GLOBAL HEALTH WATCH
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GLOBAL HEALTH WATCH
As part of the Indian dialogue^ on the Global Health Watch, Community Health Cell,
Bangalore hosted a meeting on behalf of the NGO forum. Prior to the meeting, with a
view to generate some pre-dialogue discussion and also as a means of focussing on the
questions of what, how and who, a questionnaire was sent out. The meeting itself had
presentations by various ‘watches’ already working and sharing of a few campaigns. There
were also group discussions where the participants were divided into smaller groups and
asked to discuss the questions in details. This paper is compilation of the responses from
the questionnaire as well as the ideas that were generated during the discussions. The
attempt would be to not only highlight the more commonly felt views but also to reflect
the whole range of views that were received and discussed.
During the meeeting after the group discussions question wise range of responses were
presented and the groups discussed and added any points they had specifically discussed.
In the paper we present both the range of views and a sense of the discussion that
followed.
1 What are the inequalities and inequities in Health in your country ?
• Regional differences, including differences in access to services and spending on
services, inequalities arising due to areas being isolated and interior, rural and urban
differences and North / south diferences.
• Class - economic status, systems of graded services, different levels of monetisation of
economies
• terrorism and insurgency affected states
• urban slums
• nomadic / immigrant labour / unorganised sector of labour.
• inequal budgetary allocation against PHC and towards tertiary care
• historical processes that states go through
• inequalities arising out of inequtable distribution of information / awareness / education
• employment status
• inequality in access to quality of care
• gender - esp as sex of doctor available is most often male)
• caste
• life expectancy
• age - geriatrics / adolescent
• tribals
• religion
Recognising that the range of inequalities compiled from the questionairre was too wide,
the group felt it was important ot focus on class, caste, gender and regional differences.
It was important to realise that inequalities were not only present but were also on the
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increase. It was also highlighted that certain regions like the North East were being
systematically neglected. Another point brought up was that there was also inequity in the
access to quality care.
(b) Implementation of conventions, treaties, plans of action etc?
This was seen as a measure of commitment of the Government to the concept of Health
For All.
• A majority of the respondents felt that the government had failed to implement the
treaties
• A few felt that the government had partially fulfilled implementation and had failed to
succed due to subtle changes being made over time, and the fact that the governments
commitment to the convention was not reflected in the policies.
• There was one respondent who felt that the government had done its job.
It was brought out that it was important before asking the national government about its
commitment, one should ask whether the WHO was really committed to the HFA goal.
This was ^important dueHoThe complete distancing of WHO from its earlier stand in
Alma Ata due to pressure from from the funding agencies, recognising that the national
governments were also under similar pressures. However at the same time it was also felt
that one should not use this to absolve the governments of all responsibilities. It was
highlighted that though the govt, signs all conventions it had systematically avoided those
that made it accountable in any way. The fact that the govt, was not seen to be
implementing its commitment was also due to the fact that there were no efforts to
translate these commitmentspolicy. It was also brought out that the public was not
aware many times of the commitments made by the govt and if this had been there there
would have been more pressure on the govt. Further the unstated agenda behind most of
these Bretton Woods sponsored conventions needs to brought out in the open.
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(c) Are there any specific examples whare these inequalities are being compounded
by other factors ?
This would highlight the compounding factors which the Watch should be aware and
without tackling which no real progress can be made in achieving Health for All.
• S APs , stratification of services due to ..
• corruption- misuse of public resources
• media explosion leading to changed values
• management structures not suiting Indian ethos
• environmentally unfriendly development projects
• inadequate / untimely release of funds
• lack of infrastructure.
• Influence and vested interests of drugs and pharmaceuticals industry
• external aid
• lack of private sector effort / involvement
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complete dependence on the government
lack of seCnse of participation
lopsided priorities
poor information base /illiteracy / unaware citizenry/ lack of sense of participation
uncommitted professionals, lack of monitoring / supervising
urban bias of NGOs
insurgency / violence
eco non-friendly tourism
western based education / medical education.
There were numerous compounding factors that were identified. They could be succinctly
put as mismatch of health policy from epidemiology in the context of already existing
socio-economic inequality.
2 How would you measure health inequalities ?
(a) How would you show that these inequalities exist ?
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government data including - census /SRS / NFHS / - by disaggregating for different
comparative perspectives
qualitative and case studies , narratives
per capita expenditure in various areas
sale of drugs etc / utilisation of hospital services.
pattern of unfilled posts./ idle time in PHCs / adequacy of equipment
fees structure of various services available in a given region / financial burden
data should be sensitive to determinants of health
no need to demonstrate.
The group agreed on the fact that to truly reflect the inequalities as they aretone required
disaggregated, sensitive and autonomously collected data. Other points that were
brought out were that the data really needed to be of the village or district level to truly
reflect the inequalities. It was also felt that using rates instead of percentages would be
more representative of reality.
(b) Which sources of data and information in yor country can be used for
monitoring?
• Govt, reports - SRS / census / NFHS / NSS / expert comittee reports
• reports from other agencies - NGOs / NCAER
• cause of death survey
• HMIS
• media and media archives
• internet
• rural health bulletin
• full extent of inequalities can be appreciated only through micro studies
• large primary surveys
It was recognised that by far the most consistently available data and data from the widest
area was the government data. However the data had inherent weaknesses especially the
lack of sensitivity to determinants of health. The fact that disaggregation could not be
done below state level and also not for all variables was a definite draw back. It was also
important to recognise that the NGOs themselves had large amounts of data and these
should be made available.
(c) What about accuracy and transparency of government data ?
• every body felt that it was inaccurate and not transparent but is was the only regular
source of large scale data.
• It was felt that the quality of data correlates with the quality of health services / admin.
• SRS / NFHS - have been found reliable
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There was a general agreement that government was neither wholly accurate | or
transparent and more importantly.was not truly reflective either. The fact that the govf is
resorting to large scale fudging of data is disturbing. It was also pointed out that senior
officials in the govt, themselves were unaware of data or were fed with false data. There
was also a systematic suppression of data that is deemed ‘political’ and this was a major
stumbling block. It is also true that many National Units whose function it is to collect
these data are neglecting their function.
(d) Is there a need for primary collection or would it be possible to analyse existing data?
• There was a general consensus that there was a necessity for primary collection of data
- however these data should be collected from strictly supervised and monitored studies
and these could be small sample studies.
• A few felt that the existing data was enough to work with and a innovative analysis of
the available data would do.
It was felt that there should be a regular system of collecting data in place and this would
be a autonomous body and would provide necessary data.
(e) How is it possible to gain access to the data ?
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right to information Jaw
trustbuilding *,/
partnership with the government.
funding agencies making loan availability conditional to provision of data
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• govt data more easily available than NGO data
(f) How to verify if the data is reliable and accurate ?
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internal consistency checks
following time trends
cross - checking representative samples
small sample surveys
regular monitoring
focussing on one or two important areas
(g) Is there a need to protect sources, and if so, how?
• most responses -no (as it would decrease the credibility of data)
• two responses -yes; for fear of data being withheld in the future
• classify data into common and classified‘sources of data classified as common# need
not be protected.
(h)Who would monitor the data and how?
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academics / researchers
policy makers
programme planners
NGOs / activists
government-NGO partnerships
selected sensitive government officials
parallel monitoring groups / special research teams
individuals / groups outside the government
press / media
(ii)how?
undertaking cross-check studies internal auditing
(j)What are the cost implications?
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Most people felt that the cost implications would not be large.
A couple felt that it would be substantial
depends on design
it is cheaper in the long run to have a system in place
3. Advocacy
(a) Where can issues of inequality in health be take up?
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public fora including caste panchayats etc.
media
govt -NGO interactions
take matters to court
academic -govt interactions
focussed conferences
raising matters in the legislature
professional associations
local govt, level PRI
community to be made aware of issues at all levels
It was felt that to decide on the where the issues of inequality should be raised was of
strategic importance and therefore there needs to be a separate sitting of a core group
once the structure and organisation etc of the ‘watch’ and its mandate were decided. It
was felt that involving the people was crucial and merely advocacy by NGOs without
popular support would never be effective.
(b)How can these issues be taken up?
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publications, lay and scientific
public announcements / media releases
NGO-community groups meetings
general awareness/sensitising campaigns like jan adalats/janjatthas/ public inquests
making issues part of political agenda
by framing issues in a non-threatening manner
participate in policy making bodies , state and national planning bodies
school and college competitions
fellowships for journalists / meetings with editors
websites and e-mail campaign
regional language / regional language press
(c)With whom should they be taken up?
• as in 3(a)
• corporate sector
• members of parliament
(d)What is the likely impact?
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keeping govt health information services on their toes
watchdog on any policy having health implications
sensitising policy makers
achievement of equity
impact immeasurable before major commitments of resources are made
possible negative impacts like hostility or mistrust
depends on the method of presentation to relevant authority
public attention leading to pressurising policy makers
(e)Is there is a need for alternate reporting systems whereby NGOs can provide
shadow reports to official government reports?
• A majority of the respondents felt that there should be alternating reporting systems
however a few pointed out that need not be the prerogative of NGOs alone.
• A small minority felt that there was no need for a separate reporting system.
4. Partners.
(a) Which organisations or persons would be able to participate in this kind?
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independent academic institutions
NGOs - recognised / reliable/ reputed / grass roots / research
professionals outside government or political parties or health industry
autonomous institutions financed by govt /industry
training institutions - medical / social / nursing
govt.
IMA
press
anganwadi workers unions / other local bodies / consumer groups
PR1 and other stake holders at the district level
sympathetic bureaucrats.
It was felt during the discussion that instead of defining who would or could be partners
those who are like -minded should be encouraged to join the "Watch,’
(b) What different roles could they play ?
• design and analysis of studies
• collection and provision of data
• think tank
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advocacy groups
dissemination for wider debate
watch dog for influences of other policies on health
training government officials in data collection---- 7
networking
district level -collection and district level planning / different functions at different levels
5. Organisation
(a) How would a national watch be organised?
• Federal set up .- central secretariat with state branches including at levels SRS, govt
and
— NGOs
• network of elected / selected / involved
• as a non-institutionalised platform of various actors working on the principles of shared
responsibilities
• however it is organised it must reach the grassroots
It was generally felt that a rigid ‘federal structure’ was not necessary and loose network
was enough. A few participants felt that the functioning of the ‘Watch’ should be divided
into two. The data gathering and analysis should be looked after by/organi/sation with a
system and rigid structure, ^nd the function of sharing information, advocacy, pressurising, ,
awareness etc could be taken on by a more loosely defined network.
(b) What should be the structure ?
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international - national - NGO/ civil society / individuals
to be coordinated by an NGO person : Govt to participate as equal.
Like SRS data to be collected from NGOs and collated upwards
no need of new formal structure
four levels - core group/ advisory group / consultative group / forum of participatory
organisations.
Ideas that came up for the structure of the ‘Watch’ were generally that it should be a
network of interdependent and exchanging units. It was felt that as this can be seen as a
subeversive activity, it should not be seen to have a structure that can be co-opted by the
Funding agencies. A more detailed four level structure was also proposed. It included a
core group , an advisory group that helped and supported the core, a consultative group
that came in on specific issues, and a general members forum that provided/ used / shared
the data and undertook various activities. Another idea also shared was that instead of
trying to develop a structure a priori, an organisation should start the ‘watch’, gradually
gain credibility and a structure would automatically emerge.
(c) How should it relate to a global health watch ?
global watch - global issues - global advocacy
relationship with GHW to be part and parcel of NHW
through multilateral bodies like WHO / UNDP
using foriegn soil to make contentious observations, especially against non-democratic
states
• if in India NICNET could link up with all available sources of data it would be helpful
as a web site for the national watch
• affiliation with autonomy
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It was generality felt that in relation to a ‘Global Watch’ a ‘National Watch’ should be
autonomous, having a scope set nationally, not in any way constrained by a ‘Global
Watch,’ and to have equal access to data from western countries if it was to provide
data to them. It should be a relationship based on equality.
(d) How should the capacity of national and local NGOs from the South be
strengthened ?
capacity building for • research and ideas
• communication facilities
• data handling mechanisms
• reference libraries include web based information
• inculcating pro-advocacy role
• funding for training, interactions and for capacity building
• support of international agencies like WHO could enhance their capability for advocacy
• management information systems
• does not require any strengthening!
• by enhancing its credibility
(e) How can a wide, sustainable and independent funding base be maintained?
• independent fund-raising activity
• contributions rather than funding which always comes with a tag
• tie-up with UN organisations for fixed percentage of funds
• multilateral/govt/local funding - govt, especially supporting research
• userfees by data-users
• private funding
6.Do you have any suggestions for the national watch to feedback on global issues?
• dialogue with international organsiations
• active media lobbying through personnel dedicated for the same
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7. Additional points
emphasis on constructive criticism
impartial conduct in analysing/reporting
regular interaction with govt
ghw shall not be constrained by official charters and shall not be accountable to any
multilateral agency
• unhealthy competition and mutual suspicions are to be resolved
• It was felt crucial in all this ‘Watching’ not to forget the medical profession and the
science of medicine itself.
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C o t^\ H
DAY ONE
SESSION I;
Chair : Dr. V. Benjamin
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Dr. V Benjamin, President of the Community Health Cell (CHC) was in the chair when
the participants responded to his request to begin the meeting by observing a two minute
silence for the poor and the marginalised sections of India. This was followed by a brief
welcome address by Dr.Thelma Narayan, Coordinator of CHC, who outlined the purpose
of the meeting and hoped that the two day workshop would be able to conceptualize the
idea of a global and national body that would be able to shift) on the health inequalities
which are increasing and making life worse for the poor and marginalised - a section of
IndiaTie termed as the “social majority”. This was followed by a self-introduction made
by all the participants. In all there were about 40 participants for the two day workshop
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from varied backgrounds including Government representative, academics, physicians,
NGOs with primarily research agendas, activist NGOs, individual activists, economists,
lawyers, management experts etc.,
Next Dr. Ravi Narayan of CHC who had been involved in the Global Health Watch
(GHW) initiative since its inception by the NGO forum of the WHO.made a presentation
explaining the idea of GHW.
Originating as an article published in The Lancet in 1994, GHW as an idea for keeping a
watch on the environmental determinants of health was taken up by the NGO Forum for
Health anfr transformed i into a concept bfr‘monitoring inequalities in health and
development, because it felt that the spirit of the Alma Ata declaration of 1978 had been
progressively frittered away by pursuance of vertical and reductionist policies. Partly
because of various vertical and disease oriented programs launched by WHO and other
international donor agencies and partially because of the rapid globalization that was
bringing about a new economic order, the poor marginalised sections of society were
being neglected and they had been at the receiving end of a iniquitous health care system.
) The forum had realized the necessity of an independent ombudsmanrlike agency that
could keep a watch not only on health status of people in various countries, but also on
policies that had a direct or indirect effect on health.
Ravi told the meeting that an organization agreed to fund the entire initiative,-^ the
forum had perceived the need to have a multisourced mechanism of funding to ensure
credibility and autonomy both absolutely essential in fulfilling its functions. The
conference in Geneva he had attended had dwelt on the problems that needed to be
addressed by the proposed GHW and the issues that should be “watched”. It had felt that
the liberalization - privatization - globalization phase of the present world had
necessitated that a watch is kept on the growing inequities on the national and
international levels. Specific focuses for the proposed watch included the issue of
inequity, health and development and other policies, conflicts and disasters and global
market exploitation. Other specific issues included global environmental degradation and
loss of biodiversity, downsizing of health systems and privatization, racial and ethnic
conflicts, /various United Nations summits and conventions and their implementation
x Various groups the world over could keep a watch. It was well recognized that there was
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no shortage of data that the only problems were that they needed to be accessed and
analyzed sensitively. He felt that NGOs, academic institutions and other organizations
could collect credible information, and if the Health Watch group could act as a flexible
and interactive network, cooperating and combining a mix of research and advocacy, a
meaningful surveillance on health could be kept. This would improve the status of the
poor and marginalised in various parts of the world.
Ravi at the end of his presentation made the gathering aware of some of the issues that
were still unresolved and hoped that the discussion could attempt to look into them. ’Tkc^t
• How will data that is collected or ‘watched’ reach the people or their groups?
• How could the GHW be a truly democratic or global process in that it was not North
dominated, not funder directed or was not top-down or prescriptive?
• How could the initiative be
• Objective?
• Independent?
• Credible?
SESSION II
Learning from other Watches.
Chair : Dr.CM Francis CHC.
The forenoon session and most of the afternoon sessions were spent learning from other
groups in India who have been acting as a watch on various issues. Each presentation was
followed by a period of discussion where the participants asked for clarifications or
linked some ideas to the GHW campaign.
HEALTH WATCH..
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Dr. Gita Semof the group Hdalth Watch, started by explaining the origins of her group
after the ICPD conference at Cairo in 1994. The group emerged as a gfoufe of concerned
individuals who got together to monitor the commitments made by the Indian
government while signing the Cairo declaration on reproductive health, and has been
having regional consultations with various NGOs to collect information from field level
workers in order to confront and dialogue with Central government about its commitment
to the ICPD declaration. She felt that the post-ICPD phase had been important in
changing the government’s perspective on Reproductive and Child Health and population
policies because of the positive change seen at the global level, thus attempting to
highlight how something positive globally could be used push changes at the national
level.
The participants learnt from Gita that the Health Watch that had emerged as a network
wrtir organizations with similar agendas had decided to prioritize its activities and had
focussed on two issues.
• Removal of targeted approach ^family planning.
• Improving the quality of services.
She said that Health Watch had decided to concentrate on how to change for the better
rather than be negative in its approach. Working through a network of organizations and
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individuals, it had organizednational and eight regional consultations besides some
quick field research that formed the basis of the national level meeting.
At the end of her presentation, she shared her learnings from the entire process that has
been in place for five years,’
• It was as difficult to maintain and run a network of people / NGOs for a long time, as
to hang onto and continue grappling with the government.
• The relationships between larger and small groups need to be kept open/,and it is
important to be accountable and democratic in its functioning for it to continue.
• Government is very suspicious about Health Watch.
• Government cooperation is based on the individual personality of the concerned
bureaucrat and there is a need to institutionalize a mechanism by which a ‘watch’
could get continuous access to the government data and implementation machinery.
• As the health activities of the governments are being funded by the WB, it may be
necessary for the ‘watch’ to be part of WB’s appraisal group to get leverage / position
so as to effect change in policy.
Replying to questions, she explained that Health Watch was being funded by a number of
funders including the UNFPA, Ford Foundation, Me Arthurs Foundation and that the
network had not got to a stage where it had to decide on a common minimum program,
(rather the Health Watch remained a network of organizations with the ultimate goals
alluded to above. Gita Sen replied to Sabu that although Health Watch was seized of the
problem of ‘son preference’ almost in all parts of India, it had not focussed on it as an
issue.
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Thelma ^vohdejfed if the population lobby
behind the RCH program, Gita ended her
presentation by expressing her fears that the Cairo goals may not be achieved easily
because both the politicians and the bureaucrats come from the conservative middle class
and because of the politicians returning to the field, the RCH goals were being seen as
too radical and there was reluctance to pursue the objectives.
The chair summarized the learning points of Dr. Sen’s presentation as follows:
> The importance of taking an opportunity when one arises - here the ICPD'and using
it to bring about appropriate changes.
> The importance of involvement of bureaucrats and politicians.
> Networking with openness leading to relationship building and achievement of agreed
upon goals.
SOCIAL WATCH.
As Jagadananda was unable to represent Social Watch, Dr. Sunil Kaul presented the
paper prepared by the Center for Youth and Social Development (CYSD) Bhubaneshwar
and Voluntary Association Network of India (VANI) New Delhi on their behalf.
Social Watch arose as an NGO watch dog system aimed at monitoring the commitments
made by the government at the world summit for Social Development at Copenhagen and
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analyses social development policies and actions by state / non-state actors to achieve the
goals of the Copenhagen summit while bringing about equity. In India^CYSD and VANI
have been preparing a report annually to circulate it among government departments,
individuals and NGOs for public education and opinion building. Taking pro-poor /
marginalised positions on social or governance related inequities, it examines
government actions down to fundamental policy assumptions, and now proposes to foster
a mutually supportive and synergistic relationship between state, non-state actors
involved.
Sunil explained that Social Watch had chosen to analyze three major themes of social
developmenb?vhich.--it -termed^as Basic Entitlements which included learning, health and
housing etc^ Sustainable livelihood including access to natural resources, strengthening
skill base and promotion of local enterprises, and participation in governance. Social
Watch picks up indicators to measure the progress in literacy and basic education,
keeping specific linguistic and cultural contexts in mind and looks at issues of access to .
educational opportunities and food, hygienic housing, sanitation and water and primary
health care especially for the children, mothers and the elderly. It measures the progress
toward achievement of goals regarding access to productive natural resources, promotion
of local enterprises, right to wages, maternity benefits etc., and examines the impact of
modem production systems on livelihood opportunities. It also analyses the role that
Panchayatifaj Institutions (PRI), dalits, tribals, and women play in governance, and the
evolving legal or operational space for participation of civil society organizations in
collaborating with the state in formulation of programs and policies.
Based on these, Social Watch has chosen indicators, which will help it to develop a
Social Development Index and an Adequacy of Action Taken Index.
Gita wondered if advocacy can be focussed for issues of social development, because the
responsibility lies with a large disparate set of ministries and the society at large, unlike
health where there is the health ministry to pressurize. Anil Choudry felt it was not
necessary to focus on all commitments made at the world summits because many of them
were positively harmful for developing countries but had been signed under global
pressure. Lawrence felt that development of indices are yet another attempt at
meaningless reductionism, but Manjunath felt that it was a good mechanism to highlight
issues and carrying out advocacy. Pankaj stressed the importance of indicators though he
too felt that having indices might often hide realities. Ravi said that instead of focus/ing
on different levels of watching, we should watch and see how we can use the experience/
data gained at different levels.
The chair summarized the leyhing {joints from tfe€ presentation as follows:
> The need for any data cmlectionjcfbe actf0n oriented.
p > The dialectic on whether a ‘watch’ mu st be involved directly or indirectly with
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advocacy.
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> The effort to develdp sensitive indicators.
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NADHI
Dr.Reuben Samuel described how North Arcot District Health Intelligence came to be set
up as a Disease Surveillance system that was started initially to keep a tab on six of the
immunization preventable diseases, but gradually has increased its range to many others
like malaria, HIV hepatitis etc.,
Funded by the ICMR and a EC program he explained the system which was based on
pre-printed post cards left with the field workers who were to fill out the details on it by
observing an easily diagnosable diseas^and post it to the center^here they were fed into
computers and the data analyzed to-^uickly set -up-a methodology Ito prevent an outbreak
in its vicinity.
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He highlighted the way in which the system involved volunteers, private practitioners and
how it cost only about 5 paise per head of the 50 lakh population involved. He ended his
presentation by mentioning its limitations of being selective in its focus, and that it was
run by one private institution because of which replicability was not assured^-adding He..
howeverjthat an attempt was being made to replicate it in a few districts in Kerala.
Dr. Mohan frao attempted to clarify that GHW concept went far beyond a disease
surveillance system and was meant to include socio-economic and policy issues
surveillance. RN hoped that GHW, unlike the NADHI system must incorporate a
mechanism to report the data and analysis back to the people so that it becomes THEIR
issue.
Sunderraman, who has also been involved with NADHI was doubtful if it could be
replicated especially because he had seen the hostility and politics amongst the
professionals because of the methodology of the surveillance system. He felt that as
NADHI relied on Government and private practitioners, it missed a lot of ‘community’
perspective that may have been got by involving RMP’s and compounders etc., He hoped
GHW would involve the community in collecting information also.
Mohan Rao also felt the need of a system of information was highlighted by the
successful approach of NADHI.
Gururaj wondered if the data was compared with government’s data analysis and if the
people collecting the data understood the importance of collecting it. Nandakumar wished
that the disease surveillance system could include the issue of animal health as well. Sabu
wanted to highlight the fact that that the possibility of making money out of the survey
itself led to alteration in the quality of data.
The Chair summarized the learning points from this presentation as follows:
> Any source of data should be multiple and based on reliability / accessibility and
validity.
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> For data to be relevant in a ‘watch’ setting it must include some socioeconomic
indicators.
> And the details of who was collecting data and how, are almost as important as the
data itself.
PEOPLES WATCH
Mr. Britto told the audience that his NGO had two objectives;
• To ensure state accountability leading to a change in policing.
• Promotion of a culture of human rights through strategic interventions and education.
Peoples watch monitors human rights violations through fact finding missions whenever
there is a report of custodial deaths or caste violence in Tamil Nadu . It also provides
legal assistance to victims of HR violations as it did for the victims of torture by the
Special Task Force set up to nab the sandalwood smuggler, eerap9pan.j It tries to
intervene by providing information to national and international humafTrights agencies
eg, the National Human Rights Commission and state HRCs^ 8 (also promotes solidarity
amongst victims of HR abuses and agencies promoting HRs.Jn the past it had undertaken
campaigns against Dalit atrocities and for repealing the controversial POTA act
(prevention of terrorist activities act)
Britto also listed out the number of publications Peoples Watch has brought out so as to
disseminate information about HR and on the performance of various national and
international HR agencies. It has also published the Supreme Court judgement on sexual
harassment in the workplace.
Peoples Watch also involves young lawyers and Law College students in HR c
orientation,.^^4'
and in H^Qampaigns. It also takes up activities to train and update the knowledge of HJR
activists and movement leaders. Recently, it has also undertaken a HR awareness
program in 400 schools missionary and municipal schools.
