Archive for the 'Social Determinants of Health' Category

SocMed Uganda – Health Worker Campaign

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We’ve just returned to Minneapolis after an invigorating month in Gulu, Uganda together with medical and nursing students from Uganda, Rwanda, Zimbabwe, Argentina, Lebanon, and the U.S. As part of our SocMed curriculum, we shared an intensive month together studying the social determinants of health and developing strategies to constructively address these factors. It was a transformational month for all of us.

In a remarkable and hopeful demonstration of the power of a committed group of passionate individuals to effect change in the world, our students rapidly (in 7 days) developed a campaign to address the current health worker shortage in Uganda called ‘Focus 15 For Health.” They wrote an open letter to President Museveni of Uganda, which will be delivered to his office this week by our Ugandan medical students and they put together a video to accompany their letter.

They have requested that we spread the word far and wide to highlight the issues they are addressing. Please see the Facebook link for more details (and “like” it if you feel inclined). You can also learn more by visiting:

Many thanks,
Mike Westerhaus and Amy Finnegan
Co-Directors, SocMed

SocMed Uganda 2015 Course Announcement – Reminder

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Greetings all,

A reminder that our application deadline is quickly approaching at the end of June.  We welcome applications from all interested health professional students.


Michael Westerhaus


On behalf of SocMed, we are please to invite health professional students to apply for the fifth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience offered on-site at Lacor Hospital in Gulu, Uganda from January 5th – 30th, 2015.  Beyond the Biologic Basis of Disease merges unique pedagogical approaches including community engagement; classroom-based presentations and discussions; group reflection; theater, film, and other art forms; patient clerking and

SocMed Uganda 2015 Poster

presentations; and bedside teaching.  These approaches create an innovative and interactive learning environment in which students participate as both learners and teachers to advance the entire class’ understanding of the interactions between the biology of disease and the myriad social, cultural, economic, political, and historical factorsthat influence illness presentation and social experience of disease.

The course curriculum places considerable importance on building partnerships and encouraging students to

reflect upon their personal experiences with power, privilege, race, class, and gender as central to effective partnership building in global health.  In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty andstudent colleagues.

In our annual Uganda course, thirty health professional students enroll each year, with half of the spaces filled by students from Ugandan medical and nursing schools, and the other half filled by international students from anywhere outside Uganda.  Credit for away-rotations can be arranged.

This course is offered through SocMed, a non-profit organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

More Information and Application Process

Further information and applications can be found in the Social Medicine Course Prospectus 2015 and on the SocMed website:   Please view short videos describing the course, publications related to the course, and advocacy videos created by previous students during the course by visiting the “Resources” tab on the website.

Applications are due June 30, 2014 and can be downloaded from the website.  If you have questions, contact us at

Please do not hesitate to contact us with any questions you have.


Amy Finnegan, Ph.D.

Phyllis Kisa, MB.Ch.B, FCS ECSA

Michael Westerhaus, MD, MA

SocMed Co-Directors

Pegasus Conference: Peace, Global Health and Sustainability (Toronto, May 2-4, 2014)

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A colleague, Neal Arya a family physician at McMaster University, shared with us information about a conference on Peace, Global Health and Sustainability to be held in Toronto from May 2 to May 4, 2014. The conference seeks to bring together individuals from multiple disciplines to address the problem of poor health in the world.

The conference is being organized by Canadian Physicians for Research and Education in Peace (C-PREP), an organization created in 2012.  It is associated with Physicians for Global Survival (PGS), the Canadian wing of the 1985 Nobel Peace Prize winning International Physicians for the Prevention of Nuclear War (IPPNW).

Global health is one of three core themes addressed by the organizers of the conference; the others are Peace, Global Health and Sustainabilty (hence Pegasus).  A previous conference – Transcending Borders – was held in 2012.

The conference program is available at this link:

Posted by Matt Anderson





Can we eliminate health disparities without addressing wealth disparities?

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Our colleague, Claudio Schuftan passed along a link to the video below regarding wealth inequality in the US, a topic that has been re-introduced into the national debate by the Occupy Movement.

The issue of wealth inequality has enormous implications for health disparities.  Johann Peter Frank’s classic paper , The People’s Misery: Mother of Diseases, (now available online) shows that physicians even in 1790 understood the connections between poverty and ill-health. Indeed, the statistical evidence linking poverty and disease (or health and wealth) was so strong that William Farr, considered by some as the father of medical statistics, remarked in 1839 that “diseases are the iron index of misery.

The data on wealth disparities presented in this video poses a question:  is it is possible to meaningfully address health disparities in the US without addressing these massive transfer of wealth from the rich to the poor that has taken place since the Reagan Revolution in the 1980’s? If we attend to the bulk of the evidence, the answer is probably no. But this leaves us with the question, how do we reduce wealth disparities when the Congress has become a club of millionaires?

Any thoughts?

Key questions to guide the UN Post-2015 High Level Panel’s work and consultations on the future development agenda.

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Suggested responses by Claudio Schuftan in a personal capacity.


I. Qs on lessons learned and context:

1. What have the MDGs achieved? What lessons can be learned about designing goals to have maximum impact?

The mix of MDGs achievements/shortcomings is by now well known. The question here is: Do we really want to set goals –in terms of outcomes? Or do we rather want to set (annual) benchmarks –much more related to processes (a central critique of the MDGs). Goals, in the past and in the present, aim at achieving national averages. By design, this leaves half of those affected below the average. To be consistent with the UN-sanctioned Human Rights Framework, setting goals will only make sense if these are applied at the sub-national level, i.e., district or municipality since only this allows focusing national efforts on those territorial units so far most neglected and discriminated. With this being accepted, the concept of maximum impact will have to be redefined in the new framework.


2. How has the world changed since the MDGs were drafted? Which global trends and uncertainties will influence the international development agenda over the next 10-30 years?

The world has changed plenty; but how much due to or despite the MDGs? Let us keep in  mind that the selection of MDGs was arbitrary and top-down with many of us having complained about issues left out and about the lack of consultations when they were set. The global  trends that will influence development are, for sure, peace, the progressive realization of human rights, and our success in making democracy more a local direct democracy (as opposed to the flawed representative democracy we, at best, have now). But keep in mind that the global trends will be made up of myriad local and regional trends –certainly not forgetting those due to both economic and climate-related migration– which the new framework will have to influence in a positive direction. The human rights framework is the most effective tool we have to achieve this. In the next development phase, let the human rights perspective, then, guide the deployment of human, financial and other resources.


3. Which issues do poor and vulnerable people themselves prioritize?

First of all, ‘vulnerable people’ I think is a euphemism. [It is the same as speaking of ‘people at risk’; we tend to think that people take risks but, beware, risks are also imposed!]. To avoid any sort of victimization, we must talk of marginalized people. Vulnerable has a connotation of ‘poor them…’; marginalized tells us our social arrangements have put them in that situation. Now to the question of which issues claim holders prioritize: The question has not been answered! Why? Mainly because we have not systematically asked them. Let us do that…and then heed their advice!  I have great hope that this time we put this question at the very center of what we do in the massive consultation that has now been launched. Should I be optimistic? For people to influence priorities, development work cannot only continue focusing on service delivery, on capacity building and on (depoliticized) advocacy; what is needed is a focus on empowerment and social mobilization (the latter also called practical politics). It is not easy to say what is really empowering in community development work. Any attempted operational definition will (always) carry a certain bias depending on the conceptual glasses one is wearing. What is clear is that –in a mostly zero-sum game– the empowerment of some, most of the time, entails the disempowerment of others –usually the current holders of power. Empowerment is not an outcome of a single event; it is a continuous process that enables people to understand, upgrade and use their capacity to better control and gain power over their own lives. It provides people with choices and the ability to choose, as well as to gain more control over resources they need to improve their condition. It expands the ‘political space’ within which iterative Assessment-Analysis-Action processes operate in any community. That is what we need to pursue.

4. What does a business-as-usual scenario look like?

The business as usual scenario paints quite a grim picture, I’d say. Take, for example, the poverty alleviation discourse in the MDGs: it displaced the poverty debate worldwide: from a political discussion about its causes to a technical, risk management scheme. (N. Dentico)

Bottom line, I am not sure MDG achievements will all be sustainable. We have raced for the outcomes neglecting the participatory processes to get there, and what we see does not bode well.

