Public Health & Human Rights

Images of Public Health: H1N1 Flu

The above is a picture of chicken eggs that are being used to create (replicate, really) the 2009 H1N1 virus for use in H1N1 flu vaccines in China (same process used in the U.S. and every other country).

 

Beginning next week, H1N1 flu vaccine will be shipped to every U.S. state, where it will be available to you at your doctor’s office or local drug store or supermarket pharmacy. Is becoming sick with the H1N1 flu something to panic about? No. Is getting a vaccine to lower your chances of getting it a good idea? Yes, especially if you are:

• Pregnant (higher risk of complications to you and baby)
• 6 months – 24 yrs of age (higher risk of complications and many opportunities for close contact with others)
• The mother or father (or caregiver) of a child younger than 6 months
old (higher risk of complications and they cannot be vaccinated)
• A healthcare provider (source of infection for vulnerable patients)

The first immunizations available (next week and following weeks) against H1N1 in the U.S. will be the nasal-spray version (not for those of you who are pregnant). Soon after that injections will be available. The biggest difference between the spray and the injection (besides the obvious difference between a needle and a spray) is that the spray gives you a live weakened flu virus while the injection gives you a dead flu virus. Both are safe and effective, although you may experience some mild cold-like symptoms with the spray, as my daughter did (since it is a live virus).

The flu is coming very soon to a location near you. My family has already received our flu immunizations and we will also be in line for the H1N1 flu shots.

Other resources:

http://www.cdc.gov/h1n1flu/

http://www.who.int/csr/disease/swineflu/en/index.html

Participation, power, and rights

I want to highlight a good article by a well-regarded leader in the field of health and rights.  Alicia Ely Yamin recently wrote about the importance of societal participation, power, and its impact on health and rights.    

"A fundamental distinction of a human rights approach to development and policy-making that affects health is that it aims to enable those who are most impacted by poverty, patriarchy, and disease to be active participants in constructing the solutions to their problems..."

"Through effective participation, we can challenge political and other forms of exclusion that prevent us from having power over the decisions and processes that affect our lives and our health. Thus, if patterns of suffering and ill health must be understood as reflections of power relations as much as biological factors in a rights framework, the goal of a rights-based approach to participation should be to subvert the subordination and marginalization — the “pathologies of power” in Paul Farmer’s terminology — that prevent certain groups and individuals from realizing their rights..."

"In addition to political participation, other civil rights, such as freedoms of association and information, are essential to allowing people effective participation in health, understood as an exercise in citizenship. For example, there is substantial evidence that when small farmers have information that allows them to compare prices, rules, and policies, their participation in decisions affecting their lives rises significantly. As Peter Uvin notes, the right to information has been a cornerstone of a rights-based approach to development in India, which has had dramatic effects on health. Similarly, the elimination of discrimination, which prevents certain groups, such as women or minorities, from having an equal opportunity to voice opinions about a given issue that could affect their health, is also key to enabling rights-based participation... "

"...habit, fear, low expectations, and unjust background conditions deform people’s choices and even their wishes for their own lives."

There is much that is worth reading here.  Read her entire article and/or the other relevant articles in the most recent edition of the Health and Human Rights Journal http://www.hhrjournal.org/index.php/hhr.

Systemic social structures affect health

Excerpts from India's national newspaper, "The Hindu."  For the full article, see here: http://www.hindu.com/2009/08/22/stories/2009082255540800.htm

"Caste is a major indicator of health outcomes and mandates the need for interventions that change social structures. 

The caste system, with its societal stratification and social restrictions, continues to have a major impact on the country. The system, generally identified with Hinduism, is also prevalent among Christians, Sikhs and Muslims. While some barriers are broken in urban settings, many continue to persist in rural India. While the secular, socialistic and democratic principles enshrined in the Constitution demand equality of outcomes, the inherent caste-related inequality cont inues to dominate reality in Indian society. Much of the debate has focussed on reservation in educational institutions and employment, and rarely highlights the inequalities in health.

...

