Neoliberal Global Restructuring in Health, or the Fable of the Mongoose and the Snake

Globalization creates wealth for the few and depresses local wages and conditions of employment for the many. Globalization has brought about a shift in power: the nation state has weakened and there is a reduction in social accountability. This makes sovereign states row rather than steer in the process of development, i.e. if countries do not intensely participate in this paradigm set by the North, they are “out”. As a consequence, the poor countries’ very right to development is threatened by this unrelenting liberalization/globalization process. Globalization has put the fate of those many in the hands of large corporations. Although the corporocracy (or corporarchy of Robin Sharp) very well knows the negative effects of Globalization, few of them are committed to change. They tend to ignore the root causes of the social problems they see as patently as everyone else, but seldom address the negative social impacts of their activities. Since they lack the openness and transparency required, they pay only lip service to change and seldom change their practices (or change them in very marginal ways)

By Claudio Schuftan*

People’s Health Movement – PHM

Topical: Past Century Nineties Forward-Looking Essay

Neoliberal Global Restructuring in Health, or the Fable of the Mongoose and the Snake (Fableous Food for Thought)

What is history, but a fable agreed upon?
Peter Hoeg (1)

Globalization and its negative consequences:

The peculiar current form of Capitalism rechristened as ‘free market economics’ rules in the vast majority of countries as our century draws to a close. This paradigm –at the core of the transnational liberal order– has become the current hegemonic development philosophy as well. It goes by the motto of “trade, not aid”, no matter how uneven the former may be.
Globalization –the new Capitalism’s flagship– denotes the ability of international capital and transnational corporations to switch investments across the globe. In doing so, Globalization creates wealth for the few and depresses local wages and conditions of employment for the many.
Globalization has brought about a shift in power: the nation state has weakened and there is a reduction in social accountability.

This makes sovereign states row rather than steer in the process of development, i.e. if countries do not intensely participate in this paradigm set by the North, they are “out”. As a consequence, the poor countries’ very right to development is threatened by this unrelenting liberalization/globalization process. (2) (3)

Globalization has put the fate of those many in the hands of large corporations. Although the corporocracy (or corporarchy of Robin Sharp) very well knows the negative effects of Globalization, few of them are committed to change. They tend to ignore the root causes of the social problems they see as patently as everyone else, but seldom address the negative social impacts of their activities. Since they lack the openness and transparency required, they pay only lip service to change and seldom change their practices (or change them in very marginal ways). (4)
Moreover –in the dealings of Globalization-its intricate connections are so patently disguised as to become almost invisible. Or worse, the deceptions are so brilliantly woven into its processes that falling for those deceptions is deemed as both fashionable and progressive. (5) (6)
In the Globalization context, the privatization called for often ends up meaning denationalization with Globalization further pursuing a removal of trade barriers, (often dependence creating) technology change, and a rise in consumerism. This, on top of being rightly singled out as additionally creating and accelerating poverty, disparities, exclusion, unemployment, alienation, environmental degradation, exploitation, corruption, violence and conflict. (7) (8)
Not by accident then, has Globalization been called “the imperialism of the 1990’s”. (What is different between imperialism and globalization is just the latter’s speed of expansion).
Because the Globalization of the economy brings about marginalization on a massive scale and economic and political domination of a magnitude not seen since the days of colonialism, it is turning in to a process of Globalization of poverty and of an intensification of the plunder of the neo-colonies. The effects of Globalization are thus terribly uneven and produce big winners and losers. (9) (6) (2)
Due to these negative consequences of Globalization, communities in many Third World countries are no longer able to cope –their previously successful coping strategies diminishing daily. The immediate challenge is to bolster the same communities’ coping strategies so they can continue to help themselves under the new set of rapidly changing circumstances. (10)
Even business executives espousing Globalization are aware of its negative effects. An Asian executives poll carried out by the Far Eastern Economic Review in November of 1997 (p.38) showed 71% of the business leaders polled across the region agreeing that the benefits of Globalization had not been equitably distributed in their respective countries. 48% were of the opinion that Globalization had widened income disparities in their countries. 50% said that it was contributing to social tensions and 60% said their respective governments were not doing enough to help those hurt by Globalization.
More surprising yet is the IMF’s very own overall view on Globalization. For them, the latter links labor, production and capital markets of economies around the world. They do accept that it leads to sharp ‘short-run’ changes in the distribution of income. They further accept that Globalization is to blame for growing inequalities in developed countries as well. For example, to them, Globalization limits the ability of union workers to bargain, as well as making it more difficult for governments to implement equitable policies. (11)
Because they are unable to do the latter, governments in the Third World are simply assumed to be incapable of assuming a minimum level of welfare for their citizen. Fitting the ideology, it is then implied that it is necessary to look for alternatives in the private sector or to directly privatize services (and NGOs are occasionally a convenient form of privatization). Only that, often, such privatization strategies lower the quality of services for the poor and end up widening the gap between the rich and poor. The alternative that is being written off a-priori is the need to improve the state’s credibility, accountability and responsiveness to welfare matters.(*)

[(*): After all, the extraordinary and more equitable growth of Vietnam and China contradicts the view that a state control of the economy and the market is inimical to growth].

One has to acknowledge that most governments have not adopted the right strategies. But let us not develop yet new ones; let us make governments adopt and adapt the right and proven pro-poor strategies providing them with a set of options, and not a single pathway. Sustainable solutions proposed need to be sound and appropriate both in the way things will be done as much as in what to be done. (8) (12)
At this point, we hardly need to be reminded of the hard facts documenting the negative effects of Globalization. Tid bits of the evidence should suffice to close this quick, maybe caricaturized, review of its negative consequences:

– Under Globalization, the annual losses to developing countries run at an estimated $500 billion –an amount much higher than what they receive in foreign aid.

– As a consequence, developing countries have had a series of years of consecutive negative financial flows; this is equivalent to at least seven years of an economic hemorrhage.

