Public Health Ethics Advance Access published February 29, 2012
PUBLIC HEALTH ETHICS
2012
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A Theoretical Framework for a Comprehensive Approach to Medical Humanitarianism Ryoa Chung , Department of Philosophy, University of Montreal
Corresponding author: Ryoa Chung, University of Montreal, Philosophy, 6128, succ. Centre-Ville, Montreal, Quebec, H3C 3J7, Canada.
Tel: +514-343-7523; Fax: +514-343-7899; Email:
[email protected]
This comprehensive, integrated perspective on medical humanitarianism stands in contrast to the more mainstream apolitical view of medical emergency relief that does not engage in the broader analysis of the socio-political causes of health vulnerabilities prior to and following the immediate impact of humanitarian crises. The meaning of ‘apolitical’ here differs from T.G. Weiss’ (1999) distinction between two groups of humanitarians characterized as the ‘classicists’ led by the International Committee of the Red Cross and the ‘political humanitarians’ represented by Me´decins sans frontie`res. Weiss depicts the ‘classical apolitical’ approach of humanitarian action as governed by the view that ‘the two most essential humanitarian principles of neutrality (not taking sides with warring parties) and impartiality (nondiscrimination and proportionality) – have been relatively uncontroversial, as has the key operating procedure of seeking consent from belligerents’ (Weiss, 1999: 1). For the purpose of clarity, this article only addresses issues related to medical humanitarianism in contexts of natural disasters and does not deal with political issues, such as relations of power between warring parties. This said, it is important to question the
presumption that humanitarian medical relief, on a narrower definition of the humanitarian imperative of saving lives in situations of emergencies, can be thought of as an independent, isolated aspect of humanitarian assistance that can be separated from its larger social context, even in the event of natural disasters. I therefore describe as ‘apolitical’ any view of medical humanitarianism that does not engage in the analysis of the socio-political causes of pre-existing and future health vulnerabilities (encompassing health inequalities and health care deprivation). In contrast, should we accept the argument according to which the extent of natural disasters can be correlated to the social determinants of past, present and future health vulnerabilities, then a more comprehensive approach to humanitarian medical relief seems warranted. This approach to medical humanitarianism may be regarded as more ‘politicized’ in so far as it is attentive to previous, present and future social justice issues in the analysis of health disparities (e.g. socio-economic, ethnic and gender divides within a community) and advocates for greater acknowledgment of the role of medical NGOs as important social actors in the assessment, the perpetuation, the causation
doi:10.1093/phe/phs001 ! The Author 2012. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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This article aims to demonstrate how the impact of humanitarian crises on health outcomes is related to social justice issues, even when these crises are brought upon by natural disasters. Pre-existing inequalities between individuals and social groups within a community affect in important and complex ways the health disparities which result from natural disasters. Drawing on the thought-provoking work of Paul Farmer, my main hypothesis is that socio-political factors prior to natural disasters determine ‘structured health risks’ that humanitarian crises will necessarily exacerbate. To adequately respond to these structured health risks, medical humanitarianism cannot abide by an apolitical approach which mainly focuses on emergency relief. A more comprehensive analysis of the socio-political aspects of the health impact of humanitarian crises indicates that a more comprehensive approach to medical humanitarianism is necessary. This has three implications. First, a coherent account of medical humanitarianism needs to assess the international dimension of structural injustice that leads to structured health disparities. Second, this comprehensive approach to medical humanitarianism supports the ‘denaturalization of natural disasters’ argument. Third, medical humanitarianism should be organized around a broader and more complex approach of overlapping sequences which bridge emergency relief, reconstruction and development through a better aligned, orchestrated and coherent international effort.
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and/or the redress of health vulnerabilities associated with social inequalities. The following discussion will describe this multifaceted, integrated approach to medical humanitarianism in greater detail.
