Today we came together on this first day of the IPHU from all over our small planet:  Ghana, Guinea, Haiti, Kenya, Lebanon, Puerto Rico, Russia, Rwanda, Thailand and the United States.  The day begins with introductions that are more than asking this group of inspiring and eloquent agitators the bland recitation of names, organizations and what are you interested in; we are asked to speak of ourselves through our personal and social mandates, or, what is the change you wish to see in the world and how do you see it?  As  brothers and sisters, we respond with a passion born of being fed up with a global system that perpetuates inequality and injustice at the cost of the health of our communities, and speak of our hopes and common threads of the need for advocacy, speaking truth to power, and alternative models and ways of thinking about health and health care that is people centered, not profit focused:  “Health for all Now,” “Love Solidarity,” “Access,” “Health Activism,” “Meaningful Participation,” “Progressive Work,” “Mental Health,” “Englightening,” “Bright Future,” “Visual Healing,” “Cultivate Love,” “Health Education,” “Awakening,” “Education Action.”

Next, David Legge gives a comprehensive overview and history of the People’s Health Movement, International People’s Health University (IPHU) and the People’s Health Charter (PHC).  We go over this radical document, a unifying, organizing vision that views health as a right for ALL.  This profoundly simple understanding is so fundamental, that some of us in our small group discussions ask, “Why Not?” Not “Why Not” as this is a good idea, but “Why Not” as in why is this socially, economically and just idea not implemented and what do we as advocates and activists need to do to push this forward, use this in our work, and what do we need to include (LGBT rights, more emphasis on gender inequality, and a suggestion to create a handbook on how to use the PHC)?

Laura Turiano follows with a presentation on using a Human Rights based approach to advocate Health for All Now.    Next follows participants’ big task:  group work on our projects that advance the idea of Health for All in our communities.  Our task at hand:  present our projects with our compadres in small groups where, over the course of the week, we will support each other to: analyze, re-think, re-fine, conceptualize, strategize, and put into action our vision of the world and communities in which we wish to live.

The “formal day’s agenda” concludes with a brief introduction of the Theatre of the Oppressed by John Sullivan.   Free form movement and human sculptures is what we are and mold ourselves into as we attempt to convey the fundamental values and concepts of the days proceedings:  Hope, Inspiration, Thinking, Motivated…all conveyed through our bodies, expressions, and movements.  The consensus over dinner discussions and late night debates, rabble rousing, getting to know you sessions, is:  this is going to be a great, learning filled, intense, memorable week.

The first People’s Health Movement USA National Meeting will be held July 28-29, 2011, at Loyola Marymount University, Los Angeles CA, in conjunction with the annual assembly of Doctors for Global Health. We invite those who endorse the People’s Charter for Health to participate in identifying our medium-term goals and developing a plan to reach them. This is an opportunity for you to get more involved with the international movement that has set the people’s agenda for global health for the last 12 years.

The People’s Health Movement is a global network of people’s organizations, civil society organizations, NGOs, social activists, health professionals, academics and researchers who believe we can provide health for all by tackling the social and economic underpinnings of health status, and providing community based comprehensive primary health care. PHM in the United States has been working in solidarity with health activists around the world, and promoting solutions emerging internationally as a result of local research and action for health.

We have many challenges both domestically and internationally. At this first national meeting we need your input to make decisions about where to focus our energy and how to take advantage of upcoming opportunities. One of those is the 3rd People’s Health Assembly in Cape Town, South Africa next July. If you have thought about attending the PHA3, you should participate in this meeting.

Soon we will send out a pre-meeting survey to hear from as many people as possible as we develop the agenda.

To register for the meeting, go to
http://www.dghonline.org/2011-ga-registration-application

For more information, email phm@hesperian.org.

If you would like to participate but are unable to travel to LA, we will be setting up some kind of virtual participation connection for part of the meeting. Please email phm@hesperian.org if you would like to participate virtually.

Discussion, learning, and action across organizations, disciplines, race and class is needed to build the movement to demand for health for all in the US and globally. We will lay a foundation July 28-29 in Los Angeles.

