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Royal Institute for Inter-Faith Studies

Copyright © 2003 Bulletin of the Royal Institute for Inter-Faith Studies. All rights reserved.

Ogoh Alubo
REVISITING AN UNRESOLVED ISSUE: DISCOURSE ON
HEALTH EQUITY AND SOCIAL JUSTICE IN NIGERIA

Propelled by the high premium Nigerians place on health, Nigeria's various post-colonial governments have identified it as a priority and sought to fund it adequately. To ensure access, the right to health has been deemed inalienable by the various military regimes and in the current democratic dispensation. However, access to health care services remains unequal between regions, classes and gender categories, as well as being inversely related to need. The situation is further compounded by the rapid, but systemic, atrophy of the public health care system, which once provided free medical care, but is now hostage to the doctrine of 'self-financing,' namely, the Bamako Initiative and other euphemisms for IMF/World Bank-inspired health sector reforms. These policies have further exacerbated health inequality, leading to more exclusion in a context of rising need, especially during epidemics, including HIV/AIDS. Alongside services-for-fees for the general public is the continued regimen of special care, at public expense, for top politicians, the military and civil servants in exclusive local and overseas facilities. Nonetheless, the debate on health in Nigeria seems to have shifted from issues of access and exclusion to considerations of health as an investment and the adjustments needed to bring this about. Yet, the question of access has become still more urgent, with regular, but strident, appeals being made to the public for donations to enable sick men, women and, often, children to undergo some lifesaving procedure or obtain care that is priced out of reach. As the economic doctrine of user fees and self-financing takes hold in a context where there are only informal safety nets for the majority, human suffering is ignored both by the bureaucracy and the polity. If Nigeria's health debate revisits concerns about health equity and social justice, this may force the problem of exclusion back onto the agenda. The restoration of civil rule, since May 1999, offers this opportunity.

Mary Crewe
HIV/AIDS: THE DE-HUMANIZATION OF (SOUTH) AFRICA

HIV/AIDS has influenced how 'Africa' is being repositioned within the world order and among populations 'dehumanized' by Western countries, UN agencies and African government responses. HIV/AIDS in South Africa is forcing a reconceptualization of 'health' and social justice and affecting the relationship between state and civil society. The right to health care is being compromised by the national response, not merely for people living with HIV/AIDS, who lack access to treatment and care, but for the rest of the population, whose health needs are contrasted to and compete with HIV/AIDS. The health of society and the body politic is being affected and compromised in complex, contradictory ways. Before the 1990s, South Africa represented the extreme case of racist discrimination. In the post-apartheid era, reconciliation—a new transformed social and political formation—became the focus, as the government attempted to manage a variety of social contradictions, including modern/traditional, black/white and privilege/deprivation, as well as overseeing the redistribution of wealth and the extension of services to the population. Is the concept of 'social justice' useful in understanding and explaining this process? How may we assess the de-humanizing of South Africans through HIV/AIDS, poverty, inequality and worsening living conditions? This paper argues that a reconceptualization of the fundamental premise of social justice is needed, one that seeks to create political and intellectual space to criticize the government and find a morally defensible place to stand on issues such as social justice, human rights and HIV/AIDS, in order to transform South Africa.

Andrey K. Demin 
SOCIAL ASPECTS OF PUBLIC HEALTH CHALLENGES IN
A PERIOD OF GLOBALIZATION: THE CASE OF RUSSIA

Since 1991, Russia has opened itself up to the process of globalization and to rapid socio-economic change in almost every sphere, including public health. This paper analyzes the search for a model of social development in Russia and its impact from the perspectives of political and social science, including changes in political realities and social theories. In 1991, when Russia began its engagement with the West, it was at the peak of a political, economic and social crisis that included public health issues; since that time, it has been an object rather than a subject of globalization, particularly owing to its choice of the neo-modernization model. The paper begins with an historical survey of the peculiarities of public health theory and practice in Russia, showing that, after the late 1920s, the regime imposed radical changes on the system complemented by the suppression of public health research and the restriction of access to health data, which was only declassified in 1993. Since 1991, attention has been focused upon the economic model for health care provision without adequate consideration being given to the impact of globalization upon public health. Russia's public health challenges include depopulation, mortality, natality, migration and morbidity, as well as TB and HIV/AIDS, all of which are related to globalization and the positive and negative political, economic and social changes it has involved. Emphasis is given to the vicious circle of poverty, disease and premature death, as well as the decline in state safety nets. Attention is also given to the penetration of Russia by transnational corporations marketing such products as tobacco, alcohol and 'junk food' using the window of opportunity provided by the globalization process. In considering these problems, this paper looks at the role of major political actors in public health issues and particularly the state's reaction to depopulation, recognized as Russia's most important public health challenge by the country's officials in 2000. The paper concludes with recommendations for the development of a global public health policy and global governance.

