The Social Medicine Portal

BEWARE: HUMAN RIGHTS ARE BEING INTERPRETED TO SUIT THE FREE MARKET.

1. These days, the market is presented to us as capable of resolving all problems –even of protecting human rights; but the latter, basically through the façade of corporate social responsibility (see Human Rights Readers 190 and 191).

2. The market, it is said, must have access to everything. So people’s rights must all be ‘conveniently’ modified to allow the market unregulated access. But since thereby duties and obligations would be defined by the market, inequality will clearly be legitimized –and marginalized and powerless people will be further disenfranchised. Both equity and justice are thus ignored in this attempt and are being replaced by paternalistic ideas defined largely in market terms.

3. Even the judiciary is internalizing this ideology that looks up to the virtues of the free market thus promoting the logic of globalization and all the negative consequences it entails for human rights (HR). This de-legitimizes peoples’ justified struggles for human rights.

4. Both courts and parliaments the-world-over are today expected to be amenable to the dictates of the market. National laws, initially introduced to protect HR, are too often being ignored or even derogated.

5. Globalized capital, ever eager to extend its reach, has literally moved into an “accumulation-through-dispossession” mode by, among other things, taking the land, the biodiversity and the culture from communities, as well as by excluding vast sectors of the population from meaningful economic activity, from meaningful participation in decision-making, and by expropriating their  resources. In short, globalization has become one of the engines of the maldevelopment we currently see.

6. In the prevailing paradigm, it is seen as fitting to sacrifice HR to facilitate the expansion of global capital and of the process of market globalization. As paradoxical as it may seem, the powers that be are using both HR and democracy as legitimizing pretexts for giving free reign to the free market and, in the same vein, to transnational corporations.

7. All in all, a new variant of the ruling paradigm is being promoted, with the creation of phony “market-friendly rights”, where the very concept of HR –and thus of rights violations– is severely restricted and distorted. In it, the individual becomes a consumer or a potential consumer, not a real holder of rights.  The ultimate idea is to force a consensus on this interpretation of HR, in that way completing the deception. Those of us who are active in the struggle for HR simply must actively combat the ascension of such a new twist to the paradigm.

8. We therefore need to critically analyze this increasingly pervasive discourse of “rights”. Let’s call a spade a spade: It is ultimately being used to promote neoliberal interests.

9. To reiterate: The struggle for HR is a dynamic process of resistance and change that engages and transforms the existing unequal relations of power. HR can be achieved only through the involvement and empowerment of the community as a whole, particularly those whose rights are being violated.

Using HR standards one is using a powerful resource for transformative, action-oriented political change.

10. Ordinary people do not begin their struggle by inquiring how HR are defined in the international HR framework that their governments have ratified. It is from people’s day-to-day reality that they eventually come to identify themselves as bona-fide rights holders. Human Rights are then to become a tool for communities in their struggle to understand why their human dignity is being violated day-in-day-out. HR further help them identify who is responsible for the current state of affairs and what demands they have to place in front of those duty bearers.

11. Once in the struggle, rights holders are to move beyond single-issue struggles, i.e., largely ineffective and discredited tactics of protest against more restricted reivindications, and engage in a broader HR-based struggle.

12. This will entail embarking in a process of confronting and transforming unequal power relations and structures that are denying them the respect, protection and fulfillment of their rights.

13. Some key tools to use in this struggle will be: engaging in negotiations; in protest and resistance actions; in confronting not just the state, but also other actors (including corporations and development agencies); and in monitoring the progressive implementation of HR strategies.

14. Ultimately, the aim is to renegotiate the engagement of the people with the state and other duty-bearers.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

_____________

Mostly adapted from C.R. Bijoy, Seedling, October 2007.

LEARNING FROM EXPERIENCE: CONNECTING THE IVORY TOWER TO MAINSTREET. (C. L. Schur)

We may be intelligent, but do we have the experience? If we do, it depends whether we learn-from and apply our experience! (F. Stern)

Those who cannot remember the past are condemned to repeat it. (Santayana)

1. When really committed to human rights (HR), civil society organizations and individuals in academia have to use their (new) power with intelligence and not overvalue any theory that promotes a sense of ‘universal responsibility’ based on the false pretense that it is primarily the intelligentsia who has to bring order to a world in disarray –no matter at what cost–“or we won’t be able to live in peace with ourselves”. Such theories do not only lead to potentially infinite disconnected interventions; they intoxicate our minds with the illusion that it is we who have the leading role in the ultimate crusade in favor of what is just and fair, making us believe that each campaign we embark-on is like the final and ultimate campaign that will end all miseries of the world. As part of a true global people’s movement, we have to learn to move from being-a-potential-power to being-a-real-power in world affairs; we have to liberate ourselves from simplistic general global objectives (i.e., a general globalism) that lacks a clear sense of direction and purpose lest we get tangled up everywhere. There are concrete things to do to get us to such a position of real power…and it is the actions of those most affected –and not just of the intelligentsia– that will ultimately count. (Paraphrased from Walter Lippman (1889-1974), former NY Times Editor).

