Tuesday, July 26, 2005

The causes of the causes of illnesses

Thursday, July 21st:

On Wednesday evening, I had thought of attending a meeting of the Indian delegation. That didn't happen, but I did talk to Janet Gottschalk of the North American delegation. Janet works part-time at George Washington University and is a visiting professor at Texas A&M University, Laredo. She works on border issues and is also the co-chair for the Religious Working committee at the WHO. She is interested in working on Trade and Health and proposed we connect up with the group working at APHA. A group called C-PATH is also working on these issues and she recommended that we connect with Ellen from that group. We also talked a bit about the education for Public Policy and Public Health in the US. Her suggestion was that I stick to online courses and self-study!

On Thursday, I decided to diligently attend every session I could, inspite of tiredness and muscle aches (in my usual fashion, I had taken a few tumbles in Cajas – but this time, blame the mud!) Plenary A was on the revitalization of the spirit of 'Health for all' and Alma Ata. The Alma Ata declaration was signed in 1978 by most of the countries in the world and promises to provide comprehensive Health Care for all by 2000. This amazing document has almost been forgotten in the mainstream for many reasons: the fall of the Soviet Union and decline of socialism, the rise of neoliberalism, the change in economies, expanding globalization etc. Details can be found at:

The testimonies covered local initiatives in Health Care and mobilization. A speaker from the Phillipines talked about the problems with militarization that her group of community health workers faces, in spite of which they have made strides. An aboriginal activist from Australia talked about the start of their movement in 1972 and the energy they got from attending Alma Ata. The Aboriginal community has been very marginalized, receiving less money for health care and facing the government's 'divide and rule' policy. A recent development has been 'personal responsibility' statements, wherein both communities and providers pledge to meet certain standards.

A short film from Guarjilla, El Salvadore was screened which talked about the resettlement of refugees who had fled to the Honduras during their civil war. Health workers had been selected from the community. They, along with an external group, worked to improve health indicators by constant monitoring through household surveys, the combination of education, treatment and rehabilitation and community radio. While malnutrition rates are 33% nationwide, they are only 12% in Guarjilla.

The next presenter, from Mozambique, talked about a comprehensive health care approach his NGO is implementing, which includes education, sanitation, small enterprises and credit programs. The primary health needs are met by training activists in rural sector and traditional birth attendants. Working groups aimed at finding problems and solving them are set up in all communities. Home visits, prenatal care, immunization and sexual and reproductive health are all part of the program. The difficulties include poor access to information, low sustainability of committees, lack of infrastructure and a poor economy.

Two community health workers from Haiti talked about the work their group Zanmi Lasante does with HIV/AIDS education and treatment. Next, a speaker from Venezuela talked about her country's 'Barrio Adentro' program. The mayor of Caracas had visited Cuba and requested its President for help in improving the medical facilities. Instead of 50 doctors, Fidel Castro sent 100. The program was expanded to the entire country by Hugo Chavez. An official mission has been formed and an agreement signed with Cuba. Health services are now completely free. She said 'Please get the word out that Hugo Chavez is not a terrorist'.

The final testimony was from a street child in Canar province (of which Cuenca is a part). In poetry and spoken word, he eloquently described the plight of street children. 'I don't have a face or a name. I look for you, but cannot find you... I am as important as the birds you feed... I have infections, but the nurses don't treat me... It's not my fault that I was born... My life is a bad dream. Why have you forgotten me?'

Next was the turn of the panelists. First was David Sanders from South Africa. He talked about the progress in Global Health – improved life expectancy and control of diseases – and the widening gap in health outcomes between and within countries. Since the 1980's, there had been mixed success in health due to a split in the health care movement. Some chose to do selected interventions, with some success like with the UNICEF's GOBI (Growth monitoring, Oral Rehydration Therapy, Breastfeeding & Immunization) program. But such programs leave out crucial gaps that can only be addressed using a Comprehensive health approach.

In the 1990's, there were reversals in health indicators due to globalization, health sector 'reform' and HIV/AIDS. Health care packages were now being drawn up with a basic set of deliverables and essential services. The cost-effectiveness of selective interventions was analyzed by the World Bank, with some very strange results. One example is the conclusion that case management of diarrhea and promotion of hand washing is more effective than providing safe water! David showed a cartoon of a man saying 'I'm hungry' and a fat executive eating a scrumptious meal replying 'Stop talking politics'!