Maurice Eisenbruch
KHMER ROUGE AND TRADITIONAL HEALERS AS MEDICAL ANTHROPOLOGISTS?: RETOOLING HEALTH
AND SOCIAL JUSTICE IN CAMBODIA 

The aim of this paper is to examine how a society such as Cambodia's, which has undergone massive trauma, might heal and, in particular, whether traditional healers can help with the healing. The paper draws upon a participant observation of more than 1,100 healers carried out over 12 years in order to reveal how various forms of traditional healing instil illness and suffering with meaning and how the Khmer Rouge manipulated and reconstructed local explanatory models of illness to reflect their fundamentalist ideology. It describes the fate of traditional healers under Pol Pot and examines the cultural meanings assigned to mental illness, sexually transmitted diseases (including AIDS) and malaria by both traditional healers and Khmer Rouge cadres. As Pol Pot showed, the dismantling of systems that provide social justice is most effectively done by those who know the culture. This paper asks whether the retooling of social justice might also be most effectively handled by the traditional harbingers of cultural meaning, namely, the healers. The challenge posed by the 'outbreak of peace' matches the one that accompanied war. In Cambodia, it encompasses alarming new incarnations of trauma as AIDS sweeps the country, parents traffic daughters, children shoot parents, lovers hurl acid and youths descend into Ecstasy.

Rune Flikke 
PUBLIC HEALTH AND THE DEVELOPMENT OF RACIAL
SEGREGATION IN SOUTH AFRICA

This article analyzes colonial medical practices as secular theodicies that helped shape social injustice in South Africa and suggests that European delineations of disease were integral to the country's colonization. It starts by demarcating conceptions of Africa as the 'diseased continent,' arguing that this trope was informed by a dominant medical paradigm that localized threats to European health in Africa's climate and topography. In the second section, I argue that the birth of bacteriology in the 1880s created new public health concerns that situated disease in extra-corporal spaces. In the race-conscious colonies, these public health spaces were inserted between European and African social bodies, presenting African pathology as a dominant threat to public health. In the final section, I argue that medical discourse in the interwar era increasingly focused upon African culture as the source of disease and enveloped Africans in medical discourses on the peculiarities of the African mind. The European medical cartography of Africa and Africans thus emerges as a strategy of distinction, which provided a precedent for racial segregation.

Eugene B. Gallagher and Kristi S. Yingling
MEDICALIZATION IN ARAB SOCIETY AND BEYOND

Medicalization is a powerful social, cultural, economic and clinical force that has been studied in many contexts around the world. This paper focuses upon medicalization in Arab/Middle Eastern culture, looking specifically at the increased application of biomedical thinking and medical care within Arab nations. Two examples of medicalization are discussed. The first is consanguineous marriage, which is widely practiced in Arab societies. It serves to illustrate how marriage systems and reproductive choices can change when information concerning the risk of birth defects is introduced. The second example is infantile diarrhoea, a major cause of infant mortality in developing countries. It shows that popular methods of healing may be called into question with the introduction of newer medical knowledge and progressive standards of medical practice. These two examples indicate how medicalization can change personal identities and call into question traditional values concerning marriage, reproduction and healing. Also discussed are modernization and the concept of health care as a vehicle for social justice. The WHO's 1978 'Health for All' initiative is also explored in the context of health disparities and health as a human right. 

