Health in the Time of Disaster

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Hurricane Dorian ravaged the Bahamas, and is set to make landfall in the United States. A hurricane, in itself not extraordinary during this time of year, that has undoubtedly increased in ferocity due to the changing climate. Humanitarian crises and disasters like these will only increase in frequency as well as intensity as time goes on. As we reckon with what the consequences of a planet heating beyond repair would mean, the question of what it will mean for our human rights, and in particular the human right to health, remains under-explored.

Perhaps the most obvious consequence of the increase and violence of natural disasters, is the fact that it will be more and more difficult to physically reach the people affected, affecting their accessibility to healthcare. Indeed, an increase in humanitarian crises will mean that more people will have difficulty accessing clean water, food, and medicines,  and will be more at risk of developing infectious diseases. Unsurprisingly, the most vulnerable and poorest populations, both within countries and between countries with the Global South more affected than the Global North in this respect, will be hardest hit when disaster strikes. The vulnerable and poorest being hardest hit means that they will be likeliest to need medical assistance, and simultaneously means that it will be harder to reach these communities. This is a bind that most, if not all, healthcare systems are likely not sufficiently prepared to tackle, but it is already a reality for many people around the world.

As briefly mentioned in the above paragraph, another consequence of a global rise in temperature is the increase in infectious diseases and parasites. The global rise in temperatures will likely make previously uninhabitable parts of the world for parasites more attractive to them, and they will increasingly appear where they would normally not be found.  In addition, water scarcity as a result of drought can lead to poor sanitation which will increase the incidence of diseases such as cholera. Again, unsurprisingly the people bearing the brunt of these issues are poorer communities in the Global South. 

Beyond communicable diseases, mental health issues are an under appreciated consequence of the global climate emergency. ‘Ecological grief‘, a sense of grief borne out of the changing ecological landscape, and a loss of a way of living, seems to be particularly felt by people who live in synchrony with nature. Indeed, indigenous communities, like the Greenlandic Inuit, have increased mental health issues related to a loss of their way of life, their ability to live with nature and off of nature. Voices of many indigenous communities who have been losing their land, their livelihoods, and their ability to live in synchrony with their ancestral lands are rarely heard, but the climate catastrophe has dire consequences on their mental health. Ecological grief, ties together the climate crisis, mental health, and indigenous rights. In general, a sense of climate despair seems to be affecting people’s mental health across the world, making many people question the point of existence as a sense of hopelessness about the situation takes over. Whether our mental health services, especially in a world where there are not an awful lot of mental health professionals, are capable of rising up to this challenge remains uncertain.

Health, whether physical or mental, communicable or non-communicable, is a fundamental human right that is under pressure in a changing world.

The United Nations rapporteur on human rights and extreme poverty, has said that human rights might be threatened due to climate change. The world’s wealthiest might be able to escape the worst of climate change’s effects whilst the world’s poorest will have their right to housing, food, life, safety and, as I outlined here, health, threatened. When it comes to human rights, and particularly the gains we have made in health and the precariousness of these gains, it is imperative that we keep them at the heart of our climate policy and the societal debates we are having on what best to do to tackle the climate crisis. Health, whether physical or mental, communicable or non-communicable, is a fundamental human right that is under pressure in a changing world. The potential repercussions of that are dire if our policymakers and health systems do not adapt to these realities quickly. Conversations surrounding ambitious policy proposals like the Green New Deal ought to centre human rights in general, however the right to health should not be underestimated or kept on the back burner. At the end of the day, vulnerable, poor, and indigenous communities will bear the brunt of our complacency, and we cannot afford to let that happen.

Healthcare as a human right

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Any discussion of universal healthcare is seemingly conducted as if it is a solely partisan issue. The left wants universal healthcare, the right doesn’t — so goes the argument. However, the fact of the matter is that the United Nations’ Universal Declaration of Human rights, article 25, states that:

(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

The countries that have signed up to this declaration have implicitly or explicitly accepted healthcare as a human right. Most countries provide free or affordable healthcare to its citizens, but how it manifests for non-citizens seems to differ between countries. We can do better.

