The Washington PostDemocracy Dies in Darkness

Aligning health and economic priorities makes sense — if we choose the right ones

Public health and economic well-being can go hand in hand, unless we pursue economic growth at all costs.

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases and chief medical adviser to the president. (Andrew Harnik/AP)

When the Centers for Disease Control and Prevention reduced the time recommended for quarantine after exposure to covid-19 from 10 days to five, it was quickly criticized for subordinating public health to the economy.

But public health and economic well-being are inextricably intertwined — something that became very clear 50 years ago when international leaders attempted to resolve both global economic and health challenges.

After decades of economic growth following World War II, many economies began to slow down by the 1970s. The 1973 oil shock helped precipitate inflation and unemployment, together known as “stagflation,” throughout the developed economies of Western Europe and the United States.

Stagflation in developed nations meant less demand for commodities, leading to less favorable terms of trade for the developing countries that were economically dependent upon exports. Western banks, flush with petrodollars, were only too happy to fill in the gaps by providing loans to developing countries. When the United States and other countries raised their interest rates near the end of the decade to combat inflation on the home front, the interest rates on debt repayment crushed the economies of developing countries across Africa and Latin America.

But this crisis also created a moment in which radically new ideas about global relationships proliferated.

The 1970s saw the cresting of what journalist and historian Vijay Prashad has called the “third world political project.” Newly decolonized countries in Africa and Asia sought to organize their interests collectively within international institutions like the United Nations through voting blocs like the “Group of 77,” established in 1964. Despite having politically decolonized over a century earlier, many Latin American countries allied themselves to the third world political project because they shared the problems of economic dependency on and deteriorating terms of trade with developed nations.

In the early 1970s, these developing countries promoted a New International Economic Order (NIEO), an interlocking series of proposals for reforming terms of trade. In 1972, Mexican President Luis Echeverría presented the United Nations with the NIEO’s newly written Charter of Economic Rights and Duties of States, and two years later, the U.N. General Assembly officially adopted it.

The Charter, and the NIEO more generally, sought to reframe the goal of development as the satisfaction of “basic needs” instead of the pursuit of economic growth at all costs. Orienting development toward the satisfaction of basic needs implied rethinking the productive structures of the economy so that they produced more equitable outcomes within and between nations.

Soon, public health became part of this economic conversation. By the late 1960s, the postwar ethos of top-down disease eradication was also being challenged. Danish physician Halfdan Mahler became director general of the World Health Organization in 1973 and assumed a key role as an advocate for a public health grounded in the resources, needs and local technologies of individual communities. The WHO slogan during this period was “universal primary care for all by 2000.” Like reorienting the productive economy around basic needs instead of growth, this slogan implied that grass-roots communities should define health and attendant needs for themselves rather than remain bound by the top-down models of health that failed to meet pressing issues and made them dependent on imported medical technology.

In other words, in both the economy and global health, proposals aiming to liberate the developing world from unfavorable trade relations and its dependence on the technology of the developed world proliferated throughout the 1970s. These movements to reform the economy and global health were not on parallel tracks but promoted a unified vision of health and economic well-being.

Delegates to the International Conference on Primary Health Care in Alma-Ata in September 1978 affirmed that “health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal.”

The national representatives at Alma-Ata — physicians and public health and development experts — defined primary 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 country can afford to maintain at every stage of their development.”

The Alma-Ata delegates also explicitly linked the struggle for universal primary care to the NIEO. “Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries,” claimed the Declaration of Alma-Ata.

In places where community-directed primary health care took off, such as Costa Rica, the long-term benefits for public health have been notable. In a recent article for the New Yorker, Atul Gawande writes that “Although Costa Rica’s per-capita income is a sixth that of the United States — and its per-capita health-care costs are a fraction of ours — life expectancy there is approaching eighty-one years.” Meanwhile, in the United States, health expectancy in 2020 was 77.3 years, according to the CDC.

In the end, though, the pressure to service rising foreign debt obligations ate away at developing nations’ ability to pursue unified efforts to reform the economy and health in the 1980s. In particular, the idea of strengthening national health systems was at odds with the need to trim national budgets to satisfy international creditors. A vision of “selective primary care” instead of “comprehensive primary care” narrowed the ambition of primary care to pincer-like interventions. The 1980s saw the triumph, instead, of “neoliberal global health” focused on distributing cost-effective technologies and building public-private partnerships.

The reaction against the CDC’s updated quarantine policy showed that, in their gut, many Americans believe that economic well-being depends on achieving individual and community health. Making policies to recognize this reality may not require replacing our economic priorities with health-focused ones, but instead by making political arguments about how you can’t have one without the other.