Major organizational challenges and difficulties in transportation have caused some discontent among participants in the People’s Health Assembly. There were 5 or more venues of events and no centralized transport to get people to events. The wealthier people from Europe and the US had no problem taking taxis – $1 USD to cross town 2 or 3 times a day; but those from Asia and Africa were often forced to walk, causing them to miss many events. And people with disabilities, of course, had it even worse, because many of the events were inaccessible. Sad to say, none of this is terribly surprising, and it reveals how much further we need to go to create equitable systems that can truly confront the structural inequalities. Even with the best of intentions, the organizers of the Assembly – health activists from NGO’s worldwide – were unable to create a system that would meet the needs of those most in need.
Fortunately these issues have been taken into account, and the organizers have committed to doing better for the next meeting, expected to take place in Africa in a few years. In any case, by the last days of the People’s Health Assembly, many of the 1500 or so people present had crossed paths a few times and something of a community feeling emerged, despite the challenges. Outside of every venue informal groups gathered where one could easily join a conversation with people from Nigeria, Peru, Puerto Rico, Bangladesh, Switzerland and Argentina – and as in any event of this size, it is these informal meetings that, perhaps, have the most lasting impact on people’s lives and work when they go home. For my part, because I had been widely sharing the new Hesperian Foundation publications on water and sanitation – which we are obligated to distribute for free – I was fortunate to meet dozens of the people who will use these materials in their home communities. Many of them shared stories of their work with me, and expressed deep appreciation for the solidarity and support shown by those of us from the North who are able to do this work.
One young man from deep in the jungle in Peru especially struck me. Jeiser Suarez, an indigenous Shipibo man from near Iquitos, on the Peruvian Amazon, works tirelessly to maintain his culture’s traditions, to ensure that garbage and contamination are minimized, and to preserve the jungle ecosystem where he lives. Jeiser traveled 6 hours by canoe and 5 days by bus to get to the health assembly because he felt that meeting other people doing similar work would strengthen his resolve and his abilities and because, as he said very clearly, “My culture is in danger and we need allies.” After we had talked for some time, in one of the most affecting moments of the week, Jeiser gave me a gift – a necklace of Guayruro beads (red and black beans that grow along jungle waterways) bearing a crocodile tooth that his own grandfather had taken from an animal he’d hunted years ago. The beads are for protection, he explained, and the crocodile tooth for bravery.
Jeiser Suarez with friends
Anyone interested in learning more about the Shipibo might want to begin with the website that Jeiser told me about: www.shipibo.com
The final day and the Cuenca Declaration
At the end of each People’s Health Assembly a declaration is drafted that promises action on many of the themes that have been discussed during the meetings. In this case, the document is called The Cuenca Declaration; a draft of it was read to the entire assembly on Friday morning, with many breaks for applause and a time set aside after for comments. Because the Declaration is still in draft form, I cannot include any of it here, but those interested might check the People’s health Movement website (www.phmovement.org) in a few weeks.
A document that contains similar information, summing up many of the issues dealth with by PHM, is called Global Health Watch: an alternative health report, and was released at the gathering. I’m not sure whether or not the document is available on the web, but to give an idea of the kind of stands taken by PHM, here is the introduction to the report:
Origins
The Global Health Watch comes out of one of the largest ever civil society
mobilizations in health. Its roots lie in the influential and lasting campaigns
of the 1970s and 1980s when activists across the world challenged the global
health divide between North and South and rich and poor. They formulated
practical proposals for change and influenced the content of the ground-breaking
1978 Alma Ata Declaration. Community-based health care, the essential
drugs list and controls on the marketing of infant formula are just some of
the results of this advocacy, which has changed the lives of millions of people
for the better.
During the 1990s, many activists came together again to take up more of
the continually emerging challenges in global health – and to tackle some of
the most intransigent ones such as poverty and inequality. A People’s Health
Assembly, held in Savar, Bangladesh, in December 2000, was the first step towards
launching a global social movement to attain the aim written into the
Constitution of the World Health Organization (WHO): ‘the enjoyment of the
highest attainable standard of health is one of the fundamental rights of every
human being without distinction of race, religion, political belief, economic
or social condition’.
Some 1500 people from 75 nations attended the People’s Health Assembly
and collectively drew up and endorsed a People’s Health Charter. The Charter
is a call for action on the root causes of ill-health and many people’s lack of
access to essential health care, and set the agenda for the People’s Health
Movement that emerged out of the Assembly.