An equally important question is: What does a business-as-usual mode foretell?  As another example, take the following: if current trends continue, by 2015, 3.7 million more children in Africa will suffer from malnutrition than are today. My crystal ball tells me we will see more fundamentalism more ‘…springs’, growing frustration, more (understandable) explosive conflicts; perhaps some empowerment in the process, but empowerment in an unpredictable direction; some good, I’d expect. What this tells us is the urgency for the post-2015 agenda to address the real deep structural causes of widespread disempowerment of those that live in poverty/happen to be poor.

Perhaps the most crucial element missing in the MDGs was a conceptual framework of the causes of underdevelopment (or maldevelopment). In the 1990s, UNICEF pioneered the now widely accepted conceptual framework of the causes of malnutrition identifying its immediate, underlying and basic or structural causes importantly showing that addressing each level of causality is necessary but not sufficient. This omission of the MDGs cannot be repeated by the new framework we are all trying to come up with. An adaptation of the already well accepted UNICEF framework is perhaps the best way to address this omission. Are we up to the challenge?


II. Qs on the shape of a post-2015 development framework:

5. How should a new framework address the causes of poverty?

Based on the new conceptual framework on the causes of maldevelopment I plead be arrived at by consensus, the post 2015 framework will importantly have to work on deconstructing neoliberal globalization –the latest incarnation of raw capitalism. Why? Because it is not about the alleviation of poverty (much less about the chance of eradicating it); it is about a quantum reduction of disparity the world over –among and within countries. It is about working out new mechanisms of redistribution of wealth and power. And such a redistribution will only come through empowerment and social mobilization from below; with people going from having voice to exerting influence. I worry that all the good intentions of the UN to address the structural causes of poverty in the conceptual framework will lead to another 10 years of failure if it does not politicize this issue. The rich have no intentions to give up their power and privileges; non-violent counter-power has to be organized and applied. Dialogue has to become a dialogue of equals.

6. How should a new framework address resilience to crises?

Ultimately, the common denominator of most of the man-made crises can be attributed to the excesses of capitalism. (It is not really the excesses of capitalism but capitalism itself that cause the problems; those excesses are only the inevitable result of raw capitalism, more systematically implemented). Decisive steps must be taken by the new framework to foster the social mobilization needed to make sure effective disparity reduction measures are launched nationally and internationally. [ Internationally, this means giving accredited NGOs a seat, voice and vote in UN and in government deliberations. Environmental crises have both natural and man-made causes. As Rio and Rio+20 have shown us, we can effectively address the latter. The new framework must depart from this premise and thus, as a minimum, incorporate Rio+20 recommendations.


7. How should a new framework address the dimensions of economic growth, equity, social equality and environmental sustainability? Is an overall focus on poverty eradication sufficiently broad to capture the range of sustainable development issues?

The economic growth model has been shown to be unsustainable, mostly (but not only) on environmental grounds. Does the new framework have an option not to deemphasize economic growth as the main development goal? It actually needs to denounce it in no uncertain terms.

Reaching equity and social equality inevitably points to the fact that both need the processes of empowerment and social mobilization I insisted-upon earlier.

For environmental sustainability, the roadmap has already been worked-on by the experts in  Rio and Rio+20 so that the new framework has to adopt its recommendations.

As said, the focus ought not to be on poverty eradication, but on disparity reduction which has connotations for urgently needed actions both in rich and in poor countries including changes in many, if not most, aspects of ODA.

The disparity reduction approach is necessary, but not sufficient to capture the range of sustainable development issues. Rio+20 is clear about this.


8. What should be the architecture of the next framework? What is the role of the SDGs in a broader post-2015 framework? How to account for qualitative progress?

The broader architecture of the next framework must absolutely be based on the human rights framework. Enough of lip service. It is time for deeds (related, nothing less, than to the Universal Declaration of Human Rights and to the UN Charter). From now on, we have to look at the development process from the perspective of claim holders and duty bearers in their dialectic relationship. This language must be adopted and both groups have to be made more confident and assertive in their respective roles, i.e., claim holders placing concrete demands/staking claims and duty bearers abiding by UN Covenants, Conventions and General Comments. The concept of progressive realization is another one to be given center stage.

The role of the Sustainable Development Goals is also key. We only have one planet! Heed the recommendations from Rio!

Also related to the architecture, there will have to be a global UN body with executive powers following up on the implementation of the new framework. (The MDGs did not really have this; it was left to countries to apply them; there was no global accountability). This body must be endowed with funding. It must have some kind of an executive ombudsperson role on issues of implementation and must work towards influencing international financing mechanisms being made available.

To account for qualitative progress, yearly benchmarks have to be set by each country (especially for the poorest districts/municipalities) based on processes that must be implemented en route to the progressive realization of the different human rights. Civil society organizations are to be appointed as watch dogs for the achievement of these benchmarks; they need to receive funds specially earmarked for this.


9. Should (social, economic, and environmental) drivers and enablers of poverty reduction and sustainable development, such as components of inclusive growth, also be included as goals?

The word enablers is a rather vague one. So is inclusive growth. I had already suggested a) that we need to deemphasize economic growth as the main development goal, b) that the selection of outcome goals is likely to be less useful than the use, inclusion and of yearly processes-achievement benchmarks, and c) that disparity reduction, and not poverty reduction, is the term to be used from now on.

Indeed, the three drivers mentioned in the question need to be tackled –but absolutely not forgetting a fourth one, namely the political driver. Each is necessary, but not sufficient. [The UN being non-political is to be understood in terms of non-political-partisan, but, by God, it needs to act more decisively on issues political in nature it strongly stands for; therefore, when needed, calling a spade a spade. Some agencies do it more that others].


10. What time horizon should we set for the next phase in the global development agenda (e.g., 10, 15, 25 years, or a combination)?

I am more inclined for five years with yearly-interval benchmarks as yardsticks of progressive realization. Yearly achievements/shortcomings can thus be assessed and adjustments made accordingly, as needed, in a participatory manner. With the world changing as fast as it does, I am sure that major adjustments are justified every five years –at least at the country level.


11. What principles and criteria should guide the choice of a new set of goals?

The human rights principles of non-retrogression, universality and inalienability, indivisibility, interdependence and interrelatedness, equality and non-discrimination, participation and inclusion, and accountability and rule of law are, once and for all, to guide the new framework. The assessment of these principles being respected is to be built-in into assessing annual benchmarks.

The main criterion that must go with this is for countries to be mandated to participatorily draw-up long-term and annual plans for the progressive realization of human rights Human rights are all closely related to the development process. (Such plans could be a requirement for ODA as well). The new framework must demand these progressive realization plans be drawn up.


III. Qs on themes and content of a new framework:

12. To what extent can we capitalize on MDGs achievements and failures in developing our post-2015 development agenda?

To a great extent and to begin with, the agenda can not again be drawn top-down –a challenge that I still see unresolved. Opening up the consultation to development workers worldwide reading this is only a variance of a top-down model.  We not only can, but must capitalize on both the positive and negative lessons learned from the MDGs. Which lessons? Ask the recipients of MDG ‘benefits’! This calls for governments and local civil society the world over to jointly open, in the next year, a wide dialogue on post-2015 options. Seed funding is needed if we are serious about this.


13. What is the legacy agenda of the existing MDGs that will be inherited in the next framework? Which elements should be revised in the light of lessons learned, such as the importance of girls’ education and gender equality?

Positive points notwithstanding, the legacy of MDGs shortcomings, as I see them, is that they had donor over-influence; had a technical over-emphasis; paid no attention to acting on the underlying social and economic inequalities; they lacked a systematic long-term financial commitment; had a predominant focus on health and education; and overlooked the entire participation and political economy contexts. Furthermore, they did not quantify the obligations of the rich countries (this assumed that poverty is a problem of poor people only); actions to be taken in the rich countries must simply be part of the next framework.