Replying to questions, Britto explained how his NGO had carried out a public inquest
into the causes of police attack in Tirunelvelli. He also talked about theirjinkages to the
Dalit Movements and the activities regarding violence against women. When asked about
the relations of Peoples Watch with the police, he said that PW had also been carrying
out training programs for the police officers.
The Chair summarized the learning points form the presentation as follows:
> The two other methods of collecting data and building awareness ie. Fact finding
teams and Public inquests.
PUCL KARNATAKA.
Prof. Hassan Mansoor talked about PUC( and admitted that PUCL had not worked on
health because traditionally the HR model used in India has been a western one, and has
been more interested in police / state violence. He felt that the world perspective on L"
r(
7
needed to include health as it is definitely a political topic. Prof. Mansoor stressed the
need for everyone to join hands on the issue of societal violence, which included gender,
caste and communal violence.
He talked about his work in 770 slums of Bangalore and cautioned everyone that violence
is likely to increase. He opined that unless governments were held accountable the state
might emerge as the ‘big killer’.
Replying to a question he said that PUCL was different from PUDR but both worked
together on occasions. Amar felt that HRs should not be confused with constitutional
rights. A discussion emerged on the issue of Public Interest Litigation and Prof. Mansoor
explained that the recent trend to dismiss PILs was an attempt by the Courts to curb PILs
being filed on frivolous grounds, as it was being used by middle and upper middle class
students to force changes in the failure percentage of universities rather than its intended
purpose of protecting the rights of dalits and the marginalised.
Mohan Rao also shared his experience of being party to the PIL filed/to stop the practice
>f unbridle^research on women under the guise of reproductive rights, and he felt that
the courts had been silent on the main demands and instead picked the least controversial
one i.e. To ban Quinacrine. Amar pointed out that Health Rights might also be seen as
political rights and GHW may heed to be aware of this if it goes into advocacy issue. He
also stressed the need for a broadening of understanding of Human Rights as an issue.
-h
The Chair felt that to really have an impac^health has to be understood as political and M
vital to the concept of human dignity.
SESSION III UNDERSTANDING EQUITY.
Chair Dr. Sukant Singh.
As Dr. Abel had to leave, he shared his experiences of ‘watch’ in RUHS A at CMC
Vellore, before the presentation on Equity. Abel shocked some of the audience by
announcing his finding that female infanticide may be the leading cause of IMR, not just
in the infamous districts of Salem and Madurai, but every where in Tamil Nadu. He said
that in-depth studies carried out by his health workers had revealed this, although he
admitted they had not been able to tackle the issue.
He also talked of how the meticulous record keeping and credible data base at RUHSA
had helped in changing UNICEFs prescription of Growth Monitoring as an essential
component of child health. He disclosed that his presentation in a UNICEF conference
had been behind the evaluation of the Tamil Nadu Nutrition Program (TNIP) and its
found
being
fraudulently
filled out,)
being closed because growthjnonitoring forms :were C
.
J C.....
’. ’
to declare a success, whenQie had brought to ligh^^^anj-organized study^Jn
Te fact that
mothers were invariably refusing to get theif'cETld weighed and it was not possible to
monitor the growth of children because of the traditional belief systems.
V
8
Abel also talked of his latest study on HIV whereby he had found that only 1% of rural
girls and 6-12% of rural boys were indulging in premarital sex. Based on this finding he
had convinced his peers that promoting condoms to/adolescent might not be useful at all.
In the discussion that followed, Thelma pointed out that though WB and IMF gave only
marginal amounts of funds, they managed to get disproportionately large leverage in
deciding the policy and we needed to look at ourselves before we endorse
UNICEF/WHO/ or other agencies’ policies. RN informed that he had attended a WB
review meeting where he had received documents that' admitted that no district has been
helped by any WB loan given for any program.
EQUITY
Dr Pankaj Mehta from Manipal Hospital in a very organized presentation, tried to explain
what equity meant. He said that in simple words it could be equated to fairness. Equity
according to him meant thtJS^peoples needs rather than their social privileges guided the
distribution of opportunities for social well being. In health care, equity had to be seen in
resource allocation, services received and services that are purchased.
He felt that it was easier to define equity through its opposite, inequity, which had moral
and ethical dimensions and referred to differences that are unnecessary, avoidable, unfair
“dunjust
He reminded the participants that equity is socially destabilizing and that disregarding
health equity is incompatible with long term productivity.
Pankaj displayed the various tiers at which inequity in health was apparent, starting at the
Global Level where there is a divide between North and South, and rich and poor nations,
and down to the family level where women and girl children were discriminated against.
He also talked about the causes of inequity enshrined in sociocultural customs, and
poverty, and the growing threat of globalization and liberalization increasing inequities.
He laid special emphasis on inequities faced by women from the time they are conceived
to the time they are cremated by listing out a long list of types of discrimination that
affects their health.
Ravi Narayan thought it was important not to stereotype the terms we use because
inequity is not associated with developing nations but that it is even more distressing in
the so called developed nations.
In an effort to understand the feasibility of perceiving inequity in government data the
next two presentations focussed on equity in government data and programs.
Dr Ravi Kumar talked briefly about equity in National Health Programs and showed
statistics about Karnataka whereby it was apparent that inequities persist in health care.
For instance, he said that only 25% of posts for lab/ technicians in Karnataka have been
filled up. He also showed how cross analysis in data reveals that although all CHCs in
f '
9
a
Karnataka have been given Ultrasound Machines, most CHC doctors are not trained to
use the machines or interpref their result
He also highlighted the fact that the urban health centers had no health workers at all, as
if everyone in urban centers was capable of paying for private health care.
IJe said that Karnataka was spending 30% of its GDP on the social sector, which is close
p.to the desirable level of 40%.
Mr. Mohammed in the last presentation of the day Mr .Mohammed of St. Johns Medical
College, explained the various types of data available with government and equity in
government health information.
He explained that Census was the only data that could supply data right upto the village
level, but it was carried out only once in ten years and the analysis was available too late.
Listing out the various data the responsible departments and the levels at which they were
carried out, Mohammed clarified the differences between Central (S^gistration System
(CRS) and the Sample Registration System (SRS) and the Model registration System
(MRS). He stressed the need for a demand to release the data of Health Management
Information System which he informed was collated from district level upwards and
because of its regularity and continuity, he felt could be of immense use to NGOs and the
idea of GHW. He also felt that as socio-economic information is not available in any of
the systems except the decadal census, it might be impossible to desegregate data to
check socio-economic equity from available government data.
It was felt that GHW will need to demand the inclusion of Socio-economic and caste
status data.
DAY 2 OF THE GHW MEET
SESSION IV
The first session of the day was spent discussing the types of irregularities seen in India,
ways to measure them, the spheres of advocacy, roles that partners can play in a GHW
framework, organizational structure, and the relation of a National Watch with a Global
Watch. The three sub groups were given some common issues and some individual
themes for detailed discussion. The themes were based on the questionnaire that was
circulated among the participants before the meeting
1
A
99/
'
SESSION V
(
The session after the tea break was devoted to some case studies of advocacy or
campaigns carried out by leading groups related.
VI
10
CEHAT
Amar Jesani shared the experience of 2 campaigns launched by CEHAT, one against
medical malpractice, and the other to promote medical ethics. He said that CEHAT had
identified that the private sector was more popular and was providing the major chunk of
health care because it was better than the others in understanding people’s beliefs and
cultures.
He stressed the importance of ‘negative information’ to launch a campaign, something
that he has learnt from his successful experiences. Amar said that focussing on the ills of
society by advertising or writing letters to the editor and asking people to send
information about malpractice brought a flood of letters, highlighting and filing cases of
malpractice of doctors and hospitals in the High Court also encouraged the media to take
up such cases and very soon the whole city had woken up to the cause. He said that
challenging the Government was important and one should be ready to face isolation
from medical peer groups. Amar also cautioned that it was necessary to keep good
relations with socially conscious journalists as media may often try to prevent the cases
of some hospitals catching spotlight.
Regarding the medical ethics campaign, he said the CEHAT had started the Journal Of
Medical Ethics and it was continuing for five years on subscription, which should be
considered successCEHAT had managed to get together a lobby of ethics-minded
doctors who have been regularly contesting elections for the Medical Council but every
time the elections have been rigged, and this has been brought out by an inquiry^well. J '
The participation in these various processes was in a spirit of mainstreaming thepe ideaso)
Amar felt that that any data churned out had to be focussed on those who were going to
use it and understand it.
Answering questions, he informed that in one of the malpractice cases filed by CEHAT’s
campaign, Mumbai High Court has decreed that patients have a right to their medical
record. During the discussions the Chair felt that the uniqueness of CEHAT’s
campaigning had been the coupling of education and awareness building (both among the
victims and perpetrators), with negative campaigning and confrontation.
PEACE
Anil Choudry of Popular Education and Action Center listed out the activities of his
NGO, which works through field, based organizations in the Hindi belt.
• Facilitating learning
• Supplying material continuously
• Networking to distribute information
• Counseling within/with groups
• Linking people / grassroots organizations with other specialist organizations.
'•
11
To do this, PEACE has a Public Interest Research Group, which simplifies data, makes
its relevant for the reader, distributes it and helps in advocacy for policy changes. It also
does social analysis, organization building and helps in organizing campaigns.
‘
According to Anil^^ounderstand anything it must have experiential basis and should be
local-specific.'J It campaigned against the New Economic Policy and also produces^
handbooks on various acts and conventions that India sign^tHe stressed the need for
NGOs to be continuously updated and PEACE attempts to do this by enabling people to
generate / analyze data. PEACE’S main aim, he said, was to bring back the culture of
questioning, instead of accepting. RN said that any such training or awareness building
should be towards a questioning of the situation rather than adjusting to circumstances.
An innovative form of networking that was apparent with PEACE was the concept of
sharing infrastructure, where other groups were welcome to use computers, stationery
and skills etc., of PEACE during their campaigns, this led to credibility and trust and
solidarity and information sharing.
BELAKU TRUST
Sarswathi Ganapathy talked about her experience as a neonatologist turned social activist,
after visiting areas on the outskirts of Bangalore. Her initial visits to the rural areas had
shocked her because of the poor quality of care in community and/paftum practices. She
talked about intramuscular Pitocin administration to mothers in laboj, and of payments
that poor patients had to pay for greasing the palms of every health care provider, leading
to a very high ‘cost’ of ‘free’ treatment. Shetai&dike Amar earlier, spoke of the easy
acceptability of private practice regardless of ‘quality’ due to the fact that-the^ treated the
patients better tha^he generally rude governments doctors.
y .^3
kTler method of campaign is to talk to everyone about her indignation. This spreading of
/ awareness itself was enough as the collective response to her anguish showed the
• . possible ways ahead^ Another crucial part of the Belaku experience was the openness to
I learn as one went alongAthis was crucial as each problem was so complex that ready
made answers were never available. Thisz in her view has paid dividends because she has
now got the local pharmacist and the local nurse with her and with them had formed
village health fora that discuss health matters. Saraswathi wondered if these fora could be
linked to the national Health Watch to “collect’ data on how bad it is’. Another
interesting point highlighted was that not only was the quality of data available bad, but
there seems to be a subconscious filtering out of the socio-economic-cultural flavors of
the data collection and the data itself. She also noted that with the researcher lies a big
responsibility, that was not only analyzing what you have learnt but what you are going
to do about what you have learnt.
RN endorsed Jjer experiences and said that the corruption that she had seen and we all
see, somehow never forms a variable in research and hence escapes being analyzed as a
cause of ill health.
12
VIMOCHANA
Donna Fernandes gave a passionate account of Vimochana’s campaign of highlighting
the issue of homicidal killings of young brides that were being written off as accidental
deaths. She shocked many in the audience from outside Bangalore when she said that
cases a day were being admitted to the Victoria Hospital Bums ward. And 70 to 100 of
those admitted were dying every month in Bangalore. She talked about how
VIMOCHANA started by documenting all such women’s names,speaking to the parents,
and using this data as a base,tag4 getting many police cases reopened. They held press
conferences and public awareness programs where VIMOCHANA highlighted the
callousness towards such a horror at every level from the filing of FIRs to the performing
of post-mortems to society as a whole. She claimed that the biggest criminals were the
professionals, a charge she substantiated with instances which VIMOCHANA had found,
where doctors had taken money for a false post-mortem, and police had taken a portion of
the dowry for the price of their silence, showing the depth to which they could stoop.
The VIMOCHANA campaign also included a public TRUTH COMMISSION and its
efforts paid off when the police commissioner was hauled up to the floor of the
legislative assembly and censured by the legislative house committee.
Despite this, Donna felt that it was important to sensitize the police, a task
VIMOCHANA is carrying out. Its efforts had also led to the drastic improvement of the
condition of the once horrific bums ward.
The meat of her narration was her statement that ‘it would not be enough to be a
watchdog; GHW would have to be a barking dog to be effective. However one cannot
bark if one is not watching.”
DEPARTMENT OF SOCIAL MEDICINE AND COMMUNITY HEALTH.
JAWAHARLAL NEHRU UNIVERSITY
Dr. Mohan Rao from JNU shared his experience about the Quinacrine campaign in which
he and the faculty of the School Of Social Medicine and Community Health had
launched.
He started by providing a background about China’s entry into the WHO in 1978
coinciding with the Alma Ata Conference and how it had successfully raised its life
expectancy of 22 years to 62 years in a matter of just 30 years. He also talked about the
decline of the role of WHO and the rise of WB’s importance on health since the late
eighties.
Terming RCH as a now acceptable term for Family Planning, he was worried the ‘target
free’ would be translated to ‘responsibility free’ as already shown during the quinacrine
scandal. He detailed the abuse of Quinacrine that was being used by a Calcutta
gynecologist running an NGO as a research project for permanent sterilization of women
despite ICMR having failed at it and WHO’s strong views against it. Couched in
13
I
language of ‘women’s empowerment’, the research had incensed various sections of
society and as individual members, many of the faculty of JNU and the women's groups
out of the many backing the campaign, had filed a Public Interest Litigation. The PIL
sought to highlight,
> The issues of accountability of NGOs / voluntary organizations
Punishment for doctors involved in such practices
> ICMR to trace the thousands of recipients of such corrupt practices and compensation
given as in Bhopal. A
> Need for a system J monitor the Public Health Action and research.
However in a shockingly superficial judgement, the court had trivialized the matter by
merely banning quinacrine and closing the case. Mohan Rao tried to highlight how even
well planned activism can miss the target once you get entangled with the tangles of
bureaucracy and judiciary.
PEOPLES SCIENCE MOVEMENTS
Dr Sundar Raman talked about his NGO and said that its main aim was to question the
scientific profession and acheivements. Because of the fact that the scientific
professionals and their work had not benefited the poor and the marginalised, Peoples
Science Movements (PSM) had attempted to raise people’s consciousness about this fact
in an effort to make Science and Technology more relevant to the needs of the majority.
For anyone trying to do this, he felt that one needed
• Public awareness
• Possibility of organized action by people
• A place on the political agenda.
Sundar said that any campaign needed about 2% outreach to remain visible as a
movement, more than 20% to make an impact, but to effect a change, one needed to
reach out to at least 50% of the people.
PSM has also been making advocacy campaigns of which the main is
• Demands on the state for policy change and state intervention making the state pro
masses# in letter and spirit and action
• Demand on medical profession to sensitize them on existing inequalities, their role in
its continuance and their responsibility.
• Demand on the people culturally and educationally making them more aware of their
rights and duties. ,
• Demand on PRI^ to make health and local appropriate development part of their
agendas.
The advocacy work of the PSM has had a large support base especially from women’s
groups / progressive writers / cultural societies and trade unions. Talking about PSM’s
campaign for drug policy he said PSM had used mass awareness drives^mass publication^
and organized jathas, rallies, lecture dialogues, seminars and boycotts.
J?
1
ul
or
14
He felt that Community Action for Health must not be a substitute or a parallel to the
state action, but should try to improve them by empowering communities, women, and
PRI’s and by creating awareness. He felt that any community health action program must
be able to provide visible gains in health to sustain the interest of the community and the
health activists. He felt that a campaign must be able to link up with other sections of
society and mobilize people for policy issues.
Anurag endorsed his view about science moving away form the people and said that
unless medical professionals so not look beyond the germ theory of disease, people will
not be benefited. Other members felt that not only should the discussions include germ
theory vs social theory but question the much broader conceptual framework
(reductionism) in which these arose.
SESSION VI
The last session saw a discussion on the questionnaire that had been circulated before e
the dialogue. Sunil made a presentation of the range of responses each question had
elicited /f^rm the responders and the groups fed in their perspectives on the rather
comprehensive list of responses. An attempt was made to prioritise and practically
simplify the issue at hand. A report of the same is attached as ^nnexure no —
(IM
The meting ended with Dr. Benjamin and Dr Ravi Narayan trying to elicit at least one
commitment from each of the participants. It was decided to set up a core group to carry
the process forward. The members who volunteered were
1.
2.
3.
4.
5.
6.
Dr. Mohan Rao.
Dr Muraleedharan.
Dr Sundar Raman.
Dr Sunil Kaul.
Dr. Ravi Kumar
Mr As Mohammed.
Anil committed that PEACE would send monthly monitor of multilateral and trade
agreements to CHC. Ravi on behalf of CHC gave a commitment to send a report to
everyone and to the NGO forum of health. There was also the suggestion to form an egroup. CEHAT which has a website (www.cehat.org) said that GHW could be part of the
website and be updated regularly.
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Systems
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registrati
on
Nation (local)
SRS
To provide reliable
estimates of births &
deaths
Cont.
enumer
ation
National
State
S.Unit = 6671
Pop.= 0.6%
Births & Deaths by other
demographic and social
characteristics including
religion, literacy and
occupation_________ _
Births & Deaths with
age, sex, rural/ urban
MRS
To provide most
probable cause of
death for rural India
Cont.
enumer
ation
Nation and
State
Sample PHC
= 1,731
Deaths & Births
Age, sex and cause wise
death rates for rural
India
HMIS
To provide timely
aggregated information
on health upto PHC
level_______________
To provide state and
national level estimates
of fertility, IMR, practice
of FP, MCH care and
utilisation of MCH
services
Cont.
Nation
Births & Deaths
Age and sex and cause
wise death rates
Nation
Fertility, IMR, FP
practice, MCH care and
utilisation of MCH
services by sex, age,
urban/rural,
caste/religion
CRS
NFHS
Others
MICS/R
CH
Ad
Organised
by________
Ministry of
Home affairs
Information
available at
District levql /
village level
Dept, of
Panchayat
Police
Health
Revenue
Directorate
of Census
opm., Eco.
and Stat.
Health & FW
Directorate
ofH&FW
and
Eco. and
Stat.
Directorate
ofH&FW
District wise
Ministry of H
&FW
State level
State level
State level
Dist ict level
[
. y
zCO^UNITY HEALTH CELL
Phone
Fax
Email
5531518 / 5525372
(080) 5525372
sochara@vsnl.com
No. 367, ‘Srinivasa Nilaya’, Jakkasandra, 1st Main, 1st Block, Koramangala, Bangalore - 560 034.
Communication Two
24th September 1999
Dear
Reg: Global Health Watch (National Meeting : India)
Further to our invitation to you dated 9th September with enclosures, we have noted the
confirmation of your participation and welcome you to the National Dialogue on Global Health
Watch.
Enclosed are the following:
G)
A registration form to be filled in and sent to us as soon as possible (to reach us not later
than 3rd October, 1999;
(ii)
An extract from the WHO-NGO Policy Consultation in 1997 when the GHW with equity
focus was developed;
(iii)
An overview of NGO initiatives on Watches’ all over the world. Though the compilation
from WHO is strong on 'Northern Watches', we hope through this meeting to enhance the
information of 'Southern Watches' as well.
(iv)
We await the questionnaire sent to you earlier. Due to oversight, page 6 which was
corrected was sent without modification. A replacement of this page is enclosed.
Do send us the questionnaire and registration form to reach us not later than 3rd October, 1999.
The questionnaire is really a stimulus to think about the idea. There may be sections you do
not wish to fill. There may be ideas you have that are not included. Please complete as
much as you feel is relevant and send as soon as possible so that we can compile the responses
and enhance the interactive / participatory nature of the meeting.
Looking forward to your participation,
With best wishes,
Yours sincerely,
Dr. Ravi Narayan.
Enclosures : as above
ESi You can use fax No. (080) 552 53 72 or Email : sochara(a)vsnl.com to speed up the
process.
Society for Community Health Awareness, Research and Action
Registered under the Karnataka Societies Registration Act 17 of 1960, S. No. 44/91-92
Registered Office: No. 326, Sth Main, 1st Block, Koramangala, Bangalore - 560 034.
GLOBAL HEALTH WATCH (National Meeting : India)
Date :7th/8th October 1999
Venue : Ashirvad, No. 30, Off St. Mark’s Road, Bangalore 560 001.
Registration Form
1. Name
2. Academic / Work Background
(Mention Discipline and focus of experience)
3. Organisation Represented
4. Address
Fax No.
Tel No.
Email :
5. Postal address (If different from above)
6. Arrival on
By
(mode)
7. Departure on
By
(mode)
At
(time)
At
(time)
6th night
8. Accommodation : required / not
required:
Dates
7th night
8th night
9. Will like to Present experiences / or
issue of
10. Travel supported by own organisation
11. If no in 10, then Require Fare
Yes
No
(estimate)
12. Any Special suggestions?
Date :
Place :
Signature
(Send back latest to reach us by 3rd October, 1999)
ISfeE
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WHO/PPE/PAC/97.3
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Outcome of o Formal Consultation with
Nongovernmental Organizations held at WHO Geneva
2 and 3 May 1997
lyig^gfan
JlHSb
-(Q
w
WORLD HEALTH ORGANIZATION
WORLD HEALTH ORGANIZATION
Special thanks mustthefollowing individuals in NGOs who made
an important
nbution to the preparation ofthis report:
Dr GlOV^mKallerio, Bahai International Community
77115 / eportfrom NGOs was coordinated by Dr Roberta Ritso.
72
Mr Peter Iversen andMs Kimberly Inge
of WHO s Policy Action Coordination (PAC) team
’/’■
© World Health Organization 1997
other-without the prior written permission of WHO
The views expressed in documents by named authors
No °fA
05
onlc> mechanical or
are solely the responsibility of those authors.
Executive Summary
The WHO Policy Action Coordination Team convened a
formal consultation in Geneva on 2 and 3 May 1997 with
representatives of more than 130 nongovernmental organizations
(NGOs) to review the new global health policy, "Health for All in
the 21st Century."
The WHO/NGO consultation brought together not only
NGOs working directly in public health, but also those NGOs in
sectors that indirectly influence health, such as education,
agriculture, business, environment, and habitat, as well as NGOs
that address inter-related issues such as human rights, gender,
women, children and individuals with disabilities. Multisectoral
NGOs representing a broad and diverse spectrum of concerns
contributed specific examples from communities worldwide that
"health is everybody's business."
WHO’s major aims for the meeting were to consult NGOs
on global health policy development; to identify the potential roles
of NGOs in implementing the new global health policy; and to
identify, strengthen, and create new structures for NGOs to
collaborate with WHO at the local, national, regional and
international levels.
(
In the past five years, the series of United Nations Summits
have abundantly illustrated the immense influence of NGOs in
global policy development.
A Global Health Watch system, to be managed and
operated by an NGO group and modelled after Amnesty
International's work in human rights, was proposed as a new
collaborative structure that could serve a crucial function in
stimulating the political will necessary to-prompt the timely
translation of policy into action and to monitor how well
governments, NGOs, and the private sector are fulfilling Health for
All responsibilities.
i
i
The views of NGOs which participated in this consultation
on renewing the Health for All strategy were explicit in calling for
NGOs to promote the adoption of a universal "Health for All Value
System." Its essential features include:
i
t
1) championing the importance of health as a human right,
based on principles of social justice that maintain:
-Everyone is of equal worth
-Everyone is entitled to respect and personal autonomy
-Everyone is entitled to be able to meet his or her basic
needs.
2) promoting ethics, equity, solidarity and sustainability as
well as a gender perspective in all health policies.
The call for Health for All is fundamentally a call for social justice.
Specific priorities, such as promoting the advancement of
women and increasing the participation of women in
decision-making, have direct effects on health status. NGOs shared
a wealth of experience in approaches to influencing policy and
practice related to improving women’s health, with far-reaching
effects on policies and programmes on improving the well-being of
men, women, and children. Some NGOs expressed the opinion
that only when women are able to function as full partners in every
level of decision-making will the moral and psychological climate
necessary to attain Health for All be achieved.
There was common agreement amongst NGOs on the need
to promote a vision of health as being central to sustainable
development. They deplored the fact that 1.5 billion people around
the world still do not have access to basic health services.
Eradication of poverty is essential in all efforts to achieve a good
standard of health.
The NGO Forum for Health, a group of multinational
NGOs with a common interest in primary health care and global
health, stated that: ’’At its heart, Health for All is a moral and
ethical imperative. We call for a more profound definition of health
to include the spiritual dimension as an essential component.”
Many NGOs echoed the belief that unless and until the
spiritual implications and ethical challenges of Health for All are
acknowledged fully and addressed systematically through a process
of consultation with all key players, including WHO, NGOs, and
governments, the achievement of Health for All will be hampered.
There was general agreement that WHO could work more
effectively with NGOs in the future if it were able to work with a
broader range of multisectoral NGOs and not just the narrow range
of NGOs now admitted into official relations with WHO. This
would mean a review of existing criteria and arrangements for
official relations with WHO, as well as a strengthening of WHO’s
ii
I
I
i
current NGO liaison office to promote expanded partnerships and
working relations.
