Monthly Archives: September 2019

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.

To share power, someone has to give up power

Over the past few years I have been peripherally involved in various discussions with male colleagues about gender equity. The conversations have had a predictable ebb and flow.

Women’s empowerment. It’s great in theory, but who wants to give up power? Not these men. [source: reddit; https://bit.ly/2wd2AJC]

The consensus, at least among my colleagues, is that gender equity is a good idea. In the abstract, we fully endorse it. The practice is another matter. It is not that we don’t want to share power. We’re enlightened! We know there is a problem, but can it be someone else’s power that is shared?

The reasoning goes something like this. I should not have to share power. I’m talented, I got here on merit, and I deserve everything I achieved. It is an absolute social good when I have power. For me to give up power would not be good, because I wield it benignly and actively promote gender equity. It would be great if another man gave up power because that would support gender equity.

At a fundamental level, power is a zero-sum-game. There are only so many seats around the high tables of power, and if someone gets a seat at the table, someone loses a seat. Sure, we can squeeze an extra seat in here or there — but there are limits. If someone sits on a panel, someone else cannot sit on the panel. If 50% of the world’s population suddenly achieved fair access to power, power that had been largely controlled by the other 50%, competition would increase sharply.

In 2017, the World Health Organization Director-General Tedros Adhanom Ghebreyesus, tried to fudge the arithmetic [it has since changed]. He appointed a substantial number of women to senior positions in WHO. He did this by increasing the pool of senior positions, and he appointed women to the new positions. Unfortunately, many of the new positions were without substantive portfolios, and without real power. In effect he dragged some extra stools to the table. Chairs for men. Stools for newly appointed women.

The strategy had all the right visuals without the structural capacity to support gender equity; i.e., the fair distribution of power.

Gender equity is a good idea. It will be achieved through structural changes that share power and resources, not through appeals to people’s better nature nor through empty gestures. The test of whether one person’s power has increased is whether another person’s power has been diminished.