Daily Archives: October 9, 2013

Meet me where I’m at


A lot has been written about barriers to accessing health.  There are many journal articles and research papers on this topic, and on ideas of how to overcome them.  I’m not trying to reinvent the wheel, so this is simply an attempt to write about some of the things I have seen in the past months. While working at HIPS, doing direct services with different sub-populations in Washington DC, I’ve learned about barriers to health and simple (and complex at the same time) ideas to start addressing these barriers.

I recently went to a talk on Hepatitis C (HCV) and how it is disproportionately affecting African Americans in the United States.  According to the CDC, more than “75% of adults with Hepatitis C are baby boomers, i.e., born from 1945 through 1965” and within “the African American community, chronic liver disease, often Hepatitis C-related, is a leading cause of death among persons aged 45-64 years”.  Many of the clients that HIPS serves fit into this category.  One of the health services HIPS provides is HCV testing and counseling, and although we are reaching a lot of people, there is still a lot to do in the city.  As I was listening to the different speakers, I just kept on thinking about our clients, and how we could talk about HCV and encourage more people to access testing.  But testing for HCV is not the hardest part. It’s what happens next: whether the results are negative or positive.  How can people remain HCV negative, what can they do to reduce the health risks, how can they access treatment and accompaniment if they are positive, and how can we reach out to that percentage of the population who doesn’t even know they could have HCV?

A few days after the HCV talk, while doing night time outreach with HIPS around DC, I encountered several Latino clients, who were happy and even relieved that there was someone who could give them information and answer a bunch of questions they had about safer sex practices in Spanish.  One man, originally from Mexico, was very shy at the beginning, but after being surprised I was a native Spanish speaker, started asking me questions about different condoms, HIV testing, and risky behaviors.  He shared some concerns regarding his health, and that of his partner, so I shared some information, specifically about organizations that were closer to where they live in the city and that have Spanish-speaking staff. He told me, “Oh, I know about that clinic, but I lost my health insurance, and they won’t cover us for that.  Plus it’s really hard to go to some places, with our work schedules.”  After giving him other referrals and answering his follow-up questions, we left to keep on with our night route.  I couldn’t stop thinking about him and his wife, and how they were so frustrated, confused and fearful for several weeks, because they had not been able to get information or health services according to their needs.

These brief examples illustrate many of the barriers that people face to accessing health.  And although they seem very clear, they are complex in so many ways.  Outlining them is important, so that we can start thinking about possible alternatives to addressing them.  Some of the most important and interconnected barriers I could identify (and I’m sure there’s more I have overlooked) are the following:

  1. Limited access to education, and specifically health education and information.
  2. Limited access to prevention, treatment and post-treatment care (this includes hindered access to health insurance).
  3. Generational gaps and differences between age groups.
  4. Ethnicity and race, and the social constraints that are embedded in these.
  5. Language.
  6. Citizenship and immigration status.

And so, we could start addressing these complex barriers to accessing health by taking some simple and complicated issues into consideration.

Talking to people in their language.  By this I don’t only mean to talk to people in a language that they can understand because that’s their first or native language, I also mean talking to people using intelligible vocabulary.  If you are trying to reach out to an African American man in his late 60’s, veteran, currently using intravenous drugs . . . talk to him in his language.  If you are trying to reach out to an undocumented working Latina in her forties who thinks she is HIV positive . . . talk to her in her language. Meet them there, at this point of their life’s journey, acknowledging that they have knowledge and power. Knowing that you have the privilege to be sharing health information with them, meet them at their education level, generational understanding of well-being and health, and socioeconomic status.  Start there.

Promoting spaces for people to ask questions.  People know what they want and need. Ask them.  Listen.  Meet them there.  Provide as many safe spaces as possible for dialogue, health education and information sharing.  Design education materials and strategies taking into consideration important characteristics of the populations you are trying to reach (and ask people what characteristics are important for them in the first place).  How can we convey the important message of HCV testing within the 45 to 65-year-old generation among African Americans in DC?  Start by asking them.  We must pay attention to the social and cultural contexts of populations, so that the educational strategies are more effective and efficient.  And provide information so that people can make better informed decisions, without forgetting that people can decide whatever they want.

