Fighting Poverty and Disease in an Integrated Approach
Audibert, Martine, Bulletin of the World Health Organization
The classic approach of development theory based on observation of advanced countries--a sequential development of the primary sector followed by the secondary sector and the tertiary sector--encouraged the notion that each country of the world would evolve by following the same steps. At the time of agricultural and industrial revolution, capital accumulation and technological advances were considered to be the main factors of development. This scenario has not been encountered in the so-called developing countries, however, and development is still a remote aim. Some economists have been spurred to rethink the role of different factors in development, especially the human factor. In this way, the chapter "Interrelationships of poverty and disease", reproduced here from the 1951 WHO monograph by C.-E.A. Winslow, (1) may be considered as the starting point of a more holistic approach to disease and, therefore, to health.
In 1951 health economics was not yet born, and disease was studied from a strictly epidemiological perspective. In considering poverty as a cause of disease, this work embraced a wider view, leading some 40 years later to concepts such as sustainable development and a focus on human beings. The road towards these concepts was long for at least two reasons. First of all, in the early 1950s health was still defined as a lack of sickness. Secondly, heated debates arose around the fear of overpopulation, because of progress in medicine that allowed the possibility of drastic decreases in mortality without any effect on fertility. This fear has not disappeared at the present time, and it is surprising to see that the arguments advanced in Winslow's paper in order to reassure or convince alarmists are up to date, as Anand & Sen illustrated in 1996. (2) Winslow showed that the spectre of overpopulation was a false debate. He put forward several elements that are still present today:
* Discussion around preserving, through public health programmes, those who are in or before the productive period of life recalls the present debate around age-weighted justification in estimation of the DALY or QALY health measurements. (3,4) The question was and still is: do we have to give preference to the present or future generations?
* Preventing disease and death increases the efficiency of the population. This was a strong argument and was the basis of human capital theory developed in the 1960s, (5) leading to a spread of studies on the assessment of economic effects of diseases. Studies undertaken in 1968 by Barlow on the economic effects of malaria eradication, (6) or in 1974 by Weisbrod on the economic effects of parasitic disease in Santa Lucia, (7) would be considered the most complete work on the relationship between disease and development. However, because of several difficulties in assessing economic effects (owing to the coping process phenomenon and underemployment of the active population), this field research was partly abandoned until fresh interest was aroused by Sens work on human capabilities (8, 9) and also by the emergence of acquired immune deficiency syndrome (MDS). (10-12)
* Saying that the greatest promise of increased agricultural development (turning deserts into fertile fields through irrigation) accrues to those areas handicapped by preventable diseases, such as sleeping sickness, allows the economic importance of disease to be highlighted. This reason was put forward for the creation of the Onchocerciasis Control Programme (OCP) in West Africa in 1975. (13) Numerous sociological and economic studies within this programme confirmed that much fertile land lay idle because of disease.
* Increased prosperity is in general associated with lower reproductive rates, though it is not always true. In analysing this relationship, Winslow introduced the concepts of "man-with-nature" instead of "man-under-nature" or "man-over-nature", and human aspirations and development, concepts now found in sustainable development and human development approaches. …