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The epidemiology of functional apartheid and human rights abuses
Soc. Sci. Med. Vol. 40, No. 3, pp. 281-284, 1995
Pergamon
0277-9536(94)00227-4
Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/95 $7.00 + 0.00
EDITORIAL THE EPIDEMIOLOGY OF FUNCTIONAL APARTHEID HUMAN RIGHTS ABUSES
AND
H. K. HEGGENHOUGEN
Over the past several years we have witnessed the dismantling of apartheid in South Africa, culminating with the all race election in April, 1994. To reach this stage, the cost in human lives has been considerable, but a cost greatly overshadowed by the lives lost and maimed by apartheid itself. We can only hope that the new South Africa will be born and allowed to mature without the price of additional loss of lives, and without the replacement of one form of apartheid with another. The world might well congratulate itself by apartheid's collapse. Yet, in countries throughout the world, the structure and practice of a functional apartheid persists--in the United States[l] and other developed countries as elsewhere. While we may share in the celebration of the collapse of apartheid in South Africa we should not be blinded to the tenacity of apartheid in its various guises and its destructive consequences throughout the world. Groups of people are marginalized, exploited and abused, as a result both of their ethnicity and of their class; for being 'the Other'. They are those often considered less than human--the 'gooks', 'trash', 'Inditos' or 'subversivos', supposedly not true and equal citizens in their own countries (the 'others', those apartheid: set aside). Whether apartheid is official government policy or de facto (functional) may be a significant distinction but the health impact on 'the others' may not be obviously distinctive. A decade ago the WHO publications, Apartheid and Health and Apartheid and Mental Health, spoke poignantly and quite 'radically' of the ill health effects of apartheid[2]. The epidemioiogy resulting from the direct and 'hidden' human rights abuses of functional apartheid point to a worldwide epidemic of pandemic proportions--to incredible human suffering and needless death. Other health 'risks', albeit severe, pale in comparison. Of course, infectious diseases are important and are responsible for the majority of morbidity and mortality in the world. Thus, malaria, TB, schistosomiasis and other specific diseases do warrant our attention. But, as we seek to prevent and to treat these diseases we must recognize their disproportional prevalence among certain groups of people and that they are as much an outcome of functional apartheid, and the synergistic relationship
with malnutrition, including diarrhea, as of specific vectors. The degree to which functional apartheid occurs, and to which marginalized people are abused and suffer (as identifiable groups), does of course vary from country to country, yet its presence in one form or another is pervasive. Unfortunately, there are ample examples. In terms of so-called 'ethnic cleansing' Rwanda and the former Yugoslavia are but extreme examples. The thousands of accounts of the horrendous abuses suffered by Guatemalan Maya populations--marginalized both by ethnicity and class--is another. In 1974 Vincente Navarro spoke metaphorically and dramatically but, I believe, correctly, when he stated that the equivalent of 20 nuclear bombs explode every year in Latin America without making a single sound[3]. From all accounts, and not only in Latin America, they are more numerous t o d a y - and still quite silent. There is obvious violence in the world, of course. Civil wars, homicides, torture (whether state sponsored or not), rape and a pervasive climate of fear in the lives of all too many have been a part of recent and current world history. Cambodia, Guatemala, El Salvador, Liberia, Nicaragua, Rwanda and the former Yugoslavia come immediately to mind, and the past history of countries such as Argentina, Uruguay and Chile serve as testimony. Until recently, in a country such as Colombia, the national homicide rate was ten times that of New York City. And in the United States, where a woman is raped every six minutes, violence is also rampant [4]. These human rights abuses quite clearly explain a great deal of the epidemiological, physical and mental health, patterns for people in these countries. But the point Navarro wanted to make is that violence is not only direct but also 'hidden' and silent. It is the violence resulting from the inequitable structure of apartheid (of 'otherness'). It is this violence against which the Zapatistas in Chiapas say they are, finally, openly fighting. It is a violence which, according to even PAHO and similar institutions, claims more than one million Latin American lives a year. They may not talk about it in terms of apartheid or human rights abuses as such but to state 281
282
Editorial
