Global Health Exam 2
Global Health Delivery (GHD) Project
1. Adapting to local context 2. Constructing a care delivery value chain 3. Leveraging shared delivery infrastructure 4. Improving both health and economic development
National Malaria Eradication Program
Cooperative undertaking by state and local health agencies of 13 southeastern states, the CDC, the PHS
Kay Region in Haiti
o "Extreme" or "deep" poverty o Hunger, infectious disease, women's and children's health problems (malnutrition, basic childhood diseases) o Haitians in rural areas are more likely to experience various forms of suffering and premature death o Need for historically deep analysis that also attends to "axes" of power and difference o "Culture" too often used to make a place like Haiti seem backward and removed: it's a HISTORY: when we start talking about this as a "culture," it's disconnected from other cultures...but that's not true o Example of social suffering
Beliefs about Malaria in Southern Ghana
o Asra: what we would call malaria o Symptom complex that includes fever, chills, headaches, pains, yellow eyes, bitter taste, deeply colored urine, loss of appetite, weakness, vomiting o Caused by excessive exposure to the sun (which is inevitable in a place like this) and imbalance of bodily energy o Treatment via home remedies
"Social Advantages of Having HIV in Brazil"
o Benefits of government-sponsored programs for families and children with HIV o Street children are not afforded access until they contract HIV o Anger among mothers when their children test negative for HIV because means they can't/won't get health care
Magic Johnson
o Came forward as HIV+ when he was playing in the NBA o Not overcoated as homosexual (married, had kids, American icon of athletic prowess, playing at highest levels of athletic achievement) o Like Ryan White, non-stereotypical patient
Global Burden of Disease
o Came out of a report issued by the World Bank o Wanted to make its most pronounced intervention in the area of global health→ standardize global health studies
Theodicy
o How do we explain evil in the world? o Was God present in the Holocaust? o What is a sufferer's relationship to God?
"After Life" by Joan Didion
o Husband died at dinner of a heart attack o Death is both objective (end of organic living) and subjective o Textures: ordinariness of death-event; speed, quickness, blur; confusion, lack of preparation; technical terms used by the paramedics and health professionals at the scene of the heart attack and the hospital; temporality of loss and grief; loss is loss of familiarity: wanting to discuss things with spouse, assuming his presence; silence and space o We are entangled with relationships that we (know we) are going to lose
Suicide in China
o Leading cause of death for young adults, mainly woman in china (18-35 for woman) o 90% occur in rural areas: men are moving out of rural areas, leaving women behind with little prospect of marriage o rural-urban migration patterns and a shift away form a community-based care model to a market based system
Office of Malaria Control in War Areas
o Predecessor to CDC o Established in 1942
SARS
• Icon of global health: people wearing breathing masks to prevent getting it • Spread by international travel
Factors Involved in ID Emergence
• Microbial adaptation and change • Inter-species transmission (zoonoses): movement of a disease from animal to human (example: Ebola) • Adoption of exotic animals (example: Swine flu, avian flu)
The Big Three in Global Health
HIV Tb Malaria
Emerging Infection Diseases
a decline in infectious disease leads to a rise in chronic diseases, like cancer and heart disease (because people are living longer)
Commodification of Kidneys
o "Commodity Fetishism in Organs Trafficking" by Scheper-Hughes o Commodities have a price and are seen as not having a source o Different hands picked those tomatoes in Shnucks, but you see them as the same on the market because they have the same price o Kidneys last longer from living sources → part of the economy of getting them thru this market o Kidneys from poorer countries cost less, so if your insurance won't cover the cost of a full kidney/you can't pay it, you might travel to a poorer country/buy an organ from there because it is cheaper ($1,500 in the Philippines vs. $30,000 in the US) o Selling kidneys & the problem of informed consent o Prisoners subjected to kidney extrication, cadaver violations, "kidney theft" o Transplant tourism: travelling somewhere to get a kidney/transplant for cheap o "Yes, but it will save a life": doctors around the world may not disclose the source of a kidney (I.e., they know it's coming form someone poor) o Scheper-Hughes will be blunt to them: do you (the doctors) know this is coming from someone poor, may not have informed consent, did this so they wouldn't starve, etc?