This first edition of the Global Health Watch takes up the Charter’s call for
action and suggests ways in which the global movement of people concerned
with health can take its principles forward. In the process, it has brought together
health activists, health professionals and academics from around the
world to put together an alternative world health report. It is aimed primarily
at all those around the world who work in health care or for health and who
represent an important section of civil society. They usually have a certain
standing in society that enables them to be influential in promoting action
on global health.
But aren’t there enough world health and development reports already? The
World Health Report, produced by the WHO; the Human Development Report
compiled by the United Nations Development Programme; an annual report
produced by UNAIDS; the annual State of the World’s Children produced by
UNICEF; and the World Development Report issued by the World Bank every
year. The Global Health Watch is different, however. The paragraphs below
outline how and why health workers from all over the world have expressed a
need for such a report.
The politics of health
The co-existence of wealth and widespread, severe poverty suggests that the
latter can be avoided. The cost of achieving and maintaining universal access
to basic education, basic health care, adequate food, and safe water and sanitation
for all has been estimated at less than 4% of the combined wealth of the
225 richest people in the world (UNDP 1998: 30). In many countries in which
hunger is prevalent, there is enough productive land to feed their populations
many times over. Alternative social, political and economic arrangements at a
national and global level could change this stark reality.
The Watch therefore sets out an explicitly political understanding of the
current state of health around the world. This is nothing new – public health
has been recognized as a political concern for many years. As the famous
nineteenth century German pathologist, Rudolf Virchow, explained, ‘medicine
is a social science, and politics is nothing more than medicine practised on
a larger stage’.
UNICEF has devised a conceptual model for explaining child morbidity
and mortality. It states that, amongst other factors, the political, social and
economic systems that determine how resources are used and controlled need
to be considered so as to determine the number and distribution of children
who do not have sufficient access to food, child care, clean water, sanitation
and health services .
The UNICEF model is applicable to other aspects of health (for example,
AIDS and maternal health) and echoes the analytical approach used by the
Watch to highlight how the distribution of power, political influence and economic
resources shapes the pattern of health globally.
Poverty and development as a public health issue
Poverty is the biggest epidemic that the global public health community
faces. It underlies most cases of under-nutrition, fuels the spread of many
diseases and deepens vulnerability to the effects of illness and trauma. Poor
countries are unable to give their health and social services adequate resources, resulting in a poverty of health systems that compounds poverty at the
household and community levels.
The challenge of improving global health is therefore inextricably linked
to the challenge of addressing widespread and growing poverty. According to
the official statistics of the World Bank, the number of very poor people has
increased by 10.4 percent between 1987 and 2001 to 2735 million – almost
half the world’s population (Chen and Ravallion 2004). Furthermore, there is
reason to believe that the World Bank’s methodology for measuring poverty is
flawed and underestimates the true breadth and depth of poverty worldwide
(Reddy and Pogge 2006). The extent of poverty demands that tackling it is at
the centre of health programmes and health policy analysis, and that understanding
its causes and engaging with the political and economic reforms is
essential to abolishing it.
Health workers engage with the health effects of illiteracy; the lack of access
to clean water and sanitation; hunger and food insecurity; the degradation of
the environment; and militarism and conflict. These public health issues highlight
the common challenges shared by health workers, teachers, engineers,
geographers, farmers and biologists, to name just a few professions in fulfilling
the universal right to health and dignity. The Watch aims to promote health
as a theme that can bring together different sectors of civil society around a
common agenda for human development and social justice.
Inequity
Increasing levels of poverty have been accompanied by growing inequality.
The income gap between the fifth of the world’s people living in the richest
countries and the fifth of the poorest was 74 to 1 in 1997, up from 60 to 1 in
1990, 30 to 1 in 1960, and 11 to 1 in 1913. The world’s 200 richest people more
than doubled their net worth in the four years to 1998 to more than $1 trillion.
The assets of the top three billionaires are worth more than the combined GNP
of all least developed countries and their 600 million people (UNDP 1999).
Although inequality is commonly described in terms of differences between
rich and poor countries, one fifth of the richest people in the world come from
developing countries (Navarro 2004). Similarly, poverty and widening disparities
are not confined to poor countries – inequalities have risen in wealthy
nations over the past two decades.