that, "more than one million children under age five are dying each year, the majority from diseases which are preventable with today's technology" [5] is not too far apart. Elsewhere it is no less drastic. And the inter-relationships between the two kinds of violence also cannot be ignored. It may no longer be particularly fashionable to speak of 'social pathologies' when discussing health patterns, especially for marginalized groups; people's eyes glaze over--they throw their hands up in despair --when 'poverty' is wheeled out as the underlying, root, cause of disease. Health problem seem, then, too overwhelming, the required tasks, too difficult. But, though difficult to handle, the evidence for such a connection--for acknowledging the social and human rights roots of disease--is inescapable, and our inattention, whether from dealing (and quite meaningfully so) with the more specific and 'manageable' (aspects of the) problems--with 'what (we feel) we can d o ' - - o r from plainly feeling such an association irrelevant, allows the continued attack on our public health; that is, if we, as public health and social science and medicine professionals, think of it as 'our' health at all and not as 'just their's'. The importance of class--of poverty--and of ethnicity in terms of health risks must not be considered too simply, however. It is not enough to make the link, especially since there are ample examples of relatively poor regions and countries of the world with much better health indicators than those of much richer groups and nations. A range of interconnected stressors affecting people's lives must be considered. Albeit class and ethnic differences may exist, the degree to which basic human rights and social welfare policies exist is also important. As is people's sense of dignity - - t h e degree to which people are able to live in dignity, whether poorer than, or of an ethnicity different from, the majority of the elite, must enter into the equation. Within the field of international public health the PHC Declaration of Alma Ata in 1978 served as a watershed for a wider perspective in thinking about why and how people get sick and for a reformulation of efforts to improve health. However cynical we may be of the PHC policies now professed by most countries, and though we lament the rather limited nature of presently existing vertical rather than comprehensive PHC efforts, the interconnection of human rights and socio-economic factors and health has been legitimized and stimulated--again, brought onto center stage--by this Declaration. But, precisely because the concepts of equity and social justice-and not only the establishment of equitable health care systems--are central to the PHC philosophy, it becomes difficult to implement comprehensive PHC programs since these, ultimately, must question and try to correct inequitable social relationships. We are left with asking whether Primary Health Care will be allowed to succeed [6]. To use Guatemala as an example, the Nutritional Institute for Central America and Panama (INCAP)
established in the early 1970s that 70% of all (Mayan and Ladino) Guatemalan children were malnourished. Seventy percent! By the 1980s INCAP confirmed that the rate had increased to 80% [7]. If health is to improve in Guatemala the root causes of malnutrition must be attacked. A 1982 PAHO study concluded that 93% of all deaths of children between 1 and 4 were avoidable. Malnutrition must be attacked, of course, not only because of its deadly synergism with disease, but because of basic humanity and the human rights of children and adults [7]. The health of Guatemalans is not only infected as a result of the structural violence of functional apartheid but has also been deeply affected by direct violence (large scale torture and murder) and a pervasive atmosphere of fear. Doughty asserts that "only the Spanish conquest equalled [the] devastation of holocaust proportions..." which has occurred in Guatemala since 1954 [8]. By and large, medical anthropologists working within public health and in collaboration with epidemiologists have concentrated on the significance of cultural factors in explaining epidemiological patterns and in promoting successful public health interventions. In the most negative sense anthropologists have been used to finding the culturally relevant buttons to push to market preconceived 'effective and necessary' public health interventions. In a more positive light, anthropologists have been interpreters and intermediaries ensuring that public health interventions are mutually agreed upon and culturally appropriate. Other contributions have concerned the health impact of the stresses of immigrant and refugee populations, and the relationship between degrees of acculturation and health. Such work has obviously been of great significance and continues to be of importance. Cultural practices do influence disease patterns. Despite this importance, however, I urge anthropologists, and other social scientists concerned with public health to include in their work human rights and socio-economic (class) issues to a much greater extent. It is fundamental to public health. Any understanding of epidemiological patterns-any efforts to improve the health of people showing low health indicators--must consider, and attempt to affect, human rights and inequitable socio-political and economic conditions. The recent focus of national and international public health debates on 'violence and health' and 'health and human rights' is a promising development (and hopefully not just a passing fad) which has re-emphasized the importance of these issues. For example, at the Harvard School of Public Health in the United States there is now a Center for Health and Human Rights, and Harvard Medical School initiated a course on "Culture, Poverty and Infectious Diseases" in 1994. Though not to be forgotten, our gaze must examine more than specific vectors and the so-called unhealthy behaviors of people, to include the total condition of
