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Some reflections on how nutrition improves

I was in Rome in early September. Not to see the Pope or the Piazza d’Espagna. But rather to contribute to our global efforts to bring the struggle for food sovereignty eventually a step closer to reality. The occasion was a meeting called by civil society, spearheaded by FIAN, to consolidate a civil society position towards the call by FAO’s Committee on World Food Security (CFS) to launch a Global Strategic Framework for Food Security and Nutrition (GSF) by October 2012. The GSF is meant become the framework to coordinate and guide joint actions by a wide range of actors regarding food policies at the global, regional and national levels.

Civil Society Organizations have consistently maintained that this GSF must be at the centre of joint action and see it as a much-needed global reference for policy-makers. For civil society organizations though, the GFS is above all about ensuring that policies are significantly more people-centred.

The result of our discussions were included in the first draft of the joint civil society political statement on the Global Strategic Framework and compiled by a civil society drafting team (of which I was part). The statement contains the vision and the demand of civil society that people who produce, distribute and need food must be in the centre of policies. The key role of food providers and consumers is highlighted in the draft, including that of social actors such as social movements and smallholder organizations of fisher folks, peasants, pastoralist, indigenous people and other. Finally, the Civil Society Statement stresses the need of setting clear accountability and monitoring responsibilities as a priority issue.

Most important was a back-to-back meeting to the above. It was about organising a Global Right to Food Network to strengthen worldwide efforts to end hunger and malnutrition by promoting better cooperation between likeminded partners and to voice our demands louder for the fulfilment of the right to nutrition. The call is for civil society to more proactively demand accountability through empowering its cadres to foster active community mobilization. The seed for the network was planted and we will certainly hear more about it in the future.

You will ask: Did you get to see the Coliseum and the Fontana di Trevi? Barely and passing by only. It was an intense 3 days…

Some reflections on how nutrition improves

Here is a quick summary of some actions that have been deemed relevant to nutrition in impoverished countries around the world:

• Equitable economic development is positively related to nutritional improvement, by way of its impact on poverty, equity, household food security and social expenditures. A threshold exists at around an average of $US 500 per capita income; above this, social expenditures rise significantly with rising income.
• Equitable growth strategies are a more efficient long-term means of alleviating poverty and indirectly improving nutrition, than are compensatory (targeted) poverty alleviation programmes  (as I said in my August column).
• Quantity, quality and distribution of social expenditures are central for the above to happen.
• Mutually reinforcing long-term effects on nutrition can be had by investing in women’s health and in their education, as well as in other women’s issues.
• Social discrimination against women is common in countries where nutrition has not improved as much as would be predicted by their economic growth.
• Nutrition programmes give visibility to nutrition, but may only promote broader awareness which is not the ultimate goal. Participatory processes in these programmes are as important as their activities as such.
• A mix of top-down and bottom-up interventions is the most pragmatic and effective approach often generating synergies.
• The most successful and sustainable nutrition programmes have strong community ownership. Decentralised decision-making power is crucial.
• Nutrition issues can and have influenced broader development policies. The availability of relevant disaggregated information, of democracy, and of a free press, do contribute to this.
• Development of an explicit nutrition policy is a vital prerequisite to the mobilisation of sectoral awareness and support.
• A synthesis of the recent lessons learned (pertaining to reasons behind real nutritional improvements) still leaves us with some apprehensions, because, when malnutrition (an outcome indicator) improves, it leaves no explicit track or trail of why it did so. It basically is still left to us to sort out the  reasons.

Finally, I do not think the Road Map for Scaling Up Nutrition (SUN) represents a set of nutrition-relevant actions that fulfils several, let alone many, of the criteria above. See my July column for why I think this.

‘Detective work’ done by honest and qualified researchers should sharpen our wits and improve our capacity to bring together all relevant elements of observed and sometimes puzzling ‘realities’. Only then can we decisively choose which nutrition-relevant actions are best in any given setting. Armed with this information, we can also oppose and even confront nutrition-irrelevant or anti-nutrition actions.

I have for long been convinced that people will feed themselves well, if their environments enable them to do so. The nature of enabling environments varies, of course. Governments and agencies – including non-governmental organisations – do not always foster enabling environments. They are usually either part of the problem, or else are neutral.

Sharing a common conceptual analytical framework has proven to be crucial to understand the causality of malnutrition, and to develop at least some beginnings of a shared political view. We have tried to do this since the 1980 UNICEF conceptual framework for nutrition as agreed and published by UNICEF. But this is only the first step. Creating political awareness of the problems of malnutrition is no longer enough. Our goal has to be to mobilise resources and people for action for nutrition-relevant actions.

The first requirement is a correct analysis of the relevant causes. Only then is it possible to intervene effectively. Engaging communities actively in service delivery, in capacity building and in their own empowerment, becomes central to the creation of enabling environments. What needs to come first is local. National or global environments are just as important, but are more remote to communities.

Fostering effective local democracy may well be a move to tackle the ominous health and nutrition consequences of non-enabling environments, and also to engage people in policy and political issues.

Outside agencies and agents can support effective local democracy. Governments – and other organisations – that say they respect and protect impoverished people’s entitlement to food, care and health, but do not positively and actively fulfil these obligations, should be openly confronted. Needed actions, include ensuring household food security, food sovereignty, the care of women and children, and the provision of basic health services, as well as environmental sanitation. Governments must be pressed to make needed interventions in these fields.

With encouragement, communities will be able to take on responsibilities. They will also be able to engage the resources they control in making their entitlements more attainable. Also, they will be better able to mobilise and to fight for resources that they do not control (This assumes that their government is not so repressive as to make this impossible). The key twin issues are community mobilisation and community empowerment. This is what creates an enabling environment, which is ultimately linked to the underlying and basic determinants of ill-health and malnutrition.

Here are two scenarios. The first is more down-to-earth:

Economic development is positively related to nutritional improvements. Economic growth – only if and when it trickles down – is said to help to prevent and control ill-health and malnutrition in poor countries. But the effects of such aggregate economic growth are not immediate (nor automatic) on poor households’ disposable income. This is thus an illusion. We should not be deceived.

A good road towards empowerment now, I believe, is a wide movement to promote education and income generation activities for women.

Income generation for women can short-cut the ‘waiting-for-trickle-down’ syndrome emptily promised by structural adjustment and by conventional donors. Income generation activities can generate more immediate needed additional modest household income – a true bottom-up solution.

In the poorest households, women’s income generation can result in sometimes quite significant increases in disposable household income, even if the total income is low.

As an intervention, income generation by women attempts to blend the technical with the political in the battle against malnutrition. It more directly deals with the basic causes underlying the ill-health and malnutrition that characterise poverty worldwide.

Income earned by women is, to a much higher degree than that of men, used for family well-being expenditures –nutrition included. Women’s modest, frequent income more directly affects the proportion of every increase in income that goes to consumables, including food and also basic services

Income generation by women does not of itself correct the immiserating impact of unfair political and economic systems. But women’s income generation can target some key determinants of ill-health and malnutrition. Also, it can organise and empower women in a way that prepares them for taking more active roles in participating in decisions and actions concerning food and nutrition in their families and in their communities.

Here is my more dreamy scenario:

Some of us have for too long lived surrounded by four walls, in an immutable environment, with the line of our professional horizon barely perceptible. Have we thus grown up inside an impenetrable armour of good manners and conventionality?

