On a warm dusty Friday afternoon last week, a diverse group of health workers committed to human rights advocacy jumped in a VW-style bus (a.k.a. matatu) and headed to a Kenyan hospital 2 hours outside of Nairobi. We had gathered in Kenya as members of Physicians for Human Rights (PHR), an international nonprofit, to attend a conference on the right to health organized by local Kenyan health workers. We settled in for the ride...two American doctors and one nurse, two PHR staff, and two remarkable African colleagues...Stephen Rulisa, a prominent young Rwandan doctor, and Margaret Byabakama-Muyinda, a seasoned nurse advocate based in Uganda. As Nairobi ebbed away, boisterous lorry trucks emblazoned with bright Swahili, English, Arabic, and Hindi slogans rumbled past us and occasional herds of camel and goats spotted the landscape. Inside the matatu, however, our group was engrossed in conversation, collectively processing lessons from the Kenyan conference on health rights that had concluded the day before.
We attempted to understand statistics that told the broader story of structural barriers to equity and health, particularly for women. In Kenya, for instance, where a poorly funded public medical system often charges fees to patients in order to stay afloat, a woman who has suffered sexual assault or rape is charged 3000 Kenyan shillings (nearly $38 US dollars) by some hospitals to submit a paper form documenting the crime. Given that more than half the country lives on less than $2 a day and many less than that, it's no surprise that the majority of sexual assault cases go unreported in Kenya. Other statistics reveal major gender-skewed weaknesses in the country's health system...40% of maternal deaths in Kenya, for instance, are attributable to complications of unsafe abortions. The deeper structural barriers that have led to these statistics are driving the rights and health of women and, by extension, their families into the shadows. Kenya is by no means the worst offender in this regard...in fact, every country (including the US) has its share of statistics that point to the human impacts of policies that are not based on the right to health.
The matatu jostled along, and our discussion continued. We attempted to process the stark consequences of missed opportunity in Kenya and elsewhere. Unlike many countries in Africa that lack adequate numbers of qualified health care workers, Kenya produces a relative abundance of trained nurses. But the problem is that a lack of funding, clear policies, and effective implementation has prevented the public health sector (hospitals, clinics, dispensaries) from employing these nurses. So Kenya's health infrastructure remains thirsty for workers in a sea of relative plenty, and patients continue to pay the ultimate price. In the US, we face similar though less severe forms of irony in the distribution of our health workforce...while the need for prevention-oriented primary care clinicians grows in the US, the supply of primary-care graduates from our health professions schools dwindles.
But our conversation on the road to Kenya's Eastern Province didn't center on these statistics and stories. Instead, we kept returning to a few central themes...politics and leadership, governance and power. These themes possessed a powerful gravity...we couldn't help but discuss them. It was as if our ideas of health and equity and our desire for concrete results revolved in tight orbit around a larger central sun of civic life and politics. Empowerment and governance, fairness and transparency, participation and accountability...each of these concepts became the foundation of our free-flowing conversation of health and human rights.
As the asphalt road turned to bumpy gravel, Stephen told us of Rwanda's governance reforms after the 1994 genocide. For instance, since evidence shows that women are often central agents of change in terms of health and civic life, he said, the Rwandan government focused on women's involvement in governance. Now, Rwanda, a country that most Westerners associate with the horrors of genocide, leads the world in the percentage of women in elected office. (By comparison, as of 2002, the US ranked 52nd out of 179 countries with regards to women in national legislatures). While many critics, including Zachariah Mampilly, rightly point to the Rwandan government's autocratic methods and suppression of core democratic institutions like freedom of the press and civil liberties, the fact that so many women hold positions of power in parliament may bode well for the country's health programs and, perhaps eventually, lead to a greater degree of democratic development.
