Wednesday, 29 July 2015

Social Determinants of Health: Structural adjustment and the Zambian Medical Association

One in every 13 Zambian children does not survive to their fifth birthday; in Iceland it is one in 500.

Of a population of 14.5 million Zambians, 2 million have no access to sanitation facilities. Practicing medicine under these circumstances is a challenge – not least because of shortage of human resources for health.

Given this background I was particularly delighted when Dr Mujajati Aaron, President of the Zambia Medical Association, came forward and said he wanted to be part of my call (as President-elect of the World Medical Association, WMA) to National Medical Associations to rise to the challenge of social determinants of health and health equity. Dr Mujajati Aaron invited me to speak at the annual meeting of the Zambia Medical Association – the theme: the role of the Government and Zambia Medical Association in addressing social determinants of health and increasing health equity in Zambia.

Great.

Aaron began by asking why this theme? It sounds like social science not medical science. But then he cited figures such as those above and said we cannot solve these problems without action on SDH.

Dr Mzukisi, Chair of the South African Medical Association, said it was a pleasure to come to Zambia not pursued by the South African authorities. He was a great ally when he claimed that the WMA had recognised the importance of shifting from health care to health.

I felt as I do when hearing a much loved piece of music when Jairos Miti discussed early child development. He said we must look at conditions in which parents live as determinants of how parents care for children. Such examination will lead to understanding of children’s health and development.

I was very much taken with the presentation of Gabriel Banda, a former assistant to Kenneth Kaunda, first president of independent Zambia. Again sweet music intellectually, as he talked the language of social determinants of health. He said that basic needs bear closely on people’s health. Basic needs include: water, sanitation, food, shelter, energy, education and learning, livelihood and incomes (of individuals, households, and nations), communication, freedom from violence, safe natural environment and health care. And health can affect basic needs, although he focussed on social causation.

Zambia’s history, he said, is an illustration of what we are seeing in Greece now: of how austerity can damage a country and its population’s health. In his account, Zambia got into financial difficulties that led to a familiar deadly dance with the IMF. In the 1980s if a country was in financial trouble and appealed to the IMF for help with its debts, there was a standard response: we’ll help with debts and you pursue structural adjustment programmes (SAP).

SAP sought to commercialise and marketise provision of goods and services, reduce public spending through spending cuts, removal of subsidies, and increase in tax income, privatisation of public enterprises and liberalisation of finances. Spending cuts involved retirement of workers in the public service and reduction of the retirement age. Institutional memories and capacities declined in health and other fields.

Mr Banda said SAP wanted to make everything business and business everything. By his account, the austerity that SAP brought completely undermined the country’s advances, since independence, in meeting basic needs. The population did not like it. There were riots and people died. In 1987 President Kaunda said: that’s it. No more austerity; we will not continue to implement SAP. But that meant Zambia could not pay its debts. Sounding like Greece? Sanctions brought Zambia to heel and the country was forced to go back to the IMF and World Bank, and continue with liberalisation and diminution of services. Arguably, this hampered the country’s ability to deal with the new HIV/AIDS epidemic.

Given the IMF’s history, as exemplified in Zambia, the fact that the IMF is saying that in Greece, the EC and European Bank are imposing terms that are too tough, tells us either that IMF has learnt something from their grisly record, or that the EC and European Bank have learnt nothing at all from the history of the devastating effects of austerity.

I came away from my meeting with the Zambian Medical Association very encouraged. (But then that is my default state.) They have limited financial resources, the Medical Association has no paid staff, but they would really like to be part of a network of National Medical Associations that are dealing with social determinants of health. They see it as an absolute necessity.

Oh, and Dr Mujajati Aaron said: if you haven’t seen Victoria Falls, you haven’t been to Zambia.

I have and I have. Here’s the evidence:




Monday, 1 June 2015

Celebrating Scholarship

It has been a fortnight of celebrations. Celebrations of scholarship.

