Bioethics for the Medically Deprived
- Yeruham Frank Leavitt, Ph.D.
Eubios Journal of Asian and International Bioethics 10 (2000), 125.
Chairman, The Centre for International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev, Beer Sheva, Israel
Our dream of Asian Bioethics took a big step forward in January, 2000, when I headed an Israeli team -- with international membership -- to carry out the first phase of a Mother and Child Health Education Project for thirty village mothers from among the Dalit population in the Palar River Delta area of Tamil-Nadu, India.
The Dalit ("untouchables") have suffered for thousands of years as the most discriminated-against people in the caste system. In spite of efforts on the part of Indian national and state governments to wipe-out caste discrimination, ancient customs and behavior patterns change agonizingly slowly.
Eubios readers will recall that during 1997, 1998 and 1999, Darryl Macer, Jayapaul Azariah and I travelled around Asia on a Japanese Monbusho grant to hold seminars and generally enourage Asian bioethics. It was through that experience that I began to realize that the bioethics which I have been teaching is for rich people in rich countries. To mention some of the subjects on the ethics of which I teach and write, you have to be very wealthy -- in comparison to most of the world -- even to be able to consider as a viable option such things as heart transplants, neonate intensive care or amniocentesis. I have heard people in rich countries like Israel and the United States refer to themselves as poor. These people have simply never seen or imagined places where women put their babies to sleep on rags on the street at night, among cars, trucks, wagons and the excrement of people and animals, because they have nowhere else to sleep.
Millions of people around the world have no, or almost no, medical care at all. I have argued in a number of conferences that medicine cannot be ethical unless it is egalitarian. The bioethical principle of Distributive Justice would, at the very least, demand that we try to help the medically deprived people of the world before we address many other bioethical issues.
The major sponsor of our team was "Mashav", the Department for International Cooperation of the Israeli Ministry of Foreign Affairs. Cooperating sponsors were the Dalit Liberation Education Trust, (whose Managing Trustee, Henry Thiagaraj, was part of the planning from the beginning), the A.M.M. (Murugappan) Foundation, Chennai, the School of Life Sciences, University of Madras, and the Delta School of Nursing, Kadalur.
This was of course not the first health project which "Mashav" has sponsored in a developing area. But our project is unique in that although it is Israeli initiated, our team has international membership. Eszter Kismodi RN,JD, who taught the unit on Family Planning and Sexually Transmitted Diseases, is Hungarian and now Founder and Chairperson of that country's Patients' Rights Office. Mrinalinee Pendse BA, MA, is from Pune, India. With a background in philosophy and Sanskrit, she is now doing an advanced degree in environmental education (an ideal bioethicist). She taught our unit on Environmental Health and the Healthy Use of Water. And Ronald Orie Browne, an American and a student in the MD in International Health Programme jointly sponsored by Ben Gurion University and Columbia University, did the daily evaluation and wrote up the report of the project. We were also helped extensively by Jayapaul Azariah and Aruna Sivakami of the University of Madras.
The other Israeli members are, Raya Gal RN, who taught Healthy Pregnancy and Healthy Childbirth, and Micharl Karplus MD, and Eilon Shany MD, both pediatricians, who taught Newborn Health, Nutrition, Development and Disease Prevention.
The other unique feature of our project is that the pupils are not health professionals but village women, many of whom illiterate. At the end of the two-week course we appointed thirty of these women, from twenty villages, "Health Ambassadors", with the assignment to return to their villages and spread the message of healthy behavior, not by preaching but by good example and gentle explanation.
We were greatly helped, with translation and in many other aspects of the project, by Mercy Kanakan, RN, Principal, and Srinivasan, Instructor, and many of the students of the new Delta School of Nursing, recently established with twenty Dalit village girls as students. The nursing school is now conducting monthly meetings of the Health Ambassadors and sending us regular reports. We hope that when these girls become nurses, they will carry on projects of this sort themselves, and we will only be advisors. This is also part of bioethics, carrying the principle of Autonomy outside the narrow area of clinical decision making: our job is not to preach to or to do things for people in developing areas, but only to respond to invitations to help them learn to do for themselves.
We were also greatly helped with information by Prof Chandra, a pediatrician at the Tamil-Nadu Ministry of Health.
I almost forgot to mention my own role in the teaching. I taught the unit on Bioethics, by conducting a discussion of actual events in village life, under the categories of: Do Good, Don't Do Evil, Be Fair, Respect Individual Choice, and Think about the Meaning of Life. One example of the sort of thing we discussed is: what do you do if a pregnant woman begins to bleed, has to be rushed to a hospital 25 kilometers away, there is no ambulance, and the woman and her family have no money for the taxi or motor rickshaw? Before teaching the unit I was very hesitant and uncertain about the possibility of teaching Bioethics to uneducated village people. So I intentionally scheduled a very short unit. But I found that, as in the title of a book known to Eubios readers, bioethics can really be "for and by the people". And I found the discussion no less intelligent and serious than many comparable discussions in medical and nursing schools. As among university students, there was a wide difference in views with respect to spiritual matters. Some believed in the efficacy of magic with respect to health and disease, while others were more scientifically sceptical, constantly asking: "How do you know that?" Next time I want to devote much more time to bioethics.
We hope to return in October, 2000, to give a refresher and continuing education course to our original thirty Health Ambassdors and perhaps to start a new group. Plans for the future, on a larger scale, include getting them a motor vehicle which can be used as an ambulance, improving water quality, building a modern clinic, and establishing a school for Developing Country Health where physicians, nurses and students in these disciplines from all over the world can study.
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