When I was a wee 20-year-old volunteering at a children’s hospital in Ecuador for several months, I was forced to confront the socio-economic determinants of health for the first time. One of the major problems identified by the social workers and doctors was that the kids they were treating (most commonly for acute respiratory infections, malnutrition, diarrhea etc – all the things we read about) was that they were often re-hospitalized because they returned to the same conditions of squalor that had contributed to their illness in the first place. As we read about the tension between vertical and horizontal approaches to public health, I find myself repeatedly thinking of those kids with whom I forged relationships, and asking myself what approach I would advocate for them. Repeated oral rehydration therapy, or addressing sanitation and water supply for the communities? It’s obvious that horizontal approaches are more concerned with quality of life, in the long-term, than with statistical outcomes of acute vertical interventions to impress donors. As one of the articles we read pointed out, it’s great to save children from death… but only if they will be able to live lives of dignity. In a global political climate still unwilling to adopt public health policies based on true empowerment of the marginalised, so-called "diagonal approaches" seem like a possible vanguard for a transition toward more horizontal-leaning approaches.
Most of the articulations of the differences between horizontal and vertical have already been made on the discussion board, so I’d like to contribute to a couple new things to the conversation, a bit on the philosophical side, but hopefully not too tangential.
1 – "Human nature." I’ve noticed some of our dialogue slipping into these murky waters and I thought I’d share a quote from a white South African professor, Dr. Ric Turner, who was banned and eventually assassinated by the Apartheid state for his radical anti-racist writing and mobilising. He doesn’t write explicitly about health, but I’ve found his work to be useful to my thinking about the tremendous challenges of global health, which seem to be provoking some degree of overwhelmedness in some of us, myself included.
“The concept ‘human nature’ plays a very important role in our ‘commonsense’ thinking. We often explain difficult phenomena, such as war, corruption, jealousy, as being products of ‘human nature.’ And the idea that there is a fixed human nature is reinforced by a glance at the other people in our social milieu. They all seem to want much the same thing, to behave in the same way, to expect the same sorts of things out of life and out of their relations with other people. But a slightly wider glance shows that from society to society what people want and do varies enormously. Perhaps the only uniformity is that each group believes that the way it behaves is normal ‘human nature’…”^
In the public health field (and more generally), what we miss by labeling the decisions of rich nations to act selfishly in the interests of their powerful elites as “human nature” is the wide range of other possible alternatives – choices – that could be made. It’s not fair to say that the farmers of a small Malawian community who come together to form a cooperative structure in which everyone benefits equitably are somehow “going against” human nature. They, as any others, are making a choice. (Of course, people don’t always get what they choose, but that’s a separate question).2 – Don’t give up! … also known as “Utopian Thinking”
In the face of really daunting social circumstances in Apartheid South Africa, Ric Turner wrote a chapter called “The Necessity of Utopian Thinking”, which we global health folks might be inspired to consider. Here’s a little excerpt^:
“There are two kinds of ‘impossibility’: the absolute impossibility, and the ‘other things being equal’ impossibility. It is absolutely impossible to teach a lion to become a vegetarian. ‘Other things being equal’ it is impossible for a black person to become Prime Minister of South Africa… To understand a society, to understand what it is, where it is going, and where it could go, we cannot just describe it. We need also to theorise about it. We need continually to refer back and forth between what we see in the society and what is essential to any society…It is probable that many of our social institutions and personal ways of behaving will chance. The fact that something exists is no guarantee that it will continue to exist. A glance at some of the institutions which other societies have taken unquestioningly for granted: cannibalism, slavery, polygamy, communal property ownership, non-competitiveness, nudity, vegetarianism, male supremacy, matriarchy, promiscuity, Puritanism, the rule of divine emperors or the rule of hereditary aristocracies, and even, on occasion, democracy – should make us a little more hesitant in taking absolutely for granted such institutions as social inequality, the school system, ‘national growth’, war, and racial oligarchy in South Africa.”
I like this as a way of thinking about the different approaches to public health, measuring each against what we see as essential in society, and keeping in mind that (slowly, often so painfully slowly) societies change. Instead of resigning ourselves to global health disparities as the inevitable consequence of ‘human nature’, we need to be asking ourselves questions like “what changes to the current system would be necessary to create a context in which the choices to strengthen health systems and empower historically oppressed communities would be the socially accepted and desirable choice?” --- culture change takes a long time, but can begin with folks like us initiating dialogue.
And one last thing regarding resources – we are *constantly * talking about the shortage of resources to be able to implement the health systems of our dreams. True, the *current allocation * of resources prohibits the realization of the comprehensive, horizontal approaches. But as the diagonal article pointed out, the wealthiest nations would need only contribute 0.7% of their GDP to foreign assistance, and of that, 15% would be spent on health, in order to meet the proposed needs of the Global Health Fund. How much money are we, globally, spending on war and major arms deals? South Africa has followed the American example and scandalously spent a huge chunk of its budget in the 1990s on the most expensive model of fighter jets, undermining the possibilities of investing in quite necessary human development measures like housing, health, and education. We are living in an age of tremendous abundance – it’s a matter of how those abundant resources are prioritized.
^Turner, Richard. The Eye of the Needle. Johannesburg: Christian Institute of South Africa, 1972.
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