Wednesday, January 23, 2008

Equal rights in a divided world: A continuous fallacy

by Dr Chesmal Siriwardhana

Based on the Keynote address delivered by Dr Athula Sumathipala (MBBS, DFM, MD, MRCPsych, PhD), Kings College, University of London and also the Honorary Director Institute for Research and Development in Sri Lanka, at the seventh Annual Convention of Sri Lanka Foundation Institute

The WHO constitution defines health as ‘a state of complete physical, mental and social well being and not merely the absence of disease or infirmity’. This, by now, has become the classical definition of health, conceived in the aftermath of the Second World War when peace and health were taken as inseparable.

Although, according to its critics, widening the definition of health to psychological and social dimensions was a major advance, and also conceptually important, it had no direct operational value. According to many of the critics; ‘This definition is a fine and inspiring concept and in its pursuit guarantees health professionals unlimited opportunities for work in the future, but is not of much practical use’.

In today’s troubled world, this definition has run into most serious problems at the conceptual level, which in turn has impaired its guiding role when the conflict between health needs and resources has become of paramount importance both nationally and internationally.

The universal declaration of human rights Section 25 Article, states that everyone has the right to a standard of living adequate enough for health and well-being of himself and his family including food, clothing and other basic components. It also discusses the right to highest attainable standard of physical and mental health including reproduction and sexual health. However, the biggest dilemma is the fact that 89% of annual global expenditure on health is spent on 16% of the world population, which bears only 7% of global disease burden.

The dilemma continues as although more than 90% of the world’s potential years of life lost belong to the developing world, only 10% of global health research funds are given to that part of the world where 90% of the disease burden is. Adding to the woes is another finding by a study analyzing five leading international medical journals, which shows that only 7% of research output originates from the 90% of disease burdened countries. These findings cast great doubts about the ‘evidence based medicine’ being currently practiced. Also when taken into consideration in the same context, the situation about mental health does not have much of a difference where the leading American and British Journals has only published 6% of research from the 90% of disease burdened countries, called in other words as developing world countries.

In the light of these developments, the all important issue that comes to light is whether evidence from 10% of the global population should be applied as a general measure to 90% of the population?

To complicate the inequality issues further, the drugs for neglected tropical diseases, such as many protozoan, fungal and helminthe infections, are not available for billions of poor people in our part of the world. Out of 1233 drugs developed between 1975 and 1997 only 13 were for tropical diseases. This scarcity will get worse by the introduction of the WTO administered international Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). This agreement will affect the prices of many essential drugs further.

The gap between the income of the richest and poorest 20% of people in the world increased from a nine fold difference at the beginning of the 20th century to a 30 fold difference by 1960 and rapidly increased to over 80 fold difference by the year 2000. As a result of all these social and economical phenomena, poverty and health has significant and strong relationship with low income, impoverishment, indebtedness, female gender and low education, particularly with mental illness both in developing as well as developed countries. As a result, out of the first 10 most important diseases that burdens the whole world; five are mental illnesses, the top one being major depression.

Professor Solomon Benatar, the Professor of Medicine at the University of Cape Town, South Africa, said that"despite spectacular progress in science and technology during the 20th century, as we enter the 21st century the world is more inequitable than it was 50 years ago. Disparities in wealth and health within and in between nations are widening inexorably and the rapidly expanding global economy has failed to reduce poverty and improve health for all. This is evident both in terms of access to health care for individuals and in relation to health of the whole population. Billions of people live in degrading poverty with little if any access to health care and the universal declaration of human rights remain an unrealized aspiration for majority of "world’s people".

Unfortunately this is the stark reality that stares at us although we never seem to notice it.

In an era characterized by widening disparities in health and human rights across the world, it is necessary to reflect on the extent to which human rights considerations are selectively applied for the benefit of most privileged nations. Are human rights only for intellectual debates and discussions behind closed doors or is it for the benefit of poor common man on the ground?

There had been 16,000 major disasters over the last hundred years and over 500,000 deaths. In 2006, 44% of disasters happened in this part of the world, in Asia. Disasters cause destruction, death, disease, displacement, disappearance, distress, and disarray. All these have short and long term physical as well as psychological implications.

