The weekly International Health Policies (IHP) newsletter is an initiative of the Health Policy unit at the Institute of Tropical Medicine in Antwerp, Belgium.

Dear readers,

This week’s newsletter comes against the sobering background of unresolved regional tensions in the middle east  which have currently escalated in widespread violence in the Gaza-Israel conflict. Apart from the concern of innocent people getting hurt on all sides, one can only hope, that at the very  least, access to health care is restored and the safety of civilians, health workers and journalists is ensured on all sides. The title of the newsletter IHP #742 was A World Unhinged and it unfortunately it is more appropriate than ever two weeks on. Man-made tragedies aside, this past week brought strong earthquakes in Afghanistan which have left over 2,000 dead (estimates). The natural disaster has captured less new space but is one of the deadliest earthquakes in the world this year.

Against the bleak backdrop of natural and man-made disasters, the Global Forum for Adolescents ’23 offered moments of hope. The Forum brought together experts on adolescent health and activists through their virtual platform. EV Alumni Shakira Choonara reports, “… the Forum builds on 100+ convenings and reaches one million youth through the ‘What Young People Want” campaign.” Also read Reem Elsayed’s blog on Reimagining youth engagement in public health in Africa on IHP. Meanwhile, one would’ve thought the continuous bipartisan reauthorization of PEPFAR would go on, but perhaps, that is too much to ask for bipartisanship, even for the greatest act of humanity in the history of infectious diseases, according to Dr. John Nkengasong. In a little big win this week, Claudia Goldin became the first woman to win the Nobel Memorial Prize in Economic Sciences solo – here is hoping for swift changes to improved gender parity in the social and economic space. Also, some more progress on the path to combating malaria, the WHO recommends a new anti-malaria vaccine for children.

And finally, your regular editor is away on a long-overdue break; we are joined by EV 2022 alumni, Ismael Kawooya, as IHP resident for the next few weeks.

Enjoy your reading

IHP editorial team

A few years ago, on my first day as a student in Europe, I took a walk at 0100hrs. Not because I had to be someplace. But because I could.

Of course. No place, and no one is immune from sexual abuse. As the Harvey Weinstein saga of sexual harassment unfolded over a month ago in October, the #MeToo [hashtag] started by activist Tarana Burke, and popularized by actress Alyssa Milano, served as a catalyst to bring to the forefront the voices of the “every person.” Interestingly it also led to reflections by those who couldn’t bring themselves to #MeToo their stories, as articulated very well by writer Veronica Ruckh, “It doesn’t have to be “bad enough” for it to count. And regardless of whether I’m comfortable or you’re comfortable saying #MeToo, we all need to admit that we have a problem.” Parallel movements brought up stories of #ididittoo and #silenceisdeafening – perhaps an enabler to reflect on deliberate or unintentional behaviours which have led to those in a vulnerable position being exploited.

Nowhere in the world are the vulnerable spared from harassment. For those who reside in parts of the world where sexual violence against women (and men) is worse than others, there is solidarity in this global movement against the abuse of power, and in the strength of the voices brought together by a simple hashtag. Thousands marched in a #MeToo march in support of survivors of sexual harassment in Los Angeles last Sunday. I can only hope that such movements, lead to a greater recognition of the risk of day-to-day sexual harassment that women and others are at risk of. The ever looming risk of sexual harassment may play out in other ways as well, like young girls being kept home from school, being denied the opportunity to play or work outside of the home space (though harassment by those known to the victims is fairly common as well).

Meanwhile, on a somewhat different note, yet related, because of its impact on mobility – hazardous levels of air pollution in Delhi, and across much of the northern parts of the Indian sub-continent have driven many of us indoors. I write this introduction from my apartment in Delhi, where I have been indoors with an air-purifier running 24×7. There is little incentive to step into the smog filled city. Speaking of freedom of mobility, hundreds braved the smog to walk Pride and commemorate 10 years of Delhi Pride – a much needed splash of color to break up the monotonous gray Delhi skies. But three hours of being outdoors left me exhausted – the air is debilitating.  Reading about the impact of extreme levels of air pollution on our health doesn’t help. This is not good. I miss going on my long evening walks. I miss being able to have the option of going out for a run. I miss the right to be able to breathe (even the National Green Tribunal believes the right to life has been ‘infringed with impunity’). Of course, as I whine about the air (and reminisce about the sunny, blue Belgian sky – an oxymoron surely!), I acknowledge the privilege of being able to afford an air purifier, mask and have the luxury of being indoors. Quite unlike the millions who sleep and work in the open, and have no recourse to clean air, or the millions of women who cook indoors on wood fire. Furthermore, the increase in pollution is certainly not helping the country’s growing burden of Non-communicable Diseases. The Lancet’s First comprehensive analysis of health in India estimates that household and ambient outdoor pollution are responsible for almost 10% of the disease burden in India in 2016. Currently, those of us in Delhi are living the numbers. The media tells us that breathing the air in Delhi is akin to smoking over 44 cigarettes a day. Hospitals have seen an exponential rise in respiratory disorders.

For now. I’m going to put on a mask and go for a gentle stroll. Dystopia does not feel like the future, nor, fiction. We’re living it. Loss of mobility and freedom is unpardonable whether due to harassment on the street, a polluted environment, lack of urban infrastructure. It’s time for solutions.

The majority of health workers in lower tiered positions, such as within primary health care provision, are women. Despite women making up a significant proportion of health care workers, they are grossly underrepresented in leadership positions across the world. This is not unique to the health sector. In the corporate world, for example, the report on The State of Women in Healthcare: 2015 indicates that only 4% of CEOs are women.

Greater participation of women at the leadership level has been shown to result in policies which enhance the position and rights of women. For instance, Rwanda which has the highest level of women parliamentarians of any country, has also over the years invested in policies on ending violence and discrimination, investing more in health services, and investing more in improving women’s participation in the workforce. In the case of Rwanda, the participation of women at the political level went way beyond the 30% quota instilled in 2003. Contrast this to the Kurdistan Region of Iraq, where despite a similar quota women constitute only 3% of leadership positions. This raises the question of the need for, and role of, quotas for women at the leadership level.

Encouraging women’s representation through quotas?

Deliberate efforts like putting quotas, reservations, and affirmative action to ensure participation of people from marginalized, vulnerable or less vocal sections of the populations could encourage more women’s participation at multiple levels of policymaking and the workforce. But do they really work? Are quotas a legitimate way to reach equilibrium and ensure at best some form of equal representation at the top? While quotas might ensure that more women have a seat, do they actually increase women’s meaningful and effective participation? If not, what is needed alongside quotas to ensure women’s meaningful and effective participation?

While a quota system may provide a way to encourage women’s representation at the leadership level, it is only a short-term solution. If women’s participation at the top is going to be meaningful and effective, longer-term strategies are needed to transform the unequal gender norms, roles, relations which perpetuate and reinforce gender inequities within the health system and inhibit women’s participation at the leadership level.