2. If we do not heed the advise above, we always come up against the same limit: ‘it cannot be done’ from the ivory towers –no matter how hard we try. We need to let go of old patterns to let new forms emerge; forms that we can, in partnership with the most affected, test in small trials in mainstreet.

3. Committees our peers set-up in which those whose rights are being violated negotiate what really are compromises, more often than not, actually serve to defend the special interests of the conveners. I’d say this negotiating has reached its limits. We will not get anything more out of it. This, because we do not take into account the very important special interests at play. (Ultimately, the interests of those defending their old prerogatives play against the interests of those chronically under-represented and ‘under-voiced’ in negotiations, e.g., women, minorities, the marginalized). To foster real progress in HR, activists must know who the various interest groups are and what really ‘makes them tick’.

4. Furthermore, experience shows us that we need to denounce the discrepancy between the letter of the law (which often upholds idealistic and noble principles) and actual practice (which is either indifferent and insensitive or outright repressive and oppressive….even if passively).

5. In our struggle for HR, it is not enough to reject and oppose what the neoliberal Establishment stands-for –if it is not done in the name of making real structural transformations. Most of the time, the struggle is only advanced in the name of a sometimes single-issue opposition built around either a ‘defense of the environment’, of a rejection of ‘traditional morals’ or of just supporting piecemeal positions to address selected aspects of the faulty international social and economic order. Not so in the case of the HR-based framework. 6. Because of this, the following caveat has to be kept in mind: Contrary to what so many nowadays prophetize, manifestations of street euphoria in mainstreet (in Davos or in WTO meetings) do not have much of an ultimate political or HR transcendence. Instead of being real innovators, these alleged ‘avant-garde protesters’ with their rhetoric, and street revolutionaries with their slogans, are far away from the main body of claim holders and instead contribute to the banalization of the radical changes really needed. (I have found, they actually do not bother even to read on these matters or read very little). They often play to the hands of the Establishment without realizing they are party to a confused idealism that, in fact, governs their actual conduct –which has no real teeth. All this is anarchic, devoid of a center or action-direction and often does not even wield new ideas. These street revolutionaries should instead be looking for real transcendence by de-facto rejecting the market-controlled world we live in with its built-in social class prejudices and HR violations, i.e., not only should they protest verbally or physically, but have a HR-based-reasoned-action-agenda and a de-facto insertion in processes at grassroots level.* (Paraphrased from M. Vargas Llosa)

*:In a way, this is al challenge for us HR activists, i.e., to bring these potentially valuable strategic allies into the realm of real HR work.

7. The above non-systematic overview that comes from experience, but is brief to the point of a caricature, gives us pointers to what some of the important issues we need to tackle are when replacing the current paradigm by the one with the HR-based framework at its core. I invite colleagues in our readership to reflect on these points and to discuss them with peers. We have to bring these issues to a level of ‘impertinent consciousness’ where it bothers us not to act. (Sub-comandante Marcos)

8. To finish, I ask: How long will it take for the conventional literature to break with the current paradigm, conceived –and now guarded– by its protagonists who reside in the ivory towers of the world…who you and I well know?

Claudio Schuftan, Ho Chi Minh City cschuftan@phmovement.org

Actions and activism in fostering genuine grassroots participation in health and nutrition.

1. You may often have asked yourself as to whether your individual contribution in the field of health and/or nutrition makes or is making any difference.  This, of course, depends.  Alone, each of us is indeed helpless to change very much.  Standing alone to-right-the-world’s-wrongs is a false ideal. We have thus plenty to learn from the lessons of mutuality or even of militancy.  Individual concern (let alone compassion…) is just clearly less powerful than organized solidarity. (Tikkun)   Or, to use an old adage, ‘divided we beg, united we demand’.

