SONGSOPTOK
INTERVIEW WITH CHRYSSA
HEALTHCARE – A
RIGHT OR A PRIVILEGE?
SONGSOPTOK: Do you consider primary healthcare
to be a fundamental right? Is it deemed as such in the society you live in?
Please explain your answer with a few examples if possible.
CHRYSSA VELISSARIOU: Regardless of our age,
gender, socio-economic or ethnic background, we consider our health to be our
most basic and essential asset. When we talk about well-being, health is often
what we have in mind. The right to health is a fundamental part of our human
rights and of our understanding of a life in dignity. The right to the enjoyment
of the highest attainable standard of physical and mental health, to give it
its full name, is not new. Internationally, it was first articulated in the
1946 Constitution of the World Health Organization (WHO), whose preamble
defines health as “a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”. The preamble further
states that “the enjoyment of the highest attainable standard of health is one
of the fundamental rights of every human being without distinction of race,
religion, political belief, economic or social condition.” The 1948 Universal
Declaration of Human Rights also mentioned health as part of the right to an
adequate standard of living (art. 25). The right to health was again recognized
as a human right in the 1966 International Covenant on Economic, Social and
Cultural Rights. Since then, other international human rights treaties have
recognized or referred to the right to health or to elements of it, such as the
right to medical care. The right to health is relevant to all districts of
Greece: every district has ratified at least one international human rights
treaty recognizing the right to health. Moreover, my country has committed itself
to protecting this right through international declarations, domestic
legislation and policies, and at international conferences. In recent years,
increasing attention has been paid to the right to the highest attainable
standard of health, for instance by human rights treaty monitoring bodies, by
WHO and by the Commission on Human Rights (now replaced by the Human Rights
Council), which in 2002 created the mandate of Special Rapporteur on the right
of everyone to the highest attainable standard of physical and mental health.
These initiatives have helped clarify the nature of the right to health and how
it can be achieved.
SONGSOPTOK: What is the
system of healthcare in the country and the society you live in? Is it a just
and equitable system in the sense that all citizens enjoy the same benefits
across economic and social classes?
CHRYSSA VELISSARIOU: The economic crisis in Greece may offer an opportunity for the
reorganisation of the health system, and although primary healthcare reform is
high on the political agenda, questions remain about the direction of
restructuring. THE POLITICS OF PRIMARY HEALTH CARE IN GREECE. Weaknesses in the
Greek health system include poor continuity of care, excessive use of curative
services, lack of preventive measures, low levels of satisfaction, high rates
of out-of pocket payments, and significant inequalities in the range and
quality of health services. In the past a plethora of occupational funds had
offered different packages of primary healthcare coverage. In some cases they
used their own infrastructure (GP-led health clinics) and/or contracted private
physicians and laboratories, situated mainly in urban and semi-urban areas. In
1953 the state established the first public medical posts in rural areas a few
years later, obliging medical graduates to offer their services to local
populations as fully employed civil servants. In 1983 the Greek National Health
System (Ethniko Systima Ygeias [ESY]) was founded following the Alma Ata
Declaration's emphasis on primary care. It foresaw the replacement of the
existing primary healthcare infrastructure with ESY urban and rural health
centres and the unification of social health insurance schemes. In the next
decade 176 health centres and 19 small hospitals were established in rural
areas offering health services accessible to all, comprehensive and free at the
point of use. Unfortunately, the 220 urban health centres envisaged by the ESY
implementation plan, were never established. The sickness funds' primary care
infrastructure and variable benefits remained untouched, due to opposition from
physicians engaged in private practice, and social groups who received enhanced
healthcare benefits. The 1983 reforms missed a unique opportunity to overhaul
the fragmented system of social health insurance and to create a universal,
integrated primary healthcare system. From 1994 to 2009 numerous primary
healthcare reform plans sought to promote users' freedom of choice, to
introduce the family/personal physician as the cornerstone of primary care
system's structure, and to unify primary care services. A purchaser–provider
split, selective contractual arrangements with existing providers, gate keeping,
and capitation payments for family doctors were endorsed by all of these plans,
but ultimately none were implemented. Their failure was partly due to the Greek
state's administration but mainly to obstruction by those with vested interests,
such as private physicians, part-time social security doctors, and wealthy
insurance funds. In March 2011 the government passed yet another bill for the
unification of primary care, introducing the capitated ‘personal doctor’ as the
referral point within the healthcare system. It also left intact all existing
primary healthcare providers, created incentives for entrepreneurs to invest in
primary care facilities, and tried to integrate these providers through
selective contracting with a single social health insurance purchaser. One year
later this crisis-led ‘reform’ is partly implemented, facing mainly the
opposition of the Greek Medical Association based on the reasonable fear that
single private surgeries will soon be absorbed by primary healthcare corporate.
