The Social Medicine Portal

WE ARE REALLY IN CLOUD CUCKOOLAND IF WE ACCEPT THAT NEOLIBERALISM IS A BENIGN SOCIAL IDEA THAT BACKS THE HUMAN RIGHTS FRAMEWORK. (Theodore MacDonald)

2010 RPSM Social Medicine Projects

All graduating residents from the Residency Program in Social Medicine complete a social medicine project. This year’s graduates presented their  projects during Social Medicine Rounds on May 25,  June 1, and June 8, 2010.  What follows are the project abstracts:

Drs. Viraj Patel, Vanessa Pratomo, Rahul Wadke, Insung Min, Dana Schonberg and Humberto Jimenez

Adamma Mba-Jonas, MD
Exploring Concomitant Acceptance of Seasonal and H1N1 Influenza Vaccine
The purpose of this study was to explore patient willingness to accept influenza vaccinations during the 2009-2010 influenza season, which was unique due to the concomitant H1N1 pandemic.  It is well documented that many patients, particularly minorities and those of lower socioeconomic status, routinely do not receive seasonal influenza vaccine. This card study sought to investigate patient’s attitudes towards and uptake of the seasonal and H1N1 vaccines, and to determine whether patients acceptance of seasonal influenza vaccination was in some way altered this past season by concerns about H1N1.

Cameron Page, MD
Are Internal Medicine Doctors Serving Our Patients’ Reproductive Health Needs? A cross-sectional survey of the reproductive health needs and preferences of women in an urban Internal Medicine clinic.

Celia Quinn, MD, MPH
Breastfeeding Support in Pediatric Practices
The objective of this project was to identify specific breastfeeding challenges among the CHCC clinic population with the aim to improve educational materials and breastfeeding support in the outpatient setting.  A qualitative study utilizing focus groups and semi-structured interviews was designed to elicit thoughts about breastfeeding support in the hospital, at home, and in the clinic.  Analysis revealed that a key theme was interest in educational materials specific to situation and culture. Participants preferred materials explaining problems they had experienced (e.g., sore nipples). They expressed enthusiasm for scenes of cultural familiarity. Women described lack of support for breastfeeding in the hospital, at home, and in the community. Availability of formula in the hospital contributed to early supplementation. Additionally, lack of understanding among family members about the frequency of breastfeeding was identified as a barrier in the home. Participants also expressed a perceived disapproval with public breastfeeding as a barrier within the community.

Women who choose to breastfeed weigh perceived benefits against the difficulties they face, often with little support. Improving support in the outpatient setting requires messages that acknowledge these challenges and help families to find ways to address them. Materials for breastfeeding promotion should exhibit cultural variety and address specific challenges. Development of educational materials targeting family members should be considered. Qualitative methods can serve to elicit additional information for quality improvement in breastfeeding educational materials.

Margo D. Simon, MD
“PGY-What?”  Towards an integrated residency program in family medicine and psychiatry
People living with mental illness have substantially higher rates of other illnesses, including chronic disease, substance abuse, and HIV/AIDS, as well as poorer health outcomes.  They are among the most marginalized not only within in society at large, but also within our healthcare system.  Obstacles to accessing care in an increasingly specialized and fragmented system are often insurmountable, especially for those with psychosocially disordered lives.  Because of the sociological overlap of these healthcare needs, integration of services benefits not only those with “triple diagnosis,” but also the many living under the complex conditions of urban poverty in the U.S.  Under these conditions where mental health, socioeconomic status, and health outcomes are intimately intertwined, a family practitioner-psychiatrist offers ease of access to multiple integrated levels of care and a uniquely trusted relationship, which are essential to maximize health outcomes and minimize health disparities.  Yet, too few combined residency programs exist to train physicians to address the complex needs of people living with co-morbid medical and mental illness, none of which are in major metropolitan areas.  Therefore, a 5-year training curriculum that independently fulfills the ACGME requirements for each family medicine and psychiatry residency program was developed in an urban, underserved, academic medical center setting.  This case study examined the feasibility, strengths and limitations of such a primary care-based integrated residency curriculum.

Humberto Jimenez, MD
Will existing recommendations to improve LGBT patient comfort be applicable in diverse health centers? Thoughts from the MSM population at Family Health Center–a needs assessment.
The objective of the project was to assess the level of LGBT patient comfort at Family Health Center and identify areas of improvement.  Since the recommendations published from the Gay and Lesbian Medial Association was extracted from work at Fenway, Mass., at an exclusively LGBT clinic, the applicability of such recommendations is questionable.  We sought to extract ideas from our patients about which of these strategies might work at FHC and asked them about other ways LGBT patient comfort could be improved. Patients were key informants identified by FHC providers.

