Category Archives: Health

Health, Our Western Identity, Politics

Apocalypse Now (and Again)

Leave a comment

The world did not end yesterday.  At least, not for you.  Not for me.  Yet in places like Syria, Pakistan, and South Africa, individual worlds = came to an end.  The culprits?  Not the dreaded riders of the Apocalypse, but well familiar stalwarts like hatred, greed and violence.

Earlier this week the United Nations launched its largest appeal ever, for nearly £1 billion, to address the crisis caused by the war in Syria. The months of fighting have provoked supply shortages, mass migrations and huge numbers of wounded against a background of intensifying cold, grief and devastation. And what will the UN do with that money?  The multi-billion dollar international humanitarian industry is virtually locked out of Syria.  It simply does possess the skills and capacity to work effectively in what can only be described as a very modern humanitarian crisis:  security risks, lack of authorisation from the government, and an insufficient ability to negotiate and maintain access in such circumstances.

Even MSF has struggled enormously to open hospitals inside Syria, vitally important to those reached and yet insignificant compared to the larger needs. Put simply, in the midst of such epic crisis, and despite Herculean efforts of Syrian doctors and nurses, ordinary Syrians have preciously poor access to drugs or medical care.

It’s not the obvious cases of civilians in war – old people, women, children, and even babies –wounded in bombings and shrapnel injuries. Or the psychological trauma.  It’s the slow fade that shocks me, the banality of chronic conditions: diabetics who run out of medication, children with asthma, and women who need caesareans.  Where would I get my resupply of statins in a place like that?  I’d have to give up sausages.

Earlier this week in Pakistan, polio immunisation campaigners were assassinated in a series of targeted attacks. No medical work can be carried out effectively in the atmosphere of mistrust caused by years of deliberate misinformation, rumours, or such a blatant abuse of the medical act as having spies pose as doctors (see my earlier blog on the good doctor Afridi or humanitarians as spies).

Humanitarians can’t shoot their way into town.  If you headed an NGO, would you be able to ask people to go out and vaccinate?  Where a nurse “armed” with nothing more than a syringe might end up between the crosshairs of a weapon? The pursuit of political and military objectives erodes trust in healthcare itself, and children fall ill and die of diseases – diseases for which prevention is simple in theory, but dangerous in practice.

And far from the week’s headlines, in places like Uzbekistan, Swaziland and South Africa, highly virulent strains of tuberculosis (TB) spread. Increasingly resistant to treatment, TB causes people pain, suffering and debilitation until death liberates them. Those who are “lucky” enough to access treatment are administered a highly toxic drug regimen that lags on for years – and given an only per cent chance of cure.

Syria, Pakistan and South Africa lie far apart on the map.  The common denominator of much suffering in these nations, as in so many others, is the space between people who need care and people who can provide it.  This lack of access – and the deaths that result – is as preventable as polio; it is not the doing of cosmic forces beyond human control.  No, I’m afraid the world does not end in one big bang – it blinks out in the bits and pieces of human lives.

[I drafted the original version of this blog as a letter to the editor but it didn’t get picked up.  P and S from the office contributed a great deal to the editing.  Thanks]

Critique of Aid, Health, Our Western Identity

What’s a Little Aid Between Friends?

9 Comments

[Apologies for the gap!  Been too busy.]

Whenever I open the internet the same vital message greets:  “Medical Aid Where it is Needed Most – Independent, Neutral, Impartial.”  That’s the top of MSF-UK’s web page.  Here’s the current headline:  Hurricane Sandy  MSF Teams in New York to Help Those Hardest hit by Sandy.  It has been a top story on the website for over a week.

The last few blogs have looked at the core humanitarian principles.  Not about how they come under attack by those opposed to our brand of goodness – badboy militia groups, depraved dictators and Western leaders who want aid to do their bidding – but how it these lofty values have Savile-ized by us, humanitarians who enshrine these principles in the Ark of their very being.