PRO-CRISIS PROVISION OF PRIMARY CARE SERVICES IN GREECE
Primary health care in Greece is fragmented, tripartite, and
based on a complex public/private mix of the ESY, social health security, and
the private health sector. The ESY consists of 201 rural health centres, 1478
rural medical posts/surgeries, three urban health centres, and the outpatient
clinics of 140 public hospitals. Health centres are considered as decentralised
units of the ESY regional hospitals and rural medical posts are considered as
satellite units geographically attached to health centres. All health centres
are tax-financed, receiving budgets on a retrospective basis in accordance to
last fiscal year's payroll and overhead costs but not weighted for local
healthcare needs. ESY health centres and medical posts are staffed with 1787
full-time salaried medical doctors (mainly GPs, pediatricians, dentists, and
specialists in internal medicine) and approximately 2414 other health
professionals, most of them enjoying permanent tenure. ESY centres and their
satellite surgeries offer 24-hours a day, free at the point of use, preventive,
curative, emergency, and rehabilitation services to their rural populations of
10–30 000 citizens. Outpatient clinics of ESY hospitals offer specialist and
diagnostic services to urban and semi-urban populations, free of charge with
minimal co-payments during working hours, and on a fixed fee-for-service basis
during evening hours. No referral system exists, and users can bypass primary
care to seek specialist services. Although ESY health centres represent a major
breakthrough, their weaknesses include shortages in personnel and equipment,
lack of medical record documentation, low technical and scale efficiencies
compared with social security's primary care units, and low users' satisfaction
rates, a fact that causes a constant flow of patients from rural to urban areas
in search of better care. Social health security consists of 36 occupational
sickness funds that offer different packages of primary healthcare coverage to
almost 95% of the population. Some funds have their own primary care
infrastructure, while others purchase services from contracted private
physicians and laboratories. Their health units are staffed by full-time
salaried medical doctors (mostly specialists) and part-time salaried doctors
who are also free to do private practice. Within this complex regime, users
have free access, during working hours, to a range of mainly curative and
diagnostic services at their insurance fund's primary healthcare units and/or
access, on a co-payment basis to contracted private physicians and
laboratories. No referral system exists and social security beneficiaries can
directly seek hospitalization at public or private hospitals. Although this
primary care infrastructure substitutes to some extent for the absence of
public primary healthcare services in urban areas, it still suffers from many
weaknesses including surprisingly low users' satisfaction rates, excessive use
of curative and diagnostic services, and unethical practices; social security
doctors often use their posts to attract patients to their private offices. The
resent legislation regarding PHC has been inadequately promoted. Primary Health
Care in Greece is provided by a heterogeneous network comprised of services of
the National Healthcare System (“Ethnikon Systima Ygeias”, ESY), Social
Insurance Organizations (SIOs), regional authorities (municipalities,
perfectures) and private practitioners. The main characteristics of the present
PHC network are fragmentation, ineffective central coordination and
inconsistency in the availability, accessibility and quality of PHC services
between urban and rural areas. Health promotion services are inadequate. Recent
legislation reforms target unification of the health sector of the SIOs to form
a new organisation which will be responsible for the PHC network in Greece. In
addition, the legislation on decentralisation confers the responsibility for
local PHC policies on the regional authorities. Effective enforcement the new
legislation is expected to have a favourable effect on the Greek PHC system. It
is crucial that quality assessment and management systems are developed to
monitor the changes.
SONGSOPTOK: Do you think that free healthcare cannot be a right, but
it can be a privilege and a shared burden of sacrifice for the sake of the
social contract?
CHRYSSA VELISSARIOU: No it is a right . WHAT IS THE RIGHT TO
HEALTH? A. Key aspects of the right to health
• The right to health is an inclusive right. We frequently associate the
right to health with access to health care and the building of hospitals. This
is correct, but the right to health extends further. It includes a wide range
of factors that can help us lead a healthy life. The Committee on Economic, Social
and Cultural Rights, the body responsible for monitoring the International
Covenant on Economic, Social and Cultural Rights, calls these the “underlying
determinants of health”. They include: Safe drinking water and adequate
sanitation; Safe food; Adequate nutrition and housing; Healthy working and
environmental conditions; Health-related education and information; Gender
equality. • The right to health contains
freedoms. These freedoms include the right to be free from non-consensual
medical treatment, such as medical experiments and research or forced
sterilization, and to be free from torture and other cruel, inhuman or
degrading treatment or punishment. • The right to health contains entitlements.
These entitlements include: The right to
a system of health protection providing equality of opportunity for everyone to
enjoy the highest attainable level of health; The right to prevention,
treatment and control of diseases;
Access to essential medicines; Many of these and other important
characteristics of the right to health are clarified in general comment N° 14 (2000)
on the right to health, adopted by the Committee on Economic, Social and
Cultural Rights. The Covenant was
adopted by the United Nations General Assembly in its resolution 2200A (XXI) of
16 December 1966. It entered into force in 1976 and by 1 December 2007 had been
ratified by 157 States. Maternal, child
and reproductive health; Equal and
timely access to basic health services;
The provision of health-related education and information; Participation of the population in
health-related decision making at the
national and community levels. • Health services, goods and facilities must be
provided to all without any discrimination. Non-discrimination is a key
principle in human rights and is crucial to the enjoyment of the right to the
highest attainable standard of health (see section on non-discrimination
below). • All services, goods and facilities must be available, accessible,
acceptable and of good quality.
Functioning public health and health-care facilities, goods and services
must be available in sufficient quantity within a State. They must be
accessible physically (in safe reach for all sections of the population, including children,
adolescents, older persons, persons with disabilities and other vulnerable
groups) as well as financially and on the basis of non-discrimination. Accessibility
also implies the right to seek, receive and impart health-related information
in an accessible format (for all, including persons with disabilities), but
does not impair the right to have personal health data treated confidentially. The facilities, goods and services should
also respect medical ethics, and be
gender-sensitive and culturally appropriate. In other words, they should be
medically and culturally acceptable.
Finally, they must be scientifically and medically appropriate and of
good quality. This requires, in particular, trained health professionals,
scientifically approved and unexpired drugs and hospital equipment, adequate
sanitation and safe drinking water. Human rights are interdependent,
indivisible and interrelated. This means that violating the right to health may
often impair the enjoyment of other human rights, such as the rights to
education or work, and vice versa. The importance given to the “underlying
determinants of health”, that is, the factors and conditions which protect and
promote the right to health beyond health services, goods and facilities, shows
that the right to health is dependent on, and contributes to, the realization
of many other human rights. These include the rights to food, to water, to an
adequate standard of living, to adequate housing, to freedom from
discrimination, to privacy, to access to information, to participation, and the
right to benefit from scientific progress and its applications. It is easy to
see interdependence of rights in the context of poverty. For people living in
poverty, their health may be the only asset on which they can draw for the
exercise of other economic and social rights, such as the right to work or the
right to education. Physical health and mental health enable adults to work and
children to learn, whereas ill health is a liability to the individuals
themselves and to those who must care for them. Conversely, individuals’ right
to health cannot be realized without realizing their other rights, the
violations of which are at the root of poverty, such as the rights to work,
food, housing and education, and the principle of non-discrimination.
SONGSOPTOK: What, in your opinion, should be the role of the
government for ensuring equal healthcare to all citizens? What role is played
by the government of the country you live in?
CHRYSSA VELISSARIOU: The right to health is
NOT only a programmatic goal to be attained in the long term. The fact that the
right to health should be a tangible programmatic goal does not mean that no
immediate obligations on States arise from it. In fact, States must make every
possible effort, within available resources, to realize the right to health and
to take steps in that direction without delay. Notwithstanding resource
constraints, some obligations have an immediate effect, such as the undertaking
to guarantee the right to health in a non-discriminatory manner, to develop
specific legislation and plans of action, or other similar steps towards the
full realization of this right, as is the case with any other human right.
States also have to ensure a minimum level of access to the essential material
components of the right to health, such as the provision of essential drugs and
maternal and child health services. Accountability compels a State to explain
what it is doing and why and how it is moving, as expeditiously and effectively
as possible, towards the realization of the right to health for all.
