What We Do and Why We Do It

 

Keynote Address By Jack Geiger, MD, 2002 DGH General Assembly

 

"And that is what we do: make a road out.

We work with people to build a road out of

their circumstances, out of the inequity,

out of the poverty."

 

 

What is it that we really do? Why do we do it? And how long will we have to do it? The "we" here is all of us is this room and all of the people who are engaged in human rights work, in volunteer health work, in social justice work in the world. It is a collective "we" of some of the most important and precious efforts that have gone on, that are going on, and that are going to have to go on.

 

Let me begin with a reference to a book I came across a couple of years ago, by a historian at the University of Chicago, Philip Klinkner, called The Unsteady March. This historian's analysis is so named to dispel the myth that in the US we have made some sort of steady, seamless, uninterrupted, if slow, progress toward equality, social justice and racial justice. That is not the way it's happened at all.

 

As he documents, progress in these areas has occurred in short bursts of 5 or 10 years at most, which have occurred only when, by and large, three major conditions have been met in our history: we have to be at war; we have to have an ideological enemy that requires our political leaders to start to emphasize democratic rhetoric and ideologies; and we have to have domestic organizations that are strong enough to hold those political leaders to their words, to say if we're going to have a democratic ideology, then we better have a democratic society. That was true after WWI, it was true after WWII, it was true after, or during in fact, the Vietnam War. What's also true, as The Unsteady March points out, is that each of these bursts of 5, 10 or, at the very most, 15 years of progress, is followed by 30, 40 or 50 years of stagnation, if not regression. One only has to look at this morning's newspaper to know which part of the cycle we are in now.

 

Certainly we are in a time of extreme reaction of imperialism, of imperialist aggression at home and abroad, of oppression and civil rights violations and threats at home that I think are unparalleled, not just since the 1950's but since the Palmer Raids of the 1920's. To site one example, John Ashcroft and the Justice Department now have the legal power to compel book sellers to report to them the book purchases of anyone they're interested in. And they're being very creative about the other invasions of civil liberties that have accompanied the so-called war on terrorism.

 

I wrote a chapter on terror and civil liberties for a book called, Terrorism and Public Health that will be out at the time of the American Public Health Association meeting. It is indeed scary. In researching that chapter, I read a comment by John Ashcroft when he was asked about how come it was 5,000 people, all of Middle Eastern descent, whom he rounded up immediately after 9-11. He said, "Oh no, it wasn't ethnic, it wasn't racist. We just went and rounded up a set of people who fit a set of generic parameters." That is the all-time classic euphemism, I think.

 

It occurred to me that would have been a perfectly apt description of the Nazi Nuremberg laws. I started to think about what had preceded the Holocaust. It significantly involved physicians in Germany, the courts and other institutions in German society. Really, the beginning was with the euthanasia, the murder of the physically disabled, of the mentally retarded, and others who were characterized—and this is the key phrase that I want to talk about this morning—as life unworthy of life. "Life unworthy of life." That phrase was involved in that Holocaust, involved in every genocide, involved in one way or another in many of the human rights violations and examples of social injustice that we have dealt with for so long.

 

What we deal with in our work, quite apart from the extremes of genocide, is a variant of that: "Lives less worthy of life." When we say that the poor have a mortality rate that is multiple times the rate of the rich, when we say poor children die in our country and in the developing world at rates far higher than those of the better off, we are saying that we permit a condition which in effect says they are less worthy of life. We are sending this message because we let it happen, because we have social policies that almost assure that it will happen, and we let it happen stubbornly and continually.

 

In 1950, the overall mortality rate for African Americans in the US was 50% higher than the white rate. In 1995, the overall mortality rate was precisely the same, 50% higher than the white rate. These are persistent, stubborn, manifestations of a social belief that there are lives less worthy of life than others. And it is this fundamental premise that underlies the inequities we confront both domestically and internationally. And we know that the size of the gap between the top and the bottom economically, between nations and within nations, is an almost perfect correlate of morbidity and mortality. The greater the gap-and as the gap grows-the greater the level of morbidity and mortality. Yet the global community pays relatively less attention to it.

