Harmony and Action in the Caribbean

A population made up of indigenous people, escaped African slaves, French, Spanish and English colonialists, Creoles (mix of Europeans and Africans), Javanese, East Indians, and then sprinklings of Jews, Chinese, Brazilians and a few others – what language do you imagine they might speak?

Why Dutch, of course. This is Suriname, now independent of the Netherlands. It wasn’t always a Dutch colony. In the 17th century the English got New Amsterdam from the Dutch and the Dutch got Suriname from the English. Who got the best of that deal? New Amsterdam, of course, became New York.

Check the map. Suriname is up there on the Caribbean coast of South America between French Guiana and (British) Guiana. It’s capital as every school child knows, well some do, is Paramaribo.

Suriname is special not only because it is the only Dutch-speaking country in South America but it has a population of just over 500,000 and vast swathes of pristine tropical forest. Like much of South America it has a chequered past. But it is now a democracy. I was there, at the invitation of PAHO (Pan American Health Organization), because the government of Suriname has taken on board the importance of social determinants of health and action through, Health in All Policies (HIAP).

Francoise Barten, who I met first at the People’s Health Assembly in Cuenca, Ecuador in 2005, was there to greet me on behalf of PAHO.

The government really are engaged. After a meeting with the Minister of Health I was hosted by the Speaker in the House of Assembly, the Parliament, and gave a lecture to the House on social determinants of health. The next day, at a big national meeting, especially big for a tiny country, the Vice-President, Minister of Foreign Affairs, Minister of Health and Speaker of the House were all there. I have been invited to give a keynote address before, with ministers on the platform. They usually give their speech and leave. A noble exception was the Swedish Minister of Health. This time the ministers all stayed at least for the morning session.

I was also hosted by the Suriname Medical Association and the Faculty of Medicine and gave a talk on The Health Gap.




Above: With First Lady of Suriname, Liliane Ferrier, and Guillermo Troya, PAHO Rep in Suriname

I met the first lady who is leading a country-wide initiative on early child development. We had a good meeting. The First Lady said that she was also the champion across government for HIAP. I told her that I think Suriname is showing the way on whole of government action on SDH. Impressive.

With the First Lady at our meeting was psychologist, Liliane Ferrier who had said to me publicly at the big meeting: I have been waiting for you in Suriname for 25 years!

A little insight into the country. The doctors gave me two books by a Surinamese novelist Cynthia McCleod. McCleod? In Suriname? A little research revealed that her unmarried name was Ferrier and she was the daughter of a President of the country. Liliane is a Ferrier. Any relation? Yes. First cousin. The former President was her uncle. Liliane’s background included Jewish, Chinese, and a lot else besides, including time spent in the Netherlands.

There is great willingness and interest on the part of government to be active on social determinants of health. An important step is good documentation of the extent of inequalities in health and in the determinants of health.

We may well do some work with them in evaluation of their initiatives on early child development.

Dinner at World Medical Association General Medical Assembly - Moscow - October 2015

Speech

Odd topic for a blog perhaps

My heart is full. On inauguration as WMA President, my speech invited National Medical Associations and individual doctors to rise to the challenge of health equity. I talked inequality of social and economic conditions damaging health and said that, at our best, doctors flourished in the cause of social justice. That evening, as I wandered around at the informal dinner chatting to people, the representative from Trinidad and Tobago said to me: you look like you are ready to dance.

“Not dance,” I said, “I’m floating; floating on a sea of well-being”. The question had been whether doctors would think that a message of social determinants was relevant to them. Yet, so many of the representatives here in Moscow have expressed their enthusiasm. The Danish Medical Association says that it is about to release a policy report that will deal with social determinants of health. They said that they had a Danish Marmot Review – Finn Diderichsen’s report – but now the doctors want concrete policy development. The Bolivians wanted to know how I could help. Colombia, Mexico, Costa Rica, Uruguay, Brazil, Argentina, Chile, Nigeria, South Africa, Trinidad and Tobago – all expressing enthusiasm. CMAAO, the Asian Network, wants us to work together. Alabania, India...it goes on.

The doctor from IPPNW had tears in his eyes because both in my inaugural address and at the informal dinner I had mentioned Bernard Lown. The first time was to quote his “never whisper in the presence of wrong”. The second was to say that working in the cause of health unites us, whatever the politics of our countries, or whether our leaders are locked in conflict. I cited the example of IPPNW and working for peace. At the height of the Cold War, two great cardiologists, Bernard Lown from the USA and Dr Chazov from USSR co-founded International Physicians for Prevention of Nuclear War. Building on their shining example, we should have a global movement of Doctors for Health Equity.

After the informal dinner a dozen doctors from Confemel, the Latin American network of Medical Associations, kidnapped me ‘just for five minutes’. At the end of a lively 55 minutes we celebrated our commitment with a little Tequila. I said that we were going to conduct a review of social determinants and health equity in the Americas and wanted to involve the Medical Associations. I in no way counted myself as knowledgeable about Latin America but in the last few years I had visited Brazil, Argentina, Uruguay, Chile, Peru, Colombia, Ecuador, Cuba, Costa Rica and Mexico, as well as the US and Canada. And next week I was going to Suriname. We agreed to explore how to work together and to meet in Buenos Aires in April, if not before.

My heart is full, and my diary overflowing.

I noted for our hosts from the Russian Medical Society, the importance of the great Russian authors for all of us. I said that in a recent profile in the BMJ, I had divided my life into three: before, during, and after reading Tolstoy’s War and Peace. I had a second reason for drawing attention to Tolstoy and that was Isaiah Berlin’s famous essay: The Hedgehog and the Fox. Berlin begins the essay by quoting the Greek poet Archilocus: the fox knows many things but the hedgehog knows one big thing. Berlin thought Dostoevsky was a hedgehog and Tolstoy a fox. Given my obsession with social determinants of health, was I a hedgehog? But in my book, The Health Gap, drawing on our various reports, I emphasise that improvement in health equity requires action through the life course from early child development through to older age. Action can also take place at the level of individuals, communities, governments local and national, and the planet. To keep up with the evidence on that array of possibilities, and changing when the evidence base changes, means being rather fox-like. A hedgehog with fox-like qualities is to follow in the tradition of Berlin’s estimation of Tolstoy’s view of history. Forgive this oversimplification, but Tolstoy, in his musings about theorise of history explores the question of how much influence the individual has, even Napoleon, as against the grand historical sweep. The question of free-will against determinism has resonance in public health. Are individuals the architects of their own poverty and ill-health? Or is it determined by stronger social conditions? It is a terrain worth re-visiting.

The hospitality of the Russian Medical Society and the experience of being in city whose dramatic history is embodied in its astonishingly varied architecture was a fitting backdrop for some big debates appropriate to the WMA.