International human rights law does not prescribe an exact formula for domestic
mechanisms of accountability and redress, so the right to health can be
realized and monitored through various mechanisms. At a minimum, all
accountability mechanisms must be accessible, transparent and effective. States
have the primary obligation to respect, protect and promote the human rights of
the people living in their territory. So seeking the implementation of the
right to health at the domestic level is particularly important. Where domestic
mechanisms exist and function, they are often quicker and easier to access than
regional or international mechanisms . Administrative
and political mechanisms are complementary or parallel means to judicial
mechanisms of accountability. For instance, the development of a national
health policy or strategy, linked to work plans and participatory budgets,
plays an important role in ensuring accountability of the Government. Some of
the most crucial measures related to domestic enforcement are the provision of
judicial mechanisms for rights considered justiciable in accordance with the
national legal system. Such mechanisms should provide remedies to individuals
if their right to health is violated. The incorporation into domestic laws of
international instruments recognizing the right to health can significantly
strengthen the scope and effectiveness of remedial measures. It enables courts
to adjudicate violations of the right to health by direct reference to the
International Covenant on Economic, Social and Cultural Rights. Domestic
courts, including supreme courts, have increasingly heard cases relating to the
right to health. For instance, the courts in Argentina have ordered the State
to ensure an uninterrupted supply of antiretroviral drugs to persons with
HIV/AIDS, to ensure the manufacturing of a vaccine against an endemic disease,
and to ensure the continued provision free of charge of a drug against bone
disease. Another issue examined by the courts has been the exclusion from and
termination of health coverage, particularly by private health insurance. In
some cases the courts referred to Argentina’s ratification of the International
Covenant on Economic, Social and Cultural Rights and other treaties to reaffirm
the constitutional status of the right to health.
SONGSOPTOK: According to the data published by World Health
Organization (WHO), nearly 16 000 children under the age of 5 die every day in
the world (5.9 million in 2015) from infectious, neonatal or nutritional
conditions. Is this a reality in the country you live in? If so, what would
your suggestions of improvement be?
CHRYSSA VELISSARIOU: The Greek Constitution
contains a number of solemn proclamations affecting the status of children:
that childhood shall be under the protection of the State; that families with a
large number of children, war orphans, and everyone who suffers from incurable
physical or mental illness have the right to special care by the State; and
that the latter also have the right to enjoy measures that secure and
facilitate their independence, their professional integration, and their
participation in the financial, political, and social life of the country. It
also states that the State cares for the health of its citizens and takes
special measures for the protection of the children. Furthermore, it proclaims
that housing for those in need is the responsibility of the State. Another
guiding principle enshrined in the Greek Constitution and legislation that also
has a bearing on children is the prohibition of discrimination based on race,
gender, physical or mental disability, language, or social status.While the
Constitution does not further elaborate on the scope and the extent of these
general pronouncements, subsequent statutes and secondary legislation that have
been enacted are based on the constitutional mandate to secure the rights of
children and to prohibit discrimination. Furthermore, the various policies,
services, and programs designed for children that are adopted and implemented
by the State at a central or regional level and that are discussed below
reflect to a large extent the country’s efforts to protect its children.
Nevertheless, Greece still faces numerous challenges, especially in the areas
of violence against women and children, trafficking of persons, and
discrimination against Roma children.In Greece, children under the age of
fifteen constitute about 15.5 percent of the overall population (11,000,000),
which is below the average percentage in the European Union. Greece, as other
European countries, has experienced in the last few years a high rate of influx
of immigrants. As a result, a new multi-cultural and multi-ethnic society has
emerged. There are approximately 130,000 immigrant students, mostly from
Albania and other Balkan countries, that attend local schools and benefit from the
services and programs offered by the Greek State. In Greece, there is no
centralized agency designated to provide care and assistance and to supervise
the various services provided by the State. Instead, a number of government
agencies are responsible for providing social welfare and health services, as
well as free education and child care. Generally speaking, the Ministry of
Health and Welfare is responsible for health services, and the Ministry of
Social Assistance is responsible for assistance to children who are vulnerable,
that is orphans, the handicapped, and trafficked children. The Ministry of
Health and Welfare and the Ministry of the Interior have joint responsibility
at the national level for early childhood care. Local authorities are responsible
for preschools and child care services; the Ministry of Education supervises
the early childhood programs at the national level. The Ministry of Labor and
Social Security handles the social insurance benefits and the family allowances
for each child. The Social Insurance Institute (IKA) administers benefits
through local offices. The general framework law on social care is Law
2646/1998 on Reorganization of the National System of Social Care and Other
Provisions. Based on the constitutional mandate that social care is the
responsibility of the state, the Law reaffirms the right of access to social
care and welfare services provided by the National Health System to everyone
who legally resides in Greece. Thus, the main objective is to ensure
participation of all people in the services provided, in order to ensure that
all people have an acceptable standard of living. Consequently, as long as
foreign nationals and their children have proof of legal residence, they are
eligible for the welfare services and programs offered, including daycare
centers, infant care centers, state-run holiday camps, and others. The
institution of foster parents was introduced in 1992. Minors under the age of
eighteen who have no place to stay or who live in unhealthy family living
conditions could in theory be placed with foster families until they attained
the age of majority. Children with special needs could stay with foster
families beyond that age. However, the Greek Ombudsman reported in 2005 that
the foster parent program was not put into operation. Since 1973, the state-run
orphanages have been converted into child care centers. Abandoned children or
those with no place to stay, from the age of five to fifteen, are accepted free
of charge. The decision to place a child in a child care center is made based
on a report prepared by the social worker assigned to the case and upon
verification that living with family or relatives is not feasible. Orphans who
have lost one or both parents are given preference, followed by children whose
single parent is blind, deaf-mute, handicapped from birth, mentally ill, or
incarcerated. Children between the ages of three and six are accepted at
state-run kindergartens. There are also state-run nurseries that cover the
needs of children from the age of eight months until they are accepted at
elementary schools. Since 1960, Law 4051 on Supporting Unprotected Children has
offered financial benefits to children who meet certain qualifications.