Increasing women’s value within the health system

Community health workers –the cornerstone of early primary health service programs, and for many people their only contact with the health system – are largely women. Women who take on this position often do so for little or no pay. Even as one acknowledges the role of the female community worker, we wonder if they would be better paid and organized if the majority of the workforce were men. Studies have found, however, that even within the same occupation (including those that are female dominated) not only are women promoted less frequently than men, but they also earn less. Gender inequities within the health system are a reflection of gender inequity within society. Gender pay inequity can therefore been seen as a reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important or worthwhile, and their role has health workers is no exception. As we usher in the Sustainable Development Goals, we should strive to progressively change the value placed on women’s work and role within the health system, and offer equal opportunities and compensation to reflect this.

Minimizing gender bias within the health system

The issue of women’s role within the health system is becoming increasingly important, especially as we start to see a feminization of the medical workforce. In many countries, for example, the number of medical graduates are increasingly female. It will be interesting to see if the feminization of the health workforce translates to the top – as more women enter the health workforce will this be reflected at the leadership level? This is unlikely if we do not first minimize gender bias within the health system (and society more generally), which devalues women’s work, leads to lower compensation, and means that less women are given the opportunity to advance within their career.

Minimizing gender bias within the health system “requires systematic approaches to building awareness and transforming values among service providers,” along with developing policies and strategies to remove barriers to women’s career advancement and ability to engage in leadership roles. Women make up a large majority of the health care profession – it is time that they are recognized for their contribution and adequately represented at the top.

Note:  This blog is based on an online discussion with 14 members of the new cohort of the Emerging Voices. Over the past few weeks we engaged in a discussion on gender in health systems (one of three parallel discussions) with these 14 EVs. One of the most visible themes to have emerged from the discussions, and also perhaps an instinctive reaction of health system practitioners was that of gender (here mostly in the context of women) within the context of human resources for health and human resources in general.  The blog presents reflections on the issue of leadership and HRH from our discussions.

It has been said before, and it appears to have been proven once again this week: social media can be used for the good, the bad and the ugly. In these times of increasing polarization and xenophobia, we’ve seen plenty of the latter (social media often seem to further increase polarization, rather than boost empathy for the downtrodden), but this week we saw some positive examples of the impact of sustained social media and mass campaigns. ‘Clicktivism’ is often ridiculed, but it remains a vital tool in the 21^st century, especially if combined with mass media attention and grassroots action.

Social media, often used for crowdfunding can also be used to highlight social causes and advocate for issues.  It offers an opportunity for civil society, including consumers to engage with others and reach out to a wider audience, as well as, bring people together for a common cause. Sometimes it takes a while before social media commotion and campaigns have an impact, but eventually, in some cases, the resilience of committed citizens pays off (like on the issues of TTIP and tax optimization by Apple & co, where substantial “progress” was made this week!). In the US, the EpiPen story seems to be heading in the same direction. The (ongoing) EpiPen story could provide lessons relevant to the numerous ‘access to medicines’ battles that lie ahead in the coming years, in developing and in developed countries.

Over the last two months, social media campaigning and the resulting uproar held one big pharmaceutical company accountable to its consumers, for the price of the (now notorious) “EpiPen” – a drug used to tackle severe allergic reactions by Mylan Pharmaceuticals that has gone up by a handsome  450% since 2004. This week, Mylan Pharmaceuticals announced it will launch, and make available, a generic version of the drug within the next two weeks at approximately $300 (as compared to the branded product priced at $608). Still a hefty sum, but hey, it’s a start.

The cost of an EpiPen at $608 for a 2-pack today is prohibitive for many, including those with health insurance, but in an interesting turn of events, a petition against price gouging by actress Mellini Kantayya on Petition2Congress, early July,   gained momentum on social media and brought discussions on the prohibitive profit margins of pharmaceutical companies  into the mainstream (including in the media and, hitting the jackpot from a campaigner’s point of view, in the US presidential campaign, with the likes of Bernie Sanders and Hilary Clinton also taking a stance). In order to quell the negative attention or perhaps pacify outraged consumers, Mylan already announced coupon and patient assistant initiatives to lower out of pocket payment on EpiPen, and announced a generic version of the drug. Let’s hope more is in store.

Of course, campaigning for more ethical pricing by pharmaceutical companies isn’t new. Take the (now somewhat old) news of the case of Gleevec – a cancer drug by Novartis – for which a seven-year litigation (Novartis v. Union of India & Others ) was fought on whether the patent for the drug was valid or not. Over the last few years, activism by medical professionals in the US, highlight 5- to 10-fold increases in cancer medicines, and their impact on the outpatient expenditure. Doctors, researchers and others have called for better regulation of drug prices within the context of improved access to medicines and better health policies. Increasingly, access to medicines is becoming an issue in both developing and developed countries.

This particular petition was unique, though, in that it harnessed the tools offered by the internet and social media, and was largely led  by family members of those with life-threatening allergies, particularly parents, and not patient advocacy groups or larger organizations working in the area of access to medicine. The case is also interesting as the issues of affordability and ethics of drug pricing feature here within the context of a society (and consumers) from a high-income country, many with health insurance. Development of generic drugs is one of the ways, though not the only way, to improve access to medicines – but it certainly remains a key tool for those in low resource settings. One may also wonder why regulatory agencies and government would not engage in in the evaluation of pricing policies, based on the assessment of the real development costs.

The discussions on the pricing of EpiPen by Mylan in the media, and more so on social media, might have started in the US, but the platforms on which they were conducted indicate the role of these  tools to fight injustices all around the world, even for those living in low resource settings. With the Internet now available to almost all, including some of the poorest who can’t afford basic medicines and face daily injustices, the use of social media offers the possibility to have their voices heard. Still, while this blog echoes articles similar in their congratulatory examination of the role played by social media in this (early) victory, it would be unfair to ignore the other factors which might have led to Mylan introducing a generic version of the medicine, as well as offering other mechanisms to reduce the out of pocket costs on the EpiPen. For one, the cause was relatively easy to “sell” – the little children, the fact that it wasn’t just the poor who have to cough up the high cost of the EpiPen, and thus the ease of identifying with users might all have garnered greater empathy. We wonder if policymakers, civil society and the media would have been equally “emphatic” had it been an NGO or an activist organization advocating for ethical drug pricing and consumer rights, say, for the homeless.  Clearly, also, in many settings across the globe, social media are far less “free”, and the strategic use of social media for a cause, certainly in combination with grassroots action, is thus less obvious.

For the moment though, we’re happy for all the reasons which might have led to the rise of the issues of ethical pricing for medicines, monopolies by the medical sector, generic medicines and access to medicines into the mainstream discussion. At a time when ‘resilient health systems’ are favoured by key global health stakeholders, it’s perhaps good to keep in mind that another kind of resilience might be even more important – that of the voice of the people, as Owen Jones put it earlier this week in an eloquent Guardian op-ed on TTIP & Apple, people who are determined in their protest against injustice. Perhaps, electronic and internet platforms provide a more affordable and accessible mechanism for effective social mobilization, with all the caveats mentioned above.

Acknowledgment: The authors thank  Raffaella Ravinetto for her important inputs

Sustainable Development Goals in Action: Our World, Our Dignity, Our Future – the theme for this year’s EDD, put the focus of the conference squarely on the 17 (!) SDGs. People, Planet, Prosperity, Peace and Partnership – the 5 Ps of the preamble of the United Nation’s 2030 agenda, formed the overall ‘framework’ for EDD16’s rather heavy agenda. And indeed – for those used to attending conferences which focus quasi-exclusively on health – attending an event which brought together the multiple facets of development and people’s well-being was a refreshing experience. It also gave us a chance to attend and contribute to discussions on sectors outside of health, but which impact health directly and indirectly.