Poverty was defined in the MDGs as a state in which people have to live in the equivalent of less than $US 1 a day (but inflation is likely to make the one dollar in 2000 worth around 60 cents by 2015); and China, Cuba, and Vietnam (where, by the way, I live, so I am in a position to know), have long focused on structural development concerns, but have not labeled them as ‘Millennium Development Goals’, i.e., not wanting to play the MDGs game.

These are all shortcomings we do not want to carry over to the next framework. Beware: the elements to be revised, such as the ones insinuated in the question, are not for us reading this questionnaire to decide! Additions and revisions are to come from consultations with claim holders and duty bearers down below in many little places giving this process the flexibility needed in terms of the participative selection of contents and the timing of their participative introduction.


14. Which issues were missing from the MDGs and should now be included? How to address inequality, jobs, infrastructure, financial stability, and planetary boundaries?

It is not for us to decide these issues. They must come from dialoguing with claim holders and duty bearers at national and sub-national level importantly including women and youth organizations, trade unions, social movements, parliamentarians, local civil society organizations, organizations of migrants (who cannot be ostracized as non-citizens!)…

Inequalities are a result of power imbalances so, obviously, the organization of a counter-power is the answer for the next period; rights holders have to become de-facto claimants through processes of empowerment and social mobilization.

Employment issues must be discussed directly with trade unions for inputs.

Nobody knows better the shortcomings in infrastructure than their daily users (and/or those who need it and do not have it); we have to reach out to get their inputs.

Financial instability is a trademark of the cycles of boom and bust of capitalism and, as we now know better, is caused by the reckless behavior of greedy megabanks and financial institutions and individuals. Global and national regulation –including people’s audits– must keep them at bay making sure taxpayers never again bail them out for the disasters they bring about. A Tobin-type tax is an issue whose time has (belatedly) come. People’s audits also must be introduced to look into the issues of odious foreign debt in poor countries.

For planetary boundaries, we should fall back on work done by UNEP and in Rio; but what is needed for the new framework is to set aside funding to educate the public at large, all over the world, about these boundaries so as to make this an additional  topic of their empowerment and mobilization.

All the above notwithstanding, remember the most crucial element missing in the MDGs was a conceptual framework of the causes of underdevelopment (or maldevelopment) alluded-to earlier.


15. How should a new framework incorporate the institutional building blocks of sustained prosperity, such as freedom, justice, peace and effective government?

I wish I understand what ‘institutional building blocks’ are. So I am a bit at a loss here. But anyway, first of all, the concept of sustained prosperity must be de-linked from the concept of economic growth with the latter having to be seriously questioned.

Freedom, justice and peace are all embedded in the human rights framework which will have to, once and for all, be the guiding framework for post-2015 development agenda. [It is a real pity (or a scandal? ) we are facing having to wait another 24 months for this to become true!].

As for effective government, I have always said that elected officers are as good as the people who elected them; electors deserve those they elect(ed). The problem is that (the often anachronistic and formal) representative democracy is made use of every 4, 6 or 8 years. “You made a bad choice? You are stuck till the next election”. Under these circumstances, nothing short of making the accountability/watch dog function a function of civil society (with commensurate funding) will be good enough in the new framework. Actually, the ultimate purpose of social mobilization is the application of local direct democracy to remedy the serious shortcomings of representative democracy.


16. How should a new framework reflect the particular challenges of the poor living in conflict and post-conflict situations?

I assume that by ‘the poor’ actually the question means ‘poor people’ (or people living in poverty). I hope I make my point…

If we are talking about ‘particular challenges’, can we expect the new framework to have general recommendations here? Is this a contradiction? Would global recommendations have any chance to work?

I strongly feel this is, par-excellence, a topic for South-South cooperation (with commensurate funding). Countries living in conflict and/or post-conflict can give better advice to others on what to do/not to do. The international community’s help should come in the implementation of the recommendations coming from such S-S cooperation –the help firmly based on the principles of their extra-territorial human rights obligations now recognized by ECOSOC.


17. How can we universalize goals and targets while being consistent with national priorities and targets?

The first question I have here is: Must we again universalize goals and targets? And then: Does the MDGs experience tell us universalization of national level targets was a good thing so as to follow it now? I have said that I personally prefer the setting of benchmarks over the setting of goals and targets (whatever the difference is between these two).

National priorities have to be based on a progressive realization of human rights long-term plan with annual benchmarks. The priorities must be disaggregated to the district/municipality level so as to first concentrate actions on the x% of the most marginalized ones. (Vietnam has done so with a hundred thirty some districts). [This applies equally to giving priority to marginalized groups in society; I do not need to name them here since they are well known]. This all is what the human rights based approach calls for! So, nothing new here. In this case, we are talking about a human rights principle that is not subject to progressive realization, but calls for immediate implementation, namely the principle of non-discrimination.

The only way another set of universal goals is going to get us further in the next phase is to mandate those goals be achieved in each district/municipality and not as a national average.


IV. Qs on partnership and accountability for development:

18. How will a new framework encourage partnerships and coordination between and within countries at all stages of development, and with non-state actors such as business, civil society and foundations?

If the framework should encourage partnerships and which partnerships is the first question to be asked here. We need to know which partnerships the question refers to. Partnerships with whom?

‘Partnerships’ between countries have a very sorry historical past in the realm of neo-colonialism. Partnerships in traditional ODA do not have much to show for either in terms of each partner wielding equal weight in decision-making (this includes partnerships with often non-transparent/non-democratic mega philanthropies and foundations).

South-South partnerships are an upcoming potentially promising avenue the new framework should definitely refer to, explore and foster.

A special worrisome ‘animal’ here are public-private-partnerships that have been plagued by devastating conflicts of interest and by claims of white-washing the conscience of participating TNCs. Quite a bit has been written about this and I will not go into more details. (I call your attention to seminal work done on this by IBFAN and by Judith Richter).

[It would be desirable the new framework calls for greater transparency of mega philanthropies with an opening-up of their internal decision making processes].

The new framework simply has to put in place mechanisms through which governments together with representatives of civil society have a controlling stake in all partnerships. Governments and civil society organizations have learned (and suffered) by now and are now up-to-the-job, from now on, to take this mandated role.

At global level, PPPs are also a big worry at the UN in general (Global Compact) and in UN agencies. The People’s Health Movement has been active in denouncing this state of affairs in WHO calling for concrete and definitive measures to be taken. The question also calls for  coordination between countries and within countries. The latter, I understand well. But does ‘between countries’ refer to foreign aid? If yes, I have made my point. If not, this coordination will have to be further explained.


19. How specific should the Panel be with recommendations on means of implementation, including development assistance, finance, technology, capacity building, trade and other actions?

I would say the Panel should not be specific on such means, but perhaps propose a range of options. It is for the participatory country and sub-country level to work on them and gain full ownership of the ones finally selected. There should be a specific time period and funding set aside for this.

As regards development assistance, foreign aid has to be made to abide by the human rights framework and by the principles of extra-territorial obligations.

The transfer of technology is a key additional issue. At grassroots level, the technology has to be appropriate, as decided by its direct future users. Otherwise, we have witnessed how TNCs transfer second hand technology to developing countries –technology they have replaced by a more advanced one in rich countries. This perpetuates underdevelopment and must, therefore, be countered.

Capacity building: my experience is in health. I have seen the proliferation of aid-funded vertical programs, be they for TB/HIV/malaria or for family planning… They all duplicate in big part the training offered with the same service provider at the point of delivery being called out for yet another training. Add to this that often different donors repeat the very same training due to a total lack of coordination. The service provider attends mostly for the sitting allowance provided and returns home not applying what has been learned. I call this disease ‘workshopitis’. The remedy? In health, we need roving multidisciplinary provincial teams that go facility by facility, stay 2-3 days in each, observe how services and extension/outreach work to the community are provided, correct deficiencies, add new knowledge, leave a list of to-dos and return in three or six months to check on changes only to make yet a new round of recommendations, and so on.

Trade is also a big problem. Rich countries have stayed away from using WTO as a vehicle for their international trade deals and have opted for bilateral free trade agreements where they can better use their muscle to extricate more favorable conditions. The negative human rights consequences of most of these FTAs are nothing short of appalling. The rich in the poor countries may benefit, but not poor people. The new framework cannot possibly ignore this fact at the risk of coming up with a ‘robbing Peter to pay (rich) Paul’  agenda of development. [Not coincidentally, this also applies to poor countries servicing their odious foreign debt].