Viraj Patel, MD
A Community Based Health Needs assessment of Bangladeshi Immigrants in the Bronx
South Asian immigrants, and particularly Bangladeshi immigrants in the Bronx is a rapidly growing community. The limited data that exists on this community show high rates of cardiovascular disease. However, little else is known about the health needs of this population. To address this lack of information and address the health and social concerns of this group through a social justice platform,  we formed a community-academic partnership (Westchester Square Partnership). Community Health Promoters have been recruited and trained to help administer a variety of programs. They have also conducted a community mapping project and a health needs assessment. The project continues to grow and more programs are being developed to address the needs of this community

Vanessa Pratomo, MD
Conceptualizing patient centered care in the context of social medicine
This was a qualitative study looking at how family medicine residents  conceptualize their practice of patient centered care, learned patient  centered care and view the relationship between patient centered care  and social medicine. This study consisted of interviews of nine RPSM  family medicine residents from the class of 2009.  In identifying  common themes, we hoped to identify areas for future study, better  understand how residents learn to be patient centered, and discover  possibilities for improving the psychosocial curriculum.

Rahul Wadke, MD
Psychosocial barriers to care in patients with diabetic foot ulcers.
Patients with diabetic foot ulcers have identifiable psychosocial barriers to care that delay initial presentation and impede treatment adherence. The study aims (using  qualitative analysis of patient narratives) to identify barriers to care from psychological, educational, social, disability-related, and financial sources and to explore the perceived role of health care providers in overcoming those barriers.

InSung Min, MD & Dana Schonberg, MD
Introducing Training in Correctional Health to Residents
This project aimed to expand correctional health training in medical education. A card study performed at a number of Montefiore clinics found that a significant portion of our patients and communities were involved with the criminal justice system. Involvement in the criminal justice system is associated with numerous complex medical and psychosocial issues yet traditional medical education fails to adequately train health professionals to work with this population.

In response, we conducted a literature review of existing training programs in correctional health. This was followed by the creation of a Marginalized Populations Elective during which residents rotate through the intake center of Riker’s Jail. The final part of the project took steps towards creating a standard national curriculum in correctional health to train health professionals to effectively treat those involved in the criminal justice system.

Mary Foote, MD
Medical Advocacy for Immigrant Detainees
For my project I performed medical reviews for clients being held in immigration detention facilities.  Clients were referred by a lawyer for a medical record review to address various issues pertaining to the medical care that clients had received while in detention.  Reviews were performed for various reasons including: 1) to help assess and improve care pertaining to a specific medical complaint. 2) to assess cases for potential medical parole. 3) to review cases to determine the causes of poor outcomes.  Upon review of the records, a summary was compiled with a focus on potential issues with medical management and included a summary of accepted standard of care for the given condition.  The client and lawyer were then able to use the summary as a tool to advocate for improved medical care within the immigration detention system.

Joy Hao, MD
Patient Characteristics Associated with Physician-Delivered Smoking Cessation Counseling in a South Bronx Community Clinic
This study seeks to determine patient-level characteristics associated with the receipt of smoking cessation counseling at CHCC, and to evaluate whether patients’ beliefs and attitudes regarding the importance and efficacy of smoking cessation counseling are associated with receipt of smoking cessation counseling.

Stephanie Lovinsky, MD
Managing Pediatric Asthma Medications: The Transition from ED to Clinic Care
Two projects developed from related concerns. Are our children receiving treatment for chronic symptoms of asthma in the face of an acute exacerbation in the ED?  And if so, how is that information reaching the primary care providers? I performed a retrospective chart review of patients evaluated in the pediatric ED for asthma and quantified controller medication prescriptions. I then designed an Asthma Health Passport to bridge the gap between providers in the ED and primary care clinics.

Victoria Mayer, MD
A Community-based partnership for residency education in obesity and nutrition
The obesity epidemic in the United States is disproportionately prevalent in indigent communities, where access to healthy food is problematic. For resident physicians to become effective in reducing this health disparity, they must develop culturally competent knowledge and skills to address obesity and nutrition.  We have developed a partnership between a community organization, the South Bronx Food Cooperative, and our primary care residency program with the goals of supporting a local effort to improve access to healthy food while fulfilling a need to train residents in nutrition and obesity.

