At a two-day conference held in Cairo last week, Yasmine Fathi confronted the challenges facing healthcare in the region "Health for all by 2000" was the slogan of the 1978 Alma-Ata Conference, held in the Kazakh (then Soviet) Republic. Health ministers from 134 countries gathered with WHO and UNICEF representatives to declare equity, sustainable development and peace to be at the heart of their vision for a healthy life for all. Five years after the deadline they set, has the state of health in the world improved? Does everyone have equal access to healthcare? In developing countries, at least, the slogan remains a far cry from reality. On 14 and 15 May, a conference entitled "People's Health: Determinants, Current Challenges and Opportunities", constituted an attempt to address the failure. Organised by the Association for Health and Environmental Development (AHED) in association with the People's Health Movement (PHM), it brought together various stakeholders in the health sector from Egypt, Palestine, South Africa and India: Helmi El-Hadidi, former Egyptian minister of health, David Sanders, public health professor at the University of Western Cape, South Africa, and many others. In the opening statement, AHED Chairman Alaa Shukrallah pointed out that in the last few years, healthcare system and professionals alike came under severe attack from both the public and the media, who complained, mainly, of two shortcomings: the quality of medical assistance and lack of access to effective services or medication. Negligence, misconduct, often abuse, he said, are but a few of the perils of the current system. Shukrallah cited newspaper headlines to demonstrate: "125 kidney failure patients dead by expired injections"... He emphasised three factors: the structure of the healthcare system, the professionals who operate it and the patients. Budget allocation and monitoring were identified as principal failures: the latter will significantly reduce cases of negligence, for instance. The ethical orientation of professionals is equally vital. Medical professionals in Egypt are groomed to be the crème of society but they end up working for measly salaries, unable to make ends meet. Their attention is channelled away from state hospitals and into the more lucrative private practices. Nor are patients sufficiently aware of their rights to confront the physicians in question. Egypt had efficient medical care from ancient times to the 14th century, Shukrallah explained, with the Islamic world constituting the principal beacon of medical knowledge through the 11th century. It was not until the Mohamed Ali era that the system had deteriorated sufficiently to necessitate importing the Western model, which focussed on treatment at the expense of prevention, and has yet to be adequately applied. There is more to healthcare than the treatment of disease, though -- a point made by many a participant. "You cannot simply tackle the illness," Maria Zuniga, PHM steering group member, opined. "You have to look at social, economic, political and environmental factors: it's a package." Poverty, unemployment, pollution, an injurious working environment: all contribute. In some countries it is a challenge to meet health expenditure requirements. Ethiopia, for one example cited by Sanders, spends 22 per cent of its national budget on health and education, yet it amounts to no more than $1.50 per capita on health. Even if Ethiopia spends every last penny of its budget on healthcare, it would still not meet the WHO target. Likewise with working environments. Shukrallah recalled that, treating a pregnant woman who suffered from asthmatic bronchitis in a Cairo shanty town as a young doctor, he was unsure what medication to give her: "Finally I asked her, where do you live? It turned out that she lived in a dusty house with several other families." In a dust-free environment she might not require medication at all, but the dust was unavoidable since, even if she stopped dusting, those who shared the apartment with her would not. Even more unfortunate is the case of the workers at an asbestos factory in the 10th of Ramadan City -- an environment known to cause various lung diseases and several varieties of cancer, including mesothelioma. Employees who worked there without safety or health provisions since 1983, Sayed El-Tayib -- one of them -- pointed out, were unaware of the risks: eight have since been disabled, and 46 suffer from a range of diseases. Maher Boshra, the Better Life Association chairman, made a similar point about children working in quarries, where both the machines they use and the rock powder constitute major threats: many were savagely killed by the machines, or, inhaling the powder, contracted abiding and health-threatening diseases. From working conditions to war and occupation: according to Jihad Mashal, general director of the Palestinian Medical Relief Foundation, medical vehicles and personnel are frequently shot or otherwise attacked before they can reach patients in the West Bank, which is now divided into 300 isolated clustres, hampering mobility. In 2004 alone, he testified, 125 Palestinians died as a result of prevention of medical aid. "Last year 70 per cent of the patients waiting for treatment were forced to meet the ambulance at the checkpoint, where 66 Palestinian women gave birth." Participants agreed that socio-economic conditions were of profound importance. Both, however, many went on to say, are subject to neo-liberal policies adopted in the framework of globalisation. According to Sanders, such policies -- promoted by international organisations like the World Bank, the International Monetary Fund (IMF) and the World Trade Organisation (WTO), and reflected in specific agreements like the GATS (General Agreement on Trade in Services) and TRIPS (Intellectual Property Rights Agreement) -- can have a significant effect on the quality of health services. As early as 1989, Henry Kissinger, a firm supporter of the policies in question, pointed out that, rather than having an immediate positive effect, they would initially widen the gap between rich and poor, giving way to "trickle-down effect" in time. Yet, as Sanders insisted, in the last two decades the gap has widened more than ever: from 1990 to 2001, external debt as a percentage of gross national income in developing economies rose from 88.1 per cent to 100.3 per cent. In some cases the situation is so dire that the entire national income cannot cover the debt. "This debt was accumulated through policies seeking to invest in infrastructure and liberalise the market," Shukrallah added. "Would it be better to be born a Japanese cow than an African citizen?" Sanders asked. The answer, he said wearily, is, "yes, since an African citizen has an annual income of $500, whereas a Japanese cow has an annual dairy subsidy of $3,000." Reduced access to drugs is another flagrant example of the negative effects of these policies. The TRIPS agreement, applied in Egypt as of January 2005, forbids the local industry from producing generic drugs patented to multi-nations -- which products are far more affordable to the average citizen -- with the result that pharmaceutical companies", as Shukrallah put it, "will decide the prices and have a monopoly over the drugs during the designated period" of 20 years starting at the moment they are introduced into the market. Consequently, older-generation drugs will be available to everyone, while only the rich will be able to afford the newer, more effective drugs -- another social divide. According to Helmi El-Rawi, a researcher at the Egyptian Initiative for Personal Rights (EIPR), what is more, such agreements undermine humans rights agreements ratified by Egypt. Raouf Hamid, professor of pharmacology at the National Organisation for Drug Control and Research said that governments should unite and challenge these agreements. In South Africa, he pointed out, the TRIPS agreement was applied to AIDS drugs, causing a crisis. Yet the state defiantly continued to produce the drugs at a local price. "About four pharmaceutical companies and 35 countries united -- and they won the case in the end." The assault of neo-liberal policies is equally evident in health sector "reforms", according to Sanders, which focuses on enhancing efficiency through delivery of a core set of essential services, greater involvement of the private sector and decentralisation. This focus on efficiency, Sanders argued, has led to an imbalance in the quality of medical service available, with a consequent deterioration in immunisation, for example, which declined from 90 per cent in the late 1980s to 75 per cent in 2000. Nor was health insurance spared: insurance services started in Egypt in 1964, and 42 per cent of the population are now covered. A current government proposal to privatise the service, on the pretext that it will improve efficiency, however, undermines the sustainability of these schemes. Speakers concluded that, so long as health is thought of purely in terms of disease and cure, the decline of the healthcare system will continue. Health is rather a political, social and economic issue, and in order to achieve the health for all vision, the powerful interests of globalisation must be opposed; political and economic policies must to be changed. "Believe me," rallied Shukrallah, "the slogan is possible, but only if both the national and international will to achieve it is there."
