I’m winding down my time in Mexico City at the FAB conference and the International Association of Bioethics — my first ever on both counts. It was exciting to meet so many folks in person, especially at my first meeting of the IJFAB editorial board!
I also had the opportunity to catch up with an old friend who travelled from Morelia to spend the weekend after the conference with me. I went through a Feldenkrais Method training in Mexico with Adriana Delgado, a wonderful contemporary dancer, who at the time (12-16 years ago) was leading a dance troupe in Mexico City that integrated dancers with disabilities.
Catching up with her over the weekend was a delight in itself, and also gave me an interesting perspective on several themes of the conference. Two things we talked about stand out for me.
One was her personal experience of Mexican health reform. At the Congress, we saw no fewer than three current or former ministers of health on the main stage. Julio Frenk was part of a riveting panel with Norm Daniels and Thomas Beauchamp, speaking about Mexico’s on-going process of health system reform, with a focus on progressive realization of a human right to health (Daniels) and the role of data (bridging Beauchamp on the need for new models of research ethics) for accountability to the public, to using ethical guidance in health systems reform (Frenk’s theme). Frenk spoke of social inclusion, equal opportunity, respect for autonomy, social responsibility, and financial justice as the key ethical principles [another unofficial link to the full pdf] that guided the progress the Mexican government has made, starting with his tenure as Minister of Health, on achieving universal health care, as they claim now to have done.
My friend Adriana, as a dancer, teacher, actor, and educator working in movement, is self-employed. As such, she’s one of the 50 million Mexicans who were without health coverage in the old system. In that system, access to affordable health insurance was tied to employment in the public (ISSSTE) or private sector (IMSS—Seguro Social). Now, with the Seguro Popular, she has health insurance. The system she described sounded like you might expect of a two-tier system prioritizing financial protection from the effects of catastrophic care in one of the wealthiest of the “poor” countries: long lines, perfunctory primary care—but when you’re really sick—although only in certain and somewhat arbitrarily chose ways—access to good specialist care.
Women’s health was a very important aspect of the new health system design, according to Frenk. The system is also based in “financial justice,” which he summed up in the talk as only a good political communicator can: he said that the system shouldn’t be punishing you for being sick by charging you money at exactly that point in your life. When I put those two things together, I formed certain expectations in my mind of what that would look like for a woman enjoying this new coverage by the Seguro Popular.
I was surprised when my friend, who as a dancer and actor is also a wonderful communicator, told me with great black humour and expressive gestures about her pap smear under the new plan: how she had to go out from the hospital to buy the supplies herself, because the care under the Seguro Popular includes the pap smear, but not the supplies needed to do it.
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Charitably, I can only think that the system must have been crafted under severe financial pressure if they are sending those eligible for Seguro Popular out to buy their own pap smear supplies. Think about all the women you walked by in Mexico City (if you left the Hilton, which I think most of us did) selling “alegrías amaranto” in the street, with their children alongside them. Who would ask these women to buy their own pap smear supplies? Why would any government put anything in the way of cervical cancer prevention for women? With a 5-year mortality rate in Mexico of 4769 per 100,000, running close to breast cancer’s 5680 (numbers for Canada: 503 vs. 4924), and effective screening test at hand, the pap smear should be a priority.
The real picture is much more complex, as this article by Asa Cristina Laurell shows. (Her website has a more recent account of the smoke and mirrors of Mexico’s so-called universal health coverage here.) Pap smears always fall somewhere between the public health system and primary care. In Canada, my family physician gets a bonus if she remembers to offer a woman of our age group the option to get a pap smear and we choose to do so. In many places, it is likely a public health nurse doing a pap smear. Laurell documents how Mexico’s historical underspending in the public health sector was not addressed in the reforms that Frenk championed first as a politician and Health Minister and now academically, having moved from politics to the position of Dean of Harvard’s School of Public Health. She describes how Frenk has implausibly claimed that his reforms (of 2004) contributing to Mexico’s falling cervical cancer mortality from 2000-2005.
Asa Cristina Laurell lays out the risk to ordinary Mexican families of the “real” agenda behind so-called universal coverage: the separation of funding from delivery, and the opening of the latter to competition from public and private providers, and ultimately the weakening of the combined insurer/provider that provides care to the largest number of Mexicans, the Seguro Social.
Given the very highly publicized role of ethics committees in all this reform, we should spare no energy in evaluating claims about the ethical grounding of the system.
Another series of comments Adriana made stood out. At academic conferences, one of the things we like to do is complain that we don’t feel we are having an effect in the real world. In particular, we’ve all heard someone who is coming off their time at the WHO or with the UN, and who left in despair at whether that kind of work makes any difference.
I was struck by how many times Adriana talked about using these documents whose utility we like to doubt in her day-to-day life as a feminist in Morelia. One story involved how torn she felt about coming to Mexico City or staying in Morelia for events concerning violence against women organized for this upcoming week around Beijing +20. Another more surprising story is how she convinced her fellow organizers of a bicycling conference to invite a feminist bicycling advocate and academic to speak, by reference to international standards of gender inclusion and impact. I commented to her on why this struck me, and she said something along the lines of “¡es importante que la gente no se desanime!” — it’s important that these academics and bureaucrats I was telling her about don’t get discouraged.
¡Animemos, entonces!