Lysette Ramos, MD
Nonresident Fathers and Fatherhood: A Needs Assessment
Research has shown that a father’s involvement in a child’s life impacts every domain in their functioning, from birth through adolescence.  However, 24 million children in the United States (34 percent) do not live with their biological father.  In 2000, the Bronx was one of the five counties in the US with the highest percentage of single mother households (> 30%). This trend has been more pronounced for African American children, with 50% living in single mother homes in 2007. This study’s objective was to obtain data on the parenting experience of nonresident fathers by exploring their perceived roles, learning processes, challenges, and supports.

A qualitative study was undertaken using semi-structured interviews (n=5) with nonresident fathers recruited from CHCC and a focus group (n=11) with a community organization in the Bronx that serves nonresident fathers. Themes identified are presented to increase awareness of the unique challenges and perspectives of nonresident fatherhood in order to provide appropriate education, support, and anticipatory guidance.

Jennifer Reckrey, MD
Surrogate Decision Making:  Residents’ Perspectives
There is a substantial literature about what it is like for health care proxies, families, and other surrogates to make health care decisions. Less is known, however, about what residents bring to the table.  What do residents experience as they try to help surrogates make decisions?  How do they learn to do this? What do they think their role in the process should be, and how do they decide when to give surrogates recommendations or advice?

To explore these questions, I conducted 45 minute semi-structured interviews with second and third year family medicine residents at Montefiore, Jamaica, and Beth Israel hospitals.  Interviews were transcribed, a coding scheme was developed, and these codes were applied to all interviews.  Preliminary analysis of the data suggests that residents receive little formal education about how to help surrogates make decisions despite the significant emotional burden of these interactions.  Residents adopt a broad range of roles when interacting with surrogates, including advice-giving.  Yet residents uniformly express concern that recommendations may negatively impact patient and surrogate autonomy.  This concern adds to the emotional burden of the interactions.

Miriam Shiferaw, MD
Global Health Training in Pediatric Residency: Interest, Needs and Barriers to Participation
I performed a cross-sectional survey of the pediatric residents at the Children’s Hospital at Montefiore to assess residents’ previous global health experiences, satisfaction level with their current global health training, interest in having increased exposure to global health education and also their perceived barriers to participating in an international global health elective.  The goal of this project is to use the needs assessment as a framework to inform the development of a global health curriculum for the pediatric residents over the next two years.

Marianna Borkovskaya Shimelfarb, MD & Guido Grasso-Knight, MD, MPH
Taking a Step Towards a Healthier Workplace
As part of our Departmental Social Medicine Project we drafted a survey to assess physical activity among Montefiore employees and also provider views on healthy lifestyle. We made the survey available online through “surveymonkey.com” and through notices in the Montefiore Bulletin. Our goal is to contribute to the broader efforts to improve the healthiness of our workplace for our staff and patients.

Melissa Berlin, MD & Lisa Lapman, MD
Zumba: The Effect of Dance on Quality of Life in Community Dwelling Seniors in the Bronx
Our project investigated the effects of dance on quality of life and vitality in seniors. At the RAIN Senior Center, we taught a 12 week Zumba class (a Salsa Dance Exercise class) and conducted pre and post-class surveys using the Vitality Plus Scale (VPS) and a modified version of the SF36. We also collected demographic data and followed attendance rates. Although our study design did not have enough power to achieve statistical significance, we did find a definite trend towards improvement in the VPS. We hope that this data can be utilized in a larger study to quantify the effects of Zumba on Vitality in Seniors in the Bronx.

In health care as elsewhere, cheaper is not always better.

So the dirty little secret has come to light. As it appears, in health care, cheaper is not always better. The “pioneering” research produced by the Dartmouth group, propagating the belief that many areas of the country spend more in health care than others, while providing no better, and sometimes worse, care (the study used comparisons within Medicare) because in these regions doctors are simply “wasteful”, may have been based on faulty research after all.

At least this much was admitted in a recent article in the New York Times, even as the very New York Times editorial board, and key reporters such as David Leonhardt, have been all along major supporter of the science and philosophy underlying Dartmouth and of the many “cost-saving and quality improving” measures that will be implemented under the new law, the “Patient Protection and Affordable Care Act”. One key measure is to reduce “superfluous” services to Medicare patients, and thus “rein on waste, fraud and abuse“.  Somehow, this will not undermine, but rather improve, the quality of care provided to them, or so says the law.