Still, we made sure to attend a few of the sessions on health; naturally, most focused on health within the context of the SDGs – with policies, governance and of course, ‘partnerships’ as the dominant themes. Gender, sexuality, sexual and reproductive health featured in an interesting session on Challenging the Influence of Religion and Universal Access to Sexual Reproductive Health and Rights – which focused on the challenges in bringing about deeper social change set against the sociocultural context. This was a session with experiences shared by the panelists and the audience alike! The “all-female, all Asian” panel might have pleased the likes of Owen Barder and Ilona Kickbusch, but it also somewhat represented the huge challenges facing access to sexual and reproductive health around the world.  Change will be impossible without engaging men in the dialogue –with the panel thus unintentionally symbolic of reality. One of our favorites was the session Time to Think Urban: The Challenge of Building Smart, Sustainable Cities – which had a debate-style discussion format. The session’s introductory remarks focused on urbanization – current trends, the future of urbanization as well as ongoing work (towards the preferred future); then the debate moved on to the – in our opinion critical – discussions on integration and making urban spaces more livable. It’s all nice and lovely to build ‘smart’ and/or ‘resilient’ cities, but one would also like to live in a ‘livable’ city, first and foremost. Not everybody wants to spend (like Elon Musk) his final days on Mars.

What can we learn from such a high-profile event? Well, as is often the case with major frameworks, after years of debates on the definition of the goals and the rationale to pick one rather than the other, hours spent on appropriate wording, the development world is now gradually shifting its attention to more practical considerations – more precisely how to implement these SDGs – 17 goals, 167 targets (and don’t even get us started on the indicators!). To be fair, even if you don’t suffer from vertigo, like one of us does, it’s hard not to feel a bit dizzy in the face of such a challenge! If one was to compare with one of the other mega-events that happened over the last month, more specifically the 69^th World Health Assembly in Geneva, the task of addressing 17 goals in 14 years felt like less over there – perhaps because the focus was largely on one SDG? And yet, with the WHA69 discussions still fresh, one can’t help but draw some parallels between the two events, especially the focus on partnerships, and the focus on the ‘key’ role of the private sector.

In the end, the conclusions of many of these sessions did not look unfamiliar: we need quality education, good governance, empowerment, quality health care, etc. One word was missing though: accountability. How come that such a powerful concept was left out? Well, that’s up to you to judge. Another key issue, that comes as a prerequisite for any progress towards the SDGs: the resources – or to be more precise, the issue of “ever-shrinking” financial commitment to health and development, in line with the dark trend towards an ‘ever more diverging’ European Union. True, NGOs like Oxfam tried to open this Pandora’s Box and brought up the issue of constrained financing (fair taxation for sustainable development for example), but financing for SDGs largely remained at the margins of the discussions. One could perhaps be a little more precise here: a new ‘dogma’ is gradually emerging on the (according to “the development powers that be”) necessary shift towards deeper engagement with the private sector and a strong focus on SDG 17: partnership, often equated to Public-Private-Partnerships. With ‘Leveraging’ and ‘blending’ as some of the preferred buzzwords in this brave new SDG world.

This answer seems quite unsatisfactory to us. There is a key issue to be addressed here, that will decide whether the SDGs will be transformative or not: is everyone going to bring their fair share to the table? And let’s not believe in charitable actions conducted under the mantra “Corporate Social Responsibility”. This is about raising sufficient funds via progressive taxes, for which a democratically elected government is held accountable. Can we imagine – as Eva Joly, European Deputy and 2012-green party’s candidate for the French presidential election rightly pointed out – that we can make any progress towards SDGs while in today’s world, Low-Income Countries receive only 1% of the revenues generated by oil extraction on their territory – a figure to be compared to 69% of the oil revenues collected by the Norwegian government.

At a time when diseases such as Ebola and Zika go beyond boundaries; when war and political unrest have created one of the biggest humanitarian crisis in recent times, we would perhaps do well to remember that all-encompassing goals and partnerships to achieve them are all very nice; but perhaps what the world really needs, is a definitive, concerted effort to actually commit to improving the well-being of people.

Blood is sourced from other people, largely through donations. Voluntary blood donation is preferred over paid donation to prevent exploitation, as well as safer blood (for more on why voluntary donations are preferred, see here).  Large disparities exist in blood donation rates between high income countries and low income countries. Almost 50% of blood donations are in high-income countries, at a rate of 36.8 per 1000 population, with it dropping to 11.7 for middle income and 3.9 in low-income countries. Disparities also exist in the way in which blood is used across countries. With very young children of less than 5-years receiving up to 65% of blood transfusions in LMICs whereas it’s those above the age of 65 who undergo blood transfusions in high income countries. In many countries such as India, almost half the collected blood is from those below the age of 25.

India, much like other LMICs, faces a chronic shortage of blood with a 25% gap (the WHO recommends at least a 1% reserve of a country’s population). For those of us living in cities in India – we’re better off. We might not have ready access to blood, especially for emergency services, and there is hope and the opportunity to arrange donations in exchange of blood used for scheduled and routine purposes (replacement blood – a concept wherein patients needing blood from a hospital would first have to provide donors from among family or friends – a separate donor for each unit of blood). It’s not unheard of getting urgent text or Facebook messages – usually from friends, of friends– all tapping into a network of people to look for potential blood donors. The country does not have a central blood agency; the Red Cross is well known for its blood donation drives, and creating visibility in this area of work. The private sector flourishes; even as stories on the poor standards and exploitation abound.  From time to time the media picks up stories which reflect inadequate resources and regulation. The chronic shortage of blood is the perfect condition for an illegal market to flourish, nicknamed “red market” in this article. Horror stories of abuse and exploitation of the poor and vulnerable by an underground industry.  The situation is perhaps even worse in rural and remote areas with places like Chhattisgarh facing a deficit of almost 81per cent.  Even when available, quality and safety present major concerns; data sourced from National AIDS Control Organization (NACO) via a right to information initiative, indicate health system constraints have led to poor resources for testing, often leading to infections. It is estimated that in the past year alone over 2,000 people have contracted HIV as a result of blood transfusions in the country. And while efforts are being made to ensure regulations are in place to ban paying donors, to ensure quality and testing of blood by blood banks – the capacity to implement, regulate and ensure compliance is limited. And if exploitation and neglect weren’t horrific enough, one hears of things which border on the absurd, such as this week’s news when local authorities in the north Indian state, Punjab seized 7,600 liters of fake blood plasma – made of refined oil, soya bean milk and egg yolk. This really makes me wonder if people have lost all conscience.

Studies attribute the limited availability of blood in LMICs in general to a number of factors, including low donation rates, perhaps because of low awareness and poor health infrastructure; poor storage capacity and high prevalence of transfusion-transmissible infections in the blood supply from LMICs which often leads to greater wastage. Limited awareness and stigma on blood donation also contribute to lower donation. However, efforts, especially in the context of improving maternal health, have been undertaken over the last decade to set up blood storage facilities at first referral units, community health centres and primary health centres. India also has a National Blood Policy, and the regulation and monitoring is undertaken by the Drugs Controller General of India and also has the engagement of the NACO.