In Solidarity,

People’s Health Movement–USA National Meeting Organizing Committee

Sri Shamasunder
Sarah Shannon
Laura Turiano
Jyoti Puvvula
Linda Sharp
Lily Walkover
Evan Lyon

Posted by Matt Anderson

The theme of the Assembly is Community Action for Health and Social Justice: Health Begins Where We Work, Live, and Play.  Here is a synopsis of the Program:

Keynote Speakers: America Bracho and Theresa & Blase Bonpane

Dr. America Bracho is the Executive Director of Latino Health Access a community health center in Orange County, California.  She was the subject of a 2009 profile by Bill Moyers which discusses her work as a community organizer.

Theresa and Blase Bonpane are founders of Office of The Americas, an educational group dedicated to furthering the cause of justice and peace in the hemisphere.  The Office sponsor a weekly radio program on KPFK (Los Angeles) called World Focus.

Panel discussions:

Health and Human Rights of Migrant Communities

• Steven Wallace, PhD- UCLA Center for Health Policy Research
• Kyrsten Sinema- Arizona State House of Representatives
• DREAM Act students
• Irma Cruz Nava, MD- CEPAFOS, Oaxaca, Mexico
• Samaritans Patrol of Arizona

The Right to Food and Food Justice:

• Anuradha Mittal- Executive Director of the Oakland Institute
• Anje Van Berckelaer, MD- Robert Wood Johnson Clinical Scholar
• (others TBA)

Other activities:

• Tour of Father Greg Boyle’s Homeboy Industries and Skid Row
• Physicians for Social Responsibility discussion on nuclear technology
• Update on People’s Health Movement-USA
• Lively conversations, networking, socializing, and music
• Updates from DGH partner communities in Mexico, El Salvador, Peru, Guatemala, Sierra Leone, Uganda, and Burundi.

EARLY BIRD REGISTRATION PRIOR TO JUNE 1ST. SCHOLARSHIPS AVAILABLE FOR STUDENTS AND ANYONE WITH NEED!

Please register now at www.dghonline.org

posted by Matt Anderson

Dr. Binayak Sen

On 24 December 2010 the court of Raipur, state capital of Chhattisgarh, India, rewarded the health and social justice life of pediatrician Dr. Binayak Sen not with honors, medals or an honorary degree, but with a sentence to life in prison.

The message from the Government of India: if you work as an advocate with the poor, you are against the government and will be punished severely. It is a message to any who would work toward a more just world, in accompaniment of the marginalized, stigmatized and poor.

Dr. Binayak Sen, who is vice-president of the Indian Human Rights organization PUCL (People’s Union for Civil Liberties) and is the recipient of the 2008 Jonathan Mann Global Health and Human Rights Award, was accused of transporting letters for a jailed Maoist leader who was under his medical care. Though the prosecution showed nothing but circumstantial evidence (better said, no evidence at all—all visits of Dr. Sen with the prisoner were attended by prison guards, none of whom saw any letters, and two of whom were declared “hostile” by the court when they testified that it would have been impossible for such an exchange of letters to happen), the judge ruled—using as the Lancet editorial (see below) notes “a section of the penal code first introduced by the British to quell political dissent and later used to convict Mahatma Gandhi”—that Dr. Binayak Sen is guilty of “sedition.”

Outrage at such treatment of a man many consider mentor, hero and teacher resounds globally in journals such as the Lancet (Lancet 377:98 on 8 January 2011, “Binayak Sen’s Conviction: A Mockery of Justice”) and British Medical Journal (BMJ 2010; 341:c7438 “Civil rights groups decry conviction of Indian paediatrician who pioneered community health”) and within the press in India.

See: Facts about the Dr Binayak Sen case – The Times of India http://timesofindia.indiatimes.co. m/india/Facts-about-the-Dr-Binayak-Sen-case/articleshow/7125220.cms#ixzz1AbSIjDmn

Physicians for Human Rights (PHR) has called for Dr. Binayak Sen’s release.          http://physiciansforhumanrights.org/library/news-2008-05-20.html

Dr. Binayak Sen has worked for many decades with the poorest of the poor. He is well known as an advocate for health and social justice, an outspoken critic of police brutality. Apparently, his effectiveness is such that the Indian Government feels the need to silence him.

Go to http://www.binayaksen.net/ to learn more about the intricacies of the case and the condemnation of the court ruling, including a recent article concerning Nobel Laureate Amartaya Sen in the Times of India, in which he is quoted as saying: as an Indian citizen and a human being, I must exercise my own judgment to ask if this is correct. Sedition means pulling the state down by violence. It cannot be suggested that Binayak did this. On the contrary, his writing indicates violence is wrong. There is a deep moral argument against sedition here [in Binayak Sen’s book]. Amartaya Sen goes on to say of the ruling against Binayak Sen: It has a threatening nature and seems to have political motivation. Any intelligent person would find that the judiciary acted very peculiarly. I hope the high court or Supreme Court quashes this.