Indeed, for New York Times editors one key problem in our health care system has been all along the “profligate” behavior of doctors. If we can tame this behavior, our collective savings will be extraordinary, the Times and its health reporters have asserted repeatedly, and will enable us to eventually provide health care to all Americans at lower costs. Promoting this view, The Cost Conundrum, by Atul Gawande, a Harvard-affiliate doctor and author, became “required reading” in the White House, and turned its author into a Washington star virtually overnight.

But as it turns out, the research may have been faulty.

Just so as not to clog cyberspace with redundancies, here an excellent analysis of what the Dartmouth study really showed (you guessed it: correlation is not causation), and what may have been the motivations of researchers who  promoted the study (you guessed it: money!).

Single payer anyone?

SOCIAL MEDICINE AS A PRAXIS IS PROFOUNDLY LINKED TO THE PRAXIS OF EMANCIPATORY HUMAN RIGHTS.

Food for an emancipatory thought

Human Rights Reader 242

Time was when we could; we’ve come to the time we can; we do not want to come to a time when we’re out of options. (adapted from Haiku #1533, J. Koenig).

1. As HR activists working in health, we face a double challenge. We must work for fundamental economic, social and political changes underlying what we know as the social determinant of health and, at the same time, we must work on changes in the specific field of health where additional localized resistance (often by doctors) is to be reckoned with. We thus need to set-up networks –not forgetting the health workers, organized or not– to integrate our health and our human rights (HR) aims in what will inevitably become a political challenge. (As this Reader has repeatedly said, HR are a powerful idea which should be spread, starting with concerted efforts to launch more and more HR learning activities).

2. Actually, it is the HR-based framework that contains the powerful ideas; ideas that are at odds and counter neoliberal ideology, ideas that are a counter-power to the prevailing market forces –and, let’s face it,  that is why the spreading of the HR idea is opposed. The powers-that-be fear HR as they entail an emancipatory praxis, a praxis that eventually is a counter-hegemonic force against globalization. The HR-based framework legitimizes power in the hands of claim holders, away from male, adult, middle and upper-class property owners. In so doing, the HR framework confers on rights holders a legitimate claim on the resources necessary to fulfill specific HR –and that is feared. HR are ultimately the legal expression of a collective will –and that is feared. Moreover, the HR-based framework prioritizes dignity and solidarity over accumulation, over competition, and over the market, as well as the inclusion of environmental rights –and that is feared. (I think I am not being harsh in my analysis here; I am just calling a spade, a spade).

3. A ‘decent minimum’ cannot be set on inalienable human rights. There is thus no such a thing as ‘basic rights’ or ‘low intensity human rights’ (the latter seeming to be what is, at most, acceptable to the powers-that-be as they relentlessly foster the process of globalization with its ‘low intensity democracies’ the world over). (B. de Souza)*

*: Fact: Strong democracies encourage claim holders and shield them from drastic reprisals. (T. Schrecker)

4. “Things have a price,” says Emmanuel Kant, “but man, in contrast, has dignity”. Things that have a price are interchangeable, can be sold, and/or can be used as tools. Human dignity, on the other hand, implies that human life is an end in itself, irreplaceable and never exchangeable; it cannot be made into an object or thing, and it cannot serve as an instrument or a commodity. Dignity is violated when something associated with life acquires commodity status and becomes –either directly or indirectly– an object of profit; we see this all the time in processes that subordinate life (and nature) to the interests of accumulation: health is regrettably no exception.

5. Capitalism has made health too much into an economic concern. The right to maintain and restore health (mostly the latter) thus became dependent on a business, and a new corresponding morality came into being with it –and for HR, as much as for social medicine, this has become a nemesis, an issue central to their respective raisons d’etre.

6. Some feel that the emphasis on individual rights (as sanctioned by UN human rights treaties) has created an obstacle for social medicine which is all about collective or community rights. **

**: Allow me an unorthodox metaphor here. Conventional wisdom would suggest that ‘In HR work, the I is a We or it is not at all; united, we are part of a choir; outside it, our music is atonal’. (C. Fuentes)  But then, conventional wisdom can sometimes be wrong…

7. In the unequal societies of Capitalism, health policies have medicalized health problems; we all know that much. The human right to health (RTH) presupposes a right to the non-medicalization of life –since medicalization is inherent to the commodification of health. (That has made health a topic of what has become known as bio-politics). The RTH arose within the context of the social welfare state, true; so it is, in principle, since then that the RTH fell in the realm of bio-politics. But real action to defuse the many violations of this right and to start staking claims against pertinent duty bearers took a good 40 or more years to gain momentum.