We have been trained to please and serve and, I’d say, have ended up limited by our own routines, the prevailing social norms and our hidden fears. Has, for too long, fear been our companion? Fear of authority and of what people will say, fear of the unknown and of what is different, fear of the unpredictability of social justice, fear of leaving the protected cocoon of our guild, fear of facing the dangers of the real world out there, fear of our own fragility and of the ultimate truth?

Could it be that our truth has been made up from omissions, courteous silences, well kept secrets, order and discipline? While masses of the impoverished share the same space and time with us, yet it is as if they existed separate from us. And under such circumstances, have our aspirations really been more to achieve virtuosity and recognition?

We do not know in what turn of the road traveled we lost the person we used to be. We are not sure any more, which of the causes we championed were meaningful, which we won and which we lost. If we made some mistakes and had uncertainties and fears about the future, we feel we have paid dearly for them already.

But also, I want to believe that we feel suddenly empowered. A new mood allowing us to make meaningful decisions in our professional lives is infusing us. We are willing to pay the consequences for it.  We do not owe an explanation to anyone for these changes.

This sense of optimism and commitment invades some of us, particularly in preparation for our upcoming Rio2012 congress. Our fears have dissolved as we have lost our fear of fear. We now find new strengths as we face new risks. We are finding new forces within ourselves that we always had, but did not know we had, because we had never used them. We are ready to join the growing number of explorer-doers seeking new ways out to the problems of the world. We feel pride as women and men who are reinventing equity in our work.

Some of us walk victorious, while others still carry disillusions mostly having suffered early defeats. But we feel we own our destinies, our future, and our irrevocable newly acquired dignity. We finally understand talk about liberation, about rights and empowerment, and about freedom from want in new ways and yearn to discuss with others what we see and feel about each of them.

We can now live each day without necessarily making worthless plans. We feel we have a blank sheet in front of us where we can write our new plans and, in the process, become whoever we want to become, without anybody judging our past. In short, we can be reborn. (1)

And then I woke up. Will post-Rio shatter this dream? It is up to us all! Dreaming is OK, but being naïf is not.

Yet, I hope I have here advanced some ideas that might provoke you to contribute to this movement, to get closer to the time when real democracy and the respect of human rights are no longer a dream.

Reference:

1          Allende I., The Daughter of Fortune, Plaza y Janes Editores SA, Barcelona,

1999, pp 296-301.

Please cite as: Schuftan C. Some reflections on how nutrition improves [Column] Website of the World Public Health Nutrition Association, October 2011. Obtainable at www.wphna.org

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

DEVELOPMENT COOPERATION* CLAIMS ALTRUISM AND MORALITY, BUT IS DRIVEN BY AN IMAGE OF MORAL SUPERIORITY.

Food for a not really altruistic thought

Human Rights Reader 276

The human rights-based framework opens our eyes to the outdated traditional model of aid. Since the new human rights narrative focuses on global justice and on pluralism, it criticizes international development agencies as ‘a cosmopolitan elite that is wrongfully embracing Globalization’ and it challenges the latter’s supremacy.

_________

*: Also referred to as foreign aid, development aid or overseas development cooperation (ODA).

For foreign aid to be effective in reducing poverty it must first and foremost be disbursed in good faith for that purpose –without political naiveté or double talk.

Unfortunately, aid is still seen as ‘temporary assistance’, a sort of noblesse oblige on the part of rich countries (whose riches, to begin with, derived in good part from the impoverishing exploitation of many of the present aid-dependent countries). (S. Taylor and M. Rowson)

1. The notion that today’s aid dependent countries can, with the right macroeconomic framework and new trade rules, grow into fiscal independence within an ethically-defensible-time-frame is simply mistaken. (S. Taylor and M. Rowson)

2. The evidence that foreign aid presents to us, namely that mostly technology will save the world is, these days, less and less plausible.**

**: Take two examples:

i)The UN-sanctioned human right to nutrition is often –but should not be– interpreted as the right to food aid. It is communities that have to decide their own food policies thus exercising what is referred-to as food sovereignty. (M. Arana-Cedeno) From that perspective, the right to nutrition should also be understood as an economic right, a cultural right, as well as to include the right to safe water, the right to participate, the right to information and the right to a sustainable environment. (D. Alhindawi)

ii) As regards the human right to health, foreign aid investments on quality health care services and on actions that tackle the social determinants of health (SDH) are not alternative pathways; they are indeed complementary. In the case of AIDS, this means that HIV is more than a virus; as someone said, AIDS is about power relations in the bedroom and in the boardroom of both donor and recipient governments. (M. Sharma)

3. Actually, foreign aid disarticulates the state from the citizen; governments listens to the concerns of donors rather than those of their own citizen.

4. Foreign aid cannot work when it is donors who identify the different needs of people rather than letting the people concerned actually articulate their needs. So donors must get away from doing so much of the talking and moving more towards listening. (A. Vaatz)

5. What is essentially missing in development cooperation is for it to consistently strengthen the people’s understanding of democracy and of their rights as individuals and as communities.

6. Therefore, for foreign aid to work, it needs to move towards a convergence of different, but compatible interests between donors and end-recipients (claim holders)…and, so far, human rights (HR) are not part of those converging compatible interests.***

***: Moreover, too often, politicians and civil servants have interests at odds with ODA.

7. Furthermore, to comply with foreign aid conditionalities, governments make administrative reforms as required by the donors rather than in response to the civic and political struggles of its citizens.

8. Let’s call a spade a spade: Donors have a clear political presence in many a country; they seek to influence change in that country through their financial leverage. In that effort, there are intense internal political struggles. Donors thus exert patronage through networks of clients within and outside government.**** This, because aid officials need to demonstrate to their head offices that they are having a tangible influence on the local scene. ****: If needed, donors use informal ‘shadow conversations’ that are at odds with government policy. (R. Eyben)

9. Putting many foreign and national experts in a room does simply not guarantee that one will get the best answers. [Not unless one starts by asking the key right questions… which is more important than knowing all the answers]. The same applies for guru-like experts and jet-set consultants that are regularly brought in from the North.

10. Development agencies purport they know the solutions to given problems… and others should benefit from that. For instance, the World Bank considers itself a ‘knowledge bank’; it thinks progress is intrinsically linked to knowledge and knowledge transfer is supposed to be the key to accelerate progress in poor countries. This raises expectations in the latter: People there hope-for and expect advice and expertise from outside.

11. The recipient country ownership rhetoric only hides the fact that the donors continue to pull the strings. Donors do not want to make themselves superfluous. Period. The talk of ownership is thus a lie; wouldn’t you agree? (A. Vaatz)

In human rights work, we put our money where our ideals are…i.e., where the risks are.

Human rights activists oppose aid more because it is borne out of compassion than because it is ineffective. (G. Garcia Marquez)

12. Donors have a continuing obsession with project management tools –prominently so with the logical framework matrix (or logframe for short). This allows them to pin everything down from the outset. Logframes are  primarily used in an effort to (narrowly) demand and interpret accountability. Ask yourself: How much detail can/should a logframe contain? With too much detail it becomes cumbersome and, over time, inaccurate. From the HR point of view, the most important part of it is the rightmost column which lists the Risks and Assumptions –most of them falling under the structural causes of underdevelopment.*****  In that case, the logframe’s Objectively Verifiable Indicators (OVIs) should then measure changes in structural conditions and in HR principles (rather than measure the achievement of sectoral objectives and activities).

*****: A typical example, of an assumption with structural implications would be: “The government will be actively responsive-to and will complement project-launched activities by, alongside, investing its own resources and demanding a participatory decision-making planning and implementation”.

