Presentation at Forum for African Affairs/MDGs youth meeting in Eldoret
Friday 09 October 2009
The traditional view has been that the MDGs that refer to health are goals 4, 5, and 6. Goal number 4 deals with reduction of child mortality, goal 5 with maternal mortality and goal 6 with combating HIV/AIDS, Malaria and other diseases. It is clear from a close reading of these goals that the framers of the MDGs intended them to be the main preoccupation of health service delivery systems worldwide, but more so in developing countries including our own.
Unfortunately, due to the discrete nature of the goals, and the difficulty that reading complex documents brings especially in this parts where reading is at best endured during school years and at worst dismissed as the pastime of the ‘bookworm’ or ‘nerd’, there has been a significant disconnect from what I would consider the point of the MDGs.
Careful reading of the UN MDGs indicates that all the goals are closely interlinked, and attainment of any one of them increases the chances of attaining any and all of the others. Let us look at these goals in more detail:
Goal 1: Eradicate extreme poverty:
Poverty and health are closely interlinked. Poor people are more likely to put themselves at risk, and when they do contract diseases, are less likely to have access to high quality health care. Due to the stresses and strains of life in the lower socio-economic echelons, new ‘lifestyle’ diseases like substance abuse and dependence, HIV/AIDS and even mental illness are becoming an everyday feature among the poor. Eradicating extreme poverty will therefore go a long way in improving health outcomes and the quality of life of our populations. Similarly, neglecting health in the search of better economic growth rates is likely to be counter-productive. Populations that are unhealthy are definitely not going to be able to achieve their full potential! I therefore posit today that MDG number one IS a health goal!
Goal 2: Achieve universal primary education:
To the casual observer, this goal does not look like it has anything to do with health. A closer examination, however, demonstrates the clear link between ill health and poor school outcomes. Unhealthy children spend more time away from school than healthy ones, and due to the metabolic demands of ill health, they also have less energy to dedicate to the cognitive demands of our competitive educational system. Further, children from homes in which the primary breadwinner is unwell with such chronic illnesses as HIV, cancer, or mental illness are less likely to go to school, and would instead be utilized to help in boosting the family income. This goal is therefore unlikely to be achieved unless the health of the population is put on top of the agenda!
Goal 3: Promote gender equality and empower women:
Once again this is s goal that is directly linked to the health of the population. Promotion of gender equity is definitely an issue in the health sector. Discrimination in access to health care is heavily skewed against women in our society. In our resource-poor setting, we often make decisions from a male standpoint that has difficulty considering the needs of our women-folk, resulting in unnecessary deaths and suffering among our women. As a matter of fact, the prevalence of HIV among women is almost twice that among men! This would indicate that a specific focus in health care delivery must target women, yet there is little evidence that this is the case.
Unequal gender distribution of the health workforce has resulted in stereotypes and low sensitivity in dealing with patients in our hospitals. For instance, every female health worker is has probably had to deal with the tag ‘sister’, while every male health worker must answer to the honorific ‘daktari’.
Goals 4, 5 and 6 are self-explanatory and deal with discrete health issues, and I will not dwell too much on them. Suffice it to say that from my perspective, a neglected health issue that will come back to haunt us as we focus on these MDGs is MENTAL HEALTH. Without having programs dealing with the mental health of our population, I would go as far as saying that the MDGs are set up in a way that all but guarantees failure. As a matter of fact, I would summarise ALL the MDGs into one sentence (if I was among the architects of the goals, that is): Ensure access to quality mental health services for the entire population (by 2015, or whatever year is convenient!). However, I must only work with the substrate I have been given.
Goal 7: Ensure environmental sustainability:
There is no denying the relationship between the environment and health. Many infectious diseases, which are the bane of our existence, are picked up in our environment. Indeed, a key component of disease prevention programs involves environmental manipulation to reduce risk factors for disease. It should be noted that environmental issues cut across the entire human experience, and the Mau forest saga has clearly demonstrated this. Health workers often take stands to protect the environment against degradation by those whose horizons are short and whose vision of a future does not go beyond a few months to years.
Goal 8: develop a global partnership for development:
This is a goal that cuts across all the other MDGs, and the need for partnerships in health is no less than in the other areas. Indeed, in few other spheres of human existence is partnership demonstrated more than in the health sector. Health workers share knowledge no matter where it is generated, and innovations in health care delivery are publicized for all to use. Expanding these partnerships will have a greater impact on the health of our people. Using the expanding IT platforms including satellite and fibre optic technology, we will be able to deliver high quality health services comparable to any other country in the world.
It is clear therefore that these goals are not discrete planks that can stand on their own in any way. Isolating three of the MDGs and ascribing them to health workers is therefore the height of folly. Indeed, even if health workers had nothing to do with the other five goals, the goals would definitely have an impact on them as citizens of the world, and on their work as health care service providers!
THE ROLE OF HEALTH WORKERS
Having said that, I would like therefore to dwell on what health workers can do in order to hasten the achievement of the MDGs. With the background I have laid, I will not restrict myself to the three so-called ‘Health-relate MDGs’, but I will take a holistic approach that ensures that none of the goals is left behind.