The renewed and strengthened partnership of WHO and
NGOs, and the efforts to reach out and involve the diverse
communities represented by the NGOs, contributed to promoting a
sense of hope and a vigorous renewal of effort in a spirit of world
citizenship to achieve the vision and aims of Health for All.
y
OB;
I
iii
Chapter 3: Future action by NGOs to enhance health
The needfor a gender
perspective will be
vitalfor planning and
implementing policies
and strategies and is
complementary to the
advancement of equity.
Representing the most vulnerable groups
NGOs have a long experience of working with communities
and representing their needs and priorities. In many countries, NGOs
provide the only health care or social welfare services available to the
poorest and most vulnerable groups. They operate where no
government or formal health care services are available, often free of
charge, and work with volunteer staff or at very low cost. They are
much closer to the grass-roots of society than any government
services, or United Nations agency, and are in many cases the only
voice of these underserved populations. NGOs often complement and
support the work of formal government services. To enhance the
effectiveness of this work by NGOs, there must be better coordination
between WHO and NGOs, with clearer priorities and goals.
i
I
7
Equity and gender
Helping to ensure equity in health is one of the most important
contributions of NGOs, and there is ample evidence of their impact
in this area, particularly through their work with the most vulnerable
population groups. More particularly, NGO groups with a special
interest in women’s affairs and gender differences can have significant
influence in ensuring gender sensitivity in health policies and
practices through effective advocacy, information sharing and
lobbying.
WHO-NGO
partnership should be
^oen to all those that
m contribute to
certain issues within
the scope ofthe entire ■
work of WHO,
including the renewal
ofthe Health-for-All
Policy. Mechanisms
for ongoing NGO
consultations twice a
year should be
established.
NGOs have already played an important role in getting equity
and gender issues high on the development agenda through their
effective action at the numerous United Nations Conferences, and
Summits, of the past decade. NGOs from all sectors played a
significant and successful role at these summits in consciousnessraising, advocacy for equity and gender equality, and lobbying of
governments and development agencies. This will continue to be a
vital contribution by NGOs in the future.
Many women’s groups had a strong focus on health, several
of which participated in the Geneva consultation on the new global
health policy, such as the All India Women’s Conference, Associated
Country Women of the World, International Council of Jewish
Women, as well as the Global Alliance for Women’s Health and the
International Community of Women Living with AIDS. For the
future, stronger alliances were needed amongst these NGOs, with
each partner identifying its specific strengths and future’ role.
C)
I
8
Healthy Women’s Counselling Guide
Several NGOs recently joined WHO's Special Programme for
Research and Training in Tropical Diseases (TDR) in a project to advance
gender perspectives in health through the development of the Healthy
Women's Counselling Guide. This guide focuses on women's health in a
holistic sense across the lifespan, not restricted to their role as a mother or to
specific periods in their life.
A number of WHO technical programmes worked with a group of
women’s interest NGOs.to develop a series of clear and simple health
messages. These were to be distributed by NGOs and health workers to literate
and illiterate women. The messages were developed in collaboration with rural
women and community-based women's groups in Sierra Leone, Kenya and
, Nigeria in the form of "soap opera "radio tapes, and illustrated booklets. The
impact of the guide on women’s health issues has involved a number of
international donors and foundations as well as the United Nations Drug
Control Programme in a model of participatory cooperation on gender and
health.
r
I
!
<■
■ • .
Advocacy and political support
NGOs can also play an important and increasing role in the
future in advocacy for health, drawing the attention of governments
to inequities in health services, in housing and education or in
exposure to environmental hazards. They already play an important
role in the political arena through successful lobbying of government
to address inequalities and social injustices. They exert considerable
influence on public opinion and act as the moral conscience of
society.
NGO Global Health Watch
NGOs at the Geneva consultation expressed deep concern ±at one
and a half billion people throughout the world still did not have access to
basic health care services. To address this glaring inequity, a group of
NGOs, known as the NGO Forum for Health, proposed to set up a Global
Health VVatch to monitor how governments, United Nations agencies,
including WHO, and NGOs themselves were fulfilling their commitments
to Health for All.
The NGO Forum for Health, formerly known as the International
Primary Health Care Group, is long-established with members from a wide
range of multisectoral interests, and has a major focus on primary health
care and the Health-for-All Initiative. Its members are particularly wellplaced to monitor and report on equity in health and development at
country, regional and global levels.
ES
/
9.
Today, the State faces
pressures from above,
below and within.
From above,
globalization of trade,
travel and
communication has in
some countries led to
marginalization from
world trade and
increased exposure to
a range of
transnational threats
to health. From
below, demandfor
decentralization and
the growth of local
government have
reduced the needfor
centrally planned
policies.
NGOs and the changing role of government
The changing role of government is one striking feature of the
closing years of the twentieth century, which will become more
marked in the coming decades of the next centuiy. There is certainly
a loss of power and prestige, as well as resources, in the government
sector, which has a significant impact on health and social welfare in
general. This is in part due to the economic constraints of the recent
past.
Privatization in the health sector, as well as in many other
sectors, is another trend which has an immediate impact on health.
Private enterprises, as well as nongovernmental organizations, are
stepping in to fulfil the role of government in many areas of health
care services. It is clear that market forces operating in the health
sector, if left unchecked, will prevent access to services by the poorest
and most vulnerable communities, operating counter to the principles
of equity.
. If NGOs are to play an important role in the future by
providing services for the poorest groups and helping to ensure
equity, this means a closer collaboration with government and a clear
definition of roles for NGOs.
It is clear that multisectoral NGOs, operating in all areas of
social development, will have an equally important role to play in
promoting health, working alongside and in partnership with NGOs
representing the health science professions and formal health care
sector.
Better coordination and cooperation
For the future, it is clear that NGOs could be much more
effective if their work was coordinated amongst themselves, and if
there was much closer cooperation with both the government sector
and the efforts of WHO and other development agencies. This will
require changes within both WHO and NGOs and give a broader
scope of interaction.
For joint policies and plans to achieve this greater cooperation
and coherence, there needs to be a much closer relationship between
NGOs and WHO, with joint policies and strategies for action, based
on common goals and a recognition of clear priorities. The expertise
of NGOs at country level, especially with the poorest communities,
should be clearly recognized by WHO, which lacks effective direct
contact with the grassroots levels of society. NGOs should be invited
by WHO to collaborate on policy formulation and strategy
development, instead of merely being' acknowledged for their
successful implementation.
10
•n;
I
I
WHO should look more closely at effective mechanisms for
k
The criteria for
admitting NGOs into
official relations with
WHO should be
revised to take account
of the new policy
directions which
emphasize social
development. The new
criteria should
recognize different
organizational
structures for NGOs,
such as networks.
collaboration with NGOs and establish joint committees and
procedures for partnership in the health sector. Changes are needed
both within WHO and within NGOs to facilitate these joint ventures,
and WHO could benefit in particular from the experience of NGO
groups in the many different sectors which impact on health, such as
education, environment, food and agriculture.
WHO can contribute by promoting the role of NGOs to
governments, and by emphasizing the complementarity of the NGO
contribution to health and health care. To facilitate this at the country
level, WHO country offices could make an inventory of the NGOs
working in each country, their- resources and their areas of
cooperation. This would form the basis for a joint and coherent plan
of action for future cooperation on health between governments,
• NGOs and WHO or other international development agencies.
NGO action on the Family and Medical Leave Act
The National Council of Jewish Women (NCJW) in the United
States has recently proposed significant changes in the Family and Medical
Leave Act to make provision for more parental involvement in children’s
education and welfare. A comprehensive study carried out by the NCJW
called Parents as School Partners showed that constraints in both the
workplace and the school setting made it difficult for parents to participate
in school and community activities.
The findings of the NCJW study will be used to enhance
community participation in a wide range of projects, involving public
Information campaigns and information fairs.
A-
11
Possible Threats of Globalization for Health
Global Factors
Health Status
Consequences and possible
negative impact on:
Macroeconomic prescriptions
(e.g. SAPs*)
= marginalisation, poverty, inadequate
and decreased social safety nets
Trade
+ tobacco, illicit drugs and
alcohol, increased
marketing, availability and use
Travel
# infectious diseases South to
North; harmful lifestyles and products
North to South
Migration
+ inequalities and ethnic conflict leading to
refugee growth and civil conflict
Food security
+ greater vulnerability in Africa as China
imports more grain
Environment
+ global and local threats from rapidly
increasing, unsustainable consumer-led
demand .
Technology (direct medical)
# diagnosis outstrips treatment;
treatment increasingly unaffordable
for poor
Values
# equity and human rights under pressure
from global homogenizing forces
Foreign policy
# xenophobia, tough immigration laws as
some States try to isolate themselves
from global forces; threat to
multilateralism in face of common
global challenges
Communications and media
# marketing of health-damaging
behaviour; erosion of cultural diversity
= possible short-term problem that could reverse in time
+ long-term impact profoundly negative
# great uncertainty
* Structural Adjustment Programmes
14 .
I
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
1. Introduction
During the last 15 years there has been a dramatic increase in the number of NGOs and an increase in their
areas of activities. Many of these NGOs fill a “watchdog” function, e.g. NGOs or netw orks of NGOs monitor
State's behaviour in relation to Human Rights (HR) and social security systems, or they monitor the
environmental degradation, alerting the global and national community when action is needed. One common
feature of these “watchdogs” is that they are associations of human beings in their private sphere of life or
NGOs, coming together for a cause and acting as citizens with or without special expertise. This development
has been especially marked in the developing world. Civil society steps in w'hcrc States fail to. are reluctant
to, or cannot act. Some of the most well known w'atches are active w'ithin the field of HR. such as Amnesty
and Human Rights Watch. These watches are prominent and have been successful within their field. Another
area where watches have had success and have been acting for a 10-15 year period is the environment (for
example Earthwatch, World Watch Institute and Earthscan). There is an emerging demand and need for a
“watch” to focus on health and public health.
This document will
1) present conclusions relevant for a Global Health Watch (GHW)
2) discuss likely parameters for‘•success”, of a watch: What working methods, what level of cooperation and
with who, and what form of information dissemination has been successful?
3) give an example of a method for impact assessment of advocacy dc\ eloped by the "Social Watch”.
4) give an overview of NGO's/walchcs active in the field of hcallh/hcallh rights.
For a description of NGO’s contacted or discussed see annex 2
2. Conclusions to be drawn for a Global Health Watch
There is a need for a global network with unified objective/focus on health and health rights, since
no such watch exists.
The founding idea of an NGO has to be a grassroot initiative, and cannot be fed into an NGO. There
arc today many initiatives within health. A GHW would profit from cooperating/networking with
them.
The active participation of volunteers even within research has shown to be very successful and to
increase the sense of ownership: a GHW could be enriched by the energy that volunteers provide.
Networks seems to be the most profitable way of cooperation, combining a unified goal with freedom
of work. This w'ould also make it possible to profit from all the already existing NGOs working in
health and avoid duplication of efforts.
The rights perspective is increasingly common in all parts of the world!
Using scientific methods, striving for measurable comparable results gives credibility GHW could
benefit from cooperating with the Social Watch and their lulfilled commitments index, also
considering that their mandate partly covers health.
Q
Considering the capacity for disseminating information and making an impact already existing
w'ithin the NGO community, a GHW would profit from cooperating with most global NGO's
mentioned in this document.
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
3. Determinants of Success
3.1 What is “success” in this context?
Relating the success of these NGOs to their objective, which is generally broad and unattainable (for
example, a world with “no human rights abuse” or a world with "no environmental damage*') it is difficult
to measure results. In some cases however, clear results arc seen, such as Amncstx 's success in some of their
individual cases of political prisoners, China’s change of agricultural policy as a result of Lester Brown’s
report “Who wall feed China”1, the International Baby Food Action Network's (IBFAN) work together with
WHO and UNICEF on the International Code of Marketing of Breast-milk Substitutes w'hich was
subsequently adopted by tlie World Health Assembly in 1981 or the fact that the Pugwash Conferences2 and
Joseph Rotblat received the Nobel Peace Prize in 1995 for the work on slopping the nuclear arms race
Other signs of successful advocacy are less visible. Some NGO s have mentioned a change in the public
debate3, or that politicians and legislators use a vocabulary and concepts earlier introduced by that NGO.
SIPRI has pointed out that there is a discussion/dialoguc at all is a sign of success, since an NGO has a
unique possibility to provide a non committing forum for discussion.1 SIPRI also mentioned that the public
is more aware of issues relating to peace and conflict research now than 10 years ago. which can partly be
ascribed to the work of all NGOs active in this field. Amnesty acknow ledges that the fact that work is being
done at all in certain fields, even if no tangible results can be shown, is belter than lolling issues being
completely forgotten.
3.2 Possible denominators of success
Listed below arc some of the factors that the NGOs themselves identify during interviews as having been
important for their success, sec also tabic in annex 1 for an oven iew of denominators. The watches perceive
their success differently and their work methods diflcr. explaining whv not all factors arc applicable to all
watches. The factors listed arc core factors found in many successful watches.
Abbreviated version of table, annex 1
Overview of Global NGOs and dctcnninants of success
1
2 3
5
6
7 8
Amnesty__________
X
x
x
Earth summit W
Earthscan________
Earthwatch_________
x
x
X
X
X
X
X
X
GLOBE___________
X
X
Human Rights Watch
X
x
IBFAN___________
IPPNW__________
X
IPPF_____________
X
X
X
X
x
X
X
MarineWatch
Multinational Monitor
Northwest Environment
PRIO
X
X
X
X
X
X
X
X
1 The author Lester Brou n is the director of Work! Watch Institute.
2
The Pugwash Conferences on Science and World Affairs, inception in 1957. members are scientists. some former nuclear engineers.
3 Freds och konflikts forskning. Uppsala Universilet
4 Stockholm International Peace Research Institute (SIPRI). that acted as a bridge East-West during the Cold War. Interview Jean Pasqual Sander
23/9
I
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
Project Ploughshares
Social Watch_______
The Pugwash Conf.
Women's Rights Action
X
x
X
x
x
X
X
X
X
Alan Guttmacher Inst
X
X
X
X
Women Watch______
X
World Watch Institute
X
X
___________________
X_______________
X
X
1. Grassroot initiative, 2. Combining research & advocacy, 3. Cooperation with national NGOs, 4. Credibility, 5. Effective dissemination of
information, 6. Flexible networks, 7. Members professional status, 8. Participation of volunteers
“Being a grassroot/citizen’s initiative” (1)
That the NGO is a true grass root initiative has been shown to be a cornerstone of success. A movement
based on the initiative of people that have a strong urge to work/fight for their issue is immensely important
for the strength of a watch. An NGO with this foundation will have a large number of volunteers ready to
work for it and it will benefit tremendously by the word of mouth method of spreading their information. In
practice this is the core of a functioning, active, civil society. For examples, sec table in annex I.
Active participation of members/volunteers (8)
Members of NGOs are involved to different degrees. They may hold a passive interest, they may actively
participate within designated fields or they may be involved in higher level functioning of the organisation.
To use members and volunteers in research missions and advocacy, has shown to be successful. For example.
Amnesty is a democratic organisation who's mandate is entirely defined by its members. Members also take
part in the research and fact finding missions together with employed researchers and representatives of the
organisation, besides acting as members on behalf of political prisoners. Earthwatch docs not conduct anv
research without having the research teams consist of approximately 50% volunteers. In fact, Earthwalch
builds its organisation on the idea of linking researchers and the public for a common cause. IBFAN is
another organisation that ascribes their success partly to (he fact that their organisation is founded on grass
root initiatives.5
Cooperation with other national NGO's/Country representation (3)
hi order to access information, to reach a broader population when disseminating information and to activate
people at the grass root level, many of the watches cooperate with national NGO's. Being affiliated with a
global reputable NGO also legitimizes the work of smaller NGOs in countries where civil society is not
functioning freely. In areas where it is impossible for national NGOs to function the watches have country
representation, or regular fact finding missions.
Credibility (4)
The information the watches 1) receive and 2) disseminate must be 100% reliable or the NGO will loose its
credibility, especially since the watches function as a kind of citizens police. Many of the successful
watches like Amnesty7 and Human Rights Watch have developed systems to collect information and
rigorously assess it. By being active, independent and objective and at the same time identifying new
important issues many of the organisations have achieved crcdibilitv.
How is this done?
The NGOs use renowned researchers employed long term by the NGO to perform fact finding missions and
conduct research, as well as in some cases members or x olunteers. The watches constantly monitor activities
using tlie media, official documents and most importantly, the organisations ow n contacts on the ground, such
as local NGO’s and like-minded organisations. Naturally information from reputable research institutions
3 Tina Pfenninger IBFAN 22/9
A Global Health Watch” - Initial overview.of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
which^are not themselves trying to change public opinion is used. Also fact finding missions and in some
cases representational missions to influence a country are used.6
Effective dissemination of information (5)
When the NGO has access to objective information it must inform the relevant population. For many of the
NGO s the target population is very7 large to achieve maximum impact in a global society. These factors have
been considered by successful watches:
•
1
Timing, some of die w'atches perform an analysis to get maximum impact for their report.7 World Watch
Institute tries to time their publications with for example large symposiums on different issues, such as
the tobacco and the climate issues.
• Accessibility/availability. Infonnation must be accessible and available both to professionals and laymen
to achieve broad recognition. For example “The State of War and Peace??8 by D. Smith director of PRJO
is written in a pedagogical and easily accessible way, accessible to an interested member of the public.
World Watch Institute’s yearly publication “State of the World” is available in 28 languages and in a
number of universities over the w'orld. The use of new7 information technology like websites on internet
and e-mail has made infonnation available to a vciy- large population previously not reached.
• Targeting population-. If the target population is identified al the stage of writing a report it w'ill get a
better public response. ’’Who will feed China” by Lester Brown, World Watch Institute, is an example
of that. Human Rights Watch has offices in all regions of the world to be able to target policy makers and
legislators.9
Flexible networks/cooperation (6)
Many NGO s discussed in diis document arc networks of NGOs, following a loose organisational structure,
which seems to promote ideas and cooperation.
i
Members status (7)
SomeNGOs lend credibility of their members, that is the members professional background. These are the
NGOs where professionals, as individuals, have joined themselves together for a cause related to their
professional life. For example; the Pugwash movement where nuclear scientist arc working for a nuclear
weapon free world, and GLOBE, an association of legislators and policy makers working to enhance
cooperations between parliamentarians on global environmental issues.
Combination of research with advocacy and participation (2)
To combine performing research, with advocacy and participation of members is a fruitful work method
Prioritizing
For NGOs with a broad mandate, prioritizing is difficult, but necessary. This implies choosing to act or not
6 Director, media programme Amnesty, /Xnita Tiessen 24/9
7 Human Rights watcli, Susanne Osnos 23/9
g
Published by Penguin 1997, ISBN 01405137365
For example in Brussels, Tokyo (Japan is a major donor), and Washington.
t..
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
balancing urgency and the possibility' to make an impact with available resources. A pragmatic application
of International Law is required, i.e. to base the activities on the demands of the real world and then to apply
necessary and applicable international and national law.
3.3 System of measurement, qualitatively and quantitatively, an example
Not many NGOs have a formal system of measurement available for outside researchers, to evaluate the
impact of their advocacy. A system is a set of indicators, thus making comparison possible between projects
or even between NGO’s. However, many of the interviewees trust their “experience”. This makes it difficult
to objectively conclude which methods of work have been more effective than others.
An exception is the newly instigated Social Watch and their “Fulfilled Commitments Index” (for a
description of the Social Watch see annex 2). The Social Watch has developed a system of indicators, both
qualitative and quantitative, to measure the “rate” of fulfilment of a number of Conventions ratified by a
individual states. They divide their indicators into two categories “Political Wilf' and “Distance from Goals”
and have managed through a complex but comprehensive system to create internationally comparable
fulfilments status report for individual countries (see annex 3). Each catcgoiy is divided into subcategories,
and they in turn are divided into packages of variables. The Political Will category is aimed at measuring the
degree to which the governments express their political will to change social policy. The Distance from Goals
categoiy describes how far or near a country is from what they have committed to.
4. Other NGOs Involved in Health
Some global NGO’s are involved with health related questions within specific areas, mostly regarding health
determinants. There are also a number of national NGO's involved in health, more or less focused on special
issues. As a result, there are a number of iniliatix es within many different areas of health, all striving towards
different goals. No NGO is working solely with a unified focus on human health and health rights.
Overview of global NGO’s activities in the health field
NGOs
HEALTH ACTIVITIES
Italics indicate
national NGO
Amnesty
Amnesty fights torture and has recently started to work for the elimination of female genital
nutilation (FGM). They organised a conference in Ghana 1996 on 1-GM and has a mailing
■ campaign.
Earth Summit Addresses health determinants. Monitors stales fulfilment of promises made al lhe Earth Summit
Watch
n Rio, has the past 5 years monitored li’ealies in lhe follow ing areas: climate change, biodiversity,
forests and Agenda 21. Specific reports: An assessment of national action to implement agreenents made at the International Conference on Population and Development (for example
concerning the availability of family planning sen ices), a report on the fulfilment of the Cairo
Programme of Action “Clean Drinking Water: A new Paradigm for Providing lhe World’s
Growing Population with Safe Drinking Water” and a report that lead to the global phase out of
eaded gasoline.
Earthscan
publisher
Publishes in the area of a sustainable development, specific areas regard children and the
environment and primary health care.
A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
Earthwatch
ne of Earthwatch’s programme areas is World Health; projects studying Public Health and
^ndigenous Systems of Resource Management and Medical Care. Specific projects arc; “Maternal
Tealth in Africa (Zimbabwe)”, “Helping the Homeless”, and “Community Health in Cameroon”.
GLOBE
Dne of GLOBE s working groups is dedicated to Human Health, while other working groups
iddi-ess health determinants such as Fresh Water and Population. Specific outcomes of the Human
health working group are two action agendas: Children’s Environmental Health Action Agenda
ind Sexual and Reproductive Health/Rights Action Agenda.
Harvard
empowers patients with concise accurate infoimation to help readers make informed decisions
Women's (and ibout their“ own care.
Men fs) Health
Watch
A Publication
Health A ction s involved in health education
___________
_
and research,
works mainly with community based organisations.
Information \ Work is emphasised on reproductive health.
Network
Health in Action Develops and maintains a centralised infoimation system on prevention and promotion programs
esearch and evaluation initiatives in Alberta.
IBFAN
^ims at impi oving infant health through the protection of breastfeeding, and especially the
mplementation of the International Code of Marketing of Breast Milk Substitutes.
International educates and advocates to prevent nuclear war (by humanising statistics) and antipersonnel mines
Physicians for the
Prevention of Nu
clear War
IPPF
■’romotes the reproductive and health rights of women and men
Lymphovenous ^n NGO focused on the treatment and daily life of people sulTerine from dy sfunctioning lymphatic
Canada; Health fystems. Monitors treatment and research of the disease.
Watch
Multinational published by Essential Information Inc. “ tracks corporate activity, especially in the Third World
Monitor
focusing on the export of hazardous substances, worker health and safely, and the environment. Is
iisseminated in the Third World and the United States.
Social Watch
Founded after the Copenhagen Social Summit and the Beijing Conference to monitor and report
)n the implementation of conference commitments by governments and international
..J organisaions. It’s mandate covers health as a part of Social Policy. 1 he Social Watch also uses public
icalth indicators to measure progress of social systems in individual countries
The Alan
Guttmachcr
Institute
Piotects reproductive rights oi individuals and families focusing particularly on young, poor or
otherwise disadvantaged people. Provides reliable infonnalion on contraception, sexual activity
ibortion and child bearing.
’
J’
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
The
Monitors the implementation of the Convention on the Elimination of All Fonns of Discrimination
International Against Women and the human rights of women under the other human rights treaties.
Women’s
Rights Action
« Watch
Welfare Watch Provides data on the consequences of implementing the new Welfare Act in the United States.
Wham!
Worldwatch
Institute
\ direct action group committed to demanding, securing and defending absolute reproductive
freedom and quality health care for all women, in the United Slates.
Within health WWI focuses on life style issues such as smoking (the lessons that can be learned
rom the west really makes it possible to act in other parts of the world). Earlier their focus was on
copulation and reproductive health.
A Global Health Watch - Initial overview of NGO initiatives
PREPARED FOR THE NGQ FORUM FOR HEALTH, GENEVA
ANNEX 1
Overview of Global NGOs and determinants of success
A Citizen’s initia- Combination of Cooperation with
tive
research with ad national NGO’s
vocacy and par
ticipation
Amnesty
yes
yes
yes
Credibility
yes
Effective dissemi
Flexible
Member's specific Participation of
nation of informa-jnetworks/forms of professional sta
volunteers
tion
cooperation
tus
yes
yes
yes,
yes
sometimes
Earth Summit
Watch
yes,
yes
yes
after Earth summit in
Rio
Earthscau
A publisher
Earthwatch
GLOBE
yes
yes
yes
yes.