University graduations are moving occasions: times of celebration of achievement and hope. There will be time for disappointment and frustration, time for cynicism and loss of ideals. But not now, not at graduation. Now is the opening up of possibilities to make a difference. Perhaps that is why the Americans call the completion of University studies: commencement. In Sweden they call it promotion – my fortnight was bookended by graduations in Yale and Lund. In both cases, the University itself put on a grand occasion to honour their graduates – to celebrate scholarship. It is wonderful and moving, and a special interlude in the rhythms of what we do the rest of the time.

When in Britain the previous government raised university fees, the arguments seemed to be that lucky university students will gain economic benefit from a degree; therefore, they should pay. And Universities are pushed to show that they contribute to the economy. They do. But universities are about much more than enhancing earning power for individuals and the nation. They are places of scholarship and commitment, of morality and reason. And graduation is a time to celebrate this higher calling.

I was at Yale on 18 May for their graduation. I come with my inequality baggage of course. Yet awareness that these Yale students, many of them, had enormous privilege just to get to Yale, and accumulate even more being a graduate, didn’t stop my enjoyment of the splendid occasion. In the School of Public Health graduation ceremony, Jordan Emont, who spoke, brilliantly, on behalf of the students said they were united in their desire to contribute to a healthier future for the population, to confront the challenge of health inequalities. He spoke not of increased earning power but of the special bond with his fellow students and their joy of learning.

I was slightly disoriented. The academic procession, in full academic regalia, was accompanied by Elgar’s Pomp and Circumstance March. Shades of ‘Last Night of the Proms’, the BBC’s annual patriotic flag fest. Land of Hope and Glory, a British patriotic ode, in the US? The Dean, Paul Cleary, assured me that there was no political significance; they always played Elgar at Commencement. Paul was a great host and clearly a great dean as one graduating student after another hugged him. An oxytocin surge to warm up a formal afternoon.

Yale awarded me the Centennial Winslow medal in commemoration of the Founder of Yale School of Public Health in 1915. I quoted Winslow. In 1940 he wrote: In 1890 public health was an engineering science. In 1940, it is a medical science. Tomorrow it may be a social science. We must “pay attention the social environment that man has made for himself and in which he lives and moves and has his being…” Not a bad description of social determinants of health. Thank you, Charles-Edward Amery Winslow.

Winslow understood relative inequality. He wrote: “the sense of inferiority due to living in a substandard home is a far more serious menace to the health of our children than all the in satinary plumbing in the United States.” Wish I’d said that.

Some American politicians seem to be mired in pre-enlightenment thinking. Quoting Kant, I suggest to the graduating students that each of them “have the courage to use your own understanding”; and still moved by my meeting with him, I quoted Bernard Lown: Never whisper in the presence of wrong.
 
Could you take someone seriously who looked like this?
 

Tuesday, 12 May 2015

Taking Tea with Bernie

“I’ll just nip upstairs. There’s something I want to get for you.” And he does.

The 93 year old Dr Bernard Lown nips upstairs and comes back with a signed copy of his memoir, The Lost Art of Healing; and another slim volume Never Whisper in the Presence of Wrong. The latter is a selection from speeches he gave on nuclear war and global survival. Never whisper in the presence of wrong. It resonates. And he lived by it. Still does.

I am at Harvard briefly as a Bernard Lown visiting professor. It will entail another couple of visits to Harvard – no penance. The best part is the privilege of taking tea with Dr Bernard Lown at his home in Chestnut Hill, a leafy suburb of Boston. (I suspect that there is an inverse correlation between age of Harvard medical professors and the distance west of the Longwood Medical Area of Boston that they live. The newer the recruit, the further out they have to live. Harvard professors, high status, no doubt have long life expectancy, keeping the desirable properties occupied. That said, at 93, Dr Lown must be among the more senior. He is relatively close in.)

I know him as the co-founder, with brother cardiologist Evgeni Chazov of the Soviet Union, of International Physicians for the Prevention of Nuclear War (IPPNW) in 1980. They were awarded the Nobel Peace Prize in 1985. Leaning against a wall, I nearly dislodged a photo of Lown meeting with Mikhail Gorbachev in the Kremlin.