An ‘equity lens’ is important because political and economic institutions
are shaped in ways that can reinforce unfair advantages and widen socioeconomic
disparities. International trade rules and regulations are stacked in
favour of richer countries and multinational corporations; debt cancellation
is given at the whim of rich nation creditors rather than as a response to the
pressing needs of citizens of poorer countries. The conditionalities imposed
upon poor governments by the World Bank and International Monetary Fund
(IMF) are undemocratic and have included the privatization of public assets,
thereby undermining public education and health care systems, and eroding
social safety nets.
The Watch therefore emphasizes not just poverty, but also the relationship
between rich and poor, between the powerful and the marginalized. Improving
the situation of the world’s poor cannot be achieved through aid or charity
alone; profoundly unequal power relationships need to be tackled first and
foremost. Health professionals can influence many of the decisions that will
lead to a fairer distribution of wealth.
Human rights and responsibilities
Article 25.1 of the Universal Declaration of Human Rights states that ‘everyone
has the right to a standard of living adequate for the health of himself and
of his family, including food, clothing, housing and medical care and necessary
social services’. Article 12.1 of the International Covenant on Economic, Social
and Cultural Rights recognizes the ‘right of everyone to the enjoyment of the
highest attainable standard of physical and mental health’.
Such declarations are a reminder that human rights encompass more than
political and civil liberty human rights; they also incorporate social, economic
and cultural rights. Universal human rights are not limited to a vote, free speech
and freedom from oppression, but include a right to household food security,
essential health care and other requirements that underpin human dignity.
Human rights discourse is often centred on the duties of states and governments.
Violations committed against people by governments, under the
guise of officialdom and the law, or with the complicity of the state, are rightly
condemned because they not only deprive people of the objects of their rights
(such as food and essential health care), but also attack and subvert the very
notion of rights and justice. There is in addition an acceptance that governments
are in breach of their duty if they fail to ensure in a reasonable manner
the progressive realization of human rights through the use of resources under
their control. Governments that allow corruption and fraud, for example, or
inappropriate public expenditure on armaments when large sections of the
population lack access to the basic means of survival and dignity, are committing
human rights violations.
However, a moral conception of human rights implies that social, political
and economic institutions must also be held to account. This is enshrined
in Article 28 of the Universal Declaration of Human Rights, which states that
‘everyone is entitled to a social and international order in which the rights and
freedoms set forth in this Declaration can be fully realized’.
For example, while a legal right to adequate food is important, and while
governments are obliged to ensure the progressive realization of this right,
political and economic arrangements that determine how food is produced,
controlled and sold may be as important, if not more so, in determining
whether this right is fulfilled. Such arrangements might include historically
unjust patterns of land ownership; the control of food production systems
that leads to monopolies; the speculative hoarding of basic staple foods and
excessively high food prices; or the dumping of heavily subsidized produce
from rich countries onto poor ones in a way that decimates local agriculture
and subsistence economies.
These examples suggest that even if governments do all they can, social,
economic and political arrangements that keep people living below the poverty
line when there are reasonable alternative arrangements should be considered
violations of human rights, even if these arrangements are legal. This implies
obligations not just on governments but also upon citizens and non-government
actors to re-shape political and economic arrangements to ensure the
fulfilment of rights.
Given global integration, governments, corporate actors and civil society
have transnational duties and responsibilities towards the fulfilment of universal
human rights. At present, the emphasis in human rights discourse is on
the responsibilities of governments towards their own citizens. Transnational
responsibilities for the fulfilment of human rights tend to be limited to avoiding
or preventing direct violations of the civil liberties of citizens of another
country, or merely invoke a weak humanitarian response to help out with aid
and other forms of assistance. Economic cooperation with corrupt and undemocratic
governments is not considered a human rights transgression, nor
is the maintenance of trade rules that perpetuate or deepen severe poverty.
In sum, the Watch embodies a human rights perspective that emphasizes
social and economic rights; identifies political and economic institutions,
including the manner in which economic relationships are organized and
structured, as being beholden to human rights declarations; and calls for a
greater recognition of transnational responsibilities towards the fulfillment of
human rights.
Mobilizing civil society and holding institutions to account
In light of the evidence that social, political and economic arrangements
are failing to address the current state of ill-health, poverty and inequity adequately,
a stronger mobilization of civil society committed to the fulfilment of
human rights is needed. The Global Health Watch is explicitly linked to many
civil society struggles for health and justice. Many of the individuals, networks
and NGOs associated with this report participate in civil society mobilization,
lobbying efforts, policy advocacy and development work on the ground. The
Watch draws on their experiences and offers credible analysis to strengthen
their work.