A leading publisher
publications in gen
eral ordered by other
org that disseminates
yes
yes
no
yes
no.
yes.
not a network
The idea of EW is
joining scientists and
laypeople in mission.1
yes
Members arc legisla Annual conference
tors and
md ongoing exchange
parliamentarians
of information
around the world
Human Rights
Watch
yes
Responded lo need in
lir groups in Moscow
and Warsaw
yes
yes
yes
yes
Scientific methods
Closely cooperates
Offices in strategic
with HR monitors in ind proven lo right on locations, strategic
other countries
numerous occasions plan for each report
published
yes,
yes
Members ARE Globe
yes
yes
Works like an um
brella organisation
Uses local monitors,
but not volunteers bA
of risks
A Global Health Watch” - Initial overview of NGO initiatives
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A Citizen’s initia Combination of Cooperation with
tive
research with ad national NGO’s
vocacy and par
ticipation
Social Watch
The Pugwash
Conferences
yes
yes
Credibility
Effective dissemi
Flexible
Members specific Participation of
nation of informa- networks/forms of professional sta
volunteers
tion
1 cooperation '
tus
fA
yes
yes,
a*
•
•
yes
yes
Organisation of repu- Members being policy
table scientist and
makers, so info
members of govern juickly reaches policx
ment
makers level
rhe International
Women’s Rights
Action Watch
■
?
yes
yes
manifesto issued by
B. Russel and A. Ein
stein
*
yes
yes
Highly distinguished
participants with di
rect possibility to in
fluence policy
yes
The Alan
Guttnuichcr Insti
tute
no
Women Watch
(UN initiative)
no
Workhvatch Insti
tute
yes
yes
yes •
yes
yes
Publishes a wide
range of material and
educates
no
no
yes
no
no
yes
yes
UN information and
organisation
yes
?
yes
yes
timing, targeting and
planning
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
A Citizen’s initia Combination bf Coo peration with
tive
research with ad national NGO’s
vocacy and par
ticipation
IBFAN
IPPNW
IPPF
yes
yes
no
yes
yes
by leaders of family combines advocacy.
planning associations expert panels and par
in Bombay
ticipation
Marine Watch
a publication
yes
Multinational
Monitor
no
Northwest Envi
yes.
ronment Watch linked to World watch
A publisher
Institute
PRIO
Research Inst.
Project Plough
shares
no
Credibility
Effective dissemi
Flexible
Members specific Participation of
nation of informa netttworks/forms of professional sta
volunteers
tion
cooperation
tus
yes,
yes
is a network
partnership of 150
national groups
yes
yes,
yes
yes,
IPPF is an interna uses scientific meth
ods with advisory ex
tional network
pert panels
?
yes
no
yes
yes
yes
yes
yes
no
yes
yes
yes
is a federation of au a majority of family
tonomous and
planning experts
voluntary associations
9
?
no
yes
?
?
no
yes
Wide distribution in
region
yes,
no
individual researchers
yes.
yes.
yes
highly renowned re Publications are ac
searchers
cessible. popular and
timed
yes
uses data to influence cooperates with re
Canadian government searchers in Africa,
Sweden and the EU
9
no
Publishing mainly
reaches Canadian gov
and donors
Engagement model
for change, but no
active volunteers par
ticipation
“A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
Health in Action
Alberta Centre for Well Being
11759 Groat Rd, Edmonton, AB T5M 3K6, USA
Phone: +1 403 453 8692 Fax: +1 403 455 2092
e-mail: cjsmith@incentre.net
internet: www.health-in-action.org
HiA s aim is to maximise the effectiveness of
injury prevention and health promotion programs
in the province (Alberta), by developing and
maintaining a centralised information system that
will consolidate descriptive infonnation about
prevention and health promotion programs in
Alberta.
Health Action Information Network
9 Cabanatuan Rd, Philam Homes, Quezon City
1104, Philippines,
Phone: +63 2 927 6760 Fax: +63 2 927 6760
e-mail: hain@mnl.sequel.net
internet: www.hain.org
Involved in health education and research, pub
lishes the twice-a-month publication ‘‘The Drug
Monitor" to provide objective and independent
information on pharmaceuticals and the drug
industry’.
Human Rights Watch
485 Fifth Avenue, New York, NY 10017-6104,
USA
Phone: +1 212 972 8450 Fax: +1 212 972 0905
e-mail: hrwnyc@hrw.org
internet: mw.hnv.org
Investigates and exposes human rights violations,
globally. Challenges governments and stands with
national activists.
IBFAN The International Baby Food Action
Network (Tina Pfenninger 22/9)
Europe Regional Office
GIFA, PO Box 157, CH-1211 Geneva 219, Swit
zerland
Phone: +41 22 798 89 64 Fax: +41 22 798 44 43
e-mail: philipec@ipro.Iink.ch
internet: www.IBFAN.org
Aims at improving infant health through the pro
tection of breastfeeding. Implementation of the
International Code of Marketing of Breast-milk
Substitutes and subsequent World Health Assem
bly Resolutions relating to infant health are a key
part of IB PAN's work.
IPPNW International Physicians for the Pre
vention of Nuclear War
126 Rogers Street
Cambridge, MA 02142-1096, USA
Phone: +1 617 868 5050
Fax:+1 617 868 2560
e-mail: ippnwbos@igc.apc.org
internet: www.healthnet.org/IPPNW
Is a foundation of national medical associations
committed to the elimination of weapons of mass
destruction. Combining prophecy (describing the
reality), education and advocacy IPPNW have
been so successful that they received the Nobel
Peace Price in 1985. They have now broadened
their mandate to include land mines and other
weapons of mass destruction.
IPPF, International Planned Parenthood
Federation
Regent’s College, Inner Circle, Regent’s Park,
London NW1 4NS, United Kingdom
Phone: +44 171 487 7900
Fax:+44 171 487 7950
e-mail: info@ippf.org
internet: www.ippf.org
Promotes and defends the reproductive and health
rights of women and men. In particular advances
family planning through information, advocacy
and services
A Global Health Watch" - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
ANNEX 2
NGO’s
INTERVIEWED OR INVESTIGATED
Amnesty
United Kingdom
99-119 Rosebery Ave, London EC 1R 4RE
Phone:+44 171 8146200 Fax: +44 171 8331510
e-mail: amnestyis@amnesty.org
internet: www.amnesty.org
Amnesty International aims at contributing to the
observance of human rights as set out in the Uni
versal Declaration of Human Rights, by promot
ing awareness, adherence and to oppose viola
tions of political freedoms.
Earth Summit Watch
1200 New York Ave., N. W., suite 400
Washington D.C. 20005 USA
Phone: +1 202 289 6868
Fax:+1 202 289 1060
internet: www.earthsummitwatch.org
Monitors action by governments to implement the
declarations made in the Earthsummit in Rio and
to move towards a sustainable development
Earthscan
Earthscan Publications Limited
120 Pentonville Rd, London N1 9JN, United
Kingdom
Phone: +44 171 278 0433
Fax:+44 171 278 1142
e-mail: earthinfo@carthscanco.uk
internet: wivw.earthscan.uk
Earthscan is a publisher of books on environment
and sustainable development. It's aim is to in
crease understanding of environmental issues and
to influence opinion and policy to promote a sus
tainable development.
Earthwatch (Tom Coward 15/9)
680 Mt Auburn Street, PO Box 403 Watertown,
Massachusetts 02272, USA
Phone: +1 800 776 01 88 Fax: +1 617 926 8532
e-mail: info@earthwatch.org
internet: www.earthwatch.org
Supports scientific field research through
volunteers and scientists working together (an
active partnership scientist-citizen), to improve
public understanding of a sustainable world.
Earthwatch believes that this will empower peoplc and governments to act as global citizens.
Essential Information Inc,
publisher of “Multinational Monitor'
Phone:+1 202 387 8030
e-mail: monitor@essential.org
MN tracks corporate activity in the Third World
focusing on the export of hazardous substances,
worker health and safety, labour union issues and
the environment
GLOBE Global Legislators for a Balanced
Environment
e-mail: globeinter@innet.be
internet: www.globe.org
Enhances international cooperation between par
liamentarians on global environmental issues.
Tries to provide a forum for parliamentarians to
forge balanced, informed policy responses to
pressing global environmental challenges.
Harvard Women’s (an Men’s) Health Watch
164 Longwood Avenue
Boston, MA 02115
e-mail: hhp@warren.med.harvard.edu
internet: www.med.harv a rd. edu/p ub 1 i ca t i ons
Newsletter from Harvard School of Public Health
that seeks to clarify issues around women's health
and to proved accurate information to help
readers make informed decisions about their own
care.
^aview °f ng°
The Alan Guttmacher Institute
120 Wall Street,
10005 New York, N.Y. USA
Phone:+1 212 248 1111
Fax:+1 212 248 1951
e-mail: info@agi-usa.org
internet: www.agi-usa.org (att Beth Friedrich)
Welf e Watch
the . mberg School of Communication
Uni usxzy of Southern California
internet: www.welfare.org
An independent not for profit corporation for
research, policy analysis and public education in
the field of reproductive health. Provides the pub
lic with the latest news releases, research find
ings, publications and policy developments within
the field and publishes periodicals such
as “Family Planning Perspectives" and “State
Reproductive Health Monitor”
WW is an infonnation centre for legislators, citi
zen activists, journalists and the general public
and pio\ ides data on the implementation and
effects of the Welfare Reform Act.
Wham!
P.O. Box 733, NYC 10009, USA '
Phone: +1 202 560 71 77
internet, www.echonyc.com/~wham/wham.htlm
A direct action group committed to demanding,
securing, and defending absolute reproductive
freedom and health care for all women
Worldwatch Institute
1776 Massachusetts Ave., N.W.
Washington D.C. 20036-1904, USA
Phone: +1 202 452 1999 Fax: +1 202 296 73 65
e-mail: worldwatch@worldwatch.org
internet: www.worldwatch.org
Conducts interdisciplinary non-partisan research
and widely disseminates the results of it in order
to foster the evolution of an environmentally sus
tainable society. Publishes yearly “Slate of the
World . Lester Brown published highly success
ful “Who will feed China?"
^C^vJ-rC e -
Cxi H O
"A Global Health Watch” - Initial overview of NGO initiatives
PREPARED FOR THE NGO FORUM FOR HEALTH, GENEVA
Marine Watch
PO Box 810, Point Reyes Station,
CA 94956 USA
Phone: +1 415 663 8700
Fax:+1 415 663 8784
An international news journal focused on the
Earth's oceans, in depth substantive reporting
aimed at the reader with a high level of compre
hension
e-mail: subscriptions@marinewatch.com
internet: www.marinewatch.com
Northwest Environment Watch
1402 Third Avenue, suite 1127
Seattle, WA 98101-9743
Phone: +1 202 447 1880 or+1 888 643 9820
e-mail: new@northwestwatch.org
internet: www.northwestwatch.org
Research and publishing organisation, fosters a
sustainable economy and way of life in the Pacific
Northwest.
PRIO International Peace Research Institute
Oslo
Fuglehauggata 11, N-0560 Olso, Norway
Phone: +47 22 55 71 50 Fax: +47 22 55 84 22
e-mail: info@prio.no
internet: http://macink44.uio.no
PRIO is an independent international institution
conducting information activities trough semi
nars, guest researchers and publications, for ex
ample “State of War and Peace Allas ” bv Dan
Smith.
Project Ploughshares
Institute of Peace and Conflict Studies, Conrad
Grebel College, Waterloo, Ontario, Canada N2L
3G6, Canada
Phone: +1 519 888 6541 Fax: +1 519 885 0806
e-mail: plough@waterscrv 1 .uwatcrloo.ca
internet: http://waterscrv 1 .waterloo/~plough
Using publications, student participation and
letter writing campaigns to reduce Canada’s mili
tary spending.
Social Watch
c/o IteM, Jackson 1132,
Montevideo 11200, Uruguay
Fax:+598 2 419 222
e-mail: socwatch@chasque.apc.org
internet: www.chasque.apc.org/socwatch/
Was established after the World Summit on So
cial Development in 1995 to produce an annual
report on the fulfilment of what was agreed at the
summit. The Social Watch is a network of global
watch dogs monitoring social development poli
cies. Reports arc produced inside each country by
NGOs actively working in social development.
The Pugwash Conferences
69 Rue de Lausanne
1202 Geneva Switzerland
Phone: +41 22 906 1651 Fax: +41 22 731 0194
e-mail: pug3vash@hei.unige.ch
Strives to bring together influential scholars and
public figures concerned with disarmament and a
nuclear free world seeking solutions for global
problems
IWRAW The International Women’s Rights
Action Watch
Humphrey Institute, 301- 19th Avenue South
Minneapolis, MN 55455 USA
Phone:+1 612 625 5093
Fax:+1 612 624 0068
e-mail: iwraw@hhh.umn.edu
A global network of individuals and organisations
that monitors the implementation of human rights
of women. Independently reports to the human
rights bodies.
HeatthantfcKmatechaage
On Nov 1 and 2,1993; at the Worid Health Organization’s headquarters in Geneva, an international group of experts met to discuss,]
the potential health impacts of climate change. The meeting was organised for the WHO Division of Environmental Health and was J
chaired by Dr Rudi Slooff of WHO. Their task is now to update and expand the 1990 WHO publication Potential Health Effects o£s
Climate Change. They will also contribute to the work of the Intergovernmental Panel on Climate Change, especially to the working^!
-group on impacts of climate change. The proposed WHO publication is planned for 1995 and will include contributions on direct^ g
&
I®
Si
it
Rs
effects of increased temperatures on cardiovascular and cerebrovascular deaths besides potential impacts on vector-bome;:j
diseases, other communicable diseases such as cholera and algal biotoxin poisoning, effects on fresh water supply and food!
production, and impacts of a rise in sea level. Almost all these topics were covered in a Lancet series, that ends this week with the^
initiation of a discussion of questions to be tackled by the WHO group—namely, how to monitor possible health effects and what j
strategies are needed to prevent them.
s|
|
J • g
" ‘
I
Global health watch: monitoring impacts of environmental change , |
T
I
Andrew Haines, Paul R Epstein, Anthony J McMichael, on behalf of an international panel*
The eleven articles published in The Lancet over the past
seven weeks have shown how anthropogenic damage to the
biosphere has potentially important implications for health.
The underlying processes are global in scale, and the
natural systems affected are part of earth’s life-supporting
infrastructure. This type of health risk thus differs
noticeably from more local environmental health hazards
that are usually addressed at a toxicological or
microbiological level. The impacts of global environmental
change on health may be indirect and present only after a
long delay. How can public health scientists predict and
monitor the population health impacts of this novel
challenge?1 We need to detect effects early so that
countermeasures can be developed ^nd tested, to find out if
there are previously unsuspected impacts, and to give
impetus to policies to reduce greenhouse gas emissions (and
other causes of global environmental change).
Climate change, the chosen focus of the Lancet series,
could affect health in a variety of ways. Direct effects of a
rise in temperature (particularly increases in the frequency
and intensity of heatwaves) may include deaths from
cardiovascular and cerebrovascular disease among the
Correspondence to: Prof Andrew Haines, Department of Primary
Health Care, UCLMS, Whittington Hospital, Highgate Hill,
London N19 5NF.UK
elderly. Indirect effects are secondary, such as changes in
vector-bome diseases or crop production, and tertiary,
such as the social and economic impacts of environmental
refugees and conflict over fresh water supplies.2
Traditional epidemiological monitoring of disease and
mortality has limitations because there may be undesirable
delays before changes in chronic diseases are detected.
Other approaches must also be used, including biological
markers to give early warning of damage, the monitoring of
carriers of infection such as insects and rodents, and remote
sensing for large-scale monitoring. There is growing
__________________________ -
/I
I
g:
ir
,
•Dr Paul R Epstein (Harvard Medical School, USA). Prof Andrew Haines
,|;
(UCLMS, Whittington Hospital, UK), Dr Martin Hugh-Jones (WHO
Collaborating Center, School of Veterinary Medicine, Louisiana State
University, Baton Rouge, USA). Dr Charles F Hutchinson (College of
Agriculture, University of Arizona, Tucson, USA), Prof Laurence
Kalkstein (University of Delaware, Newark, USA), Dr Steven A Uoy
|
McMichael J
J
(Harvard University, Cambridge. USA), Prof Anthony Jj McMichael
(University of Adelaide, South Australia), Dr Stephen S Morse.
(Rockefeller University, New York, USA), Dr Neville Nicholls (Bureau o
s
Meteorology Research Centre, Melbourne, Australia), Prof Martin Parry
(Environmental Change Unit, University of Oxford, UK), Dr Jonathan Pa
(World Health Organization, Geneva, Switzerland), Dr Sandra Poste
(World Watch Institute, Washington DC, USA), Dr Kenneth Sherman (Ub .
National Oceanic and Atmospheric Administration, Narranganse
Rhode Island), and Dr Rudi Slooff (World Health Organization, Geneva,
Switzerland).
iI
t
I
J
Si
Vol 342 • December lb l99^
1464
GOES-W
tas’w
NOAA-9
1430L
Observing System (GCOS) and a committee forGCOS has
now been set up. GCOS wiU cover alt components of
atmosphere, biosphere, cryosphere, hydrosphere, and land
surface climate, and that coverage is. beyond the scope of
current monitoring programmes such as Global
Atmosphere Watch and the World Weather Watch network
of satellites, telecommunication, and data processing
facilities (figure 1).
Two other observing systems (ocean and terrestrial,
GOOS and GTOS) will enable GCOS to provide a fuller
picture/More than eighty international organisations and
programmes are involved in global environmental
monitoring, and the potential for overlap and lack of
coordination is great. Until now health has not been
adequately taken into account. A selection of these
organisations is shown in figure 2.
GMS (Japan)
140* E
LANOSAT 4
METEOR
(USSR)
AI
® SPOT (France)
LANOSAT 5
GOES-E
75*W
i
I
Mos-1 (Japan)
INSAT (India)
74*E
^^NOAA-T 0730L
METEOSAT (ESA)
3*Longitude
.
..
Figure 1: Earth observing satellites in operation (as of April,
1992)
awareness of the need to link environmental issues with
health—for instance the 1993 World Bank report Investing
in Health includes forest and fresh water resources.3 We
argue for integration of health into existing and planned
environmental monitoring systems. In this final article we
consider five aspects of monitoring, with cross-reference to
the series where appropriate: biological, environmental,
and human health indicators; data needed to monitor
indicators; technology for measuring them; organisations
doing the work; and gaps in information.
t
I.S--
I
Direct Impacts (Kalkstein, Dec 4)
The direct effects of temperature on health are mainly
manifest as an increase in death rates amongst the elderly
during periods of high temperature and can best be detected
through analysis of mortality data collected daily. Such data
are currently available mainly in developed countries but
this information is needed for urban centres in less
developed countries. Aggregation of deaths into weekly or
monthly statistics is of much less value because an increase
in mortality tends to be short-lasting and may be followed
by a period of lower than expected mortality. Changes in
morbidity and in seasonal patterns of disease can be
detected in primary care data such as those collected from
sentinel general practices around the UK.5 This database
demonstrates, for instance, that consultations for asthma
Climate (Maskell et al, Oct 23)
The scientific assessment of climate change is being
updated by the Inter-Governmental Panel on Climate
Change (IPCC).4 The Second World Climate Conference
in Geneva (1990) recognised the need for a Global Climate
II
IS
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International governmental organisations/programmes
International non-governmental organisations/programmes
lnternat'onal science programmes
[
f
) Experiments/projects
Figure 2: Links between major International global environmental organisations, programmes, and projects
li?hkS MurTT??"'13 °f understanding”- (Adapted from figure 5 in Global Environmental Change: the UK
!||// - programmes
mentioned'inl'a7c'et
sed’esby
”)the
-------'W'e nas
earch Framework
1993, published
UK--Global Environmental Research UIr,ce
Office.' owlnoon
Swindon;>lnis
this figure
has been simpllfled
simplified to emphasise
_3nc6t senes.)
K
’ /ti S' CbU'*boc a Science (|SSC). Problems of Environment (SCOPE), Oceanic Research (SCOR).
^manXXYfHDP);
Observing (GCOS), Ocean Observing (GOOS). Terrestrial Observing (GTOS).
■1
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Some of
generally composed of non
1
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including
water systems.
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Rgure 3: s«a8urfaceteni
^raturesoffsouth^st^ Un|ted
States (Feb 12,1989)
I
a™. «2 “ ™5x™ 2'15
I
“<■ »»r the,
Ecosystems (Dobson <- ' -
and Carper, Oct 30)
Illnesses of plants, birds fish
' —1 and mammals can
can be
be
■ The factors which
competitors nr^
f parasites and j
pests are nutrients,
factor is dismrbedXXTameir^ 7U— ‘more
“UrC than
tnan one
declines and its resistance tT’ thesystem’s Alienee
Biomdicators are used to mn •
PeStS may decrease
TTie abundance and distribution" ;n,VlrOnmencal toxins,
insects and algae can be used a ,
" SPeCieS such as
health. When an indicator is ■"dlCators.of ecosystem
surveillance for health on r
3 50 a disease, vector
Global Terrestrial ObseXTs03" bedirectly 'inked. The
network of sentinei sitesrCqUires 3
now is that run by UNESCO7! x/‘network avaHable
utNhSCO s Man and Biosphere
by stellite11 i^™^Sy^ms-^«ected for instance,
diseases. In particular, vegetaion^nd"0" VeCt0r-bo™e
bigh-resolution radiomem h=
>.
produced by
mortality rates and popdafo, rf6”1 “elated with
Several types of remote sensing
°f tSCtSe fliesanimal and vector habitats- X TTxmcUSed ” indicate
satellites (figure n ha
’'
LANDSAT and SPOT
respectivelyXdhavebeenu^
B^.and 10 m,
w
■il
I
and mosquitoes. The US Narin
habitats of ticks
Administration is sponsor^
Aeronautics and Space
‘"formation for vector-bornTT0’100'1161180^53'611*'6
control.7 Improved surveilla
monitoring and
incorporated within the n t' SyStemS should be
observation platforms Tn.
8enerauon of earth
meteorological, topogranlX^ SyStems combining
must becomemoreacS:’ "d ep1'demi°1°^l dam
Climate change may first h^ mpIer t0 usediseases at the margins of thei C lmPaCt °n vector-borne
global warming iso'ther^^hiftTjr1 dribl“
borne disease may follow ln rh. P01^3^ and vectoryellowfever,’ le’C for vivax X Same djrection UO-C for
malaria). Climate chance m' ? i™’ 2° C for fa,ciParum
which vector-borne diseasTs'are f S°
a'dtude «
sites m Kenya, Rwanda, Costa Rica^’
h‘gh altitude
good sites for monitoring. Field Mudie^ ^"""3 m3y be
^y-tbekeptgoingmdefinIt^U^n-n^
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a
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Rgure 4: Satellite
-y.
views of Ethiopia
Left-third dekad (10-(
oay period) of June. 1992
areas are better —J
2'
• ,.:r.
Vol 342 • December II, 1993
1
P
Ia
THE LANCET
,,
k
effect of temperature .
g-
-
| ^ges in seasonal pat^of
||
£ Vector bome diseases?.
f.
g k--J-.; ■/
K
How
> Dalb-mortality,
Urban centres in developed and developing countries
1u5.an.heat
effect)
f.'^ntinel'popu^
:
’ ..
..
.. ■Primary care data; local field surveys, communicable
.
Marine (and freshwater) ecosystems •
^Algae/cholera ..£
Primary care morbidity data, hospital admissions
.'•■\;Marglns of distributions (latitude and altitude)
.<
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Cataract
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Emerging diseases
regions'1 especially In the Interior of continents
7
Low^ying.regions
Local studies (“sea truth"), communicable disease
surveillance centres, remote sensing
Measures of run-off, Irrigation patterns, pollutant
concentrations
r
' ■
Local population surveillance’
■
High and low latitudes (taking distribution of ozone
-
....
' depletion Into account)
As for skin cancers
. Remote sensing, measures of crop yield, food access, and
nutrition from local surveys - ’
Cancer registries Epidemiological surveys'
Epidemiological surveys
Areas of population movement or ecological change
Identification of "new" syndrome or disease outbreak
population-based time series Laboratory characterisation
Summary of main elements of monitoring scheme
H monitoring may be possible .through local primary care
facilities with health staff trained to diagnose malaria and
other conditions reliably and to keep accurate records.
In Latin America, Chagas’ disease could be monitored in
g Chile and Argentina, currently at the edges of the endemic
area. Schistosomiasis could also be susceptible to climate
5
change, especially if irrigation patterns change. In the USA
g there is a possibility of the spread of five vector-borne
■<'1 ™
diseases—malaria, yellowfever, Rift Valley fever, dengue
g fever’ and arbovirus-induced encephalitides.9 The use of
the Southern Oscillation Index, based on differences in
& atmospheric pressure, to predict outbreaks of Australian
B B encephalitis was discussed by Nicholls.
S
Climate change may result in the elimination of some
.S
vectors and/or pathogens—for instance, as a result of very
8 h0t dry conditions> as in Honduras (Almendares et al).
§ Local influences, such as deforestation, need to be
'J?
distinguished from climate change.
hs'..
I£
I
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Os
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11
Large marine ecosystems (Epstein and others
Nov 13)
Changes in coastal ecology from local and global influences
have direct impacts on health. Environmental monitoring
of nutrients, currents, algae, and fish must be supplemented
by: (1) monitoring algae for Vibrio cholerae\ (2) surveillance
coastal communities for cholera andI for fish (eg,
ciguatera) and shellfish poisonings; and (3) surveillance of
coral reefs (warming and ultraviolet radiation may cause
bleaching10).
