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 (www.alames.org ); and one from the International Federation of Medical Students’ Associations (www.ifmsa.org ). 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).
THE RIO SOCIAL DETERMINANTS MEETING
EPIDEMICS ARE GREAT WARNING
SIGNS AGAINST WHICH THE PROGRESS OF
CIVILISATIONS CAN BE JUDGED
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 PEOPLE’S HEALTH MOVEMENT
SPEAKING OUR TRUTH TO POWER
AND MAKING OUR MARK
THANKS TO WHO AND TO BRAZIL
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 (www.ghwatch.org ). We believe we are making our mark. The change will come. It must come.
References
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 www.wphna.org
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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.
Dr. Binayak Sen has worked for many decades with the poorest of the poor. He is well known as an advocate for health and social justice, an outspoken critic of police brutality. Apparently, his effectiveness is such that the Indian Government feels the need to silence him.
Go to http://www.binayaksen.net/ to learn more about the intricacies of the case and the condemnation of the court ruling, including a recent article concerning Nobel Laureate Amartaya Sen in the Times of India, in which he is quoted as saying: as an Indian citizen and a human being, I must exercise my own judgment to ask if this is correct. Sedition means pulling the state down by violence. It cannot be suggested that Binayak did this. On the contrary, his writing indicates violence is wrong. There is a deep moral argument against sedition here [in Binayak Sen’s book]. Amartaya Sen goes on to say of the ruling against Binayak Sen: It has a threatening nature and seems to have political motivation. Any intelligent person would find that the judiciary acted very peculiarly. I hope the high court or Supreme Court quashes this.
Dr. Binayak Sen is a member of Jan Swasthya Abhiyan, the PHM (People’s Health Movement) India. He has touched the lives of many—and this is perhaps considered his greatest crime, the crime of being a positive example.
Dr. Binayak Sen was first arrested in 2007. Though he has severe cardiac disease, he was kept without adequate treatment for two years—until an international campaign, including several Nobel laureates, achieved his provisional release on bail.
When a government punishes work dedicated toward health and social justice, it is making a statement that is global in nature. Its action must then be denounced globally. Please consider acting now in solidarity with Dr. Binayak Sen. Address the government of India with its own shame, by signing the petition directed to The President of India, Rashtrapati Bhavan: http://www.petitiononline.com/sen2010/petition.html
Consider expressing in print your disappointment that this sentence, egregious and wrong, has happened. Inquire into the health, not just of Dr. Binayak Sen, but of the patients who he has not been and will not be able to attend to because of his sentence. Demand that, in the name of justice, as well as health, the sentence be refuted (still legally possible by the Supreme Court of India) and his work instead granted the affirmation it deserves.
Please share what is happening to Dr. Binayak Sen with colleagues, local community members and your own government representatives, no matter where you live. Consider writing to him yourself, to express your solidarity and your appreciation of his example.
Some have calculated that, with current development trends remaining the norm, poverty will be eradicated in something like 70 or more years.
It is fitting to devote this column to the MDGs since the UN just deliberated over them thirty days ago as we reached the 2/3 mark to 2015.
At the People’s Health Movement (PHM), we consider ourselves to be MDG-skeptics. For long now, we actually have been trying to create awareness of the MDGs limitations and have therein been playing a veritable devil’s advocate role.
You may ask: Why being MDG-skeptic? For starters, we want you to agree with us that achieving the MDGs will only result in modestly advancing global health and nutrition …if at all.
I will thus here try to convince you that ‘having the passion’ is not enough. Given a long past experience, this alone risks ending up with many words and many promises.
Why do I try this? Because civil society inputs are vital in this debate. Yes, indeed vital: But not as ‘MDG yesmen’ (or yespersons to be gender correct).
Ultimately, I want you to be convinced by this column that the fallacy we need to uproot is that health and nutrition programs addressing the urgent needs of women and children implicitly address equality and human rights.
In the human-rights-based approach (HRBA) nothing is left implicit!
I also want you to agree with us at PHM that the MDGs operate too much using a ‘deficit-filling approach’ to poverty and to address preventable ill-health, preventable malnutrition and preventable premature deaths. It is not about filling the last bit of the cup; it is about refilling it from the bottom.
Poverty, ill-health and malnutrition are the result of the ongoing process of social exclusion; and the HRBA specifically explores the critical exclusionary mechanisms that need to be tackled –now! Consequently, concrete demands need to be placed on duty bearers –now– because where someone has a right, someone else has a duty.
Gone are the days of us ‘working with beneficiaries’: We are now to talk about ‘mobilizing rights holders’ (claim holders) to demand changes they are due.
The implication of this is crystal clear: Political forces cannot be fought with morals and technical fixes. Therefore, we believe that acting politically is the way to reach ground zero in nutrition work.
Why?
The easiest and shortest way to answer this question here is to elevate a number of truisms about the MDGs to the category of ‘mini-iron-laws’. They would be the following:
We think MDGs suffer from:Donor overinfluence, technical overemphasis, inattention to action on underlying social and economic inequalities, lack of systematic long-term financial commitments, and a predominant focus on health and education rather than on the entire political economy.
Further, MDGs:
Perpetuate a focus on communicable diseases.
Encourage quick-fix technical approaches.
Offer too little too late and are not really new, but rather rehashed versions from earlier goals set by the international community. [As somebody said, The Alma Ata Declaration of 1978 can more fittingly be called “the people’s MDGs”].
Emphasize average outcomes across an undifferentiated population. [At that, they focus on outcomes disregarding the processes through which we are to achieve them].
Mostly provide a template-of-targets-for-the-bureaucratic-mind.
Do not recognize that poverty is a function of human rights violations.
Posit housing, health care, and access to food and water not as non-negotiable and universal human rights, but as ‘needs’ to be met.
Infuse neoliberal priorities into development policies often using just the language of human rights so that, ultimately, they attempt to wash the face of neoliberalism by emphasizing what is possible and doable …for donors and the market.
Do not represent a development paradigm break; they are instead a set of indicators embedded in a paradigm –the neoliberal paradigm.