Bernard Lown - Image Source Boston Globe 2008


But there’s so much more. All over the world, patients with cardiac arrhythmias can be treated with cardioversion, a DC electrical shock to the heart, timed to miss a vulnerable interval in the cardiac cycle. Lown developed that. Patients with heart attacks used to be confined to absolute bed rest for weeks. Now they are mobilised quickly to prevent venous thromboembolism and pneumonia. Lown and Dr Samuel Levine, his mentor in cardiology at the Peter Bent Brigham Hospital of Harvard, were responsible for that. Patients treated with digitalis and diuretics could develop fatal cardiac complications. Lown showed that low potassium – which could be caused by diuretics – made digitalis potentially toxic. He did as much as anyone to draw attention to the issue of sudden cardiac death.

He was an early and firm believer in the importance of the mind in both the onset and recovery from cardiovascular disease. Had he done nothing else, his reputation would be secure as having made a fundamental and lasting contribution to the management of patients with cardiovascular disease. But he always saw clearly his wider responsibility to society.

Why is a cardiologist based at Harvard School of Public Health? He graduated from Johns Hopkins in 1945. American paranoia about communism, which led to the excesses of McCarthyism, meant that belonging to many student organisations with a social responsibility put you beyond the pale politically. Simply, his political beliefs made him difficult to employ in the fevered atmosphere of the time. Seems bizarre now. A Harvard professor, he has twenty honorary degrees, numerous medals and awards, a Nobel Peace Prize, and all the recognition as a clinician and scientist that one could imagine. Yet his undoubted ability was not enough. When the famous Brigham hospital was closed to him, he looked around Harvard, but the politics seemed to get in the way. Finally, he found Dr Fred Stare, head of Nutrition, at Harvard School of Public Health who offered him a job, and space for a research lab. Lown told Dr Stare that there were some political issues he should know about. Stare’s response: you’re an American; that’s all I need to know.

The frustration was that the two and a half hours I spent with Dr Lown, and his wife since 1946, Louise, meant that we had only just got started. He said he would give me the tour on my next visit.

Much to discuss.

Thursday, 7 May 2015

Bringing SDH to Tehran and Iran to SDH


Mostly, I don’t wear hats. But if I am going to, it may as well be more than one; in the case of this meeting in Tehran, three. The short version of the story started in Tunis. Ala Alwan, Regional Director of WHO EMRO Region, wanted to put social determinants of health firmly on the agenda for his region and wanted my help to get the approval of member states at their Regional Committee in Tunis last October. I did and we did. That was the first hat: an academic getting excited, yet again, about the social determinants of health message and possibilities for action.

Now I was hooked in. The next step was a regional consultation and I felt duty bound. Advisors to the Minsters of Health in Iran said that Iran would host it. Second hat: advisor to WHO EMRO on SDH. Senior people from most of the Eastern Mediterranean countries came together to consider next steps on social determinants of health – truly exciting.

The deputy mayor of Tehran put social justice firmly on the agenda. He appeals to the Koran for this argument. I appeal to our sense of what is right. Nine years ago when the CSDH met in Tehran, I said that members of the Commission come from the world’s great religions, and from science, rationality and humanism. But if we can agree on what is the right thing to do to create a more just distribution of health, then we work together in brotherhood.

We talked about having two or three partner countries. Iran would like to be one. Although not too much is happening at the national level on SDH, Tehran is doing interesting things at the city level. They have had several city initiatives for a healthy Tehran, including Urban HEART – health equity analysis and response tool. The WHO Kobe Centre ran the CSDH Urban Settings Knowledge Network. They did a fine job and were so pleased with the activity that they developed this tool to take SDH forward at the Urban level. We visited one “Health House” that was involving community groups in setting agendas to improve their own health and well-being. There are 374 of these health houses – one for each neighbourhood of the city (although the number of neighbourhoods has now come down a fraction). Under Urban HEART, surveys of people in local areas yielded the following top seven priorities:

  • being overweight and obese
  • waste disposal
  • being elderly
  •  tobacco
  • female breadwinners
  • domestic violence
  • unemployment

Much to do on these seven. And there is no question that central action would reinforce the local level.