Marine algal blooms can 1be detected
’
‘ by ________
___
B w.
remote sensing
and satellite radiometry is useful for monitoring sea surface
£ M temPeratures to
sampling (figure 3X~Microwave
g; bands (to measure salinity) may be helpful for following
particular toxic phytoplankton species. The next
generation of satellites (Sea WiFS, to be launched in early
XS 1994) will improve monitoring. Remote sensing needs to be
supplemented by local sampling to examine individual
< species of algae and zooplankton associated with
gastrointestinal pathogens and biotoxins. Data on winds
and currents, nutrients (including nitrogen and phosphorus
originating from sewage), fertilisers, and industrial
pollutants will help to determine when conditions are
propitious for the growth of algal blooms. In 1994 the
$
*1
monitoring of large marine ecosystems (funded by the
Global Environment Facility) is scheduled for the Gulf of
I
Guinea, then the Yellow Sea, and ultimately the world’s
other 50 coastal marine ecosystems.
A temperature increase of 2 -S’C between 1990 and 2100 is
projected to lead to a rise in sea level of 48 cm.11 The impact
will depend on land subsidence, erosion, and the frequency
and intensity of storms.
There are currently 204 monitoring stations for sea level
rise with planned expansion to 306 in eighty-five countries.
Measurements are improving under the auspices of the
Global Seal Level Observing System (GLOSS), which has
a tide-gauge network. The countries most vulnerable to a
rise in sea level include Bangladesh, Egypt, Pakistan,
Indonesia, and Thailand, all with large and relatively poor
populations. Several low-lying islands such as Kiribati,
Tokelau, and the Maldives would also be in danger. The
health consequences will be direct (eg, due to flooding) and
indirect effects (eg, due to displacement of populations and
changes in vector habitats).
Fresh water
Fresh water is rapidly emerging as a limiting factor for
human development. Rivers, lakes, and underground
aquifers show widespread signs of degradation and
depletion, even as human demands on water resources rise
inexorably. Some twenty-six countries now have
indigenous water supplies of less than 1000 m3 per person
per year, a benchmark for chronic water scarcity. By the end
of this decade, some 300 million people in Africa—one third
of that continent’s projected population—will be living in
water-scarce countries.12 Although domestic water use
accounts for less than one-tenth of water use, there already
exists a large shortfall for safe drinking water. Globally, the
expansion of irrigated areas—which currently produce
one-third of the world’s food—has slowed to about 1% per
year whilst the world population grows annually by 1-7%.
Temperature increases resulting from the equivalent of a
doubling of the concentration of heat-trapping gases will
probably raise both evaporation and precipitation globally
by 7-15%. Rainfall patterns will shift, with some areas
getting more moisture and others less. Hurricanes and
monsoons may intensify and the sea level rise will salinate
some supplies of fresh water.13
There is no global monitoring of water quantity,
although most countries individually monitor the flows of
rivers and the levels of lakes. The Global Runoff Data
f ■
&
■J. Vol 342 • December 11, 1993
1467
r
THE LANCET
Centre, under the auspices of the WMO and based in
Koblenz, Germany, maintains a database on daily river
flows from 1664 stations in ninety-one countries. These
data could serve as a baseline for examining possible shifts
resulting from climate change were a global system to be
established.14 The monitoring of water quality on a global
scale is the responsibility of the WHO/UNEP Global
Environment Monitoring System (GEMS). It promotes
the measurement of about fifty indices of quality but
practice among the 340 stations in forty-one countries
varies considerably. The monitoring of pollutants and
bacteria are relevant to climate change because changes in
runoff may alter the concentrations; however, it is the use of
fertilisers and pesticides, irrigation patterns, and industrial
effluents that are key determinants of pollutant levels.13
A specific fresh water indicator of warming could be algal
blooms, measured as chlorophyll a. There is increasing
awareness of the formation of large floating masses of
blue-green algae. Certain species can produce toxins which
may be poisonous, and rashes, eye irritation, vomiting,
diarrhoea, and myalgia have occurred in people who swim
through algal blooms. The blooms are considered to be
caused by a combination of calm sunny periods and
sufficient nutrients, notably phosphorus.16
3:i
-
11
1
Food (Parry and Rosenzweig, Nov 27)
Several systems have been developed by international
agencies to provide early warning of food shortages, notably
in Africa. These systems rely on routine data of three sorts,
that indicate food supply, food access, and wellbeing. Data
obtained on the ground, such as food stocks and planted
areas early in the season, supplement satellite data to
indicate supply; food prices in local markets reflect access;
and anthropometric measures or, in extreme cases,
mortality rates give evidence of health impacts on
populations.
Satellite data, as indicators of food supply and impending
famine, improve consistency among countries and are more
accurate and more timely than information had from
farmers or local markets, for example. “Greenness” indices
(red and near-infrared spectral reflectance) are available
from daily data from satellites. This index is linked closely
to cereal and forage production, and can be used to predict
locust infestations. Figure 4 illustrates this approach for
Ethiopia. Rainfall estimates are based on duration of cloud
cover (presumed to indicate rain).
One International Geosphere Biosphere Programme
project is a global network modelling crop yield responses
to environmental change. Another, jointly with an
International Social Science Council programme on
dimensions of human environmental change, will monitor
long-term changes in global land for agricultural use driven
by non-climatic influences such as population growth and
trade agreements.
Agricultural yields can also be affected by pests and
predators, which are themselves susceptible to climate
change. Potential examples from the USA are anaplasmosis
(a rickettsial disease .of cattle) and hornfly.17
Ozone (Lloyd and Jeevan and Kripke, Noy 6)
To assess the impact of enhanced ultraviolet-B (UV-B)
radiation resulting from stratospheric ozone depletion, two
trends must be monitored—global changes in column
ozone abundance and changes in UV-B flux at ground level.
Ozone trends have been monitored by instruments on a
&
1468
satellite,18
and by
ground-based
spectrometers.
Observations on trace gases (especially chlorine and
bromine containing compounds) that catalytically deplete
the ozone layer are needed to predict future trends in ozone
loss. A lightweight unmanned aircraft shows much promise
here; a fleet of them could fly for days or even weeks at a
time in the lower stratosphere and provide continuous data
that remote sensing techniques cannot. Serious
international cooperation on monitoring UV-B has only
just begun, although many governmental agencies are now
acquiring the expensive instrumentation. In the UK for
example the National Radiological Protection Board has
been monitoring solar UV (visible, UV-A, and erythemaily
weighted UV-B) at three sites since 1988.19 Until recently,
only broad-band measurements of UV-B region were
available but we now have instruments that provide spectral
resolution, and serial data from Toronto, Canada,
published last month20 illustrate what can be achieved.
Epidemiological monitoring of skin cancers (basal cell,
squamous cell, melanoma), cataract, and other possibly
UV-B induced disorders of the eye are needed over a range
of latitudes. Recently studies have been initiated in
southern Chile, where there has been appreciable
stratospheric ozone depletion. Whilst data on melanoma
can be captured by cancer registry data, basal cell and
squamous cell cancers may be less reliably reported.
Reliable estimates of cataract prevalence are likely to
require periodic epidemiological surveys using a standard
system to grade lens opacity.21 However, these potential
effects may take years to become manifest so markers which
respond more rapidly are needed. The International
Agency for Research on Cancer is exploring methods of
making early estimates of changes in skin cancer risk. One
possibility is to use biological markers, for instance certain
dimer-forming mutations of the p53 gene in skin cells,
which appear to be related to UV exposure.22
Emerging Infectious diseases
Emerging infectious diseases are infections that are new in
the population or are rapidly increasing in incidence or
expanding in geographical range; examples are dengue,
hantavirus pulmonary syndrome,23 and some haemorrhagic
fevers. Most emerging diseases are caused by “microbial
traffic”—that is, the introduction and dissemination of
existing agents into human populations either from other
species or from smaller populations. This process is often
precipitated by ecological or environmental change and is
facilitated by population movements and other social
factors. Re-emerging diseases are those that had been
decreasing but are now rapidly increasing again. Often
previously active control programmes against wellrecognised threats to public health have been allowed to
lapse.
Our capabilities for health monitoring and rapid
response are seriously fragmented, with insufficient
coordination and communication let alone provision for
future needs. Inexpensive reliable communications (eg, by
e-mail) are still not available worldwide, although
initiatives such as SatelLife’s HealthNet, providing lowcost access to medical databases for remote areas, and
Internet e-mail offer hope that this can soon be achieved. A
secondary network directly linking interested field
scientists could greatly aid early recognition.
In conventional epidemiological surveillance, only a
small fraction of cases may be recognised and reported.
With emerging diseases, even a single unusual incident can
Vol 342 • December U»
V:
|
■
f
THE LANCET
be significant and investigation of such a pointer requires
linked capabilities for clinical identification of a “new”
$1 syndrome or disease outbreak, for the epidemiological
investigation of the event (usually the weakest link), and for
® laboratory characterisation. Existing facilities with all the
M necessary capabilities, including some WHO collaborating
Bl centres for arboviruses and haemorrhagic fevers, can be a
IS’ starting-point. ProMED (International Program for
Monitoring Emerging Diseases) has lately been proposed
and the idea is supported by the Federation of American
Si Scientists and by WHO. Targeting so-called “critical
||: geographical areas” undergoing rapid ecological or
demographic change would be most effective. US Centers
® for Disease Control and Prevention has lately set up a
K programme on emerging diseases.
Role of WHO
WHO could have a key role in coordinating a “Global
Pgffi Health Watch” (in quotes because there is no such system)
based on environmental health initiatives in its regional
centres.26 It will therefore need to be involved in the design
and implementation of aspects of GTOS and GOOS. It can
«
help select sentinel populations in critical regions where
specific impacts seem most likely. Monitoring of health and
S climate change should be linked to information about the
Wt global health picture, including population growth.
® Existing collaborative programmes with other UN agencies
(FAO, ILO, UNEP) places WHO in an excellent position
to promote interdisciplinary activity on climate and
ecosystem health
The WHO database Climcdat specifically focuses on
|
work on the public health aspects of global climate change,
p! M It lists investigators, organisations, and projects dedicated
t0 research on climate health.t In addition the UN
International Decade for National Disaster Reduction can
provide practical input on preparedness and mitigation.
Jgfcg- Conclusion
CT®. Greater integration of efforts to collect data on health and
global environmental change is needed. Many of the
h- potential effects of climate change will be insidious and will
? take a long time to manifest themselves, and sometimes the
v links between ecosystem damage and health are unclear.
However, the creation of a monitoring network must not be
g used as a “wait and see” argument against action to reduce
greenhouse gas emissions. The Framework Climate
Change Convention signed in Rio de Janeiro last year has
If- not yet come into force (it must first be ratified by fifty
countries) but may be in 1994. It stipulates only that
developed countries should reduce their carbon dioxide
emissions t0 1990 leveIs by 1116 year 2000’27 whereas the
B IPCC states that a 60% reduction is required to stabilise
i
atmospheric concentrations.
»
Much of the burden of global environmental change may
fall on poorer countries, which are less well equipped to
S monitor, and the danger is that monitoring will focus
disproportionately on the problems affecting the rich
® nations. This raises important ethical and practical issues.
if If monitoring is to be effective international collaboration '
on epidemiological surveys, field studies, and routine data
collection to complement satellite data will have to improve.
if
i
tlf you have information on new projects related to health effects of
-------------c^_______
matc change; or desire information from the Climcdat database, please
kr contact: Division of Environmental Health, World Health Organization,
CH-1211 Geneva 27, Switzerland.
This means a partnership between the technically advanced
nations with access to remote sensing capacity, for example,
and others. A global health monitoring network is essential
not only to determine the impact of climate change but also
to shape strategies to prevent climate change as far as
possible and mitigate those effects which do occur.
>
►
We thank the following for advice and information: Alexander Leaf, Mary
E Wilson, S Elwynn Taylor, Paul H Wise, Tord Kjelstrom, S Taseer
Hussain, Raymond L Hayes, Richard Levins, Ruth L Berkelman and
Ralph T Bryan, D Anderson, Guy de The, J LeDur, K Nuttal, and
KE Mott.
References
I McMichael A. Global environmental change and human population
health: a conceptual and scientific challenge for epidemiology. IntJ
Epidemiol 1993; 22: 1-8.
2 Haines A, Fuchs C. Potential impacts on health of atmospheric change.
J Publ Health Med 1991; 13: 69-80.
3 World Bank. World development report 1993: investing in health,
world development indicators. Oxford: Oxford University Press, 1993.
4 Houghton JT, Collander BA, Varney SK. Climate 1992: the
supplementary report to the IPCC scientific assessment. Cambridge
University Press, 1992.
5 Fleming DM, Norbury CA, Crombie TL. Annual and seasonal
variations in the incidence of common diseases. Roy Coll Gen Pract
Occ Pap 1991; no 53.
6 WHO Task Group. Potential health effects of climate change. Geneva:
WHO, 1990: 58.
7 Epstein PR, Rogers DJ, SlooffR. Satellite imaging and vector-borne
disease. Lancet 1993; 341: 1404-06.
8 Maurice J. Fever in the urban jungle. New Sci Oct 16, 1993: 25.
9 Longstrcth JA. Human health. In: Smith JB, Tirpak D, eds. The
potential effects of global climate change on the United States.
Washington, DC: Environmental Protection Agency, 1989.
10 Gleason DF, Wellington GM. Ultraviolet radiation and coral
bleaching. Nature 1993; 365:836-38.
II Wigley TMC, Raper SCV. Implications for climate and sea level of
revised of IPCC emission scenarios. Nature 1992; 357: 293.
12 Postel S. Last oasis: facing water scarcity. New York: W W Norton,
1992.
13 Waggoner PE. ed. Climate change and US water resources. New York:
Wiley, 1990.
14 Rodenburg E. Eyeless in Gaia: the state of global environmental
monitoring. Washington DC: World Resources Institute, 1991.
15 WHO Commission on Health and Environment. Our planet, our
health. Geneva: WHO, 1992.
16 Elder GH, Hunter PR, Codd GA. Hazardous freshwater cyanobacteria
(blue green algae). Lancet 1993; 341: 1519-20.
17 Rosenzweig C, Daniel MM. Agriculture. In: Smith JB, Tirpak D, eds.
The potential effects of global climate change in the United States.
Washington, DC: US Environmental Protection Agency, 1989.
18 Gleason JF, Bhania PK, Herman JR, et al. Record low global ozone in
1992. Science 1993; 260: 523-4.
19 Dean SF, Rawlinson Al, McKinlay AF, et al. NRPB solar radiation
measurement system. Radiol Protec Bull 1991; 124: 6-11.
20 Kerr JB, McElroy CT. Evidence for large upwards trends of
ultraviolet-B radiation linked to ozone depletion. Science 1993; 262:
1032-34.
21 Chylack L, Wolfe JK, Singer DM, et al. The lens opacities
classification system III. Arch Ophthalmol 1993; 111: 831-837.
22 Nakazawa H, English D, Randell PL, et al. UV and skin cancer specific
P53 gene mutation in normal skin as biologically relevant exposure
measurement. Proc Natl Acad Sci (in press).
23 Centers for Disease Control and Prevention. Update: hantavirus
pulmonary syndrome—United States 1993. JAMA 1993;270:2287-88.
24 Henderson DA. Surveillance systems and intergovernmental
cooperation. In: Morse SS, ed. Emerging viruses. New York: Oxford
University Press, 1993: 283-89.
25 Ledcrberg J, Shope RE, Oaks SC Jr, eds. Emerging infections:
microbial threats to health in the United States. Washington, DC:
National Academy Press, 1992.
26 World Health Organization. WHO consultation for the development
and use of environmental health indicators in the management of
environmental risks to human health. Geneva: WHO, 1993.
27 Brown K, Maddison D. The UK and the global environment: the
conventions on climate change and biological diversity. In: Pearce D,
ed. Blueprint 3; measuring sustainable development. London:
Earthscan (in press).
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http://w ww .socwatch.org .uy/1999/eng/i nformes_nacionales_99/ind99eng 1
c
INDIA
COMMITMEN'IS: A BARREN FLUENCY?
Jagadananda
Sundar N.Mishra
Economic reforms and liberalistion is nearing a decade in India. These years have
been marked by a consistent effort to link up with international economy and spur
on economic growth. While there has been adequate mouthing of social concerns,
liberalisation agenda have never been accompanied by corresponding social
development policy and programme initiatives to specifically cushion/further the
interests of vulnerable communities. While Copenhagen declaration had been
supported with zeal it has never seemed to be a signal guiding influence in chalking
out policies and programmes. Now, standing at the completion of a quinquennium
of the Social Summit, it is important to look back at the situation and
achievements with respect to different commitments. We attempt to take a
summary look below which is broadly categorised into four thematic domains.
BASIC SERVICES AND HUMAN SUPPORT
1. Education: The Basic Enabling
The educational situation in India marked by a literacy rate of 52.21%, and a lag o.
female literacy of about 25 percentage points indicates the distance to the goal of
education for all. This becomes particularly challenging as the depressed sections
(37% literacy for the schedule castes and 30% for scheduled tribes) have been
deeper in illiteracy.
Universalisation of primary education has been sought to be achieved by increasing
the number of formal schools, non formal education centres, launching a volunteer
based total literacy campaign targeting adults and supporting the programmes
through capacity building of personnel and innovating teaching-learning materials
and methodology. Women have been treated as a special target group.
Between 1991 and 1996, the gross enrolment ratio at the primary and upper
primary level have shown annual growth rates of 0.4% and 2.6% respectively. At
the secondary level it has grown annually by 2.8%. Over the same period the drop
out rate have not come down considerably, (by 15.2% at the primary whereas only
by 8.2% and 2.3% at the upper primary and secondary levels). Enrolment in higher
education (general + professional) has grown by about 18% against an estimated
population growth of about 14% in the relevant age group.
Educational attainment has largely been sought to be achieved through enhancing
the formal system of schools etc. Comparatively the attempt through informal
means for elementary and adult education has been small. The management of
education remains the business of a centralised educational bureaucracy where the
role of civil society organisations is limited to only implementation of certain
programmes. Though in many of the states the self- governance institutions
(Panchayati Raj Institutions) are now made responsible for primary education, the
lack of resource and technical support disallows one to be optimistic in this
respect.
Apart from other functional difficulties, the sheer financial crunch (an estimated
shortfall of Rs. 32 billion in 2000) will hamstring this ponderous system to extend
india
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better quality primary education.
1.2 Health, Sanitation and Potable Water: wellbeing for Momentum
The illusive goal of Health for All by the year 2000 have been restated as ’Health
for Under privileged by 2000 which is however unlikely to be achieved. Basic
health services are sought to be provided throughout the country by a three-tier
institutional structure comprising primary, secondary and tertiary health care
facilities with appropriate referral linkages. The system spans the whole stretch
from community level to district and state levels and includes super-specialty
facilities in urban areas.
But this system has fallen short of adequacy considering the objective of health for
all. The number of institutions at the primary level suffer from combined shortfall
of as many as 31601. The medical/paramedical personnel manning these centres
number only 53.6% of the requirement. Only 11.2% of the specialist positions
required have been filled up. These shortfall are most accentuated in remote areas
where no alternative facilities are available.
Public investment on health though rising in absolute terms, has declined to as low
as 1.6%. of plan expenditure. The investment has shown an urban bias. While
three-fourths of the population live in rural areas, two-thirds of hospitals are in
urban areas. Only around 200 hospital beds are available per million population in
rural areas as compared to 2180 in urban areas (1993).
Notwithstanding these negative trends, the health situation has somewhat lookee
up. Access to basic care is enjoyed by 85% of (UNICEF, 1996) people. Infant
mortality rate has come down from 80 in 1990 to 72 in 1996. Crude death rate has
come down from 9.6 to 8.9. Under 5 mortality is still 93 for male and 108 for
female children. Life expectancy has risen from 58.1 years in 1990 to 62.4 in 1996
for men and from 59.1 to 63.4 for women. However, 16% of total population arc
not expected to reach age 40 as against a world average of 13% (Human
Development Report, 1998, UNDP)
I^Frhe problem of shelter lessness and bad sanitation worsens the health situation. Up
“from 31 million people in 1991, 41 million (close to 80% of them in rural areas)
will have no proper roof over their heads by the time next century begins. About
40% households had unclean or no water supply. There was no electricity for 69%
rural and 23% urban households. About three fourth of households had no access
to sanitation, this blea scenario brings out the ineffectiveness of the National
Housing Policy. The goal of eradicating hosuelessness has seen scanty follow up
action. The special programmes providing shelter to the weaker sections are totally
insufficient and public spending on this aspect has been out of step with the
requirement.
1.3 Food Security: The Groundwork of Growth
The food security situation seems to have improved with 94.5% of rural and
98.1% of urban households reporting adequate availability of food (two square
meals a day) in 1993-94. This picture shrouds a dire nutritional profile. More than
60% of the children suffer from protein energy malnutrition. Pregnant women
largely (50-90%) suffer from anemia. Women in poor families experience energy
deficits of 1000 calories per day during pregnancy.
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The strategy for reaching ’food security for all’ broadly has three components: a)
growth in food grain production, b) widespread distribution targeting the weaker
sections, c) guarding against loss of entitlement by raising purchasing power. The
growth rate in total food grain output has slid to reach an annual rate of mere
1.2% in 1995-96. Adding fuel to fire, the agricultural export in cereals has posted a
rising trend (35% in 1995). The public distribution system with rising number of
outlets continue to benefit mostly the non-poor in urban areas. While growth and
distribution aspects of the strategy do not appropriately further the food security
goals, the attempts to improve the ability of the poor to ’earn’ food is also not
adequately furthered through employment and livelihood support programmes.
2. SUSTAINABLE LIVELIHOOD
2.1 Rights to Resource Use : Assets to Assert
Land is an important productive asset for the rural poor who are more than three
fourths of all poor and their number is on the increase. The trend of concentration
|0f land in a few hands is continuing in the 90s. The percentage decline in the
average size of marginal holdings is much higher than the per centage decline in
the average size of large holdings. This indicates the marginalisation of peasantry
making access to land for agricultural households difficult.
Against such background, the land reforms initiatives of the government have not
yielded desired results. The areas redistributed till 1996 accounted for only 1.5%
of the net cultivated area and assignees 3.5% of the poor. Most of such holdings
are unlikely to provide economic sustenance to the beneficiaries. Despite tenancy
being banned in several states the area under concealed tenancy is increasing and
there is a hike in rent in many areas. It has been established that there are about 15
million concealed tenants going without any legal protection.
Another important intervention through legal and administrative arrangements is to
arrest land alienation of tribal farmers (an estimated target population of 63
^^nillion). These efforts have so far fallen flat because of the inbuilt loopholes. The
^Rurrent initiative to amend the land acquisition act, 1894 to expedite land
W acquisition for different ’development’ projects will further endanger the land-based
livelihood of a vast number of poor.
A sizeable chunk of people (including, of course the tribal population) depends on
forest produces for livelihood. While the forest management system of government
had been hostile to these people, from 990 onwards a new framework of joint
forest management has been introduced which gives certain usufructuary rights
and a stakeholder status to these people. The JEM results have been mixed and
often the people have been taking up protection responsibilities without being able
to meet their livelihood needs. There has been a radical enactment i.e. the
Panchayats (Extension to Scheduled Areas) Act., 1996 giving the ownership right
over minor forest produces to local self governance institutions. However, the
governments at the country and provincial level are dragging their feet in so far as
the implementation of the new legal provisions in favour of the forest dependent
poor communities is concerned.
2.2 Employment: Working Poverty Away
The Indian Labour force has grown by about 27% between 1990 and 1997. If
future projections are considered, 10 million new jobs need to be crated per annum
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at the very least. Against this backdrop the organised sector has provided only 1.6
million jobs throughout the 90s (upto March, 1 997). In fact the average annual
rate of growth of organised sector employment has sharply decelerated from
1.68% during the 80s to merely 0.82% during the 90s (1990-97). So it is the
informal employment sector which absorbed most of the work force in the 1990s
(about 92%).
This vast opportunity lag for employment is sought to be eased for the poor by the
government through self employment programmes (SEPS) and wage employment
programmes (WEPs). SEPs provide credit and subsidy for procurement of income
generating assets and also develop employable skills of beneficiaries. The WEPs
provide casual manual work through public works programmes.
The SEPs have reached about 3 million households annually as an average during
1991 - 1996. The NSS data suggest that participation in SEPs (IRDP) increased by
18% for STs and declined for SCs by about 10%(between 1987-88 and 1993-94).
Though it has been seen to be taking families above the poverty lines various
evaluation studies have demonstrated that much of it has gone to less poor and
even not infrequently to families above poverty line. The WEPs over the same
period have generated person days of employment adding upto about 3.3 million
jobs annually on an average. This only indicates the vast shortfall which still neec
to be met. On the contrary, these are without any sustainability. The NSS data
suggest that participation in WEPs declined by 28% among STs, stagnated among
SCs and declined by 5% for others (between 1987-88 and 1993-94). The assets
created through these programmes in about one fourth of cases have been found to
be ’missing’ and others of hardly any income generating potential. Considering the
widespread leakage and dubious targeting it is difficult to determine precisely what
benefits they have caused to the poor.
Real wages in the unorganised sector fell in the rural areas almost throughout the
last decade, while it rose in agriculture till 1992 and then continued to fall. In the
dualistic labour market in India, the governmental wage policy favoured the
microscopic well paid organised segment and cold shouldered the expanding
unorganised sector. The practice of wage determination for the
unorganised/informal sector across the states and regions has belied the concerns
of ensuring basic subsistence of workers which can be attributed to concerns for
employer’s capacity to pay or political expediency. On the other hand, the practices
of setting minimum wages in the organised sector have moved beyond the
concerns of basic need or even the ’fair wage’ to higher levels of living wage.
