Map of life expectancy at birth from Global Education Project.

Tuesday, January 08, 2008

A Healthy Discussion

So okay, I could wallow around in wishy-washy sophomoric philosophy for a few more days, but let's put the key issue on the table. What do we mean by good health? Sure, that's technically just a semantic question, but it's actually substantive because the word "health" tends to stand in for whatever the ultimate goal is supposed to be of the blob that ate the economy -- or at least one of the blobs, the Department of Imperial Hegemony Defense being the other.

For quite some time, the approach to this question seemed to be that death was like checkmate, the only thing that matters, and we rated the badness in the world by years of life lost. But then researchers -- economists, mostly -- started to survey people and ask them how much life expectancy they would give up in exchange for, say, not going blind or not losing their legs, and so on. It turns out that the numbers were consistently more than zero, and this led to the concept of Disability Adjusted Life Years (DALYs) or Quality Adjusted Life Years (QUALYs). That became an alternative way of judging the burden caused by various diseases and the value of various treatments.

Sure, it's an advance, but it's still narrowly biological. We're paying money for those QUALYs, for one thing, and that money might buy us something else entirely, but we still don't have a good way of making comparisons between the value of QUALYs and true love, or a new Gameboy. You can't really do it through a survey because QUALYs are just too complex and abstract for people to grasp in making such a comparison.

Amartya Sen has proposed some good stuff, much of which is hard to value in money or QUALYs. There are basic needs, such as adequate nutrition, shelter. And then there are internal psychological states, such as self respect, happiness. And there are social goods, such as the ability to appear in public without shame, ability to entertain friends, a part in the life of the community. (Sen is a genius, by the way, but you probably could have thought of those if you tried hard enough.) So look - that's the bio-psycho-social concept of health that I mentioned earlier. And they all affect each other. Each one of those states enhances the prospects for the others, but they also have independent determinants.

Now here's the nut. If the definition of health is something like Sen's encompassing definition of human welfare, then public health really is everything. But is medicine? Is it up to physicians to get involved in who ought to be ashamed or whether we have adequate housing? (The argument for the latter might be stronger than the argument for the former, or it might all depend.) If not, can public health claim those concerns, or is public health supposed to be about maximizing the stuff that health care is also concerned with, only by more general means? This is also a semantic question but it deeply affects questions such as who gets money to do what, and what you are allowed to write about and still get tenure. It also affects the framing of important public policy questions and how we argue about ethics and social change.

(You may have noticed that I am avoiding current events recently. That won't last forever but blogging can easily become largely reactive. I'm trying to beat that tendency for a few days.)

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