– From 1960-99, there has been a 60% fall in the prices of commodities other than oil! This has resulted in a reduction of two thirds in the buying power of developing countries. (13)

– As a result, the number of hungry people around the world keeps rising every year and poverty is becoming increasingly feminized (70% of all the poor are women). Free trade has been free for business and industry, but not for women and the poor. New technologies have not shown to have intrinsic pro-poor or pro-women positive effects either, although they have such a potential (which unless we help steer in that direction will invariably continue favoring the already wealthy and male). Therefore, any genuinely poverty-redressing policy is bound to be a gender-oriented policy.

A dearth of workable solutions?

There is no single universal solution in sight that will promote just the benefits of Globalization to all people: giving the same advice to everyone simply has not and will not work; this is what has been called “the fallacy of composition”.
A balanced and realistic value-free response to Globalization is difficult, especially if one considers the current reality of a unipolar world with a North-centered and North/transnationals-dominated economic order. (14)
On the one hand, the transnational corporations cannot be allowed to continue to duck and dive, invest in smoke screens, espouse gradualist solutions and attempt to derive maximum publicity from piecemeal changes. They must be persuaded, cajoled or even forced to change.

On the other hand , new insights are emerging as to the appropriate mix of market and government activities needed to complement each other. (4)

Whatever the response, promoting the economic benefits of Globalization requires mechanisms to prevent its excesses, because there is a clear trade-off between market efficiency and the social welfare of workers and peasants.
Turning again to the IMF, they see the policy responses to counter Globalization to include a mix of two elements:
a) ‘safety net interventions’ such as targeted subsidies, cash compensations, severance payments to and retraining of sacked employees, wage subsidies, and public works programs, and
b) ‘fiscal policies’ (the most direct tool of redistribution) such as levying highly progressive taxes, distribution of shares in privatized enterprises, and increased government spending in health and education (i.e. reallocation of spending to the social sector), as well as higher minimum wages, good unemployment benefits, job protection, keeping inflation low, subsidizing lower quality commodities, and giving better access to credit, justice and public services. (11)

How this is to be achieved, and whether the IMF plans to go for broke for these changes remains unsaid in the source here cited.

The truth is that, in the real world, the more radical visions or sustainable solutions calling for deeper social and environmental change have been diluted or silenced further with the onslaught of Globalization. In a mix of insensibility and unresponsive, the prevalent attitude has been to selectively reject (depending on the bias) the main features of any criticism and to keep important issues from surfacing to critical consciousness. This is what has been called “the exclusion fallacy” (“…if we have not considered it, it is not important…”).
In the international scene of (mercenary) technical development assistance, for example, issues of substance are turned into technical matters by paid consultants while underlying more structural issues get obfuscated. Or, what amounts to the same, aid agencies too often remain unwilling to respond politically to political situations. (3)

The Equity/Equality approach:

Equal relations between unequals reinforces inequality!(3)
To illustrate this, think for a while that equity under Globalization is a bit like the fight of the Mongoose and the Snake:

Both are of about the same strength, but invariably the mongoose wins –it is more resourceful and it organizes its strategy better to strike.

The First World is like the mongoose; the Third World is like the snake.

The lesson of this fable is that an asymmetry in the use of market power aggravates inequality. The affluent always end up having more political clout (and more wealth). Therefore, promoting self-interest (the soul of the market) is simply not enough. We have to put some heart into it; add solidarity to self-interest. (15) (16) [A modicum of anti-greed policing actions may help as well…].

To achieve greater equity, a set of “equity modifiers” have been proposed. These include: targeting interventions (geographically and/or to vulnerable groups or individuals), land reform, educational/water and sanitation/health/nutrition and family planning interventions, employment generation, grassroots participation in setting priorities, development of the non-farm rural economy, aid to rural women, and the levying of taxes on polluters and degraders. (2)
As pertains to gender, the latter has reached a unique status in the transnational liberal order. Gender equality is (finally) considered compatible with the basic tenets of the neo-liberal credo. But economic equality, not. (17)
Remedies proposed to specifically increase equity and access to basic services thus include financial and non-financial approaches. To recap and add, among the former are the targeting of subsidies (i.e. selective subsidies of goods and services disproportionately consumed by the poor), prepayment plans (e.g. community-based health insurance), exemptions and the selective dropping of some fees (e.g. health and educational). Among the latter are a greater emphasis on decentralization, on the use of social marketing (*), on prevention and on improvements of the quality of care (in health), as well as on a fairer urban/rural distribution of resources.

[(*):Social marketing –one of the sweetheart companions of Globalization attempting to give it a human face– focuses on high-powered “Madison Ave-type” messages and communication strategies that pursue behavior modification and not informed choices. It is quite obvious that we should rather be trying to better understand what motivates people to change and why, and then letting them decide by themselves what steps to take to get there].

Surprising as it may seem, the IMF thinks that more equity need not hamper growth, it could indeed reinforce it! (sic) They actually see a strong negative link between high unequal distribution of assets and subsequent rates of growth. They see equity only requiring ‘equality of opportunities’, though, not necessarily ‘equality of outcomes’. In that sense, they agree the poor need to increase their human capital. Equity, to them, is critical for the political viability of Globalization… (sic). Therefore, decentralization and changing the composition of public expenditure is for them a must. For instance, expenditures on health have to increase, they say, but to be equitable, they have to be concentrated on preventive activities in rural areas and should be targeted to the lower income quintile (*). (11)

[(*): Beware that valid arguments have been raised against ‘targetry’: Targeting misrepresents complex realities, involves big cost in monitoring, distorts policy and destroys political momentum for structural changes. (18) (19)

Regardless of whether the IMF follows up with concrete actions on what they philosophize, we need not apologize to act with a more resolute equity bias beyond lip service since such a bias is an important corrective to the other more dominant inequitable value biases out there in the heartless market place. (One of them, for sure, is basing decisions on interventions on cost-benefit analyses only; cost-benefit analyses are understandable to economists and policy makers, but they are grounded in a different reality than most of us live in. Economists make decisions guided by what is ultimately measurable if convertible into monetary value only). (20)
Is this more resolute equity bias a radical proposition? Yes. Is it necessary? Absolutely. Is it impossible? Possible. Is it likely? Not very likely based on my latest dispassionate reality check. But what, then, are the alternatives and could they do the job on time? (5)

The Human Rights approach:

A human rights framework is the emerging UN response to foster development in the new millennium.
Globalization may be inevitable, but what it looks like is not –there are forces that can shape it, and human rights must be one of those forces. (21)
As someone said, human rights can set limits to the sways of the market. (22)
To restate the dogma of Human Rights, they are indivisible; they do not apply some yes and some no, some today and some tomorrow, some to us and some to them, some to the rich and some to the poor, some to women and some to men. These obligations are universal for their implementation. We are therefore compelled to operationalize civil, political, economic, social and cultural rights in our daily work..
We have to be on the lookout, though. There is still much righteousness and hypocrisy in this field. One can easily lose faith in those who preach human rights and have little to offer.