If I was trying to access a health service or ask questions about my health to a service provider, I would like her or him to meet me where I am at.  I would want that service provider to not patronize me, to understand that I am an empowered individual in some areas of my life, and that there are some barriers (that I might be able to point out on my own) for accessing health.  I would want that health service provider to talk to me as a person.  If you wanted to access health services, you would want to be treated in a similar way.  So let’s do that for others.  Meet clients, patients, and community members where they’re at in terms of their health, their needs and their context.  Let’s start there.

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China’s Main Internal Challenges In the Next Decade


As China’s celebration of Golden Week, the holiday commemorating the founding of the People’s Republic on October 1st, 1949, winds down and millions of Chinese return to their everyday routines, it is a time to consider the obstacles that the world’s most populous nation currently faces. China’s famed economic growth has been slowing recently and many wonder if Beijing will be able to persist and maybe eventually overtake the United States. In a recent book, Yan Xuetong, the Dean of Tsinghua University’s International Relations Department and one of China’s most prominent public intellectuals, optimistically forecasts that China will, in fact, be able to maintain its growth. Yan argues in History’s Inertia (lishi de guanxing), his new book, that China should be able to maintain its economic boom over the next decade and maintain an annual growth rate of roughly 5% after that, which will be enough to see China become a global superpower. The key to achieving this, Yan asserts, is introducing substantive reforms that will allow the country to adapt and overcome circumstances just like during the “reform and opening” that Deng Xiaoping oversaw in the 1980s. Those reforms allowed China to recover from decades of stifling central control and grow into the powerful nation it is today. Here is a rundown of some of the main issues these new reforms will have to address in the coming years. All of these topics are worthy of extensive and in-depth exploration, but a brief overview will suffice for now.

Corruption: This is probably the most serious issue because no matter what reforms Xi Jinping and co. introduce, nothing will happen if Beijing can’t enforce them adequately and uniformly, and local government officials are notoriously evasive when it comes to doing things that they don’t exactly want to. As I predicted in an earlier post, Beijing seems intent on demonstrating that it is serious about cracking down on high-profile corruption; Bo Xilai’s life sentence, which was harsher than many expected, is a strong indicator of this seriousness. Beijing’s merciless conviction of one of the nation’s most well-loved and well-pedigreed rising political stars should have sent a clear message to those who might consider graft or using their offices for personal gain. Xi has gone on the record saying that tackling corruption is his highest priority; taking down a highly visible crook is one thing, but most Chinese are more concerned about small-time official corruption than headline-grabbing national cases. The local corruption cases are the cause of most of the things that make the Chinese lose faith in their government, such as poorly constructed infrastructure projects that collapse, contamination of food due to poor industrial oversight, and a general lack of faith in the justice system. For real success over the long term that will help maintain the public’s confidence in the government, Beijing needs to keep doing more to create a pervasive anti-corruption culture in all levels of government, not just catch the big fish.

Population and labor force: China’s population is expected to peak at 1.4 billion around 2026. While a population as large as this brings its own particular problems, the biggest threat to continued Chinese growth and stability stemming from this is the dependency ratio. The dependency ratio is the number of non-workers (i.e., dependents) to workers in an economy and is a crucial indicator of growth prospects; an economy that is too weighed down by elderly and children will have difficulty accumulating savings, among other things. China is aging quickly, setting up a series of major problems later on. This is tied to the fertility rate, which has been falling for decades and is currently 1.56. China’s labor force peaked in 2011 and saw a decline of .6% in 2012. As the labor force continues to shrink, China will be hard-pressed to keep up its economic growth. Beijing has been thinking about reforming the One Child Policy for some time but has only adopted the mildest of modifications. Improvements will not happen overnight even if radical policy changes are made; indeed, with a chronic problem like this, only long-term solutions can work, so radical adjustments would not help even if the Party wanted to take that route. Since there will not be enough working-aged adults in China to comfortably support both themselves and dependents in coming years, one solution may be to allow in more immigrants, but given the already huge population, this is politically sketchy at best. There have been other consequences of China’s artificially manipulated fertility, such as gender-based selective abortions that have caused men to severely outnumber women, but arguably the labor force issue is poised to create the biggest stumbling block for the country.

