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Health as if everybody counted blog

Subscribe to feed Viewing entries tagged social determinants on health
Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 06 November 2012
in CHNET-Works!

"The fog comes," Carl Sandburg famously wrote, "on little cat feet." With roughly the same amount of fanfare, in September a consortium led by Sir Michael Marmot published a summary of its findings on how to reduce health inequities in the 53 countries of the World Health Organization's European region. The region includes some of the wealthiest countries in the world, and some of those with the smallest disparities in health, but is hardly homogeneous. Mortality among children under 5 ranges from just over 2 per 1000 live births in Iceland to more than five times that figure in Bulgaria and Romania. Child poverty on a standardized cross-national measure is higher than 30 percent in Romania, three times as high as in the Nordic countries and a few others. And urban air pollution (concentration of particulate matter) is more than five times as high in the capitals of Turkey and Bulgaria as in those of Estonia and Iceland.

The consortium's argument will be familiar to readers of earlier reports in this vein, including the original Commission on Social Determinants of Health, but several points are worth mentioning because of their direct and immediate transferability to the Canadian context.

  • who euro-review-pic-1Air pollution remains a health hazard in many European cities.
    Photo: eifelyeti110’s photostream; reproduced under a Creative Commons 2.0 licence
    The consortium writes that "[h]uman rights are central in our approach to action on the social determinants of health". The fact that this was not true of the 2008 report has been identified as a significant omission by the distinguished human rights scholar Audrey Chapman, among others.
  • Social protection – including "a minimum standard of healthy living for all" that includes a nutritious and sustainable diet – is clearly and correctly identified as essential for reducing health inequity. Further, the consortium refers approvingly to the United Nations Social Protection Floor Initiative, a relatively low profile effort that is explicitly linked to a human rights approach. Could this be the start of an overdue convergence of concerns about health equity and social policy that often have been addressed by separate organizations and groups of professionals working in isolation from one another?
  • The effects of unemployment and exposure to hazardous work environments are foregrounded, at a time when youth unemployment is higher than 50 percent in two WHO Euro countries and a source of concern throughout the region.
  • Also foregrounded is the issue of health inequities among older Euro region residents – a concern with much broader applicability as populations age and social exclusion threatens to increase, especially in countries with high levels of economic inequality, a troubling trend that was evident even before the economic crisis.
  • Most importantly, both the economic crisis and many policy responses are identified as threats to health equity. In the consortium's words: "Recognition of the health and social consequences of economic austerity packages must be a priority in further shaping of economic and fiscal policy in European countries," with health and social affairs ministries and – at the transnational level – the World Health Organization, UNICEF, and the International Labour Organization given a voice.

who euro-review-pic-2Social exclusion threatens the European elderly, especially those with limited resources.
Photo: Zilverbat.’s photostream, reproduced under a Creative Commons 2.0 licence
Think, for a moment, about what institutionalizing this last recommendation would mean in a Canadian jurisdiction like Ontario.

My previous posting featured an important new report on redesigning social assistance in Ontario. Its arrival, too, could be described with reference to little cat feet. Ontario would do well to adopt both the consortium's insights about the inseparability of social protection and health and its view that "current economic difficulties are a reason for action on social determinants of health not inaction." But where will the necessary leadership come from? However well intentioned the proponents of taxes on 'junk food,' availability restrictions and warning labels on French fries may be, it may not come from them.

Related resource of interest

Video of Sir Michael Marmot's keynote speech at the Canadian Medical Association annual meeting in August 2012, which focused on health equity, is now available online.

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Unemployment isn’t working for public health, Part 1

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 17 October 2012
in CHNET-Works!

