Archive for the 'Ethics' Category

BUSINESSES DO NOT PLAY A ‘CRITICAL ROLE’, AND CALLING ON THEM TO ENGAGE AS EQUAL PARTNERS IN A HUMAN RIGHTS-BASED DEVELOPMENT PROCESS, IS NOT CALLED FOR.

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Human Rights: Food for an interfering thought

 

Human Rights Reader 404

 

Innovation is not a prerogative of the private sector.

 

  1. More and more, we are seeing a process of outsourcing the international development agenda. The current trade and investment regimes are already favoring wealthy countries and corporations. And where has this led us? To the balance already being outrageously skewed in favor of private interests. (Look at WHO’s financing, for instance).

 

  1. In this Reader, I have more questions than I have answers:

 

  • What track record do businesses really have for being part of the solution?
  • What is the incentive for TNCs to exert their enormous power and influence in any way beyond maintaining the status-quo that has delivered so many benefits to them? So, Who benefits from the current state of affairs?:
    • The gargantuan pharmaceutical and food and beverages industry, intent on protecting their profits?
    • Governments that now are increasingly elected on the back of private election finance?
  • Does all this imply that the incentive structure only operates in one direction –not the human rights direction?
  • Is the assumption such that we should have less confidence in the aptitudes of the public sector, so that it must do more to operate on business terms? …even when those are the same terms that have led to the current highly inequitable, unsustainable, human rights-violating patterns of development?

 

  1. Since public and private incentives are currently so poorly aligned (a marriage in hell?), it is hard to imagine how public entities operating more and more along private lines will keep up with their primary public responsibilities, including as the main duty bearers for protecting sustainability, inclusiveness and human rights (HR). The question really is:
  • At what point should projects vital to human and environmental wellbeing happen regardless of a business take on the issue?

 

  1. Many businesses (of course, not all –I am not a business basher…), encouraged by years of deregulation, think of themselves as existing outside any social contract –or as able to select the parts of such a contract useful to them— for instance picking deliberate strategies that reduce their tax bills even as they are underpaying workers who then have to rely on social protection schemes paid for by general taxation. As a privileged group, big corporations are able to set their own norms, mostly related to their own survival and profitability, and further expect the public sector not to stand in their way. Large transnational corporations have pushed this approach so far that some progressive governments at the United Nations have called (and are acting upon it) for a legally binding framework to regulate them so as to provide appropriate protection, justice and remedy to victims of corporate HR abuses. But if such a new social contract keeps gaping exemptions or exclusions, it is bound to collapse. Businesses have to understand that the new global contract will be binding, not optional; it will have to be upheld and enforced, and there can be no picking and choosing –no exceptions. (B. Adams and G. Luchsinger)

 

There is no such a thing as a developed and underdeveloped world; there is only a single, badly developed or maldeveloped world (CETIM)

 

Some like to call the current development model “an evidence-free zone”. (Steven Nissen)

 

  1. Poor countries beware: Under the SDGs, more experts are coming! Not soldiers and bureaucrats to run your affairs like during colonialism, now it is an army of ‘experts’. (Note that, sometimes, experts are even more dangerous than soldiers). Experts come to tell you: “You cannot. The market will be irritated. The market will be angry”. It is as if the market is an unknown, but very active and cruel God punishing us, because we are trying to commit the cardinal sin of changing reality. I ask: Is recovering dignity a cardinal sin? (Eduardo Galeano)

 

  1. Fittingly, long ago, Immanuel Kant was of the opinion that, whoever wills the end, wills also (so far as cold reasoning* decides his conduct) the means in his power which are indispensably necessary thereto.

*: Marcel Proust used to talk about the intermittences of the heart as he observed world development going from bad to worse. (as cited by Alfredo Bryce Echenique)

 

The narrative of progress in development is no longer sustainable –unless things change (Steven Smith)

 

  1. The UN (and other development) agencies have, for decades, pitifully little to show in the implementation of actual actionable deliverables in the realm of the HR-based framework to development. It is evident that the power of interventions aimed at fulfilling HR principles and standards comes not from where they are ‘targeted’ top-down –when this power is rather to come from those who know (or suffer) how these interventions do not work to create positive change within the prevailing unfair economic and political system. This means that efforts targeted at government policy can have only limited effectiveness if they are aimed at changing relatively weak (or outright uninterested) leverage-points and individuals in the prevailing unfair system. (G. Carey)

 

  1. Even if it has been more than twenty years since their re-emergence on the international agenda, economic, social and cultural rights still remain a rhetorical aspiration. …or is there some global evidence that there have been many real advances in how they are enjoyed, claimed and enforced? This is indeed a pressing question. In a way, the affirmation by UN member states in the Vienna Human Rights Declaration of 1992 that HR and development should be seen as ‘mutually reinforcing’ still has a hollow rhetorical ring twenty five years on. (Alicia Yamin)

 

  1. On a less negative note, yes, some progress has been made on each front, particularly in the realm of discrimination, legal protection and judicial enforcement. Human rights are beginning to play a more prominent role in how we think, and how we act. But the economic and social rights of millions of people across the globe are still under systematic and renewed attacks as a result of a number of even current pervasive private/financial sector-dominated development trends. These include the imposition of regressive fiscal austerity measures and other policies fuelling economic inequality, the failure to take effective action against climate change, and the consolidated grip that unbridled corporate power now has on both national and international governance. (UN CESR) On the other hand, one of the most important innovations in human HR has been the increasing attention to economic policies such as the scrutiny of budgets, taxation, and social security systems. (Sakiko Fukuda-Parr)

 

  1. As you can see, a mixed picture. …in need of a photoshop overhaul…

 

Claudio Schuftan, Ho Chi Minh City, January 14, 2017

schuftan@gmail.com

 

Postscript/Marginalia

-In dreaming begins responsibility. (W.B. Yeats)

-We are simply acting as the folk wisdom that says: “If we do not change direction, we are going to get where we are going.” This is equivalent to the cartoon Yogi Bear’s: “When you come to a fork in the road, take it.”