13. How can a logframe address HR accountability then? The project implementation process must be focused on overcoming the structural ‘risks and assumptions’ and this requires continuous active engagement of both claim holders and duty bearers. For accountability purposes, the challenge is to identify and move to change the constraining structural conditions thus fulfilling all HR principles. (D. Curtis)  Given the inadequacies (and abuses) of the foreign aid system, the corollary to this is that the actual processes that foreign aid sets in motion must be more important than its volume. This additionally means that, when providing technical assistance or policy advice, donors must be guided by both HR principles and standards.

Foreign aid: Can human rights impacts be foreseen?

14. In a way, HR impact assessment (HRIA) overlaps with poverty and social impact assessment exercises. The three of them offer empirical evidence on the likely social consequences on the living conditions of different social groups in society. The information that comes from them has the potential to foresee and thus mitigate negative consequences or even prevent them. These impact assessments determine whether measures are politically feasible by considering existing power relations and possible opposition to the new measures. They open up space for dialogue among claim holders and duty bearers. But unless policy makers take into account the results of HRIA exercises, even the best analyses will be useless. HRIA ownership thus matters greatly. Findings usually support the position already for long held by large parts of civil society. They provide claim holders with a negotiating platform with donors. HRIAs are best if implemented by independent teams.

15. Economic partnership agreements (EPAs) and free trade agreements (FTAs) simply must have HR impact assessments and audits. To us in PHM, this is non-negotiable.

Foreign aid: wrong focus?

Often trapped in a ‘growth-only’ delusion, development cooperation vows to focus on poor people, but instead primarily focuses on poor countries…The HR-based framework definitely focuses on poor people –everywhere.

16. This is most important, because 72% of the world’s poor live in middle income countries (MICs). And there, the ratio of bilateral to multilateral aid is 2/3:1/3.

17. MICs can, in principle, support and emancipate their own poor people, but their poor lack power (are not empowered) and their governments lack any real determination and commitment to end poverty.

18. Mind you, even if –with foreign aid– the MDGs are met, there will still be one billion poor people by 2015… almost ¾ living in MICs.

19. Donors complain of unresponsive governance there; they consider ‘bad governance’ the most dangerous trap. They purport to address it face-on. The question is: What changes do they insist on? For them to engage in debates on frontally tackling inequality should not be considered an infringement on sovereignty, but a step towards HR. But do they?

20. If rich countries purport to provide poor countries with development resources, it is not at all against their own interests to do so. Otherwise, why would they do it? Much more ‘real aid’ would be for them to:

• cut subsidies to agriculture in the North,
• forgive the overpowering foreign debt of the South,
• not steal the resources (both human and material) of the poor countries,
• not dump their cigarettes, their toxic waste, their genetically modified seeds… on the countries of the South,
• not sell weapons and train the South dictators’ armies, etc.

But this would be too costly, drastic and inconveniencing for them.  Traditional ODA is just a more cozy niche to be in…

21. Does the reader really think any of the above is ever going to happen in our rich-countries-dominated-unfair-world?

22. Any time people start talking about development aid, I just automatically assume they are on the wrong side of the horse, no matter how well intentioned they are. (M. Anderson)

23. Bottom line, donor governments have been and are very selective in their support for HR (focusing mostly on civil and political rights –especially in their conditionalities). The selection of HR which donor governments choose to address (mostly chosen by narrow self-interest considerations) more often than not ignores addressing economic, social and cultural rights (ESCR) and its principles (participation, non-discrimination, rule of law, etc.).

24. But the violations of ESCR destroys social relationships, the social fabric, social cohesion and overall trust. Donors can indeed contribute to stop these violations and thus prevent these tensions from flaring up –which seems to me is in their long-term interest. But the million dollars question is: Will they?

25. After all the above is said and done, consider: A domestic fair progressive taxation system and other redistributive policies (including decisive action against capital flight) are, in last instance, more important than ODA.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

_________________

Adapted from Contact, WCC, Issue 186, Nov., 2008; Development in Practice; Globalization and Health: Pathways, Evidence and Policy, R. Labonte, T. Schrecker, C. Packer and V. Runnels Eds, Routledge Books, 2009; D+C, 36:12, Dec.2009; D+C 37:5, May 2010; D+C 37:7-8, July/Aug 2010; D+C, 37:10, Oct 2010; The Broker, Issue 19, Apr 2010; The Broker, Issue 23, Dec.2010/Jan2011; and The Broker, Issue 24, Feb/March 2011.

New slide show on racial and ethnic disparities on public health and social justice website

This is to announce a new open-access slide show, “Overview of Economic, Health, and Human Rights Issues of Racial and Ethnic Minorities,” on the Race, Ethnicity, and Culture page of the Public Health and Social Justice website. The slide show, which can be found at http://phsj.org/wp-content/uploads/2011/08/Economic-health-and-human-rights-issues-of-racial-and-ethnic-minorities.ppt, begins with quotes from Christopher Columbus and Cecil Rhodes demonstrating attitudes of colonial exploitation which have carried over to the present day, leading to maldistribution of wealth, environmental degradation, wars, and economic and educational disparities. Racial disparities in access to health care and in processes and outcomes of care are listed, along with statistics regarding inequities in the criminal justice system. Other slides cover the global situation viz a viz U.S. foreign aid, the brain drain from developing to the developed world, and the developing world debt crisis. Some suggestions for combating racism and creating a more just world are noted.

This slide show is brief, so those desiring further information on these topics can turn to other pages of the PHSJ website at http://www.publichealthandsocialjustice.org or http://www.phsj.org, including those covering Activism and Education, the Criminal Justice System, Environmental Health, and Migrant and Seasonal Farm Workers.

I would like to add more content to the Race, Ethnicity and Culture page, so submissions are encouraged. Please send them to martindonohoe@phsj.org, along with any comments, questions, corrections, etc.

The Fight to Save the NHS (publicly funded and universal National Health Services in the UK)

I recently attended the energizing Annual Meeting of Physicians for a National Health Programs. Among the highlights was a presentation by Dr. Jacqueline Davis, a UK doctor  committed to keeping the National Health Services public, universal, and free at the point of use. Her talk was very inspiring, and extremely instructive: the audience learned about Dr. Davis’ and the British people’s struggle to protect a right to health care from the same corporate forces that have bedeviled the US health care system (successfully up to now). I felt compelled to share it with readers of the Social Medicine Portal.

I hope readers are as inspired as I was, and energized to continue our unfinished quest for a right to health care for all (not ‘near’ all!).

Enjoy!

The Fight to Save the NHS, by Jacqueline Davis, Saturday October 29, 2011, Washington D.C.

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of ‘islands of excellence in a sea of misery’.

I’ve never been to this city [Washington D.C] before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president.   I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow [laughs in the audience].

I’ve been asked to speak today about our fight to save the NHS.  Who are we and why are we fighting?  We are the campaigning organizations I work with, in particular Keep our NHS Public which we started about 7 years ago in response to the Labour government’s marketisation policies for the NHS – the NHS which Tony Blair had promised would be safe in his hands.

Why is the NHS worth defending? The NHS was a great act of social solidarity when it was founded in 1948 in the aftermath of the Second World War. It’s ironic that we are told we can no longer afford it but it was created in a period when the UK had huge debts, but importantly when people believed in acting together for a common purpose, and that the state could intervene for the benefit of society.