Editorial people's lives--the context in which people (have to) live their everyday lives. In Nancy Scheper-Hughes' book Death without Weeping [9], for example, the message should be clear that it is not the culturally adapted practices allowing people to cope which should be criticized--such as mothers supposedly 'not weeping' when their children die since they are supposedly 'glad' that God so loved their child 'angelitos' that He did not want to wait to have them with Him. We should rather criticize the social conditions which make such culturally adapted coping mechanisms necessary. Considering violence, in both its direct and indirect forms--and the human rights and health issues so powerfully affecting the lives of hundreds of millions of people throughout the world, it is clear that improved health requires interventions and involvement from the outside as well as the inside. This presents ethical dilemmas to anthropologists (and others), often considered as the danger of cultural or ethical imperialism. The problem is also seen in terms of adherence to a philosophy of cultural relativism on the one hand and an agreement about cross-cultural universals on the other. These, however, do not necessarily have to be contradictory. I would argue that most anthropologists are cultural relativists to the extent that we celebrate (the vibrancy of) cultural differences, yet increasingly we agree that we have obligations to take an ethical stance--some would even argue that this is a sine qua non for anthropologists~ven if we realize (though we hate to admit it) that our ethical norms, at least in part, may be culturally derived. Renteln [10] claims that ethical positions may be culture bound or culturally derived through the process of acculturation--but by suggesting there are cross-cultural universals on which people from a range of cultures agree, she suggests that our relatively culture-bound ethical positions need not be imperialist since they often over-lap with the basic ethical positions of people in other cultures. The issue of the appropriateness of intervention is confused, of course, in that the activities of concern occur within nation states, which many hold inviolable, yet these are not necessarily discrete cultural entities. States call on "cultural relativism" for support to avoid interference for maintaining inequitable political and social relationships. A recognition of cultural differences does not absolve us from the need to make ethical stances and to speak and act against human rights abuses and social inequities. The situation in countries such as Guatemala makes this emphatic. And, in any case, outside involvement has taken place for a long, long time both in toppling progressive regimes and in keeping despots in power. This alone should make us overcome our hesitancy to 'interfere'. [Yeates poem comes to mind: "'Things fall apart; the centre cannot
283
hold;/Mere anarchy is loosed upon the world,/The blood-dimmed tide is loosed, and everywhere/ The best lack all conviction, while the worst/Are full of passionate intensity"]. According to Anthony Cohen the dilemma for anthropologists should not necessarily be a matter of cultural relativism or not, and whether to intervene but rather "the issue for us is how to translate concern into action; and an anthropologist without concern is no anthropologist at all Ill]". Improvement in public health requires changes. Changes in behavior and in cultural practices are frequently suggested and often relevant. But improving health in countries such as Guatemala call for more basic (socio-economic and political) changes. It requires an attack on the persistence of a system of functional apartheid, it requires elimination of overt state sponsored violence and torture and it requires a move towards a much more equitable system of land-distribution and employment compensation. How this can be done without putting people at further and greater risk must be included in such consideration. It may also not be appropriate for foreigners to direct such interventions in Guatemala, or elsewhere, although based on a basic and universal human rights credo (i.e. the UN Charter on Human Rights) we, as outsiders, have a responsibility to voice our concern and to assist those who are, in a step by step fashion, beginning to improve the overall conditions of their lives, to improve their health. Primary Health Care and the current concern with Health and Human Rights are two sides of the same coin-namely that basic equity, social justice, human rights and human dignity are essential to achievement of health. And it is with these issues, including, of course, the provision of easily accessible (available, affordable and acceptable) curative health services, that action must be taken. What I am calling for is by no means easy, especially since we can not look at these issues simplistically, but, as my colleague, Paul Farmer, notes, "we must play with a full deck of cards"--no matter how expert we are in our own disciplines, nor how important specific technical interventions may be, we must insist on looking at, and attempting to improve people's health, through a matrix of a range of socio-cultural (including political, economic and historical) factors not least of which are the examination, and consequences, of functional apartheid and human rights abuses. As I see it, this 'playing with a full deck of cards' is of course what a journal such as Social Science & Medicine is all about but something which, in our erudition, we sometimes neglect. To paraphrase Norman Bethune [12], this is fundamental to public health because (functional) apartheid based on greed and the human rights abuses against the 'Others" are what cause the 'wounds'--they cause (and keep causing) death and human misery.