Peace, more than any other word, represents the essence of our work in HR. (Anwar Fazal)

-Henri Bergson used to say: The future is not what ‘is coming’, but rather what we will be capable of doing and achieving. It makes no sense to wish ourselves a Happy 2017 if, like donkeys, we are going to continue accepting what is being imposed on us by a corrupt and out-of-reputation political class; wishing ourselves a Good Year of Struggles, that yes! (Politika)

 

Given what is happening in the world later this month, I cannot think of anything more pertinent to share with you than a visionary excerpt from Henry Miller’s 1933 Tropic of Cancer. He had this to say:

 

How many people and colleagues do we know that have no allegiance, no social responsibility, no hatred, no prejudices, no passion, being neither for nor against –claiming to be neutral. It is actually hard to talk to a man or woman when you have nothing in common with him or her; you betray yourself, even if you use only monosyllabic words with them.

 

The axis has shifted, the world is dying. The world is pooped out; there is not a dry fart left. Who, that has a desperate, hungry eye can have the slightest regard for existing governments, laws, codes, principles, ideals, ideas, totems and taboos? This crazy civilization looks like a crater. And the crater is obscene. But more obscene than anything is inertia, is paralysis.

 

Conversely, even as the world goes to smash, there are men and women who remain at the core, who remain combative as the process of the world’s downward spiral quickens. At the very hub of this downward spiral we must keep rolling; otherwise, the whole world will belch no more. The wheel is falling apart, but the revolution is intact. Ideas have now to be wedded to action; if there is no vitality in them, there is no action. Ideas cannot exist alone in the vacuum of the mind. I find it soothing and refreshing to move among the creatures with living, breathing pores whose ethical background is stable and solid. The task to throw ourselves into is to overthrow the existing values, to make the chaos about us a new order.

 

The wallpaper with which the men of science and technology have covered the world of reality is falling to tatters. The grand whorehouse that they have made of life requires no such wallpaper decoration. Beauty is finished. The world is still beautiful only in an old fashioned way; it is the same old world of wine and fornication.

 

It sounds nutty to me, all this palaver about things happening so fast. Nothing is happening that I can see, except the usual calamities on the front page: Love and hate, despair, pity, rage, disgust, war, disease, cruelty, terror, the evil, the sorrow, the discord, the rancor, the strife, the disorder, the violence, the hatred, the chaos, the confusion…

A new day is dawning. As the thermometer rises, the form of the world grows blurred; there still is articulation, but at the periphery the veins are all varicose and are starting to bleed. To fathom the new reality it is first necessary to dismantle the gangrened ducts of the system responsible for all the garbage we see and experience.

 

Once I thought that to be human was the highest aim we could have, but I see now that it was meant to deceive me. I see this other race of individuals ransacking the universe, turning everything upside down, always moving in blood and tears, slaying everything within reach. We are governed by counterfeit values; only the tiny part that is left is human, i.e., the rest that belongs to life. We simply have to act before a large portion of humanity is buried, wiped out forever. My world has overstepped its human bounds; what it is to be human is left to moralities and codes disregarded by those in power. Too much of what they feed us to read is mere literature, not reality. I know what they are really like. Underneath this fake morality all is dead, no feelings. They are selfish to the core. They think of nothing but money, money, money. And they look so goddammed respectable, so bourgeois. That is what drives me nuts.

 

We have got our faults, but we have got integrity and enthusiasm. It is better to make mistakes than not to do anything.

LETTER TO A STUDENT WHO IS PLANNING TO SPECIALISE IN PUBLIC HEALTH NUTRITION

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IT IS THE GRASSROOTS ‘PULL’ THAT IS MISSING, AND WE ARE NOT PUSHING GRASSROOTS MOBILISATION STRONGLY, AS WE SHOULD.

All lower-income countries need new generations of leaders in public health and in nutrition, with a new vision and energy. What about the even younger generation, of students who are already committed, perhaps passionately, to what they believe public health nutrition stands for, and who are planning a career – maybe a lifetime – in our profession? This column is addressed to them, in the form of a letter to a student. So:

Dear candidate,

So you want to join our guild of public health nutritionists. Good!  I hope you will now allow me to give you a few words of advice, some of warning, some of encouragement.

 

I start with an issue that has worried public health nutrition workers for many years now, namely how we have been doing professionally in the international arena. Over the years, many of us have shared this concern. Before you embark on your professional journey, you need to see this and other issues. What we have experienced can help you better to judge what you are most probably going to get involved with, in your future career. That is why I am writing you this letter.

 

I am one of those who do not share the feeling that international public health nutrition is much healthier today than it was ten years ago. The academic training we are giving our new graduates in public health nutrition still often is of limited relevance. This is perhaps more so for students from the South, especially when trained in universities in the North, where they have to go through core curricula that include courses of no relevance to them.

 

In judging the most important advances in nutrition in the last ten years, many of our colleagues think these have been greatest in preventing and treating micronutrient deficiencies. This comes as no surprise. Most nutritionists still like ‘silver bullet’ fixes. These are ‘technical’, and the technical realm is the one in which they feel more at home, and more in command.

