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HOME > Current Focus > Articles & Essays > Janet Hart essay on public health Public Health: By Janet De Souza-Hart INTRODUCTION I live a fairly peaceful existence. Each day, I help my kids get ready for school, take the subway to work, and carry out a number of mundane tasks quite easily. I am fortunate to work in the academic field. I derive immense satisfaction from delving into life’s deepest mysteries and most profound questions. My soul is fed by the rich dialogues that I am able to have not just with my colleagues and students, but also with my family and friends. But could I do all of these things if, each day, I struggled to get a clean, uncontaminated glass of water? Could I do any of these things if my children were suffering from malaria or measles? Not least, could I ever hope to fulfill my dreams and aspirations as a citizen of the world if my basic health needs were to remain unmet? For me, these are hypothetical questions. But for a shockingly high percentage of the world's population such questions are anything but hypothetical, and their answers would be overwhelmingly negative. This essay will begin with a discussion of the scope of our most pressing public health crises that threaten every aspect of our global society. It will then explore what it means to conceive of public health problems and solutions from a holistic, integrated perspective. Finally, it will highlight three exemplars of public health innovation and advocacy who, through their work on behalf of suffering people, embody and promote in others what Buddhists call "the greater self," a life-state that all human beings inherently possess. GRASPING THE SCOPE AND SCALE OF OUR “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services…” In many developed countries, including the U.S., HIV and AIDS are no longer front-page news. We take for granted that there are now anti-retroviral medications that seem to extend people’s lives indefinitely. One look beyond our borders and comfortable existence and it is easy to see that we have been lulled into a sense of complacency. While everyone has a right to a “standard of living” adequate for health and well-being, the reality is that the majority of the world’s population does not live with these conditions. Devastating pathogens like HIV threaten the stability of entire societies across the globe. According to the World Health Organization, there are between 30-40 million people living with HIV/AIDS worldwide, with about 2.6 million new cases each year. Sub-Saharan Africa is one of the hardest hit regions. South Africa had approximately 5.3 million people with HIV at the end of 2002, more than any other country in the world. “The most devastating social and economic impacts of AIDS are still to come,” says Dr. Peter Piot, former UNAIDS Executive Director. The “devastating impact of HIV/AIDS…affects everything from agriculture to national defense.” (1) In 2008, it was estimated that there are more than 2 million children who are living with HIV/AIDS, the majority of which do not have access to life-saving anti-retroviral therapy. And it doesn’t stop there. Even HIV-negative children experience the catastrophic consequences of this epidemic. As the United Nations Africa Recovery/Renewal project warns, “To the tragedy of the 17 million people who have lost their lives to AIDS in Africa, add the 12 million orphaned children left behind. Traumatized by the death of parents, stigmatized through association with the disease and often thrown into desperate poverty by the loss of bread-winners, this growing army of orphans—defined as children who have lost one or both parents—is straining the traditional extended family and overwhelming national health and education systems in the most severely affected countries. The problem is particularly severe in Zambia, where, according to the U.S. Agency for International Development (USAID), the number of orphans topped 1.2 million in 2000—1 in every 4 Zambian children. Of these an estimated 930,000 have lost at least one parent to AIDS.” (2)
AIDS is only one of many systemic health problems that plague humanity. As HIV infections have increased, so have other life threatening infections. Tuberculosis has morphed from a rare, treatable illness to an increasingly more common “super-infection” that is characterized by resistance to most antibiotics. Food now commonly travels immense distances before reaching someone’s table, which dramatically increases the risk of contamination with foodborne pathogens. A recent outbreak in Europe of a foodborne bacterial strain that appears to have acquired a novel and extremely deadly mutation is a serious concern. Measles, an infectious disease that is easily preventable with a safe and inexpensive vaccine, is still one of the top ten causes of death in children under five worldwide. Malaria remains one of the most ubiquitous and challenging illnesses to combat due to its complex infection cycle and mode of transmission. Joining measles and malaria in the infamous top ten causes of physical human suffering are diarrheal diseases, largely preventable with simple hygienic measures including proper sanitation. (3) How can children be educated so that they improve their lives and the societies in which they live when we can’t even give them access to clean drinking water? A lack of basic human needs creates conditions where diseases can move in, causing severe morbidity and death. The most impoverished nation in the Western Hemisphere (Haiti) is a stone’s throw from some of the most elite tropical resorts in the world. Poor living conditions in Haiti (especially in the aftermath of the January 2010 earthquake) have exacerbated several outbreaks, including a deadly cholera epidemic. (4) Similar outbreaks due to poor sanitary conditions occur worldwide constantly. Infants and small children are the most vulnerable population in terms of health and yet they are also the key to a peaceful future in these societies. We