284
Editorial REFERENCES
1. Brooks D. D., Smith D. R. and Anderson R. J. 'Medical apartheid an American perspective. JAMA 266, 2746, 1993 2. WHO. Apartheid and Health. WHO, Geneva, 1983; Apartheid and Mental Health Care. WHO, Geneva, 1984. 3. Navarro V. The economic and political determinants of human (including health) rights. In Imperialism, Health and Medicine, pp. 53-76. Baywood Pub. Co., Farmingdale, New York, 1974. (See also: Navarro V. The underdevelopment of health or the health of underdevelopment: an analysis of the distribution of human health resources in Latin America. In Imperialism, Health and Medicine (Edited by Navarro V.), pp. 15-36. Baywood Pub. Co., Farmingdale, New York, 1974. 4. Heise L. Violence against women: the missing agenda. In The Health of Women--A Global Perspective (Edited by Koblinsky M., Timyan J. and Gay J.), pp. 171-196. Westview Press, Boulder, 1993. 5. Knouss R. F. The health situation in Latin America and the Caribbean: an overview. In Health and Health Care
6. 7.
8.
9. I0. I1. 12.
in Latin America during the Lost Decade: Insights for the 1990s (Edited by Weil C. and Searpaci J.), p. 13. Minnesota Latin American Series, No. 3. 1992. Heggenhougen H. K. Will primary health care efforts be allowed to succeed? Soc. Sci. Med. 19, 217, 1984. Green L. B., Consensus and coercion: primary health care and the Guatemalan State Med. Anthrop Q. 3, 301, 1989. Doughty P. L. Crossroads for anthropology: human rights in Latin America. Human Riqhts and Anthropology, pp. 43-71. Cultural Survival, Cambridge, MA, 1988. Scheper-Hughes N. Death Without Weeping: The Violence of Everyday Life in Brazil. University of California Press, Berkeley, 1992. Renteln A. R. Relativism and the search for human rights. Am. Anthrop. 90, 56, 1988. Hastrup K. and Elsass P. Anthropological advocacy-a contradiction in terms? Curr. Anthrop. 31, 246, 1990. Bethune N. Wounds. In A way with All Pests: An English Surgeon in People's China: 1954-1969 (Edited by Horn J.), pp. 184-186. Monthly Review Press, New York, 1969.
Pergamon
0277-9536(94)00227-4
Copyright © 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/95 $7.00 + 0.00
EDITORIAL THE EPIDEMIOLOGY OF FUNCTIONAL APARTHEID HUMAN RIGHTS ABUSES
AND
H. K. HEGGENHOUGEN
Over the past several years we have witnessed the dismantling of apartheid in South Africa, culminating with the all race election in April, 1994. To reach this stage, the cost in human lives has been considerable, but a cost greatly overshadowed by the lives lost and maimed by apartheid itself. We can only hope that the new South Africa will be born and allowed to mature without the price of additional loss of lives, and without the replacement of one form of apartheid with another. The world might well congratulate itself by apartheid's collapse. Yet, in countries throughout the world, the structure and practice of a functional apartheid persists--in the United States[l] and other developed countries as elsewhere. While we may share in the celebration of the collapse of apartheid in South Africa we should not be blinded to the tenacity of apartheid in its various guises and its destructive consequences throughout the world. Groups of people are marginalized, exploited and abused, as a result both of their ethnicity and of their class; for being 'the Other'. They are those often considered less than human--the 'gooks', 'trash', 'Inditos' or 'subversivos', supposedly not true and equal citizens in their own countries (the 'others', those apartheid: set aside). Whether apartheid is official government policy or de facto (functional) may be a significant distinction but the health impact on 'the others' may not be obviously distinctive. A decade ago the WHO publications, Apartheid and Health and Apartheid and Mental Health, spoke poignantly and quite 'radically' of the ill health effects of apartheid[2]. The epidemioiogy resulting from the direct and 'hidden' human rights abuses of functional apartheid point to a worldwide epidemic of pandemic proportions--to incredible human suffering and needless death. Other health 'risks', albeit severe, pale in comparison. Of course, infectious diseases are important and are responsible for the majority of morbidity and mortality in the world. Thus, malaria, TB, schistosomiasis and other specific diseases do warrant our attention. But, as we seek to prevent and to treat these diseases we must recognize their disproportional prevalence among certain groups of people and that they are as much an outcome of functional apartheid, and the synergistic relationship