Structured Health Risks, Structural Injustice and Humanitarian Crises
Poor health and health inequalities across individuals and social groups are brought about by multiple and multi-level factors that interact in complex ways. These factors include the individual material circumstances in which people live their lives as well as social cohesion and psychosocial, behavioural, and biological factors, and the functioning if the health care system. The way people interact with or experience these factors is determined by their position in the social hierarchy along dimension of wealth and income, occupation, education, gender, race or ethnicity, and geographical location of residence. All these causal factors are in turn affected by a political, economic, social, and cultural context that determines the unequal distribution of power, prestige, and resources. (Venkatapuram et al., 2010: 4) For a number of reasons that will be identified in the final section of this article, the comprehensive approach to medical humanitarianism that is presented here is not identical to the SDH model, although it is undeniably inspired by it. Indeed, NGOs’ status as non-state actors defines their particular role and agency, hence the need to develop an alternative theoretical framework that captures both these fundamental characteristics as well as the idea that past, present and future causes of health vulnerabilities must be taken into account within a broader analysis of the health outcomes of humanitarian crises. In a number of ways, Farmer’s notion of ‘structured health risks’ can be linked to the concept of ‘structural injustice’ that the feminist political philosopher Iris Young developed, albeit in quite a different context (Young, 2007). Young’s notion of ‘structural injustice’ allows us to capture the correlation that Farmer establishes between pathologies of power, structural violence and structured health risks and to suggest, in a more systematic fashion, that they are organically interrelated within larger socio-political structures. Young writes: Structural injustice exists when social processes put large categories of persons under a systematic
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The theoretical framework of this comprehensive approach to medical humanitarianism builds on the idea that some health vulnerabilities are determined by existing social structures within a given community. Farmer’s complex understanding of medical humanitarianism is worth discussing thoroughly. However, the limited space of this article will only allow me to explore the link that he establishes in Pathologies of Power (Farmer, 20051) between social determinants and health vulnerabilities with a view to extending the analysis of medical relief in contexts of humanitarian crises caused by natural disasters. According to Farmer, several health inequalities between individuals or amongst social groups within a domestic and/or international community result from unjust power structures. Indeed, in cases of extreme domination and tyranny, power inequalities manifest through repeated violations of fundamental rights and the deprivation of basic needs. In Farmer’s words, ‘the social determinants of health outcomes are also, often enough, the social determinants of the distribution of assaults on human dignity’ (Farmer, 2005: 19). In these contexts of ‘structural violence’ (i.e., human rights abuses) engendered by unjust power structures, the ‘pathogenic role of inequity’ can be measured in terms of health inequalities. In this regard, Farmer’s analysis of the social determinants of health risks urges us to rethink the ‘Health and Human Rights’ paradigm in order to reorient medical humanitarianism away from the narrow, apolitical, emergency relief view in favor of a more comprehensive approach. In this sense, Farmer’s plea to broaden the health and human rights paradigm beyond the struggle for civil and political rights with a view to furthering the ‘struggle for social and economic rights as they are related to health’ (Farmer, 2005: 6) calls for a comprehensive approach to humanitarian assistance and legal and political advocacy, which cannot be limited to medical humanitarianism alone. Nevertheless, my claim in the present context is somewhat more modest. Essentially theoretical, it is limited to the particular role and agency that medical NGOs can in fact uphold in contexts of humanitarian crises
regardless of the failures and accomplishments of legal and political activism in other important spheres of humanitarian advocacy. What I wish to suggest is that Farmer’s notion of structured health risks also converge, in important respects, with Marmot’s—or the WHO Commission’s—perspective on the social determinants of health. The central tenets of the SDH model are well known.2 It is nonetheless useful to present them concisely:
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threat of domination or deprivation of the means to develop and exercise their capacities, at the same time as they enable others to dominate or have a wide range of opportunities for developing and exercising capacities. Structural injustice is a kind of moral wrong distinct from the wrongful action of an individual agent or wilfully repressive policies of a state. Structural injustice occurs as a consequence of many individuals and institutions acting in pursuit of their particular goals and interests, within given institutional rules and accepted norms. (Young, 2007: 170)
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Three Implications of the Comprehensive Approach to Medical Humanitarianism The first implication is the need to assess the international dimension of structural injustice that leads to structured health disparities within a society. In this connection, cosmopolitan perspectives, which have been developed in the field of international ethics, approach the problem from a revealing new angle (as I have argued in a previous article3). Indeed, the upshot of this approach is that the internal (domestic) conditions pertaining to economic growth and political emancipation of each country depends at least in part on external conditions relating to international coexistence. As a result, we might speak of increasing structural interdependence between states at a global scale. However, it cannot be denied that such structural interdependence rests on unequal political and economic power relations amongst states which are reproduced at the level of international institutions (such as the International Monetary Fund or the World Trade Organization). In this context, some countries’ opportunities for economic growth and political development are conditioned by these systemic inequalities at a global scale and do not depend on their autonomous will alone. This analysis of the co-dependence between internal conditions and international macro-structures by no means implies that the domestic responsibility of certain national governments should