Impartiality is a particularly directive principle.  It instructs that humanitarian aid doesn’t go to your friends and neighbours just because they are needy; decisions can’t be based on religion, ethnicity or relationship to the country’s finance minister.  That leaves only one legitimate basis for decision-making:  need. And it implies finding those most in need rather than simply needs per se (i.e., go to DRC and everybody has needs, but where are they greatest?).  As Mark Bradbury concludes:  Assistance that is policy-driven, rather than provided on the basis of need, is no longer humanitarian.

In theory, impartiality works pretty easily in a health clinic – take the malnourished infant with malaria before the pregnant woman with a broken finger.  It gets harder as the distance grows.  Behind Door #1 Syria: violence and displacement and war-wounded. Behind Door #2 Chad: pockets of malnutrition, measles and very poor health services or infrastructure.  How do you compare suffering?

It’s no secret (actually, sadly, it is) that the major aid agencies have bent their principles in self interest, or because means were deemed less important than ends (see “Humanitarian Negotiations Revealed” for an MSF compendium of compromise).  Home society operations like those in NYC lie at the crossroads of humanitarian action and institutional needs.  It’s only a few years ago that MSF was running operations in Luxembourg, for chrissake.  GDP is over $106,000 per person. If there, then emergency botox in Beverly Hills makes sense.

Questions have always surrounded the medical impact of these missions, which can appear almost frivolous when juxtaposed against the massive needs in places like DRC or Sudan.  Normally, though, the organization admits a certain degree of self-interest in mounting these missions, a certain acknowledged violation of impartiality.  The rationalization comes later: these activities are, after all, comparatively insignificant.

But what happens when we no longer acknowledge the compromise?  What happens when we claim to be justified in these interventions, on the basis that we have responsibilities as a civil society actor?  No doubt whatsoever that Sandy has provoked health needs in the NY/NJ area (although far greater ones in Haiti, like the increased cholera to which MSF is responding, though in comparative obscurity judging by our own websites).   But if there had been no MSF in the US, would the organization have sent in the troops?  No way.   So what does that mean for impartiality?

As MSF sections in Greece and Spain look in their own back yards, they too find health needs: health systems making drastic cutbacks under economic austerity measures that offer succor to banks and pain to people.  I understand the push in headquarters, the outrage of our Greek staff and donors,  the push from the local community, and the pressure of expectation.  A little compromise is fine, isn’t it?  I mean, it’s just between us.  How to explain to the Greeks who are living this mess that their MSF can’t respond to their crisis?

Well, we do that sort of explanation all the time in countries where there are greater needs though, of course, less affiliation.  There, we are a global actor, magnanimous to offer assistance and hence privileged to deny it.  There, we sometimes go home, as has been done in the face of stunningly bad, though “developmental”, health needs:  closed programs in places like Angola, Liberia or Sierra Leone.

The key point here is that a humanitarian organization must maintain its legitimacy precisely through its refusal to be a civil society actor; through a clarion refusal to privilege localized constituencies over the only constituency that we possess – the whole of humanity. Impartiality operates from the starting point that all human life is inherently (and equally) precious. The idea of preferential treatment should be anathema to humanitarian action, and we must fight the urge to privilege the needs of people who are, literally, close to home.

Why send doctors to Brooklyn?  Well one reason is that there are people there in crisis.  But what level of unmet medical needs in the wealthiest nation on earth?  So it is also because decisions are driven by television, by a social and political proximity to the victims.

As Nick Stockton has put it:  “‘[T]raditional’ humanitarian assistance is concerned first and foremost with the task of saving lives in imminent danger, the notion of a moral or political ‘triage’ that somehow separates the deserving from the undeserving beneficiary, is for many humanitarians ethically repugnant.” Acting upon a supposed responsibility as a civil society actor equals political triage. In the end, there is something fundamentally contrary to humanitarian action and to impartiality if we intervene on the basis that some victims are more deserving than others because of their relationship to us.

