Here is an excellent blog post from Duncan McNicholl, an aid worker with Engineers without Borders Canada, that explores how photos taken in developing countries can be used to portray people in very different ways depending on the photographer’s intent. The entire post is well worth reading, but in particular this paragraph seems to hit the nail on the head:

The truth is that the development sector, just like any other business, needs revenue to survive.  Too frequently, this quest for funding uses these kind of dehumanizing images to draw pity, charity, and eventually donations from a largely unsuspecting public.  I found it outrageous that such an incomplete and often inaccurate story was being so widely perpetuated by the organizations on the ground – the very ones with the ability and the responsibility to communicate the realities of rural Africa accurately.

On Inequality →

re: re: health reform →

Continuing the conversation:

What aspect of access to healthcare is a right? What kind of healthcare? Acute, life-threatening? Chronic, annoying? Chronic, life-threatening? Cosmetic, vanity? Cosmetic, reconstructive? Evidence-based vs. non-evidence based? Who decides what’s a right? Who/what companies influence the czar who decides?

First I would make the distinction between the right to health, the right to healthcare, and the right to health insurance (although they are inextricably linked). “Health” can be a very abstract concept, encompassing everything from the absence of disease to the more broad WHO definition. My conception of health as a human right entails ensuring that everyone has an adequate opportunity to be “healthy”, where health is defined as the minimization and prevention of “unnecessary” suffering caused by illness.

The right to have the opportunity to live a healthy life becomes meaningless without means towards achieving that end. As a classmate of mine once wrote:

It’s not that “health insurance” in and of itself is a human right, but it’s a means to ensure that we do uphold what I believe is a fundamental human right — the right to health.

Expanding access to healthcare and health insurance is an important part of ensuring that everyone has a chance to be healthy.Of course the immediate problem is limited resources — yet we live in an affluent society that can and should provide at least a basic package of health services.

I’m not advocating for everyone to have immediate access to the most extravagant health interventions such as kidney dialysis or hugely expensive end of life care. Nor do I believe that people have the right to equal health outcomes — some people will always be more healthy than others (though we should work to decrease health disparities).

Who decides what’s a right? Who/what companies influence the czar who decides?

This is a legitimate question, one that I don’t have a good answer for. Here’s what I will say: a system that determines the right to health based on ability to pay is not the answer. There has to be a more rational and ethical approach than that.

"When I give food to the poor, they call me a saint. When I ask why the poor have no food, they call me a communist."

Don Helder Camara

While I part ways with the church on many (if not most) topics, this (PDF warning) makes for a good read.

The hardest hit from the current economic recession →

Debating Paul Farmer

The UW SMPH Ethics Committee, a group of mostly M1 and M2 students, met for the first time last week. We talked a bit about a snippet from a paper entitled, “Anthropologist to activist: Paul Farmer’s changing perspectives on cultural difference and human rights,” Anthropology Southern Africa, 2008, 31(1&2).

“Farmer also argues that medicine, medical ethics, and biomedical
research have inequality as their foundation since
these erase poor people in their research and practice, for
instance spending millions on research in hair replacement,
while tuberculosis treatment, because it is an illness affecting
predominantly the poor, is hardly worth researching. Similarly,
he criticises medical ethics for its preoccupation with
questions such as brain death and organ transplantation, but
hardly noticing the suffering of millions from treatable diseases.

One gets the sense, in attending ethics rounds and
reading the now-copious ethics literature, that
these have-nots are an embarrassment to the
ethicists, for the problems of poverty and racism
and a lack of national health insurance figure only
rarely in a literature dominated by endless
discussions of brain death, organ transplantation,
xenotransplantation, and the care at the end of life
(Farmer 2003:205).

I agreed with Paul Farmer. Look at the hot-topic medical issues of our time — abortion, euthanasia, offering a public health insurance option, other healthcare reforms, etc — most deal with providing too much healthcare. When is it appropriate to stop sustaining somewhat who is permanently brain-dead? How can we control healthcare costs without decreasing the amount of care we receive (rationing)? These are questions that come to the fore in a nation in which the majority receive heaps of healthcare.

I don’t want to trivialize the importance of considering these issues of too much care: they deserve the full attention of bioethicists as well. However, the issues of inequalities in health outcomes, inequalities of healthcare provision, racism, sexism, and other forms of structural violence are typically pushed aside and not given the full attention they deserve. The number of people who will die of easy to treat, preventable diseases far outnumbers those who are grappling with the issues of too much care. It’s not even close.

This distinction between issues of too much care and too little care is by no means only issue of rich countries vs. poor countries. It’s true that many of the largest health disparities exist between rich and poor countries, but the gap also persists within rich inegalitarian countries such as our own. People here in the USA suffer from HIV, tuberculosis, and malnutrition — but perhaps we as a society are better at hiding the suffering of these people than poorer countries. This provides a basis for the charity starts at home point of view: there are plenty of people in need here in the USA, so why travel halfway across the world when valuable service can be provided at home? Besides, health interventions at home are more feasible and perhaps more likely to succeed — as this argument goes.

I think the charity starts at home perspective has two major flaws. First, poverty is relative. If we choose to use an absolute measure of poverty such as household income, people living in poverty in the USA earn about $11,000 per year + another $3000 per year for every additional person living in the household. Contrast this to the approximate 1.4 billion people living on less than $1.25 per day (about $450 per year). Granted there are differences in cost of living, but I think the point still stands that being poor in the United States is vastly different than being poor in an impoverished country.

Second, ‘home’ isn’t what it used to be. The world continues to globalize as technology improves and countries become more and more interconnected. A team of doctors can now reach even the most remote places on earth within 48 hours to deliver healthcare. The healthcare interventions do not need to be large, expensive, or complicated to achieve better outcomes in health — delivering oral rehydration therapy to a child suffering from life-threatening diarrhea is cheap and easy to administer. We are more capable of delivering healthcare on global scale now than we have been at any other point in human history.