Professor IB 60
Festskrift/FestSchrift
for Ib Bygbjerg
2005

Attempting an Answer to IB's Question:
How to make People Understand the Full Perspective of International Health?

M eanwhile, in Gokwe, Zimbabwe, whilst doing a study on malaria, an expert group encountered a commu­ni­cation problem (Ndebele 2003). When the experts talked about mal­aria it rang no bells among the locals. A descrip­tion of the symptoms was recognised as nyongo. However, substituting nyongo for malaria did not resolve the predica­ment, because when the experts went on talking about the need for con­trol­ling the mosquitoes, the locals failed to see the point: apart from the occasional bites mosquitoes did not present a se­rious problem, as it was common knowledge that nyongo is caused by eating immature sugar cane.

Bewildering as the situation may have been, communica­tion­wise the scenarios can be even more confounding. As Italian semiotician and author Umberto Eco (1999) points out our worst enemy, when faced with something we have not seen before, may be our own interpretation, our precon­ceived no­tions of the world, derived from our cultural tra­dition. Eco illustrates this with the story of Marco Polo's encounter with unicorns on his way back from China in Java. Even though the animals with horn on their muzzles did not live up to his expectations of the horselike unicorn by being black instead of white, with pelts closer to that of a buffalo, hooves as big as elephants, tongues spiky and heads looking like boars, Marco Polo believed he had seen uni­corns. Though, his con­clusion was that unicorns were not the gentle beast people believed them to be. Marco Polo was not a learned man, but he grew up in a tradition, where people knew that such a thing as a unicorn existed, even though no one had actually sighted the elusive entity. When he did see a creature with horn on its muzzle, his back­ground books, as Eco phrases it, influenced him to refer his discovery to what he already knew, instead of saying he had found an animal hitherto undescribed.

Falling victim to one's background books is so easy that it probably should be seen as a human precondition, because our background books are indispensable in trying to navi­gate in a complex world and in giving us perspective (which, de­pend­ing on the context, is also known as prejudice). For prac­tical reasons we simply cannot question everything nor reinvent the world anew every morning, but have to rely on a framework through which we can analyse and evaluate what we see. The inherent rub is barely noticeable as long as the framework in question is kept up to date; or our precon­cep­tions are not challenged by new discoveries.

To develop this let us essay that there are public background books that influence public opinion and politics. It does not take much observation to notice some divergence between the content of the public background books and an ever on­going generation of new scientific knowledge and insight. The field of public health offers many examples.

When AIDS was first was recognised in California in 1981 (WMMR 1981), an important common denominator in identifying the cases was that the patients were gay men. The initial report was soon followed by others (see e.g. Friedman-Kien 1981) that all described cases among pre­viously healthy gay men. No wonder that the background books soon had it that it was a disease solely afflicting gay men. Since gay men in many ways are at odds with main­stream society, this per­ception of the new disease as a gay phenomenon could be seen as a pretense for many govern­ments for not feeling com­­pelled to act as if they were facing a public health crisis. The background books had such a consensual impact that a critical public opinion did not find much reason to challenge the reading. Not even when new patients showed that not only did the new disease have no sexual preference, but that the routes of transmission also could be blood borne and not solely sexual, were the back­ground books revised. To make matter worse: the same basic mistakes in handling the dis­ease were made over and over again in different settings.

In his doctoral thesis Anker Brink Lund (1997) demon­strates how the public background books - although he does not use that specific term - referred HIV/AIDS to some­thing familiar by inheriting textual aspects from earlier me­dia coverage of tuberculosis, syphilis and other diseases in the mass communication of AIDS as a national and inter­na­tional HIV-epidemic. As HIV/AIDS at the same time was something never seen before, science soon generated new insights. However, the new is not in itself newsworthy; it has to gain authority. According to Anker Brink Lund authority is gained through associations, how well interpretations of reality is translated through the background books, or, in his terminology, how fact are constructed in a social context to communicate credibility from one discursive field to ano­ther. In this process the mass media formed and moulded the pub­lic opinion through spectacular events and dramatic emplotments rather than research based arguments. In the years following the recognition of AIDS in 1981 many a public health specialist or researcher tried to get words of warning out about an imminent public health crisis, but it took an event to make AIDS a household word: the collapse of American actor Rock Hudson in the vestibule of the Ritz Hotel in Paris on 21 July 1985 and his subsequent demise in October of the same year. An explanation for the quandary of the research based argument may be found by para­phrasing the Copenhagen School of Security Studies’ line of reasoning for why not any topic can be made into a security issue: a discourse that takes the form as presenting some­thing as important does not by itself create importance. At best it has a move in that direction, but an issue is only made important if and when the audience accepts it as such (Buzan et. al. 1998, p. 25).