Health, Our Western Identity

Baby Helmets for the World

5 Comments

Yummy!  There’s a Whole Foods Market in Stoke Newington.  That consumed an hour yesterday afternoon.  And about 50 quid.  The excitement mounted as I meandered through that bastion of American food and health branding.  Dare I admit to titillation at the prospect of real pretzels and something besides mayo-based sauce to put on a salad?  Or Mexican style salsas that aren’t made by Old El Paso, which seems to be the only brand sold in Britain, which is like having 65 million people who think the Ford Fiesta is the only car in the world.

Part of the WFM experience involved discovering Kallo Low Fat Rice Cakes.  Think about that for a moment.  Low fat rice cake.  That’s not exactly the same thing as a low fat English breakfast.  The label boasted 0.2g of fat.  What do you figure, that’s down from 0.3 grams?  Maybe 0.4g?  (Just for comparison sake, a rather basic version of a Full English boasts about 400 times more fat).  Oh, and a pack of Kallo’s Low Fat Rice Cakes costs £7.64, which is only slightly less than the price of platinum on the basis of weight.  People are willing to pay for health.

Our visit to Whole Foods Market came just after getting lost in Abney Park Cemetery, a hidden gem that’s part graveyard and part medieval forest.  Reading the 19th C gravestones there, it’s hard not to remark the ordinariness of children or young adults dying.  Cut to 20 years ago:  walking through Lafayette Cemetery in New Orleans, digesting the significance of family headstones with three or four children perished within a stretch of three weeks.  Makes you realize how far removed many of us have become from the reality of the human condition being nasty, brutish and short.

In the chasm between “haves” and “have nots”, we can conjure many dividing lines:  The digital divide, the education divide, the life expectancy divide.  Yet I find it hard to imagine a deeper division than the one in which the “haves” side includes a chunk of people suffering panic attacks over the fat content of a rice cake.  The luxury of that effort, the obsessive nature of that fear, the idiosyncrasy of that market all point to a rarefied environment, to say the least.

So we must ask:  How many of us shoppers at Whole Foods think of ourselves as rarefied (read: nutters) as opposed to normal arbiters of healthy living?  How close is that luxury/obsession/idiosyncrasy to those who hold power in the humanitarian business?  And how far removed is it from the world of the beneficiary?  What does this gap say about the values underlying aid programs dealing with health?  We must ask these questions because the removal – the distance – is not so easily contained to the many absurd disparities between a society in which hunger is a permanent and defining ache and one in which people study the labels of organic yoghurt as if reading the instructions to defuse a bomb.

No, the distance here is generated by the value assigned to health and, perhaps, to life itself.  It is that value – the hyperinflation of health – which underpins our worrying about the fat content of aerated rice flour.  We come from societies “evolving” to the point where the minute risk of ill health or injury prompts such overly protective behaviour as the baby helmet or the craze for umbilical cord banking.  Here lies a fundamental disjunction between medical humanitarian and beneficiary, one largely invisible to us.  How else to describe our obsession with their health; with our overweening valuation of their health more than their own valuation of it?

OK.  We live in a different world. I guess my question is the degree to which we unwittingly export our world, or impose it; to which we remain blind to our way not being the only way.

When Somali elders prefer a cataract surgery clinic to primary healthcare for their community, do we listen to their request or overrule their unenlightened undervaluation of the health of a two-year-old?  When a Sudanese woman runs a risk by not bringing her child to the clinic, what is our reaction?  Do we question our own alarm at that minimal risk?  Or do we construct an entire narrative of victimhood, where she is forced to make such a “bad” choice in order to collect firewood or care for her other children?  Or do we construct a narrative of her ignorance, where she doesn’t understand the consequences of her own actions?  We export, in other words, our valuation of risk.  Will the humanitarians of the future insist she walk three hours to pick up her baby helmet?

