Ethics and Global Inequalities in Health Care

I wrote this short piece for a discussion in a forum on ethics and international affairs. It is not related to conflict resolution per se but is an important issue for me as someone who is temporarily working "in the field", as many conflict resolution practitioners do, which is why I decided to cross-post it here.

While sick people of all ages faced with the desolate Liberian health system stay alive only by God’s grace, as they say here, the elderly and sick who wish they could leave the hospitals in Germany to just die in peace, are kept alive with the newest technology and enormous amounts of resources over months or even years, prolonging their suffering.

When I entered the office this Monday morning I expected the usual cheers of “Good morning!”, “How are you?” and “You had a nice weekend?” that greet me when I come in but instead there was complete silence and I looked into faces marked with shock. It was the sort of silence that is in fact incredibly tense and almost loud as if crying out. “Have you heard? John died this morning,” my colleague told me. John was the head driver and an extremely lovely and humble man. Working for an international NGO and being as generous as he was, he took in most of his nieces and nephews and provided for all of them in addition to his own wife and children with his moderate salary. Why did John die? Nobody knows exactly but it seems that he suffered from undiagnosed diabetes, then got malaria and the malaria treatment at the hospital made his sugar levels spike, which ultimately caused his death within only a few days. The first hospital where he stayed did not have any doctors on duty; the second hospital did not have doctors capable of correctly diagnosing his diseases.

After talking to my colleagues, I opened my laptop to check my email. The inbox showed a new message from my mother: She had just come back from visiting her 80-year-old uncle who has been sick with diabetes for as long as I have known him. He has been in and out of the hospital for more than a year now and just wishes to die at this point. He lies in a hospital bed, unable to move, unwilling to eat, and, although not having suffered from dementia before, literally losing his mind. Yet, although his condition is slowly deteriorating, the dialysis, a pacemaker and an array of other machines and pills keep him from dying. His wife, my great aunt, has in the meantime suffered a stroke due to the burden of caring for him. Now both are in the hospital. While my great uncle wants the doctors to stop treating him, yet they won’t, John’s family tried to find someone who could treat him and prevent his death, yet they couldn’t.

Death is an inherent part of life. In countries privileged with good health care, we are quick to forget that despite all our resources and skills, our lives will eventually end with death. We can sometimes be blind to the relief that death can provide for very sick people because we have learned to avoid and fight death as much as we can. And as our health care system is so good at keeping people alive, it will do so to the point where it might do more harm than good. How much effort and how many resources are invested every day into keeping people alive who wish nothing more than being discharged and allowed to die?

At the same time, health care in much of the global South is not even good enough to successfully treat diseases as common as malaria or to diagnose a broken leg. After being hit by a car, one of my colleagues was driven from one hospital in Monrovia to the next, looking for an x-ray machine and someone capable of handling it. She couldn’t find any and now simply hopes that her pain stems only from bruises and not from broken bones. Resources, equipment, knowledge, skills – all of it is lacking. “Only the grace of God keeps you alive in Liberia,” is what my colleagues say over and over.

Clearly, any solution to this paradox of unnecessary suffering in the North because of health care systems that are too good at what they’re doing and the South because of health care systems that are dysfunctional, must be much more complex than simply redistributing resources. The reasons for both are more deeply rooted in the respective political, social and even cultural contexts. And yet, the inequality that I experience here is so outrageous it is hard for me to simply “feel lucky” about where I happened to be born, give John’s family some financial support for his funeral and otherwise conclude that the reasons for global inequalities are too complex to be effectively tackled. Just how?

Empowering Women through Conflict Resolution and Communication Skills

Laughter. “Why do you ask us about corn flakes?” “Corn flakes?” “Yes, you said: “How do you usually respond to corn flakes in your community?” That was when I started exclusively using the Liberian synonyms for conflict “confusion”, “palava” and “hala-hala” in trainings…

After having co-facilitated several trainings, a local partner organization asked me to design and facilitate a training on basic conflict resolution and communication skills for several women’s groups that they support. These women face challenges in their communities where their empowerment is seen with suspicion – by their husbands who feel excluded, by other groups in the community who see them as competitors, and by anyone who sees the white vehicles with USAID logos drive into the communities from time to time to hold forums, provide trainings and provide other support to the women’s groups, leading them to believe that the women are “eating” immense sums of money as people say here. Development projects in general and women empowerment in particular never come without their challenges as I have been able to experience here several times. Especially in a deeply patriarchal culture, women’s organizations can easily appear as a threat to the power relations as they exist and therefore encounter many obstacles.

The mentor organization to these women’s groups thus approached me to hold a short training with representatives from the groups to introduce them to some basic concepts and tools from conflict resolution and discuss basic communication challenges and tools. These can help them better deal with the issues mentioned above but also with everyday problems within their own groups and to a certain degree also with conflicts in their communities, the most pressing of which according to the participants are land disputes, sexual violence, men abandoning their families and other family disputes. We discussed among other things the importance of recognizing and addressing root causes, raising awareness about the various consequences of conflicts, the benefit of staying calm and listening to all parties to the conflict instead of immediately taking sides, and ways to communicate messages clearly.

I had learned from a Liberian trainer the analogy of peacemakers or mediators as cool water. People who have a confusion are hot like fire and what you need to do is be water and cool them down. Don’t add wood to the fire by taking sides or blaming or judging but remain calm and cool the others down before doing anything else. This picture stayed with the participants. In the beginning of the training, a participant had asked what we would recommend for her to do if her sister wronged another person. I asked the group and most participants suggested telling her in front of the entire community that she’s wrong – open shaming basically. After the training I asked what they would take home with them from the training. “I will talk to both persons who have the confusion before judging”, “I will listen to the person who started the confusion and try to understand why she did it”, “I will try to stay calm and explain what I think”, “I want to be like water, fresh and cool, and bring calm to the confusion”. These comments were encouraging.

As is often the case, I felt at the end that I had learned just as much from the participants as they hopefully had from me. Such energy, passion and commitment to bring change to their communities! Three women came with their infants and toddlers and yet did not miss out on any session or discussion, one young woman presenting a “conflict tree” on sexual and gender-based violence in her community started a spontaneous passionate speech calling on the other women to stand up against SGBV, and, before leaving, the women encouraged each other through songs and calls to keep on fighting for their rights. “Women ooooh”, one shouted and the rest answered “women!” Then the mothers tied their kids onto their backs again, the groups left the room clapping and singing and set out to carry what they had learned to their communities.