Domhnall MacAuley: Equity, human rights, and access to care

Domhnall MacAuleyOften the only visible links between a conference and the host city are the presence of intense young researchers with carefully rolled posters and middle aged delegates with matching bags, wandering aimlessly through the streets. But, by inspired by Zeno Bisoffi, conference chairman, the 6th European Congress on Tropical Medicine and International Health engaged directly with the people of Verona with a public viewing of a film entitled “Come un homo sulla terra,” giving voice to Ethiopian refugees living in Rome and an open debate the following evening with authors, journalists and medical leaders. An inspired decision, and entirely in keeping with the theme of the conference: “Equity, Human Rights and Access to Care.” This engagement between the conference and the city is an example, indeed a precedent, that could and should be copied. It links health and social issues, creates dialogue and partnership, and engages with local people. The message of this conference was more than simple rhetoric. It is easy to claim to reduce the burden of suffering from behind the closed doors of a privileged medical community. These doors were partly open, encouraging social activism for health benefit.

There was no polite pretence at separating health from politics and wider social issues. On the first morning, David Sanders, from South Africa, began by pointing out that equity is about social justice- the founding principle of primary health care. He spoke about inequitable globalisation where, although there is world economic growth, there is inequitable growth. Unequal growth both in wealth and in poverty. Why, he asked, does a Japanese cow earn more per annum through subsidies, than a citizen in Africa.

One hazard of focusing on vertical aspects of health care is that we lose sight of the greater social determinants. Health cannot be seen in isolation: hand washing, for example, may be the most effective mean of reducing infection, but not if the more urgent problem is in providing a water supply. It is not simply a matter of focusing on specific medical problems or diseases, health has a much wider social context: how should local populations respond to global health partnerships with philanthropic organisations, pharma, and NGOs, and what will they do when these donors leave? And, in the developed world, are we guilty of stripping some poorer countries of their most valuable resources- their human resources? Is there an unfair trade in doctors and nurses- do we allow poorer countries train doctors and nurses and then strip these already disadvantaged countries of the most valuable assets? And how can we live with a debt crisis where developing countries spend much more on servicing the debt than they can afford to spend on health care? Meetings, conferences and individual doctors cannot solve these problems but can be advocates for social change.

There is a challenge too for medical publishing. An open discussion, ably facilitated by editors of Tropical Medicine and International Health,  Thomas Junghanss (Germany) and Susanne Groener (UK)brought together an international panel in a round table discussion on the challenge of publishing work from the developing world. There are the familiar problems of gift and ghost authorship, unequal partnerships with western academics, access to research literature and the difficulties of writing in English, which although it has become the language of scientific communication, disadvantages large parts of the world. We did not have any immediate solutions, but already open access publication and the opportunity afforded by the web has opened up new channels for communication and greater research democracy.

But, there is another uncomfortable truth. Researchers do useful work and editors publish their findings- academics, institutions and journals benefit. But, who owns this knowledge?  It is much wider than simply intellectual property rights, it is about the cultural ownership of this knowledge gained from local people. Knowledge has a value. Is this knowledge gained from research in developing counties that different from the artefacts our predecessors brought back from ancient civilisations? Could this too be an abuse of the first nations- a form of intellectual imperialism?

Domhnall MacAuley is primary care editor, BMJ.

  • Manfred Maier

    Dear Domhnall!
    Thanks for this inspiring report and thoughts- very stimulating for the Wonca Europe conference 2012 in Vienna!Manfred

  • Thanks for this Domhnall, a great reminder about why we are meant to be doing what we do as both practitioners and researchers. It is easy to be caught up in chasing grants, conference presentations and citations and to forget the political context that shapes our work. Importantly, we have to realise that the organisations and institutions that we work within, and medical practice itself, play a part in generating health inequity. Each encounter between doctor and patient, between researcher and participant is an opportunity to help subvert that, as is a meeting and conference as you describe.

  • Medicine and healthcare research and publication are very highly controlled activities. There is an elite even within the Western countries who control what is understood as knowledge within professional groups and bureaucracies (public or private). Bottom up and often emergent and tacit knowledge is always considered inferior to expert explicit and conforming to the latest construction of scientific or other rigour.
    However, things may change with the development of the user driven health movement(1) and the democratic access to mobile phone technology(2). In fact, perhaps some countries such as India might be about to undergo disruptive bottom up change.(2) At least one can aspire to such a transformation.

    1. Biswas R, Maniam J, Lee EW, Gopal P, Umakanth S, Dahiya S, Sturmberg JP and Martin CM. User-driven health care: answering multidimensional information needs in individual patients utilizing post-EBM approaches: an operational model. J Eval Clin Pract 2008;14(5):750-60.
    2. Biswas R, Joshi A, Joshi R, Kaufman T, Peterson C, Sturmberg JP, Martin CM. Revitalising Primary Health Care and Family Medicine/Primary Care in India – disruptive innovation? Journal of Evaluation in Clinical Practice 2009;15(5) in press.