Moving towards whose health?

The World Health Organisation has announced that "physical movement" will be the theme of World Health Day this year, to the fury of many third-world doctors. Hala Sakr takes the temperature of the argument
Conflict and war continue to take hold in many more areas across the world, particularly after 11 September. Now, the unprecedented escalation of violence has begun to pose a serious threat to the health of people caught in the crossfire. The negative consequences extend far beyond the direct loss of life, injuries and disabilities. The long term-price will be paid by younger generations, whose health is being harshly affected in every respect, including the psychological.
As you read this, prisoners of war and refugees are being denied healthy living conditions and appropriate medical care. Civilians have become direct targets for aggression, and are at many times denied access to health care and services. Even medical professionals are being attacked as they strive to reach out to people in need. When they do reach their patients, their ability to help is often limited by the deliberate destruction of medical infrastructure and facilities.
In such an increasingly chaotic and cruel environment, the basic human right to health has never been more questioned.
"The selective emphasis being placed on a healthy lifestyle is but a diversion from current international health problems associated with militarism, [the war on terrorism], and inflicting market economy on Third World people," said Soheir Mursi, professor of medical anthropology.
"We are seeing the Palestinians under occupation and confronting invasion, Africans burdened by structural adjustment programmes, Kosovars and Iraqis exposed to radioactive depleted uranium, or UN-documented starvation of Afghan refugees along with the threat of sanctions on places such as Zimbabwe and the de-facto sanctions on different Arab countries such as Iraq, Libya and Sudan," she added.
Haitham Al-Khayyat, senior policy adviser to the regional director of the WHO's Eastern Mediterranean Regional Office (EMRO), describes the situation in Palestine as "truly worrying -- especially given that occupation forces are targeting ambulances and preventing them from reaching people. So the wounded there are bleeding to death."
"This behaviour is against all international rules and conventions," he added.
He asserts that "the WHO has always faced many difficulties in providing means and medications. We have always tried to replenish, as much as possible, all health material and medications that get destroyed."
The WHO has also been working in Afghanistan over recent decades. "At times we were even the only international agency present," explained Al-Khayyat. "We recruited Afghan nationals so they could stay in the country and continue working, even at times of emergency when international staff were evacuated."
"We worked through difficult conditions, under different regimes and with all factions," he added.
Iraq is another "sad case" according to Al-Khayyat. "We provide the necessary medication, but unfortunately we have problems with the sanctions committee which interferes in many technical issues," he complained.
He also explained that UN sanctions on Iraq have prevented important medicines from reaching the Iraqi people. "On several occasions, many substances and drugs are refused because they fall under the term "dual use items," such as chlorine, which is needed for sterilisation of water, and nitrous oxide, which is important for anaesthesia."
It was in this context that many health professionals were surprised when the theme for this year's World Health Day (WHD) was proclaimed as "physical activity."
The theme is being considered as "an opportunity to select and highlight an important public health challenge, and to open dialogue and debate for prevention and health promotion," said Hussein A Geziary, regional director of EMRO.
He added that the 2002 slogan, "Move for health," is meant to provoke "a debate on the epidemiological shift in the global burden of disease and the factors that are fuelling this process of change."
And indeed it has.
Criticism of the idea is flooding in from all quarters. Some people within WHO itself described the theme as ridiculous, arguing that "this year it should have been something more like 'health for people under conflict'."
Mona Yassin, technical assistant at the public information office of EMRO, replied to the criticism by explaining that "this theme was chosen in May 2001, several months before 11 September."
"Moreover, themes related in some sense to the spread of global violence have been used for previous World Health Days," she said. She cited examples such as "Should disaster strike, be prepared" in 1991 and "Handle life with care, prevent violence and negligence" in 1993.
Nevertheless, the debate among health professionals is growing heated for other reasons than simply the current global atmosphere.
"This theme reflects an orientation whereby socially generated ill-health is subordinated to selected individual risk factors. Rather than considering severe health consequences of poverty, militarism, forced movement and refugees, the WHD theme focuses on risk factors related to physical activity. As a result, real problems are rendered invisible," argued Professor Mursi.
Alaa Shukrallah, chairman of the Association of Health and Environmental Development (AHED), thinks that "if such factors represent a health problem to Western countries and perhaps to some social groups in the Third World, this is hardly the case for the vast majority of the world's population. The so-called non-communicable diseases are more related to affluence than to poverty."
Some WHO officials are hitting back at the critics, however. They argue that while many forums are focusing on peace, security, terrorism and human rights and their related problems, other issues should not be forgotten. They believe that it is important to face the challenge on the many different fronts of our complicated world. However, human rights should not be overshadowed at any time and should be kept in perspective as part of a whole package.
Nevertheless, even pro-WHO voices admitted that "the counter-argument remains valid."
Preliminary data on risk factors from the WHO suggests that a sedentary lifestyle is one of the 10 leading global causes of death and disability. The WHO estimates that a lack of physical activity leads to more than 2 million deaths per year. By 2020, non-communicable diseases such as cardiovascular disease, stroke, diabetes and certain cancers will cause over 70 per cent of the global burden of disease.
