Social and economic justice: the road to health

We suspect that Sonal Singh has overestimated the extent to which our views differ from his about the determinants of health and health disparities globally. In our commentary1 we state that the chief reason for health improvements in developing countries in the second half of the 20th century — for which we cite reductions in mortality rates as a main indicator — has been a wide range of technological advances, rather than improvements in income or education.

However, our definition of technological advances is not “sophisticated medical care.” Rather, such advances include widely practicable drugs, vaccines, treatment and prevention protocols, public health campaigns (such as the eradication of smallpox) and personal knowledge (such as the hazards of smoking).2 All of these technologies arose from research.

Singh points out that there are numerous determinants of health, including distal factors such as income and education. However, income and education matter less than we might first guess. Easterlin has written probably the best review of historical improvements in health and the role of income and education.3 He concluded that focused public health initiatives were responsible for most of the declines in mortality rates in recent human history. A more recent review also found that, if anything, the linkages of health to income were greater than the linkages of income to health.4

Moreover, a determinant of health may not be an intervention. Yes, there are examples such as Sri Lanka and Kerala where good health has been achieved at low levels of expenditure. However, a careful comparison across 2 dozen Indian states found that differences in income growth (or education) over the previous 2 decades did not appear to account for variation in mortality rates for children under 5 years of age.5 Rather, coverage with an extended program of vaccination, treatment of acute respiratory infection in a medical facility and use of oral rehyhdration therapy for diarrhea showed a clear gradient from worst- to best-performing states.6

Taken to an extreme (which Singh does not do), the suggestion that we should wait for equality and social justice (desirable as these are for other reasons) to reduce mortality and disability strikes us as somewhere between romantic and nihilistic. The chief challenge today is to control some of the major diseases worldwide. Such control requires solid public health action, implementing currently known effective interventions, and research to generate new tools.1

Prabhat Jha Centre for Global Health Research James V. Lavery Centre for Global Health Research and Inner City Health Research Unit St. Michael's Hospital University of Toronto Toronto, Ont.