When a Zimbabwean man refuses to wear condoms or stop visiting prostitutes, what is our reaction to his running the risk of catching/spreading AIDS?  Do we accept his choice or, again, construct an idea of his ignorance?  More importantly, do we even register our imposition and increasingly commercial marketing of biological longevity as some sort of universal right?  Do we recognize in ourselves the front men of a pharmaceutical industry whose wet dream is a world population sucking down as many pills as we do?  What of his response to our attempts at steering him on the right path; at our incessant moral hectoring and ever-so-repetitive educational demand that he change his behaviour?  Some days, I think we miss his response altogether:  “Hey, you, loosen up.  Chill out.  Eat some deep-fried food.  Live a little!”

Critique of Aid, Health, Politics

Bugged Out Over Haiti Cholera

4 Comments

Somewhere, somebody should start a blog on how to make yourself unpopular in humanitarian NGO circles.  Here’s one sure-fire formula:  praise the UN.  Or don’t even praise them, just defend the UN.  Or don’t even go that far.  Just mention the UN without also blaming them for everything that’s wrong in humanitarian action (there is an exception to UN-bashing if, at the time, blame is being heaped on government donors in an effort to obtain funding).  So I am wary of violating the NGO ethic of cool, as well as damaging my self-image promotion, by saying what could be construed in some quarters as a sycophantic devotion to the aid world’s paragon of bureaucratic inertia.

Yesterday I came across this posting on the cholera situation in Haiti.  Voilà the House of Representatives of the United States of America, that tireless defender of the downtrodden, harvesting political hay from the fact that UN peacekeepers introduced the cholera bug into the water system of Haiti (or did they?).  Haiti was, of course, a country that effortlessly fit into one of those overused “perfect storm” analogies looking at factors conducive to cholera killing a shitload of people (estimates are 4500 – 7000).  Low population awareness?  Check.  Zero natural immunity?  Check.  Poor to zero emergency healthcare capacity?  Check.  Widespread mingling of drinking water with bodily effluent?  Double check.  Voodoo.  Check.

America’s top politicians have made their bold call:  because UN troops introduced cholera into Haiti, they are the “proximate cause” of the epidemic.  Read the letter.  Strong stuff!  You’d think they were condemning North Korea or one of those single-named dictators like Mugabe, Gadddafy, or the newly anointed (to the single-name club) Assad.  Congress continues:  “As cholera was brought to Haiti due to the actions of the UN, we believe that it is imperative” for the UN to deal with it.  Put simply:  you are the cause of this mess, so you have clean it up.

Is there one person paid to run the US possessing even a small appreciation of irony?  Let’s look at that accusation on causality for two secs.  OK.  One sec.  Because it is quite remarkable, isn’t it, when the US government endorses the idea that a powerful global actor has to clean up the messes it makes on foreign soil.  Forget Iraq.  Forget Afghanistan.  Forget Viet Nam, Cambodia or Laos.  Forget the Arctic ice pack melting away like all those pledges to build a better Haiti.  Forget, even, a drone missile or two being an uninvited guest at a Pakistani wedding.  Forget all the messes where the US govt wears the label of proximate cause like Gilligan wears a cap.

Forget them and focus on Haiti.   After four decades or so of propping up a series of Olympic medalists in the decathlon of brutal, corrupt, incompetent, venal (but anti-communist!) political leadership – not to mention that sordid little CIA relationship with local paramilitary butchers and other political interference – you would think the USG might shy away from the promoting an idea that proximate cause engenders political and moral responsibility in the poorest place in the Western hemisphere.

In the end, though, perhaps the bigger danger comes not from the US’s lack of introspection, but from peddling the idea that bacteria can be the cause of so much destruction.  (More on that next post). The cholera disaster in Haiti is caused by the interaction of vibrio cholera with a dysfunctional sanitation system, with paradigmatic urban slums, with an almost unprecedented level of abject poverty.

