Global IDEA

Health determinants are not necessarily health interventions. Interventions need to be practicable (i.e., widespread use is possible) and affordable. We agree with David Moore and his colleagues that universal primary education has social returns beyond its impact on child and maternal survival. However, safe housing, sanitation and food subsidies are more costly and less practicable than are public health interventions.1

As we have recently reviewed,2 research and the diffusion of knowledge have improved public health interventions (which differ from the more narrowly defined “medical” interventions), making them more efficacious and cheaper, which means that they are more cost-effective. Thus, mortality fell more rapidly in the 20th century than it fell in the 19th century. Access to vaccination and treatment of respiratory infections and diarrhea explain more of the decline in child mortality in India since 1975 than do differences in income growth or education.3^,4 In rural Senegal, recent mortality decline can be traced to specific interventions, even in the absence of universal safe water, sanitation or housing.5 Smoking controls and changes in saturated fat intake have decreased adult mortality in Poland.6(Declines in mortality due to tuberculosis before 1950 are a riddle. Although these declines were not due to antimicrobials, it is unclear if better living standards were responsible. Less well studied cofactors for tuberculosis may well have played a role.7)

Interventions based on “egalitarian principles” or “social determinants of health” strike us as romantic but impracticable notions. To quote Kingsley Davis from 1956,8

[It] seems clear that the great reduction of mortality in underdeveloped areas since 1940 has been brought about mainly by the discovery of new methods of disease treatment applicable at reasonable cost [and] by the diffusion of these new methods … The reduction could be rapid because it did not depend on general economic development or social modernization … Though in the literature on public health there is still great lip service paid to the necessity of general economic improvement and community welfare in the control of disease, the truth is that many scourges can be stamped out with none of this…