8. Take, for instance, the 1993 World Bank’s World Report which was devoted to health; it has guided most of the neoliberal reforms we find today all over the world –and it was conspicuously silent-on and did not even mention the RTH. Instead, we got DALYs. DALYs legitimized the denial of access to services essential for survival to those unable to pay for them. We were thus left with the damage and with the social exclusion that has resulted from our planners using this neoliberal WB indicator to measure progress.

9. But back to social medicine as a praxis linked to the praxis of human rights: Its strong egalitarian emphasis is one of the most important reasons to consider HR as central to efforts to advance health equity. (T. Schrecker) In other words, HR-based action on health is essential for health equity. Yet, still today, this action is more often talked about than practiced.

10. Since changes in health will only come about by collective action (M. Marmot),  at the community level –given appropriate and ample HR learning opportunities– the HR-based approach creates the prospect to innovate and to implement new ways of addressing the-processes-of-health-disease-and-care in a collective, mutually supportive manner. Therefore, as borrowed from the concept of food sovereignty, health sovereignty has come to mean communities themselves deciding what they need and want.

11. Bottom line, the introduction of HR not only preordains how public health work is to be done (i.e., processes), but also what its ultimate outcome should be in terms of dignity and solidarity. (D. Tarantola)

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org

______________

Mostly adapted from A. Stolkiner, Human rights and the right to health in Latinamerica: the two faces of one powerful idea, Social Medicine, 5:1, 2010.

Dr. Walter Lear Passes

Social Medicine Course in Northern Uganda

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)

Healthy People 2010: Not quite there yet

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.

ONLY WHERE AND WHEN HUMAN RIGHTS ARE RESPECTED CAN WE SPEAK OF DEMOCRACY BEING STABLE.

Food for a resounding majority thought

Human Rights Reader 241
 
The human rights framework provides a normative base for poverty reduction, while democracy organizes political and social life to this end. (Sida)
1. Ratification of UN Covenants and Conventions (has not) and does not require(d) any type of democracy. Actually, the reasons for why so many non-democratic countries have ratified many UN treaties include:
·      gaining international legitimacy;
·      attracting donor funding; and
·      having accepted them with Reservations (which is when states accept most of the text of a covenant, but with some reservations).
Although ratification of a UN Convention is legally binding, there is no real enforcement mechanism, especially if there are no active monitoring bodies (which a true democratic regime calls for). (U. Jonsson)
 
2. In their ODA, more often than not, donors fund recipient countries to focus primarily on human rights standards (i.e., on desirable outcomes –classically these days the MDGs*); human rights standards do not require democracy. In their aid, these same donors conveniently overlook their recipients’ adherence to human rights principles (i.e., the required criteria for human rights-based processes to be set in motion on a solid base); human rights principles do require a working democracy for their enforcement. This is a crucial point to keep in mind.
*: A single-issue-focus is applied to the achievement of each individual MDG –without due attention being paid-to through which processes each goal is to be achieved. Moreover, no attention is paid to whether the same are rights-based processes –as mandated by UN covenants and as clearly stated in the Millennium Declaration where the MDGs actually come from! (U. Jonsson and  D+C, 35:6, June 2008).  
 
3. The mere fact that elections are held, does not mean that democratic rules are firmly in place. Actually, the representative institutions of so-called-democracies are widely perceived as being controlled  by the dominant economic and financial groups in society. (V. Navarro) So, democracy is not only about elections –and not even a tradition of uninterrupted ‘free’ elections means there is democracy…or that human rights (HR) are respected.
 
4. Would a jobless family from Marseille, Frankfurt or Antwerp have any reason to swap places with a family in Managua, Phnom Penh or Nairobi? Probably not. Put the question the other way around, and the answer is quite likely yes. The reason is not just that France, Germany or Belgium are richer than Nicaragua, Kampuchia or Kenya. But, within its confines, democracy in Europe works better. *
*: On the other hand, look at the OECD countries: With all their democracy, they have, at best, been lukewarm towards HR violations in poor countries. 
 
5. People who happen to be poor can only be given guarantees they can assert their rights where states pass laws that protect HR and that ultimately enforce and observe them. Democracy is thus not simply a function of voting; it is a matter of HR as well –and this is mostly forgotten. A true democracy secures physical and economic access to all social services with no discrimination and implements fair rules of compensation for HR violations.
 