 

The main issues are structural

 

But malnutrition is really a political problem. It is the biological manifestation of a social disease. Some other colleagues think that advances in our field in the last ten years have included greater community involvement in nutrition programmes, and increased attention to care practices addressing women and children. This is so, up to a point. But I feel most colleagues do not really have a better, action-oriented understanding of the causes of malnutrition now, than they had in the 1990s. This was the decade in which we agreed that the correct conceptual framework of the causality of malnutrition is one that considers malnutrition as an outcome of different levels of causality. These are basic and underlying as well as immediate, and social, economic and environmental as well as behavioural and biological. All these levels and dimensions need to be addressed at the same time.

 

For the same period, colleagues have said that we have not come up with comprehensive designs for a better management of nutrition interventions. For them, this explains why we have not been effective in addressing protein-energy malnutrition. But design and management are not the main shortcomings of the last decade, or even the last thirty years. The main problem is the top-down, often curative and palliative thrust of the interventions. Also, it still amazes me that some colleagues even think that failures can be attributed to insufficient attention having been paid to the importance of nutrition counselling. This just shows their ethnocentric bias. ‘Counselling’ does not begin to address the basic problems of impoverishment and inequity that are at the root of malnutrition the world over.

 

The same bias can be found when colleagues think that reduced funding for nutrition projects is the major problem or constraint to achieving better results in the battle against hunger and malnutrition. Let us face it: If additional funding is used for the wrong priorities and types of intervention, we might as well not have it!

 

I further disagree with colleagues who think the issue of lack of coordination among United Nations and other aid and development agencies providing nutrition services is central to our non-success in our work. The causes of this confusion or even conflict are ultimately related to issues of control, egos, and ‘old boy networks’, although there are also a number of genuine points of contention among agencies, some clearly ideological in nature. Yes, the non-coordination exists, and it is a disappointment. But it is not the main obstacle to faster progress.

 

Lack of commitment by governments to meaningful nutrition interventions is another excuse that is made too often, as a blanket statement, almost as a slogan. This said, I do accept that bureaucratic obstacles are a great burden. I know this after working for six years in ministries of health in Kenya and Vietnam, the latter a country where the politics are right, but where it takes a long time to get anything done.

 

But taken together, I cannot agree with the reasons given above as to why public health nutrition is ineffective. The major negative factors are structural, and are to do with the basic causes of malnutrition. Most of what remains undone ultimately relates to matters of empowerment of those whose right to nutrition is being violated, every day of their lives.

 

The main issues are political

 

One of the real issues at stake is the genuine empowerment of claim holders, the people who are suffering from malnutrition. In the years to come, it will take a more sustained (and sustainable) bottom-up activism to reduce malnutrition on the scale that is needed. It is the grass-roots pull that is missing and, as professionals, we are not pushing grass-roots mobilisation strongly, as we should. Will this be covered in your curricula? I am a skeptic.

 

On UN and other aid and development agencies, the big issue is that there are just no real good role models. Interagency competition and rivalry is often disguised as technical, but is actually political and ideological. My experience is that none of these agencies is really engaged in making empowering and sustainable changes with a potential to win the battle over malnutrition. Your generation, dear candidate, will have to give these agencies new, bolder directions. They are not immune to the political discourse. Some need to be challenged, even confronted, for as long as they keep to their conservative, outdated positions.

 

Very few of your future professors, dear candidate, are sold on the position I present to you here. They tend to be dogmatic and conservative, sticking to outdated or obsolete concepts, and a paradigm I think is fading. This is a challenge for you as well as for them. Take your stand. We take political stands based on adopting a consistent overall philosophy, which is to say, an ideology. This puts us in opposition to those with different ideologies. It is best not to adhere to our positions as the ‘only’ ones, but as those we stand for. It is good to believe you are right, when you enter into a discussion on the deep-rooted problems of hunger and malnutrition, even when you later come to see that you need to shift your position, just as long as your revised position remains consistent. Dialectics is about change. This includes recognising and amending your own mistakes.

 

By now, dear candidate, I hope you can sense that politics are at the very centre of international public health nutrition. This means that you cannot escape the responsibility of taking a political stand on nutrition yourself. This will help you to question your own current and future education, as well as all that you will see out there in the job market that is waiting for you shortly. What this points to dramatically is the almost taboo question, so rarely addressed, asked or answered: ‘How would you classify yourself politically?’  Why is this not asked in the first place?

 

It is said that, on micronutrients and breastfeeding, more concrete achievements are possible. This is precisely the silver-bullet type option many of our colleagues choose. Why should addressing tougher underlying and basic intersectoral issues be seen as impossibly difficult?  These are what will ultimately lead to sustained improvements in public health –if we all put our hearts and minds to the task. Nutritionists in your generation need to face the more difficult choices and challenges in the battle against malnutrition and its real causes.

 

Properly understood, public health nutrition is part of the larger development perspective. I see it as being our point of entry to the big picture where it rightfully belongs, according to the integrated conceptual framework of the causes of malnutrition. Nutrition will keep its rightful identity in such an approach. To be taken seriously, our discipline has to be engaged with all aspects of development; if it stays territorial, it will remain only marginally relevant.

 

Are the impediments to public health nutrition too great?

 

Dear candidate, the current condition of international public health nutrition will continue to pose increasing frustrations and challenges for you. My acute concern is seeing how politically uninterested so many of your generation, particularly in North America and Western Europe, have become.