2. Sporadic, collective grassroots-organized acts are happening all the time   –mostly the result of non-political and personal leadership initiatives. To make these acts really count and add-up to something, they need to be progressively channeled into new patterns of higher political meaning and political impact. Human rights activists are needed to lead the way in such a transition.  This, because without continuity and follow-through actions, popular struggles will remain a heap of toothless words. (S. Ophir)

3. In the human rights (HR) context, two questions arise here: Are the fields of health and nutrition legitimate and good ports of entry for HR activism? And if the answer is yes: Are we ready for such a challenge?

4. If the answer is again yes, new forms of progressive HR learning and HR action are then needed in our line of work. Actually, to act effectively in the time before us, we need to first develop a more widely shared strategy that unequivocably points in the HR framework direction.  When adopting such a strategy, we cannot merely denounce; we must also announce a new order –an order with more empowering-health-and-nutrition-alternative-actions.  We must thus strive to become proactive, not merely reactive.

5. Today, together with the victims of health and nutrition rights violations, the inescapable challenge before us is to redefine the strategies we use in order to combat preventable ill-health, preventable malnutrition and preventable premature deaths. This invariably entails (simultaneously at the global, national and local levels) addressing and combating the social, economic and political determinants of the violations of the UN-sanctioned Right to Health and Right to Nutrition.  Only thus will we be able to overcome the present crisis in overall development thinking and praxis we now are stuck-in in these two domains.  (R. Boyte)

6. As an avant-garde, we not only need to reflect on new institutional ways of supporting grassroots HR initiatives, but we also need to become more proactive in organizing them, as well as helping generate new forms of HR knowledge and of practices-of-direct-democracy in local government. In the process, we also need to reassess the pertinence and the role of foreign aid and of private (non-official) international development cooperation in the fields of health and nutrition. This, to either reject both or to help redefine them so that they, once and for all, fit the demands of local communities.  (S. Padron)  If the latter cannot be done, yes indeed, it is high time poor countries begin considering turning down foreign aid.

7. Still proactively, we first need to help create a shared critical awareness of the immorality of the prevailing social, economic and political system responsible for the violations of the Right to Health and the Right to Nutrition we are basically left to deal with as health and nutrition professionals. For this, among other, we need to bring people both in the rich and the poor countries to a point where they become more vocal in their demands to change the mechanisms that lead to the conditions perpetuating ill-health, malnutrition, poverty and injustice. And this can only be achieved by creating a growing discontent that leads to a ‘constructive anger’ and to commensurate actions that address such injustice. Action along these lines is desirable (preferably preemptive rather than reactive), and should even be made an inescapable outcome of effective health, nutrition and development learning. The HR activist/educator thus has a key role in our midst.

8. If we are to be consequent with effective people’s empowerment, we will have to foster an authentic people-centered development (in our case using health and nutrition as a port of entry to HR issues). For this we will have to further:

i) move away from coercive or top-down practices involving any kind of ‘acceptance-as-a-fait-accompli’ (e.g., in family planning?), and move into consensus-building practices involving legitimate beneficiaries’ approval; ergo, do things departing from the-way-people-see-them in their own environment;

ii) revolutionize people’s expectations helping them to move away from fatalistic outlooks;

iii) help define a new type of collective, community sense of responsibility that replaces the prevailing individual identity;

iv) help legitimize and enforce all UN-sanctioned people’s rights;

v) increase the negotiation and bargaining capacity –or at least the defense capacity– of claim holders;

vi) as needed, aim at overcoming constraining local political structures (formal and informal);

vii) concentrate on changing the local inter-generational dynamics when required, and very specially concentrate on changing the role of women (our main contact in health and nutrition work) in overall development work;

viii) work with people towards the goal of ultimately controlling their own community resources, fighting for the resources they need from outside, and taking initiatives to shape their own future through a strengthened, militant organization;

ix) make sure people get access to relevant information, especially the type of information that will help them hold their government officials accountable; *

x) help redefine the roles and methods of so-called ‘participation’ shifting them towards methods of ‘empowerment’ –in our case in health and nutrition;

xi) constantly re-gather groups becoming marginalized, trying to make sure their special interests are accommodated in the general strategy;

xii) secure concrete short and long-term positive results for claim holders (with an initial emphasis on short-term results to foster self-confidence);

xiii) together with claim holders, monitor and evaluate said results, especially with regards to the degree of  popular empowerment being achieved, as well as probing the equality of the benefits accrued; and

xiv) promote self-education with the aim of achieving faster results.