Were set arbitrarily…from the outside…in the North…resulting in what some consider ‘the ghettoization of the problems of development’. [They can thus be seen as the-goals-of-the-rich-countries-for the poor countries].
Call for change, but not for creating the conditions to make real needed structural change possible.
Pay scant attention to the roots of inequality.
Seek to “eradicate extreme poverty and hunger” (Goal 1), but rely on the discredited notion that economic growth at the national level (GNP) can eliminate poverty
Do not denounce bad governance of the G8 countries or of the IFIs.
Are not an expression of governmental goodwill; rather, they constitute pre-set international obligations.
Have failed to provide a real sense of ownership either by poor countries’ governments or their civil society actors.
Are not global at all; they place all responsibility on the separate national governments with no global authority really in charge of their enforcement. (G. Kent)
Have actually provided something that pretends to be a moral compass together with a set-of-yardsticks to measure some types of progress; they have been too much of a counting and accounting exercise.
Disregard the effect of trade policies on malnutrition. [The negative consequences of current unfair international trade policies are actually one of the major oversights of the MDGs].
Fail to even mention women’s labor and property rights, or one of the most fundamental obstacles to ensuring these rights, namely, violence against women, and finally assume that privatization of services is a strategy-for rather than an obstacle-to economic development and improved nutrition.
All these mini-iron-laws should make make one wonder: Are MDGs just another attempt to achieve good looking statistics?
[Regrettably, you have to recognize that MDG-driven agencies feel tempted to manipulate statistics].
MDGs actually miss what most matters to people who happen to be poor (‘the bottom billion’): They overlook or ignore issues of risk, security, respect, status, dignity, voice and livelihood vulnerability –all more important to this group than mainly income and consumption issues. Moreover, let’s face it: none of the goals can be achieved without empowering women and without recognizing the centrality of decent employment (a human right). Furthermore, keep in mind that a) debt relief is a precondition for even keeping-up the hope of meeting the MDGs, and b) market liberalization strategies have been oblivious to the MDGs. [Transnational corporations are certainly not geared to invest in helping achieve them, are they?].
At PHM, we think the MDGs approach can be described as ‘human development meets results-based management’. [This said, one could wonder, is there truth in the sarcastic view that the MDGs should really be an acronym for ‘Most Distractive Gimmick’?].
For all these reasons:
The MDGs approach badly needs rethinking. We badly need a post-MDGs architecture (or one earlier than ‘post-‘, in an attempt to minimize harm and disenchantment come 2015).
Since it is human rights violations that are the raison d’etre of all MDGs (!),
applying the internationally agreed human rights framework to the MDGs approach (or replacing the approach outright) will put the spotlight on the discrimination and social exclusion gaps that we see as the most significant human rights gap in the current application of the MDGs.
In all of this, what civil society organizations are failing-us-in is in challenging the system that day-in-day-out recreates the condition of poverty as the common determinant behind all MDG-related violations of the right to nutrition. It is time for NGOs, and for colleagues affiliated with Social Medicine, to hold duty bearers to account. Yes, this is political. But can our affiliates remain aloof of politics?
What all this will mean to the agenda of all of us is what I encourage you to react to at the bottom of this column.
At the heart of the MDGs beats a fundamental contradiction: poor countries are expected to meet the MDGs by implementing the very neoliberal economic policies that have, in large measure, caused the problems that the goals are intended to address.
At PHM, we fear that, after 2015, we will have achieved nothing more than isolated islands of progress in a sea of remaining grievances and persisting human rights violations. [By sticking to the MDGs paradigm, inequalities are staring us in the face now, but will be shouting at us after 2015].
Why do we say this? Because the MDGs need not only to be attained, but also sustained long term –post 2015. [Our own George Kent satirizes the issue by proposing that, on new year’s eve 2015, we distribute a few million sandwiches to hungry children the world over so that come January 1 we will have halved hunger of under fives].
All this body of argumentation explains why I reject targeted pro-poor policies including in nutrition work; we ought to be fighting for anti-poverty policies (or rather disparity reduction policies). Poverty reduction without redistribution is only to be seen as flimsy rhetoric. Political power is a crucial precondition for a country to rise out of the poverty trap once and for all.
We need to grapple precisely with those phenomena that the MDGs take for granted, because they all affect malnutrition.
Why? Because, how can we be content with wiping out malnutrition for half the mothers and children by 2015 when that goal is possible for all of them?
Being realistic: Inequalities will remain entrenched even if the MDGs are achieved.
As Vicente Navarro says: It is not inequalities that kill people. It is those responsible for these inequalities that kill people.
What we need to focus-on are the processes that will lead to overcoming malnutrition (or achieving any of the other goals); and those processes have to be bottom-centered. Without the proper participatory processes, MDGs as outcomes may mean nothing (like a modern Christmas toy….without batteries). The process must ‘pull’ needed changes and not be the conduit for ‘pushed’, often packaged, solutions.
Had we insisted early-on on each district achieving the MDGs would have been the equitable alternative to national MDGs; in that way, one would have served the predominantly poor and minority districts. But national averages will still mean that the half of the people below the average will be suffering from ill-health, malnutrition and preventable deaths.
Civil society organizations that have not adopted most of the above badly need to go into a retreat to revision and remission their role so that they stop being part of the problem and become genuinely part of the solution. If they stick to the old ways of service delivery, food distribution, nutrition rehabilitation… the time has come for them to be named and shamed.
The rhetoric-action gap has to be stopped. NGOs cannot be shy or human rights blind any longer; they have to take issue with the social determinants of health and nutrition.
This means NGOs cannot only use a human rights ‘lens’, use human rights implicitly in their work, add a ‘human rights perspective’, have ‘human rights projects’, or ‘mainstream human rights’. They have to embark in human rights-compatible programming fully using the human rights-based approach by now well delineated. This is not a matter of choice anymore; NGOs have to decide what?, how? and when? to move in this direction. This, because governments have to simply be pushed to take up their international responsibilities towards nutrition. NGOs will have to shift their work from a welfare perspective to an economic justice perspective. Any path chosen using the latter will have to entail transforming economies more structurally.