20. How can accountability mechanisms be strengthened? What kind of monitoring process should be established? How can transparency and more inclusive global governance be used to facilitate achievement of the development agenda?

The answer is: Through civil society organizations specifically funded to act as watch dogs.

The monitoring should be based on annual benchmarks so as to check if on processes set in motion to assure the progressive realization of human rights are on course. (This presupposes each country prepares a long-term progressive realization plan of action with a, say, ten years horizon. The new framework must explicit this).

If a more inclusive global governance is to be understood as participatory governance, then the issues pertaining to governance transparency are included in the watch dog function.

What this question does not touch-upon is the issue of providing accessible redress mechanisms. The obligation of States is to take steps to prevent, investigate, punish and redress any abuse through effective policies, legislation, regulations and adjudication. States must ensure that those affected by business-related abuses or other human rights abuses have access to a prompt, accessible and effective remedy including, where necessary, recourse to judicial redress and non-judicial accountability and grievance mechanisms. The new framework must address this issue.

It is well known that CSOs are active in many countries in preparing shadow reports for the UN Human Rights Council. The framework must explicitly encourage CSOs to participate. Once the Council engages in the universal periodic review of the human rights issues of each country it issues recommendations which, unfortunately, are not binding. Mentioning this fact, may help the new framework creating greater consciousness about this shortcoming which could result in some corrective action on this in the future.


21. How can a new framework tackle the challenge of coherence among the organizations, processes, and mechanisms that address issues that are global in scope?

[I saw the concept of ‘poverty of ambition’ being used in these post 2015 discussions; I think it fits nicely here].

Since Paris has, for all practical purposes failed, I think the in-country coordination of donors and local organizations should be made mandatory for multilateral and bilateral agencies and for non-governmental donors both on general aid and aid by sector. Central in the coordination process will be addressing the global issues that the new framework will suggest be prioritized worldwide with the specific mandate to adopt/adapt them to the local realities and priorities. Coordination meetings are to be chaired by two government representatives ideally from the ministries of planning and finance and must have a representative participation of CSOs. More human and financial resources have to be specifically allocated by donors for such a coordination function.

Underlying the actual willingness and commitment of all involved agencies to work in a coherent manner will, in many cases, call for a profound exercise of revisioning and remissioning of what they do based on an honest question: Are we part of the problem or of the solution? The new framework can no longer condone silo mentality, vertical programs, each donor for himself in development work. Service delivery work is not enough; technical capacity building work is not enough; advocacy work is barely enough. Remissioning is about these institutions funding and engaging in empowerment an social mobilization work in the countries they work in.

Globally, it would be highly desirable that the new framework proposes ways to be worked out for the United Nations Committee on Economic, Social and Cultural Rights also to be involved in coherence, in processes and in mechanisms issues.

Furthermore, it seems indispensable that in the post-2015 period the UN special rapporteurs be allocated adequate budgets to allow them to have proper small staffing and more travel funds to do their (excellent) work.


22. How can we judge the affordability and feasibility of proposed goals, given current constraints?

Affordability is strictly a country by country matter. Being a cautious optimist, I think the current constraints will be overcome. Therefore, to be prominently kept in mind are the provisions of the extraterritorial obligations of rich countries. This means that countries showing well justified shortcomings to embark in the progressive realization of human rights will go to donor agencies for help. Given that the progressive realization is based on yearly progress marked by benchmarks –and countries will have ad-hoc plans– donors will be able to commit resources long-term, in tranches, based on the budgeted official progressive realization plan of each country. Coupling this with CSOs participation on accountability issues gives us some hope for (cautious) optimism on feasibility.

Affordability/feasibility issues can be and have been addressed successfully in several instances through participatory budgeting initiatives. These ought to have an important place in the post-2015 recommendations.


V. Qs on shaping global consensus for the goals:

23. How can we build and sustain global consensus for a new framework, involving member states, the private sector and civil society?

Global consensus has to be built from the bottom up, i.e., starting from the sub-national level up. This is why this consultation period up to 2015 is so crucially in need to go to the level of claim holders and duty bearers at district level. (Keep in mind that duty bearers to claim holders in the community are, in turn, claim holders to duty bearers at the national, often ministerial, level….and those, in turn, claim holders to duty bearers in the international context, i.e., there is a chain of oppressed oppressors). Thinking loud: Can a worldwide 1-2 weeks period of national debate be agreed upon and set sometime in 2014? Can we then imagine a global process of some kind of formal ratification of the new framework by parliaments, social movements, CSOs, private sector without conflicts of interest (?) and governments the world over?

Sustaining the consensus will depend on progress being made. Annual benchmarks can give us year-to-year reports of progress as perceived by representatives of the wider society. This national annual taking of stock has the additional advantage of giving the new framework flexibility to change tactics within the same strategy (…or change strategy if needed).


24. How can our work be made coherent with the process to be established by the intergovernmental Open Working Group on the Sustainable Development Goals?

All efforts have to be made to secure such a coherence. Moreover, in all issues pertaining the SDGs and pertaining to this post-2015 framework the principle of one country one vote is non-negotiable in all instances when such consultations are deemed necessary. We all are born to live in this planet as equals. [I see no problem in isolating the rich countries often voting in block against the poor countries and thus formally obstructing this or any coherence. They are already doing so! So what is left for the poor countries is to continue blaming and shaming them, remotely hoping for a future break through. In the meantime, as much as possible, the poor countries ought to act on issues as per their majority vote].



Having come to the end of this reflection, I know I have opened only a small additional window that adds to the equally important contributions of many many others. I am afraid I have often been normative (and even possibly wrong). There are too many shoulds and woulds in my comments.

The risk we face is coming up with a more radical new framework than the MDGs framework was only to see it watered down by the powers that be –as has always been the case in end negotiations.

I ask you: Why has consensus always to be pulled to the side of those who feel they have something to loose in this pathetically unequal and unfair world?


I was looking at the November 30 note the High Level Panel of Eminent Persons on the Post-2015 Development Agenda just made available and had a couple to-the-point short comments.


Is there a way we can get away from the use of the maligned term ‘stakeholder’? Stakeholders stake claims, right? The simple replacement of the word stakeholders by claim-holders or duty bearers, as appropriate (to use the correct HR parlance that we and the UN are finally trying to instill in post-2015), just might provide us with the hint of the sort of framework we are interested in fostering in the new era. Claim holder/duty bearer are in the original UN language. Stakeholders is originally business language. To have or to hold a stake in something is the same as having an interest or holding shares!!! (A. Katz)

As regards the section on human development, the second bullet talks of raising the bar and of several members focusing on the need for quality of outcomes. The MDGs have shown us that a focus on outcomes does not assure sustainability of the respective goal being kept up. It is not only the quantity and the quality of outcomes that counts; it is the participatory processes to achieve them that will matter in the long run. (Note that here sustainability is used in a different sense than in the environmental connotation of the term).

The fourth bullet tells us that many panel members pointed to the importance of rights and equity. I ask, do we have some panel members that ought not be there if this is not the unanimous outlook of the panel? Furthermore, there are still too many among us that consider HR and equity, gender…as crosscutting issues; they are not. They are core issues (!) and we have to build sectoral or other interventions around them.

As regards the section on jobs and livelihoods, the sixth bullet talks about safety nets. I feel strongly we ought, instead, to be talking about social protection mechanisms. Universal social protection is the new political and cultural horizon where health rights must be placed. Social protection is the fundamental measure to pursue redistribution of wealth. It includes social security, social assistance, labor rights, the right to public services and environmental rights. (F. Mestrum)

Safety nets take the issue of poverty as a fait accompli. So since ‘they’ are poor, we throw them a few crumbles of bread since it is morally reprehensible to us to let them starve. In reality, safety nets somehow come up with measures that avoid social discontent that could flare up into protests and thus a challenge to the status-quo. Or put another way: Safety nets are nothing but a way to manage poverty and ‘ill-being’ (as opposed to wellbeing) by attenuating social unrest. Am I very wrong?

