The Women's Division of the General Board of Global Ministries has produced three books relating to health: (1) Abundant Living: Global Health and Christian Response-Ability, a study program for adults; (2) Youth Chat: Global Health and Christian Response-Ability, and (3) A Children's View of Global Health and Christian Response-Ability.  Each of these deals with issues of global health, an important concern for Christians. 

Abundant Living (AL) devotes four chapters to issues of global health and then turns to advocacy for a wide variety of issues from income distribution, to issues of treatment of women, to desired changes in lifestyle in order to promote health, to a move to socialized medicine. 

Youth Chat  (YC), in cartoon format, covers similar subjects beginning with global health and then turning to lifestyle, environmental problems and social issues. 

A Children's View of Global Health and Christian Response-Ability (CV), also in cartoon format, takes a group of diverse children in a worldwide balloon ride to help them see the global problems.

A major weakness in each book is the scattershot and anecdotal description of global health problems.  There is no understanding of means of assessing health or health problems.  The Alma Ata definition of health is included in AL but, of course, that definition is not useful for research as it is impossible to use it to determine whether health is improving or not. There is no discussion of appropriate means to improve health over a period of time.  The distinction between public health measures and individual care is not made clear, although the public health issue of clean water is mentioned. And, there is little discussion of the difference between disaster relief and programs designed to help nations improve their health delivery system. The treatment of the network of agencies, governmental and private, involved in improving global health is inadequate, as is the awareness of research pointing to effective programs.

In each book the disparities in health status are described, although imprecisely.  Quite neglected are two readily understandable measures that are frequently used in evaluation of a nation's health.  These are life expectancy (mentioned in YC as a component of an index of human suffering) and the infant mortality rate.  Life expectancy at birth is the number of years of life a person born in a given year in a given country may live.  The infant mortality rate is the number of live born children who die before they are one year old stated as a rate per one thousand live births.  Such measures would be useful in helping readers and discussion leaders compare countries and to show how countries have changed over time. A group leader using this material would be advised to set forth a framework within which to examine health.  Three questions were suggested in the review of the adult book in Good News magazine: How is health measured?  How does health vary across countries? How does health vary across time?

Children might find it interesting, for example, to compare the infant mortality rate when a grandparent was born, when a parent was born and when they themselves were born.  An excellent source of information on this country is Health USA 2000, the most recently published issue of an annual series.  The next issue is due in September 2001. This information may be accessed at: www.cdc.gov/nchs/products/pubs/pubd/hus/hus.htm. Older children might color maps using categories showing the intensity of health problems.  For example, all countries with an infant mortality rate over 100 would be one color, etc.

An issue that youth might like to pursue is the deteriorating situation in Russia.  The question is raised in YC: "Has political freedom helped to improve the health of the Russian people?"  No answer is given.  In the early days of Communism great strides were made in the health status of Soviet citizens.  However, in the seventies and eighties, before political freedom increased, the situation began to deteriorate.  Life expectancy, especially for men, declined.  For a number of years the Soviets stopped publishing life expectancy data. 

A report in an English language newspaper in Moscow this summer stated that life expectancy in the latest official report was worse than at any time since the end of World War II. Speculation about the causes includes alcoholism, a high fat diet, pollution and a decline in real (not inflated) spending for most of health care.  For international data a useful source of data is the World Development Report (WDR) published annually by the World Bank. Not all of the data in the report originates from the World Bank.  For example much of the health data comes from the World Health Organization (WHO).  However, WDR is particularly useful not only because it contains a wide variety of useful health data but because it also includes many measures that are related, i.e. population, income, education, etc.  The World Bank, as well as the WHO, has worked with many countries to obtain comparable data, defined similarly.  From less developed countries recent data is likely to be considerably more reliable than earlier data.

All three studies under review neglect the role and the interrelationship of numerous agencies involved with global health.  The international agencies include, in addition to The World Bank and The WHO, UNESCO and UNICEF, which are also working to improve health.  All of these agencies publish useful materials available in larger public libraries and university libraries. They are also available on line at the following addresses: www.worldbank.org, www.who.int/homepage, www.unesco.org, www.unicef.org. 

