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Nobel Laureate Gives Cultural Lecture
Sen's 'Relational Reach' Links Health, Economy

By Rich McManus

On the Front Page...

Dr. Amartya Sen, the 1998 winner of the Nobel prize in economics and a master at Trinity College, Cambridge, U.K., proved as charming and self-effacing as advertised in introductory remarks by NIH director Dr. Harold Varmus, who invited Sen to give the annual director's cultural lecture June 2. Speaking before a packed Masur Auditorium, Sen, as predicted by Varmus, also challenged received wisdom by observing that robust economies don't necessarily foment higher life expectancies, and that "to rely on a doctor's view of health might be a great mistake."


"Amartya is one of those figures who achieve mythic status while retaining abundant humility and great humor," noted Varmus. "He is the recipient of so many honorary degrees that he must be a Million-Mile Member of every airline in the world." He called Sen "a writer with moral force," and "remarkable cultural range. He is sociable, witty, concerned for others, and deeply committed to his origins while thinking deeply about the whole world."

NIH director Dr. Harold Varmus (r) welcomes 1998 Nobel laureate Dr. Amartya Sen to NIH. Sen delivered the annual director's cultural lecture.

Sen, admitting he was humbled by the generous introduction, gave a two-part, 50-minute lecture on competing concepts of equity (for example, who decides what ill health is, the patient or the health care professional?) and a theme he labeled "relational reach," which attempts to unravel the complicated network of forces influencing health, among them the economy. But as abstruse as the analysis quickly got — including brief layovers at "competing concepts of individual advantage" and "competing procedures of social choice aggregation"— Sen's asides were what won the audience. At various points he compared being tethered to his lavaliere microphone to the ropes binding the village goat, and also congratulated himself on knowing at least one endearing story about Spanish dictator Generalissimo Francisco Franco: By way of illustrating the gulf between a patient's self-report of morbidity versus a professional assessment, he said that Franco's physicians, who believed he was close to death, arranged for Fascist musicians to serenade the general with the refrain "Adios, Franco," to which the still-sentient general is reported to have replied, "Where are they going?"

"There are many influences on health — the economy is one of them," Sen explained. "Economic affluence may be good for your health," he continued. "Clearly, there is a connection between income, social status and health. But how much of the variation in health is explained by income difference? How does it work?"

With wealth comes better schooling, and better marshalling of information, he said. But is it a relative lack of stress, or the opportunity for exercise (because you are not too tired at the end of a day's labor) that confers health? "Further analysis is needed," he said. "We need an integrated view of what is going on."

There is an extensive literature on life expectancy and gross national product, per capita, which are linked very closely, Sen said. But he introduced two new variables — public expenditure on health care, and poverty, "the fate of the worst off." Allowing that GNP creates more resources for public health care, he said "even without GNP growth you may be able to raise life expectancy very dramatically" by a social policy that favors the "extremely labor-intensive" fields of health care delivery and education. "It does matter how you spend your income," he argued.

He pointed out that African Americans in the United States may be poor in relation to whites, but are "tremendously rich" when their incomes are compared with Third World places such as China and India. Yet longevity is higher in these impoverished locales than in Black America.

"Yes, it's very important to think about income," Sen observed, "but it's only one variable among many. Remember, economics is about earning and spending."

Continuing his probe of the conventional wisdom, he asked what it means to be well in an area where most people are sick most of the time. He showed a chart comparing self-report of morbidity in such disparate locales as the United States, Kerala and Bihar (the latter being two Indian states he has studied). The Americans, despite their affluence, overwhelmingly report more feelings of illness.

Sen applauded the broadening of the discussion taking place today in the adjacent fields of health and economics. "Equity is a complex issue," he allowed, "but it is eminently discussable."

The so-called "dismal science" didn't get any less complicated during his talk, but neither was it unbearably heavy.

During a brief period during which Sen took audience questions, he observed that no nation has its economic act entirely together — he has only glimpsed pieces of the ideal in his travels. He noted, "It's really quite scandalous that the U.S. has so many — more than 40 million people — uninsured compared to Europe, but they have very high unemployment, in the range of 11-12 percent."

His answer to the final question placed him squarely, he said, in the tradition of economics luminaries of the past, including Adam Smith and Karl Marx: "Income in itself is not a value. Leading a good life is more important."

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