Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

Who speaks for whom in Global Health?

Speakers’ corner [Source: Wikimedia]

I had an interesting experience the other day when a friend, Mark Cheong, and I submitted a letter to one of the leading health journals.

Mark, a Malaysian academic, had done his PhD on palliative care with a particular focus on the delivery of palliative care in low- and middle-income countries (LMICs). For about six months, he and I had been discussing the ethical challenge of delivering palliative care in LMICs. It is a pillar of Universal Health Coverage. Still, there is a possibility that in weak health systems, governments could avoid their obligations to deliver curative care by choosing, instead, to deliver palliative care.

With the development of the COVID-19 pandemic, our conversation had taken a slightly different path. The modelling suggested that many LMICs would have their hospitals and clinics overwhelmed with COVID patients. The basic management tools of oxygen and ventilators, which were being rationed in High-Income Countries, would be a rare resource in poorer ones, leaving many people to die without any care at all. Our thinking returned to the palliative care question. The ethical dilemma, however, had shifted. The issue now was, how do LMICs deliver palliative care at a massive scale?

This was the subject of the letter, “Manage suffering when you cannot manage treatment”. The letter didn’t say anything earth-shattering, but it was necessary, and it had been crafted into a pithy 600 words. We had not seen anyone else raise the issue in the COVID-19 literature, which was (and still is) overwhelmingly focused on the provision of clinical care. We submitted the letter and crossed out fingers.

In terms of an academic career, a letter in a high profile journal does not amount to much. But it is a nice affirmation of one’s relevance in a global conversation. As a mentor, I have certainly encouraged colleagues to use letters as a vehicle for sharing and developing ideas. It also strikes me as important that it is academics and health professionals in LMICs who are the ones highlighting the issues that are important in LMICs. Now, you might take issue with whether I have a legitimate place in that conversation or not, but there is no doubt that Mark does.

I was surprised when, 9 days after the letter was submitted, an editorial appeared in the journal developing similar ideas. It was written by the Editor-in-Chief, a well-known advocate for many worthy causes, who lives in a high-income country. He regularly uses the pages of the journal to discuss challenging global health issues about health equity and human rights. He had more words available to develop the ideas and, in truth, he writes much better than we do. Six days after the editorial was published (15 days after submission), we received the rejection letter.

Thank you for submitting your Letter. Having discussed your Letter with the Editor-in-Chief, and weighing it up against other submissions we have under consideration, I am sorry to say that we are unable to accept it for publication. Please be assured that your Letter has been carefully read and discussed by the Editors.

I did not feel assured at all. It would have been impossible for the journal to publish the letter once the editorial was published. It was redundant. Instead, it made me wonder about whose voice gets heard? Whose voice has enough legitimacy even to have the possibility of being heard? And the reality is that power matters.

Nothing nefarious happened. Ideas are cheap, and the Editor-in-Chief had a similar idea to our’s — and he has a privileged platform from which to deliver it. The message is important, and ultimately it was delivered. Does it matter who delivered it? I think it does. Having the right to say something does not mean it is right that you say it. Comedians are very aware of this. A powerful joke from one person’s mouth falls flat when delivered from another’s. Who tells “a Jewish joke” and who uses the “N” word can shift comedy from hilarious to tone-deaf to the offensive.

To have a platform from which to advocate for justice is a great thing. It is often more important to use that platform to enable, empower and legitimise other voices (and add your voice to theirs) than to be the voice.

Covid Economics

“Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread.” [Anderson et al.]

A soup kitchen during the Great Depression. Apparently it was only men who were hungry

It is easy to see that the economies of the world are being affected by the COVID-19 pandemic. Share-markets have tumbled. Airlines are flying empty. Except for bizarre panic buying of toilet paper, malls and shops are more deserted. And if you have an employer with a large cash reserve and a bit of heart, you will be OK. There are many companies, however, that are at the margins and they are already failing because of the impact of COVID-19. Households are hunkering down: not spending, not going out.