6. Even in so-called democratic countries, many times the bureaucracy is too hierarchical**, is arrogant, aloof, despondent, dismissive, arbitrary and corrupt in its behavior… and does not care for HR –being absolutely ignorant about HR standards and principles. (One often wonders if civil servants really give a damn…).*** What we find is that civil servants have different levels of moral standards and work ethic.
**:   Thinking loud, one wonders, would organizing the civil service in trade unions change their culture of blind obedience?
***: Administrations have to serve society and not themselves, right? But too often we see them using the law to make arbitrary decisions –not in the direction or interest of HR.
 
7. Many societies function along the lines of patronage systems –where who you know matters more than what you know. This is one reason why bureaucracies should not just be seen as a machine –they are an important, but unpredictable component of any governing system and are thus not to be taken for granted.
 
8. Under this guise, would it seem somehow patriotic to subvert a bureaucracy uncaring about HR…? In our eyes, a good public administration is to serve development and to provide impetus to the implementation of the HR-based framework.
 
9. So, to what a position does all of this lead us? The problem with democracy is that organized greed always wins over disorganized egalitarianism. We thus either need more checks and balances on the greed (but that requires challenging the power of the greedy) or we need to strengthen the organization and the mobilization of the ‘egalitarians’ (which also requires challenging power). So, no easy solutions, leaving us to do what needs to be done perhaps in small steps (…?). (L. London)
 
10. Ergo, can the current world political structure be “reformed”? It is run by the rich and powerful and they are not going to voluntarily cede their privilege, are they? **** It is acknowledged that there is always a tension between reformism and revolution –and that cannot be resolved by this Reader. Our role is to point to the most progressive solution to the political problems we have inherited in the 21st century. (M. Anderson)
****: Do not dismiss it lightly: i) Democracy is seen as an obstacle, a barrier to the operation and the unbridled ambitions of neoliberalism. (T. McDonald), and ii) Dictators are the proxy facade of the owners of the wealth.
 
11. This leaves us with the question: In this context, what are HR activists to do? We will promote a firm pro-democracy stand with an unmistaken HR base! We will use HR as a decisive contribution to a bottom-centered-direct-democracy! *****  
*****: Direct democracy is the collective action that has historically allowed poor and excluded groups to make their voices heard; it is a way in which the condition of being relatively powerless can become internalized and linked to the  ability to forcefully negotiate and influence decisions by actively engaging in the political system. (D. Green).
 
12. Bottom line: Knowledge about all of this alone, or democracy alone for that purpose, will not improve HR.  Already centuries ago, Francis Bacon, said that knowledge is power. But knowledge is not automatically followed by action. Strengthening capacity is important, but without power, it is not sufficient.
 
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org 
______________
Partly adapted from D+C, 35:6, June 2008; D+C, 35:7-8, July/August 2008; D+C, 36:5, May 2009; The Broker, Issue 15, August 2009; The Broker, Issue 16, October 2009; L. Weinstein, Ed. Multiversidad, Editorial Universidad Bolivariana, Coleccion Nuevos Paradigmas, Santiago, Chile, Mayo 2009; and Development and Practice, 19:8, 2009.
 
Postscript: In the alleged ‘democratic discourse’, not all opinions affecting outcomes are backed by the same power. Am I thus being ‘HR-facetious’ if I paraphrase: “All opinions deserve the same respect” is a very harmful idea and falsely democratic. (Albino Gomez, Tiempo de Descuento, Editorial El Fin de la Noche, Buenos Aires, 2009).

Support Single Payer in California, and promote a model for the Nation

The shortcomings of the federal legislation are beginning to unravel, with people either not being able to afford a policy, affording policies that fail to eliminate financial barriers to medically necessary care, or risking financial penalties for failing “wellness” tests.

At the same time, a strong movement in support of a publicly funded privately delivered health care system is gaining steam in California, providing a model to the nation.

We do not have the money lobbyists have, but we can gather the numbers.

Support a right to health care, by supporting the growing single payer movement in California, embodied in SB810, using the sample letter below. Use this advocacy tool as a model for starting a movement in your own state.

SAMPLE SUPPORT LETTER

SB 810, the California Universal Health Care Act

Directions:  Please use the following letter as a template for your own personalized support letter.

1. Place your letter on organizational letterhead (if it’s from an organization).
2. Mail, fax or email the letter to Assembly Health Committee
   1. Email: AssemblyHealthCommittee@asm.ca.gov
   2. Fax: (916) 319-2197
3. Be sure to cc: Senator Leno at (916) 445-4722 or email at senator.leno@sen.ca.gov
4. You may also mail or fax the letter to your own legislator found at www.leginfo.ca.gov.