The American agencies working on health include the Peace Corps, www.peacecorps.gov, and most importantly the U.S. Agency for International Development (USAID), www.usaid.gov.  Many USAID health projects have been studied by competent researchers to determine both the effectiveness of the project in improving health and the likelihood that the nation involved will be able to sustain the program.  These studies have appeared in agency publications, public health journals and social science journals--especially economics and sociology.  Over time, as a result of such studies, the focus of USAID has moved away from providing sophisticated hospitals that can serve only a limited population to community projects located throughout the country.  AL recognizes this trend when it deals with village health workers in situations where it is not possible to provide a highly trained physician.

The distinction between public health measures and measures to provide individual care is extremely important.  For most, if not all of the history, colonial and national, of this country, public health measures have had a far greater effect on improving health than has physician provided care.  Clean water has been essential in improving health.  For example, in 1885 a typhoid and cholera epidemic claimed the lives of 90,000 persons in Chicago.  The average life span more than doubled in a generation after Chicago solved problems with its water supply by changing the course of the Chicago River so that it flowed backwards.  The Center for Disease Control observed that life span for the country increased by over 30 years during the Twentieth Century and that 25 of these years were attributable to advances in public health.  Public health measures include: vaccination, motor-vehicle safety, safer workplaces, fluoridation of drinking water and the recognition of tobacco use as a health hazard coupled with the education of the public about the dangers of smoking.

Clearly global health could be improved by public health measures.  However, these involve the governments of particular countries and these are often difficult for outsiders to influence.  Many nations, including Russia, have failed to educate their population about the dangers of tobacco use apparently because of a fear of a loss of government revenue when tobacco consumption, and thereby tax collections, are reduced.  Foreign aid has had a significant effect on vaccinations in many countries.  But simply providing vaccines is not enough.  Many vaccines must be kept very cold to retain their effectiveness.  Maintaining the "cold chain" has not always been successful, causing some policy makers to recommend that under some circumstances vaccines should not be provided.  A failed result can be demoralizing and may result in a lack of faith in health programs.

Local churches and the General Board of Global Ministries have long provided disaster relief when floods and famines occur.  This is an appropriate activity that can be coordinated to insure that supplies reach recipients. In contrast to disaster relief, long term aid may have confounding effects. It is widely believed that extensive food aid over a long period of time caused nations, notably India and Egypt, to fail to develop their own food supply when they would have been capable of doing so.  It is also the case that in countries with despotic and corrupt governments, aid has often failed to reach the intended recipients because high government officials siphoned off resources for their own benefit.

There are numerous references in all three books to "lifestyle choices. These references may occur in discussions involving individual choice and they may appear as part of the action program.  A useful approach in considering health is to ask the question how is health produced.  In economics Michael Grossman developed a useful and durable model.  This model has been around for thirty years and has held up when employed in high-income industrialized countries as well as low-income less developed countries.  According to the model the family produces health using a variety of inputs and a variety of ways of combining the inputs.  Medical care is one of the inputs, but so are sanitation and lifestyle issues such as smoking and consuming alcohol.  Families have different levels of efficiency in producing health.  The most important efficiency factor in the production of family health is the education of the wife and mother.  In developing countries the measure of education used is most often literacy; in industrialized countries years of schooling completed is a more sensitive indicator.  Clearly the ability of the family to obtain medical care and to live in a pollution-free environment are affected by family income.

AL spends an entire chapter on the role of women.  The concern for women is well placed.  As AL says there are some countries in Asia where the male/female ratio is weighted toward males while in most developed countries there are more women than men.  More boys are born than girls, but they have a higher infant mortality rate.  More boys than girls die in adolescence. Eventually the ratio becomes one; the sexes are equally balanced.  But women live longer than men do so that among older people there are more women than men, and the overall population ratio of men to women is less than one.  The problem in some Asian countries is that boys are more desirable than girls. Within the Hindu faith, a man strongly desires to have a son participate in his funeral rites.  Also some cultures require a costly dowry be provided for a girl.  As a result girls may be less well nourished and receive less medical care, and the result is a higher mortality rate for girls.   Among wealthy families the abhorrent practice has developed in recent years of determining the sex of a fetus and aborting females.