The intention was that people should be freed from the fear of the financial consequences of illness and that good health care should be available to all regardless of wealth, the 3 core principles being:

1. Meets the needs of everyone
2. Free at the point of delivery
3. Based on clinical need not ability to pay

And by and large it has managed to maintain those principles

Of course the NHS faces the challenges that all health systems do i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost efficient and equitable health services in the world.  And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

S o if it’s so good why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale. A successful public service is an affront to the free marketeers.  They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

S o the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost effective integrated public service into a kite mark attached to a ragbag of competing private providers. For those who are interested in how this happened I recommend this excellent book (The Plot against the NHS). It’s enough now to say that since 2000 governments have pursued a policy towards the NHS that the electorate hasn’t voted for and doesn’t want, a profoundly anti democratic state of affairs

The process actually began under Margaret Thatcher with the internal market and was continued under New Labour with the Private Finance Initiative and policies which increased marketisation. It has now come to crisis point with Andrew Lansley’s Health and Social Care Bill. After Prime Minister Cameron’s specific pre election promise of no more top down reorganizations Secretary of State for health Andrew Lansley produced a bill the size of a telephone directory, and everyone knew it was going to be very bad news.

And so it has proved. In brief the proposed changes are

The current system of commissioning care will change completely, with 80% of the budget going to family doctors (GPs). And they will be responsible for commissioning services,

NHS services, rather than publicly provided by NHS organizations, will be provided by any willing provider i.e. anyone with a mop and a bucket. They will be coyly called the ‘NHS family’.

Competition will be paramount and (according to politicians) drive improvements. Anti competitive behavior will not be tolerated. This will be enforced by an organization called Monitor, chaired by an ex employee of Mackinsey, the management consultants.

Hospitals will all have to become Foundation Trusts which are in effect autonomous competing businesses. Their only remit is to make a profit and they don’t have to offer services on which they can’t make a profit

There will no longer be a cap on income that hospitals can make from private patients. This is likely to lead to private patients filling NHS hospital beds, with NHS patients going to the back of the queue and a two tier service

Personal health budgets are being rolled out

This has all been driven with the usual spin of ‘patient choice’ and ‘power in the hands of doctors’ but even so the vast majority of health professionals and the public don’t want anything to do with this Bill

What are our fears?

Most GPs don’t have the time, expertise or interest to get involved in commissioning health care. It will be done – is already being done in some places – by private companies such as UnitedHealth which has just signed a big contract in London. If the private sector is commissioning care and at the same time delivering it is tantamount to putting the thieves in charge of the jewelers shop.

Serious fears for the doctor/patient relationship especially in primary care.  UK GPs are very effective gate keeper s to secondary care, one of the reason why the NHS is so cost effective, but it’s very important that patients trust their judgment and decisions. Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road is it because their wife has a financial interest in it? 25% of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

We fear GPs will be unwilling or financially unable to refer patients to hospitals and ‘care in the community’ is already becoming weasel speak for hospital closures

Hospitals will see their incomes reduced and will turn to private patients to make them up. Until now there has been a cap on private patient (PP)  income but that has been removed. If NHS beds fill with PPs then NHS patients will have to wait and we will see a 2 tier service develop

With services being provided by competing organizations we know there will be fragmentation of the care provided to patients and disruption of the patient pathway.

We fear that unprofitable services and patients will be quietly dropped

We fear the loss of public accountability with the private sector hiding behind commercial confidentiality (as they did with ISTCs)

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out of pocket payments and those who can’t afford it going without

And we really fear the arrival of the private companies, many of them from the US, whose behavior leaves much to be desired. They want to ‘cherry pick’ leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

The government was very clever with the Bill, which is about the deeply unacceptable break up and sell off of the NHS. They knew they would never get away with that so they sugar coated the bitter pill with GP commissioning. And GPs fell for it initially – many were excited by the prospect of holding the budget. Then they woke up to the fact that they would be doing this against the background of $30 billion to be saved over 4 years, and they would be made the scapegoats for cuts, closures and rationing. They would also have the private sector doing the commissioning, telling them what to do and probably ultimately employing them. Less than 20% of GPs now approve of the Bill and very few think it will benefit patients. But because the government have started to implement the changes before the Bill is law they have had to engage or see others do so on their behalf.

So, you see why we have to fight this. Because of the complexity of the Bill people, and in particular doctors, were either too busy to look at it or couldn’t understand it when they did. One of the problems we have had is engaging the profession because they didn’t notice what was going on, or trusted too much to our union to take on the problem or felt powerless given the lack of any visible sign of opposition.  There is also a minority of doctorpreneurs who see financial opportunities and never mind the long term consequences

Because the language used was about patient and doctor empowerment patients felt reassured by the thought of money and power in the hands of their local friendly family doctors and it has been hard work to expose the spin.

Another problem was identifying and co-coordinating all the bodies who were opposed to the proposed legislation, in particular working with the health unions who tend to be suspicious of other organizations.

Our organization was vociferous from day one, saying that the Bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10 point critiques of the Bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published. We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize on line petitions. We put a lot of energy into lobbying politicians. We have helped exposed the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster. We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within

As the Bill passed from the House of Commons  to the House of Lords the profession finally woke up and there has been a flurry of open letters, both to our union, the BMA, asking it to oppose the Bill, (published in the BMJ), to politicians in both houses and to newspapers. We, the NHS Consultants’ Association, wrote to the Academy of Royal Colleges, the umbrella body for specialist professional bodies, asking them to get involved. They are traditionally very conservative and excuse inaction by saying they are apolitical, but we pointed out that their remit is quality, training and standards, all of which are threatened by the legislation. They have since published a letter to the government stating their concerns.

Despite what amounts to a public outcry in the last couple of months the Bill is now going through the House o Lords with the prospect that it may emerge with little changed

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cosy relationship with today’s politicians.  It’s easy to lose hope but we mustn’t.  We have to take on this cosy configuration of politicians and giant corporations which have come to a ‘comfortable accommodation’ at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is.  We must collect evidence and use it to criticize and expose.  We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, ‘The NHS will last as long as there are folk left with the faith to fight for it’. We must be those folk because, personally, I am not prepared to let him down

drjcdavis@hotmail.com

THE HISTORY OF HUMAN RIGHTS IS NOT A CONTINUOUS STRAIGHT LINE OF PROGRESS. IT IS MARKED BY PERIODS OF ADVANCE, OF MORE OR LESS INTELLIGENT REFLECTION AND OF DEAD STAGNATION.

Food for a wrongly chronicled thought

Human Rights Reader 275

-History is a lady with a slow digestion. (E. Galeano)

-Being human means knowing and judging the role that extremes of greed, of moral corruption, of prejudice and

of cruelty have played in history so as to effectively combat them. (M. Vargas Llosa)

Understanding history for what it is

1. As individuals, we do not really create the historical times in which we live-in. But what we have to do is to understand the problems posed and shaped by each historical time so as to try to come up with the most forward-thinking interpretation of them that eventually leads us to fair and just solutions applicable to our time.

2. Making sense of current and recent history is a subjective, value-driven activity; we do make historical errors of interpretation, i.e., judging what is true or false in history is a value-laden process. Myths have had and have the bad habit to conquer and dominate. There thus always is a historical relativity in the judgments people (and historians) make. The powerful can always boost their honor for posterity by buying themselves a good pair of historians and  making them deliver; it is just a matter of a good pay-off.  In this same vein, I like the quote: History negotiates its terms and collects its dues, i.e.,  a ‘history enlisted by commerce’. (A. Roy)  Historians, then, are the only individuals that can (and have) modify(ied) the past. (A. Gomez) Most probably, from the claim holders perspective, worse things than have been chronicled have happened…and keep happening.