Paula Gutlove and Gordon Thompson
HEALTH, HUMAN SECURITY AND SOCIAL JUSTICE

Growing interdependence among the nations and peoples of the world demands new ways of thinking about how we can work together to pursue common interests and deal with shared concerns. Moreover, there is growing agreement that the question of security ought not be framed solely in terms of the interests of states or of powerful non-state actors like corporations. These imperatives have found expression in the concept of human security, which is an organizing principle that places the welfare of people at the core of programs and policies. Health can be a unifying dimension for human security because it provides a context within which to build an array of partnerships across disciplines, sectors and agencies. Thus, health provides a unique opportunity for deeper understanding and the implementation of human security. A people-centred approach is also a fundamental component of public health policies. It is time to reassess the role of public health in building a safer, more secure world. Health-related programs can provide an important neutral platform because health is universally valued. Field experience in integrating conflict management with health care is of particular interest in the context of health, human security and social justice. Experience in the Balkans and in the North Caucasus demonstrates that, in situations of conflict, shared health concerns can create neutral fora for discussion and collaboration. Furthermore, health issues can provide a useful platform from which to address fundamental obstacles to peace, such as discrimination, polarization and the manipulation of information. Health-care delivery programs that feature cooperation between health professionals from different sides of a conflict can be a model for collaborative action and can create the sustainable community infrastructure that is essential for social justice and human security. This paper begins with a general discussion of human security. Next, it focuses upon the role of health and social justice as major, mutually-reinforcing pillars of human security. The potential benefits of pursuing health and social justice within a human security framework are illustrated by references to two practical endeavours. Finally, the paper outlines a strategy for capturing such benefits on a global scale.

Zaid Hamzah
HEALTH CARE IN JORDAN

Generally speaking, health care in Jordan is of a high standard, with a strong infrastructure, a good number of qualified physicians and surgeons, modern and well-equipped hospitals, a thriving pharmaceutical industry and relatively wide health insurance coverage. However, much remains to be done if the country is to have a quality, comprehensive health care system. The most serious problem concerns the lack of coordination between different health care agencies and institutions, particularly after the activities of the Higher Health Council, which plans, supervises and implements health policy in Jordan, were frozen in 1989. This council has been reconvened recently and it remains to seen if it will regain its former influence. Another vital issue concerns the large sums spent on health in both the public and private sectors, despite Jordan's limited financial resources. In order to maximize the benefits of this expenditure, priorities need to be set to eliminate waste and curb rising costs. In addition, medical and paramedical education must be reviewed quantitatively and qualitatively to advance public health objectives. Training should not be confined to what is still erroneously called the 'teaching hospital,' but should be extended to other hospital and health centres, especially those in the villages. Medical insurance in the private sector remains limited and hundreds of thousands of workers and their families are without coverage. Most of them seek treatment in the facilities of the Ministry of Health and thus compete with more eligible people (namely, the insured). Associations made up of physicians, dentists and pharmacists operate according to outdated laws devised forty years ago. A particular problem is the fact that membership in these associations is obligatory. Not only does this contravene the principles of democracy and human rights, it weakens the associations and detracts from their professionalism and independence. Moreover, compulsory full-time employment in public sector institutions has inevitably resulted in a brain drain. The system must be modified to maintain the level of expertise and the flow of knowledge from one (experienced) generation to the next. This will also have a positive influence on research and development and gradually reduce the artificial division between different institutions, paving the way for more cooperation and better health services. A master plan is urgently needed that integrates all of the capabilities and facilities of the private sector with those of the public sector.

Thomas Leonard Holdstock
PSYCHOLOGY FAILS TO PROMOTE GLOBAL PUBLIC HEALTH

This paper considers the implications of the assumptions and the practices underlying the discipline and the profession of psychology for global public health. Three issues are considered. The first relates to the individualized concept of the person that forms the foundation for psychology and related mental health disciplines. It is argued that the model of the self as an independent entity does not provide an appropriate basis for mental health services to all people and cultures. The second and third issues deal with the related questions of the power in, and ethnocentrism of, psychology. The blind trust in the universality of Western psychology has been accompanied by the negation and suppression of the principles and practices guiding the behaviour of the indigenous populations of the majority (non-Western) world. In its aspiration to become a truly international discipline, it is necessary that psychology become aware of the ethnocentrism underlying the discipline, of its double-bind communication and of the extent to which it perpetuates the power of the market forces that inspired and maintain the culture of individualism. Furthermore, due to the double-bind nature of the communication implicit in each of the three highlighted aspects of psychology, the discipline runs the risk of causing damage iatrogenically.