Moreover wages in the organised sector are provided with fuller cost of living
adjustments which does not accrue to overwhelming majority of the workforce in
the informal sector. Thus one comes across the phenomenon of minimum wages
for the unorganised sector not being revised for years together which is further
worsened by the weak enforcement of the existing wage rates.
Most of the protective legislation apply to workers in the formal sector. Those
relating to stipulating of minimum wages, disputes on wages, non-discriminatory
remuneration, payment of wages, maternity benefits etc. have uncertain influence
on and little implementability for the informal sector workers.
In the face of job loss and redundancy, the concept of employment security has
seen some policy action in the industrial sector through the National Renewal Fund
in the form of worker counselling, retraining, redeployment and labour
reconversion, there is little information available with respect to its actual
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effectiveness. Outside the industrial sector the WEPs and SEPs are the only
programmes which help workers to survive, not to talk of employment security.
3. PARTICIPATION/?ARTNERSHIP AND GOVERNANCE
the constitution emphasized a decentralised structure of governance from the very
beginning which was to be realised through self- government institutions from the
local (village) level onwards. At long last, such system (the Panchayati Raj system)
came into being with constitutional status in 1993. These institutions are now
empowered to carry out development planning, implementation and other agency
functions which will meet the state system at the macro provincial level. Such
institutions are targeted to usher in citizen’s role in governance in a big way. But
the system is operationalsied in such a manner that these institutions do not enjoy
functional, administrative and financial autonomy. In most states the functions can
be amended/overridden by the governments. Relevant provincial level acts
empower the state to inspect, enquire into and suspend Panchayats resolutions.
A Financial autonomy is also not granted to the Panchayats so far, though the centre
has accepted the recommendation of the tenth finance commission for adequate
allocation. On the otherhand, the Centre has been using Panchayats as agencies to
distribute grants meant for schemes sponsored by the central government. Such
schemes by becoming the orders of the Centre smother local initiatives. The Acts
giving ownership rights over local resources (land, forest, water etc.) to local
bodies especially in areas dominantly populated by indigenous and tribal people
making have been dilutcd/obstructed by the Central/Provincial governments.
Apart from this the record of involvement of citizens and civil society
organistaions in development, planning and programme management has been
dismal. Beyond a role in strait jacketed implementation nothing much has came
about. There is no institutional role of CSOs in planning, designing and
management of development under the state auspices. There is an operational
space for CSOs which often depends upon discretion and patronage of the
government, whenever this involvement goes beyond implementation it stops at
’democratic consultation’ without incorporating any dimensions of decision
'making.
4. GENDER SENSITIVITY AND EQUITY
Primary education and total adult literacy is pursued with a special focus and
incentives on girls and women. Enrolment ratios and drop out rates are still
unfavorable to girls; but the Girls Boys Disparity Index (GBDI) has improved for
girls by 5 percentage points in enrolment ratios at primary and secondary levels.
The fall in drop out ratio has been quicker for girls than the boys. Growth in higher
education has been higher (24.1%) for girls as compared to boys (18.1%).
In the domain of health, programmes to extend health care specifically to girl
children and mothers exist which are improving in performance despite being
plagued by inadequacy of resource provisions. Though food security has
improved, it is difficult to say how the women have gained. Since women suffer
from intrafamily and intragender discrimination the current picture of household
food security might be glossing over far greater deprivation of women. This
problem has attracted little policy action over the years.
while labour force as a whole showed a confirmed tendency towards
informalisation, the little growth (little above 1%) that occurred in the organised
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sector in the 1990s was favourable to women, who registered a numerical growth
of 8%. But women continued to suffer discrimination at workplace. About 50% of
women in India perceive themselves as victims of discrimination, according to a
study by
National Commission on Women (NCM). Even in the organised sector, womei
earned 23% less than men. As much as 64%n of the gender gap in earnings was
brought about by discrimination while about 36% could be attributed to
differences in productive endowment. The situation in the unorganised sector is far
deteriorated with women getting sometimes as less as 50% in comparison to men.
Looking at policy action to reduce gender inequity one does not come across an
encouraging picture. The reports of various pay commissions instituted by
governments at different periods of time give no indication of any systematic
attempt to consider the prevalence/extent of men-women wage differentials in any
given job/occupation in arriving at new pay scales. The Equal Remuneration Act,
1976 seeks to provide for equal remuneration and prevention of discrimination
across the sexes. Though the act straddles all employment sectors including the
informal, its vagueness in defining work equality allows for disparities to escape
with impunity. Minimum wages under the Minimum Wages Act, 1948 have not
been revised regularly as required and the wage rates fixed by many states in
sectors with women worker concentration fall below the levels suggested by
National Commission on Rural Labour (1993). While women in the organise,
sector enjoy reasonable maternity benefits, there is now a provision made by
central/state governments a kin to paternity leave. But in the unorganised sector
women face job loss, and undernutrition. There is some respite given by some state
governments in the shape of a maternity allowance for upto two children to
rural/urban poor women. Similarly, the payment of compensation, provision of
creches etc. have been availed of by women in the organised sector to some extent
which is not available to women in the unorganised sector. The investigation of
employer s compliance with various labour- protective legislation discussed above
is not done regularly reducing many of the entitlement to mere promises
particularly for women. Another collusive factor is that the labour unions have
viewed the survival of women labour as more important than achieving gender
equality, in wages, employment and their access to social secunty. Thus equity in
above lines remains a distant goal only.
Women’s access to different tiers of democratic power and the systems of decision
making has shown little improvement and promises which at the same time
illustrate the limitations. Political parties do not have appropriate
policies/inclination to raise women’s access to elective offices. The Women’s Bill
seeking to give more access to women to political party positions and to the
Legislatures has wobbled in the Parliament all along for the
last few years without getting required endorsement by party
leaders/representatives. Only exception is the local self governance structure of
Panchayati Raj where one third of the representatives are women. Political parties
have a poor profile of women leadership (less than 8% of top party pasts) at the
national level.
Percentage constitution of women cadres in the development administration, the
police system and the diplomatic corps improved by about 10% in the 1990s. The
presence of women in the top judicial system remained quite marginal (about 3%).
While reservation for women in these positions has helped to some extent, lack of
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training and other facilities for capacity building has retarded women’s progress in
this respect.
5 UNFINISHED AGENDA AND THE NEW CENTURY
As we see, the country and its development actors are left with a burden of
responsibility rather than a sense of fulfillment at this juncture. Looking from the
vantage of the people whose problems and sufferings elicited the global response
of the Copenhagen Summit, we see that most of the non-achievement can largely
be ascribed to a tendency of development administration to stand apart and away
from the people it serves. The unfinished agenda which the Copenhagen
commitments hold aloft, will forever be elusive but for a qualitative shift in this
tendency. Redefining the goals alongwith the concerned poor and vulnerable,
working out a functional partnership with the civil society organisations, PRIs and
organisation of the poor for resource use and development from local level
onwards, recognising them as equitable stakeholder and releasing their initiatives
are the key processes of action which must needs to be begun to fulfil the
objectives of commitments early in the next century.
* Produced by Centre for Policy Research and Advocact, a Unit of CYSD, Orissa
in collaboration with Voluntary Action Network India (VANI), New Delhi
Institute del Tercer Mundo- Social Watch
An NGO watchdog system aimed at monitoring the commitents made by govermments at
the World Summit for Social Development and the Beijing World Conference on Women
unuucui
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UNITED KINGDOM
MAKING PROGRESS... BUT NOT ENOUGH
Fran Bennett
Dk' new Labour sovenvnen; has identified poverty and social exclusion as kev
issues, and declared its bitention to tackle their root causes in a
ctos,>"uepa*i/nenttil, buexrated way. It is comtnitted to rrtaitistreamin^ ttettder
awareness, and improving representation of women and ethnic tninorities. Sm its
approach to social development is not couched in the ionguaee of social and
economic rights, ar redistribution, but of inclusion, opportunity and
responsibility^- and the Copenhagen commitments are not used as reference
points. Critics have accused it offailing to challenge sufficiently die current
supply-side and market-orienied ordiodoxies, and of echoing the residuaiisl
rhetoric about welfare common in the USA..
«We Commit Ourselves to creating an economic, political, social, cultural and
legal environment...»
The UK government has incorporated the European Convention on Human Rights
into British law, facilitating legal challenges on civil and political rights. But it is
more sceptical about the value of legislation guaranteeing social and economic
rights; and, although it has signed the Council of Europe's revised Social Charter,
it has refused to ratify the collective complaints procedure. In the area of children's
rights, however, the government has set up a group which includes NGOs to help
monitor progress on achieving the goals of the UN Convention on the Rights of
the Child.
The government has made progress towards devolution in Scotland, Wales and
Northern Ireland. Regional development agencies are also planned in England, bu
fairly tight financial control of local authorities is still maintained.
Power over resources for social regeneration may be devolved to some local
communities.^ In some areas (especially crime), ministers tend to perceive the
views of NGOs as not reflecting the real concerns of local communities?
Proposed legal reforms to decision-making and appeals in social security and
asylum/immigration, and availability of legal aid, affect important policy areas for
disadvantaged groups. Although some changes are positive, others have been
criticised for sacrificing fairness and individual rights to speed; and measures to
tackle anti-social behaviour' are seen as draconian by some.
«We Commit ourselves to the goal of eradicating poverty in the world...»
The Prime Minister says the government should be judged on whether it improves
the living standards of the poorest.- The government also highlights «social
exclusion*, seen as dynamic and multi-dimensional. It set up a social exclusion unit
in the Cabinet Office, which can take a cross-departmental approach. The unit is
tackling specific issues, and investigating indicators of social exclusion. But its
direct communication with people in poverty is rather unstructured; and outside
organisations are consulted, not involved as co-participants.
The government has not drawn up a national anti-poverty strategy with
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goals and targets. However, the Prime Minister describes government policies as
an anti-poverty strategy in action, which includes: cutting unemployment; tackling
low pay; getting benefits to people in need; education, to prevent future poverty;
regeneration of the poorest neighbourhoods; getting public services to people in
need; and bringing in new allies as partners^ He has promised an annual
progress report The government is also investigating the exclusion of
low-income people from financial services and the withdrawal of shops from poor
areas. But one commentator suggests between 350 thousand and 1.95 million
more people could be in poverty (on under half average income) by 2002,
depending on government policies and unemployment level£
Poverty has become more concentrated in small areas. Funds are being released
from local authority housing sales for reinvestment, and a series of area-based
programmes is targeted at disadvantaged neighbourhoods. But these areas often
have to compete with one another in bids for additional resources.
The government embarked on «welfare reform», widely interpreted as meaning
reductions in social security spending. Following opposition to benefit cuts for
'lone parents, and protests about threatened cuts for disabled people, the
government is now proceeding more cautiously, with increases in benefits for
specific groups. But most benefits will probably increase only in line with prices,
not rising prosperity.
The government says tackling the root causes of poverty means focusing on
opportunities, especially education and employment. This approach has been
welcomed -but criticised for under-emphasising low income, and over-emphasising
paid work rather than unpaid caring.
The government has fulfilled its manifesto commitment to reverse the decline
in spending on overseas aid, and made encouraging statements on the need to
tackle the debt burden. Its creation of a separate department for international
development, and Cabinet status for the minister, moved international poverty up
^the policy agenda. Its policy on development includes a clear focus on poverty,
Wvhich is consistent across departments.- But on trade and investment issues, it
P could give more emphasis to the extent to which globalisation creates «losers»,
and to poverty as an issue to be tackled internationally.
«We commit ourselves to promoting the goal of full employment...»
A government aim is «full employment for the 21st century^ But the emphasis is
on employability and other supply side factors, not direct job creation; and the
Bank of England's control over interest rates is seen as prioritising controlling
inflation over reducing unemployment.
«New Deals» have been set up for young and long-term unemployed people, lone
parents and disabled people. They include temporary job subsidies, work
experience, education/training and personal advice. They have been broadly
welcomed, though critics point to the disproportionate share of resources for the
young unemployed, the one-off nature of the funding, and compulsion (with
potential loss of benefit) for young people.
There is concern about the low quality of «cntry level» jobs for unemployed
people, who often do not progress to better employment;-" marginal jobs are not a
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route to social inclusion.— The government signed the European Social Chapter,
but has made clear it will not support all proposals for more regulation. Rights at
work, including union recognition and employment protection, are to be
improved.-”
Another goal is to «make work pay». A statutory minimum wage will be
introduced, benefiting some 1.5 million workers;-” But unions criticise its
inadequate level, and in particular the lower rate for young workers. There will
also be reductions in national insurance contributions for low-paid workers and
their employers.
«... Io Promoting Social Integration by fostering societies that are stable, safe and
just...»
The government created a Race Relations Forum, to give ethnic minority
communities more direct access to it, and is consulting on anti-discrimination
action.
Asylum and immigration policy and practice are now less secretive. But the
government’s use of detention has been strongly criticised; and proposed
policy changes include abolishing asylum-seekers' rights to cash benefits and
choice over housing location, and curtailing appeal rights- ” This is in line with
proposals for more restrictive policies towards refugees in the European Union as
a whole.
One in four ethnic minority electors has not registered to vote. Turn-out rates
for black Africans and black Caribbcans in the general election were lower than for
other groups, "- reflecting political alienation. New measures give additional
powers to tackle racial incidents; but police treatment of black people is repeatedly
criticised.
The government inherited anti-discrimination disability legislation widely perceived
as ineffective. It is tightening up the provisions; but many disabled employees will
still be unprotected, due to small company exemptions.
«...To Promoting lull respect for human dignity and to achieving equality and
equity...»
The government set up a «women's unit», which has now moved to the Cabinet
Office. A minister for women was appointed (inpaid). Mainstreaming of gender
issues was promised, but policy guidance to departments has not yet been
published. The government's priorities are child care, family-friendly employment
policies and violence against women. Women make up only 18% of MPs and 31%
of public appointments^2 «quangos>Az are to have a target of 50% women.
Women still receive only half men’s average weekly income^ Government
proposals would improve maternity provision, and introduce paternity and
parental/family leaved -although unpaid leave may have limited value. The UK
signed an EU directive improving part-timers' employment rights. Whilst the
government is making progress, the Equal Opportunities Commission has called
for a «super-law» to overhaul and update sex equality legislation.
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«... Universal and Equitable access to quality education*
The government has put high priority on education, from nursery schools to higher
education. Primary schools must prioritise literacy and numeracy, and targets have
been set to cut truancy and school exclusions by a third by 20024^ Twenty-five
«education action zones» are being created in deprived areas to experiment with
different approaches. The government emphasises «life-long leaming», and a
working group is to tackle poor basic skills among adults.
Proposals to finance a means-tested staying-on allowance for teenagers by
abolishing universal child benefit for this age-group are controversial. Tuition fees
are being introduced for higher education for the first time. Some commentators
say anti-poverty measures would be more effective for children from low-income
families than the current emphasis on raising «standards>*U
«...To Promoting the highest attainable standard of physical and mental health..
The government launched an inquiry into health inequalities. Other policy areas are
now recognised as influencing health status of the population. Twenty-six «health
action zones* are being created, to improve the health of the poorest. The social
exclusion unit will investigate teenage pregnancies, which are higher in poor areas.
The influence of the internal market in the health service is being reduced. Ethnic
minority groups' access to health care is being investigated. But fewer low-income
individuals visit doctors and dentists regularly than five years agaThe health divide between rich and poor has widened over recent years^2 Many
commentators welcome the government's policies -but say there is still a long way
to go.
«We commit ourselves to an improved and strengthened framework for
International, Regional and Sub-regional co-operation...»
The government has not publicised the Copenhagen commitments relating to
the UK, nor organised monitoring with outside organisations. Its
anti-poverty goals have not publicly been linked with the Social Development
Summit.
Notes
1 R. Lister, address to conference on equality and the democratic state,
Vancouver, November 1998.
2 Social Exclusion Unit. 1998. Bringing Britain together: A national strategy for
neighbourhood renewal. The Stationery Office.
3 Eg, see article by Home Secretary. The Times, 8 April 1998.
4 Speech by Prime Minister. The Independent, 8 December 1997.
5 Speech by Prime Minister. 30 January 1998.
6 D. Piachaud. «The prospects for povcrty». New Economy, spring 1998.
Blackwell Publishers Journals.
7 Department for International Development. 1998. White Paper,Eliminating
world poverty: A challenge for the 21st century . The Stationery Office.
8 The Chancellor. The Times. 29 September 1997.
9 M. White and J. Forth. 1998. Pathways through unemployment: The effects of a
Unt’dedl
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hitp://www.socwatch.org.uy/1999/eng/informes_nacionales_99/gbr99eng.lu
flexible labour market. York Publishing Services Ltd. for the Joseph Rowntrce
Foundation.
10 T. Atkinson and J. Hills (eds.). 1998. Exclusion, employment and opportunity.
CASE Paper 4, London School of Economics.
11 Department of Trade and Industry. 1998. White Paper, Fairness at work. The
Stationery Office.
12 Institute for Fiscal Studies press release, 5 June 1998.
13 Home Office. 1998. White Paper, Fairer, faster andfirmer: A modern
approach to immigration and asylum. The Stationery Office.
14 Research by M. Anwar. 1998. Commissioned by Operation Black Vote.
S. Saggar. 1998. Ethnic minorities and electoral politics. Commission for
Racial Equality.
16 Equality Indicators. 1997. Equal Opportunities Commission.
11 «Quangos» are quasi-autonomous non-governmental organisations.
18 Income and Personal Finance. 1997. Equal Opportunities Commission
19 Department for Trade and Industry. 1998. White Paper, Fairness at work. The
Stationery Office.
20 Social Exclusion Unit. 1998. Truancy and school exclusion. Cabinet Office,
zi P. Robinson. 1997. Literacy, numeracy and economic performance. London
School of Economics, 1997; I. Plewis. inequalities, targets and zones» New
Economy, 5(2), 1998.
22 National Consumer Council. 1998. Consumer concerns 1998: A consumer view
of the health services.
-3 Office for National Statistics. 1997.Health inequalities: Decennial
supplement. The Stationery Office.
UK Coalition Against Poverty
**♦•**♦**********<*
Instituto del Tercer Mundo- Social Watch
An NGO watchdog system aimed at monitoring the commitents made by govermments at
the World Summit for Social Development and the Beijing World Conference on Women
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»
BHARAT JHUNJHUMWALA
D1/31/XV Rohini ‘ Post.Box 10754
Delhi 110 0S5
Tel: 729-B5S9/789-3673 . Fax729-0635/708-1935
email: bhatatj@rida.vsn 1 .net.in
AN ALTERNATIVE VIEWPOINT ON
GLOBAL HEALTH WATCH •
to the GHW
You have given me a
difficult task of responding
proposal. I have many questions but I, will try to put down my.
basic response as simply as I can.
1
The Roles of the
Intellectual' and the ' Organization 9
It seems to me? that many of the impacts of the various 'Watch'
Lester
Brown
the realm of ideas. The Work of
I
has been in
example,
is
the impact
of
ideas not
(Overview: 1), ’ for
impact of
organization. To make it clear.j let us examine the
much greater
the works of Darwin or Marx. The impact has been
that what any NGO can claim to,have made. ‘
There is a danger of relying • on. the honours such as Nobel
Prize as well (Overview: 1, reg Pugwash). My impression is that
such honours are reserved for people following a.certain world
view which is amenable to the dominant Western viewpoint.
The point is that the real - and 'vested—interest—free' impact
can come from ideas.' It does not require an organization, NGO
or otherwise.
Organizations often develop their own narrow
vested interests. •
'•
’
I
feel that many ’ of the
have unique
‘'NGD
NGO networks which
in the
capacity'
(Draft 2:2)
are in fact a fifth column
Funded
by
foreign
money
they
have
little
developing countries,
roots in the body politic of their own countries.
It is
i s significant that there is no 'Indian* concept of an NGD’. .
We have the concept of an 'ashram* and 'vanaprastha*. The NGOs
appear
from the Christian ethic of
to take their inspiration
loving the neighbour. This is fine. The problem
arises when
if a person
this
'love* becomes organized. " It is acceptable
was earning
his own bread by running a shop
or whatever and
then he loved others by giving away part of his well
earned
income. But that is not what NGOs do at all. They earn their
breads by
'serving' - It
then becomes difficult
to ascertain
whether the 'loving is a facade for bread winning' or 'loving
is the high altar on which income, has been sacrificed*.
I find
that more often thani not, the service ethic has been
turned around
to
sustain
the vested
interest
of
the NGO
bureaucracies. These
bureaucracies support
the
Western
political interests by which they are well
fed and sustained.
This is my criticism of WHO, UNDP and Human Rights Watch, two
of the parallel institutions which find high mention in your
notes.
My considered view is that these institutions are
taking us in
the wrong path of welfarism
(see following
section).
The Indian tradition of love insists that it is an individual
affair,
There is a fundamental difference between
loving
another as an individual
with his own well earned income
(Indian
tradition);
and
loving another by building
an
organization which is also the basis of one's economic
sustenance (Christian—NGOI tradition). The former is okay. It
has no vested interest, The latter is highly questionable. One
does not know whether the 'service' is a facade for operating
as a fifth column; or it is genuine sacrifice.
words
In other words,
I
am questioning whether the objective of
'loving'
can be served by building an organization at all. An
organization inevitably smacks of
'political'
aspirations—
power in one form or the other. It becomes worse when advocacy
and
'to work/fight'
is explicitly accepted as an objective
(Overview:?).
What does advocacy built on foreign money mean? To me it means
that
foreign donors,
often
governments working
through
churches and the UN system, will tell the Government of India
to behave itself. If Government of India does not behave then
it will
be hauled up before
'international community'—read
Western powers. Is that not a fifth column?
The point I am making is like this:
1
'Love' and 'Service'
'Service’ make sense only when undertaken from
self earned income. They cannot be made vehicles of
<
earning
one's own bread as NGOs, including the proposed GHWI,
seek to
do.
'Organized' social
service is essentially politics, not
love.
2
Political activity—advocacy and fighting,
as the NGOs
and GHW inherently are, should be done within national domain
with strictly national money, There in no locus standi for GHW
to advocate.
3
NGOs and GHW would be acceptable only if
they provide a
platform for brainstorming and
think tank to such individuals
who might be serving and loving with their own incomes.
The existing WHO, UNDP and Human Rights Watch are engaged
4
in fifth column intellectual activities.
2
Welfare State
The documents sent by you emphasize the aspects of equity
(redistribution of
income) and access or 'rights'
to health
(Draft 2:1; Draft 3:2-3).
3:2—3).
This approach is premised on the
belief that people
are powerless vegetables who cannot
themselves earn and secure good health. The emphasis shifts
from increasing incomes to increasing rights. access, feeding.
I
giving or charity.
There is a fundamental economic'conf 1ict in the world today.
The Western powers want unequal
exchange to continue. They
want that the developing countries should continue
to sell
their manufactures cheap
(tea,
ores,
textiles,
etc); and
import hi-tech goods (financial services, technologies,
technologies. etc.).
This unequal exchange is being sold to the developing world in
the name of international capital
flows, free trade and
globalization.
One of
the consequences of
this unequal exchange is the
developing countries are getting poorer while the developed
countries get richer. The West wants to preserve this economic
order.
Another consequence is that there
is increasing unrest in the
developing countries due to increasing poverty etc.
The objective of
the West is to contain this unrest to
'manageable'
levels lest it spill over and destroy this
unequal exchange. The talk of equity and access to health is a
part of this containment strategy.
The objective is not to liberate the people of the developing
countries but to ensure just enough relief that they do not
the unequal
exchange and rebel
at
the existing
understand
world order.
important
instrument of
this
'risk
The
NGOs are
an
management'. They are> given money by the West to ensure that
discontent does not <spill over. Thus the talk of safety nets
(Draft 2:1), district health system approach (Draft 3:2), etc.
These approaches do not seek to increase the economic incomes
of the people so that they can acquire good
health on their
own seif-respectedly earned incomes;
they seek to make them
intellectually dependent on the government (and World Bank and
foreign donors),
kill
their self-esteem and make
them
dependent upon doles so that they never question why they are
poor in the first place.
The proposed GHW appears to be yet another instrument in this
'risk management'It may be yet another instrument to
distract us from the basic
task of
resisting
the unequal
exchange and becoming economically stronger.
It is important to note that the first para of Draft 2 was
strong on trade policies and globalization.
This has been
diluted
in Draft 3.
That is but to be expected. The global
NGOs are all
votaries of globalization and
they will not
tolerate any fundamental questioning of economic supremacy of
the West.
That is a consistent theme of WHO, UNDP and the
like.
The inner content
aspect.
3
Cuiture
of
Draft 3
is
entirely silent
on
this
It has become fashionable .to salute
'different cultural
beliefs'
(Draft 3:2).
But, this salute is circumscribed by
certain 'unquestioned' values. For example: (1) Gender equity
by making
the woman work in addition to her role as species
propagator.
Women must be made additional
economic inputs
(although their house work must be 'economically valued'; (2)
Equity must be ensured within the developing world but not
between the industrial and developing world; (3) Democracy is
okay within the industrial countries but not at the world
level.
Here it is the money—weighted vote that counts as in
the Bretten Woods institutions like World Bank or the Security
Council.
This talk of culture is hollow.
This problem cannot be sorted out without examining the very
purpose of life.
For the West it is increased consumption,
albeit of
'wilderness' and 'tigers-preserved-for —man-to-gapeat'. Within this paradigm, they will accept local
culture. If
you want to consume temples. that is okay.
For Indian
tradition the purpose is
evolution of
the
individua1
to his higher potential. If
the purpose is so
specified
it is no longer certain whether making
the woman
work will lead to her evolution or devolution. Even, increased
consumption by the poor,
poor , if fed by the welfare state, may be
devolution. These questions appear to be out—of—bounds in the
documents circulated.