I wrote a draft of this blog on a day in which the Google Doodle celebrated Viennese pathologist, Karl Landsteiner who was born on the 14^th of June 1868. Landsteiner classified blood into different groups in 1901 and created the blood grouping system we use today. It’s now also World Blood Donor Day. Voluntary blood donation in a high-income country has received reasonable media coverage over the last few days, unfortunately in the wake of unjustifiable violence; but perhaps this offers a chance for us to take this opportunity to think and include the issue of blood safety in our work as public health professionals.

In 1949, RJ Smeed, a British statistician and transport researcher, proposed a theory, which is now known as Smeed’s Law. According to Smeed, as countries grow richer, and add more cars to their roads, they begin to pay more attention to things like safety issues. Today, traffic accidents lead to an estimated 1.2 million deaths annually or about 3242 people every day; 90% of fatalities occur in low-and-middle income (LMIC) countries which account for only forty eight percent of the world’s registered vehicles.  Self-driving cars or other game changing innovations might change all that in the future, but for now, poor regulations, limited health systems capacity to address the post-crash phase of road accidents, and little or no organized emergency response systems are just a few of the factors which exacerbate the health impact of traffic crashes in LMICs. In addition, in LMIC settings it is often vulnerable road users, such as pedestrians and bicyclists who inequitably bear the brunt of road traffic injuries. Also, road Traffic Incidents (RTIs ) disproportionately affect the young: the majority of injuries and deaths occur among those between the ages of 15-29 years, among more men than women, having an impact on the overall wellbeing of the individual, as well as the household. Low health insurance, especially among poorer populations means the financial burden of medical care and sustenance in case of long-term disability can be disastrous. Studies on the impact of road traffic accidents on the financial wellbeing of a household indicate a long-term effect; almost 49% of households with an individual disabled in a traffic accident shift from house owners to renters.

Anyway, road safety got its due at WHA69 this year with the Assembly adopting a resolution to accelerate the implementation of the outcome document ‘Brasilia Declaration on Road Safety’ – towards achieving SDG 3.6 aimed at reducing road traffic deaths and injuries by 50% by the year 2020. Comments by member states highlight a few of the challenges which such a multidisciplinary issue presents, including, of course, generating funds – which Brazil highlighted as an impediment towards executing the United Nation’s Decade of Action for Road Safety (2011‒2020) more effectively. Countries such as Vietnam urged better inter-sectoral collaboration and improving the post-crash response, while Japan illustrated the impact of low-cost interventions such as using seat belts and helmets in protecting automobile riders in case of a crash. Other countries highlighted the issue of limited and poor quality data as a challenge.

The achievements, challenges and commitments presented by the member states were commendable, but much of what was presented viewed the issue of road safety from the point of view of those inside vehicles. As someone who typically drives a lot, but also loves to walk, especially in the city, enhancing road safety from the perspective of only car users simply doesn’t make sense. So I was relieved to hear one, slightly different point of view, one which resonated most with my perspective, that of the civil society organization, Medicus Mundi International. As the MMI representative said, we need a paradigm shift (another one, I hear you sigh…).

Yet, this one is actually urgent. Indeed, as already mentioned above, vulnerable road users, such as pedestrians and bicyclists, are most affected by road traffic injuries – and are often also the majority road users. Moreover, in many countries such as mine, cycling is not a choice; it’s possibly the only affordable means of transport – and that too if you’re lucky enough to be able to afford one cycle for the family. Large numbers of people in Indian cities cycle for miles and miles in extreme temperatures, walk on highways not designed for pedestrians, and tackle inefficient, uncomfortable, yet expensive, and often unsafe forms of public transport. So ‘the time is surely now’ to think about road safety from the viewpoint of the majority road users; from those who might benefit most from interventions. Advocating for safer mobility, improving the post-crash response and finding ways to prevent and reduce severity of injuries are some of the ways in which public health can play a role in reducing the burden of injuries and deaths from road traffic accidents.

In a recent article in the New York Times, Mark Rosekind of the National Highway Traffic Safety Administration was quoted on the semantics of the term ‘accident’ – whether the use of the word ‘accident’ implied that the event under discussion was one beyond anyone’s control. The article documents a shift in the use of terms for road traffic accidents: instead of ‘accidents’, the term ‘crashes’ is more favoured now. I will leave the discussion on the semantics of the word for you, the reader to explore in the article, or perhaps join the campaign ‘drop the A word’ – but I do think that perhaps viewing road safety from the perspective of crashes, and not accidents might help. Or maybe a step in the right direction would be to have an ordinary person, who cycles to work on roads with potholes, trucks, buses, cars and no bicycle lanes in 40 Celsius weather, instead of a motor sport executive as the UN’s special envoy for road safety?

Preparations for the visit began with a review of the documents which the WHO generously uploads in the weeks preceding the assembly. Unfortunately, no instruction manual comes with the documents. Help came in the form of ITM’s WHA regulars, and the people at the Graduate Institute Geneva, who conduct an introductory session to the WHA for new delegates the day before the Assembly. This critical session fortifies jet lagged participants with coffee and a thorough introduction to the WHA, supplemented by an overview of the main agenda(s) of the year – equipping us with some tools to tackle the week ahead!

Still, nothing quite prepares you for the first day of the WHA. Indeed, the first day at the WHO and UN buildings. This can be a moment in itself for first timers. A time to quietly reflect on the fact that it is, often, in these walls that decisions which affect the health and wellbeing of millions of people worldwide are taken; a place where power, politics and principle must coincide – sometimes they do anything but –  to balance the needs and interests of the various stakeholders in decision making processes on everything from health, security, aid and much, much more – often by people whose political, social and economic contexts are far removed from those on whose behalf these decisions are taken.

Returning to the Assembly itself, the WHA is not what I expected. Close on the heels of the Women Deliver conference in Copenhagen, with its walking turd, menstrual-cup chandeliers and social media, the WHA is one of gray suits and diplomatic discussions taking place in large soundless rooms. It struck me as odd, and made perfect sense that these discussions among member states on health agendas of critical importance take place in a room audibly silent, yet not. It also took me a moment to digest the fact that this is not a scientific conference with researchers coming together on a particular area of interest and study, with a sprinkling of policymakers. Indeed it’s quite the opposite – it’s a congregation of policy makers with a sprinkling of health workers, researchers, activists and others.

Day 3 at the WHA ended with a rainbow over “the Palais”; surely a cheerful note to end the day. By then, it had been three days of frantic diplomacy, closed door meetings (the Framework on Engagement with Non-State Actors (aka “FENSA”) is being discussed behind closed doors), lots of side-meetings, technical briefings and one sandwich too many perhaps. Seasoned WHA attendees or “watchers” might decide to use their time better by following discussions on a particular topic, area of interest or researcher. I had a more Dory-the-fish approach. From the plenaries, to the side-meetings, technical briefings and country discussions – trying to cram in the latest on adolescent and women’s health, urban health, SDGs and health systems. Discussions on these will follow in subsequent blog posts.

