Should global health become the next big economic engine? Is the profit motive the right prescription for delivering the right goods and services to the world's sick? A reporter raised that question at a chamber breakfast where high-paying jobs for Washingtonians was clearly the focus, as reported by the Seattle P-I.

Part of my discomfort with this question is how it's framed. It's an oversimplification of the realities in emerging countries. I recently returned from a trip to India, where I spent some time with working poor people who subsist on less than $1 a day. Their needs are different from the needs of the ultra poor - the disabled, the elderly and the orphaned.

Many locals view the government with deep cynicism in terms of being able to deliver badly needed goods and services. Instead, locals are highly self-reliant, forming their own social networks (without the Internet) and developing their own small businesses with whatever tools and resources they have.

In such environments, private-public partnerships can be more effective than either private companies or public agencies working in isolation or, worse, at cross purposes. There are many examples of these partnerships working well in rural and urban India to feed malnourished children, make loans to entrepreneurial women and replace rotting infrastructure.

Rather than get caught up in endless debate over whether global health should be a public or private endeavor, a larger question should be front and center when it comes to confronting disease and poverty in Africa, Southeast Asia and the Middle East.

We should not lose sight of a far more powerful long-term, sustainable determinant of health in these masses -- a robust democracy and free press. Is there an MPH student out there who would be interested in undertaking an analysis? It seems like there are data sets that could be examined, if nothing else, for correlation. What's happened to infant mortality rates or other health indicators where democracy and press freedom have disappeared or been established?

With democracy, people are able to hold elected officials accountable and protest corrupt or incompetent bureaucracies that fail to deliver on their promises. With a free press, people are able to exchange ideas (often suppressed in authoritarian societies) about what ails their bodies and their society. Information about the true determinants of diseases in a community, once understood in the public mind, can end an epidemic of silence and lead people to take action to reduce morbidity and mortality.

But democracy and free press aren't as easily measured or produced as, say, units of vaccine or bioengineered food. Nor can they be patented or licensed by highly-paid lawyers and consultants. And the First Amendment and Constitution don't have spin-off potential as technology does for more lucrative ventures.

Still, American democracy is perhaps our nation's most enviable brand.