HUMAN RIGHTS EMBRACE THE NON-ECONOMIC DIMENSIONS OF DEVELOPMENT*.THEY PROMOTE AND CONSOLIDATE SOCIAL SOLIDARITY. THEY ARE NOT A DISPLAY WINDOW; THEY ENTAIL A DISTINCT PROGRAM, A FULL-BLOWN MOVEMENT. (P. Drucker)
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*: The truth is that there are no purely or primarily economic solutions to human rights problems.
-Human rights is an unapologetic project for social emancipation in which suffering is related to powerlessness and freedom to living in dignity. (A. Yamin)
-A dose of religious altruism, of non-religious generosity and just a vague adherence to human rights will simply not be able to overturn the current mal-development paradigm.
-It is the shifting from needs to socially and legally guaranteed entitlements, and from charity to duty and to dignity that underpins human rights work. (A. Donald, S. Koenig)
1. For each of us human rights activists, the challenge is: How can the rules of the new human rights (HR) movement replace our routine? Innovations are fiercely resisted by some of our peers, precisely because they redefine the rules they are comfortable operating under.
2. At present, these peers rather try to bring attention to ‘their’ story and present sufficient arguments to defend ‘their’ role in the fight against poverty –and eventually against injustice. What we want them to understand is that the HR-based framework de-facto unites them/unites us! (P. Develtere)
3. In the hands of only a few of us activists, the HR-based approach (HRBA) is limited and not endlessly elastic –and its implementation will only reach so far. This is why this Reader is a perennial recruiter of new strategic allies.
4. In our hands, HR interventions pursue equity, equality and ultimately social justice. But most governments are not at all (or sufficiently) motivated (yet) to pursue the same by reasons that are linked to their simplistic or misguided (or absent) HR thinking. Therefore, only a handful of these governments have set up accountability mechanisms to protect HR.
5. We are thus left with the fact that it is the actual functioning of contemporary societies that does not facilitate the job of those of us who are seeking to tackle and defuse HR violations.*
*: I am often left to wonder: Do states ratify HR treaties gambling on the fact that they will experience little pressure to comply with them?
6. Despite this difficulty, and because the strategies of the oppressors are becoming more evident by the day, we have to move forward swiftly and be inflexible about the fundamental tenets of HR.
7. Fortunately, HR is no longer the missing word from many a UN meeting or negotiation; after initial neglect, HR have made their way onto the respective agendas. Yes, more and more, HR are being invoked to justify a variety of fundamental claims; yes, they are playing an increasingly important role in shaping public policies. But does that mean that HR (with their specific claims of individuals on governments) are moving to center stage right along power politics? (P. Farmer) Not really, I would say, even if HR are embodied in legal instruments which are formally binding on States.
The stark reality is that people with the least power to contest the denial of their rights are constrained in their ability to enjoy those rights, precisely because they do not participate in shaping public policy.
8. Although not yet center stage, the HR-based framework, for instance as applied to health, makes explicit reference to HR from the outset of its assessment of the health situation; it does not only name the relevance of human rights in retrospect; it does not use HR standards and principles as a way of naming violations after they have occurred, but as a way of preventing violations from occurring in the first place.
9. As we have said many times, the HR-based framework is based on international HR standards (i.e., desirable outcomes); it recognizes claim holders and duty bearers; it focuses on discriminated and marginalized groups; it aims at the progressive achievement of all HR; it gives equal importance to the outcomes and to the processes of development; and it upholds HR principles (i.e., criteria for the HR processes to be set in motion, namely, indivisibility, inter-relatedness, non-discrimination, participation, accountability, transparency, human dignity, rule of law, equality). **
**: Do keep in mind though: Human rights do allow diversity, but not inequality.
10. Ultimately, when using the HR-based approach (HRBA), we both observe and judge; we both present and contest evidence; we both apply morality and legality! (D. Tarantola, U. Jonsson)
11. Some say that we are sowing-in-the-ocean as we try to introduce the HRBA. But it is by considering the political economy as a whole, that the HRBA shapes more meaningful, indeed not utopian, interventions. *** (J. Bourdon)
***: As a matter of fact, the HRBA is stern with those who get stuck in old dogmas.
12. As HR activists, we thus have to act differently depending whether our recommendations are being either ignored, contested or eventually mainstreamed. (Health Insights, IDS, Issue 78, Oct 2009)
13. Bottom line, despite all the difficulties, we can neither loose hope nor the desire to find a rational solution to the HR problems at hand. New ideas, cultural restlessness and new world visions are often born simultaneously in various places…and this is reassuring. In HR work, what we need is to build and to share a true intellectual and ideological armour –transcending borders.