 

Yesterday The New York Times ran a big article about the new black South African elite, and not a word about the townships where mortality is unspeakable, to use the right word. The last time I was in Durban, just about a year ago, I walked through a pediatric ward with 70 babies and 70 mothers, all of whom were going to die of HIV infection, much of which was preventable. All of it reflecting what one can clearly say about the world's response to the AIDS epidemic: that we have decided, as we have for people of color, as we have decided for people in the developing world, that those are lives less worthy of life than our own lives.

 

Now it would be easy to say in our work that we are just nibbling at the edges, that we are not really capable of making structural change; that we don't have the resources; that we are dwarfed by governments and corporate power; that we are not really making a difference in the way the world is going to be a year later, 5 years later, 10 years later; that we are unable to change the systems. And that would not only be wrong, it misses the point in a fundamental way. The real message in our volunteer work and in our human rights work is threefold:

 

  • What we are saying to the people we work with is that their lives are as worthy as our own; that their lives are as worthy of life as everyone else's; that all life is equally valuable. By our presence and our work we demonstrate a commitment to the idea of equity, not as an abstraction, but as something that has to do immediately and directly with the lives of the people we work with.
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  • Second, what our work does—beyond our medical tasks of prevention and cure, because of the way we work, not only in the detail of community-oriented primary care, but in the principles of working with the community, and in a very real social and political sense—is empower people and communities. That is the real lesson of this burst of 15 years and the regression that followed, empowering people and communities is the only thing that makes those 15 burst years happen and is the most important thing that we do. 
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  • The third thing we are really doing is saying to the people we work with that we presume there will be a future. We presume social change. We presume a future that will be different.

 

Let me tell a true story.

 

In 1957, I was fortunate as a medical student to go for six months to study with Sidney and Emily Kark, the inventors of community-oriented primary care, in South Africa. The Pholela Health Center where we worked was in one of the most impoverished, sickest, poorest areas in sub-Saharan Africa. 600 square miles of a Zulu tribal reserve. Men were off eleven months a year in the factories and mines. Women, children and the elderly were left behind in near starvation, in toxic environments, on land that wouldn't grow very much, with not enough water. There were enormous rates of illness, but the health center did start to turn that around.

 

Two years after I was there, the apartheid government closed it down, along with a network of health centers that the university and the Karks had started, and all went into exile. One of the people that had been the clinical director there was the great social epidemiologist John Cassle. About 10 years later, John returned to South Africa and decided to visit the Pholela area, to see if there was any residual evidence that the health center had been there. He was struck by the fact that, in comparison to other areas similar in size, composition and population, there was a visibly, markedly higher degree of educational aspiration and level of educational achievement.

 

When John Cassle told me this, I was startled because we had seen exactly the same thing in Bolivar County, Mississippi, in our own health center work. Indeed, the Delta Health Center Project was a copy of the Pholela project. We had 600 square miles of Northern Bolivar County, the difference was the land was rich rather than poor. But the poverty, the illness and the morbidity were as extreme. This population had a mean educational level of 5th grade, and most of that was in inferior, rotten, segregated schools. One of the things the health center had done was open an office of education, simply to put people in touch with educational resources, knowledge of scholarships, knowledge of how to apply, that they had been systematically cut off from by racist segregation. In the first decade in that county, our program produced seven doctors, five PhDs in health sciences, some 20 registered nurses, six social workers and others, so we had the same phenomenon.

 

Now fast-forward to the mid-1980s. The Committee for Health in Southern Africa used to organize a workshop in New York every two years and bring ANC people in exile to meet, give papers, and report on the struggle and what they were doing. One time a tall, distinguished pediatrician with advanced training in tropical medicine and public health, gave her talk. We were walking across the street afterwards, to get lunch, and I asked idly, "Where did you grow up in South Africa, where were you born?" She answered, "Pholela." I immediately asked, "How old were you in 1957?" and other rude things.

 

It turned out that as an 8-year-old girl she had been one of my patients when I had been there as a medical student. Indeed, she had a clear vision of this weird white foreign couple that had been working at the health center. Well, here she was out of Pholela, with all of this advanced training. It seemed like a perfect example of what John Cassle had described and what we had witnessed in Mississippi. So I asked her if she thought that the health center had made a difference in terms of educational aspiration and achievement.