Actually, with Globalization, “Might is Right” has come back with a vengeance. And in a defeatist stance, we have so far accepted this fact and have bowed to the forces we think we cannot effectively oppose. (23)

To make the human rights approach concrete and giving it substance is a political task. Their enforcement and holding governments accountable for their human rights record can only be achieved through political action. Soft approaches will not do. (24)
Steps in the right direction, at this time, will be the establishment of National Human Rights Committees and the setting of concrete examples of rights-based programming. But bolder steps will have to follow.
Furthermore, we have to fight the indifference of our youth to the present human rights situation. Our young and upcoming colleagues also remain largely indifferent to the overwhelming negative effects Globalization is having in the world. [It is during our youth –when we have faith in and fight for the ultimate answers– that we have to interest the upcoming generation in Globalization. Later, we cave-in and accept that we are always going to have to live with the big questions leaving the responses to undefined others]. We have thus to enroll the youth before they resign themselves to the fact that all they can do is pose the same unanswerable questions over and over again (even if in new ways), without sticking their own necks out to seek the right answers. (1)
Our youth seems more interested in the information superhighway. As if Marshall Mc Luhan’s predictions were right, in terms of action orientation, the Internet has so far been more part of the problem than of the solution. There is a valid growing lament that wisdom, imagination and virtue are lost when messages double, information halves, knowledge quarters, and often deceiving noise without origin, quality and purpose is everywhere. We have to overcome this downward spiral by using the same medium to give more appropriate direction and guidance on options to counter Globalization and more aggressively foster human rights.
Our endeavors to achieve the latter two in the new millennium will only succeed if and when the youth becomes more central in the process of intellectual rejuvenation (a role they are now not taking up), and women (whose gender roles are being explicitly suppressed) also move more to center stage. [We need to invert the M of Men to a W of Women beyond mere rhetoric…] (25)
In sum, an effective challenge against Globalization and its negative effects on human rights is possible, but demands the same kind of intellectual commitment and vigor that characterized anti-colonial or independence fights.
Questions of the relevance, accountability and utility of the social sciences in this process need to be explored. Are they confronting the real problems? Are the problems of Globalization and the violation of human rights being made focal points of the social sciences’ analyses and actions? Western intellectuals have simply abandoned their commitment to challenge the exploitation and oppression of the poor as they continue being brought about by Globalization. Concerted campaigns and struggles against poverty, tyranny any exploitation will form the only sustainable basis of an intellectual renaissance of our youth and of ourselves.

Bolder steps are needed:

When we talk about Sustainable Development, we’re talking about what we should try to become today and in the future and what that compels us to do now.
Taking a minimalist stand towards Globalization will do no harm, but neither will it do much good. Inertia in history (has) and will always work(ed) against the more visionary and radical changes deemed necessary when the same fall outside the ruling paradigm. (1)
Development cooperation must thus become more political, because only structural reforms will deliver sustainable development.

In many an aid recipient country, conventional politics simply is increasingly losing its primacy over commerce and industry. [All too frequently we see the failure of elections as an instrument of political renewal… As somebody said, the problem with political jokes is they get elected. (26)]. Therefore, new, bolder approaches are needed. Solutions must be geared to control that which fuels the problem at its roots.

The solutions to the consequences of Globalization on the health and nutrition sector, for example, cannot be medicalized any longer. Technical assistance focused on health/nutrition matters only is not enough to uproot the structural inequities underlying pervasive and unrelenting ill-health and malnutrition in the world.
But the inertia is so great and our collective virtual view of reality so distorted and entrenched, in part due to Globalization, that the likelihood of us changing that reality remains dim. Neither greater individual responsibility nor containment strategies will do. A solution will somehow have to be imposed on us by some powerful or strategic force, either by fate or by design and it better be soon.
In short, we need to give a larger intellectual and political scope to our discussions on Globalization. In doing so, we have to manage to develop a political program of more universal appeal. We need to set up the framework that will connect all the different social actors to come up with a focused common agenda.
More than ever before, we need an overt political intervention, simply because economic violence is best counteracted by political antibodies, and what the people’s movements around the world want is simply “More”, from life, from history and from us.
When economics has ceased to strengthen social bonds and its prescriptions are actually further pauperizing millions, it is time to start thinking in political terms again. This is one of my cherished iron laws. (27)

Three caveats:

1) As hinted above, intellectual and cultural imperialism now penetrates our minds by remote control via satellite links and the information superhighway and poses great danger to the production and development of local knowledge. But this is not a fatalistic statement. While not denying that the giant tentacles of Globalization reach into every corner of the world, this should not be equated with omnipotence.

2) Stereotyping the object of criticism (Globalization) risks to emotionalize the issue rather than objectively analyzing and diagnosing it. We have to give up our quick prescriptive impulses (saying what should have been done) and become more empirico-analytical (describing and dialectically interpreting what is actually happening). (25)

3) One can set morally desirable goals so high or set goals without following them with sincere, workable policies that they remain out of all realistic reach and lose all power to determine the direction of action. Even rules can be set or imposed more as a source of comfort than of good choice. (28)

In closing:

As you finish reading this, make no mistake, these seemingly abstract issues about which we write papers are matters determining the lives of millions of people. We all know that, as Benjamin’s law says, when all is said and done, a lot more is said than done. It is therefore not enough to bring these issues under the spotlight; as someone else said, we need to make more light! (29) (30)
The facts discussed here are more than enough to allow us to go negotiate (or struggle) for new more radical equitable/pro-poor/pro-women/human rights based strategies on the highest of moral grounds. (3)
We need to awaken the ‘investigative reporter’ in us to constantly go after the human story behind the statistic. After all, journalism is the rough draft of history –and we want to be counted in shaping it. Those whose interests we claim to serve also expect it from us.