War and natural disasters seem common and omnipresent, and will likely increase with climate change. Unsurprisingly, these calamitous events will also leave the most vulnerable exposed to health risks — particularly women, children, the elderly, and the chronically ill. Particularly in war and conflict areas, getting healthcare to the most vulnerable populations can be an arduous task, made more difficult by various state actors and disparate political motivations. Attacks on humanitarian aid workers make it difficult for vital medical care to arrive to the people who need it most. The World Health Organisation’s (WHO) 2017 report estimates that 14.8 million people in Yemen have no access to healthcare, and the International Medical Corps has said that delivering healthcare to affected populations in the country is difficult with major infrastructure destroyed, and the lack of a government that could support them. In addition, Amnesty International reports that the Saudi-led coalition has restricted the access to essential goods such as medical supplies from entering Yemen. The situation in Syria is equally dire, with the WHO reporting calamitous conditions in Syrian refugee camps, and additionally refugee camps housing former members of ISIS and their children have also not received adequate medical assistance. Chatham House experts recently wrote that many people with chronic illnesses end up being under-treated in war and conflict as the nature of chronic illnesses and the nature of war make it logistically very difficult to help them. In many instances, these local makeshift hospitals end up being in rebel-held territories with Western aid organisations fearing a loss of funds if they were to support these hospitals. From a security and counterterrorism point of view this might make sense, but the fact of the matter is that vulnerable people will see their right to medical assistance denied. It is clear that healthcare as a right is often a casualty of war, with deliberate attacks on hospitals, as well as restrictions on humanitarian aid depending on whose side the territory is held by, creating more issues for the local population and constituting continuous violations of international humanitarian law and human rights.

Closer to home, it is often the case that refugees and immigrants do not get to enjoy free healthcare in the same way citizens of a country can. A report by the Equality and Human Rights Commission published in 2018, showed that asylum seekers in Britain are often afraid of seeking medical care for fear of high costs, or being tracked by the Home Office. Ambiguities and an increasingly hostile environment for migrants, refugees, and asylum seekers, create inaccessibility to healthcare for an already vulnerable group of people. Guaranteeing that everybody, regardless of background and citizenship status, gets access to healthcare that respects human rights, requires political will and leadership. Moreover, people with mental health issues are still often subject to violations of human rights in mental health care where they are often stripped of agency and dignity — this has been the observation of the UK’s parliamentary and health service ombudsman as well. In the United States, many black women are dying in childbirth because they are not listened to in health settings and their human rights are systematically violated. Worldwide, people with dementia are still fighting for their human rights to be respected. There is still a lot to be done.

So, how do we make sure that human rights are respected and guaranteed, even in disaster and conflict zones, even when someone is an asylum seeker or a refugee, and even when the patient is disabled, mentally ill or cognitively impaired? There is no simple answer, but political leadership that sees beyond manoeuvring and posturing to behold the human cost of war, conflicts, health disparities locally and globally, and the victims it makes, would go a long way. In an international setting the countries with vetos in the UN security council have a particular responsibility to look beyond political expediency and geopolitics when the stakes are so high and there are no winners. The WHO has a prime position as an intergovernmental organisation to coordinate medical response and epidemiological research, and assist local governments after a disaster or in conflict zones. Human rights organisations monitoring, researching, and advocating for human rights to be respected, in conflict and in peacetime, play a vital part in holding the powers that be to account. Academic research in how to best coordinate humanitarian aid, particularly medical aid, in disaster and conflict zones is imperative. Non-governmental aid organisations and their local partners on the ground need continued support to take care of affected citizens regardless of their affiliations in war. Disability and mental health advocates need to be listened to. And finally, as citizens we have a duty to be aware and cognisant of our human rights, the inalienability of it, and that by respecting them we are doing not only the other, but our selves, a great service. By being informed and educated on the role human rights play in our day to day lives, we can lobby and advocate our local governments, and in turn politicians of good will can effect change. Eleanor Roosevelt, the mother of the UN Declaration of Human Rights, said it best:

Where, after all, do universal human rights begin? In small places, close to home – so close and so small that they cannot be seen on any maps of the world. Yet they are the world of the individual person; the neighbourhood he lives in; the school or college he attends; the factory, farm, or office where he works. Such are the places where every man, woman, and child seeks equal justice, equal opportunity, equal dignity without discrimination. Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.

Period.

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Most, if not all, women and girls have at one point carried their entire bag to the toilet to hide the fact that they’re on their periods. Perhaps, they’d slip their pads or tampons into their sleeves so as not to offend or alert the people around them of the fact that their bodies are experiencing a perfectly normal (albeit not strictly necessary) monthly biological process. Periods are still stigmatised. Period poverty is a term that has gained some traction in recent years, particularly in Scotland where the Scottish government has put into place ways to eradicate it. Period poverty refers to women and girls being unable to afford sanitary products, which in turn causes women to turn to toilet rolls, rags and cloths instead.  Indeed, period poverty is even keeping girls out of school! This is why the Scottish government pledged to provide free sanitary products in every school, college and university, and in England there are movements to provide the same for girls there.

Further afield, period poverty and stigma are, unsurprisingly, also an issue. Not unlike women and girls in the UK who cannot afford sanitary products, women in many low- and middle income countries (LMIC) also resort to using rags, cloths, and in some cases animal skin or leaves to absorb menstrual blood. In many cases women and girls also lack safe and private (single sex) bathrooms and toilets, clean and running water, and soap to keep themselves clean and comfortable during their menstrual cycle. This often leads to girls dropping out of school, and women not working. Periods are not a very glamorous issue to talk about (not unlike many other issues that affect mainly women), but it is definitely a global health issue.

Discussing periods is often taboo in many LMIC where women on their periods are seen as ‘unclean’, and at times even shunned for the duration of their periods where they have to stay in unsanitary, cold and unsafe menstrual huts, where many women and children often end up dying. In many instances women and girls hold misconceptions and fears surrounding menarche (first period) and subsequent periods, with many harbouring fear of infertility or curses (and Sommer et al., 2014). A lack of access to proper hygiene during the menstrual cycle can lead to a higher risk of infections, and bodily odours can lead to further stigmatisation. Menarche can also have a mental health effect on girls, who often feel anxious and sad about a ‘loss of childhood’ once they have experienced their first period. Thus, beyond the physical issues that a lack of access to sanitary products, hygienic toilets and sanitation, and the risk of infection that comes with it, the stigmatisation of periods and the cultural associations, taboos and silence surrounding it can have a detrimental effect on mental health as well.

That is not to say that all hope is lost. Just like the community activists in the United Kingdom, there are many women in LMIC who are fighting to make menstruation and women’s health more accessible and acceptable to talk about and are fighting to end period poverty all around the world. NGOs such as Myna Mahila, which gained some more international recognition after the Duchess of Sussex’s involvement, and organisations such as Plan and the UN are also trying to play their part. Not unlike tackling the stigma of dementia in LMIC, it is important for us to understand the cultural contexts and aid local community activists where possible.

In Western feminism we talk an awful lot about ’empowerment’, but sometimes seem to forget that at the end of the battle for empowerment there is supposed to be power. For women to gain more power and influence in a truly more equitable society, it is imperative that women can get an education, take charge of their own lives and most importantly do not feel like prisoners in their own bodies. We have long known that once women are more educated, there is a decline in poverty, and once women are financially independent there is a decline in vulnerability to sex based violence. If we truly believe in empowerment for women, we will need to fight to remove the taboos and stigma surrounding menstruation and eliminate period poverty whether it occurs in Scotland or in India, the United States or Uganda. It’s not just a women’s rights issue — it’s a human rights and a global health issue. An issue that should, and hopefully will, be eliminated once and for all.