My third hat was as President-Elect of the World Medical Association. The President and Board of the Iranian Medical Council invited me to a breakfast meeting with them. I told them I was trying to get the doctors involved on SDH. Could I interest them? I also noted that they were not members of the WMA. Perhaps I could interest them in that too? It looks rather positive on both counts.

Alireza Marandi was a member of the CSDH. He is an MP in Iran and President of the Academy of Medical Science. He expressed his willingness. If we think of the Academy as representing academia, and we have the doctors, the city level, and the Ministry of Health, we could be in business. Especially as the Minister assured me that he is setting up a cross-departmental commission on social determinants of health.


Monday, 2 March 2015

Social Determinants in a Post-Conflict Colombia


An attractive proposition?

Taking a social determinants approach to planning for a “new” peaceful society? How could it not be attractive. We have been arguing that health and health inequities tell us how we are doing as a society. It follows that planning for a new society should have social determinants of health at its heart. Hence the invitation to come to Colombia and be part of that discussion was irresistible.

There was a second reason I had to go to Bogota, and it relates to our social movement. We, IHE colleagues Jessica Allen, Ruth Bell and I, conducted a workshop for the Inter Academy Medical Panel on social determinants of health in Trieste Italy in summer of 2014. I said at the end of the workshop that there were senior representatives of Academies of Medical Science from 22 countries represented here; if only two of them went home and got active on social determinants of health I would consider the workshop a success; if three… a bonus; any more … I would be in heaven.


So far we seem to have three: South Africa, Morocco, and Colombia, with Tanzania in the wings. Prof Luis Alejandro Barrera Avellaneda of Pontificia Universidad Javeriana in Bogota, who had been at the workshop, said that they were planning for a post-conflict Colombia, would I come and address their new inter-sectoral commission on public health, meet ministers, have an exchange with some of their university professors, and participate in a day-long conference on social determinants of health.





He, and Professor Francisco Jose Yepes Lujan, co-hosted my visit with generous hospitality. Significantly, the Minister of Health was present at the dinner at which the University rector presided. It suggests a good channel of communication. I found the Minister open, engaging and willing to discuss social determinants of health. Some of the Twitter commentariat suggested otherwise. I do not know what that is about.

Post-conflict Colombia? Any outsider who claims to understand Colombia’s recent history is not concentrating. People were born liberal or conservative, or socially excluded. In Britain these partisan differences are debated with childish insults, in Colombia with deadly weapons. A civil war in the late 1940s that led to a military dictatorship was followed, in 1957, by sixteen years of Liberals and Conservatives agreeing to take it in turn to lead the government. It was something that could not last. And indeed it did not. Marxist guerrillas, private armies of the right (the paramilitaries), the infamous drug cartels with their own armies – it is hard to keep track of all the violence. Arguably, with political assassinations and kidnapping, the cartels overreached themselves, and were smashed. There is still a drug trade in cocaine – it partly funds the guerillas. But the drug-related violence between rival gangs seems to have moved to Mexico.

Emerging from all of this violence, the government is in the process of signing an agreement with FARC the leading rebel group. It is a fragile peace, watched with suspicion by many. More than 200,000 people, mostly civilians, have been killed in the fighting, and 7 million people, out of a population of 48 million, have registered with the government’s victims unit as having been internally displaced by the violence, or kidnapped, injured or otherwise affected. Whew! How to row back from such pain.

I made a presentation to the Intersectoral commission on health, chaired by the minister of health and with representation from 9 ministries. As background to our discussions I had been sent an excellent report documenting health and their approach to social determinants of health in Colombia (see link below). We will, of course, have to see what happens but the existence of this intersectoral group led by ministers who in their speeches show a keen understanding that key determinants of health lie outside the health care system is hugely encouraging.