Michael Humphrey
HEALING AND JUSTICE AFTER ATROCITY: CHALLENGING IMPUNITY

This paper explores the problem of the moral recognition of human suffering after mass violence. In post-conflict societies, truth commissions and trials have been used to address the legacy of violence and to form the basis for national reconstruction through truth-seeking, justice and reconciliation. However, in those countries that held trials and truth commissions more than 15 years ago, these rituals of political transition have not closed the door upon past atrocities. In South America and elsewhere, movements for the 'disappeared' continue to motivate human rights movements and individual victims to know the truth—even if justice itself must be suspended—producing transnational human rights alliances and prosecutions designed to challenge the impunity of perpetrators. This paper looks at the way in which truth commissions and trials have shaped post-transition politics of identity and national reconciliation by drawing upon material from Uruguay, Argentina, Bosnia, Rwanda and South Africa. It further considers the social and political consequences of the official framing of conflict through human rights hearings and legal cases—for example, in the International Criminal Tribunal for the Former Yugoslavia (ICTY) construction of the Bosnian wars as an ethnic conflict—for broader movements for justice. Of particular interest is the role of the legal and healing professions, which seek to translate individual suffering as a legacy of violence into claims of the right to challenge impunity. The paper argues that these ongoing movements for the moral recovery of victims are essential for anchoring justice and reconciliation in a more reflective public morality about the past and the present. Moreover, they point to fundamental cultural processes at the core of law-making: the role of the suffering victim as a primary source for institutionalization.

Craig R. Janes
MARKET FETISHISM & ATTENUATED PRIMARY CARE: 
PRODUCING POOR MEDICINE FOR POOR PEOPLE 
IN POST-SOCIALIST MONGOLIA

Beginning in 1990, Mongolia, a former client state of what was then the Soviet Union, undertook sweeping free market reforms under terms prescribed by Western development institutions. Principal among these were reforms to Mongolia's Soviet-style health system. This paper reports the results of a research project designed to explore the consequences of these health sector reforms from the perspective of Mongolians living in urban and rural communities. Drawing upon interviews with householders, observations, medical records and illness histories (as reported by patients), I argue that the effective implementation of health reform has been compromised by the development of a private, primary care model in which physicians are largely unable to provide appropriate treatment for even the most common of ailments. Because of flaws in the national health insurance system and the uncritical development of a private sector of health care, poor Mongolians have limited access to secondary and tertiary care. I conclude by arguing that the valorization of market mechanisms by international development institutions and NGOs results in a conflation of distributional efficiency with medical and public health efficacy. This has resulted in a system of attenuated primary health care for the poor and vulnerable. Even when modified by government concerns for justice and equity, the global/ Western push for privatization in Mongolia has primarily done what it has done elsewhere: produced poor medicine for poor people.

A. K. Jeyanithe and Kalinga Tudor Silva
INJURY, ILL-HEALTH, COLLECTIVE SUFFERING AND ETHNICITY AMONG DISPLACED WAR VICTIMS IN SRI LANKA

Using ethnographic research among people displaced by the armed conflict in Sri Lanka and extending lines of argument developed by Veena Das in her work on victims of the Bhopal Disaster, this paper examines the interplay between the health problems of the displaced and notions of collective suffering and ethnicity among Sinhala, Tamil and Muslim refugees in selected camps and settlements in Sri Lanka. The war, the resulting displacement and the humanitarian response to both of these have served to promote ethnic segregation and minimize natural and harmonious social interaction across the ethnic divide. Most importantly, ethnicity has shaped identity, as well as notions of collective suffering, feelings of injustice and vulnerabilities among the affected populations. In the context of armed struggle, members of each ethnic group use their own group as a coping mechanism and see some portion of the rival group as the primary cause of injustice in the social system, as well as the cause of their own suffering. Such interpretations of their own reality foster violence and aggression against ethnic rivals and motivate those who are most desperate and traumatized to become suicide bombers or attackers fighting for their own ethnic group or national liberation. In the light of this analysis, there may be some justification for Benedict Anderson's view that ethnicity and nationalism have come to replace religious meanings and value systems. However, ethnicity and nationalism become powerful imaginary and political forces among ethnic groups not merely because of the media—even the electronic media linking diasporic groups?but because they provide a framework for the meaningful interpretation of daily encounters with ill-health, injustice and collective suffering. 

