Saturday, June 28, 2014

What Ramadan Can Teach Us in the Struggle for "Health for All"

"In 20 years from now, at the half century of Alma-Ata, we could see a different world, with basic health care reaching many of the poorest families.  However, to achieve this goal, we have to revitalize the original revolutionary principles of Alma-Ata, sticking consistently to the core values of universal access for care, equity, community participation, intersectoral collaboration, and appropriate use of resources."
—Lawn et al, Alma-Ata 30 years on: revolutionary, relevant, and time to revitalize
This Ramadan (the Islamic month of fasting), I find myself reflecting on the 1978 Declaration of Alma-Ata, a groundbreaking achievement in the history of public health.  Adopted at the International Conference on Primary Care in Almaty, Kazakhstan, the Alma-Ata Declaration defined a comprehensive approach for addressing poverty, ill health, and malnutrition that shifted the focus from biomedical interventions alone to the inclusion of social determinants, from hospitals alone to entire communities, in the struggle to attain equity and social justice in global health.

Alma-Ata and the Lessons of Ramadan

While the Alma-Ata Declaration most immediately resonates with the enshrining of health as a human right in Islam, I believe that its connection to Muslim ethics in general and Ramadan in particular extends even further, reaching toward the very heart of this month's teachings.  The ritual of fasting provides a means of not only cultivating God-consciousness but also encouraging collective empathy and the provision of basic necessities to the poor.  This is emphasized by the Qur'anic instruction for Muslims incapable of fasting to feed one indigent person for each day of Ramadan that is missed (Qur'an, 2:184).  The guidelines of the Alma-Ata Declaration, which establish a commitment to providing basic health services at the local level and rectifying gross inequities in health, are thus intimately related to these lessons of Ramadan.

I would argue, however, that fasting also offers to teach us something less obvious and more meaningful about the nature of social justice, something never explicitly mentioned in the Alma-Ata Declaration, and that is the need for sacrifice.  There exist many well-intentioned individuals who, in the words of physician-anthropologist Paul Farmer, "think all the world's problems can be fixed without any cost to themselves."  Central to the practice of fasting, beyond empathy and charity, is voluntary abstention for a time from what is otherwise accessible, without which the act of worship is incomplete.  For public health and medicine in an age of energy scarcity, similar discipline and sacrifice in the face of unsustainable practices of consumption may be the only means of making lasting progress toward the vision of the Alma-Ata Declaration.

Peak Oil, Health, and Healthcare

The reason for this is that the remarkable improvements in health achieved by low- and middle-income countries in recent decades are increasingly threatened by peak oil, or the predicted peak and decline in global production of petroleum products.  While many disagree on the timing and nature of the "peak," imminent changes in the price and availability of crude oil are predicted to severely affect the health and nutrition of poor communities, whose populations and health systems are extremely vulnerable to fluctuations in food and fuel prices.  Even without the additional implications of climate change and environmental degradation, the challenges of peak oil threaten to directly and indirectly exacerbate existing problems of poor governance, armed conflict, shortages of health workers, and dependence on foreign aid in the face of growing population size.

While generally absent from the lexicon of heath professionals, there is little doubt that peak oil is intimately tied to our modern healthcare system, which is largely built around the use of petroleum-based products or production methods.  Perhaps the most notable of these are plastic disposable products in the hospital waste stream, which continue to occupy limited landfill space and partly explain the contribution of healthcare costs to oil prices.  Moreover, overuse of various lab tests, high vehicle use among healthcare personnel, and the overall dependence of healthcare on the transportation sector add to the problem.  With declining availability of cheap oil, the healthcare system will inevitably need to adapt to survive by substantially curtailing energy consumption and resource waste.


As Muslims around the world refrain from consuming food or drink during the daylight hours this month, my thoughts are consumed by the relevance of fastingthe embodiment of sacrifice and moderationto the impending threat of peak oil to the health of all.  In this crisis of consumption where neither the blame nor cost is equally shared by all communities, empathy toward those in most need among us must be central to the future directions of our collective response.  For all of these reasons, I pray that the lessons of Ramadan can help guide us as we seek ways to adapt to the growing challenge of peak oil while preserving the vision and commitment of the Alma-Ata Declaration to equity, social justice, and health for all.

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