Dr. Binayak Sen is a member of Jan Swasthya Abhiyan, the PHM (People’s Health Movement) India. He has touched the lives of many—and this is perhaps considered his greatest crime, the crime of being a positive example.

Dr. Binayak Sen was first arrested in 2007. Though he has severe cardiac disease, he was kept without adequate treatment for two years—until an international campaign, including several Nobel laureates, achieved his provisional release on bail.

When a government punishes work dedicated toward health and social justice, it is making a statement that is global in nature. Its action must then be denounced globally. Please consider acting now in solidarity with Dr. Binayak Sen. Address the government of India with its own shame, by signing the petition directed to The President of India, Rashtrapati Bhavan: http://www.petitiononline.com/sen2010/petition.html

Consider expressing in print your disappointment that this sentence, egregious and wrong, has happened. Inquire into the health, not just of Dr. Binayak Sen, but of the patients who he has not been and will not be able to attend to because of his sentence. Demand that, in the name of justice, as well as health, the sentence be refuted (still legally possible by the Supreme Court of India) and his work instead granted the affirmation it deserves.

Please share what is happening to Dr. Binayak Sen with colleagues, local community members and your own government representatives, no matter where you live. Consider writing to him yourself, to express your solidarity and your appreciation of his example.

Participants in the Liberation Medicine Course. Dr. Narayan in black Tshirt.

Dr. Narayan began by noting that this was his second trip to the Bronx. He had spoken to students at Albert Einstein College of Medicine in 2003 when he and his wife, Thelma, had presented at the GHEC conference in New York. He was here now as adviser to the Obama Administration’s Inter-Faith Initiative and also to consult with PAHO about community health. He seemed a bit bemused by the fact he had been invited to work on faith-based topics, but learned he had been chosen because of his work (see below) in getting several religious groups in India to work together.

Dr. Narayan told us he represents a collective of people still enthusiastic about the goal of Health for All.

Medical Training and Work in Refugee Camps

Dr. Narayan is a physician and graduated from medical school in Bangalore in 1971. After graduation and “quite by accident” he went to work in refugee camps along the border with Eastern Pakistan (now Bangladesh). As background, he told us that there were nine million refugees who walked across border into India because of a rampage by the Pakistani Army. Their sole crime was to participate in a democratic election. In this election the East Pakistanis (the majority in Pakistan) had voted for their own leader; in principle he was to become the Prime Minister. The West Pakistanis objected and sent the army to East Pakistan. The refugees walked across the border into western India where the government set up some thousand camps. A liberation struggle developed in East Pakistan which would eventually become the independent state of Bangladesh.  Seven to eight months after this exodus, the refugees returned home.

The experience of working in the camps caused a paradigm shift in his thinking. Were it not for this paradigm shift, he might have ended up on the east coast of the US, the goal of many well-educated Indian physicians. In fact, he noted with a wry smile, during this trip to the US he had been meeting with many of his old medical school classmates. Instead of coming to the US, however, he had been transformed by the “very human experience” of being a doctor working with a community. He had learned to listen, to see patients as participants in their own lives, to consider mental health, and to look at the social context of health. He had been exposed to a series of experiences – genocide, rape – which had been absent from the medical school curriculum. He was challenged to look at social, political, economic determinants that he learned very little about in medical school.

After working in the camps, he returned to the medical college and specialized in public health and preventive medicine. These were, he noted, the only specialties that would allow him to continue to work with people in the community as opposed to working in the hospital or outpatient clinic. He would later get a public health degree from the London School of Tropical Medicine and Hygiene and do further studies at the All-India Medical School (“India’s Johns Hopkins”).