Joop de Jong 
PSYCHOSOCIAL AND MENTAL HEALTH PRINCIPLES FOR USE IN TIMES OF ARMED CONFLICT AND NATURAL DISASTER

Disasters like wars, earthquakes, floods, cyclones, landslides, technological accidents and urban fires occur in all parts of the world. Armed conflicts alone have produced about 12 million refugees and 25 million internally displaced people. Many of these refugees, internally displaced people and other victims of conflict have suffered, and continue to suffer, the effects of traumatic stress. The ratio of disaster victims in developing countries to disaster victims in developed countries is 166:1. The ratio of morbidity and mortality following disasters in developing countries to developed countries is 10:1. Psychological problems tend to affect some 30-40% of the disaster population within the first year. According to the World Bank and the WHO, almost half of the estimated total burden of disease worldwide can be attributed to mental and behavioural problems. This paper focuses upon three aspects of providing mental health and psychosocial care in (post-)conflict emergency situations, as well as during the subsequent phases of rehabilitation and reconstruction. First, it explains why it is important to go beyond a dyadic helper-patient relation in contexts in which few mental health professionals are available. Next, it considers the selection of priorities for intervention and training in situations of massive traumatic stress. Finally, it presents a preventative and curative intervention model that can be used in an eclectic way in post-conflict or disaster situations and that can be tailored to specific local socio-cultural contexts.

Bruce Kapferer
INJUSTICE, SUFFERING AND THE STATE: SORCERY AND
RENEWAL IN CONTEMPORARY SRI LANKA

This paper addresses sorcery practices in Sri Lanka. These are practices that are directed toward the relief of everyday traumas of a personal nature, as well as those related to the state of violence that has developed in conditions of enduring ethnic war. Sorcery practices have much to do with the crisis of the state and embed a state ethos, although one at considerable variance from that described by Foucault for Europe. One aspect of the paper, however, traces through sorcery the interconnections between health, suffering and the nature of the state.

Jihad Makhoul
A STRUCTURAL PERSPECTIVE ON POVERTY AND HEALTH 
INEQUALITIES IN LEBANON

This paper attempts to identify some of the many aspects of poverty in Lebanon and the structural conditions that underlie them. It presents relevant findings from two ethnographic research projects led by the author in rural and urban areas of the country. Data collected using qualitative methods, such as interviews and observations of groups and individuals, has been subjected to thematic analysis, which reveals the presence of two major poverty-related themes in both of the communities studied: economic hardship and the inadequate marketing of local agricultural produce; and poor access to the health services and education available to more affluent sectors of the population. The paper indicates that the root causes of poverty and its manifestations in Lebanon are structural in nature and are the consequences of an interplay of factors at many levels. At the national level, the lack of a development policy and of appropriate regulation of foreign labour, in addition to regional political and economic conditions have exacerbated social inequality in Lebanon's low-income and war-affected areas. 

Hans Egil Offerdal 
RESTORING HUMAN DIGNITY IN A SICK WORLD: SOME SELECTED INTERFAITH PERSPECTIVES ON SOCIAL JUSTICE AND HEALTH

This paper attempts to demonstrate that the absence and denial of human dignity is the most threatening and highly underestimated disease faced by the contemporary world. Departing from the WHO's definition of health as "a state of complete physical, mental and social well-being," it argues that the poor mental health of the citizens of the developed world leads to the dehumanization of the majority of humanity—that is, social injustice. Seeking to develop and strengthen the idea of 'the right to be human" in a polemic contrast to human rights, the author argues that one of the fundamental lessons of religious reflection is the protection of human dignity and that religion is the only sound justification for that defense. It follows from this perspective that depriving people of their 'right to be human' is a dehumanizing act according to both religious and humanist understanding. Using sacred texts and traditions, the paper makes a selective, interdisciplinary comparison of Islamic and Christian understandings of 'the right to be human,' as well as social justice, in an effort to arrive at a framework for an interreligious diagnosis of the state of the world that may lead to the restoration of human dignity in a global society suffering the consequences of inhuman actions.

Camilo Perez Bustillo 
THE RIGHT TO HAVE RIGHTS: INTERNATIONAL POVERTY LAW AS 
A NEW PARADIGM IN THE STRUGGLE FOR GLOBAL JUSTICE

This paper argues that contemporary international human rights have traditionally been marked by a conceptual and structural imbalance between the relative recognition and enforceability of civil and political rights, on the one hand, and economic, social and cultural rights, on the other. This disequilibrium is inherently unstable and unsustainable, producing a 'poverty of rights' amid the unprecedented globalization of concentrated wealth and generalized misery, and is historically grounded in the dialectics of the origin of international human rights law in the intertwined processes of the European conquest of the Americas? colonialism, imperialism and slavery—and their epistemological implications. The relationship between issues of health and social justice are addressed within this context and explored in terms of its importance for the duality between neglected rights and neglected peoples, with emphasis on the case of indigenous peoples in Latin America. The paper further argues that there is an emerging paradigm of 'international poverty law,' rooted in the demands of 80% of the world's population for the satisfaction of their basic human needs and reflected in efforts to secure recognition for a 'new international economic order,' the 'right to development' and, more recently, the construction of a new 'global moral economy,' as set forth in critiques of the devastations of 'neo-liberal' globalization.