Partially adapted from Development in Practice; D+C, 36:2, Oct.2009; and A. Gomez, Tiempo de Descuento, Editorial El Fin de la Noche, Buenos Aires, 2009.
I requested a year off from school to go to Haiti and work with the Cuban doctors after completing my 2nd semester of 3rd year at ELAM (the Latin American School of Medicine). I am one of 120 American citizens studying medicine in Cuba free of charge, with plans to practice medicine upon graduation in underserved communities of the United States and around the world.
When I arrived, I found several international ELAM graduates (http://elamedicosinternacionalistas.wordpress.com), including 7 United States graduates (http://www.michaelmoore.com/words/mike-friends-blog/cuban-trained-us-docs-complete-haiti-mission), and a number of Haitian medical students working alongside the Cuban doctors. We were stationed at a field hospital set up by the Henry Reeve Brigade of Cuban doctors on January 28th in a small central park of Croix des Bouquet, just outside Puerto Prince. Together we served displaced earthquake victims and patients suffering from inadequate health care services.
In the first six months the hospital was established, we addressed the needs of more than 70,312 patients; 53,588 at the hospital and 16,723 in the field. We performed a total of 2,506 operations on-site, with 786 major surgeries; including emergency caesarean sections, ectopic pregnancies, thyroidectomy, hernias, hydroceles, hysterectomies of uterine fibroids, orthopedic surgeries and more. We assisted 116 natural births. We diagnosed 3,533 patients with our on-site laboratory and diagnostics center. We saw 3,192 patients for x-rays and ultrasounds. We treated 8,778 patients with physical therapy, and we hospitalized 2,053 patients on-site (Information provided by the Henry Reeve Brigade of Croix des Bouquet Statistical Report, June 2010).
When you stepped out of the hospitals and into the streets the only question that came to mind had to be, “where is the aid?” It was obvious, even six months after the earthquake that little progress had been made, with little to no evidence of monetary support. Hundreds of thousands of people were still living displaced in make-shift tent cities. The city still resembled a disaster zone with buildings teetering above cracked foundations, while corpses remain beneath the rubble. The doctors seemed to be the only relief effort making a difference.
The Cuban doctors were accomplishing more than what the international community was willing to recognize. Croix des Bouquet was just one of several field hospitals established by the Henry Reeve Brigade to serve communities in and around Puerto Prince free of charge. CNN even had to apologize after interviewing one of the Cuban doctors and crediting him as Spaniard. Fortunately, Cuban doctors aren’t looking for recognition; they are out to save lives and continue to do so all over the world.
The Henry Reeve Brigade has since moved on to other emergencies, like the fires plaguing Russia. Other Cuban doctors have replaced them to continue serving the Haitian community free of charge. Brazil and Cuba have signed a trilateral accord with the Haitian Health Minister to establish three hospitals staffed by Cuban doctors located in communities surrounding Puerto Prince where health services are limited to non-existent. Cuba has been dedicated to sending doctors to Haiti for 11 years. Amidst the unfortunate circumstances of the earthquake, they continue to fulfill their commitment to the Haitian community by sending doctors. With the success of the students working alongside the doctors, they now have plans to send more students in the years to come.
Note: Article written by Joanna Mae Souers. Photograph titled, “Joanna Mae Souers on Wound Care” was taken by Cuban photographer, Juvenal Balán. The other photographs were taken by Joanna Mae Souers.
As Medicare celebrated its 45th anniversary July 30, the White House sent its present: a Deficit Commission, composed by some of the very folks who were unable, or unwilling, to see the $8 trillion housing bubble that brought the financial system to a halt. Nope. It’s no joke: these folks are now at the forefront of the campaign to “save” Medicare and the budget.
But, does Medicare need to be saved? Let’s do a little history.