On January 1 of this year, workers at the Electro-Motive Diesel locomotive plant in London, Ontario were locked out of their jobs after refusing to take a 50 percent pay cut. In February, the parent company (Caterpillar Inc.) closed the plant and moved production to Indiana. Now, a story in The Globe and Mail reports that just 68 of the 485 union workers who lost their jobs have found new full-time work. Marriages are crumbling; food bank use is climbing; and the plant stands vacant. (Readers may want to access both this and an earlier, equally important story – also by reporter Tavia Grant, whose coverage has been stellar – before the Globe's content moves behind a paywall.) The situation of former Electro-Motive workers is part of a larger picture of deindustrialization: citywide, one in 15 Londoners – an estimated 24,000 people - live in a household receiving Ontario Works ('welfare'). This means, by definition, an income well below Statistics Canada's Low Income Cutoff.

electro-motive-london-1The vacant plant in London, Ontario previously occupied by
Electro-Motive Diesel

Many health researchers and practitioners in Canada have been slow to grasp the health implications of economic restructuring and the changing nature of work. (The authors of the landmark Code Red study in Hamilton, the topic of an earlier posting, are a notable exception.) Elsewhere, understandings are more advanced. One of the nine knowledge networks that supported the WHO Commission on Social Determinants of Health addressed employment and working conditions; a fine summary of its findings appeared in BMJ in 2010. The International Labour Organization has for years been promoting what it calls a Decent Work Agenda. The agenda does not specifically refer to health but recognizes the importance of employment and working conditions for overall well-being, especially in the context of the post-2008 economic crisis. Until July 2012, the ILO's Global Job Crisis Observatory kept tabs on how the crisis was affecting employment, and is still a valuable source of background.

So long as governments see little alternative to the reorganization of production across national borders in search of lower labour costs and more 'flexible' employment regimes, an increasing proportion of the population – certainly in the high-income world – can anticipate a future of shrinking earnings, precarious employment, and reliance on multiple but often unpredictable income streams. This is not a fact of nature, but rather a consequence of political choices. The Commission on Social Determinants of Health correctly attributed the unequal distribution of opportunities for leading a healthy life to "a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics." Nowhere is this clearer than in the decline of employment as a central concern of public policy. It is time for all those concerned with studying and protecting population health to come clean on this point, and to demand that political leaders do the same. Where, for example, are the voices of the province's Medical Officers of Health on this issue?

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People who get it, Part 1

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 05 September 2012
in CHNET-Works!

Optimism is hard to sustain these days. Canadian policy-makers and research funders seem to be losing much of their interest in social determinants of health; health policy remains unresponsive to evidence of easily remediable inequities within our health care systems. Lack of coverage for outpatient prescription drugs is one conspicuous example, as noted in the previous posting. So it's refreshing to feature three Ontario conferences organized by people who 'get' both health equity and social determinants of health. (Full disclosure: I am on the program of the first two events.)

richard wilkinson-1Richard Wilkinson, Professor Emeritus, University of Nottingham.
Photo: Wikimedia Commons
Health Promotion Ontario is a group of health promotion professionals now celebrating its 25th anniversary. On September 27, HPO is holding a one-day conference on the theme "Building Connections between Promoting Health and the Social Determinants of Health." Speakers include Ketan Shankardass of Sir Wilfrid Laurier University; Penny Sutcliffe, the Medical Officer of Health with the Sudbury and District Health Unit; and (via Skype) Richard Wilkinson, one of the world's leading authorities on economic inequalities and health.

In my experience, students in medicine and public health are often far ahead of their profs in understanding the social patterning of disparities in health, and the graduate students at the University of Toronto's School of Public Health provide a stellar example. On September 28, their annual student-led conference will be, to my knowledge, the first meeting in Canada specifically to address the theme "Health, Austerity and Affluence". The opening keynote will be given by Armine Yalnizyan, senior economist with the Canadian Centre for Policy Alternatives, which has a long-standing research program on economic inequality. Other speakers include David McKeown, Toronto's Medical Officer of Health, whose department has a long history of foregrounding health equity issues in its work, notably in a 2008 report on income and health inequalities.