Willem van de Put
HEALTH AND SOCIAL JUSTICE: SOME NOTES ON COMPLEX 
CRISES, HEALTH AND SOCIAL JUSTICE

There is an international crisis in health, with killer diseases striking largely at the people who live in disadvantageous economic circumstances. Infectious disease is often socially produced and social inequalities contribute not only to disease emergence, but also to the course of disease in those affected. Complex crises and chronic warfare creates vicious cycles of poverty, ill health, depression and more conflict. This paper explores the relationships between elements of complex crises and poor health and proposes some concepts that may help to make sense of attempts to improve the health situation of some people. An important point of departure is the 'capability approach,' in which the capacity of the poor to improve their condition is a central element in assessing crisis situations. The paper argues that health interventions in the midst of complex crises work toward breaking cycles of both poverty and conflict in various ways. Health, as a universal value and a condition for rehabilitation, is both a means and an end in itself. The organization of health care implies rehabilitation of the social fabric and, hence, building the trust necessary to restore basic social functions. Examples are given of health interventions that have led to effects beyond the scope of health care systems alone. 

Jack Saul
PROMOTING COMMUNITY RECOVERY IN LOWER
MANHATTAN AFTER SEPTEMBER 11, 2001

The field of International Psychosocial Response to disaster and massive violence has much to contribute to an understanding of the social impact of the September 11 terrorist attacks and subsequent events in New York City. The author presents lessons learned from his experience in Kosovo and other international contexts that have been applied to promoting collective recovery in the his own Ground Zero community in lower Manhattan. Programs that promote healing in trauma-affected communities may contain a number of themes. First, they bring people together to promote positive connections as a foundation for social support, education and access to existing resources. Second, these programs can provide opportunities for people to organize their experience and emotions and tell their stories in ways that can be affirmed by the community. Third, they can facilitate conversations, which shift the focus away from stressful experiences and haunting memories to the affirmation of strengths, problem- solving and positive visions of the future. And, fourth, people can come together to reassert their connection to nature, spirit, the seasons, holidays and other events, which are life-affirming and growth-promoting. One of the challenges faced has been the shifting of the dominant discourse of institutions and funders away from one that focuses primarily upon a medicalized view of psychological trauma to one that recognizes and enhances the inherent strengths and resilience of individuals, families, communities and cultures to recover from such events.

Charles Surjadi 
EXCLUDING MIGRANTS FROM BASIC HEALTH AND 
SOCIAL SERVICES: A DILEMMA FOR PUBLIC 
HEALTH OFFICIALS IN JAKARTA

Since 1972, the government of the city of Jakarta has issued urban identity cards to people from outside of the city who hold a permanent job or are enrolled in a school or university there. Every year, after the Idulfitri and New Year celebrations, certain areas of the city are subject to a door-to-door search and illegal residents—who are generally in Jakarta to look for jobs—are sent back to their places of origin. However, many of the people residing in the slums or in homes constructed in prohibited areas, such as along the railway, the river, or flood plains, are seasonal migrants, some of whom remain in Jakarta for many years, while continuing to have close relations with their home towns. Out of 263 kelurahan (the smallest administrative units in the city), 30 or more than 10% of them have prohibited areas with populations of more than one million residents. Due to the impact of the prolonged economic crisis, which started in 1998, illegal areas are proliferating as more people arrive in the city to seek employment. Since 1999, the government of Jakarta has implemented a policy of excluding these people from social benefits, including nutrition and health services, as well as such basic services as potable water and waste disposal. Starting in 2001, the city government has endeavored to remove illegal residents from these areas, employing a level of force that some NGOs have classified as government violence. On the one hand, the government tries to alleviate poverty by providing a social safety net but, on the other hand, it excludes the residents of illegal areas from the net, even though the majority of these migrants suffer from malnourishment and poverty. This situation poses a dilemma for public health officials who are obliged to improve the health of the people, especially the urban poor. This paper describes the illegal areas of Jakarta, considers the migrants' health and nutrition and looks at the psychosocial effects of the government's operation to remove the residents of illegal areas and demolish their homes, in addition to several types of violence faced by the urban poor. It also discusses the effect of the government's operation, which may introduce even more violence, and the dilemma faced by public health officials. This paper calls for a community-based approach to the challenges facing Jakarta, together with good governance, in order to prevent state violence and emphasizes that current government actions are indicative of political failure.