 

Those who say that international public health nutrition was just one fashion that now has had its day might be right, after all. If so, this is because our vocation may have turned out to be irreversibly irrelevant in global terms in addressing malnutrition, the rates of which are now rising again. It is just tough trying to beat the gigantic odds of inhumane and often outrageous economic globalisation, structural adjustment, and expanding ‘market economies’, that have no room for the problems of impoverished people.

 

But international public health nutrition must not and cannot be a passing fashion! We invite you to join in. If leaders and citizens turn their back on problems like these, they are part of a movement towards an inhumane, unjust and unsustainable world that will have gone wrong, for ever.

 

Yes, you can make a difference

 

In closing, dear candidate, I convey to you my confidence and optimism that our work has the ability to make a difference. The question is, what difference, and what for. Routine, pat solutions will not do. It is not a matter of an increasing number of activities in international public health nutrition starting to take place again in low-income countries. It is a matter of what kind or type of activities. Issues of inequality and of the right to nutrition are at the base of the problems at hand. And if nutrition is used as a way to revert such inequalities, I will be an optimist. But we need your upcoming generation, dear candidate, to get the job done. Perhaps you can start by questioning the curriculum you will be exposed to.

I have worked in many places on most continents, and this, in my experience, is what awaits you if you decide to join us. I see your role as a potential agent of change. I hope that, by now, you have a sense of what motivates us, the older workers who keep going as best we can, and of what we stand for. Principles include those that are ethical and social.  Motivation can include romantic approaches such as those of charity and the desire to help the needy, but what’s most needed are political approaches that attempt to fight inequalities and injustice by empowering people to fight for their own rights.

Unfortunaytely, many of our commitments and energies wane as we get older, dear candidate. Do what is bold, now that you are young. Reach for the stars.

Very cordially,

Claudio Schuftan

Ho Chi Minh City

 

 

ARE YOU MDGs-SKEPTIC? I AM.

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October blog

Claudio Schuftan

ARE YOU MDGs-SKEPTIC? I AM.

Some have calculated that, with current development trends remaining the norm, poverty will be eradicated in something like 70 or more years.

It is fitting to devote this column to the MDGs since the UN just deliberated over them thirty days ago as we reached the 2/3 mark to 2015.

At the People’s Health Movement (PHM), we consider ourselves to be MDG-skeptics. For long now, we actually have been trying to create awareness of the MDGs limitations and have therein been playing a veritable devil’s advocate role.

You may ask: Why being MDG-skeptic? For starters, we want you to agree with us that achieving the MDGs will only result in modestly advancing global health and nutrition …if at all.

I will thus here try to convince you that ‘having the passion’ is not enough. Given a long past experience, this alone risks ending up with many words and many promises.

Why do I try this? Because civil society inputs are vital in this debate. Yes, indeed vital: But not as ‘MDG yesmen’ (or yespersons to be gender correct).

Ultimately, I want you to be convinced by this column that the fallacy we need to uproot is that health and nutrition programs addressing the urgent needs of women and children implicitly address equality and human rights.

In the human-rights-based approach (HRBA) nothing is left implicit!

I also want you to agree with us at PHM that the MDGs operate too much using a ‘deficit-filling approach’ to poverty and to address preventable ill-health, preventable malnutrition and preventable premature deaths. It is not about filling the last bit of the cup; it is about refilling it from the bottom.

Poverty, ill-health and malnutrition are the result of the ongoing process of social exclusion; and the HRBA specifically explores the critical exclusionary mechanisms that need to be tackled –now!  Consequently, concrete demands need to be placed on duty bearers –now– because where someone has a right, someone else has a duty.

Gone are the days of us ‘working with beneficiaries’: We are now to talk about ‘mobilizing rights holders’ (claim holders) to demand changes they are due.

The implication of this is crystal clear: Political forces cannot be fought with morals and technical fixes. Therefore, we believe that acting politically is the way to reach ground zero in nutrition work.

Why?

The easiest and shortest way to answer this question here is to elevate a number of truisms about the MDGs to the category of ‘mini-iron-laws’. They would be the following:

We think MDGs suffer from: Donor overinfluence, technical overemphasis, inattention to action on underlying social and economic inequalities, lack of systematic long-term financial commitments, and a predominant focus on health and education rather than on the entire political economy.

Further, MDGs:

  • Perpetuate a focus on communicable diseases.
  • Encourage quick-fix technical approaches.
  • Offer too little too late and are not really new, but rather rehashed versions from earlier goals set by the international community. [As somebody said,  The Alma Ata Declaration of 1978 can more fittingly be called “the people’s MDGs”].
  • Emphasize average outcomes across an undifferentiated population. [At that, they focus on outcomes disregarding the processes through which we are to achieve them].
  • Mostly provide a template-of-targets-for-the-bureaucratic-mind.
  • Do not recognize that poverty  is a function of human rights violations.
  • Posit housing, health care, and access to food and water not as non-negotiable and universal human rights, but as ‘needs’ to be met.
  • Infuse neoliberal priorities into development policies often using just the language of human rights so that, ultimately, they attempt to wash the face of neoliberalism by emphasizing what is possible and doable …for donors and the market.
  • Do not represent a development paradigm break; they are instead a set of indicators embedded in a paradigm –the neoliberal paradigm.
  • Were set arbitrarily…from the outside…in the North…resulting in what some consider ‘the ghettoization of the problems of development’. [They can thus be seen as the-goals-of-the-rich-countries-for the poor countries].
  • Call for change, but not for creating the conditions to make real needed structural change possible.
  • Pay scant attention to the roots of inequality.
  • Seek to “eradicate extreme poverty and hunger” (Goal 1), but rely on the discredited notion that economic growth at the national level (GNP) can eliminate poverty
  • Do not denounce bad governance of the G8 countries or of the IFIs.
  • Are not an expression of governmental goodwill; rather, they constitute pre-set international obligations.
  • Have failed to provide a real sense of ownership either by poor countries’ governments or their civil society actors.
  • Are not global at all; they place all responsibility on the separate national governments with no global authority really in charge of their enforcement. (G. Kent)
  • Have actually provided something that pretends to be a moral compass together with a set-of-yardsticks to measure some types of progress; they have been too much of a counting and accounting exercise.
  • Disregard the effect of trade policies on malnutrition. [The negative consequences of current unfair international trade policies are actually one of the major oversights of the MDGs].
  • Fail to even mention women’s labor and property rights, or one of the most fundamental obstacles to ensuring these rights, namely, violence against women, and finally assume that privatization of services is a strategy-for rather than an obstacle-to economic development and improved nutrition.