Eligible children are those below the age of fourteen (and in some instances up
to sixteen) who live with their own families and are: orphans who have lost
both parents; orphans without fathers; children whose fathers cannot support
them for reasons of health; or children born outside marriage. Children who live
in state-run institutions do not qualify for these allowances. Other state-run
institutions also provide a small allowance to children of single parents, to
those close to the poverty line, or to those children whose families experience
medical or social hardships. The government also made monetary contributions of
a lump-sum, at the beginning of each school year, to families with children up
to sixteen years old who attend public schools and whose annual income is no
more than €3,000 (about US$4,161, at the exchange rate of €1=US$1.39, effective
Sept. 17, 2007). Another allowance was €1000 to families with children studying
in cities other than the place of residence of their families. Other laws
directly or indirectly assisted low-income families with children. An annual
allowance of €15 to purchase school items was given to families of the
unemployed and to single-parent families. Another example is Law 3227/2004, on
Measures against Unemployment, which gave an incentive to employers to hire
unemployed mothers of at least two children. The incentive consisted of a
subsidy of an amount equal to the employer’s insurance contribution liability
for providing insurance coverage for the employed mothers. The subsidy was
equal to a year’s contribution for each child of the employed mother. Moreover,
the same law exempted women farmers from contributing to the Farmers’ Fund
(Agricultural Insurance Organization O.G.A.) for every child born after the
first child. The government also provided pensions for low-income families in
rural areas and financial incentives for children who attended school. Other
government programs also provided a certain amount of money for families with
three children. It should also be noted, that the National Center for Emergency
Social Care, which operates as a legal entity, under the authority of the
Ministry of Health and Welfare, has extended its services in almost all regions
of Greece. Thus, separated children or victims of human trafficking may receive
emergency assistance in such centers. But almost all the beneficial above has changed after Crisis in 2009. Now more
than 250,000 children in Greece do not have access to public healthcare and
don’t do the necessary vaccinations, the Greek branch of Doctors of the World
said during a press conference on Wednesday. Speaking to journalists, general
secretary Liana Mailli noted that this number is an approximation, as Greece
doesn’t provide data on inoculations to the European Union, as it is supposed
to. She also said the number was valid two years ago, before the dramatic rise
of the refugee and migrant flows to Greece. “To the old numbers, we must now
add the children of refugees who we don’t know how many vaccinations they’ve
had. All these issues create an explosive situation and there’s a real risk
that diseases which had been eliminated, such as diphtheria, tetanus,
pertussis, measles and polio, will reappear,” Mailli said. After the dismissal
of a large number of doctors, she added, the state-run health insurer EOPYY and
other health facilities “have been decimated and cannot serve the insured, let
alone uninsured children.” Greek children now have some of the worst dental
health in Europe. It is a measure of the country’s economic depression, and
could be storing up more problems for the future. In few places are the wounds
of Greece’s economic depression more evident than in the mouths of the nation’s
children. By most indicators of dental health, Greece is one of the
unhealthiest places in Europe. The number of Greeks 16 years or older reporting
unmet dental care needs was 10.6 percent in 2013, according to Europe’s
statistical agency Eurostat. That compares to a European Union average of 7.9
percent. Dental problems are particularly acute among children, according to a
recent survey by the Hellenic Dental Federation, a supervisory body. And the
financial crisis has made things worse. In the decade up to 2014, 60 percent of
all dental problems in 15-year-olds were left untreated for at least a year, up
from 44 percent in the previous decade. Almost all the five-year-olds surveyed
– 86.8 percent – suffered dental problems that had not been treated, the survey
found. “Teeth are unfortunately considered a luxury,” said Niki Diamanti, a
dentist who works at Hatzikosta Hospital, one of two public hospitals in the
northwestern town of Ioannina. “If, five years ago, people went to the dentist
once a year, now they go every five years.” Anybody living legally in Greece
has a right to health care. Therefore anybody who can prove his or her resident
status can access health care. However, the health sector has been particularly
badly hit by the crisis. Patients must pay a fixed price of 5€ for every
hospital visit. Doctors frequently ask their patients to buy their own
plasters, needles and bandages as the hospitals are out of stock. According to
Médecins du Monde, the situation is worsening. The organisation has started
distributing enriched nutritional products to some children; the most
vulnerable families can no longer cope. People are even going directly to the
NGO headquarters for free checkups and the situation is becoming difficult for
the organisation to manage. According to the Hellenic Centre for Disease
Control and Prevention (a public health organisation, financed by the Ministry
of Health) the number of children with HIV/AIDs is low. However,
mother-to-child transmissions have been diagnosed as a consequence of
nationwide deficiencies in screening pregnant women. Systematic AIDs tests are
now carried out on pregnant women to prevent mother-to-child transmission. This
is one more article were an English journalist witnesses the situation of the
healthcare in Greece after the crisis: “In October I visited Greece to see the
impact of austerity on the Greek people, in particular on health and
healthcare.I joined healthcare workers and the Greece Solidarity Campaign to
visit hospitals, clinics and food markets. I spoke to healthcare staff,
volunteers, politicians and local government officials. What I witnessed
appalled me - and brought tears to my eyes. In Greece’s biggest hospital, the
Evangelismos Hospital in Athens, conditions were worse than those I have seen
in developing countries. The moment the hospital doors open on ‘emergency’
days, people flood in. The collapse in official primary and community health
care services means everyone who needs healthcare comes to A+E - whether for a
major accident, medication for a long term condition or to get their child
immunized. Staff told me that serious trauma cases often have to wait hours for
X-rays and treatment due to understaffing and that, if too many cases come in
at the same time, people die before they can be treated. The ‘austerity’
conditions imposed on Greece by the Troika (European Commission, European
Central Bank and IMF) as the price of its debt bailout have closed many
hospitals (including three psychiatric hospitals) and primary care clinics.
Those that remained face drastic staff cuts. Thousands of health workers have
been sacked. 30% of the Greek population is living in poverty, with no access
to affordable healthcare. Healthcare is funded through insurance paid by
employers and when people lost their jobs they lost their health insurance. The
Government claimed to have reinstated health care for the neediest but doctors
and nurses told me it was a sham. The promised tribunals to assess and means
test the claims of those who can’t afford health care have yet to be
established. At Evangelismos I saw 50 psychiatric patients crammed into a 25
bed ward, sharing two toilets and just one psychiatric nurse. Psychiatric patients
of all ages and both sexes lay apathetically on trolleys on both sides of the
long corridor. I turned a corner and saw another corridor similarly lined.