This will require extensive human right learning as a means to more proactively engage in a true human rights dialogue with claim holders and duty bearers.
It is no news that the world is increasingly shaped by powerful global forces, the action of many of which have dire consequences for the right to nutrition and for the social, political, economic and environmental factors that influence all MDGs; the latter factors are increasingly determined at a supranational level. As a result, local and national level efforts to influence the determinants of malnutrition can have only a limited impact. It is thus all too easy for the individual health and nutrition practitioner in the public sector to feel powerless. Yet while these practitioners, on their own, may indeed be relatively powerless, together they can achieve a great deal –and that is the role the People’ Health Movement has taken up (www.phmovement.org) …and the one Social Medicine readers should be considering.
Bottom line:
Real life is more complex than MDG slogans.
The poor and the marginalized are not where they are by accident.
The objectives we should strive for are not to stabilize the problem of malnutrition, but to make it disappear by tackling it at the roots.
Not all the problems of malnutrition are structural. Granted. But if the latter are not addressed the chances of the MDGs advancing global health and nutrition are nil.
We have to avoid ‘othering’ people as ‘poor’ and thus as inferior to the non-poor. (Isn’t that what the MDGs implicitly do a bit –or a lot?).
The shortcomings of the MDGs depicted in this column should be denounced publicly to demystify the ‘silver bullet’ aura of just pointedly going-for and achieving the eight MDGs.
The MDGs cannot be achieved without respect for human rights overall and in particular for minority and women’s rights. They cannot be achieved without redistributive steps either. (But beware: Redistribution always takes place: just not from the rich to the poor!).
So, in the name of the wretched of the earth, are we to change the world? Or are we the victims of those who have the power to change the world? If the second is the case, is what we usually discuss in our professional meetings going to change things? [Food for thought here: Was this taken up in our just concluded meeting in Portugal?].
To close, I would like to share with you the real existential doubt I have: Do we actually live in a world of high-flown objectives, ambitious target setting and obscure acronyms?
Postscript:
Before I leave you, were you aware:
that the promises of the rich countries are not quantified in the MDGs paradigm? (The obligations of the poor countries are! …this assumes poverty is a problem of poor people only, right?).
that a dramatic overlooked point in the Millennium Declaration and the MDGs is that inflation is likely to make the-year-2000-1U$/day a mere 60 cents/day by 2015?
that, in the case of the nutrition MDG, official responses, so far, seem to be more concerned with quelling or preventing food riots than with addressing the underlying and basic deeper causes of chronic malnutrition? (G. Kent)
that, if current trends continue, by 2015, 3.7 million more children in Africa will suffer from malnutrition than today?
that China, Cuba and Vietnam have long focused on core MDG concerns, but have simply not labeled them as such?).
We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:
Course Invitation 2011
We invite you to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).
For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.
Sincerely,
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115
We invite medical students to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).
For more information, we invite you to view the short video about this year’s course, available at:
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.
Sincerely,
Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)
Two articles in the Perspectives section of a recent issue of the New England Journal of Medicine (May 6, 2010) provide an interesting view into the state of the U. S. public health system. In the first, Dr. Howard Koh provides an evaluation and reaffirmation of the Healthy People initiative, started in 1979 by the Department of Health and Human Services as a way of systematically setting health goals, collecting relevant data, and monitoring outcomes for health-improvement activities in the U.S.(1) He points out that while small but measurable improvements in quality of life have been acheived in the last decade, the goal of eliminating disparities in health outcomes has been largely unmet. In the second, Dr. David Hemenway, laments the state of funding for public health in the U.S. and attempts to explain the underfunding of public health measures.(2) Taken together, they highlight a trend that is widely understood by advocates in social medicine: underfunding of public health initiatives directly impacts the level of disparity in health outcomes.
Healthy People 2010 focused on two main goals: increasing quality (and quantity) of life for Americans and eliminating health disparities. Dr. Koh demonstrates that the results have been mixed. For 28 focus areas, ranging from access to quality health services to oral health to vision and hearing, just over half have seen improvement and nearly 20% have seen their target met. By some measures, we have either remained discouragingly far from stated goals or actually worsened. Cigarette smoking, for example, which is the leading cause of preventable death worldwide, decreased from a baseline of 24% in 1998 to 21% in 2008, far from the stated goal of 12%. We are significantly more obese as a nation than we were ten years ago. Approximately 1/3 of all adults over 20 years of age are obese, up from under ¼ two decades ago. Unfortunately, the gains and losses in the health of Americans are not equally shared. The goal of eliminating disparities remains, according to Koh, “unmet.” Increased rates of obesity, for example, are greater in Blacks and Mexican Americans than they are in Whites. Dr. Koh cites a review by Sondik et al (3), who demonstrate numerous examples of increased disparities in indicators of quality of life and overall health. They conclude that “overall, in the area of disparity reduction, there is not much good news.”
Dr. Hemenway points out that “it is generally acknowledged that public health is systematically underfunded and that shifting resources at the margin from cures to prevention could reduce the population’s morbidity and mortality.” He cites four reasons for the underfunding of public health: first, the benefits of public health measures are not immediate and therefore require a delay of gratification. The costs are immediate but the results are both distant and unpredictable. Second, “the beneficiaries of public health measures are generally unknown.” Money flows more readily towards identifiable victims than hypothetical victims of future events. Third, the benefactors of public health intitiatives are unknown by the beneficiaries: “when people benefit from public health measures, they often don’t recognize that they have been helped.” The current TEA party movement provides a wonderful, if tragic, example of this, blind as it is to the concrete benefits of taxes and government. Fourth, public health efforts often suffer from disinterest or, worse, outright opposition. Hemenway cites “status quo bias” and “tradition-bound resistance” as examples of human characteristics that impede progress in public health initiatives.
It is reasonable to hypothesize that the systematic underfunding of public health initiatives contributes directly to disparities in health care. And it is likely that the Healthy People Initiative will never realize the goal of eliminating disparities until public health funding can be consistently and meaningfully funded. After all, it is the poor, the under- and un-insured, who tend to benefit most from public health initiatives like vaccinations, clean water supply, and clean air, and who suffer disproportionately in their absence. Michael Harrington, in his landmark book, The Other America (1962), wrote about an America that was “hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.” Nearly five decades later, these problems have not gone away. As Healthy People 2010 comes to an end, in some cases they are worse.