All these mini-iron-laws should make make one wonder: Are MDGs just another attempt to achieve good looking statistics?

[Regrettably, you have to recognize that MDG-driven agencies feel tempted to manipulate statistics].

MDGs actually miss what most matters to people who happen to be poor (‘the bottom billion’): They overlook or ignore issues of risk, security, respect, status, dignity, voice and livelihood vulnerability –all more important to this group than mainly income and consumption issues. Moreover, let’s face it: none of the goals can be achieved without empowering women and without recognizing the centrality of decent employment (a human right). Furthermore, keep in mind that a) debt relief is a precondition for even keeping-up the hope of meeting the MDGs, and b) market liberalization strategies have been oblivious to the MDGs. [Transnational corporations are certainly not geared to invest in helping achieve them, are they?].

At PHM, we think the MDGs approach can be described as ‘human development meets results-based management’. [This said, one could  wonder, is there truth in the sarcastic view that the MDGs should really be an acronym for ‘Most Distractive Gimmick’?].

For all these reasons:

The MDGs approach badly needs rethinking. We badly need a post-MDGs architecture (or one earlier than ‘post-‘, in an attempt to minimize harm and disenchantment come 2015).

Since it is human rights violations that are the raison d’etre of all MDGs (!),

applying the internationally agreed human rights framework to the MDGs approach (or replacing the approach outright) will put the spotlight on the discrimination and social exclusion gaps that we see as the most significant human rights gap in the current application of the MDGs.

In all of this, what civil society organizations are failing-us-in is in challenging the system that day-in-day-out recreates the condition of poverty as the common determinant behind all MDG-related violations of the right to nutrition. It is time for NGOs, and for colleagues affiliated with Social Medicine, to hold duty bearers to account. Yes, this is political. But can our affiliates remain aloof of politics?

What all this will mean to the agenda of all of us is what I encourage you to react to at the bottom of this column.

At the heart of the MDGs beats a fundamental contradiction: poor countries are expected to meet the MDGs by implementing the very neoliberal economic policies that have, in large measure, caused the problems that the goals are intended to address.

At PHM, we fear that, after 2015, we will have achieved nothing more than isolated islands of progress in a sea of remaining grievances and persisting human rights violations. [By sticking to the MDGs paradigm, inequalities are staring us in the face now, but will be shouting at us after 2015].

Why do we say this? Because the MDGs need not only to be attained, but also sustained long term –post 2015. [Our own George Kent satirizes the issue by proposing that, on new year’s eve 2015, we distribute a few million sandwiches to hungry children the world over so that come January 1 we will have halved hunger of under fives].

All this body of argumentation explains why I reject targeted pro-poor policies including in nutrition work; we ought to be fighting for anti-poverty policies (or rather disparity reduction policies). Poverty reduction without redistribution is only to be seen as flimsy rhetoric. Political power is a crucial precondition for a country to rise out of the poverty trap once and for all.

We need to grapple precisely with those phenomena that the MDGs take for granted, because they all affect malnutrition.

Why? Because, how can we be content with wiping out malnutrition for half the mothers and children by 2015 when that goal is possible for all of them?

Being realistic: Inequalities will remain entrenched even if the MDGs are achieved.

As Vicente Navarro says: It is not inequalities that kill people. It is those responsible for these inequalities that kill people.

What we need to focus-on are the processes that will lead to overcoming malnutrition (or achieving any of the other goals); and those processes have to be bottom-centered. Without the proper participatory processes, MDGs as outcomes may mean nothing (like a modern Christmas toy….without batteries). The process must ‘pull’ needed changes and not be the conduit for  ‘pushed’, often packaged, solutions.

Had we insisted early-on on each district achieving the MDGs would have been the equitable alternative to national MDGs; in that way, one would have served the predominantly poor and minority districts. But national averages will still mean that the half of the people below the average will be suffering from ill-health, malnutrition and preventable deaths.

Civil society organizations that have not adopted most of the above badly need to go into a retreat to revision and remission their role so that they stop being part of the problem and become genuinely part of the solution. If they stick to the old ways of service delivery, food distribution, nutrition rehabilitation… the time has come for them to be named and shamed.

The rhetoric-action gap has to be stopped. NGOs cannot be shy or human rights blind any longer; they have to take issue with the social determinants of health and nutrition.