These narrow uncomfortable beds, crammed together, were all the personal space
patients had. Nurses and doctors told me it was impossible to do any
therapeutic work. Despite the overcrowded conditions, the ward was eerily
quiet. I got the impression most patients were sedated, or perhaps had just
given up in despair. ‘Austerity’ and cuts have led to a sharp rise in
depression. Suicide is up 45%. The patients in Evangelismos were the lucky ones
- many others who need beds have been abandoned on the streets, with no
community based support. As we were leaving a doctor appealed to me to tell
people in the UK what I had seen and heard. He said they wanted “solidarity,
not charity”. People are organizing to resist and defend their communities
against the worst impacts of austerity. One expression of this is the
mushrooming of community based “solidarity” structures to help people who lack
food or healthcare. Social solidarity health clinics have been set up all
around Greece staffed by volunteers who try to provide basic care for those
with no access to healthcare. Doctors,
nurses and pharmacists volunteer in these clinics, but not nearly enough to
meet the needs. I visited the Social Solidarity Clinic in Peristeri, a district
of Athens with a population of about 400,000 people. The volunteer staff,
doctors and nurses who worked there told me that most local state run health
clinics had been shut. The government had closed all the polyclinics then
reopened some recently but with only 30% of the doctors that they need. Whereas
previously there had been 150 doctors providing services to the district, there
were now only 50. A polyclinic for a population of 400,000 people had no
gynecologists, no dermatologists, and only two cardiologists. “We want our doctors back” – said one of the
volunteers I spoke to. Thousands of doctors have left the country. Those that
remain – including senior hospital doctors - earn about €12,000 a year. The
Peristeri social solidarity clinic had been running for 1.5 years and had 60
volunteers including about 25 doctors who offered their services free. There
was a simple consulting room and a small pharmacy with donated medicines.
Clinic volunteers said that people with long term conditions like diabetes or
with cancer had particular problems getting the treatment they needed.
Uninsured cancer patients can’t afford chemotherapy. The solidarity
organisations appeal to people on chemotherapy to donate one day’s worth of
medication for patients who can’t afford to the drugs themselves. The Greek
government passed a law in January allowing so that if people get into debt
their property can be confiscated. Some people decline further treatment rather
than accrue debt from healthcare costs that might lead to their family losing
their home. Greek mothers are now charged €600 to have a baby and €1200 for a
Caesarian or complications. It’s twice that for foreign nationals living in
Greece. The mother has to pay the fee on leaving the hospital. When the charges
were first introduced, if the mother couldn’t pay, the hospital kept the baby
until the payment was made. International condemnation led to that practice
being discontinued and now the money is reclaimed through extra tax - but if
the family can’t afford that then their home or property can be
confiscated. And if she still can’t pay
she can be imprisoned. An increasing number of newborn babies are abandoned in
the hospital. One obstetrician I spoke to called it the “criminalization of
childbirth.” Contraception is unaffordable for many – health insurance does not
even cover it. There are many more abortions – 300,000 a year –and for the
first time the death rate in Greece is outstripping the birth rate. People
can’t afford to have babies. It’s hard enough to feed and care for existing
children. A recent report compiled by Unicef and Athens University estimated
that 34% of Greek children were at risk of poverty. An article in the Lancet
(Greece’s Health Crisis: from Austerity to Denialism 22 Feb 2014) reported that
the stillbirth rate had risen by 21% and the infant mortality rate by 40%
between 2008 and 2011. Many families are living off the meager pensions of a
grandparent– typically about 500 Euros a month.
The collapse in primary care systems means that thousands of children
are not being immunized. It costs about 80 Euros for a course of childhood
immunizations and many families cannot afford that. Collapse of the public
healthcare systems has led to a doubling of TB rates, the reemergence of
malaria after 40 years and a 700% increase in HIV infections. Food poverty is
also worsening people’s health. 1.7
million Greek people, nearly one in five of the population, do not have enough
to eat, according to the OECD. We visited a food market in Athens organized by
the social solidarity movement, which organizes the distribution of food direct
from farmers to the population. The social solidarity food markets cut out the
middleman so the food is cheaper than in the supermarkets while the farmers get
a good price. In return the farmers donate a percentage of their product, which
is distributed free to local families in need. Across the market a banner was
strung saying “Putting hope into practice”. This, for me, epitomized the spirit
I encountered everywhere I went – hope for change combined with a very
practical approach to creating support structures. People I spoke to were clear
these were not intended to be a substitute for state provision – they can’t be
– but a means of sustaining life and resilience to prevent people sinking into
destitution and despair. They said that
what was needed was action at government level. The success of the Syriza party
is no surprise. We met Alexis Tsipras, Syriza’s leader, who said that
rebuilding the healthcare system would be a priority for his government if
elected. He did not kept his word though. Our European supervisors have no
pity. The Greece Solidarity Campaign has launched an appeal for medical aid for
Greece, prioritizing the purchase of immunisations for children. I myself I
wrote a most popular poem inspire by all this situation. It is about people
with cancer during crisis especially kids and I wrote it to raise awareness:
THE BALD SAINTS
There are some living Saints
with bowed bald heads'
Some holy beings
some aetherial acrobats
they're balancing on a tightrope at nights
amongst pain and life '
who just want to depart in peace
but they feel they have a duty to complete
therefore to still exist
for the sake of whatever they had been engaged to serve '
for the sake of whatever they shouldn't anyway leave behind
alone'
to serve Love for as long they can bear it,
to do not give up hope for what will future bring ...
Potentially our overt or covert idols in deed ...
They often have a beautiful adolescent's or infant's form ...
Unspeakable the pain, severe heart's shame!
Ah! For some laudanum they just beg to withstand existance'
we, as despicable traitors or in a deep sleep resting
we dare to deprive the Gladiators of Courage
even from the opportunity to fight with a simple sword ...
Dedicated to my friends or unknown cancer patients or other
severely ill patients , especially to the Young Heroes among them, who often in
the merciless greek society of the financial crisis are seeking even
painkillers to find or are humiliated to resort to the charity, which
fortunately is offered by some of us.
Please donate painkillers for cancer patients in Greece . They can
no longer afford them so they can not
cope with their pains.
Community clinics all over Greece fight voluntarily to provide
FREE medical assistance to the UNEMPLOYED and POOR civilians with NO SOCIAL
SECURITY or with very little income.
http://mki-ellinikou.blogspot.gr/
http://mkie-foreign.blogspot.gr/
http://www.kiathess.gr/index.php/2012-09-24-23-48-18
http://koinwnikoiatreiolarisas.blogspot.gr/p/blog-page_4.html
SONGSOPTOK: “Free access to healthcare is a fundamental human right.
