Canal and the Rest

Word Association game. Panama…Papers. There is, though, a canal. Actually, the Canal. A rather important canal that antedated the Panama Papers. It is hard not to think Panama Papers as you fly in to the city and see the remarkable cluster of tall buildings. Where did the money come from for these buildings? The Canal, in part, but money dirty and clean, or making the transition from the one to the other clearly plays a part. Panama’s economy is now 75% Service.

I last visited Panama in 1975 as a young doctor just completing his PhD in epidemiology at UC Berkeley. Stony Stallones, Dean of the School of Public Health in Houston, had called me and asked if I would like to spend 6 weeks leading a field trip to measure blood pressures in villages along the Caribbean coast of Panama, and in the city of Colon. A few Spanish 1 classes at Berkeley and off went Alexi and I. One way of learning how to conduct a field epidemiology study is to lead one.

In 41 years Panama made the transition from poor country with poor health to upper middle income country, per capita Gross National Income $18,200 at PPP, with life expectancy of 77.8 years. I look at the life expectancy statistics and decide that the salad is safe to eat. Not so, 41 years ago.

Panama may have got richer but it a fair bet that a country that is growing rich from its financial dealings and its Canal revenues will have big inequalities. The 80:20 ratio of earnings (the share of total income enjoyed by top 20% compared with the bottom 20%) is 18 in Panama. By contrast it is 13 in Costa Rica and Chile, 9.8 in the US, 7.6 in the UK, 4.0 in Norway and 3.6 in Sweden.

My visit started with an invited address to the National Assembly – the Congress. My challenge was to see if I could get the elected delegates to stop using their smart phones and listen. I did, more or less. I started with my visit of 41 years ago and commented on the remarkable and welcome improvement in income and health since then. But, and it is a big “but”, next door neighbour Costa Rica has national income of $13,000 (at PPP) but life expectancy that is 1.5 years longer. Further, it is highly likely that the big inequalities in income are correlated with big inequalities in health, but there are almost no data on health inequalities.

I know there is real concern with the rate of violent crime in Panama. I made the case to the Congress that ill-health and crime cluster geographically and socially. Action on the social determinants of health will likely have the benefit of reducing violent crime. (It may do nothing for white collar crime – but that is another question, see above and below). My parting message was that we need cross-government action on social determinants of health. I reminded them what we said on the cover of the CSDH report: social injustice is killing on a grand scale.

The President of the Assembly listened. When he opened the Public Health Congress the next evening, he said that social injustice kills. That is a start to cross-government action.

It had been arranged for me to meet the Canal Minister. I was keen to hear more about the Canal but made sure I told him about SDH. He said that the health minister should hear this and he fixed it. When I met the health minister, he said that the Vice-Minister of Social Development should hear this, and they both (Health Minister and Social Development Vice-Minister) came for lunch the next day. I was getting a feel for how the political hierarchy works.

The Canal represents about 9% of Panama’s GDP, so the Canal Minister is important. They just spent around $5.5billion putting a third lane in. Panamax is the largest size of vessel that could go through the existing Canal. NeoPanamax is the larger size that can go through the new larger channel. I had a guided tour of the new facility that opened only a month ago. Impressive.

There is a real concern among Panamanian colleagues that “health” in Panama has meant building hospitals. Primary care is under-developed and is much needed.

Among the many questions, I was asked by one Panamanian: what about corruption? My response: when we began the CSDH, I said that if governments were inactive or worse then we were sunk. Mirai Chatterji, with her experience of the Self Employed Women’s Association in Gujerat said: absolutely not. If governments won’t do it, civil society can and should. It is the power of social organisation. Then shame government into action.

Through all my various lectures and meetings in Panama I had the sense of a great deal of good will and commitment to social determinants of health and health equity. An important step forward is to develop monitoring systems and then to put in place cross-government action. We will watch this space with great interest.

Working together to improve lives

I was back in Gujarat last weekend visiting street vendors who are members of SEWA – the Self Employed Women’s Association. It was nearly ten years since I visited with the WHO Commission on Social Determinants of Health (CSDH). After that visit I wrote:

I can picture the lives of the vegetable sellers of Ahmedabad from the outside, as they sit on the streets of the market area in the sun and the monsoon rains, with a small pile of vegetables on the rag in front. I cannot begin to understand how it feels from the inside to live the life of one of the poorest, most marginalised women in India. You start with some significant social impediments: you are poor, from a scheduled caste, you had no chance of education, and you are female. The only employment you can envisage is what your mother did: become a vegetable seller. This means you have to borrow money at usurious interest rates to buy your vegetables, pay inflated prices to the middle man in the wholesale market, deal with police harassment as you sit on the road side, and worry what to do with the children while you earn your few rupees. On the morning of my visit an elephant swaying through the market was simply one more hazard.

On this latest visit, Mirai Chaterjee, a leader of SEWA and a member of the CSDH, took me back. The street vendors in this area, the women at least, are members of the union, SEWA. Mirai introduced me to the local leader. She said (in Guajarati) that she remembered me from ten years earlier. Goodness. How come? This is not exactly a tourist attraction, and they don’t get so many outsiders come to visit.

Mirai is the one on the right

This woman was a street vendor as was her daughter. But the next generation? They are getting educated and do not want to go into the vegetable market. It is tempting to believe that the childcare SEWA provides is a significant step towards education. We know from evidence elsewhere in the world that enrolment in pre-school education is a significant predictor of educational success.

Interesting. These women are Dalit, outcastes. They have presumably married other Dalit for generations. But caste is not destiny, or should not be. Give the children the opportunity to be educated and they seize it and, presumably, flourish.

There are many other ways that SEWA has been active in improving the lot of its members. The wholesale vegetable market is a prime example. The wholesalers were forcing small farmers to sell at low rates and passing produce on to the retailers at high rates. Large profit for them; hardship for the street vendors. SEWA, against opposition from the, largely  male, wholesalers, set up as middlewomen: buying from growers at reasonable prices and selling to retailers with modest profit.

SEWA Bank is an important part of the jigsaw – small loans to street vendors without extortionate interest rates. Health care, insurance, legal representation, housing are all active areas for SEWA and its members.

Inspiring stuff. SEWA shows how collective action by civil society can transform lives.