The next day, the conference itself at Javeriana University was hugely oversubscribed. I took this great level of interest as an expression that our social movement on social determinants is alive and well. The Minister of Health followed the University Rector (President) in opening the conference. I have notionally shared platforms with Ministers of Health in many countries. But the ministers almost always – Sweden was an exception – make their speech, and leave before any of the substantive presentations. I don’t take it personally (perhaps I should?). Here the Minister stayed and personally made commitments to me to send me examples of their cross-sectoral action.

A lively discussion included a challenge from the left. Have we any examples, I was asked, of successful action to diminish health inequities. Presumably not, because the problem is capitalism, which inevitably increases inequalities, and there is nothing that can be done. It is a point of view we had heard while conducting the Commission on Social Determinants of Health. Nothing that can be done? All of our recommendations useless? To me, it is a counsel of despair.

I had four responses to this challenge. First, I am arguing that social determinants implies addressing the causes of the causes. My interlocutor wants to address the political causes of the causes of the causes. Go for it. Do it, by all means. I wish him luck.

Second, the country with the best health in the world, and relatively narrow health inequalities, is Japan, a successful capitalist country; followed by the Nordic countries, also successful capitalist countries. In fact all the countries with the best health are capitalist countries. The question is not whether we want to reconstruct a better version of the Soviet Union or North Korea, but how, as Thomas Piketty argues in his Capital in the Twenty first Century, to construct capitalist societies that are fairer, more just, and less unequal.

Third, it is not true that the evidence shows that until we smash capitalism we can not make progress. There are two ways to gauge success: health of the most disadvantaged, and the health gradient. There are examples from all over the world of the health of the most disadvantage improving – a major societal success. But, in many countries they have not been improving as rapidly as the better off. It remains a major challenge to address the social gradient in health. That is why we are in business.

Fourth, there are examples of reducing the slope of the health gradient, from Peru, Brazil, Bangladesh. It is simply not true that we cannot make progress on addressing the causes of the causes, without removing capitalism. That said, as we argued in the CSDH, commitment from the top of government is vital in addition to mobilisation of social movements from society.


In Colombia, itself, there has been considerable progress in reducing poverty, but poverty is still at very high level with strikingly high levels of inequality. There is much to be done. An intersectoral commission to improve health inequity is an important step in building a post-conflict Colombia.





Tuesday, 24 February 2015

Is it not better to light a lamp than curse the darkness?


A question we have been asking for at least the last five years: what can doctors do on social determinants of health? Not least, I posed this question when accepting election as President-elect of the World Medical Association. I finished my speech with a quote from Ghandi. Dr Jitendra Patel, (now immediate past-) President of the Indian Medical Association, said: I will start a hunger strike and won’t finish until you come to Ahmedabad. We will take you to a tribal area and show you what we are doing to improve the lives and the health of tribal people. People, that is, who have been socially excluded from the mainstream of Indian society and live in great poverty.

I had to go to check on Dr Patel’s state of nutrition. Indian hospitality certainly enhanced mine.

Gujarat is not one of the most populous Indian states – population “only” 60 million; Uttar Pradesh is 200 million. About a three hour drive from the big city of Ahmedabad, near the Pakistan border, is the Virampur area of the Banaskantha District. Getting there was an ordeal of embarrassment and gracious hospitality. At four stops organised by local branches of the Indian Medical Association we were greeted by dancers, drums, pipes and banners saying: Welcome to President-elect of the WMA. There followed garlands of flowers, shawls draped round the neck, and a slight sense of disbelief on my part that this could be happening.

At Virampur, we were part of a ceremony of opening a new multipurpose facility to aid the work of the Samvedana Trust  in improving the lives and the health of tribal people in the area.