The Honorable Bill Monning

Chair, Assembly Health Committee
State Capitol, Room 6005
Sacramento, CA 95814

Fax: (916) 319-2197

Dear Assemblymember Monning:

I am writing to express my organization’s strong support for single payer, universal health care and for SB 810, the California Universal Health Care Act.  I urge your support for this important legislation and request that you work hard to bring it to the Governor’s desk this year.

Passage of federal health reform has greatly increased the importance of California’s advocacy for universal health care.  Federal health reform is the tipping point for health reform, not the end goal.  Single payer remains the gold standard for health care reform and is the only model that will achieve truly universal coverage.

SB 810 will dramatically reduce premiums for businesses and families, will cover all medically necessary health care, will eliminate the risk of medical bankruptcy, and is proven to contain health care spending over the long term.  Importantly, SB 810 will save California businesses and state and local government millions of dollars in employee health care costs and is the only plan that responsibly funds retiree health care.

Around the world, every wealthy nation except the United States achieves universal health care through some variation of a single payer model of health care.  All other nations spend far less than we do and in return receive higher quality care and more of it.  California families and employers can no longer afford to foolishly waste 30% of every health care dollar on a private health insurance bureaucracy designed to minimize the payment of claims instead of maximizing the health of the people.

SB 810 would dramatically increase patient choice and provider competition by guaranteeing every Californian total choice over his or her doctors and hospitals instead of the narrow provider networks that restrict choice today.

SB 810 would significantly lower health premiums for businesses and families that are struggling to pay unaffordable premiums that rise as much as 40% every year.   This legislation will help middle and lower income families and businesses that are the backbone of California’s economy.

SB 810 will create jobs, ease the burden on California’s budget and improve health care for every single Californian.  I urge your support.

Sincerely,

Name

Organization

THE DOZEN HATS WORN BY HUMAN RIGHTS ACTIVISTS.

Food for an eye opener thought

Human Rights Reader 240

Activists do not need to be original thinkers as much as they need to be original listeners.

They are not only witnesses, but doers, particularly social mobilizers.

1. As a starter, a random list of desirable attributes can be an eye opener.

Human rights activists are expected to be: agenda setters, catalysts, promoters, conveners, finders of seed money, collectors, disseminators, advocates, educators, linkers, sponsors, defenders, observers, judges, presenters of the proper and contesters of the faulty evidence, pushers of changes-people-can-believe-in (D. Gwatkin), visionaries that see tomorrow when others only see today, active opponents of corporations that violate social and environmental standards in their operations, vectors/promoters/ announcers of the new human rights (HR) paradigm…

2. But realistically, on the one hand, HR activists cannot be omnipresent –granted. So they have to opt to carry out certain roles more effectively and rule out other. (J. Cloke, Development in Practice) But on the other hand, HR activists do not usually operate in conventional give-and-take terms; they have an agenda in which some elements are non-negotiable: HR are non-negotiable.

3. Since there is no point any longer to abide by the several myths entrenched by the hegemonic Northern-led development paradigm (which still treats its perceptions as if they always were the product of objective facts), HR activists have to undo old hierarchies and undo myths that come from it. They also have to undo myths that come from the obsolete overseas development assistance (ODA) model that comes with it …a particularly odd model indeed (a remnant of colonialism?). The model reminds us of the absurd of a court allowing a thief to spend some more of the money he has stolen before passing sentence. (U. Avnery)]. 

6. HR activists have a big task in front of them: a task much deeper, more complex than a public visibility campaign; a task that is more than just the physical bringing together of likeminded people. They cannot lower their guard; they have to unlearn and change much of what they learned about how society works –since the glass is already full and they need to make room for new, HR-based concepts… Ergo, they cannot advance without being all-encompassing in their work, i.e., work with both  the powerful and with the still unorganized poor and marginalized people that have, for too long, been relegated to (…or opted to?) live in a state of resignation. It is for activists to raise consciousness thus widening the scope of people’s alternatives, opening a whole new cosmo-vision to which they need to be introduced-to.

7. HR are obviously a global theme, but less obvious is the fact that HR are ultimately a theme that is resolved at the individual and community level –at the conscience of each individual and member of that community. Thus the important priority role of HR activists in pioneering human rights learning.