In the wake of the Ebola crisis, and more recently Zika and Yellow fever outbreaks/crises, the WHO role in responding to health emergencies, as well as developing country capacities to respond to global health emergencies was high on the agenda. Margaret Chan’s severe warning against untreatable gonorrhea provided comic relief to an audience presented repeatedly with the terrifying possibility of a world without usable medicines, the threat of Anti-microbial Resistance (AMR), another “hot topic” at the Assembly.  A lot is going on. Maybe too much; almost everyone has remarked on the packed agenda – some appreciate it, whilst others (including China) expressed the need to limit the items for discussion on the Executive Board and WHA menu. Anyway, against the backdrop we know, global health security and the implementation of the International Health Regulations (IHR) have emerged as a priority.  The issues of UHC, global health security and health system strengthening towards achieving the SDGs, and of course in the context of health security are some of the leading themes under discussion. In addition, almost all discussions, whether it’s on improved emergency response, or improving the health of women, children and adolescents highlight the need to invest in human resources (Committee B this year). With the need for an estimated 40 million health workers by 2030 this is certainly a pressing issue and one that has been stressed upon, as Dr. Marie-Paule Kieny, Assistant Director-General – Health Systems and Innovation, emphasized: “there is no health security without health workers”. Discussions on the migration of health workers, looking for better economic prospects have been highlighted in technical sessions and other discussions; however committee proceedings on human resources for health are not yet over.

Over to some of the (usually packed) technical briefings then.

Health in the 2030 Agenda for Sustainable Development: Intersectoral Action was the first technical briefing of the week. The session focused on partnerships, intersectoral action and health system strengthening towards achieving the SDGs. Gender and the role of women towards achieving the SDGs, as well as using the goals in the SDGs, particularly on health workforce strengthening was emphasized as an opportunity to increase the participation of women in the workforce. David Sanders from the University of Western Cape brought attention to the issue of health worker migration, articulating a need to potentially compensate countries for “brain robbery”, in other works, the migrant health workers trained in source countries. The second technical briefing, Survive, Thrive, Transform: implementing the Global Strategy for Women’s, Children’s and Adolescents’ Health summarised the Global Strategy and called for country leadership to provide the necessary stewardship and financing towards improving the health of women, children and adolescents – the next generation. Dr. Chan emphasized the need to engage men in the discourse on women and adolescent health, emphasizing that “It’s not either/or. We need to work together”.

Conclusion

It was interesting to note that almost all discussions stressed on the need to focus on the health workforce; the need for partnerships not just for implementation, but financial stability – of programs, institutions and overall health sector development at the national and global levels. Interestingly the private sector received much attention and emphasis across sessions. Throughout, the need to increase and generate funding at the national level and reduce dependence on overseas development assistance was emphasized. Of course, this would also imply strengthening links between the ministries and getting cozy to the ministry of finance, and learning their language. As was said during a session on the High-Level Commission on Health Employment and Economic Growth, “If you want to sell a message to a hard-nosed finance minister, equity isn’t going to cut it, efficiency is”. Women were almost in a calculative way equally represented at all panels which was interesting (Twitter didn’t seem to agree, though). Anyway, it is extremely heartening to see a large number of female participants, some of whom can be seen with their infant children. I do think the WHA needs to make a conscious effort to engage with and bring across young researchers from less wealthy countries. I noticed a number of young people and medical students from North America and Europe – but few (at least none that I spoke with) – from developing countries.

A focused summary on the various subjects tackled during the last three days will require dedicated blog posts (keep an eye out!). I do think it’s necessary to prepare and be ready for any health emergencies, but also feel that we must not lose our focus on strengthening health systems, especially in low resource settings – this I believe will ensure a far more sustainable and consistent readiness in times of national and global health crisis. Many global health people make this connection, clearly, but ‘hard-nosed’ ministers of Finance and their bosses sometimes don’t.

Time at the WHA is flying by faster than expected; as a newbie you can jump right in, or ease into it as I did. However, it is going to be a while before I can comfortable cue into what transpires behind the words, and become proficient in “Geneva-nese.”  Do watch out for my book on ‘The WHA for Dummies”.  For the moment, in the words of Dr. Chan, I’m going to “roll-a-skate”!

Our tastes can be subjective and sometimes dependent on the familiar. For those who grew up eating a particular cuisine relocating to a foreign country can present a gastronomical challenge. Throw in supermarkets with aisles full of more food choices than one could possible try in a life time, with a dash of the alien in the form of language, and you’ve got a cohort of foreigners heading straight for the golden arches of homogenous heart-attacks in a bun. And then there are those, such as myself, who have grown up eating all kinds of food, from all over the world – with a taste so diverse that almost every cuisine has a dish linked to memory.

And this brings us to ITM. For the extraordinarily warm and welcoming people that belong to the Institute of Tropical Medicine family, who welcome new cohorts of students, researchers and others from across the world every year, explaining the concept of a cold “smos”-y lunch perhaps presents a peculiar challenge. For some of their students like myself, these sandwiches made of super bread, cheese and meats were a real treat (yes, thank you, I still crave the apple-watercress-honey sandwich from the corner shop). For others, it was something to politely wash down with delicious Belgian beer or European wine, before dashing (more like scurrying) off to their rooms to eat a “real” meal of rice, meat and vegetables – warm just like it should be in the cold and damp.

Food can bring people together or tear them apart (you say blue, I say brie). Karibu (or welcome in Swahili) opened in January 2014 to much excitement among all. An ITM cafeteria on the ground floor of three blocks of brand new student housing, Karibu catered to the crowds, Karibu would make an Indian “global dining” enterprise proud. From fish & chips, to spaghetti Bolognese, to salmon burgers… they covered their bases well and took fusion dining seriously. In deference to non-meat eaters, offered *shocking* a pretty good vegetarian meal option. The Portobello mushroom burger gave some serious competition to its bovine version.

We now had a place where we could bring our own lunches, or choose from a range of subsidized cold and warm food options. Unlike American university cafeterias there was just enough of a range to have a choice, but not so much to leave you stressed out trying to decide your lunch. There was free entertainment too. For the uncoordinated, the foosball presented a challenge, but the advantage of being a foreigner is that you can get away with feigning ignorance, “foosball? Friends? Who? Let me get on with my lunch I say.” For the snoozers you have the patio chairs to sit on and chat over lunch in the delicious summer sun. Some oscillated between lunching at the formal dining hall and the more informal lunch gatherings under the pear and apple trees in the courtyard of the Rochusstraat building, a former monastery.

Dining out is sometimes an interesting cultural experience. My first dining experiences with people from richer countries, more than a decade ago involved splitting the bill almost down to the exact cent. I wondered why. I see this happening in metropolitan India today, where it’s now the norm. We go out to a restaurant and split the tab. Maybe because when you reach a certain level of equity in terms of income and standard of living, not to mention urbanization and the shift in social norms, the need to either show-off your status or wealth by picking up the tab is not as significant. I do see the wisdom of it now…it’s easy, fuss free and saves a great deal of awkwardness at mealtimes now. I draw a parallel here with my limited experience at some weddings which I’ve attended in the west, where the cost of the present is less relevant than the thought behind it; different from India, where how much you spend or what food you offer at a wedding can make or break your social standing, and often determine the quality of your daughter’s marital life. Then there are cultures where eating off the same plate, together, is a way of bringing people together. Of course, this has been blamed for undernourishment of young children who often eat smaller portions and are slower at eating, so tend to miss out on the good stuff.

