In a year in which we have focused on the global spread in influenza H1N1, the international reach of disease is obvious. Indeed it is upon such pandemics of infectious disease that the international community has focused historically. The first globalisation in the early 19th century was marked by pandemic cholera and the beginning of the differentiation between the developed and the developing world.
This historic focus on pandemic disease and the differences in types of infection between countries and regions has obscured the essential similarities between peoples. Advances in molecular biology have made us realise that we belong to a homogeneous species derived from comparatively few female and male lineages. This explains why we seem to be susceptible to the same infections and non-communicable diseases. Further, our ability to treat and prevent infections has led to a rethink of control strategies and brought into focus the role of social and infrastructural factors in the control of disease and, equally importantly, the promotion of health in their prevention. As control of infections enhances life expectancy, non-communicable disease becomes more prominent, and this adds to the challenges to be faced. All this hard-won advance and understanding may be placed in jeopardy by global warming. We cannot yet predict the impact of these changes on the ecology of disease, but the results of climate change will not spare those ecologies that determine the patterns of disease in humans.
The prospectus for this journal lists some of the topics that need to be addressed:
•The social and economic aspects of disease, both communicable and non-communicable. In some ways it is obvious that the poor are more likely to be ill and the costs of disease impact upon them more cruelly. Nonetheless, our knowledge of how this scenario plays out in different societies and under different social conditions is deficient. We need to understand more about social attitudes to health and disease in different cultures.
•Evaluation of disease control programmes. When we try to control disease we need to know what works and to recognise that having effective biomedical tools is not enough. A good tetanus vaccine has been available for about 80 years and a good hepatitis B vaccine for 20 years, yet both diseases are major problems worldwide. Cost is often mentioned, but we need to be aware of the political, social and cultural context of interventions and to try and understand their importance.
•Health systems research and policy. The context within which disease control and health care are delivered is the health system. The lack of a robust and effective health-care infrastructure defeats many interventions. Understanding how health systems work and how well they integrate with their social and cultural setting is central to the delivery of effective health care.
•Management and economics of health care. The management of the health system is a crucial component in the delivery of effective health care, whether considering primary health-care systems in the community or the operation of tertiary-level referral hospitals. Health care is not a free commodity, and the costs and benefits must be considered. Even in resource-limited situations, economics will in part depend on how the benefits are accounted. Too often only the costs are considered.
All these matters relate in part to health-care delivery or what have been called ‘disease systems’, but the health of a population is determined not only by exposure to disease but also by the possibility of living a healthy life. Lifestyle influences are of particular significance for non-communicable diseases.
Around 1830, life expectancy in England and Wales overtook that in sub-Saharan Africa. This is not to say that life in England and Wales during the 19th century was acceptable by modern standards. In 1900 life expectancy was lower than in much of sub-Saharan Africa today. Indeed, in the UK in 1900 more people died during the first year of life than died before the age of 65 years in 1990. But now “as Peter Laslett was wont belligerently to declaim ‘the old have monopolised death”’.1
So why have some human populations become healthier? It is probable that most of the gain in life expectancy among the wealthy countries has occurred as an epiphenomenon of development and the consequent availability of public goods such as adequate food, clean water and sanitation. Reduction in infant and maternal mortality has played a crucial role. Infection was largely controlled by public health measures.
We tend to forget that much of this gain occurred before the availability of most of the effective medical interventions; most drugs were invented in the last 60 years and most vaccines in the past 100 years. However, the availability of medical interventions, including vaccines, mass chemotherapy and chemoprophylaxis, has accelerated these improvements and made possible in principle the control of infectious disease worldwide.
It may be that we now have the technology to increase life expectancy and without the concomitant trauma of old-style development; indeed, this seems to be an assumption underpinning some health-care interventions. Whether such an aspiration is desirable is unclear, but it has some credibility in the context of concerns about global warming. Be that as it may, older people will become at greater risk of non-communicable diseases, and these diseases will be the predominant threat to health worldwide.
The aspiration of ‘health for all’ faces many challenges; as a journal, International Health will be at the forefront of the debate about how this can be achieved. Whatever the means that find favour, the goal must be to make death the monopoly of the old, worldwide.
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