References:

(1) P. Hoeg, ‘An experiment in the constancy of love’, in Tales of the Night, Panther Books, Haverhill Press, London 1998, pp.120-121.

(2) P. Hazel, IFPRI.

(3) Y. Tandon, ‘WTO: What strategies for the South?’, South Letter, 3:34, 1999, pp.14-16.

(4) R. Welford, UNRISD News, No.17, Autumn/Winter, 1997, p.7.

(5) C. Thomas, ‘You can’t skate into a buffalo herd’, WorldWatch, 12:4, Jul/Aug 1999, p.5.

(6) C.R. Bijoy, ‘Mismanaging health’, LINK (ACHAN), 13:2, Sept. 1995, pp.15-17.

(7) K. Bezanson, IDS, Univ. of Sussex.

(8) U. Jonsson, UNICEF, in SCN News, No.18, July 1999, p.81.

(9) S. Ramphal.

(10) J. Tagwireyi, MOH, Zimbabwe.

(11) Finance and Development, 35:3, Sept.1998, pp.2-5.

(12) E.A. Graffy.

(13) Human Development Report 1997, UNDP.

(14) LINK (ACHAN), 13:4, March 1996.

(15) A. Anderson.

(16) R. Ricupero, UNCTAD.

(17) J. Baudot, UNRISD News, No.20, Spring/Summer, 1999, pp-1-3.

(18) S. Maxwell, IDS, Univ. of Sussex.

(19) More on this forthcoming in C. Schuftan, and G. Dahlgren, ‘Can significantly greater equity be achieved through targeting?’ manuscript in preparation.

(20) P. van Esterik.

(21) L. Haddad, IFPRI, in SCN News, op.cit., pp.12-14.

(22) R. Jolly, SCN News, op.cit., p.11.

(23) President Mahatir Mohamad, Kuala Lumpur, 9/2/98.

(24) B. Ramcharan, UN High Commission for Human Rights, in SCN News, op.cit., p.16.

(25) N. Nieftagodien, ‘Globalization and social sciences in Africa’, CODESRIA Bulletin, Nos.1+2, 1999, pp.56-60.

(26) Henry Cate VII.

(27) D. Cohen.

(28) F. Nuscheler, D+C, March 1998, p.5.

(29) H.F. Johnson, Minister of International Development and Human Rights, Norway.

(30) W. Clay, FAO.

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*Claudio Schuftan, M.D. (pediatrics and international health) was born in Chile and is currently based in Ho Chi Minh City, Vietnam where he works as a freelance consultant in public health and nutrition.

He is an Adjunct Associate Professor in the Department of International Health, Tulane School of Public Health, New Orleans, LA. He received his medical degree from the Universidad de Chile, Santiago, in 1970 and completed his residency in Pediatrics and Nutrition in the Faculty of Medicine at the same university in 1973. He also studied nutrition and nutrition planning at the Massachusetts Institute of Technology (MIT) in Cambridge, MA in 1975. Dr. Schuftan is the author of 2 books, several book chapters and over fifty five scholarly papers published in refereed journals plus over three hundred other assorted publications such as numerous training materials and manuals developed for PHC, food/nutrition activities and human rights in different countries . Since 1976, Dr. Schuftan has carried out over one hundred consulting assignments 50 countries in Africa, Asia, Latin America and the Caribbean. He has worked for UNICEF, WFP, the EU, the ADB, the UNU, , WHO, IFAD, Sida, FINNIDA, the Peace Corps, FAO, CIDA, the WCC (Geneva) and several international NGOs. His positions have included serving as Long Term Adviser to the PHC Unit of the Ministry of Health (MOH) in Hanoi, Vietnam under a Sida Project (1995-97); Senior Adviser to the Dept. of Planning, MOH, Nairobi from 1988-93; and Resident Consultant in Food and Nutrition to the Ministry of Economic Affairs and Planning, Yaounde, Cameroon (1981). He is fluent in five major languages. He is currently an active member (cschuftan@phmovement.org) of he Steering Group of the People’s Health Movement and coordinated PHM’s global right to health campaign for 5 years.

Breaking News: Link 173

Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Breaking News: Link 173

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Female Genital Mutilation in Nigeria: is it over?

Female Genital Mutilation (FGM) is a worldwide plague affecting 29 countries at least. In Africa it is ingrained in the society. Nigeria's Government outlawed it in May 2015, but doubts remain whether this will actually improve on Nigerian women's conditions and refresh the African debate on FGM

by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

Female Genital Mutilation in Nigeria: is it over?

In Nigeria almost 19,9 million out of 86,9 million girls and women underwent Female Genital Mutilation (FGM) in 2013.

In this Country the practice is deeply rooted in social beliefs and its origin is shrouded in uncertainty either as an initiation ceremony of young girls into womanhood or a tool to ensure virginity, curb promiscuity, and protect female modesty and chastity as well. Due to its strong religious nature, it is not easy to identify a single practice bound up with FGM.

Finally, the practice was banned on 25 May 2015 when the former President Goodluck Jonathan signed the “Violence Against Persons (Prohibition) Act, 2015” as a move aimed to eliminate violence in private and public life by banning any form of physical, sexual, psychological, and domestic assault, along with harmful and discriminatory practices, while inflicting proper punishment on offenders and providing maximum protection and effective remedies for victims.

As such, based on its 6 ^th article stating that “the circumcision or genital mutilation of the girl child or woman is hereby prohibited”, the Act prohibits FGM in the whole Nigerian Federation.

Despite optimism that the Act will allow women and girls to escape FGM, doubts remain whether it will be enforced throughout Country and entail adequate punishment on offenders.

Admittedly, the May move is not new to many states in the Country which signed a bill criminalizing FGM several years ago. Since the Edo State outlawed the practice in 1999, other states, e.g. Rivers, Ogun, Osun, Cross River and Bayelsa among others, did the same, wherein Section 34(1)(a) of the 1999 Constitution of the Federal Republic of Nigeria was the basis for banning the practice nationwide. It states, indeed, that “Every individual is entitled to respect for the dignity of his person, and accordingly; no person shall be subject to torture or to inhuman or degrading treatment”.