Rwandan Genocide
o "Hutu" and "Tutsi" o categories reified after German and Belgian colonization, including the use of racial science and ethnic ID cards o 1962: independence, Hutus as ruling party govern via violence, even as world community continued to pour in aid and development money o 1 million Tutsis killed in 100 days in 1994 o refugee camps o redevelopment since 2000
"The 'Right to Know' or 'Know Your Rights'?" by Joseph Amon
o "right to know" movement began as a strategy of protecting the uninfected, disclosing private info, discriminating against the infected o You don't only have a right to know if you have HIV/AIDS, but if your neighbors, coworkers, etc do o shift in 2001 as WHO focused more on patients, evidence of how concepts of "rights" and the aims of global health policy shift over time...but still practical problems with testing o "Mandating testing..may seem like an effective public heath approach, but it fails to address the barriers and real risks that people like Alice face" o what happens once people know? Criminalization, domestic violence, stigma, loss of job/property o What about the "right to health" guaranteed by the UN/WHO? What happens if you know you're positive but can't access treatment? o Fixing patent laws to reduce cost of pharmaceuticals/let the government make them illegally and cheaper o Accept family members with the disease o Accept comorbidities/develop methods to treat BOTH together
Emmanuel Levinas
o "useless suffering": no way to give meaning to suffering o His response to the Holocaust: what was the point of that? o We need to validate each other's suffering as totally useless o 1st and 2nd order suffering o 1st order: acknowledging it as useless for others (need to acknowledge it's meaningless -- it is what it is) o 2nd order: acknowledging it as useless for ourselves (taking on someone's suffering, like offering to make chicken soup for your friend who has a cold even though you don't have a cold -- giving it that kind of meaning) o We can't explain it, but we can understand that it is useless o Trying to explain it gives it a reason which is violence to sufferers
Constructing a Care Delivery Value Chain (CDVC)
o "value for patients": overall health outcomes per customer o emphasizes integration of normally separate interventions (e.g.: prevention and treatment) o CDVC model emphasizes care as a system and not a set of discrete interventions o case study: AMPATH in Kenya
Empirical Studies Shift the Tide
o 150 patients follow HAART therapy in 2001 Partners in Health study in rural Haiti o Doctors Without Borders reports similar success in poor townships in South Africa o Once people started getting treatment, they would seek further treatment afterwards o Farmer says "who cares if they can't tell time so that they can take their meds at the right time, we will tell them the time"
Haiti and Rwanda
o 1994 Rwanda: genocide of 1 million Tutsis at the hands of the Hutus o 2010 Haiti: earth quake causing 200,000 deaths and destruction of 60% of infrastructure o Haiti: poorest country on earth o Similarities: both are former colonies built on exports; both have endured long dictatorships; both have deep poverty o healthcare becomes confounded and challenging because of poverty - and poverty because of long histories o Goal of Partners in Health: "to draw on the resources of the world's leading medical and academic institutions and on the lived experience of the world's poorest and sickest communities" o This contrasts with what Garzhouzi said: he said focus on the basics (just a little help is better than none, don't waste time with the fancy stuff)
Great Leap Forward (1958-1961)
o 35 MILLION Chinese people died in THREE years! o No way to understand this if you weren't part of the culture and history o Communists wanted to industrialize China overnight o Farmers (peasants) had to give up their tools so they could be melted down so that they could use the metal to build factories, machines, etc → but now the peasants didn't have any agricultural tools o Trying to coordinate production/distribution of rice led to massive famine o Structural violence because POLICY related (top-down engineering) o BUT also social suffering
"The Invisible People" by Behrman
o AIDS epidemic: "greatest human catastrophe of our time" o Shameful lack on involvement from the U.S. o BUT Farmer disagrees: the worldwide effort to combat AIDS "captures the promise of medicine and global health" o Sure a fraction of the world is getting treatment, but why isn't everyone?
Community Health Workers (CHWs)
o Accompanier: delivers medicine to patients (not physicians, pharmacists, etc...just community health workers); refer sick to clinics; provide health education; offer social support in homes o These people are trained, speak their language, understands folk syndromes/idioms, have a local understanding of things like sorcery o "vital interface between clinic and community" (do NOT do the work of doctors/nurses) o Comes out of Alma-Alta Conference (health for all): not just delivering HIV meds, delivering primary health care/generalized health services along the way
Cartesian Dualism
o According to the book o Strict division between mental and physical health→ seen as separate o Mental health is subordinated in global health o Example: depression is seen as less serious than cancer (to diagnose depression, it is "fuzzier," where as cancer is easy to diagnose)
Case Study: Polio in Uttar Pradesh
o Adapting to local context o 1985: vaccine coverage still less than 50% o government efforts in 1990s expanded coverage to >90% o predominantly Muslim population in Uttar Pradesh saw outside intervention in negative terms o Earlier family planning programs by government aimed to sterilize Muslim population there a few decades before so they were wary of institutional, external, medical intervention
Disability-Adjusted Life Years (DALYS)
o Attempt to capture years of life lost to disability and mortality in a comparative perspective o Used to set health priorities, research priorities, attend to disadvantaged groups and focus on cost-effectiveness o Years lost (YLL) + years lived with disability (YLD) = DALYS o Disability weights o Age weights o Doing this math can help compare different people with different circumstances in different countries with life histories—helps world bank allocate money o New capacity to see burden of mental illness o BUT problem of simplifying "illness" in numerical terms; standardizes a strict division between mental and physical health; allows mental health to show up, but still a Cartesian division