The following month, the Canadian Society for International Health hosts its annual conference in Ottawa (October 21-23). Especially noteworthy is the Sunday morning opening session, which features sociologist Saskia Sassen and economist Dean Jamison. Sassen, whose work was the topic of a previous posting, is one of the most thoughtful observers of globalization and its consequences for human well-being; she is not only an academic but also a multilingual advocate, who somehow finds time to write for publications like the wonderful Occupied Wall Street Journal. Jamison, formerly of the World Bank and now at the University of Washington, was one of the leaders of the Disease Control Priorities Project , whose 2006 book Disease Control Priorities in Developing Countries remains a valuable resource. (Unfortunately, the DCP project web site is temporarily out of service.) Even if you can't attend the entire conference, the Sunday session is well worth taking in if you are from the Ottawa area.

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“A social movement, based on evidence”? *

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Wednesday, 21 March 2012
in CHNET-Works!

Sir Michael Marmot, who chaired the Commission on Social Determinants of Health and later led a review of influences on health inequalities in England, has called for "a social movement, based on evidence, to reduce inequalities in health" (1) and even claims to identify the beginnings of such a movement. Has such a movement begun to coalesce, and what are the prospects for its success?

In a recent book on women's resistance to workplace sexual harassment in the United States, Carrie Baker defines social movements as "a mixture of informal networks and formal organizations outside of conventional politics that make clear demands for fundamental social, political, or economic change and utilize unconventional or protest tactics" (p. 4) and argues that the resistance she studied fits that definition, even though much of the action took place in courtrooms, administrative hearings, and Congressional committees. Crucially, the coalitions that formed to fight sexual harassment connected women who were not otherwise similarly situated in socioeconomic terms. Restaurant workers, middle managers in banks and federal agencies, and lawyers trying to make partner in their firms were united - sometimes temporarily and precariously – by lack of legal protection from sexual harassment by male colleagues and superiors.

social-movement-pic-1ACT UP demonstration, St. Patrick's Cathedral, New York City, December 10, 1989. Photo: Richard B. Levine

A parallel can be drawn with what is almost certainly the most successful contemporary health-related social movement, that involving treatment and prevention of HIV/AIDS. At the forefront of that movement was the AIDS Coalition to Unleash Power (ACT UP), co-founded in New York City in 1987 by playwright Larry Kramer, who was to become identified as the public face of the movement. ACT-UP quickly adopted the tactic of mounting high-profile demonstrations in places including Wall Street, the US Food and Drug Administration in Washington, DC, and St. Patrick's Cathedral (to protest against Catholic opposition to AIDS education and condom distribution). Some of ACT UP's approaches were controversial, but it "added enterprise and erudition" to confrontation, and the organization and its tactics quickly spread nationally, and even internationally.

In the early years of the epidemic, AIDS was an equal opportunity killer. This is less true today, yet the solidarity forged in the formative years of AIDS activism survives and crosses both class and national boundaries, as seen for example in the transnational support that South Africa's Treatment Action Campaign (TAC) has mobilized. That support was critical in convincing pharmaceutical companies to abandon legal efforts to prevent South Africa's government from buying lower-cost generic antiretrovirals, and TAC continues to appeal to a global audience for maintaining access to AIDS treatment.

social-movement-pic-2ACT UP demonstration, Paris, 2005. Photo: Kenji-Baptiste Oikawa, reproduced under a Creative Commons Licence.

Here's the rub.

Effective social movements are not based on evidence. Social movements can use evidence in various creative ways, but they are based on rage, hopelessness, desperation, hope, or combinations of these. That's where their energy comes from. Normally, as shown by the examples of ACT UP and resistance to sexual harassment, their protagonists share a particular vulnerability even though they may otherwise have little in common. If we go farther back in history, the movement for female suffrage and the trade union movement are useful case studies; movements to abolish slavery, in which some protagonists had no personal stake yet were willing to place themselves at considerable risk, provides a partial counterexample.

What shared passions or vulnerabilities (and effective social movements require at least one of these, and often both) will provide the basis for reducing health inequity by way of action on social determinants of health in Canada? What more needs to be known about social movements in order to create an effective one around this agenda? The answers are far from clear, which may be why the agenda is making slow progress.

social-movement-pic-3Launch of Poverty Free Ontario Campaign, Sudbury, September 2011. Photo: Cait Mitchell (used with permission).