This means NGOs cannot only use a human rights ‘lens’, use human rights implicitly in their work, add a ‘human rights perspective’, have ‘human rights projects’, or ‘mainstream human rights’. They have to embark in human rights-compatible programming fully using the human rights-based approach by now well delineated. This is not a matter of choice anymore; NGOs have to decide what?, how? and when? to move in this direction. This, because governments have to simply be pushed to take up their international responsibilities towards nutrition. NGOs will have to shift their work from a welfare perspective to an economic justice perspective. Any path chosen using the latter will have to entail  transforming economies more structurally.

This will require extensive human right learning as a means to more proactively engage in a true human rights dialogue with claim holders and duty bearers.

It is no news that the world is increasingly shaped by powerful global forces, the action of many of which have dire consequences for the right to nutrition and for the social, political, economic and environmental factors that influence all MDGs; the latter factors are increasingly determined at a supranational level. As a result, local and national level efforts to influence the determinants of malnutrition can have only a limited impact. It is thus all too easy for the individual health and nutrition practitioner in the public sector to feel powerless. Yet while these practitioners, on their own, may indeed be relatively powerless, together they can achieve a great deal –and that is the role the People’ Health Movement has taken up (www.phmovement.org ) …and the one Social Medicine readers should be considering.

Bottom line:

  • Real life is more complex than MDG slogans.
  • The poor and the marginalized are not where they are by accident.
  • The objectives we should strive for are not to stabilize the problem of malnutrition, but to make it disappear by tackling it at the roots.
  • Not all the problems of malnutrition are structural. Granted. But if the latter are not addressed the chances of the MDGs advancing global health and nutrition are nil.
  • We have to avoid ‘othering’ people as ‘poor’ and thus as inferior to the non-poor.  (Isn’t that what the MDGs implicitly do a bit –or a lot?).
  • The shortcomings of the MDGs depicted in this column should be denounced publicly to demystify the ‘silver bullet’ aura of just pointedly going-for and achieving the eight MDGs.
  • The MDGs cannot be achieved without respect for human rights overall and in particular for minority and women’s rights. They cannot be achieved without redistributive steps either. (But beware: Redistribution always takes place: just not from the rich to the poor!).

So, in the name of the wretched of the earth, are we to change the world? Or are we the victims of those who have the power to change the world? If the second is the case,  is what we usually discuss in our professional meetings going to change things? [Food for thought here: Was this taken up in our just concluded meeting in Portugal?].

To close, I would like to share with you the real existential doubt I have: Do we actually live in a world of high-flown objectives, ambitious target setting and obscure acronyms?

Postscript:

Before I leave you, were you aware:

  • that the promises of the rich countries are not quantified in the MDGs paradigm? (The obligations of the poor countries are! …this assumes poverty is a problem of poor people only, right?).
  • that a dramatic overlooked point in the Millennium Declaration and the MDGs is that inflation is likely to make the-year-2000-1U$/day a mere 60 cents/day by 2015?
  • that, in the case of the nutrition MDG, official responses, so far, seem to be more concerned with quelling or preventing food riots than with addressing the underlying and basic deeper causes of chronic malnutrition? (G. Kent)
  • that, if current trends continue, by 2015, 3.7 million more children in Africa will suffer from malnutrition than today?
  • that China, Cuba and Vietnam have long focused on core MDG concerns, but have simply not labeled them as such?).

Red Cross Report on Medical Complicity With Torture of 14 "High Value" Detainees

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ICRC logoIn April of 2009, the Obama Administration complied with a Freedom of Information request by the American Civil Liberties Union and released four secret memos outlining the Bush Administration’s justification for various “interrogation techniques” that amounted to torture.  These memos are available at the ACLU website.  They are essential reading for Americans who want to understand what has been done in the name of our country.

Shortly after the release of these memos, New York Review of Book’s journalist Mark Danzer posted the entire text of the February 2007 report by the International Committee of the Red Cross regarding the interrogration of 14 “high value” detainees by the CIA.  The report was published as part of two excellent articles (“US Torture: Voices from the Black Sites” and “The Red Cross Torture Report: What It Means“) written by Danzer.

The report is of particular interest to health care personnel because it details the alleged roles of medical personnel in the torture of the 14 detainees.  Rather than summarizing the contents of the ICRC report, we excerpt below the entire text of Section 3 entitled:  Health Provision and the Role of Medical Staff.

During the course of their detention, detainees described three principal roles for health personnel whom they encountered. Firstly, there was a direct role in monitoring the ongoing ill-treatment which, in some instances, involved the health personnel directly participating while certain methods were used. Secondly, there was a role in performing a medical check just prior to, and just after, each transfer. Finally, there was the provision of healthcare, to treat both the direct consequences of ill-treatment detailed in previous sections, and to treat any natural ailments that arose during the prolonged periods of detention.

Throughout the course of the initial phase of the detention, the ICRC received alle­gations that health personnel were directly involved in monitoring the health effects of ill-treatment. In some cases it was alleged that, based on their assessments, health personnel gave instructions to interrogators to continue, to adjust, or to stop particu­lar methods. As with other personnel within the detention facilities, the health person­nel did not identify themselves, but the detainees presumed from their presence and function that they were either physicians or psychologists.

For certain methods, notably suffocation by water, the health personnel were allegedly directly participating in the infliction of the ill-treatment. In one case, it was alleged that health personnel actively monitored a detainee’s oxygen saturation using what, from the description of the detainee of a device placed over the finger, appeared to be a pulse oxymeter. For example, Mr Khaled Shaik Mohammed alleged that on several occasions the suffocation method was stopped on the intervention of a health person who was present in the room each time this procedure was used.