Unfortunately, available data show that FGM continues to be practiced at a constant frequency over the years. Indeed, despite legislation, this practice has been uninterrupted due to the lack of law enforcement and effective measures of punishment.

The prevalence of FGM significantly varies by state. In the states cited above, the percentage of girls and women aged 15 to 49 years who have undergone FGM remains high (between 26 per cent and 50 per cent), with the Osun State ranking higher (51 per cent to 80 per cent).

In the face of this, it is a ray of hope that the share of 15-19 years old girls who have undergone FGM is seemingly in decline recently.

Lev Tolstoj in his masterpiece “World and Peace” says “writing laws is easy, but governing is difficult”. As can be seen in this instance, laws are not sufficient if they are not underpinned by a social framework that makes they sustainably work.

Since May 2015, Nigeria has taken a big steps, and hopefully they will translate into a real improvement on Nigerian women’s conditions. Unfortunately, the previous experience of single states leaves more than a doubt for material change. Indeed, due to FGM’s strong religious/cultural nature, laws will expectedly fall short of non-discriminatory targets unless they are supported by strategies to change specific social behavior.

Hence, increasing awareness on health implications of FGM and equipping the law to effectively punish offenders could definitely serve as a deterrent against FGM and its practitioners.

The Nigerian’s ban of FGM could be instrumental to refreshment of the relevant African debate.

In fact, even though several countries passed legislation outlawing FGM (e.g. Benin, Chad, Cote d’Ivoire and Djibouti, among others), FGM still remains a social plague. As such, only 36 out of the 54 African countries have ratified so far the 2003 “Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa” banning FGM all over the Continent. Three of them (Botswana, Egypt and Tunisia) have neither ratified nor signed the “Protocol”, while other countries (such as Algeria, Burundi, Chad, Central Africa Republic, Eritrea, Ethiopia, Madagascar, Mauritius, Niger, Sahrawi Arab Democratic Republic, Sierra Leone, Somalia, South Sudan, Sudan and Sao Tome and Principe) have signed but not ratified it yet.

In view of all of the progress yet to be made, it is remarkable that things are changing, even though. In fact, today, a greater percentage of women do not tolerate FGM any longer. Today 62 percent of Nigerian girls and women think that FGM should come to a stop, the ratio is even higher in other countries.

Overall, the framework described here shows that Nigeria’s Act against FGM formalizes the beliefs of arising population providing a credible basis for real change due to changing views not only in the Country but in the whole Africa as well.

2015: A Year in Review through PEAH Contributors’ Stands

Authoritative insights by 2015 PEAH contributors added steam to debate on how to settle the conflicting issues that still impair equitable access to health by discriminated population settings worldwide

by Daniele Dionisio*

PEAH – Policies for Equitable Access to Health

2015: A Year in Review through PEAH Contributors’ Stands

Now that 2015 just came to its end, I wish to thank the top thinkers and academics who enthusiastically contributed articles over the year. Their authoritative insights meant a lot to PEAH scope while adding steam to debate on how to settle the conflicting issues that still impair equitable access to health by discriminated population settings worldwide.

Find out below a list of summaries and relevant links:

Beatriz Becerra Basterrechea, Member European Parliament, pointed out that …there is a total lack of transparency on the prices paid by governments for medicines. There is no public access or transparency regarding the clinical trials which test the efficacy and security of our medicines. We do not know how much has been invested in research nor do we have mechanisms to trace costs of production. A legislative effort should be undertaken to achieve transparency in industry’s investments in R&D as a process which would benefit both corporate public image and patients’ access to medicines….

As regards challenging antimicrobial resistance, Shila Kaur, Coordinator Health Action International Asia Pacific (HAIAP), reminded us that at the 67th World Health Assembly in May 2014, WHO Member States agreed to a Global Action Plan (GAP) to tackle the escalating antimicrobial resistance, including antibiotic resistance, global public health emergency. She regretted that … Despite having undergone two rounds of consultation with the global health community prior to its tabling at the WHO Executive Board meeting in January 2015, the draft GAP gives no indication on how developing and less developed countries, with limited or even non-existent technical resources and capacities, will design and implement their own national plans…

Inherently, Garance Fannie Upham, Deputy General Secretary, AC2BMR/WAAAR World Alliance Against Antibiotic Resistance, extensively reported on the book “AMR Control 2015”. As per her words…This book gathers more than 30 outstanding authors on a broad range of topics and concepts, from proposals for new Intellectual Property Rights approaches to R&D for antibiotics, to the latest data showing that the 44 billion dollars spent on antibiotic for animal husbandry may only be wasteful, to the need for urgent investments in water and waste management by banks and investors, or, last but not least, as it is top in the just adopted United Nations Global Plan of Action on AMR: infection prevention and control (IPC) as a must against AMR, Ebola and MERS.

As regards these issues, Matteo Zignol and Mario Raviglione, Global Tuberculosis Programme World Health Organization, underlined that …Surveillance of resistance to anti-TB drugs remains a cornerstone of any effective TB control programme worldwide. With the availability of new technologies and new drugs, and the prospect of new regimens for the treatment of TB and MDR-TB, surveillance of drug resistance is evolving and adapting to continue being a critical tool to inform public health actions to fight TB.

In unison, Kaspars Lunte, Team Leader Sourcing and Special Projects, Global TB Drug Facility, Stop TB Partnership/UN Office for Project Services added that …Stop TB Partnership’s Global Drug Facility (GDF) was established in 2001, with the aim of using donor funding to consolidate demand from different countries and negotiate affordable prices for quality-assured anti-tuberculosis drugs. Today, as one of the main players in the complex global market for TB drugs, the GDF plays a crucial role in not only shaping drug supply, but also in reducing the price of medicines.

From a complementary perspective, Giorgia Sulis, Lucia Urbinati, and Alberto Matteelli, Division of Infectious and Tropical Diseases – WHO Collaborating Centre for “TB/HIV co-infection and for TB elimination”, University of Brescia, Brescia, Italy, remarked that …Persons with LTBI (latent tuberculosis infection) have no signs or symptoms and are not contagious; however, they are at risk of progression from latency to active disease. On average, this happens in 5-10% of those affected during their lifetime, but some (“at-risk”) populations have a substantially higher risk of progression than the average. Hence, diagnosis and treatment of LTBI may represent an attractive strategy for TB prevention.