*: Information given to people for use through the fashionable ‘social marketing’ approach is definitely not the type of information conducive to any meaningful participation; social marketing simply does not bring about the needed sustainable structural changes –at best, it allows people to tolerate and cope-with an unjust situation. Social marketing tells people what to do, but not what for  and why…

9. Only through the constant practice of such people-centered development activities –often through trial-and-error– will we overcome the limits of existing flawed development models and theories. (L. Padron)

10. In short, starting with/from our work in health and nutrition, we should all contribute, to the best of our abilities, to generate popular alternative development strategies with the corresponding set of tactics to implement them.  But to make a difference, remember that standing alone changes little; so: Network with other like-minded activists in the HR field!

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

Remembering MLK

In times when militarization is on the rise as income inequalities increase and Americans lose jobs, homes, and access to medical care, even as Wall Street bonuses reach record highs,  it seems fitting to remember the speech that Martin Luther King gave at the Riverside Church in New York on 4 April 1967.

May we all find the courage to not be silent when silence is betrayal, and the inspiration to strive for a future of love, social justice, and respect for human rights.

POVERTY AND HUMAN RIGHTS.

“I have often been asked what is the most serious form of human rights violation in the world today, and my reply is consistent: extreme poverty. “

Continue reading ‘POVERTY AND HUMAN RIGHTS.’

Some reflections on the human rights of women.

Allow me to present these reflections in the form of bullets:

• A truly women-centered approach to human rights (HR) has to depart from the principle that there are an array of ‘securities’ that are indispensable for the well-being of women.
• Providing such securities has remained unresolved.
• Poor women are simply still left-out from the access to the services that can fulfill their rights.
• No matter where, women need assured security in, at least, the areas of:
  • income,
  • access to food fuel and water,
  • education/literacy/vocational training,
  • the support they get to take care of their children and their own gender-related needs,
  • their health, housing, and sanitation needs, plus
  • HR-based legal protection, environmental and personal safety including freedom from domestic violence.
• A women-centered approach to women’s rights calls upon us to focus our work more on the underlying and structural/basic causes of neglect, abuse, ill-health, malnutrition and unnecessary preventable mortality of women and their children.
• It explicitly emphasizes the need for a new set of priorities not given enough attention in current development programs. 
• To pursue this approach, we need to start with a) an explicit activity that identifies households (HHs) with women living insecure lives with many of their rights in any of the above areas being violated; to b) then, turn to demanding a more comprehensive set of interventions that simultaneously and progressively (without discrimination!) addresses the violations identified.
• The identification of HHs with vulnerable women should be accompanied by c) the identification of proven coping mechanisms utilized by other HHs and women in getting access to the different resources and services that fulfill their rights under similar difficult local conditions.
• The challenge, then, is to d) foster the needed consciousness raising for women for them to effectively place claims in front of pertinent duty bearers, as well as to e) find interventions that support the adoption of the successful coping mechanisms by a larger proportion of at-risk women in that particular environment. This becomes the basis for selecting interventions and, most importantly, for organizing women locally.
• All this requires a bigger emphasis on social mobilization programs and on coordinating locally active agencies particularly local NGOs and grassroots civil society organizations.
• If such women’s groups do not yet exist, preliminary efforts will have to be made to organize them.
• What this will also mean is that health, nutrition, water, basic education, etc. approaches impinging on women will need de-facto integration in concrete gender-specific action plans.
• Findings of the HH survey are to be discussed in community participatory fora, and if such fora do not yet exist locally, efforts will have to be made to organize them.
• When the several rights violations are identified, plans to tackle them are discussed –at the same time.*

*: This, because we consistently fail to ask ourselves “how effective is it to continue trying to tackle one HR violation at a time..?”  For instance, we now know that health or nutrition interventions alone cannot resolve the lack of access of women to get tangible results in relation to other rights that are as crucial for their wellbeing!

• Interventions selected for action will not necessarily be new, but will be combined and focused in a way that different relevant causal levels are tackled. (The more basic/structural causes are addressed, the more one will be, in one stroke, addressing several HR violations…).
• Some interventions will only need inputs (resources) and organization (mobilization) of community members and existing women’s organizations themselves; others will require organizing public pressure to get resources from outside to achieve needed results; it is this that leads to real, lasting empowerment.
• In conclusion, if towards 2015, we are to more significantly improve survival, health and nutrition outcomes of women and their children worldwide, we have to address a number of their more crucial unfulfilled rights at the same time.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

Focusing on equality of results (beyond equality of access) is the needed step towards social justice and thus towards human rights.

Communities –and not academics setting cut-off points– are the best qualified to identify the poor among themselves thus judging relative poverty.

