Reducing disease: More health and care, less healthcare?

A new report from the World Health Organization identifies five health risk factors responsible for one-quarter of all deaths around the world: low birth weight, unsafe sex, alcohol use, unsafe water and sanitation, and high blood pressure. While this list may not seem new or exciting, it certainly vindicates the aggressive use of public health and development strategies as routes towards improving global health. Reducing those five risk factorswhich could increase global life expectancy by almost 5 years will require little from doctors and medicine, but much in the form of infrastructure improvement, poverty reduction, and enhanced capacity to produce health.

Healthcare is certainly important, and global efforts to improve its quality and access should continue with vigor. But most advances of the past 200 years that have increased life expectancy and reduced disease have been in the realms of sanitation, infrastructure, and prevention. These public health efforts are naturally tied with development approaches: Polio vaccination programs in India, for example, are not likely to eradicate that disease without concurrent efforts to fix the open sewers that harbor and breed it.

Ironically, healthcare often has little to do with health or care. Instead it is often scripted as an opera of disease set against a backdrop of financial or resource shortages. But whether you are a "developed" member of the Organization of Economic Cooperation and Development (OECD) or a less developed Sub-Saharan nation, healthcare should be used relatively sparingly in the quest to improve the wellbeing of your population. Instead, efforts should favor the strengthening of those underlying factors that make people healthier, including education, housing, and family-friendly work policiesfactors that account for 80 to 90 percent of your wellbeing, compared to the 10 to 20 percent that comes from healthcare.

Moreover, community-based solutions that tap into local social capitol to improve health and reduce disease are often successful because of their refined level of "caring:" Rwandan community health workers whose home-visits ensure HIV/AIDS treatment rates on par with the best in the industrialized world; peer-counseling in Accra, Ghana that empowers low wage "Kayayo" porters out of homelessness, undernourishment, and the lure of the sex trade; or Grameen Bank "circles" of social support, that bolster economic measures of success with improvements in education, housing and sanitation.

Even in the affluent OECD, spending more on social programs, not healthcare, is what improves health. Of course financial figures should be used with care, and only as a rough metric of policy priorities: "A vision based on saving money galvanizes no one, and will ultimately backfire because it brings up the image of "cheap," and no one really wants the cheapest healthcare," says Sharon McDonnell, MD, MPH, a colleague who spent an international health career in places as diverse as Afghanistan and Geneva. "That has to do with mechanisms for paying for healthcare, but it isn't health and it isn't care."