Rural Health and Global Equity: Am I my brother's keeper?

David Satterthwaite

m Rural Health and Global Equity: Am I my brother's keeper? PLENUMSFOREDRAG VED THE STH WONCA WORLD CONGRESS ON RURAL HEALTH Dr. M. K. Rajakumar fra Malaysia er en nestor innen WONCA og spesielt opptatt av "rural health». Han er lege, politiker, organi. sasjonsmenneske og filosof. Det er umulig å liste opp alle de verv og ærestitler han har hatt både i sitt hjemland og internasjo. nalt. Det viktigste er at han er en sjeldent klok mann som det er en ære å ha møtt og en stadig glede å lytte til. I Melbourne holdt han et plenumsforedrag som Utposten har fått lov til å trykke i sin helhet. Det er vi takknemlige for. I ...close to 1,000 million rural dwellers had income and consumption levels below nationally defined poverty lines. Two-thirds were in Asia and more than one-fifth I, in sub-Saharan Africa. David Satterthwaite, lnt. Inst. for Environment and Development (US Dept. of State) There are two worlds of rural health. In one, the targets are a hetter quality oflife and longevity. In the other, it is subsis.tence and survival. This other world is not represented at meetings such as ours. Do we have an obligation to make our deliberations relevant also to the health needs of this poorer rural people who area majority of the world's population? Does the medical profession have a special burden of respon.sibility to be concerned about inequity and poverty? Do rural doctors in wealthier communities have a duty to show that they care for this other rural people? The time is oppor.tune for an initiative on rural health where rural doctors and health centres in wealthier countries put out their hands to UTPOSTEN NR .3 • 2002 work with rural doctors in poor countries to help impover.ished communities. This conference, following on our Dur.ban resolution, could change good intentions into good deeds. This meeting is for me also a renewal of many old friend.ships with people I respect and admire. I have travelled to Melbourne because rural physicians are the best audience that I have access to, with whom I can share my concerns about the world we live in. I am grateful for the opportunity to speak to you, and for the helpfulness of everyone I have related with in planning my visit. Ishall begin by speaking of the very diverse worlds of rural health, of the extreme poverty and bad health of our fellow human beings who live in the rural areas of poor countries. Then I discuss the indifference of rich countries, and the recent enthusiasm to fight poverty. I argue that physicians have a special responsibility, and that rural doctors are uniquely fitted to respond and be in vol ved. Finally, I go back to the Durban Declaration where we pledged ourselves toea Global Initiative to Achieve Health for All Rural People. Most of the people of the world live in the rural areas of poor countries. Less than a quarter of people in developed coun.tries are in rural areas, whereas over three fourths of the poorer countries are rural people. The failure stems in large part from a misconception that the main poverty problem has moved from the countryside to the burgeoning megacities of the developing world. 75% of the world's poor live in rural areas . ..making their living in /arming or farm labour. Fawzi H. Al-Sultan, President International Fund for Agricultural Development, a Rome-based UN specialized agency charged with combating rural hunger and poverty in the developing world. RURAL m The end of the "cold war" also marked the end of competi. tion to win the heart and minds of the people of the devel. oping countries. The world entered a period of malignant neglect, increased poverty coinciding with great prosperity in developed countries. There was talk of"compassion fa. tigue", even before compassion was exercised. The very thought of helping poor people was tiring. The rural people of poor countries suffered most. These poor rural people do not travel -except as refugees Aeeing war, and then nobody wants them. When they Aee to cities, they form an unwelcome underclass who are in the city, but not of it. When they seek to Aee to other lands, they are received like criminals. The modem state, emerging barely two centuries ago, set about closing its frontiers. 'I I I We now look fearfully at the hungry outsider at our shores, II and politicians know that they will never foil, when they i I I manipulate fear and hate for their private purposes. For the first time in human history, people can no longer move freely across the face of the earth. An iron curtain has de. scended between rich and poor countries. Two nations between whom there is no intercourse and no sympathy; who are ignorant of each other's habits, thoughts and feelings, as ifthey were dwellers in different zones or inhabitants or different planets; who are formed by different breeding, are fed by differentfood, are ordered by different manners, and are not governed by the same laws. .. THERICHAND THEPOOR. from Benjamin Disraeli's novel Sybi/, published in 1845 Nor can the rural poor seil their produce to rich countries. Unexpectedly, it is a leader of French farmers who speaks up for them. Within countries too, the gap between rich and poor has widened, and in each country, the rich constitute a separate nation. For most of us present at this meeting, the HEALTH AND GLOBAL EQUITY issues in health concern quality of life and longevity. For the absent majority in the rural areas of poor countries, the issue is subsistence and survival. Benjamin Disraeli saw two nations within industrialising Britain in the 19th century, and we have entered the 21st century with the ugly division of rich and poor entrenched across the earth. Support a delegate and potentially help a nation [ . ..J assist in bringing major innovations in rural health to other countries. Officia! Newsletter 5th WONCA World Conference on Rural Health Our conference addresses problems of rural health, but can we aven our eyes from the rural majority of the world that live in poor countries. Although the organisers of this meet. ing have made a special effort to get poorer physicians to attend, they are not represented here. Their voices are not heard, so we have to speak up on their behalf. The collective wisdom we have inherited in the scriptures of our separate gods, all teach us that we will be judged by how we treat fellow human beings. This is a cyn.ical age we live in, and