Cynthia Fleury-Perkins and Stéphane Besançon are calling for a reconsideration of the strategies employed in developing countries to ensure access to healthcare: the international community must take account of the dramatic rise in non-communicable diseases.
How can access to healthcare can be an accelerator of sustainable development?
Cynthia Fleury-Perkins: Care is a matrix—an operating principle. In other words, it is because we have received physical or psychological care that we are ourselves able to produce, make commitments and care about the world. There are exceptions, of course, but that is how most of us work. By caring for people, we give them the ability to create viable communities and move beyond the idea of basic survival—in other words, we empower them to develop independently. Caring breeds capability.
Stéphane Besançon: Access to care must include both curative and preventive care, as well as social support for disabilities and addictions. Access to holistic and comprehensive care, in the broadest sense of the term, enables people to become healthy, as defined by the WHO: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Only then can access to healthcare be an accelerator of sustainable development.
In your opinion, how are care and solidarity essential pillars of the rule of law?
C.F.: There are two main ways for the State, and in particular the rule of law, to lend credibility to its sovereignty: through security, by protecting its citizens from external and internal attacks, and through public health, by protecting their well-being. The two are inseparable. They do not cover everything, but they are necessary for all the rest. If you are kept safe in your environment and in your person, you are more inclined to study, and you study better. Of course, under the rule of law, there is no competition between these “rights”, and they are indivisible. A bastion of institutional trust collapses if the rule of law is no longer able to maintain people’s physical integrity.
S.B.: Care, like humanism, becomes essential. Indeed, it is a pillar of citizens’ education. It represents the ability to take “care of” but also to “exist” in connection with others, while making everyone’s existence an issue in its own right. Individuation (not to be confused with individualism), which distinguishes between concern for oneself and concern for the community, protects democracy and the rule of law by allowing the individual to become a “subject”.
C.F.: Solidarity and social cohesion are the only viable conditions for an accepted form of globalization that produces justice and social progress.
Why do you think it is urgent to reconsider vulnerabilities?
C.F.: Care builds a community and collective solidarity. The challenge of care forces the community to organize itself, to provide a standard that shows concern for its vulnerable members. Vulnerability is not like any ordinary “wound”, it is an inseparable part of our condition. The aim is not to overstate it, but denying it would have disastrous consequences. The challenge is to make vulnerabilities as reversible as possible and to create environments that do not reinforce them, or that can even greatly reduce them. The efforts we make to reduce vulnerabilities while respecting them are proof of our humanism.
S.B.: Today, vulnerable populations are defined in Paris, Washington and New York according to technocratic criteria that change on a regular basis and do not take sufficient account of the realities on the ground. The fight against non-communicable diseases, and in particular diabetes, is a perfect example. In addition to the vulnerabilities associated with being in a state of poor health, one effect of these diseases, through their exorbitant cost, is to accelerate the impoverishment of patients and their families. However, the latter do not correspond to any of the donors’ categories of “vulnerable populations”. There is indeed a gap between the frameworks and the realities in developing countries. Until this is put into perspective, development policies will overlook much of the real vulnerability. Revising the frameworks is an absolute priority to ensure the success of the SDGs.
C.F.: The problem is not how the texts are worded, as they are often very eloquent; the problem lies in the appropriation of Agenda 2030 by the member States and the low level of assessment and feedback that this generates. Only civil society has taken up the program, but it is struggling to make significant headway.
How can we curb malnutrition in all its forms?
C.F.: Malnutrition is invading all countries, due to rising insecurity, the race for profit, the loss of values, ignorance about proper nutrition, etc.
S.B.: Most donors and NGOs develop programs to combat undernutrition rather than malnutrition. Today, however, the majority of countries are affected by a form of malnutrition associated with overnutrition, which leads to a massive incidence of excess weight and obesity in their populations and, as a corollary, an exponential increase in diabetes and cardiovascular disease. Developing countries, particularly in Africa, are not spared from the dramatic rise in overnutrition, which is combined with the persistence of undernutrition: this is called the double burden of malnutrition. There is an urgent need to reconsider the strategic frameworks and programs rolled out in the field to curb it.
Why have you become involved in the fight against diabetes in developing countries and what form do Santé Diabète projects take?
S.B.: One day in Bamako, a patient with diabetes told me: “I would have preferred to have HIV. At least NGOs treat HIV-positive people”. He was right and I am appalled by this thought. But there is no access to healthcare for people with diabetes in Mali and this is the case in almost all African countries. However, in 2002, more than 20% of the working population were overweight and obese, while between 3% and 5% of the continent’s inhabitants were suffering from diabetes. I understood that no-one would do anything for these patients and that’s how the NGO Santé Diabète was born. Fifteen years later, we are still the only international NGO specializing in the subject.
C.F.: Hospital services use the Chair of Philosophy at the Hospital to design and build new solutions in an endogenous way. That is its mission. At the Hôpital du Mali in Bamako, the endocrinology department was perfectly willing to adopt a different approach to chronicity, therapeutic education and the humanistic philosophy of care. As part of my commitment to Santé Diabète, I therefore participated in the development of a training program on the humanities in care at the University of Bamako’s Faculty of Medicine. We are also working on the role that the University of Patients could play in this work on developing the caring function and the alliance of humanities and health in Mali.
S.B.: Diabetes is one of the WHO’s four priority non-communicable diseases (NCDs) and affects 425 million people worldwide, or 1 in 11 adults. By 2030, it will affect 35 million people in Africa and will be one of the leading causes of disability and death on the continent. In addition to diabetes, there has been a dramatic increase in the other NCDs, and this has now become an absolute public health priority. These diseases kill 41 million people each year, corresponding to 71% of all deaths worldwide. This is a major public health and economic challenge. At the State level, a 10% increase in NCDs reduces the annual rate of economic growth by 0.5%. The cost of treating diabetes alone amounts to between 21% and 75% of GDP in Africa. If nothing is done to curb the exponential rise of these diseases, much of the effort put into economic and social development effort will be jeopardized.