Social constructs: Many studies have documented that the caste system is a social construct in the absence of any real genetic differences among castes. Caste, in many ways, is similar to race, which is also a social concept without genetic basis. Nevertheless, these social constructs seem to have a stranglehold on human thought, perpetuating prejudice and propagating unjust societal structures.

...

It is widely recognised that the determinants of health are social and economic rather than purely medical. The poor health of people from the lower castes, their social exclusion and the steep social gradient are due to the unequal distribution of power, income, goods and services. Caste is inextricably linked to and is a proxy for socio-economic status in India. The restricted access of those from the lower castes to clean water, sanitation, nutrition, housing, education, health care and employment is due to a toxic combination of poor social policies and programmes, unfair economic arrangement and bad politics.

...

Caste plays out in India just as race plays out in the U.S. and the social class in Britain. Birth seems to determine health, education, employment, social and economic outcomes. Systemic injustice requires much more than a change of heart; it requires changes in social structures. Social injustice is killing people and mandates the ethical imperative of improving the social determinants of health."

The article is written by professor KS Jacob, on faculty at the Christian Medical College in Tamil Nadu.

 

Love: The foundation for human rights

I was listening to a DVD given to me by my brother-in-law (thanks Ben) in which the speaker was talking briefly about human rights and the fact that rights, on their own, are relatively empty.  That without a solid underpinning, they become rather subjective. 

As I was thinking more about the point, I came across a relatively recent (2005) book by Thomas WIlliams on the topic of human rights from a faith perspective.  As a book I had not see before, I perused it and found it very insightful.  I also found a nice summary of the book in the journal FIrst Things from the year 2005.

What I like about the author is that he makes human rights, sometimes an elusive concept, relatively easy to grasp (although the 300+ page book is, at times, rather academic).  The author agrees with Pope John Paul II when he stated, "a person's rightful due is to be treated as an object of love."  The author writes that a right, considerably different than defined by Websters Dictionary, is "the moral capacity to claim from another what one deserves."  And what one deserves is love. 

As the author points out, Jesus stated that one of the two greatest commandments is to "love your neighbor as yourself."  So, as the reviewer in First Things states, "we must will for our neighbors things that are truly good for our neighbor's own sake."  The commandment to love one's neighbor shows the inherent dignity of all people and their "intrinsic lovableness."  So, Williams argues, this Biblical love is the most basic human right, the very basis of human rights.  Without this foundation, the concept of rights, Williams argues, falls apart and becomes simply subjective. 

Thomas Williams' book, "Who is my neighbor?" is a solid read both providing the Biblical perspective and some insight into the language of human rights.  I have not yet read the entire book, but I plan to.

 

After a long hiatus...

It's been nearly a year since I last wrote anything here.  Hard to believe!  If not for the fact that typepad had continued to deduct a monthly fee from my account, I may have abandoned this.  But, after all those months of giving money and after several attempts at logging back on and trying to remember my password, I have been motivated to renew my efforts here.  There certainly is much to talk about in the world today. 

Sometimes life just becomes too busy to write much here, which is what happened a year ago or so.  Work, home, and church all took more of my time and I just didn't have much time to write.  Which isn't necessarily bad.  But, I think I'd like to take a second run at this, although my postings may be less frequent and less verbose.

If you have just recently stumbled upon this blog and you consider yourself a "conservative," you'll find some of my views are more "liberal" than you might like.  If you consider yourself a "liberal," you'll find some of my views are more conservative than you would like.  Either way, my intention here is to wrestle with issues of health and rights from a Biblical faith perspective.

Community health workers: (Part II) The five essential components of an effective CHW program

Reviews of community health programs have shown these five components are most important to a successful program:

1) Community Health Workers (CHWs) are chosen by the community in which they live and they maintain close ties with the community.

Some programs have allowed CHW positions to be "rewarded" positions based on local politics. When positions are simply political rewards or when the workers are not local, they may lack the needed motivation.

2) CHWs have clearly defined roles.

As stated in the Lancet, "CHWs will probably perform better with clearly defined roles and a limited set of specific tasks than if they are expected to undertake a wide range of tasks."

3) Effective training and ongoing supportive supervision.

Training is not enough. It has been shown that a plan for regular supportive supervision of CHWs is important to their success, their morale, and their continued satisfaction as CHWs.