Democracy, accountability and the link to the right to health...like the dust from the road traffic, these concepts swirled around us. Over the past week, virtually every doctor, nurse and health advocate I spoke with brought up a major current news story about Kenyan ministers of parliament (MPs). And it captured our attention on the bus as well. In Kenya, MPs are among the highest paid elected officials in the world earning more than $10,000 a month. But they're only required to pay tax on their basic pay of $2500, and some don't pay even that tax. In June, these leaders unanimously voted in rare cross-party unity AGAINST a proposal requiring them to pay tax rates comparable to the rest of society. Reports now suggest that many Kenyans view their leaders as unscrupulous, ineffective, and self-serving.
And Kenyan health workers are adding their voice to the mix...if precious money paid by the public is disappearing into lavish private accounts or large administrative overhead costs, how can a struggling health care system hope to finance and support needed programs? This problem is often compounded by international aid, which has tended to fund private NGO-led health efforts rather than support and reform strained government health systems. As our matatu jostled along, we asked...are sustainable advances in health and human rights dependent on participation and the health of governance systems? We answered the question as soon as it was asked with an emphatic yes.
A middle-aged man drove past us in a blue sedan and I noticed a picture of a beaming Obama plastered on his back window. It's one of dozens of Obama stickers we'd seen in less than a week. In fact, so far, we've met more proud "cousins" of Pres-elect Obama than one would probably find in Hawaii or Kansas. I couldn't help but wonder about parallel lessons of democratic participation and good governance from the US for our group of health workers. Congressional leaders and President Bush have enjoyed historically low levels of public support...in part because of Americans' frustration with a style of governance that had been relatively opaque and unresponsive. As President-elect Obama, who won by mobilizing and reshaping the American electorate, transitions to power, attempts to increase transparency and grassroots democracy (see change.gov) hold interesting lessons and opportunities for health rights advocates. Isn't participation of those who often feel powerless to change an opaque and unresponsive health system, particularly the most vulnerable working families, the necessary means by which we achieve real progress in rights-based health reform?
In Kenya, where the public lack faith in their parliamentary leaders, some advocates at the Kenyan health rights conference were calling for Obamanian style community engagement and civic advocacy around principles of participation, transparency and equity in health care. (for an excellent example of this kind of advocacy, check out a blog by Lukoye Atwoli, a prominent Kenyan doctor and mental health advocate). For example, one local doctor mentioned that Kenyans should do more than just celebrate Obama's victory in the US...they need to find and support their own Obamas. That comment echoed those I've heard from progressive voices back in the US, who are now calling for continued community organizing and grassroots leadership in anticipation of imminent debates about US health reform.
We reached our destination and our delegation poured out of the matatu and onto the sprawling grounds of a large district hospital, one of the highest level referral facilities in Kenya's Eastern province. As we toured the colonial-era facility and were greeted by patients and health workers, we started asking about the details. How many doctors and nurses work here? What patient care protocols existed? What's the typical patient volume? What kind of lab equipment do you have?...and so on. Out of habit as much as genuine curiosity, we focused on important yet relatively technical topics that health workers are usually very comfortable discussing. I couldn't help but think about how our conversation about participation and democracy en route to the hospital was linked to the delivery and quality of health care services at our destination. The former discussion, it seemed, had highlighted the necessary means to achieve the ends we seek as health professionals.
For our group of health workers, our trip had highlighted a basic choice facing all committed to health...if our destination is health, rights, and equity, do we limit ourselves to traveling the familiar terrain of a traditional, technical biomedical approach to society's ills? Or must we expand our capacity as health advocates, lend our voice to others in civil society, and travel down the bumpy road of participation and empowerment? From Kenya to Rwanda, from Uganda to the US, I know more and more health professionals are opting to take the latter path.
Now, with the 60th anniversary of the Universal Declaration of Human Rights upon us, I head back to Los Angeles, slightly fatigued but enthusiastic. Back at home, a growing community of health professionals are employing grassroots innovative advocacy tools like the South Los Angeles Declaration of Health and Human Rights, or calling for health and human rights abroad, like in Zimbabwe. Others are joining efforts like the Rx Vote Campaign or the National Physicians Alliance's Secure Health Care for All Campaign to engage in civic life and health reform at home. And all of us look forward to collaborating with our colleagues abroad. We may no longer be in that Kenyan matatu, but we hope to continue moving in the same direction.