No irony is in place when reflecting on a World Health Day in pandemic times. Hope is what I felt when I received an invitation for Word Health Day’s WHO webinar: ‘An urgent call to work together to tackle health inequities’. Delight is what I felt early morning April 7th, when WHO sent out in advance the accompanying brief ‘It’s time to build a fairer, healthier world for everyone, everywhere’. The latter starts with a reformulation of what health equity is, and probably the best and most concise definition we have today: “Health equity is the absence of unfair, avoidable and remediable differences in health status among groups of people”. The kind of utopia we’d like to die for, in other words. Then I read the whole brief and assisted the webinar. I’m less hopeful now, and much less delighted. Let me explain why.
It’s not that the WHO brief starts off on the wrong foot. Quite the contrary: under ‘What causes health inequities?’, the link to power is duly made, twice in two paragraphs culminating with “billions of people fac(ing) a cocktail of powerful, mutually reinforcing factors that prevent them ever enjoying healthy lives”. One would expect what follows – ‘How do we make health equity a reality’ – to be as courageous as the ‘New Economic Order’ put forward in the Alma-Ata Declaration. After all, scholars like Maja Göpel, Kate Raworth and many others have shown the way. Like Manfred Max-Neef and Elinor Ostrom two generations earlier, they all call for a radical transformation of society. Today, even the International Monetary Fund is making a plea for “transformation to greener, smarter and more inclusive economies”.
Not so WHO in its health equity brief. WHO’s ‘call to action’ outlines a handful of technical actions that are indeed needed, like “improved housing conditions” to improve health and life quality (Salvador Allende not only asked for it but as minister of health also made it happen, back in 1939) or “ensuring healthy diets” (without mentioning how to counter the sugar and fast food industry, but rather advocating cash transfers to individual mothers). While recognizing the importance of education for health, part of the proposed action is to “provide equal opportunity of access to education” (can anybody go to Geneva and explain why so many kids drop out?). After describing the negative impact of commercial factors on health, the brief goes on arguing to “strengthen cooperation” with the private sector, “while protecting against conflicts of interest”. In short, nothing political (unless the politics of status quo or worse), no more words wasted on power.
Needless to say, that after reading the whole brief, I started watching the webinar with a somewhat critical bias. Though I have to admit that moderator Pascale Allotey revived my hope by picturing ‘building back better’ as “not just by patching up broken pieces together”. But then John Ataguba focused on how “the Covid-19 pandemic exacerbates the costs” of health inequity. Not exactly a revelation. Then Cesar Victora came, repeating his justified request (ever since 2003) for disaggregated data. A glimmer of hope was provided by 2016 EV Sana Contractor. She even dared to question the sufficiency of measurable data, however critically needed: “Equally if not more important is the aspect of understanding the stories behind the numbers” (Victora agreed, recognizing that disaggregated data are a necessary first step, but not sufficient to address inequalities). For a moment I hoped that people and power would come up. Yet the rest of the webinar mainly meandered around the need to redefine social contracts, without making explicit how to genuinely include the non-privileged in that process.
One had to wait for the final discussant, Michael Marmot, to hint at a political solution. “We’ve heard about the importance of access to health care and health services, but we need access to the conditions in which people are born, grow, live, work and age, and equity in power, money and resources”. I wouldn’t have expected less from Sir Michael, and I would hope people would listen, finally. Maybe this was what motivated the moderator to conclude by thanking WHO for the “real acknowledgement that health is politics”. Maybe I missed something.
Maybe I missed the late Halfdan Mahler coming back with the most compelling question he asked at the opening ceremony of Alma-Ata, back in 1978: “Are you ready to fight the political and technical battles required to overcome any social and economic obstacles?”. Or perhaps I’m just dreaming.