. Health promotion that is genuinely prevention focused would recognize this. For instance, there is little if any discussion at the conference on the Grand Challenges in Global Health -- 14 obstacles to a healthier world for which the Bill and Melinda Gates Foundation is providing $450 million dollars and which actually offers the prospect of improving the health of the world's poorest people.

But it isn't just WHO's first world conception of health promotion that works against improving the health of the developing world, it is also WHO's relentlessly anti-free enterprise and sophomorically leftist bias that conspires against the very people WHO allegedly cares about. For example, how can one explain a session devoted to "diet change and international trade" as relevant to a developing world in which malnutrition plays a role in 50% of all childhood deaths, except in terms of an ideological opposition to both the food industry and liberal trade policy? Nor is it any easier to explain the connection between "globalization, poverty and health" and, for instance, eliminating the sources of disease in unsafe water. While WHO speaks of the importance of such determinants of health as poverty, it at the same time is critical if not explicitly hostile and obstructive to both the very system and its corporations that serves as the major engine of poverty reduction.

WHO's idea of health promotion is a menace then because its first world obsession with lifestyle diseases and its leftist ideology not only fails to connect with the real health crisis of the developing world, but arguably tends to make that crisis worse. The tragedy of the Bangkok conference is that for all of WHO's professed interest in the health of all, no one in the room seems to be speaking for the world's least healthy citizens. And that's a very bad prescription for global health.

John Luik writes about health policy. He lives in Canada.


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