Public Health & Human Rights

30 years of public health yet much work to do: Alma Ata, September 1978

In the world of global health, there is much talk these days about the 30^thanniversary of what is known as the Declaration of Alma Ata. Alma Ata was the city, in today’s Kazakhstan, in which a landmark call was made, during the International Conference on Primary Care, to all governments and all people involved in the work of public health "to protect and promote the health of all people."

This declaration certainly did not begin the work of public health, but its key role was in creating a common global understanding of preventive care and public health and in elevating their importance as the primary way of assuring health for all people. Since 1978, and especially more recently, the principles declared at Alma Ata have been a driving force by many in global health, in particular at the World Health Organization.

The declaration states that primary care includes, among other things, "education about health problems and methods of prevention; promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, immunization against infectious diseases; prevention and control of endemic diseases…."

Public health and human rights are inextricably linked, and that linkage becomes clear, implicitly, as one reads the declaration. How does one, for example, educate people whose rights are being compromised? People who are being discriminated against are less likely to receive the education that they need and/or will be less able to act on their knowledge. Actually, as Jonathan Mann has pointed out, the needs of those being discriminated against are likely to remain unrecognized.

Quoting some recent examples of this health and human rights linkage from a new UNICEF publication about the health of children in Asia, notice that assuring health will also require that we work to ensure some basic rights and the removal of discrimination:

• "The right to a name and a nationality is well established by the Convention on the Rights of the Child. Yet in 2006, 22.6 million births in South Asia and 5.1 million in the rest of Asia-Pacific went unregistered. These children are almost always from poor, marginalized or displaced families …and the consequences for their health and well-being are often severe and long-lasting."

• In India, which by itself accounts for 20 per cent of the world’s under-fives, "an entrenched social structure based on caste has made it difficult or impossible for 167 million Dalit (the outcaste or untouchable communities) to access basic primary health and educational services. Dalit children are often served inferior meals at school; their parents, meanwhile, are barred from most employment and from owning land, keeping them in abject poverty, and they are discouraged from using medical services."

• "Research has shown repeatedly that the empowerment of women and girls is inextricably linked to improved maternal and child survival rates. At a most basic level, women are unable to or prohibited from seeking health care, and girl children in most countries (in Asia) are often denied food to the benefit of their brothers."

For all of us, regardless of where we live, social status and the various roles we have profoundly influence and constrain our choices. And, for those whose basic rights are being denied, the choice and the chance to live in health can be remarkably difficult. It is for us then to promote health by also promoting justice and rights.

 

Related Resources:

Here is a link to the entire Alma Ata declaration (it is short): http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

And here is a link to the full UNICEF report quoted above: http://www.unicef.org/publications/index_45086.html

Here is a link to an excellent and new publication from the WHO that explicitly describes the links between justice/rights and health: http://www.who.int/social_determinants/final_report/en/index.html

TB, leprosy and discrimination

Several states in India have effectively legislated discrimination against those with tuberculosis and leprosy.  As a recent article states,

"There are in fact many Acts in the country clearly advocating discrimination against tuberculosis and leprosy patients. A leprosy patient cannot stand for local body or panchayat elections in states like Chhattisgarh, Rajasthan, Madhya Pradesh, Andhra Pradesh and Orissa. This prohibition extends to tuberculosis patients in Orissa's Panchayati Raj Act. Further, if a member of local office contracts tuberculosis or leprosy during his/her tenure he/she may be declared ineligible for the job. In Andhra Pradesh and Karnataka, the hearing impaired and mute also cannot stand for panchayat elections."

See here for a link to the entire article, and a good website.

Paul Farmer has a lot to say about structural violence, that is societal or structural forces (law, for example) that oppress a certain segment of the population thereby negatively impacting their health.  As he has stated, "the worlds poor are the main victims of structural violence.  The poor are not only more likely to suffer, they are also less likely to have their suffering noticed."  "The task at hand is to identify the forces conspiring to promote suffering."

 

 

Friday light: Need a new ring tone?

A new approach to HIV/AIDS prevention in India funded, in part, by the Bill & Melinda Gates Foundation.  Have your speakers turned on....and click here.

Creativity knows no bounds.  I'm not sure what else to say, so I'll keep this short.

See an AP news report about it here:

http://ap.google.com/article/ALeqM5ixELbpxeyexk4KfLKIvVqzchghoQD92LC39O0

Global public health blogs I frequent

There are a handful of public health-related blogs that I frequent that I want to let you know about.  I'll probably also add these to the side bar when I have a little extra time.

The Lancet Global Health Network: http://www.thelancetglobalhealthnetwork.com/index.php.  A discussion forum for scientific and public health experts.

Global Health Report: http://globalhealthreport.blogspot.com/.  Interesting stories and experiences from longtime health journalist Christine Gorman.

 

Global Health Delivery blog: http://globalhealthdelivery.org/blog/.  A site for "health care implementers" with a lot of good information and interesting posts.

 

Global Health Policy: http://blogs.cgdev.org/globalhealth/. A great place to read and discuss the latest in a wide range of global health policy issues.

 

Subject to Change: http://vanessamason.wordpress.com/.  A blog about social change through public health.

