(In which he emerges from his dogmatic slumber . . . )
Regular blogging is obviously not my thing, but every now and then something arises that I can’t easily discuss in 140 characters on my beloved Twitter, so here we go.
A new article in PLoS Medicine flashed in my Inbox this afternoon, entitled “A Global Biomedical R&D Fund and Mechanism for Innovations of Public Health Importance.” This really grinds my gears. Perhaps surprisingly, this irritates me not because I am opposed to establishing a “biomedical R&D fund and mechanism for innovations of public health importance.” Not at all — if we can find better ways of generating pharmaceutical products for which robust evidence shows important impact on population health especially in emergent public health scenarios, that sounds fine with me.
What is not fine with me is the way in which public and population health continually seems to be captured by biomedical culture and biomedical interventions, the most prominent of which, of course, is pharmaceuticals. I am referring here to the medicalization of global health policy. Such is bad for any number of reasons. First, overwhelming evidence shows that substantial improvements in overall population health and in the compression of existing health inequities (global or otherwise) are extremely unlikely to flow from acute care services, including but not limited to drugs. There is virtually no question that collective action on upstream, macrosocial determinants of health are vastly more likely to improve overall population health and to compress inequities, which matters because these two criteria are core to any adequate theory of justice in population health.
The concern, as I have written about independently here,* and as Joe Gabriel and I discuss here, is that the frame of the debate about how best to improve global health is cast on the geopolitical scale in terms of how best to ensure access to pharmaceuticals. To the extent that the frame obscures an unquestionably more important discussion — intervention on fundamental causes of disease — it is ethically suboptimal.
Second, as Vicente Navarro has pointed out, the perpetual tendency to focus myopically on biomedical interventions for social problems — make no mistake, health is a social problem — has actually had the historical tendency to weaken larger public health and social welfare systems, especially in the global South. The emphasis on magic bullets tends to absorb resources that could be better allocated to interventions that act on structural determinants of health outcomes, on the amelioration of structural violence, etc. So even, as Navarro points out, as the eradication of smallpox is unquestionably a good thing, it nevertheless resulted in a substantial weakening of larger health and social welfare systems in some of the most resource-poor settings on the planet. This is Bad.
Biomedical interventions supported by robust evidence of population health impact obviously have a role to play in improving global health, and in responding to acute public health emergencies. But we are not going to resolve our health problems, nor compress the staggering global inequities in health, via pharmaceuticals. Social problems rooted in adverse and deeply rooted social structures must be resolved at the level, or not at all.
*This paper is essentially an article-length exposition of many of the themes of this blog post.