And so, coming back to Karibu and lunches at ITM in general…more than the food, the snooze, the booze – it brought people together, extracted researchers from desks for some priceless off-screen time. I don’t recall eating a single meal alone there. There was always someone to talk to. Newbie students, ITM veterans, visitors, faculty and staff, it was a super meeting place. ITM offered a unique cultural island where the strict social norms of splitting the tab or worrying about who is going to take a bite off your already insufficient sandwich did not apply. We freely shared food, ate together and formed bonds that extend far beyond the geographical confines of the Institute.  Of course, some of the binding factors may be attributed to Skype and Facebook.

And now, back in India with its plentiful social norms which keep you super-glued to even those you don’t much care for, as I sit at the dining hall, eating alone sometimes, I wonder why no one walks up to the other to say hi and just be curious about them. Is it the pot of gold expected after a gruelling school year? Is it because we’re all from the same country that curiosity about the other is redundant?

I don’t know. What I know is that right now somewhere back in Antwerp there is a foreign student experiencing a new cuisine to their utter delight or horror. And somewhere there is a Belgian in Brussels sniggering at silly tourists walking around with a tower of whipped cream, Nutella and strawberries on their overpriced waffle. And that the innocent waffle and the mayo laden “frites”, are perhaps partially responsible for the bad reputation of the Belgian diet. And that cafeteria food, no matter how good or thoughtfully prepared will inevitably be discussed with disdain and often blamed for the stomach cramps that perhaps came from the mouldy bread you ate, and finally for the batch of 2014, Friday evenings and lunch times made for warm, fuzzy memories.

The draft National Health Policy 2015 makes for an interesting read. There is a distinct difference in the tone and semantics of the 2015 draft NHP as compared to the existing version of the policy. Its primary objective as stated by the draft document, “is to inform, clarify, strengthen and prioritize the role of the government in shaping health systems in all its dimensions – investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and legislation for health.” A long sentence, reflecting and articulating, perhaps for the first time in a policy document, the role of the government in the funding and the provision of health services. This is reflected in the acknowledgement that despite a robust private health sector, health outcomes and financial protection for the population are linked to public health expenditure. It’s also expressed in the intention to strengthen the provision of comprehensive care at the primary care level.

The NHP goes beyond presenting a generic statement of the challenges facing health and healthcare in India. Its text reflects research done over the past decade and also ongoing debates and controversies on health care; not missing the opportunity to leverage the incident of the deaths at a sterilization camp in November 2014, to critique the concept of camps as a legacy of past regimes. The draft NHP covers a range of topics from health financing, human resources in health and health research to the challenges presented by the demographic and epidemiological shifts.

To address the changing needs of the population, the draft NHP 2015 outlines seven key policy shifts which include expanding the focus on primary care to one that assures comprehensive care and effective referrals; strategic purchasing in secondary and tertiary care mainly from government providers; assured free drugs, diagnostics and emergency services in all public facilities; focus on infrastructure and human resource development – towards a more equitable distribution of health resources; integrating national health programmes with the broad health systems. In addition, the draft NHP proposes to address urban health issues – including, but not restricted to the social determinants of health. While the Swachh Bharat Abhiyan (or ‘clean India campaign’), did convince some wealthy citizens to pick up the broom and clean their already immaculate neighbourhoods, its broader campaign and awareness created a stir and discussion on the need for the physical cleanliness. It’s a start – but more needs to be done in terms of integrating it with the broader issues of sanitation, access to clean water and issues of planning and developing living and working spaces. One gets to see an explicit need for a social movement for health expressed in the draft. Lastly, the draft NHP 2015 focuses on mainstreaming Ayurveda, yoga, Unani, siddha and homeopathy (AYUSH). With the 21^st of June as being declared to be the International Day of Yoga and the formation of the new Ministry of Yoga, this last AYUSH initiative seems well on the road to implementation.

The threat of the spread of Ebola and India’s shaky capacity to be able to tackle an epidemic, if it should so occur hasn’t been lost on the NHP. The need to strengthen health systems and the role of government towards developing the capacity to prevent and address communicable diseases has been reiterated. The document also acknowledges the need to address chronic non-communicable diseases (and brings in the issues of integration, human resources as well as Indian systems of medicine here), as well as the preventable aspects of road safety and occupational hazards. The use of information communication and technology to supplement resources and improve outreach are also included.

There is much in this draft National Health Policy that researchers, activists and those working in the area of public health have been working on over the last few decades. Some of it new, some not. The issue of increasing public financing of health care, for example, has been highlighted by several governments. The draft NHP 2015 too acknowledges the need to increase public financing in health for it to meet the goals outlined, though it remains to be seen if this will actually happen.  This policy document positions health care and health services within social determinants. Equity and quality of care in access to health services underlie almost all recommendations. Perhaps the most significant debate to emerge from the draft policy is that on the right to healthcare and whether a bill should be passed to make access to healthcare a justiciable right, much like moves in education, food and employment by earlier governments in India.

Unlike the general neglect of the private sector in government’s discourse of health in India, the draft policy acknowledges its tremendous growth in India. Acknowledging its contribution to the Indian economy, the draft policy articulates why this sector cannot be counted on to provide what is not favoured by the market: preventive care in general and equitable care to a large majority of Indians who can ill afford it in private sector. While the proposed policy provides a clear rationale for and explicit intention  to  regulate, or rather actively  ‘influence’ the private sector to align its goals with public policy goals, the draft fails to provide even broad directions as to how this might be achieved.

The semantics of the 2015 draft NHP vary from past NHPs. Presented to the public just days after the media reported cuts in the health budget, the draft NHP 2015 throws up some pleasant surprises in terms of its objectives. For the moment, we need to wait and see how much of the content of the draft policy will distil into the final version, and how its objectives will be met. The proposal with rights-based language and centrality of state (government) intervention in health sector does not fit readily into what the new government seems to be up to, with the recent cuts in health budgets and appointment of Aravind Panagariya and Bibek Debroy (possibly the best advocates for market-based approaches to development) to NITI Ayog – a smaller and probably to be the most influential think-tank that replaced the Planning Commission of India a few days ago. As the common man awaits for ‘Acche Din’ or good times, the promise that galvanized the last election and brought the Modi government to power, it is yet to be seen whether the health sector will get enough attention and of what kind.

We’re living in a world full of turmoil. It’s perhaps always been like this; as the ancient Greek philosophers said, change is constant – nothing is permanent, except change. The Greek philosophers of this day, complexity theorists, will agree.

Perhaps we’re just more aware of the turmoil than before, via abundant media and social media. Having said that, seemingly frequent outbursts of violence and natural disasters, coupled with the spiraling world population and increasing pressure on our environment seem to add an additional layer of urgency.  When Ban Ki Moon himself starts writing alarming pieces like “We’re the last generation that can fight climate change” and you see Netanyahu – of all people – walking with other world leaders for “freedom of speech” in the streets of Paris, you have a feeling that ‘The Force’ is not exactly with humanity these days. Rather, the Force seems to be hell-bent on ripping apart humanity, and even destroying the habitat of the human species in the next century or so (Enter “Interstellar” if you believe in Hollywood solutions).

Given the odds that we won’t find solutions in time to change our destructive growth-oriented economic system to avoid catastrophic climate change, if we continue on the path we’re on, even if it’s one towards “sustainable development goals”  in the best scenario, one can’t help but wonder whether in addition to social, political and other determinants of health, we shouldn’t increasingly also talk about the importance of ‘spiritual determinants’ of global health – to  look beyond the spiritual determinants of (personal) health and well-being, that is.