HIV/AIDS
o By 21st century, worldwide phenomenon o Life expectancy increasing, but still truncated o Sub-Saharan Africa: 1/3 of the population has HIV/AIDS o Clinical considerations for HIV: Co-morbidities: diarrheal diseases, pneumonia, herpes, tuberculosis, malaria o Access to Highly Active Antiretroviral Therapy (HAART) is now common in many parts of the world, extending quality and length of life (Magic Johnson began taking HIV meds in 1994 and still alive and "healthy as ever" → face of a different kind of HIV) o Ongoing need to diagnose and treat people living with HIV o Potential problem of drug resistance (happens when you don't take your medications properly → giving treatment can lead to worsening medical problems)
Cultural Barriers in Reducing HIV/AIDS
o Common cultural barriers to condom use o Importance of fathering children as part of male identity o Sexual prowess and power o Man often make decisions about condom use in sex work exchanges o "loss of sensation" o dangerous for women's bodies (latex/other forms of plastic) o Traditional and alternative healing o 70% of HIV+ men in southern California have accessed some form of CAM (yoga, acupuncture, etc) o some traditional healers around the world see HIV as a "modern disease" and others see it as "pollution" or "bad blood" capable of being addressed with tradition medicine (don't need to see physicians) o traditional healers can play an important, integrated role in public health programs by providing education and referrals - but they can also become an exclusive alternative
Community Health and Structural Barriers of DOTS-Plus
o Community health care workers provide advice, social work, and counseling in native languages and in view of cultural sensitivity o Transportation costs o Nutritional supplements o Contrasts with vertical delivery of drugs by accounting for things like nutritional supplements: otherwise, side effects like nausea/GI problems would make people not take their meds o Addressing cultural and structural barriers allows for a successful rural healthcare delivery model in a place otherwise untreatable o Model scaled up thru funding from Global Fund to Fight AIDS, Tuberculosis, and Malaria
Case Study: AMPATH in Kenya
o Contrsucting a CDVC o Academic Model for Prevention and Treatment of HIV/AIDS o Integrated testing, counseling, therapies, and treatments of OIs o General health services including reproductive health, oncology, food and social support o Eventual need for an expanded approach to screening, education, and care
Tuberculosis (Tb)
o DALYS model led to focus on TB o CDC and WHO became obsessed with the DOTS model in the early 1990s based on assumptions of cost effectiveness o Watching people take their medication o Not using DOTS+ which provides primary health care o DOTS became part of the world banks selective primary health care focus o Added to GOBI+FFF o Treatment and retreatment both used first-line therapies—Merton's "unintended consequences" Weber's "Technical Rationality" o Unintentionally created more TB when trying to treat it (Merton's) o Went in with a very technical solution, but did not consider the other facts like transportation→ led to non-adherence (Weber) o Retreated with first line antibiotics again o Led to a crisis of multi drug resistance of TB→ led to worse and more difficult to treat TB o Emergence of MDRTB
DOTS-Plus
o DOTS: directly observed therapy shortcourse (watching them take their meds) o Partners in Health initiative o Involve all levels of community o Emphasis on CHWs
"Act Up" Movement
o Demanded more attention to HIV/AIDS o "More attention": public hleath promotion, widespread awareness, destigmatization, more research o About demanding new rights but also sympathy o Focus on medicalizing the disease o Increased emphasis on condom use
"Doctors Don't Know Anything" by Seth Holmes
o Did work with indigenous Mexican farm works in California and Oregon with a focus on migrant health o This chapter is about the common notion among migrant fruit pickers from Mexico that doctors "don't know anything" o Not a literal claim; they mean that the doctors just don't "get it" (missing important aspects of these Mexican's reality) o Migrant farmworkers miss appointments, have no medical records, poor communication skills: misses the picture of their working life and circumstances o Not unexpected among people who might be undocumented, have to work very hard, don't have a lot of money, don't necessarily speak English as a first language, limited means of transportation → but doctors don't UNDERSTAND this which is frustrating to these workers o Need to work creates disincentive to seek medical help (creates reputation of one who needs help, have to repay for work missed)
"On Suffering and Structural Violence" by Paul Farmer
o Different kinds of "suffering": cancer, torture, poverty, etc o All suffering is embodied in individuals, but some is caused by social mechanisms o Case study of Haiti and the stories of the most marginalized there o Slavery, colonialism, landlessness, political corruption, HIV-Tb epidemic
Structural Violence
o Different than "direct violence" (like hitting someone, where the violence is very clear) o Often invisible and difficult to pin down a locus of agency o Normalized, routinized, taken for granted o Policies and structures that cause "bio-inequalities": different people more prone to getting shot, life expectancy, incarceration rates, etc o Not random and not fully biological (ex: African Americans don't biologically/naturally live shorter lives, but rather that is structured into how policies are made, cities are built, etc...in a way that put people in harm's way) o Although whites and blacks use marijuana at roughly the same rates, black people are much more likely to get arrested/go to prison because of it
Decreasing Prevalence of HIV
o Education regarding condom use o Also treatment: giving someone HIV meds is a method of prevention because it reduces viral load and therefore diminishes the risk for further spread (treatment is prevention!) o Farmer advocates for treatment as prevention o Transformation of HIV from death sentence to something that you can live with
Partners in Health
o Face of global health: elite, white medical professionals working with elite, white government figures to make things happen in out-of-the-way places o Let's deliver the highest standard of care o "links delivery of high-quality care for individual patients to efforts to redress some of the structural issues" o Focus on nurses stems from critique of doctors: make up 80% of workforce and deliver 90% of care; 82.5% of Partners in Health staff o Nurses become part of the infrastructure o Emphasis on the important role women can play in health care delivery
