Hospitals and Health for All by the Year 2000

Hospitals and Health for All by the Year 2000Author(s): HALFDAN MAHLERSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 71, No.5 (SEPTEMBER/OCTOBER 1980), pp. 347-349Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41987379 .

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Hospitals and Health for All by the Year 2000*

DR. HALFDAN MAHLER

Dr. Halfdan Mahler

Mr. Chairman, distinguished col- leagues, ladies and gentlemen,

Hospitals have a long and rich history of providing medical and social care. Their functions have evolved throughout the centuries in response to the needs of society as perceived by generation after generation. As the Twentieth Century draws to a close, however, they have become towers of technology, inaccessible to most people in the world. For the vast majority of the world's population have no access to hospital care. And even if hospitals are physi- cally accessible to the majority of people in the developed countries, they are psy- chologically inaccessible to most of them because of the growing communi- cation gap between those who provide medical care and those who receive it. Will hospitals continue to become more sophisticated, more costly, more alie- nated from the people they are meant to

♦Address by Dr. H. Mahler, Director-General of the World Health Organization, Geneva, Switzerland to the Congress of the American and Canadian Hospital Asso- ciations, Montreal, 29 July 1980.

serve? Or will they devote their energies to supporting the care of people in a way people can understand, dealing with the host of health problems in their daily lives for which clinical care is not neces- sarily the answer?

In the developing countries, these daily health problems that I have just referred to result from a pernicious combination of unemployment and under-employment, economic poverty, scarcity of worldly goods, a low level of education, poor housing, poor sanitation, malnutrition, affliction by disease, and social apathy. Nearly one thousand million people, living mainly in rural areas and urban slums, exist in such a state of social and economic poverty. Many hundreds of millions more are not much better off. These people have no access whatsoever to any permanent form of health care: hospital care is out of the question for them.

The daily health problems of people in developed countries all too often result from oversmoking, overeating, overdrinking, overdriving, over-using and abusing drugs, overpolluting their environment, and over-alienating themselves in gigantic urban agglomer- ations. Your health systems are over- costly; if the costs are not curbed, in a short time none of you will be able to afford universal care with the type of medical technology you are currently using.

As you can see, there is flagrant social injustice in the distribution of health resources among countries. But this injustice also prevails within countries, even the most developed.

The quest for social justices in health formed the moral basis of that momentous decision of WHO's Health Assembly in 1977 that the main social health target of governments and WHO in the coming decades should be the attainment by all the people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. This is popularly known as Health for All by the Year 2000.

What does health for all mean? It does not mean that in the year 2000, doctors and nurses will provide medical repairs for everybody in the world for all their existing ailments; nor does it mean that in the year 2000 nobody will be sick or disabled.

It does mean that health begins at home, in schools and in factories. It is there, where people live and work that health is made or broken. It does mean that people will use better approaches than they do now for preventing disease and alleviating unavoidable illness and disability, and better ways of growing up, growing old and dying gracefully. It does mean that there will be an even distribution among the population of whatever resources are available. It does mean that essential health care will be accessible to all individuals and families, in an acceptable and affordable way, and with their full involvement. And it does mean that people will real- ize that they themselves have the power to shape their lives and the lives of their families, free from the avoidable burden of disease, aware that ill-health is not inevitable.

Canadian Journal of Public Health Vol. 70, September/ October 1980 347



An International Conference on Primary Health Care that was held in Alma-Ata, USSR, in 1978 issued a Dec- laration which stated that primary health care is the key to attaining health for all by the year 2000. What then is primary health care? The Alma-Ata Conference described primary health care as essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination.

Primary health care reflects and evolves from the economic conditions and socio-cultural and political charac- teristics of the country and its commun- ities. It addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly. It includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; mat- ernal and child health care, including family planning; immunization against the major infectious diseases; preven- tion and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.

If you can take some of these components for granted in your societies, I am not so sure if you can take other for granted, for example the education of people concerning their own health problems and methods of preventing and controlling them, and appropriate - and here I underline appropriate - treatment of common diseases and injuries.

Lest you think I am delivering a ser- mon on the mount from the Alpine Mont Blanc which I can see from my office window in Geneva, I would refer you to the policy document issued in 1974 by the then Canadian Minister of

Health, Mr. Marc Lalonde, entitled "A New Perspective on the Health of Can- adians". He divided the health field into four broad elements: human biology, environment, lifestyle, and health care organization. In the light of this, five intervention strategies were proposed, namely: 1. a health promotion strategy, stress-

ing health education and the acceptance of greater responsibility for health by individuals and organ- izations;

2. a regulatory strategy, aimed at hazards to both physical and mental health;

3. a research strategy, stressing high priority diseases, such as mental illness and cardiovascular diseases;

4. a health care efficiency strategy, aimed at achieving a better balance between cost, accessibility, and effectiveness;

5. a goal-setting strategy to set goals for mental and physical health and to improve the efficiency of the health care system. The Member States of WHO have

embarked on the formulation of national strategies to attain health for all their people by the year 2000. At a recent symposium on health for all in developed countries both Canada and the United States of America presented preliminary ideas for their strategies. Canada's strategic objectives for the 1980's focus on the elimination of environmental health hazards; ensuring that the public has adequate access to appropriate health care services; the alteration of lifestyles that are not con- ducive to the maintenance of good health; individual and family income security; and the provision of appropriate social services, particularly to those who are disadvantaged.

To attain these objectives the Lalonde strategies that I have just men- tioned are pursued. For example, in the area of lifestyle, the value of health promotion is stressed. Concern is expressed over the low priority given to health promotion by the medical pro- fession, due to its preoccupation with the curative aspects of medical practice.