with malnutrition, including diarrhea, as of specific vectors. The degree to which functional apartheid occurs, and to which marginalized people are abused and suffer (as identifiable groups), does of course vary from country to country, yet its presence in one form or another is pervasive. Unfortunately, there are ample examples. In terms of so-called 'ethnic cleansing' Rwanda and the former Yugoslavia are but extreme examples. The thousands of accounts of the horrendous abuses suffered by Guatemalan Maya populations--marginalized both by ethnicity and class--is another. In 1974 Vincente Navarro spoke metaphorically and dramatically but, I believe, correctly, when he stated that the equivalent of 20 nuclear bombs explode every year in Latin America without making a single sound[3]. From all accounts, and not only in Latin America, they are more numerous t o d a y - and still quite silent. There is obvious violence in the world, of course. Civil wars, homicides, torture (whether state sponsored or not), rape and a pervasive climate of fear in the lives of all too many have been a part of recent and current world history. Cambodia, Guatemala, El Salvador, Liberia, Nicaragua, Rwanda and the former Yugoslavia come immediately to mind, and the past history of countries such as Argentina, Uruguay and Chile serve as testimony. Until recently, in a country such as Colombia, the national homicide rate was ten times that of New York City. And in the United States, where a woman is raped every six minutes, violence is also rampant [4]. These human rights abuses quite clearly explain a great deal of the epidemiological, physical and mental health, patterns for people in these countries. But the point Navarro wanted to make is that violence is not only direct but also 'hidden' and silent. It is the violence resulting from the inequitable structure of apartheid (of 'otherness'). It is this violence against which the Zapatistas in Chiapas say they are, finally, openly fighting. It is a violence which, according to even PAHO and similar institutions, claims more than one million Latin American lives a year. They may not talk about it in terms of apartheid or human rights abuses as such but to state 281
282
Editorial
that, "more than one million children under age five are dying each year, the majority from diseases which are preventable with today's technology" [5] is not too far apart. Elsewhere it is no less drastic. And the inter-relationships between the two kinds of violence also cannot be ignored. It may no longer be particularly fashionable to speak of 'social pathologies' when discussing health patterns, especially for marginalized groups; people's eyes glaze over--they throw their hands up in despair --when 'poverty' is wheeled out as the underlying, root, cause of disease. Health problem seem, then, too overwhelming, the required tasks, too difficult. But, though difficult to handle, the evidence for such a connection--for acknowledging the social and human rights roots of disease--is inescapable, and our inattention, whether from dealing (and quite meaningfully so) with the more specific and 'manageable' (aspects of the) problems--with 'what (we feel) we can d o ' - - o r from plainly feeling such an association irrelevant, allows the continued attack on our public health; that is, if we, as public health and social science and medicine professionals, think of it as 'our' health at all and not as 'just their's'. The importance of class--of poverty--and of ethnicity in terms of health risks must not be considered too simply, however. It is not enough to make the link, especially since there are ample examples of relatively poor regions and countries of the world with much better health indicators than those of much richer groups and nations. A range of interconnected stressors affecting people's lives must be considered. Albeit class and ethnic differences may exist, the degree to which basic human rights and social welfare policies exist is also important. As is people's sense of dignity - - t h e degree to which people are able to live in dignity, whether poorer than, or of an ethnicity different from, the majority of the elite, must enter into the equation. Within the field of international public health the PHC Declaration of Alma Ata in 1978 served as a watershed for a wider perspective in thinking about why and how people get sick and for a reformulation of efforts to improve health. However cynical we may be of the PHC policies now professed by most countries, and though we lament the rather limited nature of presently existing vertical rather than comprehensive PHC efforts, the interconnection of human rights and socio-economic factors and health has been legitimized and stimulated--again, brought onto center stage--by this Declaration. But, precisely because the concepts of equity and social justice-and not only the establishment of equitable health care systems--are central to the PHC philosophy, it becomes difficult to implement comprehensive PHC programs since these, ultimately, must question and try to correct inequitable social relationships. We are left with asking whether Primary Health Care will be allowed to succeed [6]. To use Guatemala as an example, the Nutritional Institute for Central America and Panama (INCAP)