Part of the aim of this alternative world health report, therefore, is to
present an analysis of the performance and effect of key institutions that have
a responsibility for promoting global health. Health and development reports
produced, for example, by the WHO, UNAIDS and the World Bank tend not to
include themselves in the analysis of factors that are promoting or negatively
impacting on health. The Watch hopes to fill this gap and provide another
means of strengthening civil society’s ability to engage with the determinants
of ill health.
Overview of the Global Health Watch
The report is divided into six sections. Part A looks at how political and
economic change at the global level influences people’s health and well-being
worldwide, noting how little control individuals have over these changes. It
points to solutions for redressing global imbalances and shows how few of the
promises made to developing countries in past years have been kept.
Part B carves out an agenda for the public sector’s role in health, with a
special focus on low- and middle-income countries. Its first chapter asserts that
the Primary Health Care Approach adopted by the world’s health ministers in
the late 1970s is still relevant today, but that the public sector role in health is
under threat, and that commercialization of health care has proceeded apace
in the last two decades to the detriment of health. It points to the limitations of
current efforts to address health priorities through selective health care interventions
and pro-poor targeting. The chapter argues for a greater commitment
to universal health care systems and for renewed investment in the public sector.
Subsequent chapters on medicines and gene technology take up the theme
of commercialization and suggest ways in which the public sector role can be
strengthened. Other chapters explore two controversial issues – health worker
migration in low-income countries that are short of health personnel; and the
political struggle over sexual and reproductive rights, including analysis of how
health care is connected to broader debates about poverty, politics and gender
injustice.
Part C tackles the needs of two particular groups of people whose rights
to health are frequently violated – Indigenous peoples and people with disabilities.
These chapters describe their struggles for rights and outline what is
needed to strengthen their claims on health and health care over the coming
years.
Part D returns to the broader picture of health. The Primary Health Care
Approach emphasized intersectoral action in health, recognizing that the determinants
of health often lie outside the health care sector. Five chapters on
education, war, environment, water and food security reveal the widespread
threats to health in a diverse range of areas and circumstances, but also point
to the potential for synergistic actions by governments and civil society actors
that could improve livelihoods in several dimensions.
Part E scrutinizes the conduct of global institutions such as WHO, UNICEF
and the World Bank, and assesses the international actions of richer nations
and big business. The analysis points to the need to redress imbalances of
power at the international level; for richer nations to fulfil their promises on
resource transfers to the developing world; for tighter regulation of powerful
multinationals; and for better management of international institutions.
Part F concludes the Global Health Watch by drawing all the chapters together
and making some general recommendations and possibilities for concerted
action by civil society organizations.
What readers of the Watch can do
A central aim of the Watch is to strengthen existing campaigns and social
movements by providing an alterative analysis of global health. The report also
includes a number of demands that we make of governments, UN agencies
and other actors. We hope that health professional associations and networks
will become a more prominent voice in existing campaigns and movements to
achieve a healthier and fairer world.
We encourage you to spread the word about the Watch widely. It is freely
available on the web and on CD from the three co-ordinating organizations:
People’s Health Movement, the Global Equity Gauge Alliance and Medact. To
comment on anything in this volume or make suggestions for the next Global
Health Watch in 2007–8, please contact any of the co-ordinating organizations
at ghw@hst.org.za.
Further information
People’s Health Movement (www.phmovement.org)
Global Equity Gauge Alliance (www.gega.org.za)
Medact (www.medact.org)
Before the journey home…
The day after the closing ceremony of the assembly, I was preparing to fly home when my old friend Rafael showed up and convinced me to stay on a few days to visit some projects and some interesting places…so I did. That same day we collected our Yaqui friend Angel Valencia, our Zapotec friend Saul Vicente and Francisco Mocoso, the President of Ecuador’s Condor Loma Foundation – a small NGO devoted to environmental and cultural preservation – and piled in a pick-up truck to visit some of Condor Loma’s conservation projects high in the Andes.