be denied with regard to their respective poverty rates and degrees of corruption. Nevertheless, it leads us to acknowledge the economic and political vulnerability of some countries in the face of structural injustices at the international level (especially those produced by the historical legacy of colonialism and/or imputable to contemporary trends in globalization). By the notion of economic and political vulnerability, I mean the lack of necessary resources and infrastructure that leave some countries and populations exposed to greater risks in the face of violent conflict or natural disasters. As Farmer writes, It is important to sound a warning about the habit of conflating the notion of society with that of nation-state. We already live in a global society. Thus, calls of a right to equity must necessarily contend with steep grades of inequality across as well as within international borders. The same holds for the analysis of human rights abuses. Nationally framed analyses of human rights – such as those appearing in, for example, reports from human rights watchdog
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Young’s notion of structural injustice rests on a social connection as opposed to a liability model of injustice. Some types of wrongs and injustices are not directly imputable to clearly identifiable actions and agents. Sometimes, injustices and wrongs are produced by the collective interactions of agents, each pursuing their own interest in the context of common social, economic and political structures. According to this social connection model, even though individual agents are not directly liable for acting wrongly toward another identifiable victim, they all share moral responsibility in the genesis and perpetuation of injustices. Young’s notion of structural injustice provides us with important insights about how we can understand the genesis and perpetuation of structured health vulnerabilities that engender what are really unjust health inequalities between individuals or groups (corresponding to socioeconomic, political, ethnic or gender divides within a society). Her philosophical framework also highlights the complex interactions between the domestic and international spheres. As such, Young’s model of social connection enables us to better understand how medical NGOs also take part in the complex interactions of numerous actors that can produce positive outcomes as well as unintended wrongs. Indeed, data indicate that some NGOs can count on annual budgets that are comparable to the annual budgets of the countries they assist (Barnett, 2005). NGOs exert political influence and, despite their claims to impartiality and neutrality, must be considered as important economic agents and political actors within this model of social connection. In light of this plausible theoretical framework which articulates Farmer’s notion of structured health risks in terms of Young’s conception of structural injustice, I argue that a short sighted view of medical humanitarianism that does not engage in the deeper social analysis of health vulnerabilities in contexts of humanitarian crises offers an incomplete picture. I will now examine three theoretical implications of this alternative comprehensive view.
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organizations – may obscure their fundamentally transnational nature. (Farmer, 2005: 20).
Relief is not reconstruction. The earthquake was what doctors would refer to as an acute-onchronic event: a disaster in a setting of profound social precarity. Building back better means adding schools, hospitals, public services – and improving governance. And to do it well, we need building foreign assistance back better, too (Farmer, 2011a). The third implication of a more comprehensive approach to humanitarian intervention should therefore call for a different conception of the timeline in which distinct though overlapping sequences of medical humanitarianism take place. A three-layered approach, involving emergency relief, reconstruction and development can help define the purposes of medical humanitarianism as well as its different stages. In fact, the Tsunami Evaluation Coalition report (Buchanan-Smith and Fabbri, 2005) seems to point in that direction. The report stresses the advantages of distinguishing natural disaster from complex political emergencies in previous debates about humanitarian aid policy: ‘This was entirely appropriate and freed up the conceptual thinking and analysis around conflict-related emergencies and associated humanitarian responses, breaking away from the technical models of natural disaster that had limited relevance to many conflict situations’ (Buchanan-Smith and Fabbri, 2005). However, at the end of the nineteennineties, ‘this growing distinction between natural disaster and complex political emergency has since been challenged by evidence of the widespread coincidence of both natural disaster and conflict related emergencies’ (Buchanan-Smith and Fabbri, 2005). In fact, drawing from empirical data, Buchanan-Smith and Christoplos (2004) cite more than ‘140 “natural” disasters occurring in countries experiencing complex political emergencies’ between 1998 and 2003 and call for a more political analysis of these so-called natural disasters. The Tsunami Report suggests that we should acknowledge and link the three dimensions of Relief, Rehabilitation and Reconstruction. Although I prefer to talk about relief, reconstruction and development, Buchanan-Smith and Fabbri’s definition of rehabilitation (the ‘reconstruction’ stage in my view) is worth quoting: Rehabilitation has been seen as the critical link between relief and development although it is a
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What political philosophers can gain from the literature on medical humanitarianism and public health is a better grasp of the notion of health vulnerabilities as a favored indicator to measure the extent, as well as perhaps certain root causes, of humanitarian crises. Health disparities during humanitarian crises point back to preexisting social determinants of health both at the national and international level. Indeed, health disparities serve as an indicator of social justice, be it at the domestic or international level. The second implication of this comprehensive approach to medical humanitarianism is the necessity of ‘denaturalizing natural disasters’. Following Farmer’s view on structural injustice, the extent and gravity of structured health risks or given health vulnerabilities will inevitably be exacerbated in contexts of violent conflict. However, as I want to suggest, following Andrew Pinto’s article ‘Denaturalizing “natural” disasters: Haiti’s earthquake and the humanitarian impulse’ (Pinto, 2010),4 these societal risk conditions will also be exacerbated in the context of natural disasters. Pinto writes: ‘What is considered natural in the context of disasters such as Haiti’s is seen as independent of