When Medicare was signed into law by President Lyndon Johnson, almost overnight millions of seniors, and later disabled Americans, were able to meet their health care needs, and rates of poverty among them dramatically decreased. Eventually, Medicare added benefits, laid the foundation of studies of health care quality, and provided a model of administrative efficiency still unmatched by for-profit insurers. Today, Medicare meets the health care needs of over 45 million Americans.
To be sure, aging baby boomers will add pressure to Medicare, and the program can be improved: rather than allowing dubious “Advantage” plans, benefits in traditional Medicare could be expanded; gaps, now covered through Medigap policies, a source of profit for insurers yet a financial burden for seniors, could be eliminated; the Kafka-esque Part D could be dumped and Medicare could be allowed to use its huge purchasing power to negotiate prices directly with drug companies, rather than banned from doing so; and doctors’ payments could stop being subject to flawed accounting formulas liable to political manipulation.
But all this is a far cry from the privatizing trends pushed by Congress and President Obama, who famously has said that when it comes to the deficit, “everything is on the table,” including the two bedrocks of America’s social safety net, Social Security and Medicare.
So if everything is on the table, how about saving Medicare by expanding it to include everyone living in America? How about replacing the insane patchwork of thousands of plans and paper-pushing designed not to provide access to care, but to undermine it, with a single paying public agent? Over $400 billion could be saved with this move alone, without adding a dime to overall costs. This amount would generously cover all — not “near” all — the uninsured, and improve the coverage of a growing number of Americans who must settle for skimpy policies and unaffordable out-of-pocket costs that drag thousands to bankruptcy annually.
And whatever taxes were needed to finance Medicare-for-All would be generously offset by eliminating increasingly unaffordable out-of-pocket costs and premiums. American families and individuals would see their health care costs precipitously fall and their health care fears vanish. Imagine the change this move would unleash — Americans no longer worried that their dream jobs offer no “health benefits” and businesses finally able to compete internationally with countries guaranteeing public health care.
There is nothing to “wait and see” about the Orwellian Patient Protection and Affordable Care Act signed into law this past March. Close to a century of failed experiments with for-profit insurance for everybody but the most vulnerable among us, who are dumped on taxpayers’ shoulders, should suffice. While millions continue to suffer and die unnecessarily, we already pay for universal health care yet not get it.
Let’s not be misled by propaganda and demand our legislators support a financially sustainable and socially just, publicly funded, privately delivered, universal health care system — a single payer national health program. It’s not too late to do things right. Let’s not take no for an answer so that we can soon sing together “Happy Birthday, Medicare for All!”
Claudia Chaufan received her medical degree in Argentina and her doctorate in sociology at UC Santa Cruz. She is an assistant professor of Sociology and Health Policy at the Institute for Health and Aging at UC San Francisco and vice president of Physicians for a National Health Program — California.
-Ultimately, by using the human rights-based framework, we strive to negotiate a new social contract or class compromise from a position of strength and power. (T. Schrecker)
1. The process of globalization with its progressive accumulation of economic and political capital sees human rights (HR) as a threat, because the HR-based approach (HRBA) emerges as an alternative to neoliberalism by focusing on divergent and rival imperatives and justifications. Conversely, the HRBA sees neoliberalism as a threat, as an economic system out of control, as bringing uncertainty, as dependency-creating, as excluding. It sees it bringing about fear, aggression, fundamentalism, as well as creating ever-expanding spaces for private interests. Despite all these self-serving attributes, neoliberalism survives as the dominant way of thinking in development. Its economists push more for individual rights (e.g., property), for limited state activity and for a free-wheeling market; they say the poor are responsible for their own poverty. (Development in Practice) Put another way, hidden in the unacceptable current social differences and social injustices is the neoliberal economic model with much money, much poverty, much silence, much omission, much disdain, much disillusion.