Pollution: China’s pollution problem includes both air quality and contamination of other natural resources. As was mentioned in an earlier post, Beijing is planning a massive 1.7 trillion RMB initiative to combat smog. This plan will reduce PM2.5 contamination by 25% , lower Beijing coal use by 50%, cap the number of vehicles at 6 million, and force 1,200 companies to either close up or meet stricter standards by 2017. This plan, if successful, could prove to be a model for the other Chinese cities that suffer the most from smog – Beijing isn’t even the most polluted – and go a long way toward satisfying the demands of the increasingly well-off urban middle class for cleaner living. The more the government is associated with unclean air, the less legitimacy it will retain in the eyes of the public as the effects become increasingly visible. Cleaning up the air and water will be crucial both to maintain the Communist Party’s legitimacy and to keep the health of the Chinese people from being harmed any further than is already unavoidable.

Water: China has about 6% of the world’s fresh water supply and has to provide for a fifth of the entire human race with that amount. According to the Wilson Center, however, one out of every two gallons of water in China is polluted. Half of all groundwater and 2/3 of all surface water is contaminated. This is largely from industrial pollution but also from power generation: 70% of all power in China comes from coal, consumption of which will increase as much as 30% in the near future. What’s more, the processing and use of coal requires a great deal of water, which is already scarce in much of China: 80% of the nation’s coal comes from water-scarce regions. Further complicating this is the fact that most of China’s water is in the south, whereas most of its agricultural land is in the north. The government has just finished a massive undertaking to re-route water from the southern, more heavily populated regions to the relatively sparsely populated north… in order to grow the food with which to feed the population-heavy south. China, as the world’s largest grain producer, desperately needs water to grow its food but at the same time is increasing its use in power generation, which demands more water, leaving less for domestic use. At current rates, China is expected to be more or less out of water as soon as 2030. Beijing desperately needs a solution here since water is literally the sine qua non of everything else it might wish to do: without a stable water supply, no country can hope to survive. A good place to start would be to cut back on energy that requires water – the tricky part is that most methods of conventional power generation also require water, not just hydropower – and to import more grain while decreasing domestic production, but this problem has no easy solution and few hard ones.

Human rights: Yan Xuetong believes that as China’s power draws nearer to the US’s, the differences in the ideological aspects of their political institutions will weaken, which will include their views on human rights. For the time being, however, Beijing is infamous for its problematic relations with ethnic minorities, its issues with human trafficking, and its harsh crackdowns on political dissenters. In order to be viewed as legitimate in the eyes of the world, Beijing must attempt to resolve these matters favorably. Even the issues that seem simple, however, like internet restrictions, are politically difficult: as long as the Party fears that an open and free internet will undermine its power, net access will remain restricted. Some observers were hopeful that a new free trade zone in Shanghai with unrestricted internet access might herald a new liberality in this regard, but these reports were ultimately proven false for now.

Much of early Chinese political thought strongly emphasizes the aspect of morality in the leadership of a state; if a state is governed with morality, others will naturally be drawn to it and validate its authority without a need for subjugation by force. In the 7th century BCE, Guanzi wrote, “If a country is large but governed by one who is petty, the country will be governed in accordance with that man; if the country is small but governed by a great man, the benefit to the country will be great.” Without this element of morality, only military strength will be able to maintain a country’s status, which will fade as its power does. This is the difference between “humane authority” and a hegemony or tyranny. If China is to become (and remain) a superpower over the next decade, humane authority will be the only way to both overcome its current obstacles and remain stable in the future. If it tries to hold onto power merely through sheer force and fails to address its underlying critical contradictions, as other superpowers have tried to do in the past, it may end up on the ash-heap of history, after all.


Alexander Bowe has an MA in International Studies from the Korbel School and is currently a doctoral candidate in Political Science at Tsinghua University.

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