The point I am making is that the documents are fundamentally
based on consumption—as—objective and the role of the state in
ensuring consumption,
They do not permit questioning of this
objective.
If
this objective is
questioned,
to apparently
obvious
sanctity
to
gender justice and equity may well
evaporate into thin air.
4
Conclusion
I
am not enthused about GHW. .1 see it as a perpetuation of
unequal global economy, I see it as yet another instrument to
keep
countries
like
India in
|perpetual
intellectual
subservience.
I
see it as a result of 'organized
love or
service', which is a contradiction and a smokescreen for fifth
column activities.
I think the only positive role that such organizations can
perform is to provide a forum for Davos—type exchange for
dissenting voices. There is nothing more that can be done.
BE-ia-iggg ig:03
FROM:CYSD BBSR INDIA
acj/n
tei ..krocwM, not tn tvnt
06/10/99
01 574 SS37SS
70:31 0B0 5525372
Centre for Youth and Social Development
Fax # 080 5525372
E - 1, Institutional Area, P.O.-R.R.L
Bhubaneswar-751 013, ORISSA, (INDIA)
Tel. : +91-074-582377/583725/583739/583774
Fax : +91-874-583726
E-mail : cysdbbsr@cal.V8nLnet.in
Kind Attr : Dr. Ravi Narayan
Further tc our
i
■ ■ ■
• conversation please find the following draft. Because of a fault
telephonic
in
our emai I am faxing it to you. Please make whatever use you"want to make of it I look
forward to later occassions where there can be more clarification and prospects for inter
relationship.
Regards
/
/
Sundar N Mishra
P:01
Social Watch India 2000 and Beyond : A perspective
What Is S'Mcfcil Watch ?
•
It analyses social development policies, and actions by state / non-state actors in so far as
they further achievement of projected goals while bringing about equity.
•
Since 1
the Social Watch India has been generating a report on an annual basis analysing
social development initiatives by mostly the governments) and also the social development
situation This was basically circulated across different government departments, individual
citizens ^nd different NGOs across the country for public education and opinion building
•
The report was basically being prepared by CYSD and VANI.
• While tlt^ report is primarily oriented to sharpen the advocacy agenda on equity issues, only
this yean onwards there is a plan to link up advocacy activities on relevant points of analysis
in the rqfort.
•
While d'j takes definite pro-poor / marginalised positions on social structural / governance
related ^equities, it takes an inclusive approach towards (possible) partnering actors.
•
It exar[j|nes government action not in terms of programmes per se but also puts in
perspeedve the fundamental policy assumptions and the context There is now an attempt to
elaboralily look at what is being done by CSO/NGOs
•
It aimsiito foster a mutually supportive and synergistic relationship between different
statc/nrnimtate actors involved
Ij
•
it is a i^ocess of proactively putting up a constructive development agenda in light of the
innovatilpo expenenccs/experiments on the ground.
Thematic namework
The follovuing are the components of analysis. Analysis on every aspect is sought to be
disagreegahjd by gender, rural-urban differences and vulmtrable giuups as far as reliable data
permit.
Basic Entylsm&nt
l’
Learning i
•
•
access i|4> literacy and basic education in keeping with tfee specific linguistic and cultural
context; J
access
further educational opportunitise building upon local knowledge system and
culturaiiirthos at the primary, secondary and tertiary levels.
Staying Nfatthy
wholesome food and freedom from hunger/mal-iMrition
hygienic and dignified shelter
♦
•
access
access
♦
access rt? sanitation and potable water
♦
access m primary health care with emphasis on the aged, mothers and children
ii
Sustttoebto
. access reproductive natural resources like forest, river, etc. of dependent communities
• opportunities to strengthen existing skill-base in a nesd-ba^TL m communities
and .cow. w market infortnatkrn Jd li^
and market onented m.mer
•
promoti^i of focal enterprises in a market-oriented manner
pSp"leS,T aCCCSS tO SU5tain8hle ^oy™5* opportuaitiea for the resource-marginalised
•
rX8r3 the impaC1 °f m°dern Production system, particularly industrialisation on
livelihood opportunities of affected people
Y iMustJWlsatlon on
right of % wages, matenuty benefits, and dignified and secure work environment
•
Participtttyn4pw1nef9Mp In governance
• Functional, administrative and financial autonomy ofPRIs
• Dalits, triads and women play folly and freely their roles in self governances
’ Ad^u«f
/ operational space for participation of broad-spectrum civil society
Zs
,n f
811011
irtlPleme^ion of public policies and programmes at all
°f colUb<"Mio" be,w“> ““ ““ «««-•
'
«xl other civil society
♦
Analysis ar|iji Indices
There
is an
'’
~“ ai|jfcfo (tnCWtP°rale CCrUin nu®nces the a™1?’* fc® yw onward. While the
analysis will 'Wu qualitative to
I SSL
W11 h* "*
to
two typ®8 of
basing on boA
f frmrtitative and qu^rtahve data The drtail, of cafouhtioa wi« be finalised after
collection of Ml
i|l necessary data The following considerations will be used while constructing the
indices.
I
Two major ai||tous of the above themes and sub-themes which the analysis
i will need to focus on
are. a) what
been the achievement so for in the respective
wN>’ extern, necessary and
spectivc arass,
areas, b)
b) to
to what
desirable stepj are being taken by the government and other cml soci
fulfilment of i|| ib »
“
~
’ e nature andlj Inactions of further initiatives
2^,V“Zt
"
'vin h™8 *“
S3SiS
■
tiX^h01;.
«" I-* or f) of Mice
uulch
is proposed
that □„
the c^d
information
be used to nrmw
analydeal
imj mn,.,io„
s The fis
, Social^evdSSJ
preparad cut oflrtB value, of afferent indicate, on the Msemd 'teL, /
«e could be .H Adequoy of Action
teta
Jerne mdicaor. on thee two
jj
b“
th, 2 .
Indicators fc| Social Devekipnwnt hide;K
On Education,|i: in- the domain of basic set
services, some mdkMars eouki be gender-disaggregated
literacy rate in i| m*rural / iffbas cotaext, and
.! across various population groups; geods- disaggregated
data on enroln|nf and achievement
caste
secofida^
P<^««OMVhigher education
levels across vf
rural / urban /1
other educatiojl
b
w
seosrtrvejo
the hveiitowtWtwd needs of disadvantaged
communities, <j||tent of resource support
(financial
"
to MudcB1»
I*™ ^d dalit
communities atjr Women amongst them.
On health, sonju indicators could be gender-disaggregaged data on access to primary health /
reproductive h<" Mt care, sanitation and'potable
disaggregaged
on infant/chikf8^-
i
On housing,!) ic*6®510 pucca and hygienic housing and dstricity, fesrosa difrirerK caaWpcpulation
groups, per |j tpita room spaoe across caste/populaiion guups codd be same indicators. On food
security, geiii| al-disaggregfitwf nutrition status incidence of aneraig. across castc/population groups,
spread of wiHic distribution system and off take ®rosa difiteest socio-economic groups,
consumption) patterns of meat, women and children across different population groups, could be
some indicatj n
,;1
In the domai||! sustainable livelihood the following indicators may be considered: Access of forest
dependent p<|| ip|e to forest resources,
of land holding
differ^ G&st&poai i&tion groups,
profile of co* disbursement of the scheduled btnks snd other fingnshl institutions, perfc
—
tormance
of other cre|| t programs targeted at the
poor,
perftwmance
of
^diVeetrepreneurship
promotion
the poor, perfotmaoce of ^dil/e^rcprenev^ship promotion
programmes)!
ratca across caste/populsticn groups and women. Retraining /
redeploymeD|| / ■compensation
redeployment
compensation schemes and tircir
their operation in tlw;
the; fee®
fece of job loss/redundancy
lossfredundancy etc,
profile of $ scess to employment generated, status of impleatenra^kai of measures oh equal1
remuneration
.....
remuneratiori ffitir' wages, maternity
benefits, protection ngnm* oc^«p«>rirm^ hazards, and pattern of
displacemeni|i md rehabilitation.
J
Tn thfi riomai A of participation and governance the followup indicMtora may be couaiderod: number
af PRIs und|j inking local planning, PRIs preparing their budgets and implementing them, PRIs
ncoessing fiiU Wial resource, existence of legal proviakxu for fejctiotral / financial autonomy,
percentage cH indigenous people / women attending / actually partic^iatnig in decision making
processes, eij| ant of participation of women / indigenous people in orientation / capacity buildingr
programmes.! lumber
ntmber of public policies, which include consultation
ccnaiitaiion with CSOs at any
anv level.
level
In the domai.| of gender sensitivity some indicators could be the fibllowing. incidence of violence /
abuse againsi women and girl children, percentage of women at dififorent levels of bureaucracy,
judiciary and n (the state legislatures / parliament, corporate leadet^p, remuneration gap, status of
inheritance, c imiership rights, safe and friendly work environnasnts.
Indicator* ? Action Taken
While consid^'hg the adequacy of action taken on any theme/sub-tbeme the following aspects need
to be considef^t
ExistiljLe and implementation of policies / laws / gpvetnnwac reBohttioiM / orders enabling
the ad |i«vement of stated objective
Functj utilised / practicable / time bound plan of action
Adeqj ne allocation and utilisation of resources (human/fiuHnoial) and infrastructure with
approl
—— ri*t provisions for devolution
Non-t|| sqr i minatory implementation (with respect to gendar, casMtfctesfi, ethnic and minority
group*)
Exten||i of
of icollaboration with civil society institutions and oegarnsMions of the target groups
in fon|| uiation and implementation of programmes
Extenj) of operationalisation
of programmes for capacity building of CSOwCBOsi etc. for
.
t
above!Iw'
................
rationed participation
AvailJ nlrtty of relevant gender-disaggreggred uafomutfioB baae or plans to generate such
infom* Mo:>n base
Exist<|| ** *of appropriate provisions to dicit women’s pattidparion st all levels
a
-
«
I
aa
3
it '
t|
is
.
j...
“
Tamilnadu Seienee Forum
Restructuring Knowledge
Today knowledge is something only
specialists possess. We go to them with a
problem - they analyze and tell us what to
do. A farmer lias to listen to tlie agricultural
scientist who decides How much fertilizer
and pesticide is needed for his crop. He does
not know how the scientist came to this
conclusion. He cannot decide whether the
advice makes sense for his crop and his
financial and social situation or if there is a
better alternative that applies to his case. He
is a mere knowledge recipient, not an active
participant in the analysis or decision
making process. Therefore he can be used,
manipulated, exploited and controlled.
Why should knowledge be centralized
with the doctor, the engineer or the
scientist? Why cannot knowledge be
restructured so that everyone can be an
active participant in the use of it?
We are not saying that everyone must be a
specialist. Nor are we saying that specialists
are not needed. We are not saying that x, y
or z should also study the profession. We
are saying something of much more
consequence. We are saying that the subject
- medicine, engineering, economics or
agriculture - itself needs a major overhaul.
Restructuring knowledge so that “users” can
be participants - they know' what they can
handle themselves (most of the things),
'yhen to go to a specialist, how to interpret
ue specialist’s advice and the ability to
|i question and judge the advice.
How to go about doing all this? Organize
people to take up this agenda - by developing
their skills so that they can handle the
knowledge themselves. As they use the
knowledge for their own needs, they will
modify it, make it more individual specific,
enrich it and in the process completely
restructure it. This process will itself bring to
the fore local leadership which will voice
and address people’s real needs.
Empowerment: I control my life. You
control yours. I know how to be healthy,
how to learn new things, how to access
information, how to run my enterprise and
how to grow my crops. So I am in control of
my life. If something goes wrong. I usually
handle it myself. If I can’t, only then I use
the specialist - for help and guidance - not to
take over my life and run it for me.
" So that it empowers.
Restructuring Health
Then - An Action-Research Project...
For more than 3 years, we have been working on restructuring the medical
profession and the public health system. We now know that:
=> Health is not something that needs a doctor - doctors know how to cure
diseases but their current training often makes them unsuited to focus on
ways to prevent the illness.
=> Top-down planning of health does not work. The village has to plan for its
own health needs. This it cannot do without the required skills to monitor
the health status, to diagnose individual problems and to address it, to
identify community initiatives to prevent diseases and promote good health
These skills are needed but easily learnt.
A large part of ill health in rural areas is due to malnutrition.
Malnutrition
is caused by several factors - less food, less number of times,
=>
lack of iron, protein, and fat in the food; poverty, gender discrimination;
lack of good sanitation leading to diseases; poor access to health facilities,
insufficient rest, etc. Though many of these factors require large social
changes, it is still possible by optimizing the resources at hand in each
individual case, to help address the problem.
We did an action-research programme in 120 villages on community' health Wc
developed modu’es to train the village volunteer:
To diagnose the causes for malnutrition in an individual child and help the
mother to address it. This advice has to be individual-tailored taking into
account several factors - food pattern, illness, family resources & time
constraints, and efforts already made to address the problem.
To provide antenatal and postnatal support to pregnant women.
To help address gynecological problems, organize support structures for
women, and help women victims of violence.
To identify TB patients, to cure simple ailments, and to refer more
complicated cases to a doctor.
We also now know how to organize such a programme on a large scale:
=> Start with a cluster of 30-60 villages (a block). Train a block resource
group. This typically consists of 4-6 full-time village volunteers (women)
and interested part-time volunteers - both men and women. This team
establishes contacts with the panchayat and forms a voluntary village health
committee in all the villages in the cluster.
Each village health committee chooses a local woman as its health activist.
The block resource group then trains this woman - the training (on the
modules mentioned earlier) is done through camps as well as on the field.
=> Regular visits to the village by the block team ensures support for the
activist as well as constant re-training and motivation.
=> A simple register helps keep track of each child, pregnant woman, birth,
death and marriage in the village with very little effort. This register serves
' as the progress indicator and helps measure the improvements. After the
initial training period of 2 years, one can see a significant measurable
improvement in the health status of the village.
=> The input required to sustain this programme after the 2-year training period
is quite small. One can therefore sustain this effort without external funding
just by local efforts. How to do this lias to be worked out for each place.
Now - A People’s Movement for Health...
=> We have started initiating this programme in 17 blocks in Tamilnadu reaching out to about 700-1000 villages. Support from more volunteers can
help this movement reach more villages more effectively.
A People's Movement for People's Science
Restructuring Education
Education should be fun, interesting & relevant. This will
improve learning levels and prevent dropouts. Easier said
than done. A boring topic can daunt the child - but
making the topic fun can daunt the teacher!
To make this dream of restructuring education a reality,
tlie TNSF is working on a number of ideas - developing
innovative experiments, teacher-training programmes,
children’s science clubs, teacher-networks, a model
school. Children’s Science magazines and book. Public
hearings for the state government’s “conunittee on
reducing burden on school children” was one part of our
efforts to change government policy on education, to re
write textbooks and make life easier for millions of
children. While we are on this joy of learning trip, we are
also working on ideas to directly increase enrollment and
prevent dropouts. Non-formal education centers for
child-labourers to lead upto 5th or 8°’ class equivalency
(and on the sly instigating them against child labour
itself) & tuition centers for children who need help are
some of the other programmes.
We work not just to replace one textbook by another. We
work to break the enfeebling notion that education is
something specialists: bestow on people. We work to
change this perspective - to that of a continuously
learning society - where education is something people
do for themselves. We work to build new structures by
which people can participate in designing their own
learning methods and curriculum - forums for
exchanging and discussing ideas, educating themselves
and each other. This is exactly what our children’s clubs
and teacher’s networks are trying to be.
Restructuring Agriculture and IT
We are also involved in action research programmes
which look into ways of improving agricultural
productivity, soil fertility and water management using
locally available materials and labour and using very
little external inputs. We arc also looking into the
information needs of villagers and developing software
and information packages for it. This programme looks
into how information and communication technologies
need to be restructured if the poor are to use them and
benefit from them.
Taking Stands on Issues
The TNSF also studies, takes stands on various issues
that affect the poor and organizes public opinion through
newspaper articles, mass rallies, demonstrations,
speeches and debates on the issue. TNSF takes a stand
against communalism, nuclear weapons, and big
industries, vested interests and multi-nationals destroying
the living habitat and the livelihood of the poor.
All India People’s Science Network
The TNSF has also linked up with similar movements
and organizations in other parts of the country to form
the All India People's Science Network (AIPSN).
Arivoli -*A People’s Movement for Literacy
When will an illiterate woman feel confident that she can read and
write? Does the fact that millions of people all over the world know
how to read and write make her task any less daunting9 How can it9
Their ability is theirs, not hers. Her confidence will come only with her
ability to actually read and write. Confidence never conics in the
abstract. It comes only with the ability - skill and power - to do things.
The early 9.0’s witnessed a unique mass-movement in Tamilnadu - a
campaign for Literacy initiated by the TNSF.
Involving the
government as a partner, the TNSF mobilized tens of lakhs of people to
read and write. Lakhs of volunteers came forward to take classes every
day for 1-2 hours. It was a huge and successful movement. The agenda
was not just literacy. Literacy was only a tool for empowerment - to
move towards organizing people for other demands. But before we
could move in this direction, vested interests, political forces and the
government machinery intervened. The movement lost its edge and
TNSF withdrew from the literacy campaigns after the first 8 district.
But even today in many districts TNSF volunteers help the literacy
campaign though the organization itself is not directly involved with it.
Not everything was lost though - the strong motivation for literacy and
education built up in people during the mass campaign remains. We
have managed to retain a small but significant fraction of the large
volunteer base and reach into every village that we could establish then.
These volunteers are now doing all our development and organizing
activities. Even today the literacy agenda is being taken forward
through neo-literate publications and newspapers, libraries and work
based continuing education modules.
Samam-Women’s Equality Movement
The literacy campaigns put us in touch with lakhs of women - young
and old. Samam was established to give voice to their urge for equality.
Many programmes were developed - one that really took root was the
savings programme. Each savings group has about 20 women who save
about Rs.20 every month. This money is circulated within the group as
a loan. The loan can be for anything - emergency hospital expjnsec
tuition fees for children, redeeming ration cards, starting da
enterprises. More than 20,000 women have been so far organized iiuv
such savings groups. But savings and loans are not the only things
Weekly meetings,*reading neo-literate newspapers, learning new skill,
developing leadership abilities, discussing and taking steps to address
local problems are even more important. The money angle is one way
for the women to get together on a regular basis. In several villages,
these groups have stopped arrack sales, struggled against husbands who
beat their wives, taken up the cause of women victims of violence, and
even fought against police injustice and inaction. The best part of these
groups is that they arc fully self-sustaining and need no external
financial support. With the help of these groups, we arc integrating
health, libraries and other support activities for women to build a
vibrant women’s movement.
'
The TNSF needs your time, talent & donation!
To join us or support our efforts, please contact:
M. Balaji Sampath and K. Kalpana
E-57 A, 7,h West Street, Kamarajar Nagar,
Thiruvanmiyur, Chennai -600 041
Phone:(044) 8266033, 4480448
bsampath@eng.umd.edu or kb@eth.net
Heatth antf climate change
■<1 SUB?
t. .
On Nov 1 and 2,1993; at the World Health Organization’s headquarters in Geneva, an international group of experts met to discuss^
the potential health impacts of climate change. The meeting was organised for the WHO Division of Environmental Health and was J
chaired by Dr Rudi Slooff of WHO. Their task is now to update and expand the 1990 WHO publication Potential Health Effects ora
Climate Change. They will also contribute to the work of the Intergovernmental Panel on Climate Change, especially to the working;|
SI
-group on impacts of climate change. The proposed WHO publication is planned for 1995 and will include contributions on direct^
effects of increased temperatures on cardiovascular and cerebrovascular deaths besides potential impacts on vector-bomeJ
diseases, other communicable diseases such as cholera and algal biotoxin poisoning, effects on fresh water supply and foodJ
production, and impacts of a rise in sea level. Almost all these topics were covered in a Lancet series, that ends this week with they
initiation of a discussion of questions to be tackled by the WHO group—namely, how to monitor possible health effects and what |
ks
strategies are needed to prevent them.
■w
Global health watch: monitoring impacts of environmental change
'll
il
tl
1
w
ill
gai
w
The eleven articles published in The Lancet over the past
seven weeks have shown how anthropogenic damage to the
biosphere has potentially important implications for health.
The underlying processes are global in scale, and the
natural systems affected are part of earth’s life-supporting
infrastructure. This type of health risk thus differs
noticeably from more local environmental health hazards
that are usually addressed at a toxicological or
microbiological level. The impacts of global environmental
change on health may be indirect and present only after a
long delay. How can public health scientists predict and
monitor the population health impacts of this novel
challenge?1 We need to detect effects early so that
countermeasures can be developed spd tested, to find out if
there are previously unsuspected impacts, and to give
impetus to policies to reduce greenhouse gas emissions (and
other causes of global environmental change).
Climate change, the chosen focus of the Lancet series,
could affect health in a variety of ways. Direct effects of a
rise in temperature (particularly increases in the frequency
and intensity of heatwaves) may include deaths from
cardiovascular and cerebrovascular disease among the
Correspondence to: Prof Andrew Haines, Department of Primary
Health Care, UCLMS, Whittington Hospital, Highgate Hill,
London N19 5NF.UK
|
„
|
.J ■ g
I
o
I
Andrew Haines, Paul R Epstein, Anthony J McMichael, on behalf of an international panel*
W
|
elderly. Indirect effects are secondary, such as changes in
vector-bome diseases or crop production, and tertiary,
such as the social and economic impacts of environmental
refugees and conflict over fresh water supplies.2
Traditional epidemiological monitoring of disease and
mortality has limitations because there may be undesirable
delays before changes in chronic diseases are detected.
Other approaches must also be used, including biological
markers to give early warning of damage, the monitoring of J
carriers of infection such as insects and rodents, and remote
sensing for large-scale monitoring. There is growing
___________________ ___ __________________ ______ — . |
♦Dr Paul R Epstein (Harvard Medical Schcwl, USA), Prof Andrew Haines
r
(UCLMS, Whittington Hospital, UK), Dr Martin Hugh-Jones (WHO
Collaborating Center, School of Veterinary Medicine, Louisiana State
g
University, Baton Rouge, USA). Dr Charles F Hutchinson (College of
g
Agriculture, University of Arizona, Tucson, USA), Prof Laurence
Kalkstein (University of Delaware, Newark, USA), Dr Steven A Uoy
|
(Harvard University, Cambridge, USA), Prof Anthony J McMichael
(University ui
of nuciaiuc,
Adelaide, ovum
South nwouui»u/.
Australia). Dr Stephen S Morse,
luruv^raiiy
.4
11
II
11
(Rockefeller University, New York, USA), Dr Neville Nicholls (Bureau o
..
.
. . ~
___ L Centre, Melbourne,
______ or^fkAartinParry
Meteorology
Research
Australia). Prof Martin< Parry
(Environmental Change Unit University<of
of Oxford, UK), Dr Jonathan Hau
Pa^ .u |
Sandra Posts]
(World Health Organization, Geneva, Switzerland). -Dr--------j
(World Watch Institute, Washington DC, USA;,
USA), ur
Dr rxenncu.
Kenneth Sherman (U ..
Administration, Narrangansett,
|
National Oceanic and Atmospheric Z.J..*
’z'
‘.
Rhode Island), and Dr Rudi Slooff (World Health Organization, Geneva,
Switzerland).
1464
Vol 342 • December I h
-w- - ■
I
GOES-W
135’W
NOAA-8
1430L
LANOSAT 4
METEOR
(USSR)
4
I
• SPOT (France)
LANDSAT 5
GOES-E
V 7S*W
I
I
(Japan!
INSAT (India)
74*E W
^'■•NOAA-7 0730L
METEOSAT (ESA)
3*Longitude
*
iI
1-
fehr
fe
la*-
'I
■>:
1II STI
•
'■
''
THE LANCET
Observing System (GCOS) and a committee forGCOS has
now been set up. GCOS will, cover all components of
atmosphere, biosphere, cryosphere, hydrosphere, and land
surface climate, and that coverage is. beyond the scope of
current monitoring programmes such as Global
Atmosphere Watch and the World Weather Watch network
of satellites, telecommunication, and data processing
facilities (figure 1).
Two other observing systems (ocean and terrestrial,
GOOS and GTOS) will enable GCOS to provide a fuller
picture. More than eighty international organisations and
programmes are involved in. global environmental
monitoring, and the potential for overlap and lack of
coordination is great. Until now health has not been
adequately taken into account. A selection of these
organisations is shown in figure 2.
GMS (Japan)
140* E
I «'•
I
......
<■--
Figure 1: Earth observing satellites In operation (as of April,
1992) :
‘
awareness of the need to link environmental issues with
health—for instance the 1993 World Bank report Investing
in Health includes forest and fresh water resources.3 We
argue for integration of health into existing and planned
environmental monitoring systems. In this final article we
consider five aspects of monitoring, with cross-reference to
the series where appropriate: biological, environmental,
and human health indicators; data needed to monitor
indicators; technology for measuring them; organisations
doing the work; and gaps in information.