And on the proximate causes of that mess, both US and Haitian politicians seem unsurprisingly silent.  Ditto for the Center for Disease Control, who managed to predict that the risk of cholera introduction into Haiti was low, presumably because they naively assumed the thousands and thousands of people making up the relief armada were well-wiped westerners who did their business in the plush Hotel Karibe.  Ditto for most of the relief effort, who seem uninterested in answerability for Haiti’s mess despite its longstanding moniker as the “Republic of NGOs”.

Special kudos, though, for the lawyers suing the UN over cholera.  Such a nice example of the little guy taking a pop at power.  But if you want to introduce some accountability for the woes of Haiti, maybe the brave lawyers should leave blue-helmeted Nepalese peasants alone and go after those champions of justice on Capitol Hill.

Health

A Fat Tax on HIV+

2 Comments

How many others missed this early April news gem?  Arizona Governor Janet Brewer proposed socking obese Arizonans who are enrolled in Medicaid or Medicare with a $50 surcharge unless they adopt a supervised weight-loss program prescribed by their doctor.  (Smokers will get nailed as well.). 

Congratulations to the Gov for the world’s first “Fat tax”.   

The Gov’s arguments run pretty simple along the surface:  unhealthy lifestyle choices and behavior eat up the healthcare budget, so let’s make these miscreants and self-indulgers pay.  After all, why should the public subsidize bad behavior?  Looked at differently:  If some guy like me wants to bicycle the streets of London without a helmet, running the lights, why take money away from cancer research to pay for his brain surgery? (It’s a slippery slope:  skiers and joggers are always breaking ankles, and that costs a lot of money, but taxing them would bring us right back to the obesity risk of blogging from the couch all day.).

If the Arizona governor sounds confused on the workings of blame here, as if people choose to be obese the same way our guy chooses to cycle recklessly, it’s because any debate on the merits or not of the fat tax as a public health policy is misplaced.  This is about trimming budgets, not waistlines.  Ha ha. From a health policy standpoint, blaming the sick sounds perverted, though I guiltily admit somewhat less so in light of estimates that the cost of obesity is the US range from $150 to $270 billion.  Isn’t that more than the continental budget for healthcare in Africa?  Anyway, from a financial standpoint, the fat tax is the sort of decision that will be increasingly more common as politicians and health officials scramble to save cash.

 Now flip to HIV/AIDS.  I recently visited MSF’s HIV/AIDS project based in Khayelitsha township, on the outskirts of Cape Town.  It’s an impressive programme, one that has led to a great deal of innovation on the treatment/delivery side of things and, more importantly, to a sizeable scaling up of HIV+ people receiving anti-retroviral therapy.  Depressingly, I found the decade of advances in HIV treatment have been unmatched by advances in preventing transmission.  It’s simple:  too many men refuse to wear condoms and they certainly aren’t interested in abstinence. 

During my visit I listened as young outreach and community education workers exhorted others on the need to do education in the taxi stands and drinking places, or called for opening hours in the evening, etc. etc.  Essentially, the same hopeful exhortations I heard 10 years ago.  As if a “new” or “improved” community messaging will actually produce a sufficient enough change of behavior to reign in this epidemic.  Aside from the fact that it doesn’t work well enough or fast enough in a context like South Africa, I’m still a fan of this sort of health education.  But limits need to be recognized.  The problem isn’t solvable through education because it’s not caused by ignorance.  That is a topic, though, for a later blog.

For now, back to Arizona.  How long before the logic of the fat tax will be applied to men and prostitutes in South Africa?  There, masses of people knowingly engage in high risk behaviour – becoming infected and (quite different from obesity) infecting others – and then fall ill.  They then assert a right to treatment.  So how long before the “no condom tax” or a “surcharge on unprotected sex”?  How long before money is switched out of HIV treatment into other health priorities at the ministry level, as is already happening on the global stage?  In the end, the Arizona fat tax heralds the coming day when budgetary pressure on the state forces a false distinction between “good” sick people and “bad” sick people.  After the obese, after the smokers, will come the reckless, be it the helmetless riders or rubberless fuckers.