A fact that should also be taken into consideration is that the global divide and disparities that already exist within societies become even more exaggerated in disasters, especially in the developing countries, as well as in underdeveloped regions in the developed countries.

Furthermore, disasters by their very nature result in vulnerability of individuals and of social groups, particularly the disadvantaged communities, whether they live in the developed world or developing world.

Few excerpts from various American and world media during ‘hurricane Katrina’ will give ample evidence to strengthen this observation; "Hurricane Katrina aftershock hurt the conscience of every American and deeply dented American self image as a dedicated, united nation able to offer quick response in different situations". To look at a another quote from London Times; (David Aaronovitch) "It isn’t the failure to act in New Orleans that is the story here, it’s the sheer, uninsured, uncared for, self-disenfranchised scale of the poverty that lies revealed. It looks like a scene from the Third World because that’s the truth. It’s a quiet disaster that’s been going on for years - a pudding-basin-full-of-poverty situation".

Two years after Katrina, lack of adequate medical care has become an important growing problem.

Next in line is the issue of right to health in the local context. As a habit, Sri Lankans only talk about the weaknesses in our country, culture and society. But in contrary to the popular belief and way of doing things, it is much more pragmatic to take a balanced view by both looking at weaknesses and strengths. In that order of things, we will take a look at the strengths of Sri Lanka in the field of health. Sri Lanka has a high literacy rate in the region. Also Sri Lanka’s high life expectancy, health indices, crude birth rate, and maternal mortality rates, are highly comparable with the west.

Sri Lanka has an extensive public health network, and has a health institution for each 1.4 sq. kilometers. In terms of world health report, Sri Lanka’s rank is 76 in comparison to India’s 112 and China’s 114. The reader should understand that the picture is not very rosy as it seems and that there are also many weaknesses in our health system. In spite of this, Sri Lanka’s health sector has an excellent infra-structure well complemented by an extensive education network.

During Tsunami, Sri Lanka did not have any outbreaks of communicable disease. Basic needs such as toilets and sanitary water facilities were set up without delays. In terms of rapid mobilization and accessibility, the country is equipped with extensive public health infra-structures. But, when it came to psychological health, Sri Lanka was not up to the mark in order cope with a large scale psychological health problem affecting a large swath of the population before the Tsunami.

Only 30 qualified psychiatrists existed in Sri Lanka at the time of Tsunami and most of them were based in Colombo. There were more Psychiatrists of Sri Lankan origin based in UK and Australia than in Sri Lanka at the time and the situation has not undergone any significant changes. There were no community psychiatrists, psychiatric nurses or social workers, meaning that no proper system existed.

However, of all that is wonderful, two years later, the World Health Organization claims that ‘mental health services were more or less based on institutional care and lacks public health, primary care and multi disciplinary perspective. Like most tsunami affected countries, Sri Lanka did not have a mental health policy. But Sri Lanka collectively achieved some strategically important steps such as developing the agenda for mental health as opposed to psychiatry bringing the public health perspective into play and the multi-disciplinary perspective to the fore and translating policy into practice. The repositioning the agenda in the right direction was a major achievement’.

All good things come after a price. A certain number of dedicated professional had to struggle collectively in order to achieve the above WHO lauded results.

We are a capable nation but the issue remains as to how we utilize our capabilities to achieve national development. If the experience of Tsunami to be taken as an example, there is ample evidence to illustrate how inappropriate external interference can impact the disaster management processes negatively, the threats brought by those interferences can act as fueling agents to various types of tensions which follows.

An example of inappropriate external interference is unnecessary promotion of compulsory counseling; counseling for everybody. Compulsory counseling is not recommended even in the contemporary west, but, in Sri Lanka, there were French groups advocating counseling whose members could not even communicate in English.

The unseen danger in imposing help to disaster survivors is that it can make them dependent, which is not considered as successful disaster management. Correct management approach should be aimed at empowering the victims to independently cope with individual losses and problems.