Access to free healthcare is not” – do you agree with this statement? Please
explain your choice.
CHRYSSA VELISSARIOU: No I don’t agree. Vulnerable
and marginalized groups in societies are often less likely to enjoy the right
to health. Three of the world’s most fatal communicable diseases - malaria,
HIV/AIDS and tuberculosis - disproportionately affect the world’s poorest
populations, placing a tremendous burden on the economies of developing
countries. Conversely the burden of non-communicable disease – most often
perceived as affecting high-income countries is now increasing
disproportionately among lower income countries and populations. Within
countries – some populations – such as indigenous communities are exposed to
greater rates of ill-health and face significant obstacles to accessing quality
and affordable healthcare. This population has substantially higher mortality
and morbidity rates, due to noncommunicable diseases such as cancer,
cardiovascular and chronic respiratory diseases, than the general public.
People who are particularly vulnerable to HIV infection – including young
women, men who have sex with men, and injecting drug users – are often
characterized by social and economic disadvantage and discrimination. These
vulnerable populations may be the subject of laws and policies that further
compound this marginalization and make it harder to access prevention and care
services. Violations or lack of attention to human rights can have serious
health consequences. Overt or implicit discrimination in the delivery of health
services violates fundamental human rights. Many people with mental disorders
are kept in mental institutions against their will, despite having the capacity
to make decisions regarding their future. On the other hand, when there are
shortages of hospital beds, it is often members of this population that are
discharged prematurely, which can lead to high readmission rates and sometimes
even death, and also constitutes a violation of their right to receive
treatment. Similarly, women are frequently denied access to sexual and
reproductive health care and services in developing and developed countries.
This is a human rights violation that is deeply engrained in societal values
about women’s sexuality. In addition to denial of care, women in certain
societies are sometimes forced into procedures such as sterilization, abortions
or virginity examinations. A human rights-based approach to health provides
strategies and solutions to address and rectify inequalities, discriminatory
practices and unjust power relations, which are often at the heart of
inequitable health outcomes.The goal of a human rights-based approach is that
all health policies, strategies and programmes are designed with the objective
of progressively improving the enjoyment of all people to the right to health.
Interventions to reach this objective adhere to rigorous principles and
standards, including: Non-discrimination: The principle of non-discrimination
seeks ‘…to guarantee that human rights are exercised without discrimination of
any kind based on race, colour, sex, language, religion, political or other
opinion, national or social origin, property, birth or other status such as
disability, age, marital and family status, sexual orientation and gender
identity, health status, place of residence, economic and social situation. Availability:
A sufficient quantity of functioning public health and health care facilities,
goods and services, as well as programmes. Accessibility: Health facilities,
goods and services accessible to everyone. Accessibility has 4 overlapping
dimensions: non-discrimination; physical accessibility; economical
accessibility (affordability); information accessibility. Acceptability: All
health facilities, goods and services must be respectful of medical ethics and
culturally appropriate as well as sensitive to gender and life-cycle
requirements. Quality: Health facilities, goods and services must be
scientifically and medically appropriate and of good quality.
Accountability: States and other duty-bearers are answerable for
the observance of human rights. Universality: Human rights are universal and
inalienable. All people everywhere in the world are entitled to them. Policies
and programmes are designed to be responsive to the needs of the population as
a result of established accountability. A human rights based-approach
identifies relationships in order to empower people to claim their rights and
encourage policy makers and service providers to meet their obligations in
creating more responsive health systems.
SONGSOPTOK: How important is the role of the private sector for
providing healthcare and related facilities in your country? What it is your
opinion about it?
CHRYSSA VELISSARIOU: The private health sector infrastructure
consists of approximately 25 000 private physicians, 12 000 dentists, 400–700
private laboratories, and the outpatient departments of the 167 operating
private hospitals. Private physicians in Greece, most of them specialists, run
their own surgeries, and may also work as part-time salaried employees at
private hospitals, receiving bonus payments for hospital admission.
Corporate-owned diagnostic centres control more than 70–80% of the country's
total biomedical equipment. Private physicians and diagnostic centres receive
users' payments, fee-for-service payments from contracted social health
insurance funds, and fee-for-service or capitated payments from private health
insurance schemes. The private primary care sector in Greece absorbs more than
65% of total private health expenditure and substantial profits are made by the
private diagnostic centres. In my view there is an urgent need for the
rationalisation and consolidation of Greece's fragmented primary care system.
The most obvious obstacles seem to be the financial interests of diagnostic
services and corporate and part-time social security doctors, as well as the
justifiable fears in some population groups of losing part of their advanced
healthcare benefits. For more than 16 years primary healthcare reform plans
have sought to overcome these obstacles by suggesting the virtual, rather than
the actual, integration of primary care services in the country. Existing
providers and their micro-regimes of vested interests would have remained
untouched. Now primary care users, once members of a geographically determined
population, become members of an ‘enrolment list’ and under the guidance of
their personal physician consume services in a mixed healthcare market. With
these proposals the Alma Ata Declaration's principles of a free, universal,
integrated, and community-oriented primary care system have been abandoned. Despite
their problems, the Greek ESY's primary healthcare centres represent the only
organisational structure able to offer holistic services to clearly defined
local populations. In a country like Greece with 27 years of experience of
community-based health centres, it seems irrational to imitate once again
controversial policies based on quasi-market mechanisms. The plan in the
original Greek ESY Foundation Act for complete replacement of the existing
primary care infrastructure, with public, community-based, urban, and rural
health centres free at the point of use, seems to me to be the only realistic
way to move forward.
SONGSOPTOK: Are charitable and Non-Governmental Organizations (NGO)
active in the domain of public health? If yes, then in what spheres? Do you
think that the civil society, either independently or through these
organizations, should become the prime actor for ensuring healthcare for all?
CHRYSSA VELISSARIOU: Human rights-based indicators
support the effective monitoring of key health outcomes and some of the
processes to achieve them. Reviews of policy, budgets or public expenditure,
and governmental monitoring mechanisms (for example, health and labour
inspectors assigned to inspect health and safety regulations in businesses and
in the public health system) are important administrative mechanisms to hold
the Government to account in relation to its obligations towards the right to
health. Some health services have established systems, either internal or
independent, which can receive complaints or suggestions and offer redress.