2. Often, there is at least an implicit complicity of rich donor countries in opposing HR activists; they argue that they rather focus on issues of bad governance in poor countries –which often ends up being more cosmetic than substantive (if not unrealistic). We counter-argue that political outcomes are not only determined by the interaction between content matters (policy) and institutional structures (polity), but by raw political interests (often post-colonial interests in the case of donors). We all know that:
in policy circles, concepts tend to be discussed a lot, but they rarely become implemented in reality, and
the crux of the matter remains one where those that have the power to define what poverty is, also have the power to define its causes and thus to decide what solutions to implement.*
* : Ideologically, rich countries act as if only the small cut-out they make of reality is the real valid one; they deny other dimensions of reality –in our case, the way the HRBA sees things. (L. Weinstein)
3. In opposing this latest manifestation of Capitalism-gone-to-extremes, what is missing is an integration of the multiple international HR obligations in the process of negotiating, among other, debt relief and free trade agreements. Existing arrangements are the result of poorly negotiated either multilateral or bilateral compromises. There is an asymmetry in the bargaining power that rich and poor countries bring to these negotiations. It is thus urgent to carry out HR impact assessments in the contexts of debt and trade, especially its effects on women and on other vulnerable groups. (T. Schrecker) Additionally, we must confront the unequal structure of representation within government, i.e., the intra-governmental distribution of power.
4. In other words, globalization, unequal representation, free-wheeling markets, dependency, the neoliberal economic model, the debt crisis, and international free trade agreements all limit national HR policy space. So, we simply have to ensure that HR priorities are not compromised by these agreements. But are we doing this…? (M. Koivusalo)
5. So, here is the deal: If one carries out a class analysis, one can determine who really benefits; if one analyzes the power relations involved, one can determine who is in control; and if one analyzes the exact role of the state, one can determine who is accountable.
6. You see? In HR work, when mapping the big picture, one already identifies the points that will require social pressure, that will require aligning interests, identifying champions, and going for early wins to reach key tipping points; …one also ponders the social cost of delaying key decisions.
Partially adapted from L. Weinstein, Ed. Multiversidad, Editorial Universidad Bolivariana, Coleccion Nuevos Paradigmas, Santiago, Chile, Mayo 2009; FAQs about the HRBA to Development, Sida, 2009; The Broker, Issue 16, October 2009; D+C, 36:5, May 2009; and Globalization and Health: Pathways, Evidence and policy, R. Labonte, T. Schrecker, C. Packer and V. Runnels Eds, Routledge Books, 2009.
“Our only hope today lies in our ability to recapture the revolutionary spirit and go into a sometimes hostile world declaring eternal hostility to poverty, racism, and militarism. Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.” -Martin Luther King, Jr.
HAVING RIGHTS DOES NOT PRESUPPOSE A SIMULTANEOUS ABILITY TO CLAIM THEM.
-There is a clear difference between having a right and having a right realized. Slaves in the US had the right to freedom before President Lincoln and native Africans in South Africa had the right to freedom before Apartheid was abolished.
-If a country (state party) has ratified a treaty, individuals move from being just right-holders to being claim-holders –with valid claims on others, i.e., the correlative duty-bearers. This forms a ‘claim-duty pattern’ in society, in which the state, most often, is the ultimate duty-bearer. (U. Jonsson)
1. Ratification is a binding act in international law. The extent to which human rights (HR) can be enforced through litigation acknowledges that: they must indeed be taken seriously. But we are all aware that court verdicts are not self-executing; popular mobilization is still essential to overcome state resistance to implement such judgments. Implementing entities responsible for the adoption and actual implementation of HR policies indeed too often enjoy unwarranted impunity. (T. Schrecker)
2. We are also aware that most countries cannot change decades-long (or centuries-long?) situations of HR violations overnight. The answer is to come up with indicators that tell us a country’s readiness to accelerate action on the progressive realization of specific HR*. We can then classify countries according to this readiness after a HR impact assessment is carried out (even if a quick one). (SCN News No. 37, early 2009) This readiness should be measured as a function of both the government’s commitment and its capacity. Commitment corresponds to willingness to act at scale (with commensurate allocation of resources). Capacity corresponds to a country’s ability to act at scale (i.e., available staff, institutions, training opportunities). (C. Nishida)
*: It is the UN Economic, Social and Cultural Rights (ESCR) Committee that has the role as the ultimate arbiter in determining what progressive-realization-of-HR-measures are deemed appropriate, i.e., their being implemented in a reasonable short time frame; the steps being sufficiently deliberate, concrete and targeted so as to meet the respective HR obligations in default. The evidence they look for to point in that direction are: legislation passed, judicial remedies applied, and social measures or policies adopted.
