Innovations for equity

A “disease systems” symposium?

In Global Symposium on Health Systems Research, Uncategorized on November 15, 2010 at 9:19 am

BY DAVID BISHAI, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH

David BishaiThis symposium is unique because it’s not about one disease.  In the land of global health, this is going to provoke suspicion and a sense that all this attention may be threatening resources and taking away the limelight from “my disease”.  In sober moments everyone realizes that nobody’s disease can be properly addressed without a strong health system.  But the logical error that plagues us all began when we framed global health as a problem of “diseases” and the solutions as “disease control”.  Although it is billed as a health systems symposium, I am afraid the week will be consumed with concerns about human activity that is fundamentally reactive and curative.  This is really a “disease systems” symposium. 

The limelight is not really being stolen from HIV/Malaria/TB/Micronutrients.  If anything the danger is that a week of “health systems” will further the misimpression that doctors, nurses, and drugs are the fundamental drivers in the health of nations.  Let’s not kid ourselves that the human activities of most concern this week really address the root social determinants of health.  The high income countries had largely  conquered infectious diseases long before the doctors had effective cures.  The growing burden of problem health behaviors is anathema in most medical encounters.  Perhaps the best evidence of the irrelevance of health systems to health systems are the Whitehall studies showing that health disparities can be perpetuated despite health insurance. In the US the sub-population with the worst health and best health care financing is our Native American population.  Native Americans face 3:1 rate ratios of mortality for injury and chronic diseases.  Native Americans have had comprehensive health financing and a chain of primary care clinics under the Indian Health Services since the 1960s.  The poor outcomes of the Indian Health Service lead some to want to tinker with the care package–but the lesson is that access to primary care is simply not enough.    Getting health systems right is an important issue for justice and human rights. Health systems are still important because the global disparity in what happens to sick people is one of the leading injustices in the world.   

But our discourse on health systems should not forget that health systems are not the foremost determinants of the health of nations.  We would have to open the concept of health systems to include sanitation, water, housing, roads, schools, jobs, and political systems to make health systems truly include the determinants of health.

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