Fernando Valadez
BEYOND POSTTRAUMATIC STRESS DISORDER (PTSD) IN THE REHABILITATION OF TORTURE SURVIVORS IN MEXICO

This paper begins with a general survey of poverty levels and the health sector in Mexico, where the situation has deteriorated over the last 30 years. Today, half of the population lives in poverty and 30 million Mexicans live under the absolute poverty line. The general health budget represents only 2% of the gross national product, mirroring a decline in health services, and about 10% of the population, among them the country's indigenous peoples, lack any health services at all. Many believe that this decline is traceable to a deliberate attempt to bankrupt health services so that they may be privatized in accordance with IMF/World Bank recommendations. Although 15% of the population suffers from mental illness, there are only 1,000 psychiatrists working in the public health sector; consequently, patients suffering from PTSD receive no attention at all. Yet, many would argue that a state that systematically employs torture as an 'investigative procedure for law enforcement' is not unduly interested in the health of citizens. This paper looks at the organization, Christian Action for the Abolition of Torture (ACAT), which tends to the needs of torture survivors, but eschews the concept of 'victimhood,' arguing that survivors are generally members of communities or organizations that, even in extreme poverty, are struggling to uphold human dignity in the face of brutal repression and torture. ACAT provides psychotherapeutic and medical attention to torture survivors inside and outside of prisons and to their family members. In addition, it works in the community to provide essential health services and preventative care, to aid in the reconstruction of social networks and to supply juridical defense. The paper categorizes 'Low-Intensity Conflict Pathology,' which includes Psychological Operations, and notes that such forms of oppression and repression have worsened since the 11 September attacks in the United States. 

Stevan Weine, Ferid Agani and Ralph Cintron
LOCAL AND INTERNATIONAL RESPONSES TO THE PUBLIC
MENTAL HEALTH CRISIS IN POST-WAR KOSOVA

The discourses on mental health in post-conflict societies that have been promoted by many Western governmental and non-governmental organizations in Kosova, as elsewhere, have tended to revolve around the relief of traumatization and the protection of human rights. These are necessary concerns, but these discourses give insufficient attention to the social, economic, cultural and political conditions related to Kosova as a 'weak state'; they do not contribute to a public mental health response to catastrophes caused by social injustice; nor do they encourage more active participation by local professionals and families. Moreover, these discourses may converge with the historical consequences of state-sponsored violence and oppression in unintended and unproductive ways, as illustrated by the Shtime crisis. Yet, in Kosova, alternative means of representing the public mental health crisis following social injustice can be found among local policy-makers, professionals and families. They emphasize the building of state structures that can protect and support families and communities. Ameliorating mental illness and social suffering in post-conflict societies requires a rhetorical re-mapping of the public mental health crisis to one based more upon local understandings of local needs and strengths. 

Allan Young
COLLECTIVE TRAUMA, PSYCHIATRIC MORBIDITY AND THE
EPIDEMIOLOGY OF DUBIOUS KNOWLEDGE

Current cases of Posttraumatic Stress Disorder (PTSD) worldwide are estimated to be in the tens of millions. If this estimate is valid, PTSD is the world's second most common mental disorder. PTSD is associated with severe distress, high levels of chronicity, co-morbidity and disability, and significant economic (productivity) consequences. Very high prevalence rates of PTSD are reported for post-conflict countries?for example, 37% for Algeria's general population and 28% in Cambodia. Still higher rates of PTSD are reported in Western Europe, North America and Australia for people claiming refugee status. These epidemiological findings are recent developments, for PTSD only entered the psychiatric nosology in 1980. Since then, the character of PTSD has been further defined to include subvarieties, notably, 'partial PTSD,' 'vicarious PTSD' and 'collective trauma.' PTSD has also attracted the attention of several critics, who have questioned its underlying epistemology and actual clinical significance. In this paper, I review these various claims and critiques. I approach PTSD from three perspectives: human memory (the 'motor' that is said to drive the PTSD syndrome), social relations (PTSD comprises a language of entitlement as well as a disorder) and history (not only the history of PTSD, but PTSD as a medium for composing history).

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