Time was when we could; we’ve come to the time we can; we do not want to come to a time when we’re out of options. (Jerome Koenig)
1. As HR activists working in health, we face a double challenge. We must work for fundamental economic, social and political changes underlying what we know as the social determinant of health and, at the same time, we must work on changes in the specific field of health where additional localized resistance (often by doctors) is to be reckoned with. We thus need to set-up networks –not forgetting the health workers, organized or not– to integrate our health and our human rights (HR) aims in what will inevitably become a political challenge. (As this Reader has repeatedly said, HR are a powerful idea which should be spread, starting with concerted efforts to launch more and more HR learning activities).
2. Actually, it is the HR-based framework that contains the powerful ideas; ideas that are at odds and counter neoliberal ideology, ideas that are a counter-power to the prevailing market forces –and, let’s face it, that is why the spreading of the HR idea is opposed. The powers-that-be fear HR as they entail an emancipatory praxis, a praxis that eventually is a counter-hegemonic force against globalization. The HR-based framework legitimizes power in the hands of claim holders, away from male, adult, middle and upper-class property owners. In so doing, the HR framework confers on rights holders a legitimate claim on the resources necessary to fulfill specific HR –and that is feared. HR are ultimately the legal expression of a collective will –and that is feared. Moreover, the HR-based framework prioritizes dignity and solidarity over accumulation, over competition, and over the market, as well as the inclusion of environmental rights –and that is feared. (I think I am not being harsh in my analysis here; I am just calling a spade, a spade).
3. A ‘decent minimum’ cannot be set on inalienable human rights. There is thus no such a thing as ‘basic rights’ or ‘low intensity human rights’ (the latter seeming to be what is, at most, acceptable to the powers-that-be as they relentlessly foster the process of globalization with its ‘low intensity democracies’ the world over). (Boaventura de Souza)*
*: Fact: Strong democracies encourage claim holders and shield them from drastic reprisals. (Ted Schrecker)
4. “Things have a price,” says Emmanuel Kant, “but man, in contrast, has dignity”. Things that have a price are interchangeable, can be sold, and/or can be used as tools. Human dignity, on the other hand, implies that human life is an end in itself, irreplaceable and never exchangeable; it cannot be made into an object or thing, and it cannot serve as an instrument or a commodity. Dignity is violated when something associated with life acquires commodity status and becomes –either directly or indirectly– an object of profit; we see this all the time in processes that subordinate life (and nature) to the interests of accumulation: health is regrettably no exception.
5. Capitalism has made health too much into an economic concern. The right to maintain and restore health (mostly the latter) thus became dependent on a business, and a new corresponding morality came into being with it –and for HR, as much as for social medicine, this has become a nemesis, an issue central to their respective raisons d’etre.
6. Some feel that the emphasis on individual rights (as sanctioned by UN human rights treaties) has created an obstacle for social medicine which is all about collective or community rights.**
**: Allow me an unorthodox metaphor here. Conventional wisdom would suggest that ‘In HR work, the I is a We or it is not at all; united, we are part of a choir; outside it, our music is atonal’. (Carlos Fuentes) But then, conventional wisdom can sometimes be wrong…
7. In the unequal societies of Capitalism, health policies have medicalized health problems; we all know that much. The human right to health (RTH) presupposes a right to the non-medicalization of life –since medicalization is inherent to the commodification of health. (That has made health a topic of what has become known as bio-politics). The RTH arose within the context of the social welfare state, true; so it is, in principle, since then that the RTH fell in the realm of bio-politics. But real action to defuse the many violations of this right and to start staking claims against pertinent duty bearers took a good 40 or more years to gain momentum.
8. Take, for instance, the 1993 World Bank’s World Report which was devoted to health; it has guided most of the neoliberal reforms we find today all over the world –and it was conspicuously silent-on and did not even mention the RTH. Instead, we got DALYs. DALYs legitimized the denial of access to services essential for survival to those unable to pay for them. We were thus left with the damage and with the social exclusion that has resulted from our planners using this neoliberal WB indicator to measure progress.
9. But back to social medicine as a praxis linked to the praxis of human rights: Its strong egalitarian emphasis is one of the most important reasons to consider HR as central to efforts to advance health equity. (T. Schrecker) In other words, HR-based action on health is essential for health equity. Yet, still today, this action is more often talked about than practiced.
10. Since changes in health will only come about by collective action (M. Marmot), at the community level –given appropriate and ample HR learning opportunities– the HR-based approach creates the prospect to innovate and to implement new ways of addressing the-processes-of-health-disease-and-care in a collective, mutually supportive manner. Therefore, as borrowed from the concept of food sovereignty, health sovereignty has come to mean communities themselves deciding what they need and want.
11. Bottom line, the introduction of HR not only preordains how public health work is to be done (i.e., processes), but also what its ultimate outcome should be in terms of dignity and solidarity. (Daniel Tarantola)
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org