certainly do not need to wait for communities to reach some critical threshold related to health in order to engage in efforts to make society more peaceful, education more accessible, and humanistic dialogue more frequent. However, along with our efforts to create peaceful democracies, economic self-sufficiency, and educational opportunities we should be making simultaneous efforts to promote health or we risk failure on all levels. How can each individual global citizen promote meaningful change that will contribute to the improvement of the lives of the world’s youngest population? In analyzing the peace theories of Soka Gakkai International President and Center founder Daisaku Ikeda, Olivier Urbain identifies a “threefold approach of inner transformation, dialogue and global citizenship” that requires “an awareness of the situation of the world and of the actual suffering of millions of people.” (5) But it is not enough to learn about suffering in a passive or abstract way. Peace is built through the active cultivation of courage, wisdom, and compassion—core qualities of the greater self. Courageous action, based on a deep wisdom and coupled with compassion, can create the conditions where human health is supported while other lofty societal goals are also achieved. It is important to explore how philosophy and action based on these qualities combine in a holistic way and contribute to the emergence of broader and greater well being. HOLISTIC SOLUTIONS AND THE ROLE “Health is a state of complete physical, mental and social well-being The health of a single person is connected to the health of society, which, in turn, is connected to the health of the environment. Physical health is just one component of overall health. Spiritual, emotional, intellectual, and environmental health are linked and equally vital. In Unlocking the Mysteries of Birth and Death, Daisaku Ikeda illustrates this point. “The ancient Indian text Caraka Samhita proclaims freedom from illness as an essential element of human happiness and the basis of good works, success, sexual desire and liberation from the bonds of illusion and suffering. 'Freedom from illness' here means more than the absence of [physical] illness. Good health is judged not only on physiological diagnoses but also on a holistic view of life that includes spiritual elements.” (6) Osteopathic physicians have long championed a holistic view of medicine, seeing the patient as a complete human being rather than a collection of symptoms. In addition, allopathic medicine has been moving in the direction of recognizing the profound importance of considering cultural and behavioral factors in addition to biological factors when treating patients. (7) The biological model of illness that has pervaded medicine for much of the 20th century is being gradually replaced by a biopsychosocial model in the minds of many health care providers. (8) This model considers not just tissue and organ dysfunction, but also factors such as patient support systems, religious beliefs, or psychological ability to adhere to treatment protocols. The thread that runs through all of this is the compassion that health care practitioners should continually develop towards their patients.
The more we realize how interconnected we are as individuals and societies, the more we can act with wisdom as we effect meaningful change. This is represented by multiple concepts in Buddhist philosophy. Integrative ideas such as the oneness of body and mind (Jpn. Shiki Shin Funi) and the oneness of life and its environment (Jpn. Esho Funi) permeate Buddhist tradition. In addition, the concept of “dependent origination” describes the “symbiotic nature of life.” Daisaku Ikeda elaborates on this idea as follows: “As Goethe, speaking through Faust, wrote, 'Into the whole, how all things blend, each in the other working, living.'" Ikeda adds: "Buddhism explains that nothing and no one exists in isolation. Each individual entity shapes its environment, which affects all other existences. All things are mutually supportive and interrelated, forming a living cosmos, what modern philosophy might call a semantic whole.” (9) Although it is easy to feel an overwhelming sense of despair due to the harsh realities that so many human beings face, there is reason to hope. While governments and organizations such as the United Nations have a role to play in improving the conditions in which people live, sometimes the most powerful forces for positive societal transformations come from single individuals. There are many examples of courageous human beings that have cultivated the greater self in promoting potent and meaningful change. As Ikeda tells us: “unlimited promise and power lies within every individual; and...for this truth to take root and flower, one must develop a 'self-culture' that transforms the very core of one’s being. What flowers from this self-culture is not the fragile, forlorn bud of the smaller self but the majestic blossom of the larger self—with its boundless capacity for empathy and understanding.” (10) I have been inspired by three examples of phenomenal individuals who embody the powerful effects that come from cultivating one’s greater self. A description of their wide-ranging impact in diverse and disadvantaged communities follows. THREE MODELS OF PUBLIC HEALTH INNOVATION "Never doubt that a small group of thoughtful, committed people can change I. Transforming inequities related to physical health: Perhaps one of the most integrated approaches to medicine is found in the efforts of Dr. Paul Farmer, physician, anthropologist, and founder of Partners In Health, an organization providing health care and humanitarian resources to the neediest parts of the world. (11) Pulitzer Prize winning author Tracy Kidder described Dr. Farmer’s life in the biography, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World. He recounts portions of Dr. Farmer’s migratory childhood, much of which was spent living on leaky boats and in cars. He then describes Dr. Farmer’s