Public health researchers and practitioners, whatever their level of commitment (which varies greatly), are at minimal risk from many of the conditions of life and work that are most destructive of health: inadequate incomes, precarious employment, hazardous exposures on the job, and the physiologically corrosive levels of stress that go along with all of those. Perhaps that is why the enterprise of health promotion still focuses far too much attention on health literacy, "choosing your sandwich with care," and similar constructs that ignore the quotidian challenges of too little money, too many demands in the workplace (including, for women in particular, the domestic workplace), and too few hours in the day. Prof. Marmot's 2004 book The Status Syndrome is eloquent on the topic of these challenges. Further, few efforts appear to have been made to make common cause and build working relationships with anti-poverty organizations or the trade union movement. (I would love to hear from readers about exceptions to this generalization, in Canada or elsewhere, for future postings.)

Gratifyingly, some health professionals now understand the importance of such alliances. For example, in a special section on advocacy in the March 2012 issue of Canadian Nurse, Joyce Douglas of the Canadian Nurses' Association writes: "Front-line nurses can speak from experience and work with organizations, associations and movements that advocate for wages that people can live on, affordable housing, healthy environments and social inclusion." As Ontario and many other provinces face hard choices about how to reduce their post-recession deficits, let's hope health professionals of all kinds understand the issues and the stakes.

* A conversation with Kumanan Rasanathan helped to clarify some of the ideas presented here, but all blame rests with me.

(1) The hyperlink is to a video interview with Prof. Marmot; the phrase is also the title of his response to a series of commentaries on his two reports that appeared in Social Science & Medicine.

Life A.D. (After Drummond), Part 1

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Monday, 20 February 2012
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As Ontario-based readers will know, on February 15 the Government of Ontario released a far-reaching report on reorganizing public service provision in an era of austerity. The report was the work of a small commission chaired by Don Drummond, a former public servant in the federal Department of Finance and subsequently chief economist for TD Bank. The other commission members were the President of Laurentian University (base salary $304,647 in 2010); the Vice-President for Communications and Community Engagement of the Centre for Addictions and Mental Health (base salary $245,352 in 2010); and the dean of the business school at the University of Western Ontario (base salary $405,000 in 2010). These figures are matters of public record, as they should be, and are available under the Province of Ontario's salary disclosure legislation. The point is that all members of the commission were, to put it mildly, isolated from many of the influences that limit other Ontarians' ability to lead healthy lives.

The report proposed that public spending on health care – the largest item in Ontario's budget, as in that of other provinces – should grow by 2.5 percent annually over the next several years, as compared with the recent trend of 6 percent annual growth. Slower growth was recommended for public education; just 0.5 percent for "social programs"; and spending reductions of 2.4 percent annually in all other programs. However, the 'how to' rather than the 'how much' aspects of the report's recommendations may ultimately be most significant, if implemented.

The report has already generated a flood of commentary, to which I don't propose to add right now. I'll be posting a longer analysis after my presentation at Public Health Ontario's PHO Rounds on March 2, the last part of which will deal briefly with life A.D. (After Drummond). Meanwhile, the Wellesley Institute has commented on the report's neglect of broader social determinants of health that affect the prevalence of and prognosis for conditions like diabetes (the topic of one of my earlier postings). And the Toronto Star's Thomas Walkom pointed out the bias introduced by the government's instructions to the commission not to consider tax increases, at a time when the fiscal capacity of Canadian governments has been drastically reduced, while allowing it to consider user fees that will have a disproportionate impact on low- and middle-income households.

