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C h a p t e r 3 Redefining Health: Challenging Power Relations Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. . . . Putting right these inequities—the huge and remediable differences in health between and within countries—is a matter of social justice. . . . Social injustice is killing people on a grand scale. —WHO Commission on the Social Determinants of Health, 2008 The fact that holders of such power may relinquish it with reluctance must not deter us from pursuing what is just. —Sir Michael Marmot, Chair of the WHO Commission on Social Determinants of Health, 2009 Before I decided definitively to pursue a career linking global health with human rights, I spent some months working and living at a small, privately funded health-care center in Haryana, India, a small state that borders Punjab . Delhi’s explosive growth since the 1990s has made the area I was in significantly less rural today. But back then, it took several hours, on several buses, to get to the health center from Delhi, and it was a different world. Indeed, Kabliji Hospital was founded as a rural health center, with the specific goal of providing free care to the poor and of the same quality that they could receive in urban areas.1 The health center was surrounded by acres of mustard fields. It was possible to walk for hours between villages. Electricity 74 Starting Points and running water were scarce and unreliable; telephone landlines did not reach very far outside the city (and mobile phones were not yet common); and the night sky still had that profound blackness punctuated by the magical iridescent radiance of stars, which is unimaginable in areas with dense populations and heavy electrical usage. Kabliji had a small outpatient clinic in the village of Ghamroj, where I would accompany the local nurses and doctors. Ghamroj has since been transformed, but at the time it looked the perfect portrait of a typical, northIndian village. Dotting the unpaved streets were neatly thatched mud huts and brightly colored saris hanging out to dry, all against a backdrop of buffalo languidly roaming the seemingly endless fields. The most common complaint at the tiny outpatient clinic was from mothers who were bringing their children in for treatment of diarrheal disease. Some of the young doctors simply prescribed antibiotics; some provided the women with oral rehydration salts and advised them on the preparation of oral rehydration therapy. Some of us noted that these women were retrieving water from a large pond very close to the outpatient clinic, where buffalo and cows could be seen bathing, drinking, and defecating throughout the day. But why would these women use this water and risk making their children sick when there was a well in the middle of the village? The young doctors and I assumed—in just the way that most conventional public health planning does—that the women must have been ignorant about the effects of dirty water on their children’s health and that they therefore required health education. And so we set about to educate them about the importance of clean water, emphasizing the links between diarrheal dehydration and malnutrition, and encouraging them to go the small extra distance to the well in the center of town. And, as in most conventional public health programming, our efforts to reshape knowledge, attitudes, and practices were targeted at mothers, not asking them about their needs but treating them as primarily instrumental, as caretakers for their children. It was some weeks after we had embarked on this endeavor that we discovered why the women were using the pond. The women’s behavior was not because of a lack of education or out of laziness—as some of the urban-based doctors who were doing their rural service had claimed. It was because most of the women who we saw repeatedly bringing their sick children in for treatment were Muslims who lived near the tiny outpatient clinic. Muslims face discrimination in India, and there is a painful history of inter-religious violence in the country. But that was not the whole story. Redefining Health 75 Ghamroj was dominated by a particular Hindu warrior caste, and these families had converted to Islam from Hinduism because they were Dalits, or “untouchables,” who fall at the bottom of the Hindu caste system. This is the case for many Muslims in India, who descend from low-caste Hindus and convert to Islam to...


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