human actions. Any analysis of such events must denaturalize them by examining the historic, political and economic contexts within which they occur’ (Pinto, 2010: 193).5 Pinto refers to the philosopher Thomas Pogge’s work on the subject of the international community’s causal responsibility in the historic, political and economic causes of disparities between nations (Pogge, 2004).6 Accordingly, the international community must gain a more comprehensive understanding of its actions in contexts of humanitarian crisis (in which medical assistance plays such a huge part). Pinto rightly warns against the pitfall of wellintentioned albeit misled, unorganized and chaotic international humanitarian efforts that are not informed by a broader analysis of the pre-existing social, political and historical causes of countries’ relative vulnerabilities which sometimes constitute the ‘foundational causes of disasters’. Indeed, the crucial concern that must now guide the international effort of humanitarian assistance in Haiti is to go beyond a shortsighted approach to emergency relief that will only help to establish what numerous observers have called a ‘new republic of NGOs’. This article argues for the need to understand medical relief as a long-term commitment. In the case of the Haitian earthquake, there is no doubt that ‘saving lives’ was the legitimate major
preoccupation of all the humanitarian agents involved. However, as Pinto argues, ‘the focus on the immediate humanitarian response appears to have prevented a consideration of how the groundwork for future development could be best laid’ (Pinto, 2010: 194). In Farmer’s words,
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nebulous concept often with hazier objectives even than relief or development. In theory, at least, its potential is in terms of gap-filling between the emergency and development phases, especially during periods of long transition (Buchanan-Smith and Fabbri, 2005: 27).
Further Critical Questions In conclusion, I would like to mention, if only briefly, some critical questions that the kind of comprehensive approach that I defend in its most theoretical aspects must address in order to flesh out its premises and conclusions as well as its practical implications. There are no satisfying answers to give to these questions at the
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present moment, but they at least indicate the general orientation of an ongoing research agenda.7 This approach undeniably draws from the SDH model. However, the social determinants of health are possibly so broad that a comprehensive approach to medical humanitarianism based on such an extensive account of the foundational conditions of just health eventually expands into a full-blown theory of social justice. In the same vein, it is important to stress that the SDH model rests on state agency in order to carry out public health programs that address the multifaceted root causes of health inequalities. Indeed, should it be true that income disparities impact health outcomes within a population, for example, then only a government is capable of redistributing income taxes in order to address both the root causes and the correspondent health disparities according to its own conception of distributive justice. In contrast, NGOs are non-state actors that cannot assume governmental functions in the place of failed or badly damaged states, hence the limited scope of their actions in contexts of humanitarian crises characterized, more often than not, by the collapse of public structures of governance. In this regard, this comprehensive approach to medical humanitarianism needs to be tailored to the specific characteristics of NGOs. As such, it will eventually address the following question (deliberately left open here): Can NGOs be considered as ‘second-best agents of justice’ in contexts of humanitarian crises and state failure?8 Although, as I have argued, medical NGOs must be considered as social, economic and political actors who play an important role in contexts of humanitarian crises, especially where and when local governance structures are severely damaged, it is important to stress that they cannot replace the state and that we must analyze their nature, their role and range of particular interventions accordingly. In this connection, the SDH model needs to be more precisely articulated in order to identify those societal risk conditions that will impact health and upon which medical assistance in contexts of humanitarian crises can act. One important implication for our comprehensive approach of medical humanitarianism is that broader social analysis of health vulnerabilities in contexts of humanitarian crises must be precisely contextualized according to specific issues encountered by NGOs in particular situations. The categories of issues must also be carefully identified since they will involve a range of problems from limited resources allocation dilemmas to cultural adaptation. As a result, it will presumably produce more modest policy recommendations than would a full blown, far-reaching SDH
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While the emergency relief stage is characterized by the immediate concern of rescuing and saving lives, the reconstruction (or rehabilitation) stage implies a broader understanding of the social determinants of health and of the necessary conditions for laying groundwork for future development. Here, I succinctly characterize the development stage as involving medical humanitarian assistance provided to communities that are not in the midst of acute emergency and/or suffering from the collapse of failed states and which can thus count on minimal government and public sector infrastructures in order to carry out longitudinal public health programs. However, as Macrae’s important research points out, it is very difficult, perhaps even impossible, in the context of protracted crises to cut out neatly defined stages of conflict along a linear political continuum between peace, war and the reestablishment of peace, when violent disruptions consistently turn into periods of truce in a cycle which spirals out of control (Macrae, 2001). Likewise, the concept of reconstruction in contexts of recurrent natural disaster that appear as ‘chronic emergencies’ as in the case of Haiti is very difficult to define. As a result, the concept of reconstruction needs to be carefully defined in future work in order to capture its salient features in contrast to emergency relief and development. In many ways, this multifaceted and sequenced approach to humanitarian assistance is a promising path towards a more comprehensive approach to medical humanitarianism. It pays due heed to Farmer’s insistence that medical humanitarianism should include a broader understanding of the social determinants of health, and that we should aim to guarantee in permanent, sustainable ways in accordance to a community’s needs and self-determined goals.