Now, we are fully aware ‘spirituality’ is close to a swear word in the evidence and results-based world of many public health people. Spirituality is, at most, something to leave on your night desk in five star hotels where you’re staying to attend some High-Level Event To Save The World, or something to crack jokes about in relation to the real origins of a famous global health initiative  (see the notorious Bono & George W Bush PEPFAR “prayer room” legend). The more socialist public health people (the People’s Health Movement crowd naturally comes to mind) have even less patience with spirituality, based on their rather Marxist analysis of the ills of our economic system.  For other public health professionals, their faith is in fact an inspiration for their work, but they usually don’t talk about it that much, it’s something private. As for the “patients”, religion is often seen as a last resort for people in low resource settings providing some comfort, even if it sometimes hampers “evidence-based interventions”. Call it the “opium for the masses”, public health style.

But here we’re trying to go beyond the topic of ‘religion’ and discuss spirituality in a broader sense.

Spirituality

At the danger of now finally being revealed as some sort of ‘New Age/paranormal lunatic’ and/or part of the lunatic fringe of the health systems research community, we refer here to ‘spirituality’ in the Deepak Chopra sense, see for example his recent book ‘Spiritual solutions’:  as a path to inner growth and a ‘true self’, going from our typically rather narrow consciousness towards deeper layers of consciousness or even, ideally, a ‘pure consciousness’ or whatever you may call it. Instead of matter, apparent arbitrariness of events and a (very unjust) outside world, the focus is on consciousness, a higher purpose and unity between the outside and inside world. (disclaimer: I’m nowhere on this path – my co-author seems to have made a bit more progress)

Obviously, Deepak didn’t invent all this – he’s just building on ancient traditions here. And equally obvious, this is all just bullshit for the many people in this world with a materialist worldview – they probably reckon Deepak Chopra rhymes with Ophrah.

Anyway, sooner or later, in our opinion, an individual is likely to encounter a flash of this ‘spirituality’/ ‘bliss’ or – if you want – something which feels like ‘evidence’ of something you can’t “rationally” explain away. In some cases, it can even be a gut-wrenching event that shatters the world as you know it, opening up entirely new paths (no, not wormholes). Anyway, in my case (KDC), that happened some years ago, experiencing synchronicity  and a few other weird things which all happened around the same time. As I like to think of myself as an ‘evidence based’ New Ager (yes, Dawkins and many others don’t believe such a category exists), I explored the hypothesis of psychosis to “explain” these events  – but decided against the hypothesis, at least for the synchronicity stuff.

I haven’t done much with it since, and to be fair, these odd experiences haven’t really come back. Or perhaps I’m less aware of possible hints of a higher consciousness, and less in tune with my inner self. “The Gates to Nirvana seem to have closed again”, if you want. Yet, since then,  I do acknowledge the possibility of the existence of a another (larger) reality– and it’s a key reason why my agnosticism (of the time) has gone. Again, we are aware this sounds like a lot of crap for people with a scientific, evidence-based bent of mind – I just give my point of view here, for what it’s worth (being fully aware by the way that also in spiritual terms, I never got very far).

Spirituality at the humanity level

To make a long story short, looking at our world in chaos, we are increasingly wondering whether humanity as a whole shouldn’t (try to) go this path – or at least the ones among us with a first  name different from Richard.

Before you’re getting worried I’m going the nihilist “Kalashnikov & 72 virgins”- route here, I clarify: if we assume that there exist ‘spiritual solutions’ for personal problems – and I personally do, even if I routinely tend to ignore possible spiritual hints in my own life  – then why wouldn’t that be the case for the problems humanity as  a whole faces today? The whole world seems in need of a spiritual transformation, not just Islam – as is now commonly claimed by pundits (by which they usually mean that Islam should become “moderate” like most other mainstream religions and go through “Enlightenment” like Christianity did for example; become a rather harmless (even banal?) faith easily combined with our capitalist socio-economic system, if I may add…).

I don’t think this is the way forward. In fact, many of us should try to find our spiritual essence in a more radical way, by looking inside. Most religions and traditions have forms that actually lend themselves to this sort of inner transformation. So it’s not something exclusive to one tradition, Buddhism for example. I think it’s time we explore these paths.

Only if enough, or a critical mass of  people  (not a “vanguard” – that would sound too Leninist ) connect with their ‘true self’, we might have a fighting chance to change this world for the better, in time. In the 1970s Maharishi Mahesh Yogi – yes, the notorious Beatles Maharishi – put forward the idea which came to be known as the ‘Maharishi Effect’ which  hypothesized that the life of populations would improve, noticeably, if even one percent of the population practiced Transcendental Meditation. Even though the effect of TM has been the subject of many scientific studies, with promising results on the mental well-being of the individual, its impact on populations is yet to be substantiated.

Whether people make progress on this spiritual path through TM or other sorts of meditation, yoga, playing tantric games, long walks in nature, doing some odd new age stuff with their chakras or just by chanting ‘Modi’, ‘Netanyahu’ or ‘Putin’ while smoking pot is less important in our opinion. But it seems urgent and vital that (many) people go inside and try to find out what ancient sages have all been talking about.

Currently, in our work environments, including in global health, we do exactly the opposite. We have all kinds of benchmarks and outside ‘performance measures’ to see how we’re doing. That sort of accountability might be required too, but the most important accountability – that to our ‘inner self’ – seems to be MIA.  There is accountability to the ‘self’, yes, in global health – but that’s very much the competitive ego-game like in the rest of the world.

It is often said that a new, so called “cosmopolitan” citizenship, is urgently needed to tackle the challenges of the 21^st century. I personally wonder whether such a broad minded citizenship is possible at all – at least at the levels required – if people don’t undergo a spiritual transformation. Do we really think a circular economy, divestment of fossil fuels, meaningful global justice, a comprehensive SDG agenda…  are possible – and in time ! – before this planet becomes uninhabitable for humans, if we don’t undergo a (21^st century) spiritual transformation as well? Maybe glass-half full people might think so. The pessimists among us beg to differ. Something more will be needed.

That is anything but a new insight, others have done so far more eloquently and way more guru-style – they tend to have gray beards/hair as well as possessing real wisdom (instead of my very brief flashes of ‘something that might very well have been something extraordinary’’). I’m just putting it forward here, because  ‘trying to find your inner self’ before taking action, is not exactly seen as a ‘way forward’ in global health circles (These circles would probably advise a ‘quick win mental health intervention’ instead).

But that’s a mistake, we think. And it’s one we can’t afford, if we take ‘sustainable and inclusive development’ seriously. Global health might – like science in general – need a paradigm shift if we really want  a sufficient number of citizens to become cosmopolitan and collaborative in time.

Time to start discussing this ?

This post is just meant to kick-start some discussion. So feel free to comment below this post.