It might be tempting to use Healthy People 2010 as an example of the ineffectiveness of public health initiatives. Or one could argue that the Healthy People initiative sets unrealistic goals. I would argue that the US government has a chance to prove otherwise with Healthy People 2020. As the DHHS plans for the next decade, healthcare professionals must push our legislators to assure adequate funding for the public health initiatives that improve all of our lives in unseen but measurable ways. We must urge them to block out the loud voices of those who would stop paying taxes without knowing what taxes pay for. Finally, and most importantly, we must ask for more coordination between those that initiate public health interventions and those that measure the results. Those who implement public health programs must work directly with those who establish goals for their efficacy. Measuring our own failure can only be of value if we have the means to turn it around.
1. Koh H. A 2020 Vision for Health People. NEJM 2010;362:1653-6.
2. Hemenway D. Why We Don’t Spend Enough on Public Health. NEJM 2010;362:1657-8.
3. Sondik EJ, Huang DT, Klein RJ, Satcher D. Progress toward the Healthy People 2010 goals and objectives. Annu Rev Public Health 2010;31:271-81.
Both for those readers who will be attending next week’s APHA (American Public Health Association) Convention and particularly for those who will not be there, we wanted to share this year’s Spirit of 1848 sessions.
Berlin Revolution, March 1848
The Spirit of 1848 is happy to share our final program for the 137th annual meeting of the American Public Health Association, with the theme of “Water and Public Health” (November 7-11, 2009; Philadelphia, PA). SESSIONS
All Spirit of 1848 sessions will be held in the Philadelphia Convention Center (hereafter referred to as “PCC”).
Monday, November 9, 2009
10:30 am to 12 noon:
The Social History and Politics of Water and Public Health (Session 3162.0, PCC 113A)
10:30 am
INTRODUCTION: Social history and the politics of water and public health.
Anne-Emanuelle Birn, MA, ScD
The introduction will lay out key factors in critically examining the social history and politics of water and public health, especially in relation to water access and sanitation. Examples of the politics of past political and social struggles for the right to water and sanitation in Europe and throughout the Americas will be used to set the context for the papers presented in the session.
10:35 am
Unclogging obstacles to water and sanitation coverage: the promise and perils of comparing Philadelphia’s history with the crisis in the developing world.
Niva Kramek, MES and Katryn Bowe, BA
Less than one hundred years ago, annual typhoid outbreaks in Philadelphia killed more than 400 people each summer for 30 years. Contaminated drinking water and the lack of a system for removing human and animal waste plagued the city, presenting many of the same public health challenges facing developing cities today. Using Philadelphia’s water history as a case study in conjunction with current practices in several developing locations, this paper will address essential issues confronting clean water and adequate sanitation: political disregard for water issues until moments of crisis; complex trans-boundary cooperation requiring a watershed perspective; the inability of epidemics alone to prompt action; persistent difficulties in financing these systems; and deep-rooted taboos surrounding human waste that discourage changing norms. Efforts to provide clean drinking water and wastewater treatment that is environmentally and economically sustainable benefit from understanding how contemporary challenges were addressed in the past. As the first city in the world to provide free drinking water and as an innovator in centralized water delivery methods, Philadelphia’s history provides inspiration. However, though understanding history can prevent repeating past mistakes, directly copying what once worked misses opportunities for more equitable, efficient, and sustainable development driven by the unique character of many areas, and of economic, technological, and social advances. Philadelphia’s mistakes demonstrate what to avoid, and it has much to learn from innovations in today’s developing areas, at a time when waste must be used as a resource and small scale technology and financing have become important tools.
10:55 am
Building inequality: sewers, civic ideals, and public health in Los Angeles, 1873-1891
David Torres-Rouff, PhD
Infrastructural development is a critical historical process within which to explore the relationship between water, human rights and public health. Throughout the nineteenth century, civic leaders in U.S. cities built sewer systems to enhance the purity of municipal waters and improve public health. Los Angeles’ city council began building sewers in 1873, converting miles of open water canals, or zanjas, into underground sewers over the next twenty years. While not an unusual aspect of urban development, sewer building in Los Angeles commenced following the resolution of an acrimonious, fifteen-year long battle between Mexican Californians, who advocated common ownership and equitable, cost-free distribution of the city waters, and Anglo Americans who preferred private ownership, fees for service, and the separation of waste, agricultural, and potable waters into separate pipes to improve the “purity” of the water supply. Following a decisive political victory in 1872, Anglos built a sewer system that fundamentally altered people’s relationship to water, converting it from a communal resource into a commodity. However, city leaders failed to build sewers where Mexican and Chinese Angelenos lived. In addition to exposing these neighborhoods to greater health risks, unequal sewerage created experiential asymmetries between Mexican/Chinese and Anglo American districts, provoking condemnations of Chinese and Mexican residents as dirty and diseased. Over time, these stereotypes have worked in lock step with the spatial and institutional barriers resulting from infrastructural inequality to limit marginalized populations’ claims to human rights in Los Angeles.
11:15 am
Critical reflections: on history, culture, and struggles over access to water and sanitation.
David S. Barnes, PhD (discussant)
As discussant, I will reflect critically on the presentations included in this session, emphasizing the practical value of historical perspective and attention to cultural factors in contemporary struggles over access to water and sanitation.
11:30 am
Question & answer period
Monday, November 9
2:30 pm to 4:00 pm:
Macroeconomics, Political Systems, and Population Health and Health Inequities (Session 3361.0, PCC 108B)
2:30 pm
Introduction to Politics of Public Health data session
Catherine Cubbin, PhD
2:35 pm
Health inequities in global context: evidence from the World Values Survey.