There were also other important issues raised at the time of Tsunami, particularly the lack of respect for dignity of individual people. Sri Lankan people affected by the Tsunami lost everything but the dignity. There were donations of expired medications, unnecessary products labeled in foreign language and products not registered in Sri Lanka, and the government had to spend millions of rupees just to dispose these unwanted products donated with good intentions.

Cultural intrusion through imposing culturally inappropriate interventions, ignoring traditional support systems in the country is serious mismanagement which opens up many avenues for debate. Another serious problem is pathologising the normal reaction to trauma. Inability to sleep, feeling frightened and other reactions are considered normal after a trauma. But, in Sri Lanka after the Tsunami, there prevailed a situation where normality was considered as abnormal and counseling was recommended as the universal method of therapy. Of course counseling has an important place among all recognized methods of treatment as it has strength if used properly. But it is not and should not be taken as the solution for every psychological problem.

As end solutions, important rights issues and the way forward should be discussed. In that sense, disaster preparedness should be a multi-sectoral approach where protection of the vulnerable survivors of disasters should be the ultimate basic step.

When all these issues are taken into consideration as a whole, clinical and research ethics become very important in order to deal with all the inequalities that exist. This should be highlighted as opportunistic exploitation of survivors for easy and cheap research has become common practice.

In this background, only ethical research should be promoted. Ethical research can be conducted even under disaster situations if only ethics are considered as a friend of research. Another important fact is the non-existing universal template for disaster management due to the reason that resources are not universally the same.

Lessons are to be learned from international experience in this regard. However, locally appropriate, culturally sensitive, simple but effective interventions are much needed in the local context.

Ultimately, the state has to be in charge of disaster management process; mobilization and co-ordination. In that context, the responsibility of academics, intellectuals, and researchers is to promote building existing strengths, particularly the statutory services, health, education and social services in order to promote local appropriate management. Lester B. Pearson, in his public address at St. Martin-in-the-Fields, London, June 13, 1972 on the occasion of the presentation to him of the Victor Gollancz Humanity Award said stated; "There can be no peace, no security, nothing but ultimate disaster, when a few rich countries with a small minority of the world’s people alone have access to the brave, and frightening, new world of technology, science, and of high material living standards, while the large majority live in deprivation and want, cut off from opportunities of full economic development; but with expectations and aspirations aroused far beyond the hope of realizing them".

Sri Lankans, as citizens of a proud nation with thousands of years of history and civilization, cannot simply leave a fallacy of history as the only escape route for future generations.

The task is to leave the future sons and daughters of this blessed land a just, fair and developed society along with the true spirit of equity and equality, without the pressure of external forces, considering the value and power of unity of different people living in this country.

In Sri Lanka, there will be no development without health, and there will be no development of health without the development of mental health.

As citizens of this country, it is our duty to work collectively in order to develop a healthy and wealthy nation, whose basic rights, health, education and livelihood will be guaranteed sans discrimination based on language they speak, the religion they observe, or the geographical location they live.

1 comment:

  1. Keep-on priding about your glorious Mahavamsa when all nations around you are surpassing you in every discipline.

    Your comparisons of India and China - both with billions in populations to a mere 20 million population - is a redundant comparision. What you need to compare are the rates of development - and if you do so, you will discover that both India and China, and in particular Tamil Nadu, have been developing at much faster rates than Sri Lanka.

    The bottom line is: Sri Lanka has been drfiting rapidly backwards whilst its neighbors have been developing much faster in spectrum of broader fields.

    Ask yourself: What is Sri Lanka's post-Independence legacy? Is life better for the average person today than it was in 1948? How much has the Rupee depreciated against the dollar in the last 60 years? How many Sri Lankan women have to go overseas as maids to make a living for their families? What has happened to the moral fabric of the society? Why are Sri Lankan kids protituting on beaches? Why do the upwardly mobile want to leave the country? Why are the visa lines at foreign embassies so long? Why does the nation has one of the highest mental illness rates and highest alcohol consumption rates? Why does the nation has the dubious honor of having Asia's longest running civil war? Assessing the answers to these questions will give you the real picture of the nation.

    Stop fooling yourself and don't mislead others. Get real and face the facts.