What does it “mean” that we see Boko Haram slaughtering innocent people, in mindless violence and horror, from a spiritual point of view? If you believe in some ‘higher purpose’ for human beings, what on earth does this mean, this very real horror inflicted on people, including using little girls as suicide bombs on markets? If you assume there is a higher consciousness, what is this “higher purpose” on earth trying to say to us? What does it “mean” that global inequality is so horrendous?   And questions like that. These questions aren’t new, in fact they are as old as this world – and some, for example people who experienced the holocaust, have in the past because of this decided against the existence of a higher reality. Yet, in the 21^st century, these questions are coming back, and they seem even more inescapable than before. It reminds a bit of what some spiritual people “felt” – ominously – in the years before World War II, perhaps, anticipating the mayhem that was coming. (we don’t “feel” anything, by the way – we’re just trying to make sense of the world now)

If you take the personal level as some sort of indication, it is said that spiritual hints can help you to find the proper path for you, but that if you insist on ignoring them, you do so at your own peril – you can get bogged down in life, meeting endless and seemingly insurmountable obstacles (I’m well aware that the social determinants crowd might get really angry about this sort of statement). But, using the same logic, could there be some similarity at the global level? If humanity insists on ignoring the spiritual ‘writing on the wall’, will, eventually, this higher consciousness “decide” to stop our very survival on this planet? ( judging from my rather childish spirituality interpretation here, you can feel this could really be stuff for a Hollywood blockbuster )

If you believe this universe is amoral, you obviously don’t have to answer these questions. The same is true, by the way, if you believe there is evil and good in the universe. But if you do believe there exists some higher purpose/consciousness (or have experienced flashes of it, even if you didn’t fully understand them), you can’t shy away from these questions.

What is going on, in the 21^st century, that humanity seems to be on the way to its own extinction?  And borrowing a leaf from development experts, do we have a ‘Theory of Change’ to get in time to the spiritual transformation needed – or is the opposite, more and more division between humans, far more likely? And where does spiritual transformation and exploring your inner truth end and the ‘occult’ begins –  or worse, serious mental health problems start?

We don’t have the answers, obviously. But it seems important to start reflecting on them if we want to make the quantum leap in terms of solidarity that this century seems to require. Even in the “secular” and competitive world that science is. And while being aware that our digital times are not exactly conducive to ‘going inside’…

(Nevertheless, we still hope you ‘like’ this articleJ. )

For the majority of the elderly in India, growing older does not offer respite from a life-time of work. Limited financial and social protection for people means that over 80% of the elderly in India work for as long as physically possible to meet their basic needs.

The elderly form 8% of India’s population. This translates to over a 100 million people above the age of 60 years. By 2050 the numbers of elderly are expected to increase to over 300 million people. For a low-middle income country, which is witnessing a rise in non-communicable diseases whilst struggling to assure basic healthcare, the status of India’s elderly is a challenge in terms of ensuring social and financial protection, providing health services, especially for the management of chronic lifelong conditions.

There is remarkable heterogeneity in the demographic, social, gender, economic and cultural characteristics of the elderly. Southern states such as Kerala and Tamil Nadu with a lower fertility rate are in the advanced stages of demographic transition. Approximately 70% of the elderly live in villages; 50% are poor and over 70% not literate, with manual labour being the only source of livelihood for many.

The 2001 Census highlighted the feminisation of the elderly population in India. For women, being female has meant a lifetime of discrimination at home and elsewhere which continues even in old age. Approximately 66% of elderly women are fully dependent on others; 32% do not own any assets of their own. In a largely patriarchal society, dependence, especially physical and financial dependence on family members may impact health seeking behaviour negatively, resulting in delay or denial in seeking care, as well as physical or emotional abuse of the dependent elderly member.

Financial constraints to meet healthcare expenses are one of the biggest concerns for the elderly and their caregivers. Households with the elderly spend approximately 13% of their consumption expenditure on healthcare; with those above the age of 65 spending 1.5 times as much on healthcare as those between the ages of 60-65 years. Medicines account for the biggest portion of health expenditure. India is one of the largest producers of affordable generic medicines in the world, yet, expenditure on medicines is high.  Health infrastructure and services, including geriatric care are largely concentrated in urban areas, as are old age homes and much of the private, civil society initiatives towards elderly care. Rural areas also include remote locations with difficult terrain, be it on riverine islands or forest areas; limited mobility, difficult terrain, financial constraints and fewer health services further impede access to health for the elderly.       .

Articles 41 and 47 of the Indian Constitution include provisions for the right to public assistance in old age and direct “the improvement of public health as among its (the State’s) primary duties”. India is a signatory to international agreements on the welfare of the elderly. In keeping with its constitutional mandate and commitments at a global level, policies for the welfare of the elderly were introduced in the 1990s. India’s first National Policy on Older Persons was introduced in 1999 by the Department of Social Justice & Empowerment. Early policies for senior citizens took a rights-based approach and presented a broad set of areas of intervention on social protection of the elderly. Healthcare and access to health were incorporated within these policies and the responsibility of care was largely entrusted with the family. Initiatives by the government for the elderly have traditionally focused on social protection in the form of pensions for those below the poverty line (BPL), a public distribution scheme for food for the BPL, as well as concessions and rebates for travel. In addition, State interventions took the form of funding to NGOs to operate old age centres and established government-run old age homes.  In 2007 the Government introduced theMaintenance and Welfare of Parents and Senior Citizens Act 2007 – legally binding offspring to care for their parents and establishing tribunals to that effect. More recently, in the wake of the Shanghai Plan of Action 2002 and the Macau Outcome Document 2007 the government formulated the National Policy on Senior Citizens in 2011. Its recommendations retain familial involvement, bringing in, now, the involvement of the government and private sector towards creating an “inclusive, barrier-free and age-friendly society”.

What has the impact of these initiatives been so far? The 39^th Standing Committee on the Implementation of Schemes for Welfare of Senior Citizens (February, 2014), encouraged the provision of separate queues for the elderly at all levels of public healthcare facilities, a move which, however well-intentioned, certainly does not address the health needs of the elderly. Priority access for vulnerable populations notwithstanding the health needs of the elderly needs to extend beyond designated queues at health facilities.  In addition, the Standing Committeenoted that the implementation of National Policy on Senior Citizens has not yet taken place.

Challenges emerge in the form of limited research and information on the health needs of the elderly. The issues of implementation of policies and the capacity to bring about reforms are other concerns, as is bringing healthcare for the elderly on the list of priorities.

Ageing and care of the elderly is largely a familial responsibility in India. Multigenerational cohabitation in one household, colloquially termed as ‘joint family’ was a common social feature in India, and continues in some places.  In the absence of comprehensive social security, this has traditionally served as a natural social protection mechanism with families collectively caring for the elderly. However, social structures are changing in the country; families, irrespective of economic status, struggle to cope with the cost of rising health care and limited recourse to quality, affordable services for their elderly As Praveen Aivalli notes in a recent reflection about the neglect of elderly in India on PLOS Blogs, “In a country where there is supposed to be a long tradition of respecting the elders (Matha Pitha Guru Deivam – an ancient Sanskrit hymn comparing parents and teachers to God), it is a pity that health services and social security systems for the elderly are failing badly”. But maybe this is exactly the problem: well-being of the elderly goes back to ‘respecting the elders’ – with care being a familial responsibility – both in Indian policy and society. This clearly no longer suffices. Families and individuals need support and resources to offer the best possible health and nutritional care to their elderly, if not the bare minimum.

NS Prashanth, from IPH Bangalore & EV 2010, provided some inputs for this piece.