The relationship between the background books and the discipline of International Health contains a certain amount of knottiness. Firstly, there is the issue of the name, because as some may remember it used to be called Tropical Medi­ci­ne and according to the background books, which these days also can be found on the Internet, e.g. www.answers.com, the short version is that »tropical medicine is the study, diag­nosis, treatment, and prevention of certain diseases preva­lent in the tropics«, i.e. tropical medicine deals with infec­tious diseases. Secondly, although a rationale behind the change of name may be understandable in terms of a wish to embrace not only the health of the tropics but also of low-income countries, the tropical pedigree makes it ardu­ous for international health as a concept. As for a simple, straight­forward definition a search for international health at again www.answers.com results in a headline that states »Health & Nutrition Systems Int'l, Inc.« and a question: »did you mean: international (organization), The INTER­NATIONAL, International Shoe Co. v. Washington (Legal Case), Inter­na­tional (New Order album), International (passenger train) more...« It should be noted though that the page tells that international health is mentioned in among others a linked article about the University of Copen­hagen Faculty of Health Sciences. Following the link www.answers.com can tell that »The Faculty produces graduates in medicine, dentistry, and human biology. In addition, the Faculty offers a Ma­ster's degree in Public Health, Bachelor's and further de­grees in Public Health in addition to a Master's degree in International Health« (my emphasis). End of digression, but it goes to show that since a clear definition does not spring easily to mind, not even among practitioners of the disci­pli­ne, it may be hard to blame the background books for equat­ing International Health with infectious diseases. Which is not untrue: Inter­national Health does indeed deal with infec­tious diseases - among other many matters.

So thirdly, there is the issue of exclusion/inclusion of these others matters. It is mind-boggling to compare the pub­lish­ing date of Abdel R. Omran’s paradigm-shifting paper on epidemiologic transition (1971) and it’s impact - or rather lack thereof - on the background books. Omran argues that the developed countries has already seen demographic and technologic transitions parallelled with an epidemiologic transition in which degenerative and man-made diseases displace pandemics of infection as the primary causes for morbidity and mortality, and that the less-developed coun­tries will belatedly go through the same process. Omran outlined three ages that constitutes the transition:
1) The Age of Pestilence and Famine where mortality is high and fluctuating and life expectancy at birth is 20-40 years;
2) The Age of Receding Pandemics where mortality declines progressively and life expectancy at birth increases to 30-50 years; and
3) The Age of Degenerative and Man-made Diseases when mortality continues to decline and eventually ap­proaches stability at a relatively low level and life expectancy at birth eventually exceeds 50 years.

Later LaPorte et al. (1996) elaborated on Omran’s theory stating that a decline in the occurrence of infectious diseases leads to an unmasking of noncommunicable diseases as people live longer. They can even discern systematic pat­terns in the emergence of chronic diseases: as economic develop­ment is associated with a roll back in both incidence and pre­valence of infectious diseases, the increased activity and ener­gy consumption accompanying economic deve­lop­ment first results in more injuries; economic development also im­proves socioeconomic status, which could lead to changes in living and working patterns with less physical activity and less physical labour and higher consumption of tobacco, al­co­hol and processed or fast food, thus beginning to unmask type 2 diabetes; about five years later coronary heart diseases is making it’s entry into the mortality records; and finally af­ter a latency of two or three decades cancers make their mark.

Looking at a country like Denmark through the specs of Om­ran and LaPorte et. al is probably congruent with most back­ground books. Yet, applying it to low and middle income countries is quite a different matter. While still being valid, Omran’s essay is also in some respects a child of it’s time: in 1971 one need not feel embarrassed for believing in a Pax Antibiotica; 1971 was years before HIV/AIDS and the emer­gence and reemergence of infectious diseases. Also, global patterns of health and disease are more complex than what can be presented in a model. Many of the unmasking signs are evident in low and middle income countries, but progress on diminishing the impact of infectious diseases has not been as successful as anticipated, and not just be­cause of HIV/AIDS. The fact of the matter is that many of the low and middle income countries fights on two health-fronts simul­tan­eously: Against the old infectious diseases and against the new degenerative and Man-made diseases. Also known as The Double Burden of Disease.

The concept of the double burden of disease represents a true communication challenge, simply because it is not in the vocabulary of the background books. When referring to re­ports from clinics in poor neighbourhoods in Dar es Sa­laam or Madras of patients with symptoms of type 2 dia­be­tes (if one knows what to look for) waiting to see a doctor, the ini­tial reaction outside of the International Health com­munity is one of disbelief: these must somehow be excep­ti­onal cases, for type 2 diabetes is a life style affliction, which they cannot have in the Third world.

Which, Ib, brings us back to a question you posed and I have attempted to answer: how do  we make people understand the full perspective of International Health? I am afraid I do not have the answer in terms of a magic bullet, only that com­­munication is not an end but a means and it takes an ef­fort, as so many others health interventions. As for the back­ground books, they for sure could do with some up­dating.

References