Professor David Sanders died in August 2019. He leaves a long legacy of analysis and teaching on global child health and public health particularly in relation to poverty and the roots of ill health, and how to tackle them. Sanders believed that the determinants of health lay in the social conditions of the population and that these had to be improved by social change and working at the grass roots rather than by top-down medical treatment with drugs; he was a strong proponent of primary healthcare as originally established by WHO and supported the appointment of community health workers who would be responsible to the local community. His work is covered in this article through a review of significant books of which the best known is The Struggle for Health and his research in the field.
- health economics
- health service
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Meeting David Sanders first as a fellow academic at the University of Zimbabwe immediately after that country’s independence in 1980, he struck me as mild in manners, better informed than me on the causes of child malnutrition, and forcefully political in his approach to health. By this I mean that he sought changes through the political system of the country, rather than through purely medical intervention. At that time, it was an act of politics to come from Europe to work in the newly independent Zimbabwe but Sanders himself was entirely local, having been born in South Africa, attended medical school in the then Northern Rhodesia and gained postgraduate experience in Britain before returning to Zimbabwe to work, both in the academic world and as a field worker with Oxfam in malnutrition prevention.
At that time I was less politicised than he, hence every conversation was a learning experience in which I felt a novice in my understanding of the roots of health or of the struggle for health as he put is so well in his important book written in 1985 about the problems faced in improving the health of the poor and the nature of ‘development’.1
Following Professor David Sanders sad and sudden death in the UK in August 2019, this article reviews his literary output and covers a small but hopefully representative sample of his many publications.
Health policy was David’s main field of interest and the focus for all his three books: The Struggle for Health1 (1985); Questioning the Solution: the Politics of Primary Health Care andChildSurvival2 (1997) and Fatal Indifference: The G8, Africa and Global Health3 (2004).
These books take an avowedly political view of health policy. Sanders covered how high-income countries became healthier during the 19th and early 20th centuries primarily through improvements in income, nutrition, living conditions, and sanitation rather than through medical care, and examines how poor countries were exploited by the early colonisers who implanted a medical system over-reliant on doctors and drugs. He pointed out how disease is rooted in social conditions yet the remedies are skewed to medication and tertiary care – similar messages to those coming also from David Werner and Ivan Illich. I would simply add the additional crime of environmental destruction.
The Struggle for Health is long on faults and short on remedies and reads now as being overidealistic, particularly in the glowing tributes to healthcare in China, where the ‘Barefoot Doctor’ now barely exists. Sanders wrote powerfully about primary healthcare, the role of the village health worker and how doctors fail to understand the social causes of disease and put profit before patient care. These are stereotypes, and there are many examples of idealistic doctors working for their patients’ best interests all over the world. In hindsight, Sanders was also unrealistic about village health workers, who should be ‘more qualified than the doctor to deal effectively with the important sicknesses of most of the people’. This still-discussed model has only been developed in a narrow range of specific circumstances and has failed to be rolled out more generally.
Questioning the Solution was a collaboration with David Werner which continued the analysis of primary healthcare. They extol the need for bottom-up care organised with the involvement of the local population, contrasting this with the top-down model handed down by western-trained doctors. Primary Health Care as designed in Alma Ata in 1978 was intended to have strong sociopolitical implications, but many countries did not have a genuine belief of this kind of approach, and nor did it fit with conventional medical care based on the curative approach by western-trained doctors. So instead, health agencies developed the concept of Selective Primary Care which focused on four specific top-down interventions under the rubric Child Survival programme4: Growth monitoring, Oral rehydration therapy (ORT), Breast feeding and Immunisation (GOBI). It was much harder to ensure community participation with the use of these programmes, successful though they were in some ways (particularly immunisation).
Sanders and Werner are strongly of the view that ORT should be integrated into a broad primary healthcare approach rather than simply the delivery of packets of salt/sugar, which have many disadvantages: mothers see them as a pharmaceutical remedy and may not give the large amounts of fluid which are required by a child with diarrhoea. The authors used this example as a way of illustrating how large agencies such as WHO may get it wrong. But balancing the need for efficient organisation with involving a population in programme delivery is always going to take additional effort and time, and ORT has saved countless lives.
Questioning the Solution expanded on structural adjustment (the debt relief programme enforced by major funding agencies which lead to cutting of public services and privatisation of healthcare) and on the role of corporate greed in relation to Big Pharma and infant formula manufacturers. Sanders’ strong belief in the need for a bottom-up approach to healthcare led to his involvement in the establishment of the People’s Health Movement5 in 2000 with the consequent People’s Health Assemblies, Charter for Health, People’s Health Watch and International People’s Health University. These contrasted with the many specialist medical organisations which have no contact or involvement with the people whom they serve, and illustrate Sanders’ opposition to the ways of the medical establishment.
Sanders’ third book Fatal Indifference (2004) analysed G8 policies in relation to major domains known to influence health: macroeconomic policy and debt; healthcare and health systems; education; nutrition and agriculture, and the environment. It will be no surprise to those familiar with his earlier writing that this in-depth analysis of the attempts by the world’s rich to solve the problems of the poor shows up the faults of the G8; in particular its commitment to neoliberal policies which have failed to improve the environmental crisis and increased the gap between rich and poor.
Sanders also conducted other dogma-challenging research, including the identification of logistical, supervisory and financial problems faced by community health workers6; the issues related to adherence to guidance around malnutrition rehabilitation7 8 and the limitations to cash transfer schemes in alleviating poverty-related poor health.9 Central to Sanders’ values was the essential requirement to tackle poverty at its roots and a 2015 paper examined this through a study on cash transfers in alleviating child poverty in South Africa.9 The Child Support Grant conferred R100 up to R320 a month (US$12–US$34) to families for each child under 18. This qualitative study showed that the grant was useful for buying staples but inadequate for other purchases in the household, and there were major administrative hurdles in obtaining the cash. The authors considered that cash transfer can only be one of a basket of antipoverty measures such as nutritional support and free access to healthcare.
Sanders’ analyses of medical care and of the social determinants of ill health are equally powerful in 2020 as in 1980 and should be a compulsory part of the curriculum for medical training. At least in the UK, general practitioners are now recognising that, for many people, medication for mental health problems should be replaced with activities, such as gardening, physical activities and community neighbourliness, and that the roots of health inequalities lie in the political system. Sanders would be joining the many doctors in the UK and around the world who are campaigning for change, not just through better funding of the National Health Service but also through fiscal policies, action on social deprivation and on climate change. As he would memorably say – ‘are you part of the solution, or part of the problem’?
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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