PUBLIC HEALTH CLASSICS
Fighting poverty and disease in an integrated approach
Martine Audibert
National Centre of Scientific Research, Centre of Studies and Research on International Development (CERDI), 65 blvd François Mitterrand, 63000 Clermont-Ferrand, France (email: m.audibert@u-clermont1.fr)
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 Sen's work on human capabilities8, 9 and also by the emergence of acquired immune deficiency syndrome (AIDS).1012
· 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. These approaches, though according that being healthier and less debilitated contributes to increased individual productivity, consider that productivity is not the exclusive focus of human development. As Anand & Sen2 remind us, human beings are not just the means of production and material prosperity; they are a part of the quality of life. This orientation opens discussion on aspects of the distribution of prosperity, previously evoked, such as inequality and inequity.
· Public health programmes need to be included in a comprehensive programme for world health in which several international organizations would have to be associated, such as FAO, UNICEF, UNESCO and the World Bank. Despite huge progress in medicine and apart from some country cases, improvements in health status in developing countries were far from fulfilling the great promises. Since the 1950s, both analyses of health determinants and analyses of links between health status, health systems and growth showed the complex interrelations between economic, environmental and social factors. Even if the need for an integrated programme for health already appeared judicious at the beginning of the 1950s, this approach was not followed, mainly because the link between the health system and health appeared to be so strong. Indeed, crude constraints and needs of health financing, and stagnation or even decline in health in developing countries in particular since the emergence of AIDS moved the mind of the world community to a more coordinated world health approach. The World Bank, the International Monetary Fund and developed countries agreed to adopt common strategies such as the Sector-wide Approach (SWAP) or budgetary aid that will progressively be subject to results in social sectors.
· In many instances, the full success of plans for the development of underdeveloped areas may require the removal of barriers to international trade. For the past few years this assertion is at the centre of controversy surrounding essential drugs and the demand for their tax exemption in developing countries.
Finally, in raising the issue of poverty's role in health, Winslow's text was considered a pioneer for approaches that recommend investing in health in order to roll back poverty.14 The statements of the Millennium Campaign of the United Nations that "the world has never before seen so much prosperity" and "the [Millennium Development] Goals are clearly achievable"15 clearly resonate with Winslow's paper when he concludes, as do Anand & Sen, that the fear of overpopulation is a false debate. 
Competing interests: none declared.
References
1. Interrelationships of poverty and disease. In: Winslow C-EA. The cost of sickness and the price of health. Geneva: World Health Organization; 1951. WHO Monograph Series, No. 7, Chapter 4.
2. Anand S, Sen A. Sustainable human development: concepts and priorities. New York: United Nations Development Programme, Office of Development Studies; 1996. Discussion Papers Series.
3. Anand S, Hanson K. DALYs: efficiency versus equity. World Development 1998;26:307-10.
4. Murray CJL. Rethinking DALYs. In: Murray CJL, Lopez A, editors. The global burden of disease. A comprehensive assessment of mortality and
disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge (MA): Harvard School of Public Health on behalf of the World Health Organization and the World Bank; 1996. Chapter 1.
5. Schultz TW. Investment in human capital. Am Econ Rev 1961;52:1-17.
6. Barlow R. The economic effects of malaria eradication. Lansing (MI): Bureau of Public Health Economics; 1968. Research Series, No. 15.
7. Weisbrod AB. Disease and economic development, impact of parasitic disease in Santa Lucia. J Soc Econ 1974;1:111-7.
8. Sen A. Capability and well-being. In: Nussbaum M, Sen A, editors. The quality of life. Oxford: Clarendon Press; 1993.
9. Sen A. Health in development. Bull World Health Organ 1999;77:619-23.
10. Schultz TP. Assessing the productive benefits of nutrition and health: an integrated human capital approach. J Econom 1997;77:141-58.
11. Ainsworth M, Filmer D. Poverty, AIDS and children's schooling. Washington (DC): The World Bank; 2002. Policy Research Working Paper 2885.
12. Bell C, Devarajan S, Gersbach H. The long-run economics cost of AIDS: theory and an application to South Africa. Washington (DC): The World Bank; 2003. Policy Research Working Paper 3128.
13. Onchococerciasis: strategic direction for research. Geneva: World Health Organization; 2002. Available from: http://www.who.int/tdr/diseases/oncho/direction.htm
14. Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization; 2001.
15. Millennium Campaign: about the goals. New York (NY): United Nations; 2004. Available from: http://www.millenniumcampaign.org/site
This section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern-day perspective. Martine Audibert reviews a chapter from a 1951 WHO monograph by C.-E.A. Winslow, The cost of sickness and the price of health, which was prepared as a basis for the technical discussions of the Fifth World Health Assembly on the economic value of preventive medicine.