first experiences witnessing the poverty and dire health of the Haitian people. The story culminates with Dr. Farmer’s current remarkable accomplishments not just in Haiti but also in several other parts of the world. One wonders how, with such humble beginnings, he could become so influential as to be able to mobilize the resources of premier institutions like Harvard Medical School on a global scale. In the New England Journal of Medicine, Dr. Bernard Hirschel describes the impact of some of Dr. Farmer’s accomplishments. “Through his patients in Cange (Haiti), Farmer became interested in multidrug-resistant tuberculosis. From Haiti, he exported treatment of multidrug-resistant tuberculosis to Peru and then to Siberia, achieving cure rates comparable to those in the United States. Through the Institute for Health and Social Justice (the research and education division of Partners in Health)...he started a movement to lower prices for the second-line drugs necessary to treat resistant tuberculosis and successfully lobbied the World Health Organization for changes in treatment recommendations for tuberculosis.” (12) This is just tip of the iceberg of what he has accomplished through patience, dedication, and resilience. His view of health is naturally holistic and based on his extensive research in medical anthropology. In describing one of Dr. Farmer’s most recent works, entitled Pathologies of Power, Dr. Stephen Miles relates this approach.
Positive change requires a mind that constantly seeks to learn and improve, a hallmark of the greater self. Dr. Farmer has developed his life through a combination of enriching life experiences and educational endeavors. Creating more access to education is an important key to developing more humanistic leaders such as him. How can we better support the intellectual health and development of the world’s children, the future leaders in society? Greg Mortenson's story demonstrates some possibilities. II. Transforming inequities related to intellectual health: Afghanistan has been and continues to be one of the most dangerous countries in the world. It has the highest recorded rate of maternal mortality in the world. (14) Those children who are “lucky” enough to survive to the age of five experience daily hardships due to extreme poverty. (15) For girls, the hardships are even more profound. Even the most basic education is a luxury. War and conflict are the reality. Few people would be brave enough to travel to this place and try to improve the lives of the children there. Greg Mortenson, co-author of Three Cups of Tea and founder of the Central Asia Institute [CAI], has done precisely that. In her foreword to the Young Readers edition of Three Cups of Tea, Dr. Jane Goodall, renowned biologist and U.N. Messenger of Peace, describes some of the challenges that Greg Mortenson witnessed when he first visited the region. She recounts, “He was horrified to find that there was no school. Imagine trying to learn from a teacher who comes only three days a week when you have no classroom and are sitting on the ground outside, often in freezing weather, and mostly without books and paper and pens. Greg made a promise that he would return and build a school.” (16) Not only did he keep his promise; he has also worked tirelessly since to transform “stones into schools” (17) on a scale that most people thought was impossible. He has accomplished all of this despite tremendous struggles, obstacles, and, more recently, criticism. (18) Some of these challenges are described on the CAI website:
The wisdom associated with listening to the local communities and empowering them to take charge of their own projects also embodies key aspects of the greater self. As Daisaku Ikeda has written, peace, harmony, and progress comes from “devoting our very lives to listening and learning from those different from us. This humble willingness to learn is profoundly meaningful, invariably fostering deep, empathetic connections.” (20) My daughter met Greg Mortenson when she was nine years old, as he accepted the 2010 Salem Award for Human Rights and Social Justice. (21) During the post-ceremony book signing, every child present was invited to the front of the (very long) line. We were touched not just by the interaction he had with these children, but also by a thoughtful gift that he gave to my daughter for her third grade teacher. You could feel the great respect he has for educators. The grassroots effect of this type of sincerity is exemplified by a quote from a young woman named Jahan whose life was profoundly affected by the work that Greg Mortenson and the CAI have done. Jahan explains, “When I was a little girl and I would see a gentleman or a lady with good, clean clothes, I would run away and hide my face. But after I graduated from the Korphe School, I felt a big change in my life. I felt I was clear and clean and could go before anybody and discuss anything. And now…I feel that anything is possible. I don’t want to be just a health worker. I want to be such a woman that I can start a hospital . . . and look over all the health problems of all the women in the Braldu. I want to become a very famous woman of this area.” (22) Acting out of their greater selves, Greg Mortenson and his colleagues have helped others to do the same, a ripple effect of positive change. Great change can come from the empowerment of women such as Jahan, as Rosa Parks, Betty Williams and Aung San Suu Kyi can all attest. But how does one actually empower women in communities with scarce resources? The story of Nobel laureate Wangari Maathai shows not only how this is possible but also how remarkable personal and social transformations can happen as a result. III. Transforming environmental, societal, and economic health: One of the most moving examples of cultivating one’s greater self comes from Wangari Maathai, Nobel laureate and founder of the Green Belt Movement. (23) In her 2004 Nobel lecture, she eloquently explains the history and purpose behind the organization.