The work began when Ketan Desai, also based in Ahmedabad, was President of the Indian Medical Association at the beginning of the century. He proclaimed the Ghandian slogan: let’s go back to the villages. Dr Jitendra Patel picked up the challenge and began with medical camps ‘under the Banyan tree’ in the tribal area of Virampur. He and his willing colleagues voluntarily treated the illnesses of tribal people from 42 villages in the area. What began with medical camps and on the spot treatment of disease grew. Over a ten year period from 2004, more than 40,000 tribal, and other poor, patients were treated – not at their expense – including over 11,000 operations at a nearby hospital, or in Ahmedabad.

Medical care to the under-served is vital and filling a gap, but as we said on the CSDH: what good does it do to treat people and send them back to the conditions that made them sick.





Note the goat sharing this woman’s front room.

These doctors went further and established the Samvedana Trust. A key figure is Dr Jitendra Patel’s older brother, Hasmukh Patel, social worker, social activist, and all-round good person. He lives simply in the tribal area on the site of the new building.

One among the many reasons, including prejudice and discrimination, for the marginal existence of the tribal groups here was the dry parched nature of the landscape. Hasmukh Patel, and the Samvedana Trust, were instrumental in establishing a system of 90 ‘check-dams’ to capture the water from the surrounding hills. With irrigation, agriculture is being transformed and migration to seek work has been reduced.




The Trust is actively involved in education, in helping gifted children to go on to further training, in promoting handicraft production as a commercial activity, and in generally promoting community development.


One of the lessons I have been taught in India is that government activity is central to improving the lot of the vast population of the nation’s poor. But so, too, is civil society. With an Indian population of 1.2 billion (in the 2011 Census) it is hard for any government to reach into the remoter corners of tribal areas, quite apart from issues of endemic corruption. An inspired and inspirational civil society organisation such as the Samvedana Trust can be transformational.

Working together to improve lives

I was back in Gujarat last weekend visiting street vendors who are members of SEWA – the Self Employed Women’s Association. It was nearly ten years since I visited with the WHO Commission on Social Determinants of Health (CSDH). After that visit I wrote:

I can picture the lives of the vegetable sellers of Ahmedabad from the outside, as they sit on the streets of the market area in the sun and the monsoon rains, with a small pile of vegetables on the rag in front. I cannot begin to understand how it feels from the inside to live the life of one of the poorest, most marginalised women in India. You start with some significant social impediments: you are poor, from a scheduled caste, you had no chance of education, and you are female. The only employment you can envisage is what your mother did: become a vegetable seller. This means you have to borrow money at usurious interest rates to buy your vegetables, pay inflated prices to the middle man in the wholesale market, deal with police harassment as you sit on the road side, and worry what to do with the children while you earn your few rupees. On the morning of my visit an elephant swaying through the market was simply one more hazard.

On this latest visit, Mirai Chaterjee, a leader of SEWA and a member of the CSDH, took me back. The street vendors in this area, the women at least, are members of the union, SEWA. Mirai introduced me to the local leader. She said (in Guajarati) that she remembered me from ten years earlier. Goodness. How come? This is not exactly a tourist attraction, and they don’t get so many outsiders come to visit.

Mirai is the one on the right


This woman was a street vendor as was her daughter. But the next generation? They are getting educated and do not want to go into the vegetable market. It is tempting to believe that the childcare SEWA provides is a significant step towards education. We know from evidence elsewhere in the world that enrolment in pre-school education is a significant predictor of educational success.





Interesting. These women are Dalit, outcastes. They have presumably married other Dalit for generations. But caste is not destiny, or should not be. Give the children the opportunity to be educated and they seize it and, presumably, flourish.

There are many other ways that SEWA has been active in improving the lot of its members. The wholesale vegetable market is a prime example. The wholesalers were forcing small farmers to sell at low rates and passing produce on to the retailers at high rates. Large profit for them; hardship for the street vendors. SEWA, against opposition from the, largely  male, wholesalers, set up as middlewomen: buying from growers at reasonable prices and selling to retailers with modest profit.

SEWA Bank is an important part of the jigsaw – small loans to street vendors without extortionate interest rates. Health care, insurance, legal representation, housing are all active areas for SEWA and its members.


Inspiring stuff. SEWA shows how collective action by civil society can transform lives.