Linda Mans and Diana Hoeflake, Wemos Foundation, highlighted that …The world is 7.2 million health workers short. Low-income countries are particularly affected by the shortage of health personnel. Too few health workers are being trained and retained due to insufficient public investments in health care and medical staff. Migration of health workers increases the inequalities and presents a challenge for all countries. Vacancies in high-income countries have a pull effect on qualified health workers from low- and middle-income countries. One of the reasons is that health personnel are leaving for greener pastures – countries where salaries are higher and facilities are better…

In his article, Matthew Rimmer, Associate Professor, Australian National University College of Law, Canberra, reported that …At an international level, there has been a growing impetus for climate action in order to address public health risks associated with global warming…. As he maintained,…At the international level, there is a need to encourage fossil fuel divestment by governments, companies, and institutions in order to promote a healthy climate and a safe planet.

The article by Lawrence C. Loh, University of Toronto and The 53rd Week, emphasized that…Modern transport planning has rapidly moved away from an expensive, outdated system of car-dependent suburban sprawl. Understanding that health is different from and more than healthcare, wider societal discourse needs to apply planning’s lessons learned to move away from a singular focus on healthcare that is similarly expensive and outdated.

To the point, Claudio Schuftan, People’s Health Movement –PHM, provided a lot of forward-looking reflections on inequality and poverty reduction, as a reliable voice amidst the efforts to address today’s challenges involving policies, strategies and practices, and push for inclusive and sustainable development grounded on equity.

From a different point of view, Tomas Mainil and Olaf Timmermans, HZ University of Applied Sciences, Vlissingen, the Netherlands, maintained in their contribution that …Globally, countries need to overcome demographic tensions in their populations. The challenge for the Dutch province of Zeeland is to develop social innovation in response to key societal challenges in tourism and health: Coastal regions are confronted with demographic changes, especially ageing of inhabitants as well as visitors (tourists) and their changing needs health-related issues. A cross-border cooperation, wherein a common approach is developed to explore problems and enhance opportunities, benefits the possibility to address this challenge…Relevantly, the article outlines a professorship aimed at establishing a crossover between the tourism and health economies, developing innovative services that fit the changed needs of both inhabitants and visitors on healthy living related services/products and have an economic and social value.

Meanwhile, Sara Gorman, Department of Health Policy & Management, Columbia University Mailman School of Public Health, pointed out that …although new technology is essential, social change and social progress depend upon people, not on technologies. Social progress relies on understanding complex systems and the people who inhabit them first and foremost.

A couple of articles by Corie Leifer, AIDS Foundation East-West (AFEW), dealt with prison inmates:

Based on evidence that prisons are often a catalyst for the outbreak of contagious disease epidemics, the first article explored …why prisoners are at greater risk for contracting certain infections, why this inequity should not be tolerated, and how this issue is innately connected to the public health of the general population. As a follow-up, the second article highlighted …a few projects that are working to address the underserved population of prisoners and ex-prisoners, particularly those who use drugs.

To the point, Lesley Doyal, Emeritus Professor, School for Policy Studies University of Bristol, UK, stressed that … The major focus in both national and international responses to HIV pandemic is now on ensuring that as many positive people as possible have sustainable access to the specific drugs. But, whatever their medical efficacy they can only ever provide a partial solution to what has become a ‘post- modern plague’ in so many of the poorest parts of the world. The coming decades are likely to be ones of increasing need and declining resources. Hence optimistic suggestions that drugs alone will soon bring an end to the pandemic will need to be treated with the greatest caution.

And this occurs at a time when, as argued by Meri Koivusalo, Senior Researcher on Health Policy at National Institute for Health and Welfare, Helsinki … The new generation trade agreements, such as the TPP (Trans-Pacific Partnership) and TTIP (Transatlantic Trade and Investment Partnership), have changed the ground and context of trade negotiations through extension of negotiations further to national policies and regulation. These new generation trade agreements have gained criticism… Relevantly, …from health policy priorities perspective, the more systemic danger of TTIP is that it could hinder necessary change of corporate profiteering and an already failing model for innovation and R&D towards pharmaceutical policy in the public interest…

On her part, Raffaella Ravinetto, Antwerp Institute of Tropical Medicine, pointed out that… In April 2015, The WHO Expert Committee, tasked with the review and update of the WHO Lists of Essential Medicines for adults (EML) and children (EMLc), recommended the addition of 36 new medicines to the EML, and of 16 to the EMLc. It is hoped that the indications of the WHO Expert Committee will be considered and followed by all the concerned stakeholders, including pharmaceutical companies and policy makers.

In this environment, the article by Iris Borowy, Aachen University, Germany, tackled challenges to global health from a multi-pronged, entwining perspective. She alerted that … Health threats from waste thrive on socio-economic inequalities in two complementary ways: while affluence in parts of the global population produces mass consumption and rapid discarding of products (i.e. waste), poverty in another part invites the concentration and uncontrolled dumping of waste which amplifies its dangers to health…On a global scale, this transfer of waste from rich to poor unfolds when high-income countries export part of their hazardous waste to Africa and Asia…

From a different viewpoint, the article by Juan Garay, Head of Cooperation Section, Delegation of the European Union to Mexico, reminded us that …Measuring health equity challenges many of the present global concepts and policies on Health. The tragic death toll from global Health inequity (injustice) requires a deep transformation of concepts and dynamics towards the universal right to Health…

On a complementary wavelength, Bashir Saiegh Saiegh, Founder and CEO of the Tulaitula Health Consulting Group, featured in-depth the World Network for Medical Diagnosis, as a clinical information system to support and facilitate the medical diagnosis and the medical treatment in resource-limited countries and worldwide.