The Green Belt Movement is significant, then, both for the environmental awareness it fosters and for the natural synergy that occurs as initial successes motivate more and more people to create value in their lives and community. The rural women of the Movement, says Maathai, “discover that they must be part of the solutions. They realize their hidden potential and are empowered to overcome inertia and take action. They come to recognize that they are the primary custodians and beneficiaries of the environment that sustains them...." (25) Maathai's insights distill how the greater self can emerge even in difficult circumstances. In her address, Maathai also explains how sustainable development, democratic participation, and peace building became intertwined in the Movement. Initially, says Maathai,
In 1939, the American philosopher John Dewey wrote that "[d]emocracy is a way of life controlled by a working faith in the possibilities of human nature." (27) Decades later his faith found perfect expression among what Maathai refers to as "the ordinary citizens" of Kenya. CONCLUSION There are many other examples of individuals who have seen a simple, sincere desire to contribute blossom into a project with far-reaching, positive effects. For example, British filmmakers Bill Leeson and David Wilson founded an organization called War Child, (28) which originally provided support for children affected by war in the Balkans and which now supports children in Afghanistan, Iraq, Uganda, and D.R. Congo. While more examples of compassionate people who have accomplished great things exist, it is easy for most of us to feel that these types of accomplishments are beyond us. But that self-limiting mindset is truly the only thing that separates us from the Paul Farmers or Wangari Maathais of the world. Sometimes improving people’s lives is not as complicated as it seems. As several economists have discovered, small things can have dramatic effects. (29) Through thoughtful analysis of experimental data, they have shown that Kenyan children who are given inexpensive medicine to treat intestinal parasites for an extra year earned a dramatic 20% more income as adults. An Indonesian child who attended an extra year of school saw a significant ~8% increase in wages in adulthood. As Boston Globe editor Gareth Cook suggests, “Sometimes big problems don’t demand big solutions, they demand many small ones.” Everyone has something unique and significant to offer. In Planetary Citizenship, Daisaku Ikeda and renowned futurist and global economist Hazel Henderson discuss basic tenets of Mahayana Buddhism, including the conviction that “everybody possesses the noble bodhisattva life-condition and has boundless potentialities.” Building on that faith they consider “how actions performed for others from the depths of our beings" also contribute to our own well being. (30) With the right mindset, we can create significant positive change as did the humanistic and visionary people described above. As I continue to live my life and carry out all of the small mundane tasks that are required of me, I simultaneously strive to cultivate my greater self. How can I be a force for positive, healthy change in the world? How can I support my children as they develop into humanistic world citizens? How can I inspire my students to be the most capable and compassionate health care professionals that they can possibly be? I aspire to express what Daisaku Ikeda describes as “the openness and expansiveness of character that embraces the sufferings of all people as one's own. This self always seeks ways of alleviating the pain, and augmenting the happiness, of others, here, amid the realities of everyday life." (31) Sometimes I feel discouraged that my impact feels so insignificant. Then I recall what Paul Farmer, Greg Mortenson and Wangari Maathai have so beautifully illustrated: Every great endeavor begins small, and with the sincerity and determination of a single individual. NOTES 1. WHO News Release: Global AIDS epidemic shows no sign of abating; highest number of HIV infections and deaths ever. Retrieved from: http://www.who.int/mediacentre/news/releases/2003/prunaids/en/ and HIV/AIDS Data & Statistics from the WHO. Retrieved from: http://www.who.int/hiv/data/en/index.html *** Janet De Souza-Hart, M.A., Ph.D. is Assistant Professor of Biology and Assistant Director of the Premedical & Health Studies program at Massachusetts College of Pharmacy & Health Sciences. Her past scholarship has focused on the molecular biology of pathogenic micro-organisms and her current research is in the areas of pedagogy and science communication. She is the creator of www.biologymom.com, a scientific resource for parents. Her greatest professional rewards have come from teaching and mentoring future health care professionals.
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The Ikeda Center
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