Walkom also pointed out the lack of attention to the employment impacts of a plan to take billions of dollars out of the Ontario economy by way of public spending cuts – indicative of a broader trend in which employment has all but vanished from the public policy agenda except when governments want to trot out the 'job creation' benefits of handouts to one or another corporate client. He predicts that implementation of the Drummond recommendation would lead to an Ontario unemployment rate of 11 percent by 2018, "even without another global crisis". Abundant evidence shows that not only unemployment rates but also the conditions of employment – full-time and secure versus precarious, casualized or entirely informal – and their effects on working conditions are key social determinants of health, so this is a point of some importance. (An aside to readers: would a future posting expanding on this evidence be of any interest?)

As pointed out by (among others) economist Erin Weir of the United Steelworkers, there is quite a bit in the report that those of us committed to social justice can support. There is also quite a bit that might be compatible with a "health in all policies" agenda, and with advancing health equity. Where will the public health community be as debates about the report continue in the coming weeks? How prominently, if at all, will population health and health equity figure in the discussions? Does the public health community, however defined, have an organizational platform capable of rapid, critical and effective response to events in the broader public policy environment? If not, it's high time we did.

Introduction

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
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on Tuesday, 25 October 2011
in CHNET-Works!

NewsPHIRN announces a new blog on research and practice related to reducing health inequity.  Written by PHIRN affiliate Ted Schrecker and a variety of invited guest bloggers, Health as if everybody counted will introduce readers to developments around the world that are relevant to Ontario, with a focus on social determinants on health.  The purpose is not only to inform, but also to stimulate online discussion about ways to introduce and advance health equity in all aspects of public policy and public health practice.

The road to (and from) Rio

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 25 October 2011
in CHNET-Works!

Some background

The title of this blog is inspired by former police reporter Michael Connelly's novels about homicide detective Hieronymus (Harry) Bosch. Raised in foster homes and orphanages after his mother was murdered when he was 12, Bosch is a relentless loner with a strong egalitarian streak, reacting to a Los Angeles Police Department bureaucracy that devotes far more attention to some deaths than to others with the axiom that "everybody counts or nobody counts." "Everyone counts" was also the theme of the United Nations Population Fund's World Population Day 2010, which emphasized the way in which a variety of social arrangements devalue the lives of women and girls.

Everywhere in the world, achieving health equity requires equality of opportunities to lead a healthy life. We must never forget that the lifetime risk of dying in pregnancy or childbirth for women in Canada is one in 5,600 while in sub-Saharan Africa, the world's poorest region, it is one in 31. Closer to home, in 2010 more than 400,000 Ontarians a month were turning to food banks, and in mid-2011 more than 150,000 Ontarians were on waiting lists for affordable housing. Housing and nutrition are among the most basic social determinants of health, and we are far from providing such equality of opportunity. For the moment, not everybody counts. Like the fictional Detective Bosch, those of us working in health equity are trying to change that. The purpose of this blog is to provide resources for bringing about that change, and a forum for discussing cutting-edge research and best practices.

The road to (and from) Rio

Forte de Copacabana On a global scale, that kind of change was a central theme of the World Conference on Social Determinants of Health, hosted by the Government of Brazil and held October 19-21 at the picturesque Forte de Copacabana  in Rio de Janeiro. The conference was a milestone in a process that began in 2005 when the previous director-general of the World Health Organization appointed a Commission on Social Determinants of Health, chaired by Sir Michael Marmot. The Commission's report, released in August 2008, began with the observation that "social injustice is killing people on a grand scale" – not the kind of language we are used to encountering in UN system documents. Some of the activities that followed the release of the report will be the subject of later postings. The Rio conference represented a specific response by WHO to a 2009 resolution (WHA62.14) of the World Health Assembly, WHO's governing body, calling for action on the Commission's report.