Jason Beckfield, PhD and Sigrun Olafsdottir, PhD
The existence of social inequalities in health outcomes is well established in social science research from multiple disciplines. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between aggregate inequality and population health across countries. Despite the theorization of (presumably variable) social and political conditions as determinants of population health and health inequities, the cross-national literature has focused on population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality, the welfare state, and economic development. We argue that these debates would be advanced by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from the third wave of the World Values Survey, we examine cross-national variation in inequalities in health. The results reveal dramatic variation in variations in health according to income and education. We find that this variation in the socioeconomic gradient can be partially accounted for by cross-national differences in economic development, population health, and, especially, income inequality. We conclude by discussing the implications of this research.
2:55 pm
Income support and women’s health reform in developing countries: the impact of microfinance.
Deborah Viola, PhD
Health systems and pathways to better health are shaped by the economic environment and the social structures and political forces that govern each country. The objective of this study is to highlight the link between globalization and women’s health reform by specifically considering the World Trade Organization Agreement on Agriculture (AoA), the microfinance response, and their health impact on women in developing countries. Low socioeconomic status has been linked to a great burden of disease and death in developing countries. Studies have illustrated the impact of the AoA on decreased earnings and employment, poverty, and reduced access to education and health care services. These burdens further exacerbate existing gender inequalities within developing countries, since agriculture practiced by the poor is often considered “women’s work.” Several studies have explored the role of microfinance in rejuvenating urban agriculture and putting poor women “back to work.” However, researchers have rarely tested whether social programs designed to alleviate poverty or otherwise improve economic well-being for large segments of the population are linked with health improvements. Further, researchers have questioned the merits of existing quantitative analyses in capturing the impact of economic and development policies on women’s health status in developing countries. We present preliminary qualitative case studies of women and the use of microfinance to suggest that such a relationship does exist and demonstrate the need for more empirical, multidisciplinary work to be done in this area if we are to truly impact women’s global health.
3:15 pm
Public health implications of economic recession.
Jessica M. Robbins, PhD
Based on literature review and local health informants, we attempted to assess foreseeable public health effects of economic recession, with a specific interest in effects that could be addressed by local public health action. Poverty, unemployment, and financial strain are incontrovertibly associated with increased mortality and poorer health in all populations, but whether and how these effects change during recessions is unclear. Overall effects of recession on mortality are disputed, but considerable evidence suggests that at national levels cardiovascular and total mortality usually decline during recessions, while suicide may increase. Birth rates may decline, but no studies on specifically urban populations confirm this. Mental health symptoms appear to increase during recessions for the employed as well as those losing work. Increases in distress and morbidity may disproportionately affect women. Pessimism and uncertainty about the future are strongly associated with ill health. Effects on smoking and alcohol use are complex, as population-wide both usually decline during recessions, although the unemployed may be least likely to quit smoking. Negative health impacts of unemployment may be most severe at the time when job loss occurs. Early accounts suggest that, in Philadelphia, individuals are postponing or forgoing needed hospital-based medical care. More patients are using public health clinics, and more of them are uninsured. Evidence on the effects of recession for specific population groups, including vulnerable populations and different age groups, is largely unavailable. Policy implications and areas in which local public health efforts might be effective will be discussed.
3:35 pm
Nancy Krieger, PhD (discussant)
As discussant, I will reflect critically on the presentations included in this session, as framed by a discussion of the importance of analyzing political systems and priorities is essential for understanding and improving population health and rectifying health inequities.
3:45 pm
Question & answer period
Monday, November 9, 4:30 pm to 6:00 pm:
Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science (Session 3438.0, PCC Auditorium)
4:30
Introduction: Indigenous Methodologies in Public Health Research: An Issue of Social Justice & Good Science
Nancy Krieger PhD
In this introduction, as Chair of the Spirit of 1848 Caucus, I will briefly describe the origins, objectives, and format of our session, whose content was jointly organized by Vanessa Watts and Suzanne Christopher. This session will focus on methods for advancing discussion and practice of the use of Indigenous methodologies in public health research. Many researchers involved in research with Indigenous peoples have raised questions regarding whose perspective is informing the research process and what it means for those involved. Indigenous methodology is an approach to culturally appropriate knowledge production and dissemination. The purpose of indigenous methodologies is to ensure that research is done in a respectful, ethical manner that is valuable and useful from the view of Indigenous people. In this session, we will explore these issues in relation to the three themes of the Spirit of 1848 caucus: (1) the social history of public health, (2) the politics of public health data, and (3) progressive pedagogy, and our overall focus on links between social justice and public health.
4:35
Legacy of conventional research with Indigenous communities and its relevance to current public health research.
Suzanne Christopher, PhD and Vanessa Watts, PhD
Recent theorists and commentators have pointed out the history of deleterious effects brought about by conducting research conventionally in Indigenous communities and with Indigenous individuals. We summarize this research and explore the relevance of this history to current public health research. Much of the previous conventional research is regarded as an expression of colonialism because it has exploited, marginalized, ignored contributions, pathologized and problematized communities and individuals. Using examples from the UN Principles and Guidelines for the Protection of Indigenous Heritage and UN Declaration on the Rights of Indigenous Peoples, we will discuss rights that Indigenous people have regarding indigenous methodologies and indigenous data. We examine underlying presuppositions and values that gave rise to this conventional research. We end by providing a definition of indigenous methodologies and indigenous knowledge that can be usefully set into dialogue with mainstream public health approaches.
4:50
The politics and purposes of Indigenous public health data.
Bonnie Duran, DrPH
This presentation will provide a brief genealogy of data collection and use (a) about “Indian Country”, and (b) from “Indian Country” and will (c) review current day Tribal recommendations and regulations regarding research approvals and data sharing. The presentation will also provide a brief introduction to the “International Indigenous Health Measurement Group” and other national and international efforts to expand the sources of data and improve the collection, analysis, interpretation and dissemination of information useful for improving the health of Indigenous populations.
5:05
Teaching Indigenous research methodologies.
Felicia S. Hodge, DrPH
Teaching Indigenous research in public health research is a valuable tool to advance the trajectory of health and wellness. Use of Western teaching methods is replaced with storytelling, grounded theory, and group process. Learning how to teach, how to listen, and when and where to place the perspectives of stakeholders addresses the barriers, strengths, and value of Indigenous research methodology.