As an useful addition, the article by Hongzhou Lu, Tangkai Qi, and Jiaying Shen, Division of Infectious Disease Shanghai Public Health Clinical Centre affiliated to Fudan University, reminded us that …Since the first H7N9 influenza case was diagnosed in 2013, the disease has involved more than ten provinces and municipalities of China. There are a number of cases diagnosed in the years 2014 and 2015, most of whom had a history of live poultry contact, although there are already strict limitations on the purchase of live poultry. This reflects the dilemma between the needs of disease prevention and pre-existing social economic factors… The authors discuss this issue starting from a recent case of human H7N9 influenza diagnosed in Shanghai and suggest measures to better manage the production and trading of live poultry.

From another perspective, Amina Aitsi-Selmi, Consultant in International Public Health, Global Disaster Risk Reduction/International Public Health, Public Health England, focused …on the Sendai Framework for Disaster Risk Reduction 2015-2030 and how it addresses health and vulnerability. As such, her article is equipped …to assist communities of research, policy in understanding the aim of the Sendai Framework and identifying synergies and foster collaboration, particularly through research and evidence-translation for policy makers.

Last but not least, Vipin Varma, Principal Advisor (Health Affairs) & Founder , THOT Consultants – Ideas Without Borders, highlighted in his article that …Since health education is the base of the modern healthcare pyramid, eradicating the silent public health epidemic of health illiteracy is the most cost-effective means to reduce the healthcare burden of developing nations, while moving the populations to greater self-reliance.

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*Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is an advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). Dionisio is Head of the research project PEAH – Policies for Equitable Access to Health. He may be reached at d.dionisio@tiscali.it https://twitter.com/DanieleDionisio

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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The Many Consequences of Violence Against Sex Workers

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Treating the Silent Epidemic: Health Literacy for All

Since health education is the base of the modern healthcare pyramid, eradicating the silent public health epidemic of health illiteracy is the most cost-effective means to reduce the healthcare burden of developing nations, while moving the populations to greater self-reliance

By Vipin Varma

Principal Advisor (Health Affairs) & Founder

THOT Consultants – Ideas Without Borders

Treating the Silent Epidemic: Health Literacy for All

Background

Health literacy, defined as the ability to seek, process and apply health related information and knowledge is an essential public health investment. My twenty seven years of clinical, management and entrepreneurial journey as a health advocacy communications consultant in India and abroad has convinced me that healthcare literacy across all stakeholders is an essential, scalable, universal, valuable product-service.

Since health education is the base of the modern healthcare pyramid, eradicating the silent public health epidemic of health illiteracy is the most cost-effective means to reduce the healthcare burden of India*, while moving the population to greater self-reliance. Health literacy asymmetry is one of the key fundamentals affecting equity of healthcare and sustainable development. Even as a policy level initiative, this gap needs to be erased first and foremost, while allocating adequate and enhanced budgets for health literacy, education and promotion. In order to truly empower our citizens for self-care, we must provide them complete health literacy in keeping with the universal declaration of human rights and the right to health, as it is one of the main determinants and entitlements of healthcare.

For a perspective, both the USA and China now see it as a public health issue to be managed based on epidemiologic principles & have developed a National Action Plan to Improve Health Literacy. Only 12% of the US population is supposed to be proficient in health literacy and the US projections are a potential saving of almost $236 Billion per annum or up to $ 3.6 Trillion over a decade, as a result of enhanced public health literacy. Given our overall literacy standards, India can therefore, also greatly benefit from a dedicated Health Literacy Program, at various levels of government.

Need of the Hour

‘Prioritize the base of the healthcare pyramid’

Health literacy is the fertile soil on which we must cultivate our citizen-centric public & private sector healthcare systems and institutions. Piecemeal, sporadic IEC (Information, Education, Communication / BCC (Behavior Change Communication) components of various vertical programs have not been able to achieve a society-wide competence in health literacy and shall therefore, require an integrated program approach to achieve short, mid and long-term outcomes of public self-reliance in wellness & healthcare. This has been validated by secondary research and interactions with senior key stakeholders across the healthcare development spectrum.

Way Forward

The Health and Family Welfare Ministries and Departments across national, state and local governments should lead and orchestrate a branded total health literacy program, integrating with the relevant departments like education, women-child development, social welfare, labor, consumer affairs, information-broadcasting, pharmaceuticals, rural and urban development, as necessary. Strategic partnerships with civil society and corporate social responsibility can also be leveraged later.

Monitoring and robust evaluation (M&E) should be built into the plans, to ensure tracking of the positive health outcomes and documentation of the high cost-effectiveness of this integrated approach, as promised by the global evidence base on health literacy. Convergence and social accountability is essential to sustainably scale-up this program. This can also integrate well with both Digital India & Skill India initiatives and at least 6,50,000 jobs** can be created nationwide in this domain, at a modest estimate of 100 health educators per district.

Suggested Policy

Given the silent epidemic prevalence of health illiteracy & the current strategic imperative of public self-reliance for healthcare, we should ideally provision about 5-10% of the healthcare budget at each level of government for dedicated health literacy activities, to achieve optimal impact.

Even for a modestly literate population, the modern healthcare pyramid with health education as its base, suggests a public health literacy program should be allocated at least 5% of the healthcare budget. The minimum spend should be enshrined in policy guidelines at all levels and grantees should also be strongly encouraged to spend this well. This relatively small but strategically significant shift in priorities, can have strong cascade effects on the entire health resource pyramid and can even invert it, if executed well.

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*The Health Literacy program concept highlighted in this article is valid for any developing nation globally and I have just written it with my country in context, but I am certain most developing and many developed countries too, still do not attach sufficient significant importance to Health Literacy across the public, social and private health sectors.

**This is a conservative estimate and can vary with the strategic intent and number of districts in the developing country under consideration.

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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COP21: Salute Inscindibile dal Futuro del Pianeta

A causa dei cambiamenti climatici la nostra salute è messa in pericolo ogni giorno. Un'aria satura di gas nocivi e fenomeni atmosferici sempre più imprevedibili e violenti danneggiano noi e l'ambiente in cui viviamo. Il recente Accordo COP21 siglato a Parigi lo scorso 12 Dicembre è un primo passo volto a ridurre l'emissione di gas effetto serra e quindi la presenza di quei fenomeni che ne sono diretta conseguenza. Ma, l’Accordo è davvero un impegno concreto da parte degli Stati? O la discrezionalità di questi ultimi ancora prevale?

by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

COP21: Salute Inscindibile dal Futuro del Pianeta

Il recente accordo sui cambiamenti climatici siglato a Parigi il 12 dicembre 2015 dimostra la vitale importanza su scala mondiale di un problema per il quale non è più possibile perdere tempo.