3. Traditionally, capacity has been equated with training, but the HR-based framework has expanded the concept to encompass acceptance-of-responsibility to meet a set of respective duties, namely
to have the authority to do so,
to have the access-to and control-over the economic, human and organizational resources necessary to meet the respective HR obligations,
to have the capacity to communicate and the capability to make rational decisions, and
to have the capacity to use the human rights-based framework in monitoring and evaluating development projects. (U. Jonsson)
4. It is regrettable that, as countries try to (or pretend to) enforce internationally recognized Economic, Social and Cultural Rights (be reminded that the US signed, but never ratified the ESCR covenant)**,
they often fail
to give the necessary weighted attention to the currently ongoing violations of ESCR in their midst,
to make reference to the absence of ad-hoc legal remedies,
to pinpoint clear, specific obligations of duty bearers,
to critically review trade and taxation policies negatively affecting ESCR,
to address women’s rights issues***,
to question why disempowered segments of society do not have the right to be heard****, and
to give due attention to issues of accountability, non-discrimination, full participation and empowerment –while they tend to focus instead on recommendations that attempt to fix or to set-up social protection nets which carry a high risk of excluding many of those most in need. (FIAN)
** : Note, importantly, that it was due to the Cold War dispute that we ended up with two separate covenants. Civil and Political Rights, and Economic, Social and Cultural Rights. There is no formal reason for this otherwise. (U. Jonsson)
*** : For instance, the realization of the women’s right to health requires the removal of all barriers interfering with access to health services, to education and to information –including sexual and reproductive health and contraception. Mind you, the obligation of not discriminating against women also requires very specific measures to redress gender inequality overall.
****: The system we are trying to change is one that keeps people silenced –not even asking questions; one that keeps the judged from judging, and keeps individuals from joining together. (E. Galeano)
5. Bottom line here is that, without the monitoring by the UN Human Rights Council***** (i.e., without any follow-up), the UN Human Rights Strategy carries the risk of contributing more to the problem than to the solution of HR violations, because it would denote a UN Strategy with ‘no teeth’. (A. Paasch, Contact, WCC, Issue 186, Nov 2008)
*****: The Human Rights Council, in existence since 2007, is made up of 47 states. It takes a broad overview on human rights issues. It is the successor to the earlier Commission on Human Rights. In contrast, the Committee on ESCR is a committee of experts, acting in their personal capacity. It oversees implementation of ICESCR.
Progressive realization and priority setting:
6. Human rights activists do not like to address the issue of choice and priority, because all rights are indivisible and interrelated, i.e., each and all of them are inherent to human dignity. There cannot be any hierarchy of rights and thus, strictly speaking, rights should not be prioritized. But because resources are limited, development programming simply requires prioritization.
7. So, in HR programming, one can indeed think of incremental solutions –provided they are arrived-at through participatory methods, i.e., the prioritization should be done with full participation of, at least, the relevant claim-holders. Outsiders’ should not decide on priorities of any kind! What we can and must prioritize are actions that will contribute to the realization of rights currently not upheld. (UNICEF) ******
******: We note though that minimum or core human rights are part of what Amartya Sen calls ‘moral-global-minima’ and are thus not part of this discussion. As per the ESCR Committee, failure to satisfy minimum core obligations imposes a fairly strict burden on states to justify their non-action or compliance.
8. Therefore, the fact that all human rights should be accorded the same respect does not preclude priority setting during the planning and programming process.
9. Bottom line here is that actions for development must be prioritized in any development approach, because resources are always limited. But no priorities should be set out-of-context, a-priori, or ‘in-general’. Better still, prioritization should be the result of a negotiation between claim-holders and duty-bearers in a participatory manner. (U. Jonsson)
We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:
Course Invitation 2011
We invite you to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).
For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.
Sincerely,
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115
WHEN YOU DREAM ABOUT HUMAN RIGHTS ALONE, IT IS JUST A DREAM; WHEN YOU DREAM WITH OTHERS, IT PRE-EMPTS REALITY. (R. Pereira G.)