An example from the Eastern Cape in South Africa was presented. This was a problem faced in tertiary centers - children were dying of malnutrition at rates of 28% - 46% across the hospitals in the region and this was unacceptable. A little analysis showed that children were dying due to delay in feeding which was the result of staffing and supply shortages. A 3 hour feeding cycle was established, but generated mixed results due to low morale and the underlying staff shortage. But in places that undertook leadership and capacity building, the results were very good. Mothers were educated about nutrition and 76% remembered the instructions. But 71% could not implement them due to poverty. All these households were eligible for but not receiving welfare. An advocacy campaign was launched through the press and the screening of a documentary on TV. Within 36 hours, the health minister arrived in the area and set up a task force for processing Child Support Grants. Thus, 'intersectoral action is required to institute real change'.

During and after the break, we were entertained by the exhilerating of a performance Cuban musician. After this foot-stomping routine, it was time for Michael Marmot to take the stage. Michael Marmot heads the Commission for Social Determinants at the WHO. PHM has achieved enough prominence to be recognized by the 'establishment' – it has a representative to the Commission for Social Determinants and a number of representatives from the WHO were present at the assembly. This has made it an eclectic mix - as Michael put it, this is the first time he has attended a conference with reports from the field and scientific discussions and performances all on the same stage. 'We have all come together on a basic idea – that health is a human right, not an economic activity', he said. We need to look at the causes of the causes of illness, which means that we have to address the distribution of diseases, government responsibility for health and social measures, poverty and inequality, environmental degradation and many other factors. The Commission for Social Determinants was launched in Santiago, Chile during March, 2005 to address this social imperative.

Michael Marmot also presented statistics demonstrating inequities in health. The probability that a 15-year old man will live to 60 is 8.3% in Sweden, 46.9% in Russia and 90% in Lesotho. In Russia, cardiovascular disease and violence have led to a sharp decline in health indicators. He also talked about the burden of non-communicable diseases and injury and the dependance of infant mortality on race and the mother's education.

There are 2 types of success for reducing mortality – the one most promoted is growth-mediated, such as in Hong Kong. But the other type, with support as in Cuba, Costa Rica and Sri Lanka has been equally successful. The commission will look into this and other issues through knowledge networks set up to collect information on specific issues. It plans to come out with a report in its 4-year term. In conclusion, 'what good does it do to treat people and send them back to the conditions that led to the disease in the first place?'

Next to speak was Dr. Espinoza from El Salvador. He talked about how the fight for Primary Health Care (PHC) can be used as an instrument for mobilization and development. He stated that we should be talking about the revitalization, not the resurrection, of Alma Ata, because it is still alive! The concept of PHC was born in communities, systemized in Alma Ata and still alive in communities. Alma Ata was a commitment. Cuba did it. Others have tried, but successes have been reversed in Nicaragua and elsewhere. Yet the struggle continues. He noted the success of the Guarjilla program, the 'silos' in North San Salvador and the healthy municipalities program in Nicaragua. Capacity has to be built at the local level, with activists then going beyond local spheres to mobilize people and influence government policy. Finally, Dr. Espinoza singled out IPHU, the International Public Health University, for praise.

Next was a presentation by the head of PAHO (Pan American Health Organization), the regional organization of WHO for the Americas. The presentation was lacklustre, talking about various resolutions and proposals and repeating a lot of textbook stuff. I later learnt that the PAHO head is a very strong supporter of the PHM model – good for her. Finally, in a short and simple presentation, Thelma Narayan talked about CHC's work in Karnataka. They have used theater for mobilization and have taken on the issues of gender and environmental justice. She talked about a situation (without) specifics where a local community campaigned successfully against mercury contamination by a factory in their vicinity. The Karnataka Task force set up in 1999 and Citizen's charters drawn up at PHC's also came up for honorable mention.

I had talked to Thelma a few days earlier about specific issues AID should get involved in. Our talk had been wide-ranging, with mention of the seeds issue (the new Seeds Bill that seeks to restrict barter and storing of seeds by farmers), health of slum populations and the resettlement of tsunami survivors. Incidentally, CEHAT has a project in Mumbai and Delhi which monitors health indicators of resettled slum residents, and CHC does some work with these populations in Bangalore. I hope I can follow up on this issue (volunteers welcome!) because it connects up the slum demolition issue. Resettlement is not the panacea many of us seem to think it is – conventional wisdom seems to be that slum residents are being moved to better accomodations and therefore should be better off. But this is often not the case. Anyway, more later...

