Global Health Watch 1 in one file

The social ecology of health and disease
The decline in mortality from infectious diseases in early industrializing
countries in the 19th century owed little to medical science and its derived
technologies (McKeown 1971). In England and Wales, for example, the mortality
rate from respiratory tuberculosis, a major killer, declined by more than
85% between 1838 and 1945, well before the discovery and isolation of the
antibiotic streptomycin in 1947 and also well before the widespread availability
of BCG vaccination for protection against tuberculosis from the 1950s
onwards. McKeown and others identified food intake and nutritional status,
potable water supplies and environmental hygiene as the key factors in the
decline of infectious mortality.
Mortality alone is an inadequate measure of population health. Nonetheless,
recent efforts to devise more discriminating measures of disease burden
that take into account morbidity, disability and functional capacities, and
quality of life have not seriously undermined McKeown’s thesis, notwithstanding
the efficacy of some modern therapeutics and procedures in controlled,
favourable circumstances. Biomedicine at best has contributed only modestly
to improvements in population health. This is the context in which the future
benefits of genomics must be evaluated.
The current focus on genome technology and the particular imagery
around the human genome is unfortunately diverting attention from public
health approaches to combating disease, ill health and poverty. Life is much
more complex than the pattern of the molecules in our genes. It is also important
to know why and when some genes in some people are switched on
and why others are switched off. A major part is played by the microenvironment
inside cells, but this is influenced by the macroenvironment, the body
as a whole and the outside world. A host of physical and social factors play
a role, and public health approaches, embedded in socioeconomic policies,
will probably remain much more important than high-tech solutions in improving
global health.
Justifiable exuberance or premature genohype?
Is genomics the panacea for human illness and infirmity? The director of
the US National Human Genome Research Institute declared in 1999 that the
benefits of mapping and sequencing the human genome ‘would include a new
understanding of genetic contributions to human disease and the development
of rational strategies for minimizing or preventing disease phenotypes altogether’.
There would be further prospects of ‘genetic prediction of individual
risks of disease and responsiveness to drugs…and the development of designer
Gene technology
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