Teaching Community Medicine

For 10 years he had taught in the St. John’s Medical School Department of Community Medicine trying to replicate for students his experience in the community of the camps. He found lots of support from young doctors who had been involved in natural disasters and been transformed by “the moving experience” of working with a community. His wife, Thelma, had this type of experience when she worked doing disaster relief. While he  described teaching this course as “10 years of great fun”, there were problems. The Department worked in five clusters of villages and they kept coming across problems, such as caste and gender, which were not medical. It was frustrating for the faculty not to be able to offer students “solutions” to these problems. Dr. Narayan cited a specific example. They used growth charts (called the “Road to Health”) to detect malnutrition in children. Over time it became clear that the children of dalits, the lowest case group, always had third degree malnutrition. “No matter what you did” it proved impossible to improve their nutritional status. The biomedical tools just did not work. They tried community-based interventions; he had attempted to organize unions. But this was a dangerous activity and he had been accused of being a Marxist. At the time, he said, he didn’t know what this meant, but he had read up on Marxism subsequently.

The faculty was frustrated and disturbed by the failure of biomedical solutions. They realized over time that medical schools always limited in their analysis to the biomedical part of problem and this led, inevitably, to a technical solution (usually a drug or vaccine).  Even when a social determinant was apparent, physicians kept it out of their thinking. After all, dealing with determinants was not taught in medical schools. They were also concerned that although they started each course with a definition of health, in the end the curriculum was entirely about ill-being. Finally, they were bothered by medicine’s orientation towards individual problems with no appreciation of collective responses.

Foundation of SOCHARA

In 1984 Dr. Narayan and three other members of the department left the medical school (“this symbolized our walking out of the biomedical model”) and established the Community Health Cell, SOCHARA. Other faculty would join them later. Rather than dealing with health problems, they wanted to work with people interested in wellbeing. They did not want to work with dispensaries, hospitals or drugs.  Rather, the wanted to work on health, wellbeing, and social determinants; they are not so concerned with medical problems.

Their focus shifted from doctors and nurses and they began to work with farmers, teachers, women, and street children. By 1990 SOCHARA was busy. It had grown by word of mouth and they were very happy doing this sort of work. They purposely avoided an academic institutional affiliation and they did not start any programs of their own. Rather they helped people to form their own networks.

But by 1990 they became increasingly aware of how decisions made in Delhi and elsewhere (he mentioned Washington) were affecting them. Malnutrition in Bangalore began to increase because millet was no long available cheaply on the local market; it was being exported. Development did not seem relevant to the people in the area, rather it benefitted other people who lived someplace else. The example of millet export showed how agricultural policy was relevant to malnutrition. They set out to study economics and social conditions.  SOCHARA by this time had an extensive network of alumni and contacts, so when they came across something they did not understand, they found a colleague who was an expert. Sometimes what they learned made sense and sometimes it didn’t. They often felt that the social sciences helped to understand what was going on, but didn’t provide tools to make things better.

In 1992 India accepted a World Bank’s Structural Adjustment Program and made significant cuts in social benefits. The result was to further polarize society. Bangalore, Dr. Narayan’s home, was now the most globalized city in the world. The expression “to be Bangalored” meant to have your job moved to India. Around his family home you could find all major multinationals within walking distance. But whereas 400 million Indians were now living in the globalized world (“I can eat McDonald’s or Kentucky Friend Chicken and wear Nike shoes”), 800 million Indians “don’t even get the basics.” There are two Indias now.

People’s Health Movement in India

By 1999 SOCHARA had come to feel the need for a countervailing power which could speak truth to power from the bottom up. This was the impetus for the formation of the People’s Health Movement in India. During its history SOCHARA had worked with 18 large networks and in 2000 they called them together in a meeting in Hydrabad. It was a diverse group which included Marxists, Gandhians, and Christians. Five representatives of each network assembled on April 7th 2000, divided themselves into working groups, and produced “five little books.” These book examined what globalization had done to health, to primary health care, and to basic needs. The content of the books was then converted into popular formats (cartoons, songs) and used to mobilize some 300 communities. In December 2000, some 2500 people packed into four trains and came to Calcutta for first national People’s Health Assembly; this launched the national PHM of India.

As an interesting side note, Dr. Narayan briefly discussed the armed resistance to British colonial rule. He noted that although we, as Americans, would be surely surprised to hear this, it was not Gandhi who had forced the English out. Rather the English left because large sections of the army had deserted (to join the armed resistance) and the country had become ungovernable. “As a result, we went from one group of Brahmins [i.e. the British], to another and the revolution was incomplete.” He sees this failure as the reason that 1/3 of India is currently under a Maoist insurgency and they (like many other progressives) are often accused of being Maoists.