3. Not even the educated public is prepared to face and correctly interpret history; I am convinced that, throughout history, the lack of universal progress in development-for-all is a fact, as much as people want to tell me that history is a progressive upward spiral. (P. Weiss)

4. Picture the history of the world as the history of a ten-thousand-year war of brains and of interests between the rich and the poor. Each side has forever tried to take-in the other side –and it has been this way since the beginning of time. The poor have won a few battles but, of course, the rich have won the war for ten thousand years: The inalienable fact is that, in order to make poverty history, the history-of-poverty-making needs to be understood. (T. Lines)

5. History already has a sufficient number of pages to teach us two things: never do the powerful elect the best among us, and policies are too often set up by bad  politicians who now, with hindsight, can be held responsible for historical inertia. (C. J. Cela) Too many politicians apply the word ‘history’ to any banality that suits their needs.

6. For instance, the price poor countries pay to sustain the rich countries is a historical fact. After all, colonies do not cease to be colonies because they are independent. (Disraeli)  In his Candide , Voltaire already had a black slave who had a leg amputated to prevent him from escaping say: “This is the price for the sugar that you eat in Europe”.

7. What we have to ask ourselves is: Is all history like this? Like the one we learn at school? Like the one historians write, i.e., a more or less idyllic, rationalized and ‘coherent’ fabrication of the hard and crude historical reality representing a mix of multiple interests?  The latter has been the forever-history, the never-ending-history we have been taught.  When historical (sociological, psychological and cultural) explanations are exhausted, there still is a vast grey area to get to the root of the perversity of human beings.

8. The history we are taught is made up of symbols giving them an aura of reality. But symbols do not always have to be seen as a sign of human irrationality*; they just show time-bound predominant elite-sanctioned beliefs, customs and discriminations that end up being chronicled by history. As a result, history rarely chronicles the setbacks of the largest part of its protagonists.

*: Climate change illustrates a case of irrational exuberance, of forgotten history and of widespread greed.

9. A certain continuity in history is undeniable; One cannot act ignoring it. For sure, more ‘modern’ visions cannot be adopted disregarding history. (M. Ovalle)

10. Some say history is a prophet looking backwards, i.e., based on what was and what was not, history announces what will be. (E. Galeano) Otherwise, it is said philosophers interpret history. After all, it is argued, philosophers are nothing but belated notaries that notarize what is happening in main street. (A. Gomez)

11. So, as you see, history is not lineal. It is made up of ruptures provoked by the accumulation of energies, of ideas and of projects that, at a given moment, cause a break, and thus the new erupts with enough strength to attain hegemony over all the old forces; thus another time is set up and a new history begins. (L. Boff) Revolution, although a violent break, is the most dramatic compromise with history.

12. Nothing is black or white in history; not even the glamorous chronicles of battles won or revolutions or a just cause succeeding; even there, we can detect those grey areas that cloud everything.

13. A final thought here is that, these days, we do not say or do anything that does not have numbers attached (statistics); judgment comes from the latter. More numbers, more graphs, more histograms with a % on the top and history thrusts forward defying anyone who contradicts (so often biased) statistics. But is this what we really want?

History and Human Rights

Isn’t it true that we often love and pay respect to our dead more than to those that are due respect and are alive? Take human rights pioneers, are they not too often ignored and ‘nobodied’. (A. Bryce Echenique)

14. For work in human rights (HR), being conscious of one’s responsibility in history means we cannot turn our backs to the compromises of history. From this perspective, what leaves me with a bad aftertaste is realizing that, as a group of HR activists, we still are in the periphery of history.

15. Today, we have to serve not those who purport they are making history, but those who suffer from the way it is made. We thus have to refuse lying about what we know to be true and in so doing resist oppression. (Albert Camus)

16. Historically, when HR have gained meaning beyond the level of rhetoric, it has always been as a result of political contestation, often long and bitter.

HR principles are thus intimately bound to values of solidarity and to historical struggles for the empowerment of the disadvantaged. (D. Tajer)   

17. A former UN High Commissioner for Human Rights described HR as “the closest thing we have to a shared-values-system for the world” (M. Robinson 2007). From such a historical perspective then, it is the mobilization of claim holders for the legal recognition of HR that will offer the most plausible route to (by nonviolent means) achieving the transformation of national and international institutions and practices that deny opportunities for good health and for a long life to literally billions of people. (T. Schrecker)

18. The rich are always one step ahead of activists, you would say, right?  Well, not anymore if we succeed in explaining key historic facts from a HR

perspective*; for this, for every step they take, we will take two. We are not the owners of history. But it is time we were. (Z. Acevedo Diaz)

*: Herein the thrust of this Reader.

19. In HR work, we are all bound by the unfair rules of history; the prevailing social order can only be subverted through international work. Motivation for change comes from the effervescence of the masses. (R. Luxemburg)

20. All this having been said, I contend that, in the era of HR, ingenuity will never again be an ingredient of history.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

_________________________

Adapted from Development in Practice, 19:8, 2009; F+D, 47:1, IMF, March 2010 and 47:2, June 2010; and from Mario Vargas Llosa, ‘El suenio del Celta’, Alfaguara, Santillana USA Publishing Co. Inc. Doral, FL, USA, Nov. 2010.

Postscript:

Beware: Mistakes of historical interpretation occur when one judges remote, past situations with the ethical, social or political values valid today. Therefore, rushing to historical judgment can be more damaging than lies. (A. Gomez)

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THE NEW PHILANTHROPIES IN WORLD HEALTH AFFAIRS.

Claudio Schuftan

Los Angeles. My main topic this month is the significance of the ‘new philanthropies’ and their impact on global public health, and in particular population nutrition in less resourced and impoverished countries. My context is this month’s UN Summit on the prevention and control of non-communicable diseases, which are now rampant in Asia, Africa and Latin America. A vital source for this commentary is an analysis by scholars from the Harvard School of Public Health and the London School of Hygiene and Tropical Medicine (1).

My pictured example is the biggest philanthropist in the world, whose interest is public health, and his foundation, whose budget is greater than that of the World Health Organisation, and which after the US government is the biggest funder of WHO. This is the Gates Foundation, about to become the largest single shareholder in the Coca-Cola company and in Kraft Foods (1), which, as stated on its website, is ‘driven by the interests and passions of the Gates family’.  Bill Gates, above, is speaking on the theme of ‘the new drivers of development’ at the 2008 World Economic Forum meeting in Davos.

People’s Health Movement

On to its world assembly in Cape Town

At the end of July I attended the annual meeting of the USA circle of the People’s Health Movement in Los Angeles. The setting was bucolic: the Loyola Marymount University campus, seen above in term time.  It was good to be with grassroots activists in the US who, suffice it to say, are having a hard time, because of the financial turmoil the US is going through. I brought with me the solidarity of the global People’s Health Movement.

Discussions were fertile and we all shared plenty of ideas on where the movement wants to go in its domestic US work over the next two years. Attention was also given on how to best contribute to the organisation of the Third People’s Health Assembly, to be held in Cape Town in July next year. This coming event is creating a great deal of excitement the world over, particularly among grassroots organisations working in health. What a great job they are doing in the US. Defending the right to health in this great nation is certainly not an easy task – let alone working against militarism and against big time polluters, as some militant groups here do.

The new philanthropies in world health affairs

Masters of our universe

Bill Gates is currently the world’s second wealthiest person. Among all the new philanthropists I have picked him because the Gates Foundation, with assets of $US 30 billion, is by far the largest foundation whose main interest is population health (1). He has become devoted to the UN Millennium Development Goals. Above (left) he is advocating them at the UN General Assembly in 2008. Also in 2008 he is (right) upholding them with colleagues UN secretary-general Ban Ki-moon, the late Nigerian president Yuma Yar-Adua, former UK prime minister Gordon Brown, Queen Rania of Jordan, and (far right) Bono. No people of the type shown in the photographs being held up were, as far as I know, present in Davos.