The ninth bullet pertaining to providing accessible and affordable basic needs to the poor closely relates to what I say above. It just, in a way, replaces safety nets by targeting the poor (note the use ‘the poor’ in the bullet; should it not be ‘poor people’? We have to be careful with depersonalizing the billions of  the affected). [I want to caution you that the same is true for when programs and projects speak of ‘targeting the poor’]. The bullet goes on to infer that nutrition, health, education, housing, clean water and sanitation will eventually cut the vicious circle of poverty. I thought the inter-generational vicious circle of poverty could only be uprooted for good with structural changes in the political and economic system that rules most of the world.  Am I very wrong?

I want to take the opportunity to express my thanks for the excellent 24 questions the panel released on this same occasion. They have the right food for thought and I hope to be able to spend some quality time pondering over them.





Reminder: Social Medicine Course in Northern Uganda – Applications Due June 30th

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SocMed invites students to apply for the fourth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience conducted on-site at Lacor Hospital in Gulu, Uganda from January 7, 2013 to February 1, 2013. This unique immersion course incorporates innovative teaching methodologies to merge teaching of clinical tropical medicine with understanding the socioeconomic, cultural, political, and historical underpinnings of illness. Through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions, the study of clinical medicine in a resource-poor setting is intersected with social medicine topics such as the social determinants of health, globalization, war, human rights, community-based health care, and narrative medicine. Enrollment is open to fifteen 3rd and 4th year medical students from across the globe, and includes equal participation of Ugandan medical students, and credit for away-rotations can be arranged.


This course is offered through SocMed, an organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging medical students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

SocMed utilizes a curriculum that places great importance on building personal partnerships and encouraging students to reflect upon their personal experiences with power, privilege, race, class, gender, and sexual orientation as central to effective partnership building in global health. In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty and student colleagues.  Please feel free to visit our website,, for more information about the course, its directors and guest lecturers, and SocMed.  Applications are due by June 30, 2012.


Please do not hesitate to contact us with any questions you have at




Michael Westerhaus, MD, MA

Amy Finnegan, Ph.D.

Course Directors

Magnum Foundation Emergency Fund Interviews Joyce Wong, LCSW & Ousara Sophouk of Montefiore’s Indochinese Mental Health Program

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Joyce Wong, LCSW

Ousara Sophouk










Joyce Wong LCSW , Social Worker and Ousara Sophouk, Family Health Worker at the Montefiore Family Health Center were recently interviewed by Pete Pin for a photodocumentary project – Displaced:The Cambodian Diaspora through the Magnum Foundation Emergency Fund. Mr. Pin, a fellow at Magnum Foundation, spent 5 months last year taking photographs of the Cambodian Bronx community. Joyce and Ousara speak about their 20 years of experience serving the Southeast Asian community in the Bronx. A link to the interview and photographs can be found on the Emergency Fund’s website.

Here is the text of the interview:

In early November, 2011 Pete Pin, EF Fellow, spoke to Joyce Wong, a licensed clinical social worker, and Ousara Sophuok, a Cambodian family health worker who immigrated as a refugee from Cambodia in 1986. Joyce and Ousara work together at Montefiore Hospital in the Bronx, New York where they provide mental health services to the Cambodian and Vietnamese Bronx community.

PETE PIN: Can you describe the clinic and the work you do here in the Bronx?

JOYCE WONG: We have been providing out-patient mental health services for the last twenty years as part of a collaboration between the Department of Psychiatry and Family Medicine. We are part of an urban medical center but we actually modeled our program after the Harvard Program in Refugee Trauma who were pioneers in the identification and treatment of torture and mass violence. With the program, mental health care is integrated in a community healthcare setting as a truly collaborative model of care.

Cambodian refugees were resettled in the Bronx in the mid-1980’s and came to our clinic for healthcare. However, physicians were not equipped to deal with a lot of the medical and psychiatric problems the patients presented. Not only were medical problems associated with lack of access to medical care—as many refugees were living and languishing in refugee camps between five to ten years—but many patients suffered from psychiatric trauma from the Khmer Rouge Regime (1975-1979).

In the mid 1980’s, we partnered with the departments of psychiatry and family medicine at Montefiore and developed a collaboration with a small mental health program to attempt to address some of these problems. At that time non-governmental organizations, especially abroad, addressed the problems of food, clothes and shelter for persons who had undergone mass violence, trauma and natural disaster. But the NGOs did not usually address their mental health needs. My colleagues at Harvard were one of the first to conduct scientific research studies when Cambodian refugees were living in refugee camps in Thailand, and found that high levels of depression existed within the refugee camps. When the refugees were resettled here in the Bronx , the focus on the mental health care needs of refugees was very progressive for that time. It was a holistic approach. This was over twenty years ago.

But how do you present mental health to someone who does not have a western frame of reference or worldview? A lot of the work in the first years was getting to know the community and going out to the community because you’re not going to expect someone to come to your door even if they are living across the street from your clinic. We established a motto of “Eat, Work and Play”: eating with the community, working with the community, and playing with the community. It meant attending weddings we were invited to, attending important religious holidays at the local Buddhist temple, conducting home visits to get a sense of the social issues that the people in the community were facing, walking up and down Fordham Road in the Bronx.

PIN: Were there things unique about the Cambodian community in regards to their trauma and their history that compounded the difficulty of providing services and hindered their ability as individuals and a community to assimilate and to make that transition from the camps to America?

WONG: It was very difficult for Cambodians because during the genocide between one to three million people were killed from a population of seven million. Much of the educated population of Cambodia was killed. Many of the surviving Cambodians that were able to flee and escape to refugee camps were rice farmers who didn’t have high levels of literacy in their own language or education. In contrast, many other immigrant groups came from countries where there was a solid infrastructure, where there’s a high level of educational attainment, and this really influences their experiences when they come to the United States. It affects their ability to navigate in their new home country and what opportunities are available to them on a day to day. The refugees that came to the Bronx from Cambodia were already a disenfranchised community and further marginalized because they were resettled in a physically and economically distressed community. To compound this, not being able to read and write, not having access to resources because of the language was a barrier on all levels: education, work, and health.

PIN: Sarah can you discuss your work in the community and how you became involved in the clinic? It’s important to stress to readers that you are yourself a member of the Bronx Cambodian refugee community, that you immigrated here under the exact circumstances as the people you have been providing services to.

OUSARA SOPHUOK: Joyce Wong had mentioned that during the war a lot of educated individuals were killed and the majority of our patients, especially the ones that came for care at our clinic, didn’t have a lot of formal education, including myself. During the war I didn’t have a lot of education, I only finished a few years in school. I escaped to a refugee camp where I studied English for six months. When I arrived to New York there was a temple three blocks from this clinic I went to regularly. That’s how the community got together. I arrived 1986 and I went to the temple where they had a Cambodian women’s program where I studied English.

One day there was a person from Adelphi University who was recruiting people for training in human services and a job program. They wanted us to go for field placement. At that time I didn’t know what I wanted so I said, “I want to work on something that relates to the community and I can help people” although I could not even help myself at that point. It was what I wanted to do, so they said “Ok you can do your field placement at the temple.” When I was doing my field placement my English was not great and I was so nervous to be doing the work. Then I looked at the people that were going to the ESL class at the temple, and I realized I knew more English than them because I studied it in the refugee camp. I said to myself, “These community members need more help than I do.” That’s what gave me a lot of courage to go to school. I went to the training for six months and at the time when I graduated from the program they were looking to hire someone to work in the mental health clinic for Cambodian and Vietnamese refugees at Montefiore.

I grew up in a family that served the community, which is where my desire to help others comes from. My father used to be a Buddhist monk in the Bronx temple and we went to the temple all the time. We prayed and ate together there so I really knew the community before I started working here. Like Joyce had mentioned, we had to eat and play so I went to the temple and I recruited people. I explained to them what I was doing and the services we had here. The people trusted me because my father was the monk in the temple and people trusted him.

PIN: When you approached people to talk about the services here, how did you phrase it, how did you talk to people? You obviously played a very pivotal role in the outreach.