Formation of an international People’s Health Movement

“Of course, internationally we were not alone.” Similar initiatives had been going on in a number of countries and in December 2000 a meeting was held in Savar, Bangladesh which founded the international PHM.  The resultant People’s Health Charter went beyond Alma Ata. He is in love with the charter: “2 pages of problems and 6 pages on how to fix it.”

Speaking of PHM, Dr. Narayan noted: “It’s a movement, you can’t pay to join it.” The work of the People’s Health Movement has evolved into four main activities: 1) the development of country circles which range from a few people who communicate by list serves to large national organizations with state and district level committees (India), 2) the publication of  Global Health Watch every five years, 3) holding of International Peoples Health Universities, 7-10 day training programs for activists from around the world, and 4) the organization of  the international  People’s Health Assembly every five years.

After 10 years of existence, he felt that PHM is now getting to be well known. Many articles have been published about PHM or by PHM members. Discussion of PHM now appears in textbooks of global health. PHM has been described as the “globalization of health solidarity from below” a description he feels is apt. He now devotes his energies to talking to students in public health and challenges them that: “If your professors aren’t teaching you about PHM, perhaps they are dinosaurs.”

Questions from the Students

“You make it sound easy, but surely there were difficulties.” Dr. Narayan noted that he had offered us just a ‘short story’ about their work, and that yes, it was a challenge and a struggle. They had been victims of political persecution. But he also noted that one of the largest challenges was to change what is inside of ourselves. They have a fellowship program (Community Health Learning Program) which is a six week experience of the movement. Two weeks are spent at SOCHARA and there are two additional two week placements elsewhere. This fellowship allows people to become familiar with their work. Their principles for selecting people are two. They only take people who are confused; “if you’re not confused, you don’t need us to teach you.” They also feel that you can’t be part of the solution unless you realize you are part of the problem. Fellows, for example, need to unlearn professional biases. “You need to see every person as a participant.” But he also stressed the importance of professionals sharing their knowledge (to demystify things) as well as accepting that other people had expertise that they did not. There needs to “eyeball to eyeball” communication, i.e. communication between equals.

“How did SOCARA succeed in getting diverse groups to work together?” Dr. Narayan addressed this question by pointing to some of the traps into which organizations fall. The first was elite capture which occurs when an elite group (perhaps the academics) takes over an organization and other groups are marginalized. There was ideological capture in which different groups competed to see who was the most left.  He feels it is important to ask: “Is this policy pro-people or pro-market?” Finally, there was individual capture in which a charismatic person takes over the organization.

“How did you get paid when you worked at SOCHARA?” First, they had to accept that they wouldn’t earn as much they would in other areas. Second, they don’t require people to be full time; there are many degrees of participation in SOCHARA. Salaried staff were actually quite few. When he was the PHM global coordinator, the movement only had four salaried people in the entire world.

Two other speakers followed Dr. Narayan. Samuel Mwenda Rukunga,  from PHM Kenya, discussed their work providing health care and advocacy in the context of religious health care institutions.  Manoj Kurian MD, Program Executive of  Health and Healing, World Council of Churchs discussed how religious faith informed his advocacy for health for all.

Interested readers may also want to look at our interview with Dr. Narayan published in 2005 in Social Medicine.

Posted by Matt Anderson

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.

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:

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:

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.

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?).

“The health-care reform process exposes how corporate influence renders the US government incapable of making policy on the basis of evidence and the public interest.”

The text of the letter can be read at this link.

American exceptionalism?

One of the many curious things about the current health care reform debate in Washington is the extent to which the US is considered to be  outside of the community of nations.  We are judged by our own standards and can learn only from our own experiences.  This phrase is neatly captured in the desire for a “uniquely American solution” to health care. (See our prior posting about “misleading messaging” and the failure of health care reform).

But what are we to say about a health care “solution” that will deny women abortions, deny care to undocumented workers and their families, not provide universal health care, and not recognize a right to health?  What are we to say about a health care system delivered up to the insurance companies and big Pharma?  Isn’t this really just a “uniquely corporate solution” to health care?

In the letter we suggest something different:

There is no excuse for the USA not to adopt a system like any of those in many other countries that cover everyone and control costs—systems that better integrate public health and individual medical care. Without such a system, comprehensive primary health care will not be implemented, nor will the social determinants of health be effectively addressed.

The belief in US exceptionalism must be laid to rest. People living in the USA are as entitled to the right to health as others, and the USA should be accountable to the same standards as any other country.