Haiti
o HIV rates skyrocketed in early 1990s o Emergence of HIV in Haiti in 1980s led many observers and scientists to postulate that HIV originated there o Discrimination and stigma against Haitian immigrants and opposition to further immigration (the "Four H" club) o Closed borders to asylum seekers in 1990s o Complex genetic analysis of early samples shows that HIV was probably brought from central Africa to Haiti in the 1960s through migrant worker routes o Complex and multifactorial spread in 1970s and 1980s: blood industry (unregulated at the time, not screened for disease); sex work/sex tourism (Port au Prince - Haitian capital); international travel
Lia Lee
o Had "quag dab peg" (the spirit catches you and you fall down): epilepsy o Social workers suggest that Lia be removed from the custody of her parents by CPS: took Lia for medical tests and discovered that she was not receiving the full dose of treatments so they put her in foster care with her aunt for months o Lia's parents inside that she needs spiritual treatment (this is a blessing, not a disease) and that meds diminish the effects of spiritualism o Parents thought medicine was sapping her energy and making her more sick o Doctors told parents that Lia would die if she wasn't given a feeding tube (deeply offended parents/violated a cultural taboo → this was taken as a threat) o For 2 years she was kept alive by modern medicine in a vegetative state o After leaving hospital in near-fatal state, she recovered → doctors attributed it to natural processes having to do with reduced swelling, parents to herbal remedies o Parents remained "non-compliant" and did not give her meds, choosing traditional therapies and rituals
Improving Both Health Delivery and Economic Development
o Have to reduce poverty to build a strong health system o Case study: A to Z textile mill in Tanzania o Health care systems strengthening: diagonal approach: "vertical" (disease-specific) programs often work, and they can be expanded or integrated to work "horizontally"; building human resources capacity; addressing the problem of international and NGO brain drain; building public sector health systems; cheaper to train doctors abroad then bring them to Europe/North America o Case study: Kerala, India
Ryan White
o Hemophilia and contracted HIV through blood transfusions o Suburban, white, cute, young, innocent → became the face of the disease (he didn't belong to a stigmatized population) o Spread the idea that anyone can get HIV o HIV funding doubled by the time Ryan White appeared on scene (thru the 80's): driven by civil rights movement and also sentimilization of figures like Ryan White
Hurricane Katrina
o Hit New Orleans dead center o Created a rupture for people who experienced it • Becomes an episode like a disease ("Hurricane Katrina survivors") o Diaspora: thousands of people relocated o Enabled forms of gentrification: property values went UP in some cases because so many people in so many parts of the city fled and those areas could be remade to nicer areas o Disproportionately affected African Americans
"The Spirit Catches You and You Fall Down" by Anne Radioman
o Hmong migrants: ethnic minority in China that was refugees in Laos after social upheavals in the 20th century → in the 1970s, became refugees in the US (California) after communist insurgency/cold war politics/counterinsurgency in Southeast Asia o Differences in legal system and question of who has power over children o Confusion about meaning of "freedom" and "authority" in the U.S.: Lia Lee's parents left communist China to come to the "land of the free" but they come here and their lives are uprooted o BUT doctors and healthcare workers don't understand or know about traditional healing practices (like lesions from coin rubbings and vacuum cups, feel that the Hmong are too loud) o Hmong have monosyllabic "yes" to indicate listening, but not comprehension (doctors continue to talk, thinking they understand, but they really don't...questions of informed consent) o Consent for obstetric care in women had to be cleared by elders, clan leaders, or husbands o Attachment to place and landscape of the Hmong o Powerful sense of cultural identity o They came from an egalitarian farming society o Lack of assimilation in China, Laos...and the US
Medical Schismogenics
o Ian Whitmarsh o Competing claims about responsibility and irresponsibility among patients and clinicians o Patients think doctors are irresponsible because they aren't paying attention to deforestation and its role in causing disease and our daily lives and how that gets in the way of taking medications o Doctors don't listen, belittle the patients, send them to jail if they don't follow orders, ignore patient requests, use poor patients as bodies for practice (while they have private practices where they make more money) o Doctors think patients are irresponsible because they are not doing what they can to get better o Role of healthcare workers and healers: asking questions, prying, taking blood samples, issues about medicines and therapies
Crossing the Cost Barrier of HIV
o Intellectual property rights and TRIPS make pharmaceuticals so expensive o Production of generic drugs in Brazil and South Africa (cease and desist issued, Clinton administration defended drug companies) o International law suits, the Clinton administration, and the pressure of public advocacy o We have intellectual property rights to protect research and development (of pharmaceutical companies) and this is how they defend the cost (this money going into making more, better drugs)
Social Suffering
o Interpersonal context of suffering o Community-based form of suffering (like sitting on their rooftops during Katrina) o Societal-level suffering as a result of major historical processes and events o First theorized by Kleinman o Different types
"A Salvage Ethnography of the Guinea Worm" by Amy Moran Thompsan