Deeply embedded cultural factors are slow to change.  Interference with cultural values by outsiders is usually unwelcome.  But one approach that is difficult to challenge is to develop projects designed to increase female literacy.  It is apparent across the world that female literacy benefits not only women but also families and all of society.  AL provides a list of benefits of educating women and children developed by UNICEF.  These benefits are also apparent in the U.S. where a recent study showed that the more education a young woman had, the much less likely she was to take up smoking.  Since studies indicate the greater harm to young woman than young men from smoking, as well as harm to the fetus when she becomes pregnant, this decision to smoke becomes an important health decision.

Advocacy issues in the three books are so disparate that it is difficult to organize them for comment.   Only a few relate to global health.  Among the issues that do relate are those pertaining to lifestyle such as the foregoing of use of tobacco, the adoption of a healthy diet and an exercise program.  That churches should accommodate for disability is appropriate.

The notion postulated by the text that socialized health care will provide an answer is not supported by our own experience.  Medicare and Medicaid came into being in 1965.  By the very early seventies the out-of-pocket costs of the beneficiaries was higher than it had been prior to the introduction of these programs.  Further, free health care does not solve all health problems. Although Britain adopted a plan providing free health care for all, including transportation to care facilities, health status continued to vary according to education.  Similarly Saudi Arabia has spent vast sums on health care, but infant mortality continues at a higher level than in countries comparable in income but with higher literacy rates.

Other advocacy statements and positions on economic issues are also problematic in the studies. The notion that third world poverty results from colonialism is untenable, as is the notion that the free market system has failed.  In some countries education increased after colonization.  Karl Marx thought that colonialism might jolt some countries into development.  As for free market economies, they have proved to be more productive than all others. Any economy will have persons who are helpless physically or mentally.  A productive economy will be better able to assist these people than a non-productive one.  And assistance will affect the productivity of those who are capable of at least some work.  Since middle and upper class persons respond to tax incentives and other circumstances, it is natural that poorer people will also respond to assistance programs.  Instead of providing a dogmatic answer, congregations would be better advised to study the issues, listen to speakers from varying perspectives and to pray about the best--or least harmful--ways to assist fragile human beings.

The three books under study raise some interesting and important issues. However, they fail to provide an adequate framework within which to view the problems.  It is very difficult to improve global health, especially when the role of wealthier nations is suspect in many poorer countries. Additionally the books provide a very opinionated, but unsubstantiated position about advocacy to help persons.

Kim Carney: Education: B.S. Northwestern University; M.A. and Ph.D. Southern Methodist University (economics) funded by National Science Foundation; extra-doctoral study Oxford University.  Employment: Department of Economics, University of Texas at Arlington (1967-96).  Teaching: undergraduate and graduate students, predominantly microeconomics, econometrics and economics of health care.  Major research and publication emphasis: economics of health care.  Additional assignments: Faculty Fellow at (then) Department of Health, Education and Welfare; Fulbright Professor at Osmania University in Hyderabad, India teaching microeconomics and econometrics to graduate students; research year in Egypt including teaching one course at the American University in Cairo; University of Texas System programs involving teaching a semester in Malaysia, a semester in London and a month in Morocco; summer at the Brookings Institute; summer at the Institute for Research on Poverty at the University of Wisconsin; summer at the Kennedy Center for Bioethics.  Consulting: for USAID health programs in Egypt, Lesotho and Swaziland, et.al.  Lecturing: various including USIA overseas lecturing in India, Nepal, Bangladesh, Pakistan, Brunei and eastern Malaysia and numerous occasions in the US.