Back to the plenary – it wound down after some audience comments. I was sitting next to Prasanna who was off to a meeting of the Global Right-to-Health campaign. This was being headed by Abhay Shukla and the objective was for participants to take up the responsibility of or to coordinate the developing of campaigns in their regions. This would involve contacting other groups – health-based groups, unions, human rights groups etc. As Abhay put it, the strength of the PHM – its lack of organizational structure and flexibility in operation – is also its weaknesses. At any rate, the PHM charter is such that any group can choose to adopt it and thus becomes a part of the network. He suggested a 6-month deadline for mobilizing and participating in conferences or fora in each region. Examples were the African Social Forum in Harare in October and the American Public Health Association in New Orleans in November. In Latin America, the InterAmerican forum and Alames had been invited to the PHA-2 to get an idea of how PHM functions – hopefully, now they would choose to use the Right to Health campaign as another tool for mobilization.

At 2.30 pm, I left the meeting to go to an afternoon session (no point calling these workshops). I finally figured out which bus to catch – this took me on a roundabout route and I might have been better off walking. But hey, I got to see more of Cuenca... The session I attended was on Seeds, a future under threat. Since there were only 3 English speakers, the translators chose to speak to us in a huddle rather than use the equipment. But it was a struggle – the translators deserve kudos for their hard work. Most of the speakers raced through their presentation and the translators have frantically tried to catch up. Things can't be this hard at the UN and other international meeting, what with diplomats reading carefully from documents, right?!

The presentations were average at best, with a lot of generalities about the field and statistics about the seed and pharma companies – nothing one cannot collect after a couple of hours on the web. The last 2 presentations may have been good, but I was way too tired and left. I had to plan my travel with Jael to Isla de la Plata, referred to in most guidebooks as the “poor man's Galapagos”. Or, as in our case, the poor woman's. The tickets to Galapagos alone cost ~$400. But for this island, we'd just have to take a series of buses to Puerto Lopez and then go on a 2-hour boat trip to the island.

After a rest at the hotel, the next stop was the meeting of the North American delegation. We talked about the Right to Health campaign. The Tennessee and Pennsylvania groups are doing some great mobilization and it was proposed that we build on them. Obviously, though, there is a lot of mobilization around the issue of health throughout the US and we'll have to connect with local groups. The truth commissions being planned in Tennessee could be organized elsewhere. It seems that one such commission has been organized during the Boston Social Forum (in which PHM-US had participated). These are similar to the Jan sunvaais in India. Everyone agreed that we should present information about PHM work in our local communities and there was an idea of coming up with an adaptive powerpoint presentation for this purpose. The social determinants work would involve feeding information to the knowledge networks and also the representative from the US to this commission (hope is faint that she will heed this information). Other groups provided updates – the militarization group had met with the European group and there was a proposal afloat to invite Dr. Salaam Ismael to the US and talk to communities. There was a suggestion that returning veterans who have been denied health care also speak at these events. Both on one stage? I don't know – it feels like the message will be diluted. But hey, maybe it would be a double whammy. And maybe more people will attend than the usual lot who turns up for these events. And maybe Dr. Ismael will get a visa... A national network of health workers is supporting 10,000 GI's who are refusing to go to war – it was suggested that we work with them.

The women's issues group has already been strong and they have had a great track. Nadia Van der Linde of Netherlands had arranged small group discussions in their session earlier in the day to come up with recommendations. Already some of them have been working on the global gag rule that prevents clinics who receive US aid from even mentioning abortion. More info can be found at www.globalgagrule.org
This was one of the issues it was suggested they work on.

Where trade and health was concerned, Janet and I gave our brief report. We were told that Ellen of C-Path would love to facilitate any contributions on our part. It was also suggested that debt relief should be a part of this sub-group. September 23rd, the day before a meeting of the WTO, had been suggested as a day to mobilize. Incidentally, Janet wore a white band to mark her participation in the Edinburgh protests. Finally, the meeting ended with the familiar headache of logistics and returning tickets to be sorted out.

Laura, Sonia and I headed out to dinner – some in the delegation had gone to the Cuban performance. Maybe I should have gone too, but at that moment, all I could think about was sleep, sweet sleep.

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