o Jimmy Carter: president, then worked on global health o Guinea worm eradication campaign in Ghana in the late 1980s o Eradicated in 2011 o BUT problematic aspects of "magic bullet" approach o Instead of robust public health approach to improve water quality thru purification, Jimmy Carter's program distributed filtered drinking straws and containers which are less effective and acceptable o Low levels of uptake (why it took 20 years to eradicate the disease): local populations weren't readily using these straws o Cultural interpretation of worms as implanted in blood at birth via ancestors or witches: doesn't matter if you use the straws, because the worms are already in your body (or not) from birth o Didn't purify the water source (worms still in the water) o Ghanaians question why international powers are focusing on non-fatal diseases rather than HIV/AIDS...worms don't really affect their lives
"The Surge: Politics, Violence, and Children in Central America and Mexico"
o Kids come to the US along train track routes, live in Dept. of Homeland Security "camps" o People can't just go wherever they want to go o Mostly coming from El Salvador, Guatemala, Honduras (incorrect notion that most people coming into the US this way are Mexican) o These areas have become key parts of the drug trade/routes o Outflux of children trying to get away from the violence o Structural violence in a way o Also a generation of children moved, just like a generation of people from New Orleans
"Political Violence, Ethnic Conflict, and Contemporary Wars" by Duncan Pederson
o Large health ramifications from things like migration, refugee camps, deployment of people to combat areas, Hurricane Katrina, etc o SO many landmines left over in places that were affected by Vietnam War (never were taken out of the ground) o Ethnic conflict and political violence in postcolonical field o Terror, mass executions, disappearances (central/south America), rape (Rwandan genocide → gendering of social suffering) o 160 wars, 24 million war-related deaths (90% civilian) since WWII o Wars have SIGNIFICANT health impacts!! o Lack of shelter, food shortages, destruction of infrastructure, emergence of infection diseases, towering levels of mental illness o PTSD may not be a simple, universal condition (important to tend to cultural meanings of trauma) o Arms trade is the largest economy in the world ($800 bil annually) and detracts from health spending
Community-Level Suffering
o Lebron James wearing "I can't breathe" shirt: he knows he is in a position of power/respect/fame but he is also in part of a community that he wants to suffer with → he has a chance to make a claim o White players on his team didn't wear those shirts because they aren't part of that community o Memorial in Ferguson: respected, people contributed to it, looked after it → makes a claim that this suffering is experienced by everyone in the community o Sandy Hook shooting: mass sentimentality, people who aren't personally attached feel that they are o To say that community-level suffering is a culture-bound syndrome doesn't mean it's purely a mental health problem
Case Study: BRAC
o Leveraging shared delivery infrastructure o Bangladesh Rural Advancement Committee: economic development after independence in 1971 o Training of female health workers o 1980s: focus on TB screening and treatment, but provision of a wider range of services and assistance o "exhibits the substantial benefits of leveraging shared delivery infrastructure in global health delivery"
Commodity Fetishism
o Marx: we fetishize commodities as if they came from no where and this is how we ordinarily interact with the market o I.e., you don't know the farmers who bring the fruits and vegetables to the market, and we are ok with that; if you maybe knew the labor of people who pick tomatoes in California, you wouldn't want to work that job and you wouldn't want to eat those tomatoes o Relationships between people are magically transformed into relationship between things: you have a physical relationship with the woman in a sweatshop in Indonesia because she made your shirt, but that relationship becomes commercialized when your credit card pays for it and allows the exchange (not just a price)
Societal and Historical Suffering
o Massive refugee crisis in Syria → such massive suffering that you can't really count it, quantify it, etc o Refugees began around WWI when people were displaced because of massive world wars, moved on to Jewish exile during WWII/the Holocaust o UNHCR working in conflict zones: trying to keep people sustained and alive o Doctors Without Borders: doesn't take sides in political conflicts so they can go in and keep people alive o Migration in Mexico/Central America o Apartheid in South Africa o World War and America o Great Leap Forward
Cultural Competency
o Means of creating new and improved forms of healthcare delivery...BUT must include an evaluation of the "culture" of biomedicine and health professionals o Cultural competency training can't be this stereotype that it's just the patient with cultural...so does biomedicine! o Cultural competency now TAUGHT in medical schools o Involves a lot of elements: actions, customs, language, personal identification, thoughts, communication, beliefs, values, institutions that are specific to ethnic, racial, religious, geographic, or social group
Asthma Epidemic in the Barbados
o Medical Schismogenics by Ian Whitmarsh o Caused by pollution caused by deforestation, industrialization, etc o Barbados culture uptook pharmaceuticals o Non-compliance o "Culture" associated with irrational fears, lack of education, refusal to adhere to biomedical knowledge and expertise...especially blaming mothers o If the kids weren't taking their medications, the mothers were blamed (became in charge of making sure they took it) o Patients critiqued the focus on drugs as part of the "Americanization" of society, including cars, industrial farming, and a Western diet
Global Mental Health
o Mental health (especially depression) contributes to the global burden of disease (GBD) o 4 of the 10 worst diseases are psychiatric o Early onset and prolonged course o Disability and suffering o Women are twice as likely to get depressed o Much higher levels of depression in Global North o all psychiatric disorders (mood based spectrum), except for biological disorders, are higher in the global north
Organ Donation
o Nancy Scheper-Hughes: anthropologist at Berkeley and founding director of Organs Watch o Argues that the organ trade is a form of structural violence o Social construction of the organ as a "gift" or "sacrifice" masks the dangers of donation (can lead to your own death/bioinequality/harm) → not portrayed as violent to the person who is donating o Gender bias in families: in places like India, organs are typically donated by the weakest, poorest, most vulnerable person in the family, usually a woman, in order to support a wealthier member of the family o Scars across the stomach symbolize masculinity and honor in the Philippines: people who have given organs for money are respected for this sign of sacrifice (selling organs to people in wealthy families in other countries) o Thorny ethical, medical, and social problems of children donating kidneys to grandparents: what if these kids grow up and need kidneys? o These minors give organs to their grandparents (who have more social power) just so that they will live ~10 years longer
