Health in development.

I have been asked to speak on the subject of "health in development". I must take on the question -- the very difficult question -- as to how health relates to development. (a) At one level the question admits of a simple answer: surely the enhancement of the health of the people must be accepted more or less universally to be a major objective of the process of development. But this elementary recognition does not, on its own, take us very far. We have to ask many other questions as well. How important is health among the objectives of development? Is health best promoted through the general process of economic growth which involves a rising real national income per capita, or is the advancement of health as a goal to be separated out from the process of economic growth seen on its own? Do all good things go together in the process of development, or are there choices to be made on the priorities to be chosen? How does our concern for equity reflect itself in the field of health and health care? I shall have to go into these issues also. However, to motivate what is perhaps the most basic issue, let me begin with the report of a very old conversation between a husband and a wife on the subject of earning money. It is, of course, not unusual for couples to discuss the possibility of earning more money, but a conversation on this subject from around the eighth century BC is of some special interest. As reported in the Sanskrit text Brihadaranyaka Upanishad, Maitreyee and her husband Yajnavalkya are discussing this very subject. But they proceed rapidly to a bigger issue than the ways and means of becoming more wealthy: How far would wealth go to help them get what they want? (b) Maitreyee wonders whether it could be the case that if "the whole earth, full of wealth" were to belong just to her, she could achieve immortality through it. "No", responds Yajnavalkya, "like the life of rich people will be your life. But there is no hope of immortality by wealth". Maitreyee remarks, "What should I do with that by which I do not become immortal? ". Maitreyee's rhetorical question has been cited again and again in Indian religious philosophy to illustrate both the nature of the human predicament and the limitations of the material world. I have too much scepticism of other worldly matters to be led there by Maitreyee's worldly frustration, but there is another aspect of this exchange that is of rather immediate interest to economics and to understanding the nature of development. This concerns the relation between incomes and achievements, between commodities and capabilities, between our economic wealth and our ability to live as we would like. While there is a connection between opulence, on the one hand, and our health, longevity and other achievements, on the other, the linkage may or may not be very strong and may well be extremely contingent on other circumstances. The issue is not the ability to live forever on which Maitreyee -- bless her soul -- happened to concentrate, but the capability to live really long (without being cut off in one's prime) and to have a good life while alive (rather than a life of misery and unfreedom) -- things that would be strongly valued and desired by nearly all of us. The gap between the two perspectives (that is, between an exclusive concentration on economic wealth, and a broader focus on the lives we can lead) is a major issue in the conceptualization of development. As Aristotle noted at the very beginning of the Nicomachean Ethics (resonating well with the conversation between Maitreyee and Yajnavalkya three thousand miles away): "Wealth is evidently not the good we are seeking; for it is merely useful and for the sake of something else". (c) The usefulness of wealth lies in the things that it allows us to do -- the substantive freedoms it helps us to achieve, including the freedom to live long and to live well. But this relation is neither exclusive (since there are significant other influences on our lives other than wealth) nor uniform (since the impact of wealth on our lives varies with other influences). …