Effective training focuses not on curative care but on health education and prevention. It has been found that most CHW trainings focus overwhelmingly on curative care despite their stated goal of providing preventive training, and this generally makes CHWs less effective than they can be. As a Lancet review paper states, "much greater attention should be given to practical, task-oriented training….Curative care provided by CHWs is unlikely to have a significant impact on mortality." Again, "CHW programs have often included simple curative care to create interest and meet felt needs, and there is a marked tendency to neglect the preventive and promotive services."

4) Incentive systems.

Most early studies of community health programs assumed that volunteers were best, but, since those early days, most studies have shown than an incentive system, monetary or otherwise, retains more workers and keeps them more satisfied in their role. High worker attrition destabilizes a program and can prevent it from gaining momentum because of the need for continuous replacements, the high training costs, and the increased difficulty of managing such a program. Some effective programs have salaried workers, others give honorariums, and others provide t-shirts, badges, bags, and other non-monetary incentives. Whatever is done, most effective programs provide their CHWs with some form of incentives.

5) Support for the CHWs and their work by health professionals.

Several studies have concluded that the single most important factor in determining the success of a CHW program is the support and respect that the workers receive from health professionals. Yet, the cultural gaps between the health professionals and the community workers are usually so great that this becomes the single biggest barrier to an effective community health program.

I will use the next post to further explain what the studies show about the relationship between community health workers and health professionals and how that relationship is so critical to an effective CHW program.

Community health workers: (Part I) Who are they and how have they been effective?

Community health workers, village health workers, lay health workers, these are all terms that describe similar roles and the literature has much to say about them. I want to summarize, in a several part series, what the literature says about community health workers and their effectiveness.

Today, in 2008, there is renewed energy about primary care and community health workers and there is wide-spread acceptance that they have the potential to make significant improvements in the health of individuals and communities, but there is also growing literature indicating that there are effective and less effective ways to use community health workers.

First, what are community health workers (CHWs) or village health workers?

Most common definitions of CHWs define them as members of the community with limited training to provide basic health and nutrition services. They usually work part time as health workers and may be paid or volunteer, however they are not usually civil servants or professionally employed by a ministry of health.

In what specific areas has the work of CHWs been found to be most effective?

Studies have show these benefits of CHWs:

• increase vaccination rates
• improve health in people with lung infections
• improve health in people with malaria
• increase breastfeeding
• decrease death in the elderly
• reduction in neonatal mortality
• improvement in neonatal care
• reduction in child mortality
• management of pneumonia and malaria
• improved community and personal hygiene
• improved diarrhea management
• effective treatment of HIV/AIDS and TB

Community health workers also bring with them benefits that are sometimes difficult to quantify in a study.  Dr. Paul Farmer calls community-based care the highest standard of care.  His organization's website, Partners in Health, states, "By improving adherence to treatment, monitoring medical and socioeconomic needs, empowering patients, and reducing the risk of hospital-acquired infections, community health workers make possible a model of comprehensive, community-based care that is the highest standard of care available anywhere."

But, what makes community health workers effective and what are the potential problems that need to be addressed?  These will be taken up in the following posts.

Images of Public Health: Community health and primary care are the answer

 

(Source: WHO World Health Report 2008.  This is Monica Korir an outreach worker visiting a home in Kenya)

For many, the allure of curative medicine seems like the answer to public health.  However, while curative medicine has an important role in health, true advances in the health of the public will come most significantly through preventive community-based primary care.

The newly published World Health Report 2008 focuses on primary care and is an important document with a wealth of information.  Describing some of the key current pitfalls in health trends, the report notes three areas of concern:

1) Approaches to health that are focused on specialized curative care

2) Approaches to health that focus on short-term disease control

3) Approaches to health that encourage unregulated commercialization of health

As the report states, "these trends fly in the face of a comprehensive and balanced response to health needs."

What is needed?  According to the report, approaches to health that 1) contribute to equity and social justice, 2) reorganize services around people's needs and expectations, 3) contribute to healthy communities through integration with various services, and 4) replace short-term control with inclusive, participatory, negotiation-based leadership.