SOPHUOK: At that time it was very difficult to translate from English to Khmer. The word psychiatrist, psychiatry or mental health literally translates to “crazy.” It’s a very strong word so I used the word “emotional health.” Instead of physical health I said emotional health and I explained to them that we have the clinic here and the doctor will take care of your physical health and we will take care of your emotional health. You have to educate the people that emotional and physical is the same, that they’re very connected to each other. This is critical because we went through a lot of trauma during the war.

At first, it was difficult for people to understand. Traditionally we didn’t talk about mental health and our feelings; we always suppressed this during the war. You didn’t say anything during the war, you kept everything inside to survive; you acted as if you were dumb. There’s a Cambodian word a ting mong meaning a scarecrow on the farm. We called ourselves a ting mong because we acted as if we didn’t know anything. We hid our intelligence to survive.

WONG: The Khmer Rouge had a slogan: “To destroy you is no loss, to keep you is no gain.” If you’re constantly told that you’re not of any value and disposable, something happens to your psyche which has ramifications for survival at that time but also psychological consequences in the future.

PIN: Is this something that you see manifesting itself decades after?

WONG: It was a coping mechanism during the war for survival, but as you said it had repercussions for the future. The a ting mong mentality became so ingrained during the genocide and the refugee years, that even after immigrating to the U.S. many Cambodians continued to wear that cloak. If you don’t bring the trauma into consciousness, then it continues to manifest itself and weigh on you every day.

PIN: You carry the weight of that with you. For me I think that’s very critical, the residual affects of trauma; that’s something the academic and resettlement community doesn’t widely recognize. There hasn’t been a lot of work on residual trauma, and this perspective is brand new in regards to the need to provide holistic, culturally sensitive mental health services to refugees that takes into account their unique circumstances.

SOPHUOK: We had to get people to understand that the clinic was a very safe place to talk about our emotional health. I had to convince them that if they said something wrong here they were not going to get killed and that here in the clinic we take care of their emotional needs. And then the people started to open their minds a little bit and began to trust us. After a few years, the program expanded by word of mouth, the doctors, and self referrals.

PIN: Please describe the community within the first year or two here in the Bronx, how their experiences were, even your experience, during that transition in the first several years of resettlement?

SOPHUOK: It was very difficult even for myself. I encountered a lot of difficulties even though I spoke a little bit of English. It was very scary to go outside and it was very difficult to go somewhere because of the culture shock. The culture was different. The living situation was different. The first years were difficult because we couldn’t go anywhere. We were like children learning how to walk step by step. We learned how to walk block by block. At that time we could only go to the temple and a Cambodian store that opened in the community. So people were not able to take the train or bus to travel outside of the neighborhood. We were both scared to get lost and confined. I’m of course talking about myself—that I felt confined—but I know that other people felt confined too. Imagine the older Cambodians who didn’t speak English. The first year was very difficult. Even now there are a lot of Cambodians who are ill and remain confined.

PIN: Yes. A lot of people don’t realize this. When I talk outside the Cambodian community the usual response is “that’s just the immigrant story,” that it’s the normal transition for immigrants when they resettle. As if all these issues can be generalized for all immigrants. However, obviously there are very unique circumstances that are endogenous to the Cambodian community as a result of the specific historical circumstances of their displacement and the resultant demographic outcomes as a result of the genocide.

WONG: Exactly. And refugees are disproportionately affected because of the multiple past trauma events of undergoing a war and genocide. The average number of trauma events a Cambodian refugee has undergone is 16. From torture, starvation, separation of family and friends, witnessing of killing, rape, and slave labor. So it’s not just acculturation, but the refugee’s past traumas and the resulting possible psychiatric distress and disability. Furthermore, these refugees were situated in economically distressed communities.

PIN: Please talk about the outreach in terms of strategies you talked about; eat, work and play?

WONG: Like our colleagues at Harvard, our approaches were a little unconventional and off-the-beaten path in trying to recruit and present ourselves in a way that community members would trust us. That really meant getting out there in the community and talking to people. Advocating for social changes, injustices. Challenging slum landlords in housing court, accessing social services, creating art programs that community members could participate in to beautify there community. The best forums usually are established places or places of faith, which play a very large role in community members’ lives. As Sarah said we often visited the temple on major holidays, made home visits, and attended weddings, funerals, religious ceremonies. We have always had a big component of also providing social services to meet the psychosocial needs of the community. We’ve had the privilege of being here for twenty years so we have followed people through the lifecycle; many of the patients grew up with us. We have been there through their marriages, through having children, through having teenage children, pregnancies, domestic violence, alcoholism, poverty, discrimination, deportation, etc. We really have run through the gamut in regards to problems and scenarios that community members have faced.

But one thing I think was pivotal for us during our time here is the realization that although mental health is very important, it’s important to stress economic and social sustainability. That comes from building community and empowering it through self-determination. So our approach has always been holistic. It was crucial when we partnered with the Committee Against Anti-Asian Violence in the Bronx, a grassroot organization in New York in the mid 1990’s. I just felt that at some point maybe six years after we started providing services, doors were closing on our community members. I didn’t feel they were progressing socially or economically; not because they didn’t want to but because of lack of investment of the US government and other institutions. So we partnered with The Committee Against Anti-Asian Violencethrough their youth leadership development project to organize and advocate for economic, social and health justice on behalf of the refugee community. We began to organize the community around other issues such as welfare rights, education rights, immigration rights, language rights, and accessing comprehensive healthcare. Witnessing the community mobilizing themselves and taking action was a highlight of my career. It was liberating to actually see the community developing consciousness and building its confidence.

If you ask me, as you’ve said before “how is it different?” I would say old models of recovery aren’t really effective anymore, and the humanistic/holistic approach to recovery is crucial. I really do feel hopeful with our community. I’ve seen that people really can recover from mass trauma and violence and can live very productive lives and can begin to trust other people again.

PIN: How have your patients progressed over this life cycle?

WONG: It’s a reality that some things may never really go away. Patients and community members still suffer from major depression; they still suffer from post-traumatic stress disorder. It doesn’t go away. But even if you have these psychiatric conditions, you can learn how to cope and live a fulfilling rich life. That’s huge. And that gives me hope. Our patients can still enjoy life, can still have positive healthy relationships with other people; you don’t have to be so isolated. I tell them they are not experiencing these things because of bad karma but because they underwent genocide and that it’s a normal reaction to terrible horrific events. I think it’s very reassuring and relieving for suffering people.

PIN: Sarah, can you elaborate on that?

SOPHUOK: I just want to add a point – about patients learning to cope and learning the result of the war was no fault of their own.  For some patients with severe psychiatric problems, the process was very slow.  We had to work very hard period. We encouraged them to do things that relieve them of suffering such as exercising, walking daily, socializing at the Buddhist Temple, engaging in meaningful activities, being of service to others.

WONG: This patient Sarah is referring to goes to the gym two to three time a week.  This was somebody who was completely homebound and confined when we started treating her 15 years ago.  She was paralyzed with her story and with her pain.  So she’s still limited in many ways but now she feels she has some control over the quality of her life and pain.  She can do things for herself; she can lead a more productive life. For us, progress doesn’t always translate into a job and although we feel work is a great value, being productive could also mean going to the park three times a week to meet your friends, or going to the temple on a daily basis. All of these activities are of great value and have a lot of healing qualities.

PIN: Again, that’s one of the issues: the old models of treatment are limited to the idea of providing English instruction and jobs.

WONG: Yes, it’s short-term thinking and a residual form of social welfare.

PIN: Yes, and what’s great about this is the fact that you have been providing services for over twenty years and it remains an ongoing process. You have acknowledged the reality that severe trauma does not magically go away.

WONG: Yes, it doesn’t go away but the way they see their lives, and the way they live their lives can still change. They are survivors, not victims anymore.

PIN: There’s a generation of Cambodians who immigrated here as teenagers or children, who came here when they were 14 or 15 and started high school here in the Bronx, or like myself were born in refugee camps but were raised in the inner-city; their experiences are very different because of their age. For the young Cambodians I met in the Bronx—and I think this goes across the board for all Cambodian diaspora communities in America—they have experienced their own unique forms of trauma inherited from their parents and compounded by the social ills of the inner-city.