5:20
Graduate researchers in Aboriginal health & Indigenous methodologies.
Katherine Minich, MHSc and Krista Maxwell, MA, PhD(C)
This paper will explore perspectives on self-location and identity, cross-cultural collaboration and Indigenous methodologies amongst Indigenous and newcomer graduate students doing research in Aboriginal health in Canada. The Institute of Aboriginal People’s Health, established in 2000 as one of the Canadian Institutes of Health Research, has made efforts to develop Aboriginal capacity in health research through its support for national Network Environments for Aboriginal Health Research (NEAHRs). At recent annual national gatherings of graduate students doing research in Aboriginal health through the NEAHRS, close to 50% of participants have self-identified as Aboriginal. Issues of partnerships with Aboriginal communities and ethics guidelines specific to Aboriginal health research have featured prominently in discussions at these gatherings. Less attention has been given to critical reflection on researcher identity, the relevance of Indigenous methodologies, and the complex and challenging power dynamics amongst researchers, and between researchers and Aboriginal communities. We will present on a participatory action-research project with graduate students which aims to stimulate individual and group reflection and discussion on these issues. This project is being jointly developed and executed by an Indigenous and a newcomer graduate researcher, and will be co-presented.
5:35
Native American pedagogy and health.
Brenda Seals, PhD, MPH (discussant)
Native Americans are challenging to reach with health education messages. Many elders and youth grow up with English as a second language. Few public health professionals understand either the diversity of the over 500 federally recognized tribes or the unique history and culture that are essential for effective messaging. Native Americans experience more poverty and substandard quality of life compared to other minority groups. Providing health care and outreach to Native Americans is also complicated by unique access to health care service issues and desires to blend traditional practices with Western Medicine. Despite these barriers, much can be done to improve messaging and education for Native Americans including: a) Building messages around family issues; b) Localizing messages focusing on community members’ experiences, art work and traditional stories; c) Providing story scenarios as the basis for health messaging; and d) Supporting community mobilization to help tribes and urban partners fully participate in and have ownership over health messaging.
5:45
Question & answer period
Tues, NOV 10, 8:30 am to 10:00 am:
Community perspectives on community-based progressive pedagogy (Session 4068.0, PCC 113A)
8:30 am
Introduction.
Suzanne Christopher, PhD and Lisa D. Moore, DrPH
8:35 am
“Will they really use our work?”: The importance of University/Community partnerships in creating relevant service learning assignments.
Jean M. Breny Bontempi and Chris Cole
Engaging public health students in learning the critical skills of conducting community-based participatory community assessments is made much more relevant when they are able to partner and collaborate with the community in a “real world” class exercise. This presentation will highlight an example of successful collaborative work with a community-based organization and a graduate community health education class to complete an agency-wide assessment for the agency’s strategic planning process. The project was designed and implemented entirely with equal partnership between course faculty and students and staff of AIDS Project New Haven (CT). Barriers to requiring service learning assignments, like this, from graduate students include their full-time work schedules, personal lives, and commuting distances resulting in a lack of time needed for students to work on-site at an agency. This experience showed that by taking on a participatory approach to conducting assessments and assigning students to working groups that met their own needs, the success of completing project was increased. The results for students, in working on a real project that will help an organization do its work better, was a motivating aspect of the process was the realization that their work would be used by the organization to improve services. By collaborating with community organizations, linking current public health issues at the local community level, and by researching organizations in the community, students realized that even the most diverse populations can be united by common goals. Making a “real difference” in the “real world” is at once inspiring and empowering.
9:00 am
Community based participatory research as a lens for reconceptualizing service learning: diverse urban students bridging campus and community.
Ester R. Shapiro, PhD, Michelle Rogers, BA, Asi Yahola Somburu, BA, Genita Johson, MD, MPH, Brian K. Gibbs, MPA, PhD, Naomi Bitow, MPH, Roland Smart, BA, and Felton Earls, MD
Service learning usually refers to residential college students assumed to be outsiders to the organizations they serve and focused on student learning and civic engagement rather than community benefit. Traditional service learning models exclude the majority of students enrolled in higher education, including ethnic minority and working-class students, who did not enroll in college full-time immediately after high-school, are commuter rather than residential students, work and care for families, and are already engaged in their communities. Community Based Participatory Research focused on health disparities offers a unique opportunity to inspire these students to undertake health professions and health research careers promoting health equity, through collaborative research addressing community problems in meaningful ways. CBPR research training supports diverse students, themselves carrying the consequences of health and educational disparities, in transforming academic and professional paths in ways that benefit their communities. While often regarded as deficits, first-hand experiences of health consequences of inequality, when combined with learning about the power of knowledge-based social action, inspire students to see participatory research as bridge and foundation for “making a living while making a difference”. This paper presents a collaboration between the University of Massachusetts at Boston, Harvard School of Public Health and Roxbury’s Cherishing Our Hearts and Soul Coalition in mentoring students who are members of communities affected by health disparities to gain research, community organizing, and policy/advocacy skills through CBPR. Presenters include faculty and community mentors and student researchers describing their experiences bridging professional development and community activism through participatory research.
9:25 am
Question & answer period
Tues, NOV 10, 12:30 pm to 1:30 pm:
Social Justice & Public Health: Student Posters (Session 4162.0, PCC Hall A/B)
This session highlights posters prepared by students of public health and health-related programs focused on intersections between social justice and public health from a historical, epidemiological, global, and/or methodological perspective.
Board #1: Evaluating the progress made towards Universal Health care for Philadelphians six years after a successful ballot referendum.
Jenny R. Pahys
Philadelphia is experiencing a health care crisis, specifically among poor and minority populations. After a successful grass-roots campaign, all wards in Philadelphia overwhelmingly approved a ballot referendum supporting universal health care for all Philadelphians in 2003. In response to this political mandate, the authorities instructed the Philadelphia Department of Public Health to act. The Department commissioned a report released in May 2005 titled Decent Health Care for All. Determining that an insurance strategy to provide health care for all Philadelphians was not feasible, this report called for the formation of an influential advisory board to best organize existing resources to efficiently deliver health services to underserved populations, produce strategies for better financing of care to vulnerable populations and to facilitate efforts to integrate ‘safety net’ programs for the uninsured. The mandate as such was thereby derailed.