Dementia, global health, and policy

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When we think of dementia we often think of the elderly, probably in care homes, possibly our own family. Most of our visions are of dementia’s manifestation in high income countries. The truth of the matter is, that an estimated 58% of people with dementia live in low- and middle-income countries (LMIC) . To add insult to injury, it was estimated that only 10% of the research into dementia is focused on people living with it in LMIC (Prince et al., 2008).

Many people in LMIC will go undiagnosed, as people often see dementia as a normal part of ageing and those suffering are often stigmatised. Seeing dementia as a normal part of ageing is in and of itself not limited to LMIC, as many people in high income countries at the very least seem to think it is a kind of inevitability. Moreover, stigma certainly also still exists in the West. Many people who are diagnosed indicate that they feel isolated, that their lives are over, that people stop treating them as fully human, and in extreme cases in certain parts of the world elderly people — primarily women — with dementia are accused of witchcraft and ostracised, and in the worst cases, even killed. 

Because dementia is a disorder that will affect more and more people as populations, on average, get older and older, it is often seen by organisations such as the World Health Organisation (WHO) and Alzheimer’s Disease International as a global health priority. Global health is a relatively new concept, with a relatively vague definition, but is generally taken to mean the promotion of equality when it comes to access and quality of healthcare worldwide. Global mental health, has a similar remit only focused on the psyche rather than (just) the physical body. Although these ideals are lofty, and the UN declared health care a human right (article 25 of the UN Declaration of Human Rights — I suggest you give the whole thing a read), there is always the looming possibility of Westerners imposing their own view on others; some would even go as far as to say it is a form of neocolonialism. That does not, however, mean that I think we should throw out the baby with the bathwater. Global (mental) health can be directed by the people of the Global South with the Global North and its institutions (such as the UN) aiding and advocating on their behalf. This means employing, and listening to, locals who will take the cultural sensitivities into account (examples include Chief Kiki Laniyonu Edwards who works to tackle stigma of dementia in Nigeria; Zimbabwean grandmothers offering therapy, Benoit Ruratotoye, a Congolese psychologist trying to tackle violence against women and particularly help the spouses of women raped as a weapon of war to come to terms with what happened, or Women for Afghan Women) . It means adjusting our diagnostic manuals and criteria so that they are relevant and valid within the country’s specific cultural context. It is working together with the spirit of true equality, seeing the people in LMIC/Global South not as people we need to convert, but people we can work with for the benefit of us all.

Returning to the lack of basic research on dementia and its manifestations in LMIC, I think it is important as scientists to be aware of our own biases and our tendency to extrapolate and apply our Western experience to that of everybody else. It is important for researchers in LMIC to have the funds and means to conduct studies on the manifestation of not only dementia, but mental health issues, in their own people and in their own cultures. It is vital that Western universities collaborate, not as superiors but as true and equal partners with the desire to bring about equality in access and quality of healthcare.

I am of the belief that basic scientists, local experts, global health professionals and policymakers would be best served in working together. Issues such as dementia and depression have different cultural manifestation in different cultural contexts. It is vital that policy is made on the basis of scientific knowledge, local knowledge, cultural sensitivity and a genuine belief in promoting equality of access and quality of healthcare. Perhaps the UN as an institution, and definitely its human rights declaration, is too optimistic or idealistic in a world full of violent realities. But it is most certainly the kind of hope and optimism we need on this blue planet we all share. Combining our knowledge (both Western and non-Western, scientific and traditional), using our privileges for good, and looking beyond our own bubble without superiority is the only way we can get closer and closer to the lofty dreams and aspirations of a truly equitable world where human rights, including the right to healthcare, are respected.