-Martin Luther King did not say “I have a nightmare”. (L. Stoddard)
-Our future may be beyond our vision, but not beyond our control. (Senator Edward M. Kennedy)
1. History is not a good predictor of the future. Our institutions and our ethics come from a different historical era and have not yet been updated to knit together a globally stable society. (J. Sachs) So I’d say that, for human rights (HR), we can safely conclude we find ourselves at a watershed of history.
2. Moreover, since in politics one should never let a serious crisis go to waste, this is the (belated) time to take bold steps. It is not by pushing for more control, more purity of intentions or more money that deepening HR violations will be avoided; to pretend being able to do more through these ‘pushes’ is to commit a sin of ignorance. (N. Boesen)
3. But is there the needed sense of urgency to take the necessary much bolder steps? If so, who feels it and who does not? Who cares about the serious HR problems affecting us the world over? Only a creative anger about the world crisis we have just lived through will lead to a renewed commitment to work towards change in the HR direction.*
*: In the realm of taking such a direction, the question then is: Does this mark a paradigm shift or is it mainly happening on the fringes of the mainstream paradigm? (We want to make sure it is shift!).
4. Unfortunately, still much is needed to more decisively embark in the HR direction: Without HR expertise**, “we are flying blind into a complex and harrowing future” –and that is a challenge. (J. Sachs) Without a vision, our efforts will likely be little more than a pipe dream.***
** : The challenge here is: Can people be made to care about HR if they do not already? People and systems need to be ready for change. Change happens through learning and learning happens only when people decide they want to learn.
***: The question is: Whose vision are we talking about here? The wider the gap between the vision of the outside interveners and that of the local people, the more unlikely it will be to achieve lasting results.
5. HR activists are well aware that the HR-based framework goes against the grain of the current uncaring system; but ‘our’ system is fragmented and an ‘international HR community’ does not really exist yet; therein lies the second challenge to embark-on in the HR direction: much networking and coalition-building is still needed. Currently, the international community lacks an appropriate framework and influence to guide HR interventions aimed at changing the structures and processes within a country, as well as at changing individuals’ perceptions and values related to HR. It is such a framework that is needed to contribute to individuals asking the right questions thus making interventions more effective. (J. de Lange)
6. One of the catch-phrases of recent years has been that we should use ‘existing mechanisms’ to solve problems rather than using new ones; this, to us, is a recklessly reactionary point of view. The dominant paradigm has had at its core a horrible simplification of what poverty reduction entails. It has been mixed with an arrogant belief that money and good intentions can fix the problems. Sadly, this has been said for years, with little to show for.
7. Current efforts are simply not serving Poverty Reduction goals; they actually never have been –if we consider the real need to rather be Disparity Reduction. So, in the case of foreign aid, for instance, (i.e., elite-driven processes between international actors and local elites) stop being concerned about the amount of aid as if it matters; what really matters is the social, political, institutional and environmental challenges that aid is willing to tackle.
8. In HR work, this Reader has repeatedly insisted, direct support to the realization of HR in essence entails a power struggle. Since, through pressure, powerful interests can change their positions and fast action can ensue, herein lies the third challenge, one pointing towards social mobilization to stake long overdue claims. **** The challenge here is to translate the ‘whats’ and ‘hows’ we see happening into practical guidelines for people working in countries where HR violations are rife.
****: Because those who hold property and assets from the outset largely shape policy and market outcomes, market forces need to be confronted through politics, social ethics and a strong and vibrant civil society. (P.H. May)
9. Far from being Machiavellian, HR activists see the world in terms of power, conflict and interests. (Even Margaret Thatcher was of the opinion that we do not have neighbors as much as rivals). That is why they bring all their arguments together to use them in a political process of negotiation *****; for that, they build coalitions for change. Sooner or later resistance to the changes they propose emerge; some groups will oppose them. That is why being strategic is better than being haphazard and why it is important to know when to act and when not to, as well as why it is important to move forward incrementally trying out what works, and ensuring inclusiveness in the political mobilization.
*****: The political nature of the HR struggle becomes clear when we realize how very far from podiums and negotiation tables real HR experts are.
10. Bottom line, the conflicts we face cannot be resolved simply by doing transfers, but imply a fundamental rethinking of the precepts of HR, of equality, of equity and of social justice.