"Aids and Accusations" by Paul Farmer
o Need to include Haiti in the scope of medical advancement o Emphasized delivering drugs to Haiti o Kay region of rural Haiti "City disease": associated with sex work, labor, travel (associated with Port au Prince) o "Sent sickness": people who had never travelled to Port au Prince still got the disease...how? o Thought as sent to you via sorcery o "Natural illness" sickness preventable via condoms o Bad blood o In Cuba, you would get put in prison for life if you tested positive for HIV...so no one got tested o Eventually changed this policy o Biopower motivates people to change behavior (i.e., taking up condoms in the community → changed parts of their sexuality/sexual behaviors)
Practical Problems in Treating Lia Lee
o Non-compliance o Drug side-effects o Language barriers (parents have no idea what's going on) o Mistrust of doctors/healthcare system o Strained relationships o Worsening symptoms and episodes
"The Struggle for a Public Sector" by James Pfeiffer
o PEPFAR: George Bush o Mozambique is one of the poorest countries in the world with among the worst healthcare systems o PEPFAR should work alongside with the public sector not in place of it o In 2000, Ministry of Health was encouraged by Clinton Foundation to scale-up HIV treatment o 180,000 new patients in first year o BUT problems with PEPFAR: funding goes to foreign NGOs rather than helping to create public infrastructure, remake structural problems, or work "horizontally" o NGOs: small and specialized geographical focus, use of foreign health professionals, internal brain drain, narrow focus on HIV o High LTFU (loss to follow-up) rates because of limited integration, transport problems, poverty, and geographical constraints o Food security: lack of food increases medication side effects o Even though PEPFAR helped scale-up treatments, the healthcare workforce remains small and the infrastructure is woeful o NGO Code of Conduct: in order to operate effectively, NGOs should avoid creating parallel systems and advocate for structural changes
Green Light Committee
o Part of the stop TB campaign o Job is to fund NGOs (like partners in health) to treat Multi drug resistant TB (TB and MDRTB) o Farmer would think this committee is a good thing, but the problem is that it has not been successful in getting funding for TB
4 H's
o People who get HIV/AIDS: 1. Homosexuals 2. Heroin users 3. Hemophiliacs (from blood transfusions) 4. Haitians
Evolution of Malaria Mortality
o Pre-WWII: quinine/tonic water as sole cure for malaria o Post WWII: heavy used of DDT spraying o Came to an end around 1970s: carcinogenic (caused additional health problems) o 1942: Office of Malaria Control in War Areas o National Malaria Eradication Program o 1947-1952: spray applications, wetlands/swamp drainage, disruption of mosquito breeding sites o by 1950s, really no malaria in the US because of these public health efforts o 1970s+: drug resistance growing (poor drug adherence in places with mosquitos; small increase in malaria by the end of the 20th century as a result) o 2000s: Global Malaria Action Plan (GMAP)
HIV Tuberculosis Nexus
o Prevalence of HIV dramatically worsens TB in poor countries o MORTB and XDRTB -54% of all cases, 95% in poor countries, 50% mortality o Complex reasons for non-adherence
WHO 3x5 Program
o Provide antiretroviral treatment to 3 mil people in low- and middle-income countries by 2005 o WHO's leverage helped to coalesce a large number of actors between 2003-2005 o Shift in accountability standards to focus on number of people being treated rather than the amount of money being spent/donated o Target reached in 2007 o Seen as a huge success for WHO
PEPFAR
o Provides treatment for > 2.5 million people in 24 nations and interventions for > 500,000 pregnant women o BUT had to agree to provide abstinence-only education o Also, beneficial for pharmaceutical company because drugs were bought at full price (consequently, able to buy less and treat fewer people)
Neoliberalism
o Puts responsibility on individual o Example: condom use education: if you get HIV it's your own fault because we warned you and even maybe gave out condoms! o Example: obesity: HUGE cause of health care in our society, not criminalized like drugs are, but we blame the people who are obese
Job (from the Bible)
o Quintessential statement on Jewish subjectivity o Job was good, "perfect," "upright," "feared God," "eschewed evil" o Satan tests Job's faith thru trials and tribulations (killing his sons, annulling his property, destroying his harvest) o The world makes no moral sense to Job! Even though he is perfect and upright o He is doing good, not sinning, but is being punished in such extreme ways o Who is punishing Job? Directly, Satan, but isn't God letting it happen? o God is enabling suffering and so the moral sense of the world starts to dissipate o BUT this suffering stakes a claim to belonging in THIS Jewish community o Later Job gets taken up as a model for Christian subjectivity o To be human is to go through suffering and that suffering relates you to both other people and God o Interpreted as an allegory of Jewish suffering and (in postwar decades) the meaning of the Holocaust o Levinas would say that lending meaning to this suffering is violent, because for people who are undergoing the suffering all there is is misery and pain and that doesn't say anything about community
"The Suffering Stranger" by Lesley Butt
o Reaction to Dying for Growth by Jim Kim: argues that poverty is the result of economic problems o Wonders about the aesthetic of the book's cover: goal of much anthropology is to "enhance descriptions of suffering" oIs it ethical to study suffering? o "Suffering strangers": destitute child as seen on the cover → what does this do for us, except make suffering evident? Just makes the child a stranger o Rather than presenting interesting stories, scholarships should break down the barriers between academic and communities by arguing for concrete actions o Critique of the structural violence paradigm o Where is the relation between narrating/anesthetizing suffering and improving their lives?