When we started this interview, I played an audio clip of a teen I photographed in the Bronx who was speaking about her experience in regards to her parent’s trauma. You can hear a hint of trauma in her voice. For me it’s very profound how trauma can be passed on generationally. This is something I see in my own life. Have you treated people like this?

WONG: Yes, definitely. Within the last year there was a young Cambodian woman in her thirties and she was severely tortured during the Khmer Rouge.

This particular woman is a single mother with a seven-year-old daughter. She is one of the more traumatized and depressed patients that I have seen in a long time. It was just so clear how her depression and post-traumatic stress was affecting her relationship with her daughter. The little girl was taking care of her mother. Her mother was usually very depressed, very angry, and not able to parent her daughter in a consistent way. When I would ask, “Are you able to cook for your daughter or spend time with your daughter” she would respond, “No, I buy Chinese food or my daughter cooks her own meals.” Her daughter was going to sleep after eleven o’clock because her mother was not able to set boundaries and limits. The daughter was put in the role of an adult and that clearly affected the mother’s ability to be a parent.

Most of our patients are on psychotropic medication because it decreases their flashbacks, depressive and anxiety symptoms. This has helped her. Once her symptoms were relieved a bit, we were able to start talking about the importance of creating a secure and loving attachment with her daughter. When you’re that depressed it’s difficult to have an understanding of how your mental health problems can or are affecting your child and make the necessary changes.

PIN: What is your assessment of the community now? You’ve told me that you feel very hopeful, can you elaborate on that?

SOPHUOK: I feel very hopeful because our patients have received services and medication to help relieve them of their symptoms from trauma. They can now participate in community organizations like the Committee Against Anti Asian Violence and Mekong. With community organizational support, plus the temple our clinic that makes me very hopeful for the future. But still we need more. We do not have enough services for our community, which limits our progress but we have been actively working on Mekong.

Joyce Wong: I just feel hopeful to hear Cambodian youth say, “We want to be in charge of our community, we want to promote culture and dignity and we want to heal our community.” This makes me feel very hopeful. With these ideas we began to envision Mekong an emerging organization in New York City that will serve Southeast Asians by trying to improve the quality of life through community organizing, promoting arts, culture, language, and social services. It is a holistic approach to community organizing. Since last year we have been working with CAAAV to transition the Youth Leadership Project into an independent organization after a community needs assessment of Southeast Asians was conducted by emerging local leadership. On March 29, 2012 we will officially launch Mekong and that is something to celebrate and embrace. I would like to think that I’ve contributed a little grain of sand that creates hope and power.




EF Fellows are recent photojournalism school graduates who work as editorial assistants for the Emergency Fund and simultaneously create New York City-based photo stories on a topics consistent with the EF mission to “address critical issues that have not received the attention they deserve, or budding crises that are still over the horizon.”

posted by: Matt Anderson, MD

About the Social Determinant of Health

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November blog                                                                                           

  Claudio Schuftan

This is a bit belated report from the Rio World Conference on the Social Determinants of Health. The conference was convened by the World Health Organization together with the government of Brazil, to whom many thanks, for their enabling many colleagues from the People’s Health Movement to attend.

The conference was billed as the way to advance the cause of Closing The Gap in a Generation (1), the report of the WHO Commission on the Social Determinants of Health. Cynics had a feeling that it would be nothing of the kind, and once again, the facts supported cynicism, I am sorry to say. Preparations for the conference turned out to be a case study of what is now amounting to a kind of ‘war of the words’. This is being fought between all those in the UN system and member states who believe in public health and public goods, and those who remain committed to ‘business as usual’ at the time when the world’s financial institutions and banks are collapsing under the weight of their own greed.

Successive drafts of the final conference’s Political Declaration were covered in crossed-out and bracketed clauses and phrases, as the wealthy nations got to work, ‘toning down’ and eliminating almost all traces of real quantifiable concrete measurable and accountable progress on behalf of the majority of people in the world whose suffering increases.

As battle-scarred public health warriors expected, the powerful nations won most of the battles. But not all.  We did not come or go quietly, and it became apparent in the conference that more and more key people in the UN system and national governments have also concluded that the current systems of political, financial and social governance are broken. In clear interventions, WHO director-general Margaret Chan indicated this almost in so many words. But UN agencies are choked with executives who believe in alliances with the transnational corporations that with its allies are wrecking our world. Some of these executives will perhaps be working for such corporations in due course. That’s where the stock options and nice pensions are.

The frustration in the conference halls was so intense that no less than three alternative declarations were circulated. One of them came from the organisation of which I am a member, the People’s Health Movement; one from the Latin American Association of Social Medicine ( ); and one from the International Federation of Medical Students’ Associations ( ). Revealing too was the fact that the representative of civil society in the panel in the closing ceremony, our PHM colleague David Sanders, was the one person during the three days to receive a standing ovation from the floor. He made comments fully in line with what I say here below.




Sir Michael Marmot, chair of the WHO Social Determinants Commission, was at the centre of the Rio conference. We believe he is as frustrated as we are. Here is what he said in a recent issue of the WHO Bulletin (2). I insert my own comments.

‘Closing the Gap in a Generation is a rousing call. Did the World Health Organization’s Commission on Social Determinants of Health really believe it to be possible? Technically, certainly’. (This is a telling word. It’s code for saying that there is pressure to take the politics out of policy issues and reduce them to technical ‘fixes’)

‘Yes, there is a greater than 40-year spread in life expectancy among countries and dramatic social gradients in health within countries. But the evidence suggests that we can make great progress towards closing the health gap by improving, as the Commission put it, the conditions in which people are born, grow, live, work and age.  These include ensuring: equity for every child from the start, healthier environments, fair employment and decent work, social protection across the life course and universal health care. To make such progress, we must also deal with inequalities in power, money and resources – the social injustice that is killing on a grand scale. At a more fundamental level, our vision is to create the conditions so that every person may enjoy the freedoms that lead to improved health – what we call empowerment’. (And does he believe that this now is really happening? Read on…)

In the three years since Closing the Gap in a Generation was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; climate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequalities’. (Quite. Exactly. He then goes on to make some rather vague positive points. But the signal is clear. The only conference that could start to make a real difference in favour of rights, equity and justice would be one that resulted in a Declaration that acknowledged the outrageous misery and poverty that has been and is being accelerated by the present dominant systems of governance. Did that happen? No, it did not. Did Michael Marmot expect this would happen? I have not asked him).






                                                                              Rudolf Virchow



The People’s Health Movement was invited by the WHO Commission on the Social Determinants of Health to give evidence, and to contribute to the Commission’s report which was published in 2008 (1).This we did. Since then it has become increasingly evident to us that the most powerful WHO member states – that is, national governments – are reluctant to redress, or even to discuss or acknowledge, the power politics that year in, year out, worsen health inequities.


Constantly, states of health and disease of populations are being reduced to technical issues, whereas in truth, these are political. This was understood during the Industrial Revolution, as the quotation from the great epidemiologist, pathologist and reformer Rudolf Virchow makes clear. Health inequities are determined by the social conditions in which people are born, grow, live, work, and age. This has always been well-known by those prepared to see what is in front of their eyes and to face these facts. Public health pioneers, such as Rudolf Virchow saw this. Robert Koch devoted a key part of his Nobel laureate speech in 1905 to the issue. Brock Chisholm, the first director-general of the World Health Organization, said in 1949 that ‘the death rate from pulmonary tuberculosis is now everywhere accepted as a sensitive index to the social state of a community’.


Margaret Chan, the current WHO director-general, also understands this, as well she might. In her opening address to the Rio conference she said: ‘Governments have responsibility towards people and their health… People are pushed into poverty due to catastrophic medical bills, and many governments are not preventing that. Progress in a civilised world should mean more than simply making more and more money. Globalisation was set to be the rising tide that would lift all boats, this never happened. It lifted the big boats but tended to sink many of the small ones. Globalisation creates benefits, sometimes big ones, but has no rules that ensure the distribution of those benefits. The world now is highly interconnected, but the prevailing goal remains to fulfil economic benefits and not to distribute them fairly or evenly. As a result differences in income, access to care, health outcomes are greater today than in any time in history’. Well said, but it would have been nice if  Dr Chan stayed until the last day when the Political Declaration was presented. Instead, she left the night before the Conference ended. Is there a hint here?