Furthermore, assessments of various kinds, such as impact assessments, offer a
way for policymakers to anticipate the likely impact of a projected policy and
later to review the actual impact of policies on the enjoyment of the right to
health. Political mechanisms, such as democratic processes, and the monitoring
and advocacy performed by NGOs also contribute to accountability. Civil society
organizations are increasingly using monitoring methods based on indicators,
benchmarks, impact assessments and budgetary analysis to hold Governments
accountable in relation to the right to health. The Treatment Action Campaign
in South Africa illustrates how an NGO effectively used social mobilization,
advocacy and resort to litigation jointly to ensure equal access to HIV/AIDS
treatment. The Treatment Action Campaign in South Africa: ensuring equitable
access to treatment for persons living with HIV/AIDS Making medicines available
where they are most needed and using its resources adequately are two concrete
examples of ways in which the Government can fulfill its obligations in
relation to the right to health and be made accountable.
Minister of Health v. Treatment Action Campaign: The South
African Government had chosen not to roll out a national programme to reduce
the risk of mother-to-child transmission of HIV. Instead, it identified two
research sites per province that alone were authorized to distribute the drug
nevirapine, thus restricting the availability of the drug, although its
efficacy had already been well established. This meant that HIV-positive
mothers who could not afford private health care and did not have access to the
research sites could not receive nevirapine. In August 2001, the Treatment
Action Campaign, a network of organizations and individuals campaigning for
equitable and affordable access to HIV/AIDS treatment, filed a claim against
the Government before the Pretoria High Court, demanding that the Government
distribute the drug to pregnant women in all public hospitals, on the grounds
that the governmental policy was unconstitutional and failed to respect its
human rights obligations. The South African Constitution recognizes the right
of everyone to have access to public health-care services and the right of
children to special protection. Decisions: In December 2001 the High Court
decided in favour of the Treatment Action Campaign and held that the
Government’s restrictions were unreasonable. In its decision upon appeal, in
July 2002, the Constitutional Court upheld the Pretoria ruling and decided that
the Government’s policy “had not met its constitutional obligations to provide
people with access to healthcare services in a manner that is reasonable and
takes account of pressing social needs”. The Court confirmed that the policy
discriminated against poor people who could not afford to pay for services. The
Government was required to remove restrictions on the availability of
nevirapine at public hospitals and clinics that are not research sites, and to
devise and implement within its available resources a comprehensive and
coordinated programme to progressively realize the rights of pregnant women and
their newborn children to have access to health services to combat
mother-to-child transmission of HIV. These decisions led to the establishment
of one of the largest programmes in Africa to reduce mother-to-child
transmission. National human rights institutions (NHRIs) are important domestic
mechanisms promoting and protecting human rights. Their functions in this
respect include advising the Government and recommending policy or legislative
changes, handling complaints, carrying out investigations, ensuring the
ratification and implementation of international human rights treaties, and
providing training and public education. NHRIs often have quasi-judicial
functions and a mandate allowing them to contribute to the development of
legislation. Most institutions may be categorized as commissions or ombudsmen.
Some countries have specific health ombudsmen. While most NHRIs have
traditionally focused their work on civil and political rights, they are
increasingly focusing on economic, social and cultural rights. They can provide
another avenue for the protection of the right to health. Selected national
human rights commissions and the right to health The mandate of the National
Human Rights Commission of India (http://nhrc.nic.in) is to protect and promote
rights guaranteed by India’s Constitution and international treaties. The
Commission has been very active with respect to the right to health. It has,
for instance, advocated upgrading health-care facilities in the country and allocating
medical staff to rural populations. It has also made several recommendations to
the Government to ensure policies in favour of the right to health. For
instance, it recommended that facilities be created in villages; that a proper
mechanism be established to ensure essential drugs are available at primary
health centres; that publicprivate partnerships be set up to maximize the
benefits of health-care facilities; and that immunization programmes of the
Health Department be organized regularly so that childhood diseases are
contained at the earliest opportunity. In a report published in February 2007
the Commission also denounced the lack of safe drinking water in many areas of
the country. The Commission has also
worked for a ban on manual scavenging, which has a very negative impact on
health. It recommended that the Government should rehabilitate and reintegrate
freed manual scavengers, that banks should facilitate loans at a favourable
rate of interest for them and that schooling should be provided for their
children. The Parliamentary Ombudsman in Finland (http://www.oikeusasiamies.fi) increasingly deals with right-to-health complaints, in
particular with respect to patients’ rights and the right to health care
(guaranteed under the Constitution). In 2005, the Ombudsman examined several
complaints related to the unavailability of adequate health services, access to
quality treatment and the manner in which patients were treated. The Ombudsman
consulted the National Board of Medico-legal Affairs to reach a decision on
these cases. The National Human Rights Commission in Mexico (www.cndh.org.mx)
has been dealing increasingly with right-to-health complaints, in particular
the refusal to provide or the inadequate provision of public health services,
and medical negligence. In 2004, the Commission issued a general recommendation
directed to relevant national and district ministers on the human rights of
persons with psychosocial disabilities who had been institutionalized in
reclusion centres. The recommendation
was based on an inquiry and visits made to such centres throughout the country
to examine their compliance with human rights standards.
SONGSOPTOK: Do you think that multinational pharmaceutical and healthcare
companies are responsible, to a certain extent, for the widely variable quality
of healthcare in different countries? Can you please illustrate your reply with
some examples?
CHRYSSA VELISSARIOU: Rational prescribing decisions should be enhanced by the quality
of interactions between healthcare providers and the companies that research
and develop medicines. The medicines that research-based companies produce and
the scientific information they provide to physicians are important components
of quality healthcare for patients. With the ever increasing number of
treatment options available to patients, healthcare providers need to be kept
up to date with the scientific advancements of new medicines. Likewise,
providing patients with information relating to medicines may encourage
healthcare providers to explore various treatment options in order to best
match patient needs. It is important therefore that the information provided by
companies is scientifically accurate and fair. Interactions between
pharmaceutical companies and healthcare professionals should always be
appropriate and support good patient care. With the aim of further supporting
these important goals, the global pharmaceutical industry has made significant
changes in recent years in the worldwide controls on companies’ interactions
with healthcare professionals. Interactions and communication between companies that research
and manufacturer medicines and the healthcare professionals that prescribe them
are important in contributing to the appropriate and effective use of
prescription medicines. These relationships are covered by pharmaceutical
advertising codes and legislation. Additionally, national bribery and
corruption legislation, such as the US Foreign Corrupt Practices Act (FCPA) and
the UK Bribery Act, could have potential application to activities in any
country for many companies. Ensuring compliance with the IFPMA Code and the
affiliated national codes is likely to help ensure compatibility with relevant
sections of anti-bribery legislation. Essentially, the code requirements are
designed to prohibit inappropriate personal benefit being offered to healthcare
professionals and often go beyond the requirements of anti-bribery legislation.