When we consider the significance and impact of the ‘new philanthropies’, it is fair and reasonable to think of Bill Gates and his foundation, because of its scale and his presence. But there are others.

Institutional relationships in global health are a growing area of study, but few if any previous analyses have examined private foundations. It is almost as if analysts feel that foundations are beyond criticism or even appraisal. Bill Gates certainly thinks so. The intentions and policies of the directors of foundations are rarely considered. This is now beginning to change (1-4).

There are broadly three different types of private foundation whose declared purpose is to protect and improve public health, including nutrition. Some were set up a long time ago, often by vastly wealthy US industrialists and which, over decades, have sought distance from their founders. These include the Rockefeller and Ford Foundations, for example. Some are similar, except that the founders are themselves alive and active in pursuit of influence on internal affairs in ways they see as akin to their view of the world. The Gates Foundation is the outstanding example, but there are others, for instance the Fundación Carlos Slim Helú, named after the world’s currently wealthiest person. Other foundations are obviously different; they are set up by and controlled by transnational and other giant food and drink companies. These include the Coca Cola Foundation, the PepsiCo Foundation, the Kraft Foods Foundation, and many others.

As I see it, the similarities between these types of foundation are actually greater than their differences. Corporations set up or fund foundations that support the corporation’s direct or indirect, tactical or strategic policies. Foundations that are historically or constitutionally distant from their founding funders still work within an ideology that is consistent with big business, particularly as seen by US industrialists. They rarely transfer money and resources to organisations that are  independent, democratic, and accountable to their members, or to voters and taxpayers.

The funders and directors of private foundations may well have altruistic motives, but it is also true that there is financial benefit in setting up a foundation. It also stands to reason that the policies of any foundation will support or at least be consistent with the corporate policies and personal ideology of the people who control the foundation.  Tax-exempt private foundations and for-profit corporations increasingly engage in relationships that can and do influence global health.

Where do foundations invest their money?

Many public health foundations have associations with private food and drug corporations. In some instances, they are invested in the stock of such corporations. Here below, for example, is a list of the main stockholdings of the Gates Foundation, taken from (1).

________________________________________________________________

Table 1

Gates Foundation stock portfolio, 2010. Some of its holdings (1)

________________________________________________________________

What this shows is that when the stock of Hathaway donated by Warren Buffett and now being transferred to the Foundation is taken into account, the Gates Foundation will be the largest single stockholder in Coca-Cola, the biggest manufacturer of sugared soft drinks in the world, and of Kraft Foods, the biggest manufacturer of confectionery in the world. Does Bill Gates think about this, when he makes decisions, or is on platforms with executive from transnational food and drink processors? Probably not, but it seems likely that they think about it, and it also seems likely that there is a basic community of interests here.

Does this help to explain the zealous attachment of the cash-strapped United Nations system to ‘public-private partnerships’ where in our field of nutrition and public health the private partners are mostly transnational food and drink processors, otherwise known as Big Snack?  This also seems rather likely to me.

Personnel move between food and drink industries, pharmaceutical houses and academia and to and from public health foundations. Foundation board members and decision-makers also sit on the boards of some for-profit corporations benefiting from their grants. While private foundations adopt standard disclosure protocols for employees in order to mitigate potential conflicts of interests, these disclosures do not always apply to the overall endowment investments of the foundations or to board membership appointments.

The extent and range of relationships between tax-exempt foundations and for-profit corporations suggest that transparency in grant making alone may not be preventing potential conflicts of interests between global health programmes and their financing.  The question of whether and how financial and institutional relationships shape foundation decision-making has yet to be properly addressed, let alone answered.

Further, it is surely fanciful to suppose that industrialists who are alive and active now, and who maintain control over foundations, are likely to change the core beliefs that made them immensely wealthy. The basic ideology that drives transnational corporations is going to be the same basic ideology that drives their foundations. Does this seem to you to be a cynical view? Surely it is common sense. But the implications are vast. It means that the strategic policies and practices of transnational corporations are pursued, albeit in a different guise, by the foundations set up in their name. Technological fixes ensue. But medical technologies make a relatively small impact on the broader social and economic determinants of health and nutrition; and the efficacy of technology cannot be guaranteed so that an over-emphasis on technology has been and is problematic.

As David McCoy says, the ways in which much private philanthropy works are hugely inefficient. For example, there are many transaction costs related to vertical top-down initiatives, and there is much collateral damage along the way. We could achieve better long-term health and nutrition improvements using an approach that tackles the social determinants.

Foundations are not all bad

David McCoy also thinks the issue is less straightforward than ‘condemning private philanthropy out of hand’. For example, he asks some important questions:

• Private philanthropy can include some expressions and actions of social

solidarity for ordinary people, but we do not condemn that, do we?

• Do we need to make a distinction between post-tax and pre-tax private

philanthropy?

• Many of us work for organisations that are funded in part by private money –

do we condemn all that private money as well?

• Is all private philanthropy worse than public aid? Are US government aid and

the World Bank loans and grants associated with structural adjustment programmes better than all examples and sources of private philanthropy?

• Are there better and worse forms of private philanthropy – in terms of the source and the spending of that wealth?
• Is there a need for us to differentiate a moral/political position from a

tactical/strategic position on private philanthropy?

• Given the pre-eminence of Gates in the global health field, what is our strategy towards the Gates Foundation? Have we ever called for a debate or discussion with the Foundation? And should we?
• Do we seek to reform, or to lead a revolt on all of the above?
• Much philanthropy used in ways that prevent the radical and structural

changes required to set up a fairer and more progressive economic system. What is our stance here?

• Aren’t private foundations not only unaccountable, but hasn’t their power grown through the ‘capture’ of other institutions, including the UN?
• Their rise is linked strongly to the relative reduction in public financing with a concomitant rise in the public-private partnership paradigm. Is there any monitoring of the revolving door syndrome between United Nations-foundations-corporate sector-governments?
• Are there adequate checks and balances to prevent the capture of public

financing and policy making by the private philanthropy/corporate sector?

I think there is much agreement on the historical analysis of the rise of these institutions, their minimising the tax liabilities of their corporate funders, and their capture of the UN (and many other public bodies). But the issues are complicated, and are only beginning to surface and to be understood (1-4).

My friend Alison Katz, on the other hand, thinks philanthropy is never positive. Her view is that the right to health and to nutrition are incompatible with private philanthropy. Private philanthropy and the diseases of poverty go together: They result from, and characterise, gross economic inequity – the root cause of preventable malnutrition, ill-health and deaths.

She believes that as nutrition professionals, we must fight for economic justice as the precondition for the right to nutrition. This implies denouncing private philanthropy.

I am on her side. These things were clear already over ten years ago when philanthropies became prominent.  Since the 1980s, most of all, big corporations have successfully fought to pay very little tax and even no tax at all. In doing so they have succeeded in destroying the tax base which is the basis for public services of all kinds, including health and nutrition.

Of course they prefer not to pay taxes, but instead to ‘give’ money (even lots of money) to health (much less to nutrition). In doing so, they open up the area of health and health services to privatisation. They thus make what should remain public goods actual tools of capital with all that implies. The implications include rapidly widening gaps in equity, and the terrifying prospect of destitution when chaotic fluctuations in the money markets occur, such as those we are once again experiencing as I write this column.