This project assesses the progress made by the city towards acting on the primary suggestions outlined in Decent Health Care for All. This assessment discerns whether an effective advisory board and a health care agenda have been assembled and whether progress has been made towards the board’s primary objectives. Second, changes in health status of Philadelphians and available health care resources over the ensuing six year period are analyzed against the values underlying the original mandate. Finally, reflections on the progress to date are presented, including an analysis of the obstacles and enablers for change.
Board #2: Infrastructure, women’s time allocation, and economic development: a multidisciplinary theoretical model.
Pierre-Richard Agénor, PhD and Madina Agénor, MPH
Background: Research shows that infrastructure—namely access to safe water, sanitation, electricity, and transportation—may have a sizable impact on health outcomes in low-income countries. The detrimental effects of poor access to infrastructure on health disproportionately affect women—especially poor women in rural areas—who tend to allocate considerably more time to household production than men. No study has explicitly explored the role that women’s access to infrastructure plays in shaping the relationship between gender and economic development using a multidisciplinary theoretical model that draws on macroeconomics, gender studies, and public health. Methods: This paper uses a three-period, gender-based overlapping generations model to investigate how women’s access to infrastructure affects their time allocation and, in turn, economic development. Results: Greater access to infrastructure can increase the efficiency of women’s time allocated to home production and child rearing activities such that they can dedicate more time to market labor, education, and their own health care. These activities have a positive effect on economic development, as healthier and more educated women can make greater contributions to the economy. Discussion: This paper suggests that investing in women’s health is a productive activity, which could be best achieved by improving their access to infrastructure. While government expenditures on education and health contribute to economic development, public spending on infrastructure may have a greater impact on economic growth as a result of its effects not only on access to education and health services, but also on the efficiency of women’s time allocation.
Board #3: Public health and people with disabilities: where we are and where we need to go.
Dorothy E. Nary, MA and Chiaki Gonda, BGS
People with disabilities, one of the largest minority groups in the U.S., have made significant progress in the last 50 years to promote their civil rights. Passage of legislation such as Americans with Disabilities Act of 1990 has increased the participation of people with disabilities in the mainstream of society. Recent public health efforts, including the Surgeon General’s Call to Action to Improve the Health and Wellness of Persons with Disabilities and Healthy People 2010, have documented the health disparities experienced by this group and set objectives to address them. Additionally, the World Health Organization’s International Classification of Functioning, Disability, and Health [ICF] now recognizes disability as “a universal human experience” and takes in to account the social, and not just the medical, aspects of disability. All of these efforts have contributed to improved opportunity and quality of life for people living with a variety of disabilities. However, people with disabilities remain one of the most obese and sedentary populations in the U.S. and still experience significant barriers to accessing health care, health promotion and wellness services. This presentation will provide a demographic profile of people with disabilities in the U.S., explain the barriers to health and wellness experienced by this group, and describe emerging programs to promote their health.
Board #4: Issues in assessment of “race” among Latinos: implications for public health.
Vincent C. Allen, BA, Christina Lachance, MPH, Britt Rios-Ellis, PhD, MS, and Kimberly Kaphingst, ScD
Measurement of individuals’ race/ethnicity is an integral part of assessing and addressing disparities in health experienced by racial and ethnic minorities. However, the measurement of the social construct of race as it relates to Latinos has been the source of much debate. The unique historical and cultural experiences of Latinos related to race and racism has impacted individuals’ responses to measurement approaches. In particular, the selection of “some other race” in surveys (e.g., by 42% of Latinos in Census 2000) is a critical issue to consider. Meaningful characterization of this growing population is becoming increasingly important; however, data collection methodologies yielding ambiguous responses reveal little about the population. This issue has implications for how health data on Latinos is collected, reported, and interpreted, and to whom resources are allocated. The burden of disparities in health experienced by the Latino community makes the need for a more complete understanding of this population of particular importance. This paper examines Latinos’ selection of “some other race” when asked to classify their race, and how this relates to their historical experience and understanding of their racial identity. For example, research indicates that understandings of race among Latinos differ from the predominant U.S. conceptualizations of this construct, thereby affecting measurement. Data collection methodologies also impact reporting of race. We offer recommendations for measuring race and ethnicity in research and policy settings in ways that have the potential to yield more meaningful data that can be used to address the health needs of Latinos.
Board #5: Reducing disparities in emergency preparedness and response for people with disabilities.
Chiaki Gonda, BGS
Typically, people with disabilities are left out of the disaster preparedness and planning process (White, 2008). Recent research indicates that the majority of emergency managers are not trained in special needs populations, which includes people with disabilities (White, Fox, Rooney & Rowland, 2007). Recent major disaster incidents such as September 11 and Hurricane Katrina, Rita, and Ike have revealed disaster response shortcomings of the public health and emergency management systems to help get people with disabilities out of harm’s way during disaster conditions. This poster will describe key findings and recommendations from the research literature and identify resources and strategies to help reduce disparity for people with disabilities during disaster events or other emergencies.
Board #6: Formulating an evaluation and data collection plan for the Baltimore Cardiovascular Health Disparities Initiative.
Sushila Murthy, MPH, MD (C), Shannon Cosgrove, MHA, and Caroline Fichtenberg, PhD
The Baltimore City Health Department is proposing an Initiative to address cardiovascular disease. Cardiovascular disease is the city’s leading cause of death, the leading cause of a 6-year gap in life expectancy between the City and the state of Maryland, and the top reason for a 20-year range in life expectancy among neighborhoods within the city itself. The Initiative, to be launched July 2009, aims to bring successful community-based public health programs to scale citywide, translating research into practice and distributing resources to communities in need. The Cardiovascular Health Disparities Initiative includes five evidence-based components, each intended for populations that bear unequal burdens of cardiovascular disease: (1) health education through faith institutions – for women over 40, (2) disease management by community health workers – for underserved patients with known disease, (3) blood pressure screening and referral in barbershops – for at-risk men, particularly African American men, (4) Salt Task Force, (5) tobacco control. Each component requires careful data-collection and evaluation to assess overall program success and target improvement efforts. This paper will focus on evaluation of the first three components. Challenges include those of translating research into practice, namely having limited resources to increase the scale of interventions and subsequent data-collection. Additional considerations include choosing indicators to compare with State and national data and collaborating with community-based organizations to determine how evaluation tasks fall within their organizational capacity. This evaluation scheme seeks to make the Initiative sustainable and serve as an example for other large community-based programs aimed at reducing disparities.