 

She thought for a minute and replied, "Without question, contact with the health center, seeing the interracial team, seeing African nurses, seeing African medical students, looking at the interaction, discovering that people could be educated, could become professionals, had a very powerful impact."

 

Then she thought a little more and said, "Well, I think for that effect to have occurred, you really had to be in that part of the tribal reserve that was close to the health center so that you were there frequently, had that kind of contact and a real chance to interact." That made sense to me.

 

And then she thought some more, and added, "Well, you not only had to be in the tribal reserve closest to the health center, you had to be close to a highway." That did not make any sense to me.

 

"Why is that?" I asked. "Because you had to really understand that there was a road out of this place," she replied.

 

And that is what we do: make a road out. We work with people to build a road out of their circumstances, out of the inequity, out of the poverty.

 

Let me close with a quotation from Camus' The Plague. You will remember that the plague in a North African town so vividly described in that novel was clearly a metaphor for fascism, oppression, etc. At the very end of the book, almost on the last page, you discover that this novel has been the journal of the protagonist, who is a physician. Reflecting on the experience of that plague year, this physician realizes that this struggle would have to be repeated over and over again because reaction and regression, terror—the plague if you will—will surely recur. But that this effort will continue, and here I quote, "By all those who while unwilling to be saints, refuse to bow down to pestilence, and strive their utmost to be healers."

 

That is what we are about. Like all healers we strive to heal. Like most healers, we refuse to bow down to pestilence. But we have an understanding of pestilence that it is not merely biological. It is also social, political and economic. This is the pestilence we fight along with the pestilence of biological agents and natural disease.

 

And to turn to the last question, how long are we going to have to do it? I think the answer is clear: for all of our lives, with the rewards and the obligation that comes with it. That is why it is so important that we have students here today. We have a responsibility to create the next generation of people who are going to do it for all of their lives. Because it is going to take that and longer.

 

It is not a reason for despair. It is not a reason for pessimism. It is the nature of what is best in us as human beings: to join the struggle, to build a life around it, to commit to it, to make sure that it will continue. The struggle for freedom is about as old in one form or another as our species is, and we are part of the people who carry that burden.

 

I congratulate you for what you have done. I commend you for this meeting. And I charge you with the responsibility for the next 60 years, and for raising the children who will be doing it after you are gone.

 

Jack Geiger, MD, MSciHyg, ScD, is the Arthur C. Logan Professor Emeritus of Community Medicine, City University of NY Medical School. His professional career has been devoted to the problems of health, poverty and human rights. He initiated the community health center model in the US, combining community-oriented empowerment and development initiatives, and was a leader in the development of the national health center network of more than 800 urban, rural and migrant centers currently serving some nine million low-income patients.

 

 

Dr. Geiger's work in human rights (HR) spans over six decades. He was a founding member of one of the first chapters of the Congress of Racial Equality (CORE) in 1943 and was Civil Liberties Chairman of the American Veterans Committee from l947-51, leading campaigns to end racial discrimination in hospital care and admission to medical schools.

 

In the 1960s he was a founding member and National Program Chairman of the Medical Committee for Human Rights (MCHR) and Field Coordinator of its Mississippi program to protect and provide medical care for civil rights workers. He is a founding member (1986) and immediate past-President of Physicians for Human Rights (PHR), a national organization of health professionals whose goals are to bring the skills of the medical profession to the investigation and documentation of HR abuses, violations of medical neutrality, war crimes and crimes against humanity, and to provide medical and humanitarian aid to victims of repression. He served as medical consultant on the UN Human Rights Center's mission to former Yugoslavia (1992), and led PHR missions to Bosnia (1993), Iraq and Kurdistan (1991), the West Bank and Gaza Strip (1990, 1998). He has also been very active in pre- and post-apartheid South Africa.

 

Dr. Geiger was a founding member of Physicians for Social Responsibility in 1961 and was a co-author of the first major publications in the US on the medical consequences of nuclear war (New England Journal of Medicine, 1962). He has published over 25 scientific articles and book chapters on the medical and biological effects of nuclear weapons, lecturing widely on this subject in the US and Europe.