One issue covered by most national codes is whether companies are able to
support healthcare professional attendance at medical conferences. While codes
in many countries deem it acceptable to sponsor attendance of healthcare
professionals at scientific meetings, and cover associated costs such as
reasonable travel, accommodation and meals, they also include a number of
caveats. In particular, the main purpose of the meeting must be scientific and
professional in nature and any refreshments provided must be incidental to that
purpose. The venue must be conducive to the scientific or educational purpose,
and international travel must be justified by the international nature of the
meeting or other logistical or security reasons. Company sponsorship of
healthcare professionals to attend meetings nevertheless remains a topic of
debate. Some countries (e.g. the United States and Norway) do not permit direct
sponsorship of attendance at scientific meetings (except for medical students
in the US), while others (e.g. France) require review of the arrangements by an
independent body. Some countries have put other measures in place such as
co-payment of expenses. International companies may also impose on themselves
policies relating to sponsorship of healthcare professionals that go beyond
external rules. This highlights sensitivity over the perception of companies
funding attendance at international educational meetings. However, ceasing
sponsorship could deny healthcare professionals without access to sufficient
funding the opportunity to hear and interact with world leaders in their chosen
field, unless alternative funding arrangements are developed or digitally-based
specialist educational services are expanded and are feasible in their country.
This is particularly important for healthcare professionals from developing counties,
where alternative sources of funding may not be available. Providing low-value
branded promotional aids (pens, pads, tongue depressors, antiseptic wipes etc.)
has long been a tradition of pharmaceutical, and other, advertising.
International rules still permit inexpensive promotional aids, provided they
are relevant to the practice of the healthcare professional. However, there is
a trend to ban promotional aids altogether and within the past five years the
US and UK , amongst others, have
prohibited branded promotional aids. At least one global company has ceased
their distribution worldwide. The rationale for a ban is not that such
promotional aids represent a gift that will affect a healthcare professional’s
prescribing or purchasing decisions but rather that such items are not
conducive to a new relationship built on mutual professional respect. In
addition, industry leaders seek to base relationships with healthcare
professionals on sharing educational information rather than on provision of items
that could be perceived as gifts. In most parts of the world, it is permissible
to provide samples of medicines to healthcare professionals and such samples
may improve patient care. However, the situation varies considerably between
countries according to local factors. In a number of countries, samples are not
permitted at all, while several countries’ industry codes restrict their
number, frequency, and the period after launch during which they can be
provided. The
attention and resources devoted to regulatory compliance regarding
communication about prescription only medicines is probably at an all-time
high. However, no set of rules is beyond improvement and changes in health
systems, as well as advances in communication technology, will mean that codes,
regulations, and laws will continue to evolve if they are to support optimal
use of medicines to benefit patients. Continuing experience with the operation
of existing codes will help inform future developments particularly in rapidly
developing countries where international pharmaceutical company activities are
expanding yet local manufacturers may not be subject to established codes of
practice. Future developments in these countries should strive for
international harmonization embracing all healthcare sectors but also take into
account national differences. and simultaneously encourage broader
participation and endorsement of codes across the industry operating in these
countries. The IFPMA Code was extensively revised in 2006 and again in 2012 It is
now well-established as an international model for effective local codes.
Continued assessment of national industry codes of practice is appropriate to
ensure that companies continue to meet the needs of patients and prescribers.
Additionally individual companies will continue to pioneer additional
standards, approaches, and initiatives. Areas that are being addressed at
national and company level include a focus on increased transparency of the
relationships between companies and both individual healthcare professionals
and healthcare organizations. Low cost promotional aids are being increasingly
restricted or banned altogether by companies and national or regional codes. Laws
and regulations may change more slowly, but, in countries where there are perceived
gaps, we can expect clarification in the form of new regulations and guidance. The
pharmaceutical industry must continue to serve as a trusted partner in
healthcare provision. Industry codes of practice can form the foundation for
governing companies’ interactions and communications and therefore play an
important part in the relationship between companies and other stakeholders in
healthcare provision. Laws and regulations will remain important and legal
action will be applied when needed. Nevertheless it will be important to avoid
a “box-ticking” approach where the only question is “Is it legal to do that?”
but rather to also encompass a code-based evaluation that goes beyond legal
requirements. International companies have established global internal
standards but they represent only a small share in the healthcare market in
many developing countries, and it would be appropriate for unified
self-regulatory codes to cover all sectors of the pharmaceutical market. We
have already seen such developments in Mexico and South Africa, and such a
model has also been proposed in India. A model of cooperation between industry
codes and legislation already works well in some countries, particularly in
Europe and Australia. Such a model could be equally successful in developing
nations.
SONGSOPTOK: Do you think that adopting the Social Security model
implemented in a lot of countries in Europe which ensures primary health
coverage to all citizens and is financed by the totality of the working
population can be relevant and efficient in all countries?
CHRYSSA VELISSARIOU: Yes I think so. A country’s difficult financial situation does
NOT absolve it from having to take action to realize the right to health. It is
often argued that States that cannot afford it are not obliged to take steps to
realize this right or may delay their obligations indefinitely. When
considering the level of implementation of this right in a particular State,
the availability of resources at that time and the development context are
taken into account. Nonetheless, no State can justify a failure to respect its
obligations because of a lack of resources. States must guarantee the right to
health to the maximum of their available resources, even if these are tight.
While steps may depend on the specific context, all States must move towards
meeting their obligations to respect, protect and fulfill.
References:
CHRYSSA VELISSARIOU: Professor of Physics, specialized in Space
Physics, candidate Doctor in Education. Prized by the Ministry of
Education in Greece. Elected in the Municipality of her hometown. Published in
Greek and English in over 20 Anthologies, internet magazines and two personal
books. Activist for Peace. World Poetry Canada and International Ambassador to
Greece 2014-2016 for Peace. 100TPC events organizer. More than 3000 poems on
her blogs. She also writes in French and German
We sincerely thank you
for your time and hope we shall have your continued support.
Aparajita
Sen
(Editor: Songsoptok)
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