people need additional arguments as well as the power of example to be kind and charitable to fellow human beings. Our biological inheritance has provided us the gift of altru.ism, a vital element in the survival of our species. The spiri.tual dimension with which we are endowed has enabled the emergence of civilisation, and recognises that caring for others, to make sacrifices for the stranger in need, are what makes us human. This is our feminine inheritance. I des pair of changing the masculine culture of testosterone.driven violence that is taking humanity, like so many Gaderene swine, to the slopes of our own destruction. If large numbers of women too were to abandon the virtue of ca ring that makes us human, then all is lost. This is a difficult message in an age of possessive individu.alism. Humanity has slowly moved to destroy the qualities that make us human. The extended family, in which every child had ac;cess to two grandparents in addition two their parents, has dissolved into the nuclear, working family, and now the single parent family. UTPOSTEN NRe.3 • 2002 Leder i EU RIPA John Wynn-}ones (t.v.), M.K. Rajaf(umarog leder i WONCA Working Party on Rural Health, Roger Strasser. We live in a harsh, unforgiving world, and people have withdrawn into the desperate, lonely, mistrustful pursuit of personal interests. The initiative has passed to politicians who can successfully feed on our fears, and appeal to the worst elements in our nature. The rest are silent. In rural life, there remains the chance to preserve some of the human qualities of fellowship and ca ring for each other, and to keep the family as a meaningful experience in our lives. This conference provides us with an opportunity to make caring part of our real life by helping the stranger in need. Do physicians have a special responsibility to act on poverty and inequity? There isea collective consensus of every one of our associations that we do have a special responsibility, but individually we are trapped in a world whose only currency 1s money. When I spoke on this vein at our first meeting in Shanghai, an Australian doctor in the audience later murmured in my hearing, that he just wanted to look after his own pa. tients. I am sure there are days most of us could empathise with that sentiment. We are in many ways a demoralised profession. Struggling to practise good medicine in an un.supportive environment, we sometimes find the heavy bur.den of ethics and ideals to be just too much to bear. Physicians are not people of special virtues, indeed some are tradesmen with medical degrees. We are selected mainly for our ability to pay for access toa medical school, and to pass examinations that tax the memory. What makes us special is our work that moulds and tem pers us, that requires us to care for others, and the expectations of our patients who could not accept our care unless they trusted us to care for people like them. There has been a change of political climate that favours the task of eliminating poverty. There are now allies for us than ever before. The United Nations made a Millennium Dec.laration in September 2000 pledging "to spare no effort to free our fellow men, women and children from the abject dehumanizing conditions of extreme poverty, to which more than a billion of them are currently subjected." Nothing much happened, then a year later on 11 September 2001, that we witnessed that awful act ofbarbarism. The cli. mate for aid changed. At a UN meeting in Monterrey, Mexico, the rich nations of the world offered greatly in. creased fund ing to fight poverty. Sad to say, it was not a reawakening of love and caring, orea renewal of Christian charity; fighting poverty, they ex.plained, was the "best way to fight terrorism". They would UTPOSTEN NR .3 • 2002 ID RUeRAL HEALTH AND GLOBAL EQUITY do the right thing, but for the wrong reasons. It was left to ecumenical groups to cry out that the heart of the matter was justice. The meeting was coordinated by the World Council of Churches (WCC) in cooperation with the Lutheran World Federation (L WF). The makings of a global alliance against poverty are now visible, and we are in a position to contribute. The WHO is also an ally. Over two decades, we have succeeded in per.suading them that family doctors are essential allies in bringing health to all the people of the world. Now they have decided to pay more attention to poverty, "attempting to approach health as a means of combating absolute poverty." Perhaps we can help them generate more enthusi.asm for this task. This isea historie opportun i ty for the professions of medicine to demonstrate to the world that we our tradition extends beyond our consulting rooms. There is an upswell of pas.sion and idealism all over the world, in horror at the direc.tion that politicians are driving the world. We naturally belong with those people who are struggling to build a hetter world. There are innumerable ways in which we could help, individually or collectively. The International Conference on Financing for Development in 2002: Ecumenical team gives priority to transformation of the international financial system '...the heart of the matter' is justice rather than monetary questions. C urrent models of development must be subjected to critique because 'a moral vision calls for full participation of all communities, especially those marginalized by poverty and disempowerment', the team said. British Medical Journal, in a reemarkable act of generosity, offers free access on line. Richard Smith now campaigns for the evidence base of medical practice to be freely available on the Web. You cannot imagine the difference it can make to the quality of care provided by a lone physician in a re.mote practice. We could all contribute a tithe for the rural poor in another country, but surely there will be some in this audience who have time and space in their lives to come forward to lead us all in a great endeavour -to make a small difference to the vast problems of man-made suffering and the inequity of man to man, but a vast difference in the lives we touch. I believe there are many of you who want to help, if only there was a way they could relate toea greater enterprise to channel their contribution. In giving a bit of ourselves to help a stranger in a faraway land, we bear testimony to our own humanity, we save ourselves. UTPOSTEN NR.3 • 2002

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