The report is well worth the read, and is full of a lot of practical evidence and guidance.

http://www.who.int/whr/2008/en/index.html

 

The rights and dignity of India's "untouchables"

There is a well-written and recent article in the UKs Sunday Herald that gives us a glimpse into the every-day plight of Dalits in India.  The writer also helps us understand some of the violence that has been taking place in India, and he helps us see the hope that many Dalits are finding.  The entire article is worth reading, and I’ve highlighted only several passages here:      

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Deekonda Tirupathi and his bride-to-be, Sucharitha, are converting to Buddhism because they are Dalits, members of society rooted below even the bottom rung of India's complex hierarchical system. Above them, four main Hindu classes, or varnas, occupy their own places in life: the priestly Brahmins; then the ruling class, the Kshatriyas; next are the Vaishyas, the artisans and traders; then follow the Shudras, labourers and servants. Those born without varna are seen as sub-human, or, as they used to be referred to, "untouchable", their lives restricted to menial jobs and duties deemed impure in Hinduism: they alone work leather, dispose of dead bodies, handle carcasses, clear human and animal excrement.

 

Our wedding couple are the latest in a long line of Dalits who hope to rid themselves of the stigma of "untouchability" and be accepted as equals by adopting a new religion. They follow in the footsteps of one of the country's greatest thinkers, Bhimrao Ramji Ambedkar, a Dalit lawyer and scholar who went on to become the main architect of India's constitution.

 

"Every day thousands of Dalits choose to embrace a new religion," says Dr Joseph D'souza, international president of the Dalit Freedom Network. "Dalits are primarily choosing Buddhism or Christianity, although some have chosen Islam. Changing their religion means they - and more important, their children - think of themselves differently. Instead of following holy texts which say they were created only for one role in life and are of lesser value than others, now they learn about a creator who made them equal and truly free. This mental change impacts on their behaviour as they attempt new careers or fight for dignity by embracing their legal rights."

 

Unsurprisingly, the talk over lunch at the wedding in Karimnagar is dominated by the topic of change. But any transition from such deeply entrenched positions may prove painful. If the caste system were to be abolished folowing next year's crucial elections then, according to Vattipalli: "There may be clashes with Hindu fundamentalists because the Hindu scriptures are everything for them."

 

His words seem to be have been born out after recent conflict in the states of Orissa, Karnataka, Tamil Nadu, Kerala and Madhya Pradesh. Trouble in Orissa alone left 13,000 people without homes when Anti-Christian violence flared up after local Hindus accused Christian Dalits of murdering a controversial holy man. Claims of forced conversions were also levelled at the Christians. (Both allegations have been vehemently denied). During the most recent clashes, one Christian woman was left dead and scores of others were injured.

 

So far the outbreaks have been relatively contained, given the size and population of the country, but Moses Vattipalli fears that Dalit empowerment may prompt reprisals.

 

"Dalits will be angry because of injustices and oppression spread over the last 3000 years," he warns. "There could be bloodshed, even civil war."

 

But Dalit campaigner D'souza takes a different view.  “Of course, any group of people that has been oppressed for thousands of years is tempted to take revenge, but I'm confident that Dalit leaders will follow the example of Gandhi and, even more so, BR Ambedkar," he says. "They will respond with a firm but peaceful defence of their rights and human dignity."

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See here for the entire article:

The oppression of ‘untouchables’ is modern India’s shame

Thousands of Indians have found a way of escaping their destiny as an outcast

Sunday Herald

By Andrew Duke

Oct. 12, 2008

http://www.sundayherald.com/life/people/display.var.2459708.0.the_oppression_of_untouchables_is_modern_indias_shame.php

Vision, hope, and dreaming of what has never been

Human beings suffer
They torture one another
They get hurt and get hard.
No poem or play or song   
Can fully right a wrong
Inflicted and endured.
History says, Don’thope
On this side of the grave,  
But then, once in a lifetime
The longed-for tidal wave 
Of justice can rise up
And hope and history rhyme.

by Seamus Heaney

 

I’ve been thinking a lot recently about conflict and health.  When one is aware of bombings, riots, stampedes, political and religious violence, and other forms of violence that are taking place around the world, it’s difficult to act as if those things don’t matter.  But, how does one respond?