Hmong Participation in the Vietnam War in 1960s and 1970s
o Recruited in Laos o Widespread casualties, mortalities, and loss of land led Hmong to cling even more to culture and identity o War led to a loss of self-sufficiency and need to migrate as refugees o Refugee camp was largest Hmong settlement in history (had never been so urbanized) and very densely populated o Hmong were blamed for their miserable condition (dependence, poor health, lack of cleanliness)
Ryan White HIV/AIDS Program
o Ryan White Care Act (1990) o Largest HIV/AIDS program in the US o Provides services and treatments for people living with AIDS in low-income and marginal population o 2006 reauthorization expanded the program to cover people living with HIV o Before, only focused on those with late-stage AIDS/AIDS in general o BUT this was a very expensive way of caring for people (like waiting to go the the ER before getting help for something as opposed to getting help at an earlier stage) o Farmer: treating people with HIV medication prevents the escalation of disease and can also reduce transmission (low viral loads)
Structural Violence & the Biosocial Perspective
o SES (socio-economic status): flexible wage labor (not permanent/stable labor, might have hours that shift); poverty and precarity o Gender: dependence on partner income; subject to abuse (domestic violence, substance abuse)/STI infection o Biology: STI acquisition (including HIV) more likely for women
Clinical Study in Haiti
o Sector 1: 25,000 population in core catchment area o Sector 2: surrounding villages o Both sectors offered the same clinical services, but sector 1 was served with DOTS-Plus (community health care workers, women's health initiatives, and other services) o Results: much less mortality in sector 1, greater weight gain, more returned to work, more denied role of sorcery in their health ; 100% of sector survive year 1 disease-free; more people started getting vaccines, prenatal care, etc
Apartheid in South Africa
o Segregation by race led to very clear health disparities (many more doctors for whites, higher infant mortality rate among blacks, school expenditures on students were different) o Segregation was a formal policy o Structural violence but ALSO social suffering o If you go to South Africa today there are still generations alive that lived through this (ended in just 1990)
"A Return to the Magic Bullet?" By Marcos Cueto
o Significant improvement in addressing malaria, especially in Africa, through the Roll Back campaign o BUT core problems of the WHO's 1950s and 1960s eradication campaign failures are still in place o Disease-specific ("vertical") interventions rather than infrastructure building and general social programs (over-emphasis on meds and bed nets) o "No one questioned the nature of the connection between malaria and poverty; simply put, malaria caused poverty, not the other way around" o 2007: Gates Foundation pledges $10 billion to eradicate malaria (but what will this money do? why aren't they just pledging to reduce poverty? it is hard for people who are beneficiaries of a particular economic order to be philanthropic like this) o More multilateral partnerships than in 1950s and 1960s (more "global") but still an overriding "vertical" approach
Institutionalizing Social Suffering
o Social suffering isn't a bad thing: refers to how suffering can be shared o This is why the CHW in Bernadette's living room takes on second order suffering (she takes on some of Bernadette's plight even if she may not have HIV, be a victim of domestic abuse, have the same subjectivities BUT decides to take on some of her suffering nonetheless) o Contrasts with biosocial approach: doctors don't take on suffering with you (might feel empathy, but don't suffer with you) o Contributes to idea that Bernadette is not individually responsible for her HIV → society/the system is!
Interpersonal Suffering
o Sometimes we want to hear about other people's suffering, sometimes we don't o Interpersonal suffering is a powerful human form of sharing
Healthcare Problems in Merced (The Spirit Catches You and You Fall Down)
o Stereotyping Hmong as transplanted "from Stone Age to Space Age" o "Counseling" and "social work" sessions leave parents more confused o Parents disagree with how much medicine Lia is getting, disagree with spinal tap, can't come into her hospital room, labeled "non-compliant" and "difficult" o "American medicine at its worst and its best": she was reduced to a collection of symptoms and doctor could keep her alive o Lia Lee's case is common: avoidance of care and lack of cultural competency o Kleinman recommended a "joint approach": bring together traditional healers and family members into the process as active collaborators and to remake the medical approach to incorporate a consideration of stories and subjectivities
"Silent Spring" by Rachel Carson (1962)
o Stop spraying DDT because it's causing more problems o Congressional hearings in which Rachel Carson testified against the use of DDT spraying o Robert Merton: unintended consequences o But in Ecuador, increased use of DDT spraying decreased malaria rates compared to places where there was not as much DDT spraying o Which is a greater health risk: being sprayed by DDT or malaria?
"Technologies of Self" by Veena Das
o Study of health and poverty in Delhi o "conception of subjectivity forged in the workshop of everyday life" o Medical pluralism in a vast field: navigation of public and private clinics, healing traditions, sources of medicine o Subjectivity composed not as a direct response to crisis, but in the flow of relationships and in relation to the power and gaze of others
Explosion in Global Health
o The "big three": tuberculosis, malaria, HIV o "explosion" in global health in the past ~10 years o a lot of this had to do with what happened around early 2000s o Gates Foundation distributes > $10 billion o Global Fund to Fight AIDS, Tuberculosis, and Malaria distributes > $22.6 billion to 150 countries o IMF and World Bank provide debt relief for poor countries
"Anthropology in the Clinic" by Arthur Kleinman
o Trait list approach: lots rules the doctors have to memorize o Think about folk illnesses: call depression "neurasthenia" to Chinese immigrants, etc.