 1. In our work in health, we see equality and social justice as one and the same thing. The point reiterated here is that we can no longer ignore our obligation to search for greater equality of results in health. As a matter of fact, there is a disturbing absence of a serious struggle for greater equality of results in all development-related professions… and that is not a historical accident.

 2. The current dearth of epidemiological data on rich-poor health differentials in both rich and poor countries is actually not a surprise or a coincidence either: it has been a quite deliberate omission. In addition to generating more data broken down by income quintile, by gender, by ethnic group, by migration status…, we need to commit ourselves, with no further delay, to do something with the data so disaggregated in a drive to correct existing inequalities –and then to use the data to track improvements (or not) in results related to human rights (HR) conditions.

 3. For a while now, there has been a renewed interest in disparity reduction and equality issues among our peers, but the same is still mostly top-down; it  seldom incorporates the contributions of those-that-happen-to-be-poor themselves. One can see a set-up for yet another failure here… 

 4. In the case of health, we thus need to make primary health care (PHC) what it should have been from the outset –a public sector-driven vehicle very centrally fostering equality of access and of results in health. (Privatization will never lead us to such a path!). Following the above argument, all will depend on how decisively and quick a shift to greater control by ‘beneficiaries-made-active-claim-holders’ occurs.

 5. Many currently proposed approaches to resolve health problems –including those of the World Bank and other donors– focus on ‘targeting’ health interventions to the poor (part of the so-called ‘pro-poor interventions’). From the HR perspective, it is a total fallacy to propose targeting as an alternative to comprehensive PHC, as the latter was originally conceived in Alma Ata. Individual targeting is equivalent to the discredited ‘Selective PHC’ approach of the 1980s, i.e., “Go for the worst cases, fix them, and improve the statistics”.*

*: From a HR perspective, the question we have to ask about targeting is: Where, through targeted interventions, are the needed sustainable, structural changes being made? (Those changes that will replace the system that reproduces poverty and ill-being generation-after-generation, i.e., changes that will avoid the recurrence of the same problems that make targeting purportedly necessary to begin with?).

 6. Let us be categorical: Targeting keeps a semblance of working towards equality. Targeting can and does stigmatize the poor creating second-class citizen that can be (and are) manipulated.**

**: We are reminded here that fee-for-service waiver schemes for the poor tried in many places have proven mostly catastrophic.

 7. Individual targeting is not a substitute for a more redistributive public policy! Geographic targeting has probably more potential (i.e., concentrating interventions in the poorest districts –but with both technical and structural interventions that address the social determinants of health). 

 8. Starting with targeting interventions as the central thrust to achieve equality of results goes against the grain of the HR-based approach. It pursues what is rather a ‘mirage of equality’. It tacitly blames the most vulnerable for being-where-they-are and tends them a rescuing hand (or throws them a charitable bread crumb…).  [Remember: In HR work, we move the focus from charity to dignity. (S. Koenig)].

 9. Targeting initiatives in health deserves to die a quiet (or not so quiet) death.

 10. The remedy?: Let inputs on alternative, truly equality-fostering schemes in health come from the more directly affected themselves; let them rise to the challenge. Devoting our energies to facilitate such a process will be a big leap forward for all.

 Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

Disparity reduction, national budgets and human rights.

The availability and allocation of budgetary resources says a lot about whether, how, and to what extent a government is committed and determined to implement its disparity reduction and thus its human rights-focused policies.
1. National budgets are a ‘black and white’ proof of whether governments are
putting-their-money-where-their-mouth-is. Through analyzing budgets, policies that promote equality between different income quintiles, between different ethnic groups, as well as between men and women can be identified. Therefore, for civil society to track the national budget is an essential tool in combating poverty, inequality and human rights (HR) violations.

2. There is a caveat though: Even if allocations are made in the national
budget, in many cases, allocated funds are not disbursed as planned for. Remember that national accounts are not audited immediately after the respective fiscal year ends. Therefore, ‘budget accountability’ has to be checked by HR activists throughout the year, because once accounts close the last day of each fiscal year nothing can be done anymore.

3. I am afraid effective disparity-reduction-policies –the way we want them to be singled-out and funded– are not and may-not-even-be reflected in budgets any time soon (and, by extension, governments are not likely to make much progress in reducing disparities…). That is a whole additional challenge: to exert the needed pressures for clearly singled-out poverty reduction measures to make it into the national budget to begin with.

4. That is why assuring a broad participation of the country’s representatives of the interests of people who happen to be poor and marginalized is so vital.