8. When faced with a given reality, HR activists have to ponder the action alternatives that that reality calls for; but these actions become viable and sustainable only when the-more-global-scenario is taken into consideration; it is the latter that opens the doors for the mobilization and solidarity work needed to bring about the switch to the new HR paradigm that will eventually lead to the concrete worldwide changes needed to effectively counter the relentless process of globalization with its negative HR consequences.*

*: A paradigm is somewhat similar to group-thinking, mindset or discourse, or an explanatory conceptual framework, or a world view or cosmo-vision. Paradigms lead to thinking inside the box. (U. Jonsson)

9. An example of how the ‘bigger picture’ needs to be taken into account is here given for activists working in the field of health. In their case: 

• the WHO Constitution provides them with an overall umbrella of what the human right to health (RTH) is;
• the text of the  UN RTH and General Comment No.12 (#) –and, of course, HR standards (i.e., the desirable outcomes pursued as, for example, some of the MDGs) and HR principles (i.e., the required criteria for the HR-based processes to be set in motion: indivisibility, inter-relatedness, universality of HR, respect of human dignity, right to life and to development, equality, rule of law, non-discrimination, empowering participation, accountability) — are the documents that provide them with the advocacy and the political framework for their activism;
• the principles of comprehensive primary health care (PHC), as set in the 1978 Alma Ata Declaration (consistent with HR standards), acquaint them with the basics on health care and with the basic and underlying social determinants of ill-health, malnutrition and preventable deaths;
• WHO’s Report on the Social Determinants of Health (SDH) provides them with guidance to assess both HR violations and the effectiveness (or not) of ongoing interventions to reverse those violations.

The knowledge generated by these documents points them to what issues need addressing in each specific locality. Therefore, everything they do in their work in health must incorporate these four elements. A campaign for the RTH has thus to integrate these elements when focusing on the ‘HR-worthiness’ of existing health systems. In short, RTH work must tap into the ongoing global efforts to drastically change health systems using the human right to health as a framework. (L. Turiano) **

**: These are also the four legs on which the People’s Health Movement Charter for Health stands, and the basis of PHM’s Global Right to Health Care campaign. (www.phmovement.org)

10. As can be gathered, in general, it is HR activists that come from the non-academic sphere that have to play the greater protagonists’ role. Among all other roles, they also have to expose local leaders (or academics…) that speak of programs, needs and injustices but, in their speeches, writings or actions, rarely address what is behind HR violations.

11. Bottom line, we expect HR activists to be competent directors who oversee the putting into action a collectively arrived-at, well-written script. It is for the players though to act-out that script as the main protagonists. ***

***: Caveat: The power to act is different from the ability to act; in an effort to achieve results, we often give responsibilities to individuals and/or institutions with the ability  –and not with the power– to act. (U. Jonsson) This is at the very core of the HR-based framework, namely, activists’ work with claim holders and duty bearers is to precisely go from the ability to the power to make needed changes.

Claudio Schuftan, Ho Chi Minh City

cschuftan@phmovement.org  

______________

A few aspects adapted from Aravind Adiga, The White Tiger, Free Press, N. Y., 2008; L. Weinstein, Ed. Multiversidad, Editorial Universidad Bolivariana, Coleccion Nuevos Paradigmas, Santiago, Chile, Mayo 2009; and D+C, Vol.36, No.9. Sept. 2009.

Postscript: Remember! You may be small, but if the light is positioned right, you cast a long shadow.

(#):General Comment 1, Reporting by States parties.

General Comment 2, International technical assistance measures.

General Comment 3, The nature of States parties’ obligations.

General Comment 4, The right to adequate housing.

General Comment No. 5, Persons with disabilities.

General Comment No. 6, The economic, social and cultural rights of older persons.

General Comment 7, Forced evictions, and the right to adequate housing.

General Comment 8, The relationship between economic sanctions and respect for economic, social and cultural rights.

General Comment 9, The domestic application of the Covenant.

General Comment 10, The role of national human rights institutions in the protection of economic, social and cultural rights.

General Comment 11, Plans of action for primary education.

General Comment 12, Right to adequate food.

General Comment 13, The right to education.

General Comment 14, The right to the highest attainable standard of health.

General Comment 15, The right to water.

General Comment 16, The equal right of men and women to the enjoyment of all economic, social and cultural  rights.

General Comment 17, The right of everyone to benefit from the protection of the moral and material interests resulting from any scientific, literary or artistic production of which he or she is the author.

General Comment 18, The equal right of men and women to the enjoyment of all economic, social and cultural.
General Comment 19, The right to social security (art. 9) (Thirty-ninth session, 2007), U.N. Doc. E/C.12/GC/19 (2008).
General Comment No. 20, Non-Discrimination in Economic, Social and Cultural Rights.