"As life expectancy has increased, people have more time on their hands to develop non-communicable diseases, which are now causing a big problem throughout the world," said Al- Khayyat of EMRO. "We need to live healthier as we live longer," added Sawsan Basiri, regional adviser for healthy lifestyles at EMRO.
But is the lack of physical activity really a global public health problem? Aren't there more important health priorities to handle first, particularly in poor countries?
The WHO is arguing the contrary. In the entire world with the exception of sub-Saharan Africa, they say, chronic diseases are now the leading cause of deaths -- 77 per cent of which now occur in developing countries.
But Mohamed Hassan Khalil, a consultant cardiologist at Nasr City Health Insurance Hospital, insisted that the major causes of illness in the Third World continue to be different from those in the developed world. "In the Third World, major illnesses comprise a trinity of malnutrition and infective and endemic diseases -- as opposed to the trinity in the developed world, which are the so called 'new epidemics,' namely heart disease, cancer and accidents," he explained.
He points out that "the trinity of causes in developing countries has increased in the past few years due to increased poverty caused by structural adjustment programmes, free trade policies and World Trade Organisation policies."
AHED's Shukrallah also found it difficult to accept the WHO argument. "Malnutrition and infectious diseases, reflected in epidemics such as AIDS and hepatitis, are still claiming millions of lives around the world. They are the real challenge of health today," he affirmed.
"In Egypt, 70 per cent of mortalities are related to Bilharziasis, liver disease and their complications, including cancer of the urinary bladder. While this form of cancer constitutes 4 per cent of all cancers worldwide, its prevalence in Egypt is as high as 28 per cent," explained Khalil.
In a meeting held under the banner of the People's Health Assembly in 2000, representatives of NGOs from 93 countries issued the "People's Charter for Health." At the time, a Latin American attendee echoed a global resentment: "Illness and death anger us every day. Not because there are people who get sick or because there are people who die. We are angry because many illnesses and deaths have their roots in the economic and social policies that are imposed on us."
The People's Charter for Health claims that people's health should be defended by challenging trans-national corporations and international funding agencies.
"On the other side, the WHO, with its slogan for WHD 2002, is putting emphasis on prophylaxis against heart disease and stroke," complained Khalil.
"Even within the field of heart disease, the major problem in the West is ischaemic heart disease which affects about 2.4 per cent of the population. In Egypt, on the other hand, although the incidence is probably the same, it ranks behind the more prevalent problem of rheumatic heart," he explained. The latter affects about 5.9 per cent of the Egyptian population and finds its roots in poor housing conditions, low immunity and under-nutrition -- all of which are linked to poverty. "Prevention of this category of heart disease entails poverty eradication, rather than physical movement."
To Mursi, the WHD theme obviously undermines the WHO's own director-general Gro Harlem Bruntland's conceptualisation of health and sustainable human development as being about "equity issues." In 2000, Bruntland clearly stated that "in our globalised 21st century, equity must begin at the bottom, hand in hand with healthy nutrition ... the 'gold standard': nutrition, health and human rights... makes for both good science and good sense, economically and ethically."
This year's theme also seems distant from the WHO's policy orientation and its call for "massive effort against diseases of poverty" as stated by a press release issued by the agency in October 2000. The press release clearly states that "Dr Bruntland believes that in order to maintain this political commitment, a popular movement is needed to keep up the pressure on decision-makers, that would stimulate people in all countries to find their best ways of carrying forward this massive effort."
AHED's Shukrallah added, "The 2002 WHD slogan reflects a gross drift from WHO's 1978 Alma Ata declaration addressing the real causes of ill-health for the vast majority of people, particularly in the Third World -- gross socio- economic inequalities between different countries and between people within the same country. Back then, strategies focused on bringing about more equality in relation to access to resources and community participation."
The WHO, however, counters that non-communicable diseases are on the rise in poorer countries, and will have an increasingly severe effect on health care systems, resources and economies. The agency correlates the shift towards non- communicable diseases to changes in lifestyle.
EMRO's Geziary stated, "Most of the Eastern Mediterranean region countries are undergoing changes in lifestyle and social conditions as a result of rapid socio-economic changes including urbanisation and globalisation of media and economy."
"Sedentary life without physical activity is now prevalent all over the world. We are also losing healthy-eating and healthy- dietary habits," Basiri of EMRO said. She emphasised that "knowing that life is hectic and people have no time, the minimum cut-off point is 30 minutes of brisk activity per day. Any type of activity that can be accommodated into routine daily life is highly recommended."
Mursi, though, is highly critical. "This is part of a trend of privatising social problems, where essentially you end up blaming the victim," she said. "In sum, this theme is nothing but a propagation of the corrupt orientation of behaviour modification and lifestyle changes, which Third World health professionals have shown to be inadequate as a basis for solving the very complex global problem of compromised health and severe health problems associated with structural adjustment and related international development policies," she concludes.
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