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We need to make room in the academy for serious scholarly work on the multiple dynamics of health and human rights, on the health effects of war and political economic disruption, and on the pathogenic effects of social inequalities, including racism, gender inequality, and the growing gap between rich and poor (Farmer, 2005: 241).
Acknowledgements I am indebted to Chris Bourne and especially to Antoine Panaı¨oti for their valuable assistance with the English version of this article. I would like to thank Lisa Schwartz and Philippe Calain for their critical comments. I also owe a special debt of gratitude toward Matthew R. Hunt, from whose work my interest for this topic originally stemmed.
Funding This research was partly funded by the Social Sciences and Humanities Research Council of Canada and the Canadian Institutes of Health Research.
Conflict of interest None declared.
Notes 1. See Farmer (2005), especially Chapter 1 (On Suffering and Structural Violence); Chapter 5 (Health, Healing, and Social Justice); Chapter 8 (New Malaise. Medical Ethics and Social Rights in the Global Era), Chapter 9 (Rethinking Health and Human Rights). 2. The WHO define the social determinants of health as follows: The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. [(WHO, Social Determinants of Health, http://www .who.int/social_determinants/en/. Cf. CSDH (2008)]. 3. For an overview of these cosmopolitan theories applied to global public health issues, see Chung (2005). 4. On the concept of denaturalization, see also Schrecker (2008). 5. See also Diaz (2011):
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model of public health carried out by a functional state. However, the daunting complexity of these critical questions does not constitute a sufficient reason to refute my main hypothesis, namely that the humanitarian imperative of saving lives does not justify a short-term view. While there is no doubt that the goal of rescue, i.e. ‘saving lives’, can justify trade-offs in contexts of acute emergency, a limited scope for medical relief can also inadvertently produce perverse long-term consequences on health inequalities. One telling example of a pressing issue that needs to be addressed within this comprehensive approach to medical humanitarianism concerns the situation of women in contexts of natural disasters. A narrow conception of emergency relief in contexts of acute crises can justify gender triage for life-saving medical interventions in favor of men (because they are considered as security and resources providers) in societies where gender discrimination previously limited women’s access to education, economic independence and political equality. Women’s health risks can be exacerbated by often ignored details such as the location of latrines in refugee camps built by humanitarian NGOs (which potentially exposes women to physical and sexual assaults when latrines are situated in unguarded places). Women’s health vulnerabilities can be perpetuated if medical humanitarian assistance provided in the reconstruction phase does not set up medical facilities, training programs and equipment in order to offer life-saving emergency c-section intervention to pregnant women, for instance.9 In light of this, the development of a more comprehensive approach to medical humanitarianism is a matter of moral consistency. More critical interdisciplinary scholarship is required to address this challenge. By showing that a theoretical framework building on the notions of structured health risks and structural injustice argues for the necessity of deepening the analysis of the social factors of health outcomes resulting from natural disasters and for the necessity of a more integrated approach of the relief, reconstruction and development phases of medical humanitarianism, this article aims to provide a modest contribution to an important collective task. As Farmer writes:
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The earthquake revealed our world in other ways. Look closely into the apocalypse of Haiti and you will see that Haiti’s problem is not that it is poor and vulnerable – Haiti’s problem is that it is poor and vulnerable at a time in our capitalist experiment when the gap between those who got grub and those who don’t is not only vast but also rapidly increasing. Said another way, Haiti’s nightmarish vulnerability has to be understood as a part of a larger trend of global inequality.
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6. For an updated version of this major book, see Pogge (2008). 7. See Chung and Hunt (forthcoming). 8. This question is addressed by Rubenstein (2007). 9. See Enarson and Dhar Chakrabarti (2009) and Phillips and Hearn Morrow (2008).