established in the early 1970s that 70% of all (Mayan and Ladino) Guatemalan children were malnourished. Seventy percent! By the 1980s INCAP confirmed that the rate had increased to 80% [7]. If health is to improve in Guatemala the root causes of malnutrition must be attacked. A 1982 PAHO study concluded that 93% of all deaths of children between 1 and 4 were avoidable. Malnutrition must be attacked, of course, not only because of its deadly synergism with disease, but because of basic humanity and the human rights of children and adults [7]. The health of Guatemalans is not only infected as a result of the structural violence of functional apartheid but has also been deeply affected by direct violence (large scale torture and murder) and a pervasive atmosphere of fear. Doughty asserts that "only the Spanish conquest equalled [the] devastation of holocaust proportions..." which has occurred in Guatemala since 1954 [8]. By and large, medical anthropologists working within public health and in collaboration with epidemiologists have concentrated on the significance of cultural factors in explaining epidemiological patterns and in promoting successful public health interventions. In the most negative sense anthropologists have been used to finding the culturally relevant buttons to push to market preconceived 'effective and necessary' public health interventions. In a more positive light, anthropologists have been interpreters and intermediaries ensuring that public health interventions are mutually agreed upon and culturally appropriate. Other contributions have concerned the health impact of the stresses of immigrant and refugee populations, and the relationship between degrees of acculturation and health. Such work has obviously been of great significance and continues to be of importance. Cultural practices do influence disease patterns. Despite this importance, however, I urge anthropologists, and other social scientists concerned with public health to include in their work human rights and socio-economic (class) issues to a much greater extent. It is fundamental to public health. Any understanding of epidemiological patterns-any efforts to improve the health of people showing low health indicators--must consider, and attempt to affect, human rights and inequitable socio-political and economic conditions. The recent focus of national and international public health debates on 'violence and health' and 'health and human rights' is a promising development (and hopefully not just a passing fad) which has re-emphasized the importance of these issues. For example, at the Harvard School of Public Health in the United States there is now a Center for Health and Human Rights, and Harvard Medical School initiated a course on "Culture, Poverty and Infectious Diseases" in 1994. Though not to be forgotten, our gaze must examine more than specific vectors and the so-called unhealthy behaviors of people, to include the total condition of
Editorial people's lives--the context in which people (have to) live their everyday lives. In Nancy Scheper-Hughes' book Death without Weeping [9], for example, the message should be clear that it is not the culturally adapted practices allowing people to cope which should be criticized--such as mothers supposedly 'not weeping' when their children die since they are supposedly 'glad' that God so loved their child 'angelitos' that He did not want to wait to have them with Him. We should rather criticize the social conditions which make such culturally adapted coping mechanisms necessary. Considering violence, in both its direct and indirect forms--and the human rights and health issues so powerfully affecting the lives of hundreds of millions of people throughout the world, it is clear that improved health requires interventions and involvement from the outside as well as the inside. This presents ethical dilemmas to anthropologists (and others), often considered as the danger of cultural or ethical imperialism. The problem is also seen in terms of adherence to a philosophy of cultural relativism on the one hand and an agreement about cross-cultural universals on the other. These, however, do not necessarily have to be contradictory. I would argue that most anthropologists are cultural relativists to the extent that we celebrate (the vibrancy of) cultural differences, yet increasingly we agree that we have obligations to take an ethical stance--some would even argue that this is a sine qua non for anthropologists~ven if we realize (though we hate to admit it) that our ethical norms, at least in part, may be culturally derived. Renteln [10] claims that ethical positions may be culture bound or culturally derived through the process of acculturation--but by suggesting there are cross-cultural universals on which people from a range of cultures agree, she suggests that our relatively culture-bound ethical positions need not be imperialist since they often over-lap with the basic ethical positions of people in other cultures. The issue of the appropriateness of intervention is confused, of course, in that the activities of concern occur within nation states, which many hold inviolable, yet these are not necessarily discrete cultural entities. States call on "cultural relativism" for support to avoid interference for maintaining inequitable political and social relationships. A recognition of cultural differences does not absolve us from the need to make ethical stances and to speak and act against human rights abuses and social inequities. The situation in countries such as Guatemala makes this emphatic. And, in any case, outside involvement has taken place for a long, long time both in toppling progressive regimes and in keeping despots in power. This alone should make us overcome our hesitancy to 'interfere'. [Yeates poem comes to mind: "'Things fall apart; the centre cannot