Other detainees who were shackled in a stress standing position for prolonged peri­ods in their cells were monitored by health personnel who in some instances recom­mended stopping the method of ill-treatment, or recommended its continuation, but with adjustments. For example, Mr Bin Attash (the detainee has had a right-sided below knee amputation) alleged that while being held in a form of stress standing posi­tion with his arms shackled above his head, and his feet touching the floor, had his lower leg measured on a daily basis with a tape measure by a person he assumed to be a doctor for signs of swelling; the health person finally ordered that he be allowed to sit on the floor, albeit with his arms still shackled above his head. Mr Hambali alleged that, after a period of the same form of prolonged stress standing, a health person intervened to prevent further use of the method, but told him that “I look after your body only because we need you for information”.

As well as the monitoring of specific methods of ill-treatment, other health person­nel were alleged to have directly participated in the interrogation process. One detainee, who did not wish his name to be transmitted to the authorities, alleged that a health person threatened that medical care would be conditional upon cooperation with the interrogators.

The second alleged role of the health personnel was to perform a medical check prior to and after each transfer from one detention location to another. The purpose and results of this medical examination appear not to have been divulged to the detainees.

The third alleged role was to provide medical care to detainees, either for injuries resulting directly from the various forms of ill-treatment employed, or treatment for common ailments that arose throughout the course of the detention.

With regard to this third role, when such medical treatment was necessary it appears from the descriptions given that the care was appropriate and satisfactory. In two specific cases, detainees indicated that exceptional lengths were taken to provide very high standards of medical intervention.

Medical ethics are based on a number of principles’ which include the principle of beneficence (a medical practitioner should act in the best interest of the patient—salus aegroti suprema lex), non-malefiance (first do no harm—primum non nocere) and dig­nity (the patient and the person treating the patient have the right to dignity). These principles guide any relationship between a medical doctor and a person whom he or she is relating to as a medical doctor.

There are accepted roles for health professionals working in recognised, official, places of detention such as police stations and prisons wherein the health professionals have the health care and best interests of the detainee as their primary consideration.’ To this end, when a person enters an official detention facility or system, a medical assessment of their medical status is required in order to meet their current and ongo­ing health needs. In the case of a normal, lawful interrogation, a physician may be asked to provide a medical opinion, within the usual bounds of medical confidential­ity, as to whether existing mental or physical health problems would preclude the individual from being questioned. Secondly, a physician may rightly be requested to provide medical treatment to a person suffering a medical emergency during question­ing. This accepted role of the physician, or any other health professional, clearly does not extend to ruling on the permissibility, or not, of any form of physical or psycholog­ical ill-treatment. The physician, and any other health professionals, are expressly pro­hibited from using their scientific knowledge and skills to facilitate such practices in any way. On the contrary, the role of the physician and any other health professional involved in the care of detainees is explicitly to protect them from such ill-treatment and there can be no exceptional circumstances invoked to excuse this obligation.”

With the exceptions detailed in the above paragraph, any interrogation process that requires a health professional to either pronounce on the subject’s fitness to withstand such a procedure, or which requires a health professional to monitor the actual proce­dure, must have inherent health risks. As such, the interrogation process is contrary to international law and the participation of health personnel in such a process is con­trary to international standards of medical ethics. In the case of the alleged participa­tion of health personnel in the detention and interrogation of the fourteen detainees, their primary purpose appears to have been to serve the interrogation process, and not the patient. In so doing the health personnel have condoned, and participated in ill-treatment.

Commentary on the ICRC Report

Medical participation in torture has been discussed in several articles in the medical literature over the past several years.  Stephen Mile’s 2004 Lancet article entitled “Abu Ghraib: its legacy for military medicine” pointed to multiple ill effects of medical participation in torture. These included damage to the reputation of the US Army and its medical corps as well as “[t]he eroded status of international law has increased the risk to individuals who become detainees of war since Abu Ghraib because it has decreased the credibility of international appeals on their behalf.”  Calls arose the same year for an investigation of doctors who had been involved in torture.

As of today no health care personnel have been prosecuted or lost their license to practice for these breaches not only of basic ethical principles, but also of international law.  Of course, the problem does not reside in a “few bad apples” who did wrong, but rather in the larger system that was designed to torture and abuse.  Medical personnel were one part of that machine.

In a 2003 chapter in the book Military Medical Ethics, Volume 1, Drs. Vic Sidel and Barry Levy argued that the concept of a physician-solider contained an irreconcilible ethical dilemma: that of divided loyalties or dual agency.

The overriding ethical principles of medical practice in our view are “concern for the welfare of the patient” and “primarily do no harm.” As we understand them, the overriding principles of military service are “concern for the effective function of the fighting force” and “obedience to the command structure.” Although there may be rare exceptions to these principles, they have been the fundamental bases of medical practice and military service over the centuries. In our view, the ethical principles of medicine make medical practice under military control fundamentally dysfunctional and unethical.

In making this critique Drs. Sidel and Levy were speaking of primarily physician-soliders who were caring for other soldiers.  But the situation of the medical personnel operating at the CIA “black sites” is the ultimate expression of the problems of dual agency in military medicine.