Roughly 1000 members of national delegations, experts identified by WHO, and civil society representatives converged on Rio for the conference. Key background documents can be downloaded from the WHO web site, and a valuable blow-by-blow description of the conference events was provided by Jim Chauvin of the Canadian Public Health Association, who is also president-elect of the World Federation of Public Health Associations. WHO's current director, Margaret Chan, opened the first day (really half a day) with a powerful speech that began: "Lives hang in the balance, many millions of them. These are lives cut short, much too early, because the right policies were not in place." She was followed by a panel of UN agency officials and government representatives including Kathleen Sebelius, US Secretary of Health and Human Services. Perplexingly, Ms Sibelius lauded the US for its steps to expand health care coverage, making no mention of the fact that countries like Canada come far closer to providing universal coverage (at lower cost) than the 90 percent she said the United States would be glad to achieve.

parallel sessionThe second day consisted of morning and afternoon parallel sessions corresponding to five action areas identified in a discussion paper prepared by the WHO secretariat in Geneva in advance of the conference. Although these sessions were webcast live, unfortunately at the time of writing they do not appear to be available for viewing or downloading after the fact. The third day (again, really a half-day) was dominated by a panel that featured powerful presentations by Finland's new Minister of Health and Social Services, Maria Guzenina-Richardson, and Zimbabwean pediatrician David Sanders, a long-time primary health care activist described as the "star of the day" in The Guardian.

What are such conferences good for?

drafting sessionUnlike the scientific conferences with which many of us are more familiar but in keeping with the standard for diplomatic events, most of the Rio meeting was tightly scripted. (The "annotated session plan" of the parallel session for which I was a rapporteur ran to five single-spaced pages.) The only concrete output from the conference was the aspirational Rio Political Declaration on Social Determinants of Health, endorsed by all WHO member states participating in the conference. As usual with such documents, drafting the declaration began months in advance, with a first draft circulated to WHO member states in August and subsequent drafting sessions in Geneva starting in September. The details were finalized during a day-long drafting session in Rio, operating in parallel with the conference but open only to the representatives of national delegations.

The Declaration was developed using a unanimity rule, meaning there is nothing in it to which any government involved strongly objected. It is nevertheless surprisingly strong in several ways. For example it recognizes the potential of the current economic crisis to undermine health, and governments "pledge to adopt coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health" (reference to such rights-based approaches has long been anathema to the United States), including such measures as social protection floors. On the other hand, it contains neither new commitments of resources nor any formal mechanisms for monitoring and accountability. Other omissions were highlighted by civil society participants in the conference, and by Dr. Sanders in his remarks on the last day. For example, the Declaration includes no mention of trade and health; no reference to the ongoing problem of 'brain drain' of health professionals from low- and middle-income countries; and the conference as a whole paid little attention to capital flight, which drains capital from low- and middle-income countries in amounts far larger than the annual value of development assistance. The lack of specifics would seem to underscore the concern expressed by Sir Michael Marmot and colleagues, in a commentary published at the start of the conference, that "social determinants of health have barely penetrated the global agenda ... and the default position of people in the health sector is to focus on health services and prevention of specific diseases."

What does it mean for Canada?

The Declaration is not a treaty; it does not bind WHO member states. Of course, the treaty status of an international agreement is no guarantee of effective implementation, as we know from the history of Canada's commitments under the UN Framework Convention on Climate Change. A useful comparison can be drawn between the 2011 declaration and the similarly aspirational 1978 Alma Ata commitment to achieve Health for All in the year 2000. In the event, the Alma Ata vision was thwarted by several elements of the political environment, notably resistance from the multilateral financial institutions that were emerging as key players in development policy for health. "The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again," wrote Prof. Marmot and colleagues. Despite the lack of specifics, the Rio declaration provides an unequivocal affirmation that an agenda of reducing health disparities by way of social and economic policy and the design of policy-making institutions is both scientifically sound and ethically imperative. Unfortunately, these points remain contested in the quotidian work experience of many of us, and no international agreement can substitute for the myriad initiatives at local, provincial and national levels that will be needed to advance the science and politics of social determinants of health. Sarah Bosely concluded her Guardian coverage, one of the few English-language media mentions of the conference, by saying that "this is one genie that looks unlikely to go back in the bottle". In the Rio declaration, those of us working in the field as researchers, practitioners and advocates have a valuable resource for keeping the genie out and active. More about this in subsequent postings.

 

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