Board #7: Walkscore.com: a new methodology to explore associations between neighborhood resources, race, and health.
Mark Brewster, David Hurtado, Sara Olson, and Jessica Yen
In recent years, interest in relationships between neighborhoods, the built environment and health has increased. One result of this has been the creation of Walkscore.com. This website allows users to enter an address and retrieve a ranking between 0 and 100, the Walkscore, by which users can then assess an address’s location-specific accessibility to neighborhood resources such as grocery stores, restaurants, bars, parks, libraries, and schools lying within the address’s one-mile radius. We investigated the association between Walkscore and health indicators for 15 Boston neighborhoods. Significant inverse correlations were found between Walkscore and neighborhood prevalence of overweight/obesity (r=-0.75, p=0.001), hypertension (r=-0.75, p=0.020), and lack of exercise (r=-0.60, p=0.018). Additionally, an inverse correlation was found between Walkscore and the percent of neighborhood population comprised by African-American residents (r=-0.61, p=0.001). No significant relationship was found between Walkscore and other race groups or with the percentage of neighborhood residents living below the federal poverty line. These findings suggest that Walkscore may be a promising tool for researchers and policy makers interested in exploring the relationships between neighborhoods and health. Furthermore, when linked with other tools, the relationship between Walkscore and the percent of neighborhood population comprised by African-American residents introduces new potential to ask and answer, through a historical and spatial lens, integrative questions relating health inequalities, racial segregation, and the built environment. We discuss interpretative considerations in using Walkscore.com for health investigations, and suggest types of data still needed for further research.
Board #8: Individual and neighborhood level predictors of fear: an examination of the effects of violence and social capital at both the individual and neighborhood level.
Erin Richardson, MS
Background: Individual and area level factors are often both important in examining predictors of health. Neighborhood factors are especially important when examining residents’ perceptions of fear and safety. Fear and safety are inextricably linked and when residents are fearful in their neighborhoods, they are at risk for numerous negative health consequences in addition to the ones they are already concerned about with respect to safety. The purpose of this study is to examine the dual influences of experiencing both violence and social capital on both a personal level and a neighborhood level and assessing these influences (as well as other individual and neighborhood level factors) and their effects on residents’ perception of fear and safety in their neighborhoods. Methods: This is a retrospective, cross-sectional analysis using data from the 2003 and 2005 versions of the California Health Interview Survey (CHIS). Individual level factors that will be examined include four main domains with a multitude of factors within each domain. These individual level domains include demographics (e.g., race, ethnicity, sex, age), health services (e.g., health insurance status, unmet health care needs), risk/protective variables (e.g., social capital) and health (e.g., health status, prior victimization). Neighborhood level factors will also be examined and include two main domains. These two domains are physical environment (e.g., recreation facilities, public housing penetration, home ownership, crowding, incivilities) and social environment (e.g., crime, segregation, police presence, neighborhood social capital). These factors are being examined as two levels of influence on individual’s feelings of fear and safety.
Tues, NOV 10, 6:30 pm to 8:00 pm:
Spirit of 1848 Caucus Business Meeting (Session 441.0, PCC 105A)
Come to a working meeting of THE SPIRIT OF 1848 CAUCUS. Our committees focus on the politics of public health data, progressive public health curricula, social history of public health, and networking. Join us in planning future sessions & projects!
Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).
Children in post-Civil War Nepal singing revoutionary songs
Special Theme: Social Medicine & War
For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.
Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write: ”Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”
Closing the Gap: Where are we one year later
In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.
The Peckham Experiment
We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!
Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.
We have just learned that The Last Straw! A Board Game on the Social Determinants of Health has been released in an English/Spanish version [para información en español, veáse abajo]. For readers of the Portal who are not familiar with it, “The Last Straw” is a board game designed to teach about the Social Determinants of Health.
The game was developed in 2004 by Kate Rossiter and Kate Reeve during a health promotion class at the University of Toronto and has won numerous awards. They designed the game to promote discussion about the social determinants of health, to help players build empathy with marginalized people and gain awareness of their own social location; and to encourage learning in a fun and supportive environment.
To get a sense of the game, you can watch the training video:
Drs. Rossiter and Reeve have also published two papers about the game:
¡La gota que colmó el vaso! es una herramienta pedagógica divertida y apasionante sobre los determinantes sociales de la salud.
*Para adquirir ¡La gota que colmó el vaso! puede contactar en inglés solamente a **sales@thelaststraw.ca* <sales@thelaststraw.ca>* o llamar en
inglés a Michael Jackel en Fernwood Books al 416-703-3598.*
El juego tiene tres objetivos: • promover la discusión sobre los determinantes sociales de la salud; • ayudar a los jugadores a desarrollar empatía con las personas marginadas y a tomar conciencia de su propia posición social; • estimular el aprendizaje en un entorno divertido y de apoyo.
De acuerdo con las investigaciones actuales sobre los determinantes sociales de la salud, la situación socioeconómica es uno de los principales
determinantes de la salud en este juego, tanto como la raza, el género, la orientación sexual y otros factores.
La retroalimentación demuestra constantemente que los jugadores adquieren una mejor comprensión de los determinantes sociales de la salud y de las
interacciones entre diversas fuerzas a nivel comunitario e individual. Tanto los jugadores como los facilitadores (“Maestros de Juego”) afirman que con
este juego se divierten mucho.
También hemos desarrollado un manual de capacitación y un vídeo en inglés para ayudar a los Maestros de Juego a aprovechar el juego al máximo.
In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.
We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The 
We have just learned that 