It’d been too long since I’d taken a fast, bumpy cold ride in the back of a pick-up through the Latin American countryside, and I felt entirely at home as we ascended out of the Cuenca valley to the central cordillera of the Andes. About an hour out of town we came to one of Condor Loma’s pilot projects – a small town where they’ve built open reservoirs to capture rainwater and mountain runoff to feed farm irrigation. We stopped to speak with a couple of campesinos who were drying beans and ended up staying for a quick drink of aguardiente to talk about their hopes for another rainwater reservoir. When we left, the friendly – and now just-ever-so-slightly-drunk – campesinos offered us some of their beans to plant, which all of us gladly accepted.
A healthy, meandering river high in the Andes
An Andean home
Continuing on, we entered a preserve where Francisco and others had been restoring vegetation to the hillsides using different methods, with the hope of seeking funds to do larger scale watershed protection projects throughout the Andes. The most interesting method we saw was one that Francisco himself had pioneered: he built worm bins across a gulley, from top to bottom, so that rainwater would collect worm guano as it flowed down the hill and fertilize the soil. Entire hillsides that had been barren were no green with brush thanks to this simple method.
Simple irrigation using a hollow log
As darkness fell we returned to Cuenca to see Angel off to the airport.
Angel Valencia
The next day Saul, Francisco, Raphael and I piled into Raphael’s ’78 Ford for the day-long drive to Banos, to get Saul to the airport and the rest of us to the final visit of my stay in Ecuador. That last day turned out to be the gem of my visit.
Descending from Banos towards the Amazon is the Pastaza River Valley, a deep and narrow canyon dropping thousands of feet and awash in green towering peaks, crashing white waterfalls, and incredible views of volcanoes both near and distant. Due to the rapid descent from cordillera to altiplano to cloudforest to primary rainforest – in a 15 minute drive you descend 2400 feet in altitude – this canyon is home to some of the greatest biodiversity on earth. The road, which follows along above the river, is a thin ribbon running between two of Ecuador’s most inaccessible protected areas – Parque Nacional Yanuncay and Parque Nacional Sangay. Rumors claim that Yanuncay is where the lost Inca treasure is buried, and numerous expeditions have literally vanished inside the remote territory. Parque Sangay, crowned by the snow capped volcano Sangay which erupts every 20 minutes, is equally inaccessible, and is claimed to be the home of 16 ancient pyramids known as the Temple of the Jaguar.
At the spot where the river is thinnest, we left the car behind and descended a path towards some waterfalls known to the public as the Paylon del Diablo – the Devil’s Pylon – but known by locals as Condor Pacha because of the stone figure of an earthly condor that rises out of the falls. Just below the falls a long rope-bridge crosses the river, and we crossed and were welcomed by Paul, the caretaker. This spot, with its view of the falls and its incredible flora, was until recently a tourist attraction visited by thousands of trash-throwing, flora-trampling, coca-cola drinking visitors. But as little as a year ago the owners of the place – an Israeli family – realized that it was too special to treat it this way and they hired Paul, an ecologist from Cuenca, to take charge. His first decision was to close it off to tourists and invite only scientists, environmentalists and students of traditional medicine to visit the part known as “El Otro Lado” – the other side. Ironically, I had visited the place as a tourist a few years back, but now I had the honor of being welcomed into the inner sanctum.
Paul lead us down the path to a fully-equipped cabin where we began to talk and talk and talk about the temples hidden deep in the jungle, about the 92 endemic species of orchids, about the ancient paths that ran through here connecting the Amazon and the Andes. How to educate people about places like this, how to begin with the simplest actions like preventing littering and continue until an understanding of watersheds and traditional cultures and the vaster questions of ecology were built. Paul and the others of Condor Loma made it clear that their mission was nothing less than to protect the entire Ecuadorian Amazon from destruction, and that they began here, at the falls of Condor Pacha because this river valley is the “umbilical cord of the Amazon.” Francisco cut in – “no, we’re not beginning here, we’re beginning up in the Andes – this is the halfway point. To protect the Amazon, you have to protect the Andes.”
After a few hours, as the sun had fallen and the intermittent rain of the cloudforest wetted our hair, we built a fire, and through the night we talked and planned and committed ourselves to continue educating, to continue pushing for human rights and protection of natural resources, to spend every waking moment raising consciousness – our own and that of others – about the work that needs to be done here and everywhere. Towards dawn, when the moon pushed through the thick jungle clouds, we ascended to a smaller waterfall, and, in the dark of night, darker for being jungle, bathed in the falls. Returning to the house, a few hours of sleep as the sun rose and then the long, dull journey home…
Andean town deep in a high valley
The mighty Mount Chimborazo
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