More on the ICRC

This posting excerpts only a small portion of the ICRC report which is worth reading in full for its careful documentation of the conditions of detention in the CIA black sites.   It is worth pointing out that the ICRC’s involvement in defending prisoners extends far beyond this report. The Committtee’s work can be appreciated on their website.  Finally, the ICRC has provided some background in response to the publication of the report. The ICRC statement concludes with the following:

The ICRC is concerned that any information it divulged about its findings in places of detention could easily be exploited for political purposes. It deplores the fact that confidential information conveyed to the US authorities has been published by the media on a number of occasions in recent years. The ICRC has never given its consent to the publication of such information.

posted by Matt Anderson, MD

FDA abandons Declaration of Helsinki for international clinical trials

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At the end of April the US Food and Drug Administration (FDA) published a regulatory change ending the need for clinical trials conducted outside of the US to comply with the Declaration of Helsinki. The FDA’s decision had been in the making for several years and is a major victory of corporate interests which have sought to loosen the ethical standards for international clinical trials. Integrity in Science has written a critique of this decision in which Peter Lurie of Public Citizen’s Health Research Group is quoted as saying that it is “in line with other U.S. efforts to flout international mores.” [Lurie had made a detailed critique of the proposal in the Lancet in 2005.]

In effect the FDA will now allow the pharmaceutical industry to run international clinical trials in which patients in the control group (i.e. those who are not getting the experimental drug) can be treated with placebos instead of the best standard medical care. The change will have important practical implications as more and more medical research is being done overseas by for-profit Clinical Research Organizations (CRO’s). Doing research in poorer countries offers several benefits for CRO’s including lower costs and – now- the possibility to use placebos in control groups.

What is the Declaration of Helsinki?

The Declaration of Helsinki was adopted by the World Medical Association in 1964 as “as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects.” It has been amended five times, the most recent version being in 2000. [Oddly, enough FDA regulators, noblesse oblige, prefer to use the 1989 version rather than the current 2000 version.]

In general the Declaration takes the position that “extreme care must be taken in making use of a placebo-controlled trial” when there is an existing proven therapy. In other words new treatments should be tested against old treatments instead of placebos. This assures that participants in a clinical trial are not denied the benefits of proven treatments. The Declaration does, however, allows for the use of placebos in certain circumstances.

Why is there concern over the use of placebos in international trials?

In 1997 Peter Lurie and Sidney Wolfe published an article in the New England Journal of Medicine criticizing trials of maternal to child HIV transmission prevention in several countries around the world. In these trials some pregnant women were given placebo treatment at a time when the benefits of AZT for preventing maternal to child transmission had been demonstrated. This meant that some women gave birth to children with HIV infection whose disease might have been prevented by the investigators. Many people found this troubling. And it is not an anomaly. Public Citizen has also criticized a Latin American trial of surfactant in preterm babies with respiratory distress syndrome which included a placebo arm.

There are generally two advantages for the pharmaceutical company for doing a trial in which their drug is compared to placebo and not to existing effective drugs. It is easier to show that a drug is better than placebo than existing therapies. Equivalence studies (which compare old and new drugs) require more patients and consequently more time and money. Secondly, if the new drug doesn’t do as well as the old drug, then doctors will prefer to prescribe the old drug.

The use of placebo groups overseas is justified by arguing that patients in poorer countries would not have access to existing standard treatments outside of the trial. The trial simply compares a new treatment against the existing “standard of care” in the country where the trial is conducted. In defense of the African HIV trials an NIH official remarked: “”Studies are designed with the people of the country and take into account the standard of care. They’re really looking at regimens which would work in that country.” (see BMJ 1997;315:763-766)

This is a very difficult argument to accept and let us speak clearly about what it means: If a study is unethical in the US, why should US researchers be allowed to do it in another country? Why should they be allowed to let children die or become infected with HIV in a clinical trial they finance and run? Let us remember that participants in a trial are providing a valuable service to the investigators. This has always implied a special requirement that the investigator protect the interests of the subjects.

What is the FDA proposing instead of the Declaration?

Replacing the Declaration will be Good Clinical Practice (GCP) a system for clinical trials that was developed by International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH).

Who exactly makes up the International Conference on Harmonization, the new arbiters of research ethics? Well, it’s the drug regulators from the US, EU and Japan as well as representatives of the pharmaceutical industry in the US, Europe and Japan. There are also three observers (the WHO, the European Free Trade Association and Health Canada) as well as the International Federation of Pharmaceutical Manufacturers & Associations. This is obviously a group of the governmental agencies and industry groups of the world’s wealthiest countries.

One wonders just whose interests the International Conference represents: the countries funding the research or the countries where the research will be done. Under what right did these bodies abrogate the authority to set international ethical standards for research? It is within this context that the abandonment of the Declaration assumes its significance.

Can’t countries set their own standards?

Clearly countries around the world are free to set their own standards for research that might incorporate the Helsinki Declaration. But the reality is that poorer countries are under intense pressure to loosen ethical standards in order to facilitate the clinical research “industry”.

A flavor for this pressure is found in a 2004 Lancet Article by Dinesh Sharma entitled “India pressed to relax rules on clinical trials.” The article begins: “India’s pharmaceutical companies are pressuring the Indian government to relax regulations governing clinical trials. If these changes go through, Indian companies will be able to capture lucrative outsourcing contracts from European and North American companies, and boost India’s research and development capacity.” The go-go nature of this pressure is captured by a proposal by the Council of Indian Industry that trials be given automatic approval if they are not cleared by regulators within a stipulated time. It is, of course, proposals like this that belie the any faith that loosening the ethical rules will not harm patient safety.

How does the FDA defend their decision?

Readers interested in hearing the FDA’s rationale can consult the new regulation published in the Federal Register. It is, however, a wonderful example of talking past criticisms. In response to concerns about placebos, the FDA simply repeat the Good Clinical Practice will assure protection of subjects.

For more information

Howard Wolinksy’s article in EMBO Reports provides a detailed description of this change and the background to it.

Other websites that have commented on this decision include GoozNews and the Global Bioethics Blog.




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