Public health is not technical, it is political


The social determinants of health cannot be addressed by fixes that address policy coherence and inter-sectoral action in health, as is being called for. Platitudes like ‘inter-sectoral action’ and ‘policy coherence across sectors’ do nothing to address the continuing violation of the right to health. It is not policy incoherence that causes the negative impact of dominant macro-economic policies on health. Actually there is significant policy coherence across sectors, including the health sector. But these policies have been greatly influenced by the currently dominant political and economic ideology. This is the issue. It has promoted a ‘market’ approach that in effect privatises public health.


Why is this continually glossed over? Why are the features of what is a reckless and ruthless not recognised? Corporations remaining free to do whatever they want to protect their bottom line. Capital flight, and a continued unfair regime of patents especially of medicines are all widening health inequities in health, across the world. This is why obesity and diabetes have become not merely epidemic, but pandemic.


For us at the People’s Health Movement, comprehensive primary health care is the backbone of any equitable health system, but it cannot be supported without active community involvement. The same is true for nutrition.


Primary health care needs publicly provided, publicly accountable health care services, working in partnership with the communities from which the people who become patients live. It involves working with community networks and organisations and engaging with communities. This can never be properly provided by private systems whether or not these are supported by health insurance schemes. Health care provision has been increasingly privatised over the last three decades. Indeed, Big Pharma has become less and less regulated. Poor social policies and programmes, unfair economic arrangements, and bad politics, are robbing an increasing proportion of populations all over the world of the opportunity to lead healthy lives. Reduction of public health and nutrition inequities depends on reform of the global economy and of geopolitics generally.


The evil of ‘trade-offs’


Taking an non-political approach to such issues by saying, as we constantly hear,  that conflicts and trade-offs between the interests of different sectors are inevitable, or that taking necessary actions will result in some negative impacts or costs for some groups, is mistaken. Differences among countries, between social classes, between men and women, between corporations and communities, can be reduced. These all are caused by the power politics that determine which actions will be taken and which will not, on the social determinants of health and nutrition. Willingness to transfer real power to communities is the key.


This is what we in the People’s Health Movement reminded delegates, in our own statements made before and during the Rio conference. But relentless pressures from the US and Europe continue to force governments of vulnerable and impoverished countries to sign up to basically unfair free trade agreements. These agreements force weak government to open their markets to – among many other items – the ultra-processed food and drink products that enrich and further empower transnational corporations. Reform of the global agricultural trade regime has continued to stall for years. Food systems thus become increasingly insecure and fragile.


The combination of the opening up of markets to the transnationals, massive subsidies to agribusiness in the North, and intellectual property rights that unfairly protect big business, gives increasing power to the transnational seeds, agribusiness and food and drink corporations, and undermines national food sovereignty. This process continues to accelerate. Thus between 1990 and 2001, foreign sales of the biggest food-related transnational corporations rose from $US 88.8 billion to $US 234.1 billion, with total foreign assets rising from $US 34.0 billion to $US 257.7 billion. These corporations increasingly dominate the global food supply system, which includes seeds, fertilisers and pesticides, the production, processing and manufacturing of food and drink products, and how these are marketed to consumers.


This trend, together with factors like speculation that creates chaos in food prices, the increasing proportion of US corn being used for bio-fuels, and the impact of industry-generated climate change, is primarily responsible for the recent critical food shortages in many impoverished countries. Food price increases and fluctuations in the last few years have done enormous damage to the reductions achieved in poverty and hunger in the past two decades. Such food insecurity has contributed to continuing widespread malnutrition, as evidenced by high stunting rates and micronutrient malnutrition, with an estimated 854 million undernourished people worldwide in 2001-2003. The UN Food and Agriculture Organizations estimates that food price rises alone have caused at least 50 million more people becoming hungry. At the same time, supplies of degraded ultra-processed snack products, sugared drinks and other degraded edible substances continue to erode and destroy previously established rational food systems, and are causing rocketing rates of obesity, diabetes and other chronic disease. Unless unfair social, economic and political regimes are successfully challenged, these pandemics will get worse. ESTIMATES THAT FOOD PRICE RISES HAVE RESULTED IN AT LEAST 50 Gender issues are not ‘one of those things’


The global distribution of child and maternal malnutrition and mortality illustrate the significance of unequal power relations. Unequal gender relations are not easy to change. An important first step is to acknowledge that these exist and that they are maintained by prevailing political and economic policies. Practical steps towards women’s equality and empowerment must be taken.


Examining of the processes that led to the Rio conference, it was hard to believe these steps were really serious. They mostly evaded analysis or even acknowledgement of the power relations which maintain health and gender inequalities. People are poor because they live within unjust societies.


Now, after the Rio conference, let me acknowledge and highlight the commitment of so many representatives of the Brazilian government and civil society, in supporting and inspiring us in the People’s Health Movement. Interventions in Rio, from that of the Minister of Health to those of Brazilian grassroots organisation representatives, resonated with us. Other ministers of health from Latin America resisted the dilution of statements in successive drafts of the Political Declaration. In the final Declaration it was evident that they had lost some, but also that they won some.


The corporations, governments and other institutions that perpetuate the new world must be confronted. The mandate of WHO includes assistance to member states in addressing the ‘causes of the causes’ of malnutrition in all its forms. The rights-based approach to health equity provides WHO with a strong mandate to direct and coordinate realisation of equitable universal primary health care coverage. The right to health is enshrined in the constitution of WHO and in that of over 130 national constitutions. This needs to be used as a powerful tool for legalisation, enforceability and implementation of policies very urgently needed to enhance equity between and within nations.








The planners of the Rio conference on the social determinants of health constantly stated that its emphasis should be on practical initiatives designed to address inequity. These are conspicuous by their absence in the conference’s final Political Declaration. 


Yet there are many practical examples of courageous countries and communities finding ways of managing national and international economic relations equitably. There is much to learn from such examples.


Confronting the power of transnational corporations in areas most relevant to global and national states of health is within the mandate of WHO. Thus, WHO has led the way in developing a global regulatory regime for tobacco control. After Big Tobacco, the next targets for rational and equitable regulation must be Big Booze and Big Snack.


Due to the economic crisis that impoverished countries did nothing to cause, there are now 200 million more people living on less than US$ 2 a day, existing in distress, malnutrition and ill-health. The international bankers and their representative organisations must be held accountable. They must contribute to addressing the vast resource gap in health, for example by paying a Tobin Tax on financial transactions. WHO member states should champion such an approach, which after all is in their own interests.


The danger now is that some countries may face the issues of the social determinants of health, but do so in a medicalised and individualistic way, by focusing on ‘risk factors’ and ‘individuals’ lifestyles’. But the real challenge is to renew relatively equitable politics and economics that truly will go towards ‘closing the gap’. We in the nutrition, public health and medical sectors are the professionals who patch up sick societies. There is ultimately not much we can do, unless we also engage politically.


The People’s Health Movement was present in force in Rio. We are thankful and feel this is a good sign. There, we were able to speak out what we believe in. We distributed our unofficial Political Declaration, which has been and evidently is being studied avidly by people in the UN system and national governments. And we have now launched our  fresh-off-the-press third report, Global Health Watch 3 ( ). We believe we are making our mark. The change will come. It must come.





1                Commission on the Social Determinants of Health. Closing the Gap in a

            Generation. Health Equity Through Action on the Social Determinants of Health.

            Geneva: WHO, 2008.

2                Marmot M. Closing the gap in a generation. Bulletin of the World Health

            Organization 2011; 89, 702.



Please cite as: Schuftan C. The Rio Social Determinants Conference [Column] Website of the World Public Health Nutrition Association, November 2011. Obtainable at





Social Medicine Course in Northern Uganda (2012)


We invite you to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.

For more information, we invite you to please see our website at: In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: and 2011:

If you have any questions or are interested in applying, please email us at Applications are due July 31, 2011.

Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)

State-Sponsored Oppression: the unjust and outrageous life sentence of Dr. Binayak Sen

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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 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.

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 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:

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.