Faith and AIDS connection: http://faithandaids.wordpress.com/.  An excellent and regularly-updated source for HIV/AIDS-related issues. 

Joseph D'Souza: http://www.josephdsouza.com/.  A justice-focused blog about India, caste, and discrimination.

Health Care, Health, and Justice - Part 4 (final): Health care as a human right

Universal Health Care (health care as a human right)

There are different definitions and degrees of universal health care, but I use it here to mean a national single-payer system that affords everyone equal financial access to comprehensive health services. This is really the only option that truly decreases health care costs because of less fragmentation and oversight of rules, and it is the one option that provides care for all.

HMOs, PPOs, HSAs, and nearly ever other health care option in the U.S. are generally market-based and for-profit. But market-based and for-profit models do not concern themselves with correcting inequalities or distributing services equally. In these models, as one author has well stated, inequities in health are unfortunate but not unjust. Some simply are winners and some simply are losers. The free-market does not negate the ability of people to be altruistic, but neither does it impose a moral duty to help. The free-market does not have time or patience for those who cannot "play" in the market—the uninsured or the poor.

The Bible argues powerfully for the dignity of all people and for their restoration, life, and healing. Promotion of justice is a clear theme throughout the Bible, and the needs of others are not to be taken lightly in view of the inherent value placed on all people. As one well-regarded religious ethicist has stated, "Justice in the Bible is unmistakably committed to the restoration of health."

Health Care, Health, and Justice - Part 3: Consumer-driven health care as an answer

Consumer-driven Health Care (HSAs) (market driven, still many rules)

Health Savings Accounts (HSA) are relatively new in the U.S. and are increasingly popular among certain segments of the population. "Consumer-driven health care," as it is called, is meant to spur competition, and thus lower costs, by causing patients to pay for most of their routine care out-of-pocket, which, in turn, will cause patients to "shop" for the best bargains.

Consumer-driven health care is a free-market approach to health care that, significantly different than traditional HMOs, asks the patient to pay full price for most routine care, rather than pooling or sharing risk with others. Similar to managed care, one must still choose an insurer, and these HSAs are simply one of the many plan options which can be chosen. They are typically called "high deductible" plans or "HSA-compatible" plans.

Consumer-driven health care is a potentially cost-saving option for some people, but there are at least two critical problems with HSAs. First, HSAs do not address the actual cost of health care. Rather than providing any incentives to health insurers to reduce costs, consumer-driven health care simply shifts the burden of payment from a pool of people to an individual.

The argument for HSAs is that they will indeed reduce actual costs because people will shop for the best "deals" thereby spurring competition. But, this is the second fundamental flaw with these plans. One does not shop for the best deal on a tetanus shot or the best deal on a hip-replacement surgery the way one shops for the best price on milk or eggs. First, this information is generally either not available or difficult to find (frequently bundled as in a "well child exam", for example), and secondly, even if it was available, people generally trust their physician’s advice and don’t "shop" for other prices or are not able, in the case of urgent/emergency care, to shop. Rather, the evidence clearly shows that when one pays for more care out-of-pocket, both unneeded and needed care decreases. A person is less likely to visit the doctor, even if they need to, when the cost of the visit is $150 compared with $10 or $15.

HSAs work for those who are healthy and relatively well-off, although research shows that even they will not seek some needed care. HSAs contribute to the fragmentation and costs of our current system and many people will be unable to afford their high deductibles leading to decreased health.

Health Care, Health, and Justice - Part 2: Managed care as an answer

Managed Care (HMOs, PPOs) (rules, rules, rules)

Health insurance companies contract with medical providers and medical facilities to provide care for their members at a reduced cost. The details of what type of health care is provided and at what cost is determined by the specific rules of the plan. Similar to home insurance, car insurance, or most other insurance, managed care spreads risk among many people, creating predictable and low costs for those covered.

Although HMOs and PPOs, and managed care in general provides good access for many people throughout the U.S., one of the single biggest drawbacks and a primary reason for talk of needed change, is the administrative costs of these programs. Hundreds of rules define who can receive care, where that care can be received, and what type of care can be given. Millions of dollars are spent every year assuring that the right people get the right care in the right place at the right time at the right cost. Rules often change annually, or more frequently, and keeping up with these rules takes a significant amount of time for everyone involved.

HMOs and PPOs work for individuals, but they only contribute to the fragmentation and administrative costs of our current system. And, increasingly, fewer people can afford them.

Health Care, Health, and Justice - Part 1: The problem

Good health is fundamental to life, and access to health care has an important role in assuring health. There is a lot of talk about the need to fix the U.S. health care system, and nearly everyone agrees that the current system is not working. Here are three major and generally agreed upon problems that need to be addressed:

1) The U.S. system is a highly fragmented one which leads to a lot of inefficiency and waste. A lot of time and money is spent simply on the administrative tasks of making sure the right people are receiving the right care.

2) The U.S. spends more than twice what other industrialized countries spend on health care, yet health of the U.S population is poorer (last place) in many categories.

3) The cost of healthy care is rising faster than income and more and more people are becoming uninsured or underinsured (42% of adults in 2007).

So, what are the available options and how do they contribute to these issues?