J
Direct Impacts (Kalkstein, Dec 4)
The direct effects of temperature on health are mainly
manifest as an increase in death rates amongst the elderly
during periods of high temperature and can best be detected
through analysis of mortality data collected daily. Such data
are currently available mainly in developed countries but
this information is needed for urban centres in less
developed countries. Aggregation of deaths into weekly or
monthly statistics is of much less value because an increase
in mortality tends to be short-lasting and may be followed
by a period of lower than expected mortality. Changes in
morbidity and in seasonal patterns of disease can be
detected in primary care data such as those collected from
sentinel general practices around the UK.5 This database
demonstrates, for instance, that consultations for asthma
Climate (Maskell et al, Oct 23)
The scientific assessment of climate change is being
updated by the Inter-Governmental Panel on Climate
Change (IPCC).4 The Second World Climate Conference
in Geneva (1990) recognised the need for a Global Climate
!
aS
GEMS
{^GAC^j
I
IgefI
Sr-
(SPAR^I
^Ga)
.PCC.
GCTE
IGBP "•
JGOFS
1
£ANI^
GTOS
i
Bl
I
GCOS
t.-'.
International governmental organisations/programmes
International non-governmental organisations/programmes
!
Ife'
gpr -
GOOS
Btfaa
'nternational science programmes
[
f
) Experiments/projects
RSure 2: Unks between major international global environmental organisations, programmes, and projects
Iteseamh
atH°"/I HnKkS‘JPemoranda of understanding”. (Adapted from figure 5 in Global Environmental Change: the UK
esearch Framework 1993, published by the UK Global
Swindon; this
this figure
figure has
has been
been simplified
simplified to
to emphasise
™°a' Environmental
En''lranmental Research Office, Swindon;
emphasise
.3006? S6r!9S.)
r
Othe^m '65 f/C_^'°Pment (UNDP)’ Environment (UNEP), Meteorological (WMO), Education and Science (UNESCO), Health (WHO).
Moni!°ring <GEMS>-Cllmate Observing (GCOS), Ocean Observing (GOOS).Terrestrial Observing (GTOS).
' stram«inhprir Prnro
/cZ^cosystems (GTEC), Geosphere-Biosphere (IGBP), Atmospheric Chemistry (IGAC), Oceanic Flux (JGOFS),
OMW .S.tratosphenc Processes <SPARE), Tropical Ocean and Atmosphere (TOGA), World Climate and Climate Research (WCP WCRP)
-_________ _________________________
IMifesr
1
'''"
1
• z.ITF*
1465
■fcs-. ■•■
the lancet
L'-
5ESSSKSSSSr ’Sma-
for monitoring of healthSed inSro
a be SUitablc
generally composed of natural systems theT’ n *
’
'
jK
&SlSXS te
fe
trypanosomiasis, dengue and^foXven<
diseases. In particular, vegeta LTd"0' VeCtOr-bo™e
bigh-resolution radiometry have h
“ produced by
mortality rates and pop^mon ri 5
with
Several types of remorZ
density of tsetse flies,
animal and vector habimr nSyigTCan be used to indicate
satellites (figure"
LANDSAT and SPOT
respectively,have beeJ TsedT'd ° r?0 m Md 10 tn.
and mosquitoes. The US Nationalhabizacs of ticks
Administration is sponsor^ r
Spa«
show seasonal 1
towards the end of th<
sh«»M. ”MeT'X
—* it possible
nta^:f”:,(D°6s"’"dcaw°«3o>
4f
•f
'pp'ppp.i
“h r:?;"ru,-al-' can be
influence the growth of parasites^ d’ THe f3CtOrS which
competitors, predators, a^d c mau
factor ts disturbed at the same ttae Z
One
declines and its resistant
’
system s resilience
Bioindicators are used to mo 7° PeStS may decrease.
The abundance and distribution rJnv‘ronmental toxins,
insects and algae can be used a ■
Y SPCCieS SUcb as
health. When an indicator is a?
°f CCOSystem
surveillance for health outcome L! 1
vector
Global Terrestrial Observing S
’rectly Iinked. The
network of sentinel
3
n°w is that run by UNESCO’ M31 network available
byy UNESCO
UNESCO ’ss Man and Biosphere
i
S~<ietected for instance,
by satellite11
J
’
information for vector-home d
control.7 Improved
incorporated within the n^r
observation pfatfX ta
SI
C USC ofsateIlite
m°™°ring and
Systems should be
°f
*
I
meteorological, topographic and e
‘““t C°mblning
must become more accessible and 'P'd^101^^! data
Climate change may first h
SlmP“ Use'
diseases at the margins of the’ C
°n vector-bome
global warming isota^h fl^
^utions. In
I
borne disease may follow in the P° e'?.ards and vector
yellowfever 8 16°C fn • 0 the SMie direction (10‘C for
Ji
I?
which vector-borne diseases are f
altItude at
sites in Kenya, Rwanda Cosm p- 0Und’ 3nd hlgh a,titude
good sires for monitoring FieldSdiestmay be
-.y
/■
is
IM
■H
iXth-4: SateU,te views of Ethiopia
ssa&w
areas are c,ouds- Red iMeasin
f°r Same period- Red shows siPnir
(Charles Hutchinson)
1466
Vol 342 • December 11, 1993
H
a
THE LANCET
i
.. Urban centres In developed and developing countries
IXre?effe?t<rf
. Daily mortality date;-.
(urban heat island effect)
f.'>tinel^
" at different latitudes
J ^^gesln^asonalpa^rt^^
|
Primary care morbidity data, hospital admissions
gins of distributions (latitude and aitltude)
r
•
fc
^/Igae/cholcra
»
Freshwater
f
I
|
I
,£ ■.
<
. -...fj -.
Ernerging diseases
g.
I g.
| BI f:
i g,
g
ii
Sa h
I
T."
....
Cataract
Illi
-
flhd low latitudes (taking distribution of ozone
j
■■ rt?- - J >'•
■•A . •;rj-
.;• Measures of run-off. Irrigation patterns, pollutant'
. concentrations-
,' ':-
Remote sensing, measures of crop yield, food access, and
nutrition from local surveys ' '
Cancer registries Epidemiological surveys
' depletion Into account)
■■■
As for skin cancers
■
••
‘
.
Epidemiological surveys
Areas of population movement or ecological change
Identification of "new" syndrome or disease outbreak
population-based time series Laboratory characterisation
Summary of main elements of monitoring scheme
monitoring may be possible .through local primary care
facilities with health staff trained to diagnose malaria and
ot^er conditions reliably and to keep accurate records.
In Latin America, Chagas’ disease could be monitored in
Chile and Argentina, currently at the edges of the endemic
area. Schistosomiasis could also be susceptible to climate
chan8e> especially if irrigation patterns change. In the USA
there is a Possibility
possibility of the spread of five vector-borne
diseases—malaria, yellowfever, Rift
Rift Valley
Valley fever,
fever, dengue
dengue
fever, and arbovirus-induced encephalitides.
r----------- .99 The
The use
use of
of
the Southern Oscillation Index, based on differences in
atmospheric pressure, to predict outbreaks of Australian
encephalitis was discussed by Nicholls.
‘
Climate change may result in the elimination of some
vectors and/or pathogens—for instance, as a result of very
hot dry conditions,, as in Honduras (Almendares et-al).
I
■ influences,
• Local
such as deforestation, need to be
distinguished from climate change.
I1' g
£F
Large marine ecosystems (Epstein and others
g,
- - Local studies ("sea truth”), communicable disease
survelllar^centres,remotesensing • ■
Local^popul'atlorisurveillance'
. critical regions
v_- ;. .
;
I
£
.0./.’.•I.,.;...;
Low-lying.reglons '
;
z: :
Pomary care data; local field surveys, communicable
,. <
oolv
S,..*..-’. >7
'regions'' especially In the Interior of continents
^Fbodsupphr" ’si^gg '
-T
^Sldn cancere.,
I
, Marine (and freshwater) ecosystems •
.j--.
jr ,
Guinea, then the Yellow Sea, and ultimately the world’s
other 50 coastal marine ecosystems.
A temperature increase of 2 • 5°C between 1990 and 2100 is
projected to lead to a rise in sea level of 48 cm.11 The impact
will depend on land subsidence, erosion, and the frequency
and intensity of storms.
There are currently 204 monitoring stations for sea level
rise with planned expansion to 306 in eighty-five countries.
Measurements are improving under the auspices of the
Global Seal Level Observing System (GLOSS), which has
a tide-gauge network. The countries most vulnerable to a
rise in sea level include Bangladesh, Egypt, Pakistan,
Indonesia, and Thailand, all with large and relatively poor
populations. Several low-lying islands such as Kiribati,
Tokelau, and the Maldives would also be in danger. The
health consequences will be direct (eg, due to flooding) and
indirect effects (eg, due to displacement of populations and
changes in vector habitats).
9yj.
Nov 13)
Changes in coastal ecology from local and global influences
have direct impacts on health. Environmental monitoring
of nutrients, currents, algae, and fish must be supplemented
cholerae;, (2) _surveillance
i >-<-> by: (1) monitoring
_ algae
_ for Vibrio------------__
Or of coastal communities- --for cholera
------ *a and
and for
for fish
fish (eg,
(eg,
g ciguatera) and shellfish poisonings; and (3) surveillance of
» J coral reefs (warming and ultraviolet radiation may cause
bleaching10).
Marine algal blooms can be detected by remote sensing
g and satellite radiometry is useful for monitoring sea surface
temperatures to guide sampling (figure 3/ Microwave
g. bands (to measure salinity) may be helpful for following
particular toxic phytoplankton species. The next
| generation of satellites (Sea WiFS, to be launched in early
/1994) will improve monitoring. Remote sensing needs to be
supplemented by local sampling to examine individual
species of algae and zooplankton associated with
gastrointestinal pathogens and biotoxins. Data on winds
and currents, nutrients (including nitrogen and phosphorus
originating from sewage), fertilisers, and industrial
pollutants will help to determine when conditions are
propitious for the growth of algal blooms. In 1994 the
Vj
monitoring of large marine ecosystems (funded by the
Global Environment Facility) is scheduled for the Gulf of
Itt
Vol 342 • December 11,1993
Fresh water
Fresh water is rapidly emerging as a limiting factor for
human development. Rivers, lakes, and underground
aquifers show widespread signs of degradation and
depletion, even as human demands on water resources rise
inexorably. Some twenty-six countries now have
indigenous water supplies of less than 1000 m3 per person
per year, a benchmark for chronic water scarcity. By the end
of this decade, some 300 million people in Africa—one third
of that continent’s projected population—will be living in
water-scarce countries.12 Although domestic water use
accounts for less than one-tenth of water use, there already
exists a large shortfall for safe drinking water. Globally, the
expansion of irrigated areas—which currently produce
one-third of the world’s food—has slowed to about 1% per
year whilst the world population grows annually by 1-7%.
Temperature increases resulting from the equivalent of a
doubling of the concentration of heat-trapping gases will
probably raise both evaporation and precipitation globally
by 7-15%. Rainfall patterns will shift, with some areas
getting more moisture and others less. Hurricanes and
monsoons may intensify and the sea level rise will salinate
some supplies of fresh water.13
There is no global monitoring of water quantity,
although most countries individually monitor the flows of
rivers and the levels of lakes. The Global Runoff Data
1467
THE LANCET
a.
Centre, under the auspices of the WMO and based in
Koblenz, Germany, maintains a database on daily river
flows from 1664 stations in ninety-one countries. These
data could serve as a baseline for examining possible shifts
resulting from climate change were a global system to be
established?4 The monitoring of water quality on a global
scale is the responsibility of the WHO/UNEP Global
Environment Monitoring System (GEMS). It promotes
the measurement of about fifty indices of quality but
practice among the 340 stations in forty-one countries
varies considerably. The monitoring of pollutants and
bacteria are relevant to climate change because changes in
runoff may alter the concentrations; however, it is the use of
fertilisers and pesticides, irrigation patterns, and industrial
effluents that are key determinants of pollutant levels.15
A specific fresh water indicator of warming could be algal
blooms, measured as chlorophyll a. There is increasing
awareness of the formation of large floating masses of
blue-green algae. Certain species can produce toxins which
may be poisonous, and rashes, eye irritation, vomiting,
diarrhoea, and myalgia have occurred in people who swim
through algal blooms. The blooms are considered to be
caused by a combination of calm sunny periods and
sufficient nutrients, notably phosphorus.16
i
Food (Parry and Rosenzweig, Nov 27)
Several systems have been developed by international
agencies to provide early warning of food shortages, notably
in Africa. These systems rely on routine data of three sorts,
that indicate food supply, food access, and wellbeing. Data
obtained on the ground, such as food stocks and planted
areas early in the season, supplement satellite data to
indicate supply; food prices in local markets reflect access;
and anthropometric measures or, in extreme cases,
mortality rates give evidence of health impacts on
populations.
Satellite data, as indicators of food supply and impending
famine, improve consistency among countries and are more
accurate and more timely than information had from
farmers or local markets, for example. “Greenness” indices
(red and near-infrared spectral reflectance) are available
from daily data from satellites. This index is linked closely
to cereal and forage production, and can be used to predict
locust infestations. Figure 4 illustrates this approach for
Ethiopia. Rainfall estimates are based on duration of cloud
cover (presumed to indicate rain).
One International Geosphere Biosphere Programme
project is a global network modelling crop yield responses
to environmental change. Another, jointly with an
International Social Science Council programme on
dimensions of human environmental change, will monitor
long-term changes in global land for agricultural use driven
by non-climatic influences such as population growth and
trade agreements.
Agricultural yields can also be affected by pests and
predators, which are themselves susceptible to climate
change. Potential examples from the USA are anaplasmosis
(a rickettsial disease .of cattle) and hornfly.17
satellite,18
and by ground-based
spectrometers.
Observations on trace gases (especially chlorine and
bromine containing compounds) that catalytically deplete
the ozone layer are needed to predict future trends in ozone
loss. A lightweight unmanned aircraft shows much promise
here; a fleet of them could fly for days or even weeks at a
time in the lower stratosphere and provide conrinnons data
that remote sensing techniques cannot. Serious
international cooperation on monitoring UV-B has only
just begun, although many governmental agencies are now
acquiring the expensive instrumentation. In the UK for
example the National Radiological Protection Board has
been monitoring solar UV (visible, UV-A, and erythemally
weighted UV-B) at three sites since 1988.19 Until recently,
only broad-band measurements of UV-B region were
available but we now have instruments that provide spectral
resolution, and serial data from Toronto, Canada,
published last month20 illustrate what can be achieved.
Epidemiological monitoring of skin cancers (basal cell,
squamous cell, melanoma), cataract, and other possibly
UV-B induced disorders of the eye are needed over a range
of latitudes. Recently studies have been initiated in
southern Chile, where there has been appreciable
stratospheric ozone depletion. Whilst data on melanoma
can be captured by cancer registry data, basal cell and
squamous cell cancers may be less reliably reported.
Reliable estimates of cataract prevalence are likely to
require periodic epidemiological surveys using a standard
system to grade lens opacity.21 However, these potential
effects may take years to become manifest so markers which
respond more rapidly are needed. The International
Agency for Research on Cancer is exploring methods of
making early estimates of changes in skin cancer risk. One
possibility is to use biological markers, for instance certain
dimer-forming mutations of the p53 gene in skin cells,
which appear to be related to UV exposure.22
Emerging Infectious diseases
Emerging infectious diseases are infections that are new in
the population or are rapidly increasing in incidence or
expanding in geographical range; examples are dengue,
hantavirus pulmonary syndrome,23 and some haemorrhagic
fevers. Most emerging diseases are caused by “microbial
traffic”—that is, the introduction and dissemination of
existing agents into human populations either from other
species or from smaller populations. This process is often
precipitated by ecological or environmental change and is
facilitated by population movements and other social
factors. Re-emerging diseases are those that had been
decreasing but are now rapidly increasing again. Often
previously active control programmes against wellrecognised threats to public health have been allowed to
lapse.
Our capabilities for health monitoring and rapid
response are seriously fragmented, with insufficient
coordination and communication let alone provision for
future needs. Inexpensive reliable communications (eg, by
e-mail) are still not available worldwide, although
initiatives such as SatelLife’s HealthNet, providing lowcost access to medical databases for remote areas, and
Ozone (Lloyd and Jeevan and Kripke, Nov 6)
Internet e-mail offer hope that this can soon be achieved. A
secondary network directly linking interested field
To assess the impact of enhanced ultraviolet-B (UV-B)
radiation resulting from stratospheric ozone depletion, two , scientists could greatly aid early recognition.
trends must be monitored—global changes in column
In conventional epidemiological surveillance, only a
small fraction of cases may be recognised and reported.
ozone abundance and changes in UV-B flux at ground level.
With emerging diseases, even a single unusual incident can
Ozone trends have been monitored by instruments on a
1468
£11
fl
Vol 342 • December 11.
d
•
|
WfewigTHE LANCET
K be significant and investigation of such a pointer requires
L$- linked capabilities for clinical identification of a “new”
syndrome or disease outbreak, for the epidemiological
® investigation of the event (usually the weakest link), and for
laboratory characterisation. Existing facilities with all the
Kt necessary capabilities, including some WHO collaborating
centres for arboviruses and haemorrhagic fevers, can be a
H’ starting-point. ProMED (International Program for
fe. Monitoring Emerging Diseases) has lately been proposed
Bl' and the idea is supported by the Federation of American
g Scientists and by WHO. Targeting so-called “critical
geographical areas” undergoing rapid ecological or
O demographic change would be most effective. US Centers
g- for Disease Control and Prevention has lately set up a
programme on emerging diseases.
This means a partnership between the technically advanced
nations with access to remote sensing capacity, for example,
and others. A global health monitoring network is essential
not only to determine the impact of climate change but also
to shape strategies to prevent climate change as far as
possible and mitigate those effects which do occur.
Wc thank the following for advice and information: Alexander Leaf, Mary
E Wilson, S Elwynn Taylor, Paul H Wise, Tord Kjelsrrom, S Taseer
Hussain, Raymond L Hayes, Richard Levins, Ruth L Berkelman and
Ralph T Bryan, D Anderson, Guy de The, J LeDur, K Nuttal, and
KE Mott.
References
1 McMichael A. Global environmental change and human population
health: a conceptual and scientific challenge for epidemiology. IntJ
Epidemiol 1993; 22: 1-8.
H Role of WHO
2 Haines A, Fuchs C. Potential impacts on health of atmospheric change.
J Publ Health Med 1991; 13: 69-80.
If WHO could have a key role in coordinating a “Global
3 World Bank. World development report 1993: investing in health,
gp. Health Watch” (in quotes because there is no such system)
world development indicators. Oxford: Oxford University Press, 1993.
based on environmental health initiatives in its regional
4 Houghton JT, Collander BA, Vamey SK. Climate 1992: the
supplementary report to the IPCC scientific assessment. Cambridge
p centres.26 It will therefore need to be involved in the design
University Press, 1992.
F and implementation of aspects of GTOS and GOOS. It can
5 Fleming DM, Norbury CA, Crombie TL. Annual and seasonal
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help select sentinel populations in critical regions where
variations in the incidence of common diseases. Roy Coll Gen Pract
O specific impacts seem most likely. Monitoring of health and
Occ Pap 1991; no 53.
6 WHO Task Group. Potential health effects of climate change. Geneva:
Ei climate change should be linked to information about the
WHO, 1990: 58.
1. global health picture, including population growth.
7 Epstein PR, Rogers DJ, Slooff R. Satellite imaging and vector-bome
ft •<£ Existing collaborative programmes with other UN agencies
disease. Lancet 1993; 341: 1404-06.
£ & (FAO, ILO, UNEP) places WHO in an excellent position
8 Maurice J. Fever in the urban jungle. New Sci Oct 16, 1993: 25.
activity
9 Longstreth JA. Human health. In: Smith JB, Tirpak D, eds. The
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to promote interdisciplinary
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7 on “climate and
potential effects of global climate change on the United States.
Cg ecosystem health
Washington, DC: Environmental Protection Agency, 1989.
3.
The WHO database Climedat specifically focuses on
10 Gleason DF, Wellington GM. Ultraviolet radiation and coral
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It lists investigators, organisations, and projects dedicated
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to research on climate health.! In addition the UN
12 Postel S. Last oasis: facing water scarcity. New York: W W Norton,
International Decade for National Disaster Reduction can
1992.
provide practical input on preparedness and mitigation.
13 Waggoner PE. ed. Climate change and US water resources. New York:
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Wiley, 1990.
14 Rodenburg E. Eyeless in Gaia: the state of global environmental
Conclusion
monitoring. Washington DC: World Resources Institute, 1991.
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g- Greater integration of efforts to collect data on health and
15 WHO Commission on Health and Environment. Our planet, our
global environmental change is needed. Many of the
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16 Elder GH, Hunter PR, Codd GA. Hazardous freshwater cyanobacteria
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$ take a long time to manifest themselves, and sometimes the
17 Rosenzweig C, Daniel MM. Agriculture. In: Smith JB, Tirpak D, eds.
links between ecosystem damage and health are unclear.
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Washington, DC: US Environmental Protection Agency, 1989.
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^5 used as a “wait and see” argument against action to reduce
1992. Science 1993; 260: 523-4.
greenhouse gas emissions. The Framework Climate
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Change Convention signed in Rio de Janeiro last year has
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atmospheric concentrations.
f'
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k
GLOBAL HEALTH WATCH (National Meeting : India)
Date : 7,h / Sth October 1999
Venue : Ashirvad, No. 30, Off St. Mark’s Road, Bangalore 560 001.
Registration Form
1. Name
2. Academic / Work Background
(Mention Discipline and focus of experience)
3. Organisation Represented
4. Address
Fax No.
Tel No.
Email:
5. Postal address (If different from above)
6. Arrival on
At
(time)
At
(time)
By
(mode)
By
(mode)
7. Departure on
6th night
8. Accommodation : required / not
required:
Dates
7th night
8th night
9. Will like to Present experiences / or
issue of
10. Travel supported by own organisation
11. If no in 10, then Require Fare
Yes
No
(estimate)
12. Any Special suggestions?
Date :
Place :
Signature
(Send back latest to reach us by 3rd October, 1999)
GLOBAL HEALTH WATCH
NATIONAL MEETING : INDIA, 7th - 8th October 1998
Community Health Cell - Bangalore
and
NGO Forum for Health - Geneva
Venue : Ashirvad, 30, St. Mark’s Road, Bangalore - 560 001. Phone : 2210 154
Tentative Programme
7,h October 1999
(Thursday)
8.30 - 10.00 a.m.
Session 1
11.00- 11.15
Session 2
Registration and Fellowship
Introduction / Inauguration
• Welcome
• Self Introduction by Participants
• Introduction to the theme <and
Objectives of the Workshop
• A Presentation on the GHW idea
• Finalisation of Programme
• Selection of Rapporteur Tearn
Tea / Coffee
Learning from Other Watches
11.15 a.m. - 1.15
p.m.
1.
10.00 - 11.00 a.m.
ii.
in.
iv.
v.
1.15 - 2.00 p.m.
Session 2 (Contd.)
2.00 - 3.00 p.m.
Chairperson :
Dr. V. Benjamin, CHC.
Dr. Thelma Narayan.
Dr. Ravi Narayan
Chairperson :
Dr. C.M. Francis, CHC
Dr. Gita Sen
CYSD’s paper was read
out by Dr. Sunil Kaul
NATHI- District level Disease Dr. Reuben Samuel
Surveillance
People’s Watch (Tamil Nadu)
Mr. M.A. Britto
Prof. Hasan Mansoor
PUCL - Karnataka
Health Watch
Social Watch
(Each presentation of 15-20 minutes
will be followed by 10 minutes of
clarifications / questions)
Lunch
Presentations will continue with sharing
by
other
participants
regarding Participants to volunteer
‘Watching’ on issues in their work.
Session 3
3.00 - 3.20 p.m.
3.20 - 3.40 p.m.
3.40 - 4.00 p.m.
4.00 - 4.15 p.m.
8th October 1999
(Friday)
Session 4
9.30-11.30a.m.
Session 5
9.30- 11.30 a.m.
11.30-11.45
1.15 -2.00 p.m.
Session 7
Understanding Equity (including Chairperson :
Case Study of Government Health Dr. Sukant Singh, CMAI.
Data) - A Panel discussion
Panelists
What is Equity?
Dr. Pankaj Mehta
Equity in National Health Programmes Dr. Ravi Kumar
Equity
in
Government
Health Mr. As Mohammad
Information
Tea / Coffee
Group Discussion
The group will divide into three and
discuss the GHW concept with
reference to the issues brought up in the
questionnaire
Evolving the Framework of a
Watch(I)
Advocacy / Campaigns some case
studies.
1. CEHAT
2. PEACE
3. BELAKU
4. VIMOCHANA
5. JNU
6. AIPSN
Tea / Coffee
Lunch
Evolving the Framework of a Watch
(II)
2.00 - 4.00 p.m.
Moderators/Resource
persons to be selected
for each group.
Chairperson :
Prof. R.L. Kapur, CHC.
Dr. Amar Jesani
Mr. Anil Chowdhury
Dr. SaraswathyGanapathy
Ms Donna Fernandes
Dr. Mohan Rao
Dr. Sundarraman
Chairperson :
Dr.
D.K.
Srinivasa,
RGUHS.
Plenary Meeting:
By Rapporteurs
Presentation
a) Short
by
Groups.
b) Presentation of responses to Dr. Sunil Kaul /
pre-workshop questionnaire. Dr. Rakhal Gaitonde
Suggestions from the Floor.
4.00 - 4.15 p.m,
Session 8
4.15 - 5.15 p.m.
Tea / Coffee
The Way Ahead - to Watch and how Chairperson :
Dr.
Mohan
to Watch? at India level
Suggestions & Commitments on NIMH ANS.
Follow-up. Winding Up
Isaac,
- Media
RF_COM_H_48_SUDHA.pdf
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