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From Four Freedoms to Four Challenges

Unfortunately, the problems of global health and poverty are almost impossible to grasp unless one has seen them for oneself.

I first saw them as a Cornell medical student working in Ecuador during the summer of 1984. I was working at the premier children’s hospital in Quito, Hospital Baja Ortiz, a concrete shell of a building left half-completed for over ten years because of an oil boom and bust cycle since the onset of construction in the seventies. We worked in Quonset Huts and an ancient structure in the shadow of the construction above.

We took care of lots of very sick kids, including children of African descent who were brought to our hospital for sickle cell crises even though we were at altitude (the thin air aggravates the condition). There was simply nowhere else to take them, and these children came in squirming in pain. There was such a scarcity of antibiotics that we prescribed based on what was available in the storeroom. The good news was that the scarcity of drugs led to minimal drug resistance. At least back then, most of the bugs were sensitive to what we dispensed.

The kids were badly undernourished. I learned that this and antecedent poverty were the cause of most if not all the disease we saw. I remember charting an infectious disease diagnosis for a patient’s infection and being gently reminded by my preceptor, a wonderful pediatrician who eventually became the country’s health minister, that malnutrition was the principal diagnosis. Yes, the child had a parasitic infection, but it was there because he was susceptible to it and exposed to foul water. My preceptor had us change the diagnosis; he was keeping score in order to argue for a change in public policy. As I recall through the haze of memory, some 70% of all admissions were profoundly malnourished, with tell-tale signs like anasarca (a widespread swelling of the skin).

It was so sad. I remember a six-year-old boy named Marcos who had a completely remediable tetralogy of Fallot, a congenital heart disease that causes poor oxygenation of blood. He would squat purple and short of breath in the hallways watching other children play. I still can see his bright and loving eyes some 24 years later, and I remember the day I went up the stairs to his ward to learn that he had died.

Perhaps medical students today could arrange passage to New York for cardiac surgery. I know they would try. But it never even occurred to me. To this day, I regret that: my failure to intercede or try to save his life. It was a failure of imagination.

In thinking about that failure, I realize that there are at least two sorts of failures of imagination that must be addressed to respond meaningfully to a world in need. The first is a failure to let this sad reality seep into one’s consciousness. This was not my problem. Down in Ecuador I did not have any problem imagining the scope of poverty or disease. It was vividly in front of me. My problem was imagining how to constructively address it, which is the second sort of imaginative leap one must take.

Most who write about global health speak of micro and macro responses to this second imaginative crisis. Whether it is building or sustaining a medical school in sub-Saharan Africa or talking about patent relief to get AIDs drugs where they are needed, these commentators work to transform idealism into practical good works.

But I want to return to the first problem of imagination, which is where most Americans get stopped. To meet these daunting challenges abroad, we must first transform attitudes at home. Only if we do both will our efforts at reform be sustainable.

The challenge of engaging Americans with global health needs is not trivial. Despite a global war on terror, American foreign policy sees the world parochially. As a people, we retain deep strains of xenophobia and isolationism. Even the issue of health care as a human right is a hard sell in a country that, despite its wealth, still does not guarantee access to care to all.

Viewing it this way, one would think that concern for human rights is foreign to the American consciousness. Perhaps this is true on the surface, but deeper down in our marrow a regard for human rights is there, and I believe it is resurfacing in today’s increasingly progressive political climate. The American concern about the global community has its modern roots in the work of Franklin and Eleanor Roosevelt. Together, they would lay the cornerstone for universal human rights; he envisioned the formation of the United Nations during World War II, and she represented the United States there as our ambassador. Later she would be the architect of the Universal Declaration of Human Rights, a fundamental charter of human decency that continues to  motivate and sustain all concerns about global health and human rights.

It all began with domestic politics and FDR’s famous speech to a joint session of Congress in January 1941. Imagine the depths of World War II. All of Europe is conquered by the Nazis. The evacuation of Allied Forces from Dunkirk took place the previous summer, and the Battle of Britain had concluded only months before. Britain stands alone to stave over Hitler’s threat. America is still neutral, although FDR has begun to articulate the lend-lease program to help Britain with material support.

It is a dire time, and the president is speaking to Congress. At this seminal moment, he gave one of his most memorable speeches. He spoke of the Four Freedoms. His words are immortal, both in their timeliness and timelessness:

In the future of days, which we seek to make secure, we look forward to a world founded upon four essential freedoms.

The first is freedom of speech and expression – everywhere in the world.

The second is freedom of every person to worship God in his own way – everywhere in the world.

The third is freedom from want – which, translated into world terms, means economic understandings, which will secure to every nation a healthy peacetime for its inhabitants – everywhere in the world.