Please, do not tell us that health services in faraway lands would collapse, were it not for private foundations. It is not a question of abandoning services in Africa and leaving people adrift. It is a question of what we are fighting for in the long run, and a question of values, principles, equity and justice.

.

  Box 1

A letter to Margaret Chan

   In 2007, Alison Katz sent a letter on this to Margaret Chan, director-general of WHO. She wrote it at a time when she worked for WHO, but under notice of dismissal. Nothing has changed since and conflicts of interest are still pervasive.  Here is part of the letter. It never received a response. You can access the full letter here.

‘It has become fashionable to focus attention on the poor, but to meet and establish partnerships with the rich. In order to address the fundamental problem  of inequality, this pattern must be reversed. It is time to focus attention on the rich and powerful, because they are the experts in the mechanisms of unequal power relations and the architects of policies and strategies which produce, reinforce and accelerate inequalities. Those systems must be closely examined by WHO and opened up to public scrutiny and democratic control. To clarify, this is not a discourse on good and evil; the issue is one of antisocial and sometimes violent systems manipulated by a handful of individuals.

‘Poor people do not attend G8 summits, board meetings of the latest Global Fund or philanthropic foundations, let alone the World Economic Forum – where Chief Executive Officers of transnational corporations are offered even more privileged access to political leaders than they already enjoy. But poor people also hold meetings and they are represented – if imperfectly – at the World Social Forum  (and in national and regional social fora), in trade unions, social and political movements and elsewhere.

‘As Director-General of WHO, you are committed to “the people of Africa who bear an enormous and disproportionate burden of ill health and premature death” and you have made this “the key indicator of the performance of WHO”.’ Katz goes on to say that the presence of the WHO director-general at meetings of the World Social Forum ‘would represent real hope and inspiration for the world’s people and an essential counterbalance to high level meetings with government leaders and their corporate backers/advisors – who are increasingly one and the same’.

‘You have gone on record saying that “the landscape of public health has become a complex and crowded arena for action with a growing number of health initiatives” and you reminded us that WHO is “constitutionally mandated to act as the directing and coordinating authority on health”.  As you know, public-private partnerships have become the policy paradigm for global health work despite the evident conflict of interest which would have outlawed such arrangements thirty years ago. Agencies and organizations with public responsibilities are partnering with the private  sector for one reason: It (appears to have) become the only source of funds. This situation has arisen, because under neoliberal economic regimes, public sector budgets have been slashed and tax bases destroyed. Those developments are themselves the result of the influence of transnational corporations (TNCs) and the international financial institutions on governments’.

‘The solution to this problem is not for public bodies to go begging to the private sector, nor to the foundations of celebrity philanthropists with diverse agendas. The solution is economic justice, including an adequate tax base, both nationally and internationally, to cover all public services, as well as proper funding of public institutions such as WHO through regular budgets so that they  may fulfil their international responsibilities unimpeded by corporate interests’.

‘You have further argued that “the amount of money being made available by foundations, funding agencies and donor governments is unprecedented”.  This will be entirely positive if you are able to use these funds to pursue your vision and priorities, as is your right and your duty.  It can be argued that, if WHO had operated exclusively on a regular budget, even with a significantly smaller workforce, but one that was dedicated to WHO’s constitutional mandate, far more progress towards Health for All would have been achieved’.

‘As you have said “Primary Health Care (PHC) is the cornerstone of building the capacity of health systems. It is also central to health development and to community health security”. PHC will remain mostly rhetoric if it is not supported by a solid, equitable tax base and other forms of redistributive justice (debt cancellation and reparation, fair trade, abolition of tax havens, democratic control  of TNC activities, etc.). WHO itself needs to set targets for the level of core funding, starting perhaps at 70% of total expenditure, and increasing annually until undue influence is removed. The private sector has no place in public health policy making at global or national level. This does not, of course, exclude responsibly designed interactions as in the past. But it does exclude partnerships, because partners  must share the same goal’.

Private philanthropy is always interested in something. Does it seem that I am being facetious when I suggest that this is furtherance of its own interests? Private philanthropy exists because of gross inequities. Diseases of poverty and philanthropy in health and nutrition will always go hand in hand. When the right to health is achieved – even partially – who will need philanthropy? Philanthropic giving is the antithesis of the rights-based approach to health and nutrition.

Private philanthropy has no place in a social justice approach to human rights, including the right to nutrition. A right cannot depend on charity, or even on expressions of top-down social solidarity. That is the nature of rights. Private philanthropy only exists because of large inequalities. It almost always confers yet more power on the giver and thereby further widens those inequalities. It is truly a vicious circle and our aim ought to be to move out of it.

This does not mean abandoning people to their suffering. It means working on a transition to a human rights-based approach at all times. In all our strategies we have to move towards the standards and principles of human rights and away from charity.

The People’s Health Movement position

The People’s Health Movement has had lengthy debates on public-private partnerships, and has protested Bill Gates opening the World Health Assembly in 2005 and again speaking there in 2011. We have vehemently and vocally opposed the privatisation of health services and have denounced the UN Global Compact. Our   entire raison d’être relates to issues of conflicts of interest, the rule of money, and the capture of WHO by industry.

We do not condemn private philanthropy action as a temporary measure to stop immediate and medium term suffering. As a way of achieving our aim of health as a human right, yes, we do condemn it. It has no part to play in the structural processes to achieve the human right to health and to nutrition. We are about creating the conditions for human rights, not to dole out goodies to salve consciences, quelling popular uprisings, and preventing real change.

My own reflections

Here is what I think, based on working for over 30 years as a nutrition and health professional mostly concerned about impoverished people in all continents apart from Europe.

Ordinary people understand well that charity is an integral part of systems of inequity. If it is to be effective, and in order to improve the situation of people, social solidarity has to take the form of political action. Hence the famous phrase of Dom Hélder Câmara the Brazilian archbishop of Olinda and Recife: ‘When I give food to the poor they call me a saint, when I ask why they are poor, they call me a communist’. When impoverished people protest in the streets, you do not hear them calling for more philanthropy. They are demanding their rights.

A solid tax base, redistributive tax systems, and economic justice are the answers.  Transnational corporations are skilled at avoiding tax. Some pay little, some pay none. Rich people generally pay far less proportionately than poor people. Over the past 30 years, the tax burden, like every other burden, has shifted massively onto the backs of the poorest.

Do we really want to put nutrition decision-making in the hands of the wealthy much of whose money comes from avoidance of taxes, which is to say not contributing to the public purse, so that the public has to come begging for money that is rightfully theirs in the first place? Or, do we want decision-making to be public and democratic including those who pay taxes? That’s the choice: rule by money – plutocracy – or rule by people –  democracy. We already condemn the ability to pay as a criterion for access to health care and to good nutrition. We should also condemn the ability to pay as a criterion for access to decision making.  When we work in health or nutrition or any public service addressing human rights, our funding should be public; we should not depend on private funding.

The more I think about this, the more it seems to me that private philanthropy provides a respectable front to the much larger hidden face of powerful and exploitative forces. We want health and nutrition for all through social justice. It is a matter of appreciation whether social justice is a revolutionary project. Compared to the current neoliberal dogma, it probably is.

People are naturally compassionate, and empathy is a human trait. When ordinary people are told the truth about how international aid or private philanthropy works, they understand very well that human rights and charity are not the same thing. People will always need to help out other people in emergencies, because human beings are like that. But in a fair world, it would be just as likely for Haiti to help out Belgium, as it would be for Australia to help out Mali.