283
hold;/Mere anarchy is loosed upon the world,/The blood-dimmed tide is loosed, and everywhere/ The best lack all conviction, while the worst/Are full of passionate intensity"]. According to Anthony Cohen the dilemma for anthropologists should not necessarily be a matter of cultural relativism or not, and whether to intervene but rather "the issue for us is how to translate concern into action; and an anthropologist without concern is no anthropologist at all Ill]". Improvement in public health requires changes. Changes in behavior and in cultural practices are frequently suggested and often relevant. But improving health in countries such as Guatemala call for more basic (socio-economic and political) changes. It requires an attack on the persistence of a system of functional apartheid, it requires elimination of overt state sponsored violence and torture and it requires a move towards a much more equitable system of land-distribution and employment compensation. How this can be done without putting people at further and greater risk must be included in such consideration. It may also not be appropriate for foreigners to direct such interventions in Guatemala, or elsewhere, although based on a basic and universal human rights credo (i.e. the UN Charter on Human Rights) we, as outsiders, have a responsibility to voice our concern and to assist those who are, in a step by step fashion, beginning to improve the overall conditions of their lives, to improve their health. Primary Health Care and the current concern with Health and Human Rights are two sides of the same coin-namely that basic equity, social justice, human rights and human dignity are essential to achievement of health. And it is with these issues, including, of course, the provision of easily accessible (available, affordable and acceptable) curative health services, that action must be taken. What I am calling for is by no means easy, especially since we can not look at these issues simplistically, but, as my colleague, Paul Farmer, notes, "we must play with a full deck of cards"--no matter how expert we are in our own disciplines, nor how important specific technical interventions may be, we must insist on looking at, and attempting to improve people's health, through a matrix of a range of socio-cultural (including political, economic and historical) factors not least of which are the examination, and consequences, of functional apartheid and human rights abuses. As I see it, this 'playing with a full deck of cards' is of course what a journal such as Social Science & Medicine is all about but something which, in our erudition, we sometimes neglect. To paraphrase Norman Bethune [12], this is fundamental to public health because (functional) apartheid based on greed and the human rights abuses against the 'Others" are what cause the 'wounds'--they cause (and keep causing) death and human misery.
284
Editorial REFERENCES
1. Brooks D. D., Smith D. R. and Anderson R. J. 'Medical apartheid an American perspective. JAMA 266, 2746, 1993 2. WHO. Apartheid and Health. WHO, Geneva, 1983; Apartheid and Mental Health Care. WHO, Geneva, 1984. 3. Navarro V. The economic and political determinants of human (including health) rights. In Imperialism, Health and Medicine, pp. 53-76. Baywood Pub. Co., Farmingdale, New York, 1974. (See also: Navarro V. The underdevelopment of health or the health of underdevelopment: an analysis of the distribution of human health resources in Latin America. In Imperialism, Health and Medicine (Edited by Navarro V.), pp. 15-36. Baywood Pub. Co., Farmingdale, New York, 1974. 4. Heise L. Violence against women: the missing agenda. In The Health of Women--A Global Perspective (Edited by Koblinsky M., Timyan J. and Gay J.), pp. 171-196. Westview Press, Boulder, 1993. 5. Knouss R. F. The health situation in Latin America and the Caribbean: an overview. In Health and Health Care
6. 7.
8.
9. I0. I1. 12.
in Latin America during the Lost Decade: Insights for the 1990s (Edited by Weil C. and Searpaci J.), p. 13. Minnesota Latin American Series, No. 3. 1992. Heggenhougen H. K. Will primary health care efforts be allowed to succeed? Soc. Sci. Med. 19, 217, 1984. Green L. B., Consensus and coercion: primary health care and the Guatemalan State Med. Anthrop Q. 3, 301, 1989. Doughty P. L. Crossroads for anthropology: human rights in Latin America. Human Riqhts and Anthropology, pp. 43-71. Cultural Survival, Cambridge, MA, 1988. Scheper-Hughes N. Death Without Weeping: The Violence of Everyday Life in Brazil. University of California Press, Berkeley, 1992. Renteln A. R. Relativism and the search for human rights. Am. Anthrop. 90, 56, 1988. Hastrup K. and Elsass P. Anthropological advocacy-a contradiction in terms? Curr. Anthrop. 31, 246, 1990. Bethune N. Wounds. In A way with All Pests: An English Surgeon in People's China: 1954-1969 (Edited by Horn J.), pp. 184-186. Monthly Review Press, New York, 1969.