Health workers occupy a unique position in the hierarchy of any state. They have authority over all citizens in matters dealing with health, and the citizenry gives them a pedestal from which to carry out their duties. They are respected, and they perhaps compete with priests as among the few individuals no one would dare lie to!
With this position and respect, health workers therefore have a great opportunity to impact positively on the lives of their clients. Often, the doctor’s word must be obeyed if one is to remain healthy. Many people are willing to let go of their usual demands and scruples once they are admitted to a hospital.
On the other hand, this powerful position also confers onerous responsibilities on the health worker. The greatest among these are summarized in the ethical codes that guide medical practice, including:
- Primum non nocere (first do no harm)
- Beneficence (do what is good for your client)
- Autonomy (allow the client room to make decisions about their own health)
- Justice (allocate available resources without regard to extraneous issues)
- Confidentiality (do not broadcast what is divulged in confidence)
These are among the principles upon which the health profession is built, and we swear to ensure that the health of our patients shall be our first consideration.
This oath therefore places us in a position to want to intervene whenever the health of our patient (our country, community, neighbourhood, etc) is threatened. I hold that it is not only good to do so, but that it is a moral imperative, and where you can, you must act!
The next segment of my discussion will focus on some concrete actions that health workers can take have an impact on their communities and thus enhance achievement of the MDGs.
1. Know ALL the MDGs and their implications on health:
It has been correctly said that knowledge is power, and you cannot develop without knowledge. Health workers cannot restrict themselves to a few identified priorities and neglect other issues that impact on the health of their communities and even their own families! It is therefore the responsibility of health workers interested in furthering the noble ideals behind the MDGs to familiarize themselves with all the MDGs, in order to be able to play a part in achieving them. As we have seen earlier in my presentation, all goals have an impact on health, and health can impact on the other goals as well.
I would go as far as suggesting that these and other national and international goals be integrated in the training curricula for health workers, so that they do not enter their professions thinking they have no role to play on a wider stage.
2. Get out of the white coat!
The problem with many health workers has been the tendency to hide behind the white coat and behave as if they are not part of their communities. Often, they dismiss public actions as ‘political’ and therefore not proper to get involved in. The problem with this attitude is that some of the best brains in any country are absorbed into health-related professions, robbing other sectors of society of these important resources. If these brains end up being hidden away in our wards and theatres, not contributing to national debate and employing their exceptional intelligence towards bettering their communities, wouldn’t this be rightly considered to be a waste?
In order to reduce this waste, I therefore propose that health workers periodically get out of their white coats and get involved in their communities, whether their actions will be construed as ‘political’ or not. Involvement of health workers in advocacy will add an important voice to issues, increasing the likelihood of action being taken.
In this regard, therefore, I am glad to identify with the clarion call of this movement: Stand up, Speak out and Take action. I urge you all to do this, and not only on health related MDGs, but on all the MDGs and other issues that threaten the well-being of our people.
3. Do your job well!
It is imperative that as we focus on actions we can take outside of our professions to further the MDGs, we also ensure that we deliver on our core responsibilities. In this country, cases are being highlighted of hospitals and health workers who treat their clients poorly for one reason or another. Medical malpractice issues are rising, and if we are not careful, the few gains we are making in improving the numbers and distribution of the health workforce will be eroded. A great deal of mistrust is creeping into the hallowed relationship between a health provider and the client, and this is not healthy for our country. As health care providers, it is our responsibility to ensure that we maintain the professional mores and ethics that guide our practice, and that we use the resources at our disposal responsibly in order to achieve our health goals. You cannot have a moral platform to stand on if you are not doing your job well; therefore, in order to be effective advocates, you must ensure that like Caesar’s wife, you are beyond reproach.
4.Take care of yourself!
Many of us are often so deeply immersed in our work that we end up neglecting our responsibilities to ourselves and our families. Substance use and dependence, HIV/AIDS, workplace injuries to name just a few are becoming common problems among health workers. I must emphasize that a health worker who is unwell is not useful to the client, and may even be dangerous! The injunction to take care of yourself is therefore an important one, and neglecting your health as a health care provider is tantamount to professional negligence! In the same vein, we must ensure we take care of our families, if not only to serve as an example to the rest of the community. We cannot afford to preach water and drink wine, given that actions often speak louder than words.
The four actions above would help to advance the role of young health workers in creating a world that is favorable for them and for posterity.
CONCLUSION: ARE WE ON TRACK?
It is fitting that as I conclude this talk this afternoon, we ask ourselves if we are on track to achieving the MDGs, including the health goals.
My humble assessment, based on various parameters, is that although these goals form the major plank of the manifestoes of all our political parties, there is simply no sustained action to achieve them. On the whole, pursuit of these goals has been subordinated to other pursuits that we are better known for in this country, namely grabbing, looting, bickering, and lately, murdering, pillaging and raping our own people.
I conclude by saying that unless we get our act together at the highest echelons of governance in this country, we will be lucky to make a dent on any of the MDGs, let alone achieving them!
Finally, I would like to thank the organizers of this forum for inviting me to say the things I have said this afternoon, and I hope I have added something to the menu of activities the young people have organized for themselves as they campaign to end poverty and achieve the MDGs.
Dr Lukoye Atwoli
Consultant Psychiatrist and Lecturer
Moi University School of Medicine