The People’s Health Movement (PHM) was established in December of 2000 in Bangalore to keep alive the goal of “Health Care for All.”  It is an organization of activists, academics, and grass roots organizations from around the world.  The website of the US circle of the PHM is at http://www.phm-usa.org/

posted by Matt Anderson, MD (a co-signator)

“Messaging” uses techniques from public relations and cognitive science that tap into people’s values and beliefs in order to create an emotional reaction that leads to opinion or behavior change. Sophisticated messaging relies upon in-depth research through surveys, focus groups and other methods to discover clusters of values and beliefs that groups of people share. Any individual tends to fall into one of these clusters. Communications can then be tailored to reach particular groups. There is no doubt that these techniques can be effective in changing minds because they are the same techniques that sell us new cars and shoes every year. They can be used to promote anything without regard for the truth or evidence. For people working for social justice this kind of strategy can never be effective.

One of the tenets of the messaging strategy is that most people don’t reach opinions based on evidence or facts. Herndon’s specific messaging strategies discourage any mention of facts. Since it is always easier to sow doubt than confidence about any change, messages with no connection to fact or reality give an advantage to the status quo. People’s beliefs are often not based upon learning but on misperceptions acquired through individual experience, the grapevine and the media. Catering to these beliefs and values means reinforcing them, even if they are untrue or against the general welfare.

Progressives are angry about the tales of “death panels” spread by the right wing. However, the messages Herndon promotes are also misleading. Not in the outrageous way that right wing messaging is, but untrue just the same. A current statement recommended by Herndon is, “Reform will give us the freedom of secure choices—to keep our plan and doctors, to choose another private plan, or the choice of a robust public health insurance option.” As it looks now, this statement is false. It is likely that only people without insurance from their employer will have the option of choosing the public plan – if there even is a public plan. If you get insurance through your employer, your employer chooses your plan options, and can switch them at any time.

Trudy Lieberman, in Columbia Journalism Review, noted another misleading Herndon frame.

(Herndon) advises: “Don’t just say ‘bring costs down,’ … It is better to say ‘health care reform will make health care AFFORDABLE—it will cost less and you will get more.” Hey guys, that’s not likely to happen if the current nostrums for reducing medical costs remain the only ones on the table. As for getting more? The current trend in health insurance—shifting costs from insurers and employers to policyholders—means thousands are getting fewer benefits, not more.

The Herndon messaging suggestions are worded this way because their goal is to get people to accept whatever ends up emerging from the legislative meat grinder as “health care reform”. Rather than messaging about specific demands, they use words with highly positive associations to state what health care WILL do: “You will have the choice of a QUALITY affordable public health insurance plan.” This phrase doesn’t explain what characteristics a QUALITY public plan should have so that people can demand those characteristics from the congress.

There is no guarantee that the health care system we get after the legislation passes will be anything like the Herndon Alliance says. Even if people agree with the messages, they also hear the claims made by Republicans. They (rightfully) don’t trust the congress to deliver what is best for ordinary people. The health care reform debate becomes a competition between which set of misrepresentations you want to believe in. And with a third of Americans illiterate or barely literate, and most getting their news from television, they don’t have any rational basis on which to decide.

Messaging works most effectively on an uninformed disempowered population and serves only to further disempower them. The Herndon Alliance disconnects people from real potential solutions to the US health crisis with messages like, ‘Health care reform will be a uniquely American solution.” This reinforces the already deeply ingrained and harmful belief in American exceptionalism, preventing people from learning from the experiences of other countries where there are better health systems.

Even health care reform activists seem to get confused by these messages. They begin to think of messaging recommendations as true statements about the actual legislation or as policy recommendations. Because of the language about “keeping your plan if you like it” some activists, are losing sight of the fact that what people really want is to be able to keep or choose their medical providers. Beyond that, “progressive” activists shouldn’t be promoting the idea of keeping your private insurance as characteristic of good reform when the private insurance system is the problem in the first place.

I am not arguing that opinion and values research isn’t useful to help activists understand what the general population or subgroups are thinking. But activists shouldn’t be so naïve as to accept the analysis and recommendations of one group without considering that group’s political goals. All opinion research is biased by the questions that are asked and the way they are asked. (I won’t critique Herndon’s research because it has been done elsewhere: HERE and HERE). Although it claims to be non-partisan, Herndon has very close ties to the Democratic Party. Democrats are the recipients of huge amount of money from the insurance, health care and pharmaceutical industries. Most analysts agree that failing to pass some kind of health care reform legislation will be a huge blow to the party. They have to pass something and Herndon has its own ideas about what it wants. What they specifically don’t want is national health insurance (single payer) and all of their messages are designed to keep people from considering that idea on its merits and convince activists that Americans don’t support it.

