Head Hurts

In public health priority-setting, I guess it does have to get down to ethics eventually.  Very head-achy stuff.

The idea of trying to arrive at an ethical framework that gets things completely right all the time across all the globe is terrifyingly hard, which I guess is why post-modernism, as described by Roberts and Reich, holds its appeal: there’s no overarching right answer for every place at every time.  You, weighing the circumstances, do the best you can to try to achieve the most ethical outcome.  While it appeals to my “well, it depends” way of thinking, this is not a reassuring framework.

On ethical grounds, but also because his piece is so based on experience and work, I favor Farmer’s approach, arguing that promoting social and  economic rights is key to realizing human rights, including (sorry, Dr. Daniels) the right to health-care.  I’ve always looked at human rights as a priority area, but it’s hard to argue with Farmer that this frame hasn’t borne much fruit, beyond shining light on routine acts of abuse across countries that make us ill at the reading.  So, the idea of marrying human rights and public health – maybe “medicalizing” human rights – holds appeal because it can hopefully give both bigger teeth.  I have an example.

About 20 years ago, I worked at a major international foundation and was at a meeting with the then-reproductive health program officer for Nigeria.  She told about a successful grant initiative aimed at reducing the terrible toll of obstetrical fistula among women in a certain region.  Fistula renders women incontinent and often leads to their being ostracized.  The major social/medical cause in that area was child marriage.  Young married girls were expected to start families right away, and their bodies weren’t yet up to the job.  The grant program worked with
Islamic leaders, persuading them that the community cost of allowing early marriage of girls was too high.  They began urging families to wait until girls were older.

This could easily have been treated as a basic human rights issue, but that framework was judged a non-starter.  There was too strong a conflicting tradition, with the well-being of females too undervalued.  Treating it as a pragmatic public health matter cutting directly to the well-being of the community, however, DID (at the time) fly.

I think this approach holds programmatic promise.  I do some work with a foundation active in the highlands of Aceh, Indonesia, where the 30+ civil war concluded just after the 2004 tsunami.  This area saw only a miniscule fraction of the money that went to the tsunami-area, and people remain desperately poor, dependent on illegal activities and reportedly ripe for a return to arms.  Domestic violence isn’t one of our issues, but it’s rife, more so than considered common in the culture, though going at it from a rights perspective would likely be unworkable.  But maybe being present in communities helping with things like rural livelihoods and education, offering hope of some economic security (and making women essential partners) might.  We’ll have to see.


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