The fourth is freedom from fear – which translated into world terms, means a worldwide reduction of armaments to such as point and in such a thorough fashion that no nation will be in a position to commit an act of physical aggression against any neighbor – anywhere in the world.

That is no vision of a distant millennium. It is a definite basis for a kind of world attainable in our own time and generation. That kind of world is the very antithesis of the so-called new order of tyranny, which the dictators seek to create with the crash of a bomb.

To that new order we oppose the great conception – the moral order.

This is a remarkable document on several grounds. Each freedom is universalized and followed by the common refrain, “everywhere in the world.” It is not enough to have freedom at home. Freedoms to be real and moral need to be enjoyed by all. Roosevelt here is articulating a universal obligation for human rights, everywhere or anywhere in the world.

Intellectual and spiritual freedoms are mixed with material relief. Here we see Roosevelt the idealistic pragmatist, synthesizing work and ideals into a moral order designed to bring relief, everywhere in the world.

And for our purposes, FDR specifically mentions freedom from want and speaks of the need for economic security and a healthy peacetime. From this we can extrapolate all of the concerns related to global health.

Finally, he urges upon us arms reduction, a global threat to health to this day and the focus of human rights activists in organizations like Physicians for Social Responsibility,which was concerned about nuclear armaments during the cold war, and Doctors without Borders, which is concerned about errant landmines and their penchant for mindless destruction of limb and being.

Roosevelt sought to remind domestic audiences of the work that remained undone, and which still remains undone. Although the work was not finished, as FDR had hoped, in his “own time and generation,” his words catalyzed the linkage between America and universal human rights.

Charles Habib Malik, the Lebanese representative to the UN and rapporteur of the Commission on Human Rights, spoke of the historic origins of the 1948 Universal Declaration of Human Rights when he introduced the document in a speech to the General Assembly. According to Harvard professor Mary Ann Glendon’s account, Malik invoked FDR’s legacy. He saw the “positive roots” of the Universal Declaration of Human Rights in the “common aspirations summed up so well in Franklin Roosevelt’s four freedoms.”

And, of course, Eleanor Roosevelt chaired the UN Commission on Human Rights and authored the Universal Declaration of Human Rights to which her husband’s speech is so closely linked. That document goes down with the Magna Carta and the Declaration of Independence as a seminal articulation of human obligations to each other.

In thirty brief aphoristic articles, the Universal Declaration articulates enduring principles of human solidarity asserting the dignity of man and the political freedoms and social structures to which we all are entitled: due process, juridical proceeding, the vote, privacy, citizenship, and asylum as well as freedom of movement, thought, belief, congregation, and assembly. Each person is also entitled to “social security”: fair wages, rest and leisure as well as “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, and the right of security in the event of unemployment, sickness, disability, widowhood, old age….”

A magnificent – and progressive – document, of international pedigree but created by two great Americans. Their regard for human rights – and the derivative issues of global poverty and health care – make these concerns ours. They are part of our nation’s finest legacy and make these concerns as American as apple pie.

To continue the tradition so nobly begun by the Roosevelts, let me respond to the Four Freedoms with Four Challenges in this 60th anniversary year of the Universal Declaration of Human Rights.

First: To use our freedom of speech and expression to give voice to the voiceless. Remind our fellow citizens of America’s great and historic legacy in human rights. Broaden their vision from the selfish to the selfless. Today and tomorrow, learn about the needs of others so we can give expression to their wants. Transcend the polemical and speak in practical terms, always with an aim to make a tangible difference in the world.

Second: To use our freedom of worship to become inspired. From whatever faith, spiritual, or secular tradition we hail, use it to motivate good deeds and tolerance of others. Build community in a way reminiscent of the global cast of characters who bequeathed to us the Universal Declaration of Human Rights. Champion a diversity of peoples and a diversity of ideas.

Third: To use our freedom from want to be generous to others who have less. Practice charity on a global scale – both here and abroad, never forgetting that poverty is no further than the soup kitchen next door. Live a bit more humbly, so that others might live. Support students and education, especially those in the health and helping professions.

Fourth: To understand the sources of our fears so that we might attend to them. This is difficult; after 9-11, we live under the spectre of fear. But I suggest that exploring our fear will bring us back to the Four Freedoms and the Universal Declaration of Human Rights, and that if we could achieve their laudable goals, the world would be a less fearful place.

Joseph J. Fins teaches medicine and medical ethics at Weill Cornell Medical College in New York City. He is the author of A Palliative Ethic of Care: Clinical Wisdom at Life’s End and a fellow of the Hastings Center. An earlier version of this paper was delivered at Health Care and Human Rights: A World in Need, a conference sponsored by The Fifth Avenue Presbyterian Church and Weill Cornell Medical College in February 2008.

Published on: February 28, 2008
Published in: Public Health

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