It is noted that health care organization consumes almost 95% of health expen- ditures. It is suggested that health pro- fessionals must play a bigger role in preventive programs and in health promotion if the public's dependency on curative medicine is to be reduced.

The interpretation by the United States of America of health for all presented at this symposium involves three interrelated components: all citizens should have access to health services; the services should be effective in prom- oting and maintaining health and reduc- ing unnecessary morbidity and moral- ity; and all citizens should be concerned with and participate in health promotion programs, including attainment of health life styles. Services should be available to all, but special attention should be given to those most in need and at risk.

Now listen to what is stated in the United States Case Study for achieving health for all by the year 2000: "Behav- ioural risk factors are today some of the leading causes of unnecessary death and disability in the US . . . Risks in the physical environment include: contam- ination of air, water, and food; work- place hazards; radiation exposure; excessive noise; dangerous consumer products; and unsafe highway design. Risks in the socioeconomic environment which affect health include income level, housing and employment status, family ties, and social supports . . . People need health education and information to choose healthy lifestyles and to make effective use of available services. Social pressures and many kinds of advertising can support or dis- courage such choices."

I continue with the quotation: "Lack of access to effective services which promote, maintain, or restore health is associated with more frequent and more severe illness ... 49 million Americans live in areas officially designated as medically underserved, 22 million in urban areas and 27 million in rural areas. 14.9 percent of people do not have a regular source of medical care. 20-25 million Americans have no health insurance - most poor or near poor -

348 Canadian Journal of Public Health Vol. 71



and 19 million American have inadequate health insurance coverage. An additional 46 million Americans have inadequate insurance against large medical bills. Almost half of all individuals with incomes below the Federal poverty level are not covered by Medicaid."

Can primary health care supply all the answers to all the problems I have just referred to? This question too was addressed by the Alma-Ata Conference. The Declaration of Alma-Ata stated that primary health care should be sus- tained by mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all. The support of other levels of the health system is necessary to ensure that people enjoy the benefits of valid and useful technical knowledge that is too complex or costly to apply routinely through primary health care. The rest of the health system therefore has to be organized in such a way as to provide support for primary health care.

Hospitals clearly have an important role to play in supporting primary health care. In addition to providing clinical care for patients referred to them because they need speical facilities and personnel with specialized skills, hospitals will have have to accept a social function that is appropriate for the closing decades of tne Twentieth Century, just as they have fulfilled important social functions throughout their history. How could hospitals be reorganized to fulfil this new social function?

You could start by reviewing the scope and content of your activities, and relating them to the support of primary health care in defined population groups. You could use your enormous human and technical resources to provide the public with properly validated information on health problems and on appropriate technology for solving them. Your prestige could serve to counteract the false health information that is being all too widely propagated, whether through ignorance or for ulte- rior motives.

You are deeply involved in the continuing education of health workers and

related social workers in the community. But this education has to relate to their problems, which are the day to day problems of people, rather than to many of the esoteric clinical problems with which so much of your time is taken up. The dividing line between continuing education and support is a fine one; you have an important function too in providing support to health workers in the community with respect to all the problems that they encounter.

The strategies for health that I menti- oned of both Canada and the United States of America concern themselves with the lifestyles of their people. You could take a lead in undertaking the research required to induce people to change their lifestyles, no easy matter as you know. But it is precisely because it is no easy matter and because you have the resources that you should accept the challenge. You see the end results of faulty food habits, excessive drinking, smoking, and accidents. Surely you should be more deeply involved in dev- ising ways of preventing and controlling these health problems.

You could act as watch dogs of the environment, providing politicians and the public with correctly assessed information on the real risks from environmental hazards and ways of preventing or overcoming them. This could include interesting yourselves in the psychosocial problems of society, for example of youth and the elderly. You could devise and carry out research aimed at arriving at concrete solutions to these problems, or at least of assess- ing whether concrete solutions can be envisaged. After all, you are part of the environment and your activities affect it both positively and negatively.

To permit you to carry out such new functions you would have to carry out a reappraisal of your existing functions and of the technologies you use. You could perform a service of inestimable value to your own and to other countries by reassessing the health technology you use. The people who work in your hospitals have grown up in an environment of technological euphoria that makes it difficult for them to dis- cern between what has stood the rigor-

ous test of scientific validation and what has gained acceptance through long continued practice or spectacular claims. Nothing short of a vast undertaking of technological reassessment will save the situation.

What surgical interventions are really beneficial? What diagnostic radiology is essential? What laboratory tests provide essential information, and what only marginally useful information? What radiotherapy in fact prolongs life? What drugs are effective and harmless? What psychotherapy is personally helpful and socially useful? What electronic equipment for cardiac patients is really life saving? Think of the enormous savings you could make, not to speak of the alleviation of human suffering, if you could discover simple tests to predict which patients are really likely to benefit from intensive coronary care. Think of the enormous increase in efficiency you could bring about by ration- alizing the use of expensive radiological and laboratory equipment.

To perform the functions I have briefly referred to would involve you not only in biomedical and bioengineer- ing research, but also in social, behav- ioural and health systems research. A combination of these facets of health research is required both to identify and to generate health technology that is scientifically sound and socially and economically acceptable, as well as to discover the most efficient and effective ways of applying this technology, whether through primary health care or by the supportive hospital system.

Mr. Chairman, distinguished col- leagues, I have indicated only some of the ways in which you could convert your hospitals into agents for the service of society instead of precincts for individual medical transactions between doctors and patients. Are you ready to accept this challenge? Are you ready to influence the hospital associations of the other countries of the world to accept it? The year 2000 is less than 20 years away. Your decisions will be vital in determining whether hospitals will play their proper role in bringing the people of the world nearer to the goal of health for all by the turn of the century.

September/October 1980 349



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Hospitals and Health for All by the Year 2000