These are the consequences of containment.

Now think about the daily wagers and piece workers, the sex workers, couriers, garbage pickers, rickshaw drivers and maids. Who will pay their bills, put food on their tables and ensure the same for their children?

Workplaces are instituting attendance rules based on health guidelines. Fevers, coughs, headaches and myalgia? Stay home! Recently been with someone who tested positive. Stay home! Etcetera. That’s fine for me. I will apply for sick leave. In all countries, but disproportionately in Low- and Middle-Income Countries, large numbers of people in the workforce are in the informal sector. They are vulnerable. Even in the formal sector, many workers have no financial protection.

Think again about the daily wagers and piece workers, the sex workers and couriers. Their capacity to pay the bills and keep food on the table is proportional to their capacity to keep working. No matter what.

Death is not everything.

The obligation of countries who have committed to sustainable development goals is to “leave no one behind”. Governments should implement their public health measures to limit the effects of the COVID-19 pandemic, but the poor should not have to carry an unfair burden.

A street sweeper in Mokhali

The “underserved” are “undeserved”

I hate the phrase, “the underserved”. I would love to remove it from the lexicon of public health. But it appears to be here to stay, particularly in North America where there is even a journal devoted to them.

A girl with kwashiorkor during the Nigerian-Biafran War (Public Domain; Wikipedia).

On a number of occasions in public lectures I have played with the phrase using a comparison of the “undeserved” and the “underserved”. It usually takes listeners a few minutes to work out that I am not repeating myself over and over again. And if you thought I had typed the same thing twice, look again. “underserved”≠”undeserved”.

My spell-checker knows the difference. It tells me that “underserved” is a spelling error and I almost certainly mean “undeserved”, and herein lies the problem. It is not simply that these two words look and sound similar, it is that there is an unpleasant semantic connection between them. It seems to depend where you lie on the political spectrum which term you use to refer to the same group of people.

On the left, the powerless and the left-behind, those with poor access to services and care would be characterised as the underserved. On the right of politics (or a nationalist left where refugees and migrants are vilified) anyone in need, the powerless and the left-behind, those with poor access to services and care are more typically characterised as the undeserved. The same people, the same need, and the same suffering, but a more or less generous view of our social obligations.

Potential living-donors should have no choice

I recently learned three interesting and disturbing facts. First, I have a distant, 5 year old relative with liver failure. He will be dead within weeks unless a suitable liver donor is found. Second the lobe from a living adult’s liver can be used to save his life. Third, I am a match. I learned these things when I was received notification from the National Transplant Registry. They also informed me when the surgery will take place, when I am to arrive at the hospital, and that I have no choice. I will be donating a lobe of my liver. It was the first time I knew about any of this.

Unless you have no choice about being the means to someone else’s ends.

Apparently my life is my own, except when it isn’t. The life of my young relative is so precious, so important, that my wishes are of no consequence. I am the vessel for his survival. I am the means to his ends but not to my own.

You can imagine how outraged I feel. I don’t feel outrage about his need, but about my lack of agency — my lack of control over my own body.

This is, of course, nonsense. Hyperbole if you like. There is no transplant registry in the world that can mandate surgery; there is no country in the world where one person’s body is just the means for supporting the life of another.

Unless you are a woman.

All over the world, as a matter of law, women are obliged to make their bodies available as the means to another’s end. In many countries, to withdraw the service is a criminal offence, resulting, in substantial jail terms. We call this protecting the right to life. They call it an unwanted pregnancy.

Article 4 of the Universal Declaration of Human Rights states inter alia that “No one shall be held in slavery or servitude.” I am the means to my own ends and I can choose when to be the means to another’s ends. Being held in servitude is being forced, for however limited a duration, to be the means to another’s ends. It is a rights violation whether it is a requirement to give up a part of your liver to save another, or to provide rental space in your abdomen.