Malaria
o Transmitted by mosquito bites: parasites travel thru bloodstream to the liver, where they mature and release more parasites that infest blood cells o Symptoms occur one month after infection: high fevers, shaking chills, flu-like symptoms, anemia o Resembles a lot of other diseases so malaria is often over diagnosed (better to treat for malaria than the flu → better safe than sorry...BUT this contributed to drug resistance) o Countries with high rates of malaria also have a lot of meds to treat it o Treatment is very complex depending on which strand you get o More than half of the world lives in a malarial region o 10-30% of all hospital admissions worldwide o Like HIV and Tb, malaria also causes poverty, accounting for $2 billion per year in lost productivity in Africa, and $12 billion in total cost globally o Prophylaxis: preventative medication (BUT you can't just live on this if you live in a place with lots of malaria...very harsh side effects)
Partners in Health in Rwanda
o Trying to scale up this model of global health o Partnerships with institutions: globally (the Global Fund) and nationally (Ministry of Health) o Implementation of "accompaniment" model pioneered in Haiti o Paying CHWs: argument that payments are cost-effective because they greatly increase adherence to medications o Model shuns the direct foreign aid model that has often failed in development projects and favors work with local communities and CHWs
Factors in Virus Transmission
o Viruses have features that facilitate mutation o Elevated replication rate, high error rates, genetic recombination o Results in significant advantages that facilitate the creation of epidemics (like drug resistance)
World War and America
o WWI: similar effects on European continent as in America o Fought for 4 years for really nothing o Soldiers forced out of trenches into No Man's Land to get hit by shells, bullets, etc o Borders didn't change, nothing o 35% of the graduating class of Oxford in 1913 died in WWI → THAT is social suffering! (generational) o PTSD: generations that are part of these wars (Vietnam, Gulf War, Iraq/Afghanistan) are so traumatized o Soldier suicide rates outnumbered deaths in action o Up until just a few years ago, being in war actually meant lower suicide rates (access to health care, camaraderie, discipline)
Case Study: Partners in Health in Peru
o Went in the late 1990s with DOTS+ program o High cure rate of 83% because of the new program (accompaniment model) o Point they are making: TB is treatable but it needs DOTS+ or accompaniment to be successful o The DALYS model led to unintended consequences because it led so much money into a simple DOTS model which resulted in more TB
Bernadette in Massachusetts
o When she first went to hospital in Boston, she was: 84 lbs; STD (syphilis) and mental health (depression) co-morbidities; very high viral load o After 6 months of DOTS+: >90% adherence; 140 lbs; undetectable viral loads; new capacity to treat STD co-infection and mental health o Health care workers aren't just the ones who deliver her meds, but the ones she can confide in about potential domestic abuse, her living situation, etc (don't just show up and hand her meds, but ask her about other parts of her life) o Structural conditions/background: mortality rate for blacks from HIV has declined LESS than it has for whites; maybe limited access to clinics, can't afford drugs, etc, even though Ryan White Care Act promised drugs to those who are marginalized/poor; she becomes more and more like the face of HIV in the U.S. (women in the African American community in monogamous, heterosexual relationships); most women get HIV from "high risk" sexual contact, vs male-to-male sexual contact for men
Adapting to Local Context
o anthropological principle o assess differences and distributions of disease across region and locales o understand local politics and tensions o work with public sector to structure access to water, food, and other resources o understand the specific of local economic constraints (like transportation using donkeys in rural Haiti) o ethnography of illness meanings and stigma o case study: Polio in Uttar Pradesh
Accompaniment
o community health care workers literally accompany you thru your health care journey so it doesn't matter if you don't wear a watch! o Contrasts with critique that people in Africa, etc shouldn't get meds because they don't wear watches and won't know when to take their meds on time, creating widespread drug resistance because of poor compliance
Global Malaria Action Plan (GMAP)
o developed in 2008 by the Roll Back Malaria Partnership o Target to reduce malaria by 75% by 2015 → didn't happen o Question of efficacy in global health o Gradual eradicative objective o Emphasis on: education and information; vector control; medical care (test, treat, track) o "Village by village" project o Bed nets: become symbol of global health intervention as it relates to malaria today
Case Study: Kerala, India
o health care systems strengthening (improving both health delivery and economic development) o public programs coordinate the state's health system and account for the majority of health care provision and training (socialized medicine) o priority on prevention, immunizations, and infant/maternal care o large investments in public education o excellent health outcomes and low per person cost o Kerala: $28 per capita, infant mortality of 14/1000 births, and life expectancy of 76 o USA: $4,703 per capita, infant morality of 7/1000 births, and life expectancy of 80
Leveraging Shared Delivery Infrastructure
o health infrastructure for different diseases can often require overlapping procurement systems, supply chains, and clinical resources o harmonizing storage of medicines in pharmacies o clinics are better prepared to diagnose and treat multiple diseases, which is especially relevant in contexts where patients may not know what illness or illnesses they have o case study: BRAC
Case Study: A to Z Textile Mill in Tanzania
o improving both health delivery and economic development o Tanzanian company contracted to produce insecticide-treated bed nets for prevention of malaria o LOCAL company employing LOCAL people o Partnership between NGOs, global capital, and a national firm o Generation of an estimated 5,300 salaried jobs and support for 24,000 people
Beatrice from Uganda
o lack of condom use in marriage led to stigmatization and property loss o She was faithful but her husband was using sex workers without condoms o Evidence of the unintended consequences of a focus on abstinence and the family o "know your right" movement: focuses on the right to health as a human right a broader concept of human rights and civil rights, and thus proposes changes in health policies and sociocultural structures o lack of funding and support o Treatment Action Campaign in South Africa linked social justice agenda and a focus on treatment o Critical for global health to focus on consequences of testing and the meaning and scope of "rights" o Emphasis on abstinence, faith in relationships, condom use
Potential for Another Influenza Pandemic
• Avian, swine, and human flu viruses can exchange genes • New subtypes of the flu • Existing vaccines would be ineffective • If the new virus contains sufficient human genes, transmission directly from person to person can occur • This is probably what happened in the great flu pandemic of 1918-1919
Social Inequalities in Emerging Infection Diseases by Paul Farmer
• Emerging infectious diseases are not only new diseases (HIV, SARS), but also old diseases (TB, Ebola) • "intersectionality" of diseases and social/structural ideas • Re-emergence of TB along with HIV • "AIDS is for everyone" disregards key differences