5. This marginalized group of society:

• must be present in the diagnosis and analysis of the country’s poverty and ill-being situation,
• must check whether assistance and services are delivered where most needed,
• must annually participate in the national budget preparation process to check for any omissions or misallocations,
• must, throughout the year, be vigilant of misappropriations or the blocking of financial resources (making sure funds do arrive at the places where they are supposed to be available for spending),
• must participate in the monitoring of program outcomes as budgeted, and
• must be vocal about all of the above and make ‘noise’ if they are of the opinion corrective actions are needed.

6. This Reader thus intends to, just briefly, remind you that national budgets (including foreign aid allocations that pass through the budget) are indeed a powerful, underutilized, instrument to keep authorities HR-accountable!

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

IT IS NOT INEQUALITIES THAT KILL PEOPLE; IT IS THOSE WHO ARE RESPONSIBLE FOR THESE INEQUALITIES THAT KILL PEOPLE. (V. Navarro)

People that happen to be poor need jobs and a livelihood;to agonize about inequality is, for them, a luxury.
(M. Klein, World Bank)

1. Both Structural Adjustment and the forces behind Globalization have fostered a polarization in a direction opposite to greater equality in health and thus opposite to the human right to health (RTH).

2. Levels of income are lower today in more than 70 poor countries than in the 1960s. The chronic stress arising from the resulting social exclusion is as damaging to health as are meager income and poor access to services. Today, around 1.3 billion people still survive on less than $1 a day. Inequalities in health manifest themselves primarily in decreased access and utilization of services by people who happen to be poor. In this respect, 1.6 billion people are worse off today than they were 30 years ago. But these indicators only tell part of the story of inequality; we do not routinely measure other.*

** Here is another piece of information you may use: The richest 1% of the world’s adults, 60 million people, with assets at least half a million dollars, own 40% of the global assets/wealth.

3. Our inaction on equality and RTH issues is explained by pure procrastination; we simply cannot ignore the underlying power-play-of-politics behind inequality since this would denote ‘evidential nihilism’ (M. Petticrew); we simply have to deal with the underlying power issue.**

** We note here something that has become one more of those iron laws, namely that maintaining things the-way-they-are requires no good reasons but, when presenting a better idea, efforts to shut it down brings-on tons of ‘reasons’. (A. Caliari)

4. Globalization does not have a human face; power differentials are at its crux. It is a process we cannot wish away. Markets reward those with purchasing power or commodities or services to sell; people and nations that happen to be poor have neither.

5. At a time of shrinking government expenditures in health in those countries, the World Bank has them pushing for a greater role of market forces in the production and distribution of health: the solution is to commercialize, commoditize and privatize health. Market forces alone (with people paying for their own care) have failed to deliver minimum acceptable health care anywhere. Because people are already paying for care, the WB assumes people are willing to pay. But willingness does not mean ability!

6. In the fee-for-service system, equality is clearly being sacrificed in the name of a not-yet-proven-greater-efficiency. Providing health care on the basis of need is being replaced by a system based on a never-really-achieved cost recovery where exemptions targeted at poor people have not worked. Safety nets are nothing but a way to manage poverty and ‘ill-being’ (as opposed to wellbeing) by attenuating social unrest.

7. Therefore, health policy makers can no longer make decisions that conflict with the equality goal. The choice is a moral one and cannot be made by the medical establishment only. The politics of health will override all other efforts to bring us Health for All and respect for the RTH. (Keep in mind that equality is the forgotten central thrust of Alma Ata).

8. We need to develop a framework for action; the costs of inaction are enormous. We also need to demystify medical knowledge –for people themselves to deal with health and disease.

9. It is in the interest of the RTH to counter the forces of Globalization rather than looking for an accommodation to-fit-greater-health into an inherently-inequitable-system. This means that a renewed commitment and resolve to foster empowering community-based activities will have to guide our actions. What will count are not our words, but our deeds. Growth and equality need not be trade-offs, but progress does not come simply from liberalizing the economics of health. The current brand of liberalization is morally unacceptable and economically inefficient. We need to adopt new approaches that can break the current unequal state of affairs. Claim holders have to stop thinking that combating inequality is a luxury.

10. Perhaps the most pressing issue for claim holders to work towards the RTH is for them to demand a universal coverage public health system in which those who pay for it are those that have more, i.e., a progressive (as opposed to a regressive) tax-based system.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

The dilemma in human rights work: when are service delivery, capacity building, advocacy and social mobilization really empowering?