Like the founding and board organizations of Herndon Alliance, Families USA, Health Care for America Now (HCAN), AARP, and SEIU, most of the approximately 200 Herndon Alliance partners are groups that either have never supported a social insurance or single payer model, or are so convinced it is not politically feasible (some sincerely and some not) they will support almost any other reform when faced with a choice. Many have actively undermined campaigns for single payer that would have had a chance for success – if all “progressives” stuck together. The same scenario we are going through nationally has happened repeatedly on the state level with the same groups. Although their goal is “high-quality, affordable health care for all Americans,” the specific policies they push are those that increase access by increasing the flow of money from individuals and the government to the private insurance and pharmaceutical companies. Families USA, SEIU, and AARP are part of the PR front groups Healthy Economy Now and Americans for Stable Quality Care that also include Pharmaceutical Research and Manufacturers of America (PhRMA), the American Medical Association, the Business Roundtable, and the Federation of American Hospitals. These coalitions have presented millions of dollars of TV commercials promoting health care reform using the same warm and fuzzy misleading language as Herndon.

The climate for health reform this year is different for one reason: the rate of profit that insurance and pharmaceutical companies are making has reached its limit in the US. They need more customers to keep growing. The current health care reform increases profits by 1) requiring people to buy insurance products 2) providing government subsidies so they can actually afford the products. Even the so-called public option, since it is completely undefined (and has functioned as a marketing slogan, a bargaining chip, and a red herring for opposition), can easily be structured to channel public funds into private profits. For example, it could be modeled after some state employees’ health plans, where the government subsidizes private health plan coverage, while assuming the financial risks involved

The question remains why so many self-identified progressives are buying the Herndon Alliance strategy and message. Some just haven’t taken off the glasses and are themselves manipulated by Herndon rhetoric. Some are looking for a way to change opinion without doing the hard work of political education and consciousness raising. For the rest, Helen Redmond had a good explanation in Counterpunch.

For the Democrats, with the exception of John Conyers and a few others, they simply don’t want to abolish the private insurance industry. They are capitalists and believe in the capitalist system that makes health care a commodity to be bought and sold. For them, health care is not a human right. And importantly, they don’t want to take on President Obama who is opposed to single-payer. Like the  true cowards they are, they will not oppose Obama on health care reform even though they disagree with him.

HCAN thinks it’s impossible to get rid of the insurance companies, they’re too powerful, and they have too much money and influence. They don’t believe a large social movement can be built to take on and win against the insurers and the government. The leadership of HCAN are the ones who would have said under slavery, “We can’t win abolition, so let’s settle for a few reforms that make the lives of slaves more bearable.”

Public relations strategies are the antithesis of a human rights based or social justice approach. Social justice requires meaningful participation by people affected by a problem. Meaningful participation means that people must have the capacity to engage in advocacy for themselves. They need to participate in identifying the problem and its causes, and be supported with the tools and resources to understand it. Then they must be engaged in making demands on their representatives, government or other duty bearers. These citizens will be resistant to PR manipulation by any party. With our government seemingly incapable of making policy based upon evidence and the general, rather than corporate, welfare, there are no shortcuts to social justice.

PHM and IPHU are pleased to announce the upcoming IPHU courses in India (September 21-30, 2009), Morocco (September 21-30, 2009) and Cuba (November 4-14, 2009). For details and registration, go to http://phmovement.org/iphu/. US health activists are encouraged to attend.

The International People’s Health University (IPHU) is one of the major programs of the People’s Health Movement. IPHU is a global university providing short courses and other resources for health activists. Courses are of a high academic standard and are documented for academic credit from established universities. IPHU short courses enable younger health activists, in particular, to make new connections, share experiences and study together. IPHU short courses strengthen the global network of people’s health activists.

Morocco – http://phmovement.org/iphu/en/morocco, in French and Arabic, Fes, Morocco
India – http://phmovement.org/iphu/en/bangalore/announcement, in English, Bangalore. This course is focused on Health and Equity.
Cuba – http://www.phmovement.org/iphu/en/CubaAnnounce, in Spanish and English, Havana