Posted in Physicians for a National Health Program (PNHP blog) on Friday, Jul 2, 2010
By Claudia Chaufan MD, PhD
In a recent issue in the New England Journal of Medicine, economist Jonathan Gruber praises the Patient Protection and Affordable Health Care Act (PPACA) as a “step in the right direction,” even as he expresses a healthy skepticism about PPACA’s capacity to control escalating health care costs, which he recognizes as “key to the long-term viability of our health care system.” Gruber also argues that there is “shortage of evidence” regarding which approach will meet Americans’ health care needs while controlling costs; therefore there is “no consensus” on what works [1].
Had Gruber looked beyond the U.S. borders, however, he would have found plenty of evidence. For instance, he would have found that U.S. consumption of health care as measured by critical indicators — per capita annual doctor visits, length of stay following heart attacks, or length of stay following normal childbirth – is no greater than the OECD average, and therefore cannot justify the extraordinary level of U.S. spending [2].
He would also have found that U.S. prices for medical care commodities and services are significantly higher than in other nations and constitute a key determinant of U.S. overall spending [3]. And had he looked into why this is the case, Gruber would have found that US high prices are determined by the exceptionally high administrative overhead caused by the system’s fragmented, public-private financing [4] and by the comparatively limited market power of American patients vis-à-vis their counterparts in countries with national health systems where the government negotiates prices with drug and medical device companies [5]. And he might have concluded that PPACA will do predictably little to change all this.
Moreover, the international literature would have shown the author the extraordinary international consensus around nonprofit financing to cover medically necessary services [5].
But what about the dramatic expansion of coverage promised by PPACA? Is this not a step in the right direction? The problem is that insurance coverage, as desirable as it may be, is not health care, but just a means to that end. And the U.S. system is notorious for providing coverage without care. High co-pays and deductibles are significant obstacles to access. Nor does health insurance offer financial security: nearly 78 percent of personal bankruptcies in 2007 that were linked to medical debt involved persons who were insured at the onset of their illness or injury [6]. PPACA, by allowing the sale of premiums for policies that will cover only 60 percent of health expenses [7], will do predictably little to change this state of affairs.
There is, however, an alternative proposal whose financial and policy soundness are based on decades of international experience and evidence. It would improve and expand Medicare to include all residents in the nation or in one state. That alternative may have to wait until PPACA unravels, as it predictably will [8].
President Obama argued that a model of reform as that implemented by PPACA would allow Americans to build on “what works” [9] – a decades-long experience with employer-sponsored for-profit health insurance. Maybe paradoxically, however, PPACA will unravel as employers realize that it is cheaper to pay a fine than pay for increasingly more expensive and inadequate policies, and employees enter the individual health exchanges implemented by the new law and find them so expensive that they “clamor for a nationalized health care system” [10].
References
1. Gruber, J., The Cost Implications of Health Care Reform. N Engl J Med: p. NEJMp1005117.
2. Peterson, C.L. and R. Burton, U.S. Health Care Spending: Comparison with Other OECD Countries. 2007. Order Code RL34175(September 17): p. http://assets.opencrs.com/rpts/RL34175_20070917.pdf (Accessed November 10 2007).
3. Anderson, G.F., et al., It’s The Prices, Stupid: Why The United States Is So Different >From Other Countries. Health Affairs, 2003. 22(3): p. 89-105.
4. Woolhandler, S., T. Campbell, and D.U. Himmelstein, Costs of Health Care Administration in the United States and in Canada. The New England Journal of Medicine, 2003. 349(August 21): p. 768-75.
5. White, J., Competing solutions: American health care proposals and international experience. 1995, Washington D. C: The Brookings Institution.
6. Himmelstein, D., U. , et al., Medical Bankruptcy in the United States, 2007: Results of a National Study. The American Journal of Medicine, 2009. 122(8): p. 741-746.
Claudia Chaufan, M.D., Ph.D., is assistant professor at the Institute for Health and Aging at the University of California, San Francisco. She teaches sociology of health and medicine, sociology of power, public health, comparative health care systems and sociological theory. Dr. Chaufan is also vice president of Physicians for a National Health Program-California (http://pnhpcalifornia.org/).
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