 

One of the foremost experts on issues of war and peace and health and rights is Barry S. Levy.  In an article he wrote back in 2002, he stated,

"Without peace, there can be no health, basic human needs cannot be fully met, health care and public health services cannot be optimally provided, and healthy and safe physical and socio-cultural environments cannot exist. Therefore, peace, by definition, is part of public health.

 

Likewise, public health is part of peace. Without physical, mental, social, and spiritual health, there can be no peace. Without health, there can be no peace within an individual, within families, within communities or among nations."

Reading and hearing the experiences and thoughts of well-respected people and those much closer to these issues than I, several themes begin to emerge regarding violence and conflict in general, and one in particular resonates strongly within me.  Vision.  We must be people with a vision of what can be but is not yet.  People who hope, not fleetingly but with certainty.  These are what I read and see in Paul Farmer, Barry S. Levy, Joseph D’Souza, and Alexander Solzhenitsyn, all people with a personal understanding of the impacts of violence on people’s lives and how to effectively respond.

 

Last week, I had the privilege of hearing Dr. Paul Farmer speak.  He is one of those people who, impressive as are his credentials and work, portrays himself humbly.  He also is passionate about his work for the poor, for human rights and justice, and for health equity.  Paul Farmer is familiar with conflict both from his decades of work in Haiti and with his more recent work in Rwanda.  And, although the talk I heard was not specific to conflict, he said several things that are relevant here.  First, that we in public health are too often the skeptics and nay-sayers, and that we instead need to be the ones open to new ideas and open to not always basing decisions on gold-plated science.  He talked about the need to ask tough questions and that by asking those tough questions we can begin to change the status quo.  That we need to ask the questions that others can’t or won’t ask because of political or other sensitivities.

 

Barry S. Levy made a similar point in an article he wrote when he quoted President John F. Kennedy who stated in an address to the Parliament of Ireland in 1963, “The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men who can dream of things that never were, and ask why not.”  Levy continued by saying that public health leaders need to “call forth leadership in others,” people who will not simply continue doing what they’ve always done, but people who will do what is needed and what is right, regardless of whether it has ever been done before.

 

Alexander Solzhenitsyn spoke of this in a speech he gave after receiving the Nobel Prize for literature in 1970.  A man who spent many agonizing years in Russia’s state prison camps spoke of seeing “beauty” in the mundane.  And, he spoke of the power of written truth in realizing visions and in changing the world for the better.

“In agonizing moments in camp, in columns of prisoners at night, in the freezing darkness through which the little chains of lanterns shone, there often rose in our throats something we wanted to shout out to the whole world, if only the world could have heard one of us.

 

We will be told: What can literature (words) do against the pitiless onslaught of naked violence? …The simple act of an ordinary courageous man is not to take part, not to support lies. Let that come into the world and even reign over it, but not through me. Writers and artists can do more: they can vanquish lies!"

Joseph D’Souza, a person well-familiar with violence, speaks too of hope and of not giving up.  And, he too knows the power of the written word and of truth in dispelling lies and promoting justice and rights.  He writes “Sometimes the task seems too formidable.  Sometimes success seems like nothing more than a dream.”  D’Souza quotes one of the Chinese leaders of the Tiananmen Square uprising from 1989, “I dream of a day in China when the ideas of freedom, democracy, human sympathy, tolerance and equality have pervaded people’s hearts and minds…”

Dreaming for justice and “seeing” what is yet unseen are deeply Biblical concepts.  Those of us who claim a Biblical faith cannot simply see the world as it is and as it happens, but rather must view with a perspective and with questions that go beyond the boundaries of the obvious.  There is an expectation about what will be but is not yet, and there is a realization that people are more than the flesh and bones we so easily mistake for the person.  

 

Hopes, visions, expectations… these are the things I read and hear that we must hold to and work toward in spite of the nay-sayers and skeptics and keepers-of the-status-quo around us.  It seems to me that these concepts are critical to health and justice in both war and peace.