Private philanthropy’s espousal of ‘creative capitalism’ or ‘responsible capitalism’ or ‘win-win capitalism’ or ‘markets that benefit the poor’ (there are many more warm phrases) surely is obviously absurd at a time of chaotic market failures. Such phrases are surely fatuous when we find that foundations are doing nothing or little to stop systematic corporate tax evasion, and are aware that international property rights laws now promote monopolies and hinder innovation and scientific development. The very least that private foundations could do, is to address the many inequities and causes of market capture, market failure, barriers to market entry, and so on and on. These issues are crucial in the health and nutrition sector, because of its particular susceptibility to market failures. If families are thrown out of their houses, or have no money to buy shoes, usually they manage somehow. If they have no food, they die.

As Alison Katz so eloquently argues and David McCoy rightly concludes, private philanthropy has become a powerful and insidious presence in our midst. Ventilating this topic now is timely, in the month of the UN Summit on prevention and control of non-communicable diseases.

Transnational corporations and foundations are deeply implicated and involved in this global pandemic. Soon, I predict, private foundations, some directly controlled by transnational food and drink companies, others with less direct links with that part of industry whose products are a cause of the pandemic, will enter big-time, into the prevention of non-communicable diseases arena. But why am I saying ‘soon’? This is already happening now. At the very least, we professionals need to become more aware of what is going on, where philanthropic stakeholders are coming from, and why.

References:

1          Stuckler D., Basu S., McKee M., Global health philanthropy and institutional relationships: how should conflicts of interest be addressed? PLoS Med 8(4): e1001020. doi:10.1371/journal.pmed.1001020

2          Anon. What has the Gates Foundation done for public health? [Editorial]. The Lancet 2009; 373, 9675: 1527.

3                Piller C, Sanders E, Dixon R. Dark clouds over good work of the Gates

Foundation. The Los Angeles Times, 7 January 2007.

4                Wiist B. Philanthropic foundations and the public health agenda. Corporation

            and Health Watch, 3 August 2011.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Schuftan C. The new philanthropies in world health affairs. [Column] Website of the World Public Health Nutrition Association, September 2011. Obtainable at www.wphna.org

I owe the analysis in the commentary to many years’ experience and many discussions with countless friends and colleagues in the People’s Health Movement. Many thanks to David McCoy and Alison Katz; and also to David Stuckler, Sanjay Basu and Martin McKee, whose extensive review cited above is a vital resource. This column is reviewed by Geoffrey Cannon.

cschuftan@phmovement.org

www.phmovement.org

www.humaninfo.org/aviva

Why Do Doctors Support the Wall Street Occupiers?

A contingent of about 40 doctors in crisp white coats, carrying signs that read “Bronx doctors for Wall Street Occupation” and “My patients need jobs, education, healthcare for all, not just prescriptions, definitely not bank bailouts,” joined the throngs of activists at the Occupy Wall Street protests at New York’s Times Square two weeks ago.

Members of the umbrella group “Healthcare for the 99 Percent,” they are one of a growing number of OWS constituencies that view their particular cause not as a stand-alone issue, but integrated with other social grievances represented by the movement.

These doctors care for the people who live in the poorest congressional district in the country: the South Bronx’s 16th district. They see large numbers of patients each day who are hungry, who don’t have jobs or stable homes, who can’t afford their prescriptions. Widespread poverty means that Motrin and Lipitor won’t do much to help these New Yorkers; their health problems have much deeper socioeconomic roots. Not surprisingly, the Bronx is the unhealthiest county in the state of New York, according to a recent University of Wisconsin study. Dr. Cameron Page, who completed his residency in the Bronx and now works at Manhattan’s Beth Israel Medical Center, says that what he calls “upstream problems” have to be addressed first, because by the time patients get to the exam room, “it’s too late.”

To read the rest of the article, click here.

posted by Matt Anderson, MD

November 10th Fundraiser for El Punto en la Montaña, a Syringe Exchange Program in rural Puerto Rico

Our colleague Dr. Rob Roose forwarded this announcement of a fundraiser for the El Punto en la Montaña Syringe Exchange Program in rural Puerto Rico. He noted that: “injection drug use and its related sequelae continue to be massive public health problems in Puerto Rico. There is very little political will or interest to support prevention efforts or offer treatment for substance users.  Over the past several years, some colleagues of ours and friends of mine in the harm reduction field have been doing some very excellent work providing syringe exchange for rural users in Puerto Rico. However, and unfortunately, their work is in jeopardy of ending due to lack of funding. ” A podcast describing the work of the clinic is available from the Harm Reduction Coalition.

HELP US STOP A DRAMATIC AND AVOIDABLE HUMANITARIAN CRISIS IN PUERTO RICO

Julia Burgos Latino Cultural Center – (1680 Lexington Ave, between 105 and 106 streets) -Thursday, November 10, 2011 – 6pm to 12am

Education + Access = Power

The AIDS crisis in Puerto Rico is out of control. Over 35,000 people live with HIV/AIDS and at least 50% of these are due to the (avoidable) sharing of contaminated drug injection. It has been proven that when free sterile syringes are made available to injection drug users (IDU), they stop sharing syringes and HIV infection rates go down dramatically. Moreover, HIV and Hepatitis C (HCV) infections are the direct result of the lack of syringe availability. Despite the epidemiological crisis in the island, the needs of these populations continue to be overlooked. While a syringe that literally costs cents can save hundreds of thousands of dollars in HIV and HCV medication treatments and unnecessary human pain, there are almost no monetary allocations to decelerate the progress of these epidemics. In fact, while HCV treatment is virtually nonexistent in Puerto Rico, studies have found that over half of PR IDU may be infected with HCV. This governmental negligence has caused a major and unprecedented human rights’ crisis. We are determined to take matters into our own hands by bringing life-saving services to PR IDU via activism and philanthropy. But we need you. Puerto Rico needs you.

Concerned NYC-based activists are asking you to support El Punto en la Montaña, a rural Syringe Exchange Program (SEP) that operates in the municipalities of Cayey, Cidra, Comerio and Aguas Buenas. While the HIV/AIDS epidemic is island-wide, drug users in rural municipalities have even less access to drug treatment services and sterile injection supplies than those IDU living in metropolitan areas, where syringe exchange, methadone treatment and other services are (somewhat) available. This is what makes El Punto unique. Since 2007, with a yearly budget of approximately $40,000, it has provided access to sterile injection supplies, education and nutritional services to over 600 rural IDU. 98% of these IDU had never received these services in their lifetimes prior to El Punto.

El Punto has been able to operate thanks to funding from private foundations such as TIDES, National AIDS Fund-now AIDS United, NASEN and MAC AIDS Fund. CitiWide Harm Reduction (a Bronx-based SEP) and the Harm Reduction Coalition have also supported this program administratively, and with trainings and supplies. While these funders and institutions have helped El Punto throughout the past 4 years, the financial panorama for 2012 is grim. We need to raise $30,000 to guarantee full program operation during 2012.

Join our efforts to face an unprecedented humanitarian crisis. Join as at the fundraiser PUERTO RICO´S HUMANITARIAN CALL to be held on Thursday, November 10 at the Julia Burgos Latino Cultural Center (1680 Lexington Ave, between 105 and 106 streets). You can also send check donations by mail to 226 East 144^th Street, Bronx, NY 10451. Please make checks payable to “CitiWide Harm Reduction/El Punto en la Montaña”.

Questions? Contact El Punto Chair Camila Gelpí-Acosta at 718-581-3983 or camilagelpi@gmail.com