Le manifestazioni del mutamento climatico in atto sono molteplici. Alcune sono talmente discrete da non essere nel breve periodo percepibili, altre, purtroppo, si palesano brutalmente con devastazioni ambientali e alta letalità, impattando criticamente sulle economie dei Paesi colpiti e sulla salute umana, animale e vegetale.

La stessa Direttrice Generale dell’Organizzazione Mondiale della Sanità (OMS) Margaret Chan, in un discorso rilasciato lo scorso 8 Dicembre a Parigi nel contesto della Conferenza COP21, affermava che “l’accordo sui cambiamenti climatici non è un trattato atto soltanto a salvare il pianeta da danni profondi e irreversibili. Ma è anche un trattato sulla salute pubblica, con l’immenso potenziale di salvare vite umane in tutto il mondo.”

Fonti OMS informano che dal 2030 i costi previsti per la sanità dovuti ai danni provocati dai cambiamenti climatici potrebbero essere pari a 2-4 miliardi di dollari all’anno. Mentre, tra il 2030 e il 2050 si potrebbero registrare circa 250.000 morti per anno causate da malnutrizione, malaria, diarrea e stress fisico da ondate di calore.

Nessuna regione nel mondo è immune dagli effetti delle mutazioni climatiche, ormai in ascesa quasi esponenziale e responsabili di effetti diretti e indiretti sulla salute. Per effetti diretti generalmente si intendono le immediate conseguenze di siccità, inondazioni, ondate di calore o di freddo, e di tempeste di inaudita violenza. Per effetti indiretti si intendono, invece, le possibili conseguenze comunque connesse al cambiamento climatico: tra gli esempi, le migrazioni di popoli (con correlato rischio conflitti), ovvero la comparsa, o l’incremento, di malattie precedentemente assenti o di minimo riscontro in un habitat specifico.

Il fatto che i Paesi partecipanti alla Conferenza di Parigi abbiano deciso di impegnarsi, anche mediante adozione di fonti energetiche “green economy”, a ridurre l’emissione di gas effetto serra (Art.4) e a contenere l’aumento della temperatura non oltre +1,5°C rispetto ai livelli pre-industriali (Art.2) potrebbe sicuramente implicare effetti positivi per la salute individuale e collettiva. All’opposto di una economia ancorata a carburanti fossili e perciò responsabile di maggior incidenza di malattie e neoplasie polmonari secondarie all’eccesso indotto di CO2 nell’aria respirata.

Oltre ad effetti ancora più gravi individuabili nel riscaldamento ambientale foriero di incontrollabili fenomeni atmosferici conseguenti a livelli mai prima raggiunti di gas effetto serra.

Ridurre l’emissione dei gas serra, quindi, è estremamente importante, con ricadute positive attese sul miglioramento della salute delle popolazioni e sulla diversificazione nell’allocazione dei budget nazionali e familiari da spese sanitarie ad altri beni di consumo, con correlato risparmio per le casse statali. Nel merito, la Commissione Europea ha stimato che la diminuzione della mortalità ottenuta mediante la riduzione degli inquinanti atmosferici comporterebbe benefici stimabili in €17 miliardi per il 2030 e fino a €38 miliardi per il 2050.

Contestualmente alla riduzione delle emissioni, i sistemi sanitari dei Paesi, soprattutto i più sviluppati, sono tenuti ad un ruolo proattivo così da ottenere una riduzione dei costi e quindi fornire una maggior offerta di servizi economicamente accessibili e con targets non limitati alla gestione e cura delle patologie respiratorie indotte. Al riguardo, l’Ospedale Universitario Nazionale di Cheng Kung di Taiwan, nel 2011 ha promosso un progetto mirato alla riduzione delle emissioni di CO2 per un valore pari a circa 5,259 tons all’anno, così da aumentare il tasso di risparmio energetico complessivo del 150% c.a. e conseguire un risparmio di circa 571,962 dollari. Ma esempi analoghi sono altresì documentabili negli Stati Uniti, Regno Unito e Corea del Sud.

Ancora citando le parole di Margaret Chan “Un Pianeta rovinato non può sostenere le vite umane in uno stato di buona salute. Un pianeta in salute e persone in salute sono due facce della stessa medaglia”.

Nessun dubbio che l’Accordo COP21 rappresenti un passo di estrema importanza, ma molto resta da fare e molte preoccupazioni devono essere sciolte. Riusciranno i Paesi a mettere da parte gli egoismi economico-politici per il fine superiore di preservare la natura, di cui siamo tutti parte, e garantire alla generazione presente e a quelle future una vita migliore?

L’Articolo 21 dell’Accordo stabilisce chiaramente che affinchè il testo entri in vigore e sia legalmente vincolante, almeno 55 Parti alla Convenzione (le cui emissioni costituiscano almeno il 55% di quelle globali) devono averlo firmato e ratificato.

Saranno questi numeri raggiunti in breve tempo? L’esperienza del Protocollo di Kyoto (1997) ci dimostra come i Governi di molti Paesi siano purtroppo lenti ad interiorizzare le giuste richieste, invece troppo spesso vissute come ostacoli al perseguimento dei propri interessi.

Il Protocollo di Kyoto riuscì ad entrare in vigore soltanto il 16 Febbraio del 2005 e gli Stati Uniti non lo hanno mai ratificato!

Lo svolgersi degli aventi sarà diverso per il COP21? L’Accordo è da considerarsi come un ulteriore esempio di buoni propositi o si tradurrà, invece, in celeri azioni condivise nell’interesse delle sorti del pianeta e di tutti i suoi abitanti?

Molti dubbi davvero rimangono poiché, mentre i 29 Articoli costituenti l’Accordo si limitano a raccomandare agli Stati di tenere comportamenti virtuosi, nessuna sanzione purtroppo è stata prevista.

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

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Global Fund Executive Director addresses parliamentarians from 106 countries at European Parliament in Brussels

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings